Testimony by Senior Deputy Assistant Administrator Gloria Steele, Bureau for Global Health, on the FY2011 Global Health and Child Survival Budget Request

Tuesday, March 23, 2010


Chairwoman Lowey, Representative Granger, distinguished members, thank you for inviting me to testify on the FY 2011 Global Health and Child Survival (GH CS) budget request. Before I begin, on behalf of my staff at USAID and the people we serve, I want to commend the strong leadership of this Committee, and thank members of Congress for your longstanding support of health programs.

The U.S. Agency for International Development (USAID) is the principal U.S. agency providing development and humanitarian assistance to the developing world in more than 100 countries. At the country level, USAID works hand in hand with national programs and partners furthering country-driven programs.

Our health programs are complemented by additional USAID investments that address poverty and hardship, including emergency food aid and assistance to boost agricultural productivity; micro-credit programs providing access to money that wisely used can lift families out of poverty; girls' education programs to improve the health and prosperity of coming generations; water and sanitation programs that prevent disease; emergency relief and food assistance following disasters.

USAID works in close collaboration with other USG partners, as well as with other donors, non-governmental, faith-based and community organizations, the private sector, the United Nations, and host countries themselves. U.S. Government assistance in the health sector in developing countries has contributed to unprecedented public health success.

U.S. development assistance has brought dramatic improvements in health to much of the developing world in the last 50 years including marked declines in infant and child mortality, a narrowing of the gap between desired and actual family size, and increases in life expectancy that almost match the rates of developed countries, particularly in some countries in Asia and Latin America.

Background and Challenges

President Obama, Secretary Clinton and USAID Administrator Shah have challenged us to accelerate progress by connecting our work on high impact health programs through a comprehensive integrated approach that will help countries strengthen their health systems. This approach will extend even beyond health services, to harness the contributions of our investments in water and sanitation, in agriculture and food security, and in girls' education, among others, to achieve better health for families and children.

Over the past four decades, with the constant support of Congress, USAID has provided global leadership in maternal, newborn, and child survival. USAID programs have contributed to substantially reducing child mortality in over thirty countries. Globally, nearly eight million children's lives are being saved each year through evidence-based health interventions that address major causes of childhood mortality; USAID has supported much of the research that identified and proved the effectiveness of these high impact interventions, including Oral Rehydration Therapy, vitamin A, zinc treatment for child diarrheal illness, to community treatment of pneumonia and essential newborn care.

While progress has been made, urgent health challenges remain. Global maternal mortality rates have remained unchanged, and today, 530,000 women still die each year from pregnancy-related causes; 6 million children under the age of 5 continue to die each year from preventable causes; over 900,000 (mostly children) still die from malaria; there are still 9 million new cases of TB with 1.7 million deaths each year; 52 million unwanted pregnancies occur annually; and millions are disabled by tropical diseases for which simple treatment exists.

Global Health Initiative (GHI)

Through the whole-of-government Global Health Initiative (GHI), the United States will invest $63 billion over six years to help the approximately 80 partner countries where the U.S. Government provides health assistance to improve health outcomes, with a particular focus on improving the health of women, newborns and children. The GHI is a global commitment to invest in healthy and productive lives, building off of and expanding the U.S. government's successes in addressing specific diseases and health conditions. Addressing wide-ranging health needs in partnership with governments, communities and other partners represents an ambitious agenda that can be met only if we work together, aligned toward common goals, with a commitment to fundamentally improve the way we do business.

The GHI aims to maximize the sustainable health impact the United States achieves for every dollar invested. The GHI will deliver on that commitment through an interagency business model based on core GHI principles: implementing a woman- and girl-centered approach; increasing impact and efficiency through strategic coordination and integration; strengthening and leveraging key partnerships, multilateral organizations, and private contributions; encouraging country ownership and investing in country-led plans and health systems; improving learning through rigorous metrics, monitoring and evaluation; and promoting research and innovation.

Through this comprehensive approach the GHI will build on the US's successful record in global health, and take these remarkable achievements to the next level by further accelerating progress and investing in a more lasting and leveraged approach to health delivery and health systems.

We in USAID are proud to be working with our USG and country partners in collaboration with Congress to address the goals and objectives of the Global Health Initiative.

FY 2011 Request

Appropriated funding for the Global Health and Child Survival (GHCS) account has increased dramatically since the inception of the account, thanks to Congressional support that recognizes the on-the-ground successes of USAID's health programs. The FY 2011 request of $3.0 billion for USAID is a substantial increase from the FY 2010 enacted level of $2.1 billion. Funds will expand basic health services and strengthen national health systems which are key investments that significantly improve people's health, especially that of women, children, and other vulnerable populations. USAID will continue to focus on scaling-up proven interventions that respond effectively and efficiently to the largest public health challenges and developing key life-saving technologies for the future.

The FY 2011 request of $3.0 billion includes, $900 million for Maternal and Child Health and Nutrition, $680 million for Malaria, $590 million for Family Planning and Reproductive Health, $350 million for HIV/AIDS, $230 million for Tuberculosis, $155 million for Neglected Tropical Diseases, $75 million for Pandemic Influenza, $18 million for Other Public Health Threats, and $15 million for Vulnerable Children. With this funding we will also continue to scale up cross-cutting objectives, such as, health systems strengthening, integration, building partnerships, research, and innovation.

Maternal and Child Health including Nutrition: is $900 million. To scale up and deliver health interventions that have the potential to substantially reduce maternal and under-five mortality. Allocations to countries are based on magnitude and severity of maternal and under-5 mortality, and operational factors, including country commitment, that predict program success. Every year, 8.8 million children die in the developing world; approximately 2/3 of these deaths are from preventable disease and malnutrition. In addition, 530,000 mothers die every year from complications related to pregnancy or childbirth, and for every woman who dies, 20 more suffer injury, infection or disease. MCH activities will be integrated with family planning programs in all countries; with PEPFAR's investments in strengthening prevention of mother-to-child transmission in countries with generalized HIV epidemics and follow-up of HIV-positive mothers and HIV-exposed and infected children; with safe blood programs; and with PMI's investments in bed net provision and treatment of pregnant women, infants and children.

By developing and implementing high-impact, evidence-based interventions, delivered at low cost USAID's maternal health programs have helped reduce maternal mortality in 15 countries by 9 to 48 percent since the late 1980s. In 11 of these countries newborn mortality also decreased by 16 to 42 percent. With USAID support, counties as diverse as Nepal, Cambodia, Ethiopia, Madagascar, Tanzania, and Afghanistan have reduced under-five mortality by 25 percent in 5 to 7 years. In the past year, USAD introduced a number of new high-impact interventions including:

  • post-partum hemorrhage prevention and management and active management of the third stage of labor (AMSTL) in 16 of the 30 priority countries, to address the major cause of maternal mortality;
  • a package of essential newborn care preventive interventions that can be used in home births as well as facilities in 19 countries - USAID-supported research has shown that this package of preventive newborn care can reduce neonatal mortality by about one-third;
  • zinc for treatment of child diarrhea in 10 countries; and
  • point-of-use drinking water disinfection for prevention of child diarrhea in 10 countries.

Our MCH program will scale up efforts to combat maternal mortality and apply a women-focused "dual-track" approach, rapidly expanding coverage of existing life-saving interventions that can be provided now (such as prevention and management of post-partum hemorrhage, the leading cause of maternal mortality in the developing world; family planning. anemia reduction; and clean delivery), with simultaneous investment in building the longer-term human resource and system capability required to provide comprehensive obstetric care.

In child health, a cumulative total of three million lives of children under age five will be saved over the period of 2009-2014 by reaching increased numbers of the most-vulnerable families with high-impact interventions, including essential newborn care; immunization; prevention and treatment of diarrhea, pneumonia and newborn infections; improved nutrition; point-of-use water treatment and other interventions to improve household level water supply, sanitation, and hygiene.

Among the important lessons learned through USAID's Maternal and Child Health programming are: that MCH is universally regarded as a core function of the health care system. As a result, USAID's MCH programs have consistently invested in approaches to strengthen key elements of health systems, from health care capacity building to quality assurance methods, to drug management and logistic systems to performance-based financing.

In countries with high mortality rates and weak health systems, reducing mortality requires bringing a basic set of high impact services as close as possible to the people who need those services. For this reason, USAID's Maternal and Child Health programs have pioneered, and FY 11 funding will strengthen and expand community-based approaches such as treatment of child pneumonia and newborn sepsis, misoprostol to prevent post-partum hemorrhage in home deliveries, and behavior change programs to promote breastfeeding. These approaches are often delivered through partnerships with NGOs, but need to be taken to scale as components of national health sector programs.

Nutrition: is $200 million. Since 1990, USAID investments have helped contribute to a reduction in underweight children from one in three to one in four today. Maternal and child undernutrition contributes to more child deaths-3.5 million-every year than any other cause. Undernutrition increases both susceptibility to and severity of common illnesses and infectious diseases. Undernutrition during a child's early years can lead to permanent damages to mental and physical development, undermining investments in health, education, and economic growth. Investing in nutrition at large scale is vital to our objectives of reducing mortality and hunger.

Our continued support to vitamin A supplementation programs have protected millions of children and reached global coverage of over 70%. One of the key lessons learned from our decades of work in nutrition is that improving undernutrition at a large scale requires a comprehensive effort that involves all sectors, and this is the approach we will be pursuing as part of the USG Global Hunger and Food Security Initiative (GHFSI). As part of this initiative and the Global Health Initiative, USAID will work with countries with a high burden of undernutrition to bring high-impact, evidence-based nutrition interventions to scale and to refine and test innovative approaches such as biofortification. This will include preventing undernutrition for young children and mothers, improving diet quality and diversity, targeting micronutrient supplementation, and managing acute undernutrition at the community level. To support a country-led process, we will also invest in capacity building, strengthening the policy enabling environment, monitoring and evaluation systems, and private sector partnerships for nutrition.

The global community is mobilized around improving nutrition as part of a comprehensive food security agenda. We have recent documented evidence of the highest impact interventions (Lancet) and what it will cost to achieve high coverage (World Bank). We know what to do and we now have global commitment to do it at scale. Our approach focuses on prevention, cost-effectiveness, and sustainability. Preventing under-nutrition was identified as one of the most cost-effective interventions in global health by the Copenhagen Consensus. We will have a balanced approach of preventing under-nutrition in the targeted window of opportunity (9 to 24 months) with nutrition service delivery (supplementation and treatment of severe acute under-nutrition). This is the "window of opportunity" (from pregnancy to two years old) for a high priority package of evidence-based and cost-effective health and nutrition interventions to reduce death and disease and avoid irreversible harm. If implemented at scale, and supported by appropriate policies, these effective interventions can significantly improve global nutrition especially among the most vulnerable - undernourished mothers and children.

FY 2011 funding increases will enable the development of robust nutrition plans and comprehensive strategies that are developed in consultation with key stakeholders and led by countries. These funding increases are consolidated in priority countries that are in line with both GHFSI and GHI priorities.

Family Planning and Reproductive Health: is $590 million. Programs will continue to improve and expand access to high-quality voluntary family planning services and information, as well as other reproductive health care. Annually, there are 52 million unintended pregnancies and there are 22 million abortions. Family planning (FP) is an essential health intervention for mothers and children, contributing to reduced maternal mortality and reduced infant mortality (through better birth spacing). Activities will support the key elements of successful FP programs, including: creating demand for and supply of modern family planning services through behavior change communication; commodity supply and logistics; service delivery; policy analysis and planning; biomedical, social science, and program research; knowledge management; and monitoring and evaluation. Priority areas include: FP/MCH and FP/HIV integration; contraceptive security; community-based approaches for family planning; expanding access to long-acting and permanent prevention methods, especially implants; promoting healthy birth spacing; and cross-cutting issues of gender, youth, and equity.

In more than 30 USAID-assisted countries, the number of married women of reproductive age using a modern contraceptive method increased to 110 million, this presents nearly a 30% increase since 2000. . Survey data collected this past year show three countries with substantial increases in modern contraceptive prevalence (Kenya: 32-39% over five years; Madagascar: 18-29% over five years; and Rwanda: 6-27% over seven years). Each of these countries has had priority status for USAID's family planning program - and in each, funding has at least doubled since 2002. Key to increasing contraceptive use has been the expansion of services available through community health workers through recruitment, training, and task-shifting; strengthening of the supply chain; and increased government commitment to family planning.

Continued progress requires: (a) sharing lessons learned and best practices with other countries especially within the regions, (b) expanding community-based approaches, including the introduction of the new "depo-in-uniject" technology, (c) expanding access to longer-acting methods of family planning to complement temporary methods, (d) integrate family planning with maternal and child health services, especially as part of post-partum and community-based services with HIV programs when appropriate, (e) elevating family planning as part of MDG-5b on the country and donor agenda, and (f) strengthening the NGO and private sector role in providing and promoting family planning information and services.

HIV/AIDS: is $350 million. Funding contributes to the President's Emergency Plan for AIDS Relief (PEPFAR) to focus on HIV/AIDS treatment, prevention, and care interventions in countries worldwide - including support for orphans and vulnerable children affected by the epidemic. Nearly 3 million people are infected with HIV each year, and AIDS is the leading cause of death of women of reproductive age around the world. USAID contributes to the interagency fight against the HIV/AIDS epidemic by, providing critical technical leadership, conducting essential operational research, and serving as a critical implementing agency under PEPFAR. USAID collaborates closely with the Office of the Global AIDS Coordinator and other U.S. government agencies to ensure that HIV/AIDS activities implemented through all agencies and funded through all accounts are part of a unified, 'one USG' strategy on HIV/AIDS.

In FY 2011, HIV/AIDS resources will continue to provide technical assistance to countries for HIV/AIDS though prevention, care, and treatment programs, including: prevention of mother-to-child transmission (PMTCT); injection safety; palliative and orphan care; and treatment. USAID will continue to work through PEPFAR to identify practical solutions to important issues facing HIV/AIDS programs worldwide. For example, with USAID support, the first clinical trial to test the effectiveness of an ARV-based microbicide was launched in 2007. When the trial results are made public this July, it will be the first trial completed and providing data on the effectiveness of ARVs used in microbicides.

One of USAID's core strengths in the USG response to the global AIDS epidemic is it's ability to support multisectoral responses that address the widespread impact of the disease outside the health sector in high-prevalence countries. In these countries, USAID is supporting programs in areas such as agriculture, education, and economic development. These programs "wrap around" PEPFAR-supported HIV/AIDS interventions and mutually support the objective of reducing the impact of the pandemic on nations, communities, families, and individuals.

Malaria: is $680 million. The President's Malaria Initiative (PMI) will continue to support host countries' national malaria control programs and strengthen local capacity to expand use of four highly effective malaria prevention and treatment measures. These measures include indoor residual spraying (IRS), use of long-lasting insecticide-treated bed nets (ITNs), application of artemisinin-based combination therapies (ACTs), and implementation of interventions to address malaria in pregnancy (intermittent preventive treatment or IPTp). Annually, 900,000 people die of malaria and 300 million people are newly infected. This level of funding will allow USAID to dramatically expand malaria programs in Nigeria and the Democratic Republic of Congo.

The program will focus on reaching 85% of pregnant women and children under five in 15 focus countries in Africa. In addition, the PMI will continue to support the development of malaria vaccine candidates, new malaria drugs and other malaria-related research with multilateral donors, including the World Health Organization and international consortia such as Roll Back Malaria. Allocation to countries is based on malaria burden, existing infrastructure, government commitment, and availability of Global Fund or other donor funding. The Millennium Development Goals for malaria can be achieved if we sustain and broaden our efforts. And as we continue to make progress in the fight against malaria, we make important gains towards other Millennium Development Goals (1, 4, 5, and 6)

In the past year, the President's Malaria Initiative, led by USAID and implemented jointly with the Department of Health and Human Services, the Centers for Disease Control and others, reached more than 50 million people.

Since 2006, substantial progress has been made in the scaling up of training, host country capacity building, and malaria prevention and treatment measures across the 15 PMI focus countries in collaboration with national malaria control programs (NMCPs) and other donors. During the fourth year of implementation, the U.S. reached more than 50 million people with malaria prevention and treatment measures. In 2009, PMI procured more than 15 million long-lasting mosquito nets for free distribution to pregnant women and young children and a total of 29 million anti-malarial drug treatments. Indoor residual spraying activities helped protect more than 27 million persons at risk of malaria. In addition, in 2009, PMI trained tens of thousands of people in key aspects of malaria control, including more than 41,000 health workers in malaria case management. In all 15 focus countries, PMI provided support to improve the pharmaceutical management of anti-malarials and other essential medicines.

Evidence of significant reductions in malaria-related illnesses and childhood deaths are already being seen. In Senegal, a 29 percent reduction in deaths in children under five was recorded in the 2008 national household survey compared with the 2005 Demographic and Health Survey (DHS). During the same period, household ownership of one or more mosquito nets rose from 36 percent to 60 percent.

Zambia has also seen dramatic reductions in mortality rates and malaria infections. A 2007 DHS survey showed a 29 percent reduction in deaths in children under five, compared with 2002. According to 2006 and 2008 nationwide Malaria Indicator Surveys, there was a 53 percent decline in malaria prevalence and a 68 percent decline in severe anemia in children under five, which is closely associated with malaria in this age group. Anemia is a primary cause of death and disability in the developing world and it exerts a devastating effect on childhood development and cognition.

In Rwanda, childhood deaths fell 32 percent from 2005 to 2008, according to DHS surveys. During the same period, household ownership of one or more mosquito nets rose from 13 percent to 57 percent. Regional and District-level impact has also been reported from Mozambique, Tanzania, and Uganda.

Partnerships with host country governments, the Global Fund to Fight AIDS, Tuberculosis and Malaria, the World Bank Booster Program for Malaria Control, the Bill and Melinda Gates Foundation, and others have made these successes possible. Successful partnerships with faith-based and community organizations are bringing tremendous value to malaria control efforts because of the credibility these groups have within their communities, their ability to reach the grassroots level, and their capacity to mobilize significant numbers of volunteers. PMI has supported more than 150 nonprofit organizations, over 40 of which are faith based.

Neglected Tropical Diseases (NTDs): is $155 million: NTD programs will fund training of community-based and professional health care workers and the targeted mass drug administration of drugs to reduce the burden of seven debilitating NTDs, including onchocerciasis (river blindness), trachoma, lymphatic filariasis, schistosomiasis, and three soil-transmitted helminthes. Every year, 400,000 people die from NTDs; 1 billion suffer from one or more tropical diseases, causing severe disability and hindering cognitive development. These diseases stunt the physical and cognitive development of children, contribute to malnutrition, can cause blindness, and have other disabling effects. Building on this strong base of scaled-up integrated programs, this request also includes funding to initiate programs to targeted elimination of one or more of the diseases. Allocations to countries are based on the incidence of the targeted NTDs.

When the U.S. Congress launched the USAID integrated NTD control project in 2006, it represented one the first large-scale effort to integrate existing disease-specific treatment programs to care for millions of the world's poorest people.

Since 2006, USAID has supported the delivery of over 221 million NTD treatments through integrated programs to over 55 million people, and is using its country-level experiences to contribute to the development of global norms and standards for integrated NTD control. The project is currently working with local partners and Ministries of Health to provide mass drug administration in fourteen countries-Bangladesh, Burkina Faso, Democratic Republic of Congo, Ghana, Haiti, Mali, Nepal, Niger, Sierra Leone, Southern Sudan, Tanzania, and Uganda.

Tuberculosis (TB): is $230 million. USAID focuses on assisting national TB control programs to deliver high-quality services to diagnose and treat TB, a vital measure to prevent the development of drug resistant disease. USAID programs have made important contributions to progress in many countries, including those with a high burden of disease such as India, Bangladesh, Kenya, Pakistan, and The Philippines. Globally, 1.7 million people die from TB and there are 9.2 million new cases of TB each year. Annually, there are approximately 500,000 cases of multi-drug resistant (MDR).

Last year, more than 1.2 million TB patients successfully completed treatment in 20 USAID priority countries, resulting in more than 600,000 lives saved. USAID will continue to scale up TB activities in priority countries, including strengthening laboratories, expanding the WHO recommended treatment strategy, and mobilizing the private sector as partners in TB programs. Country level expansion and strengthening of the Stop TB Strategy will continue to be the focal point of USAID's TB program including increasing and strengthening human resources to support Directly Observed Treatment, Short Course (DOTS) implementation, preventing and treating TB/HIV as well as partnering with the private sector on DOTS. In particular, activities to address MDR and extensively drug resistant TB will continue to be accelerated, including the expansion of diagnosis and treatment, and infection control measures, and support to the Green Light committee ensures that country programs meet international standards. USAID collaborates with the Office of the Global AIDS Coordinator to expand coverage of TB/HIV co-infection interventions including HIV testing of TB patients and effective referral, TB screening of HIV patients and implementation of intensified case finding for TB, TB infection control and, where appropriate, Isoniazid Preventive Therapy.

Managing the quality, affordability, delivery and provision of anti-TB drugs is another vital issue. USAID is a significant leader in improving TB drug management and supports the Stop TB Partnership's Global Drug Facility (GDF) which provides quality assured drugs to countries in need. USAID also provides technical assistance to help countries prepare proposals to the Global Fund and ensures the success of Global Fund grants once they have been approved. Programs financed through the Global Fund have provided treatment to six million people with active TB and 1.8 million TB/HIV services by December 2009.

Pandemic Influenza: is $75 million: USAID is intensely focused on efforts to contain and control H5N1 and other emerging diseases of animal origin that pose significant public health threats such as H1N1. Programs will focus on mitigating the possibility that a highly virulent virus such as H5N1 could develop into a pandemic while responding to the current H1N1 influenza pandemic, strengthening countries' ability to detect cases and conduct appropriate control measures. In particular, activities will expand surveillance to address the role of wildlife in the emergence and spread of new pathogens; enhance field epidemiological training; strengthen laboratory capability to address infectious disease threats; broaden ongoing efforts to prevent H5N1 transmission; and strengthen national capacities to prepare for the emergence and spread of a pandemic capable.

USAID's program for emerging pandemic threats program has had marked successes in rolling back the threat posed by the highly pathogenic H5N1 virus. Worldwide there have been significant downturns in the numbers of outbreaks involving poultry and humans, and a dramatic reduction in the overall number of countries affected. USAID will continue efforts initiated in 2008 with a coalition of UN systems partners, the International Federation of Red Cross and Red Crescent Societies, non-governmental organizations, and the private sector to develop country-level plans to limit excess mortality that would occur during a pandemic. About 40 percent of our AI funds would be targeted to support these efforts.

Other Public Health Threats: is $18 million. USAID will provide a robust response to infectious disease outbreaks, provide broad based improvements in infectious disease surveillance including hemorrhagic dengue, expand efforts to control antimicrobial resistance, and global activities to monitor the quality of drugs.

Vulnerable Children: is $15 million. Vulnerable Children programs include the Displaced Children and Orphans Fund (DCOF) and other program activities. DCOF supports projects that strengthen the economic capacity of vulnerable families to protect and provide for the needs of their children, strengthen national child protection systems, and facilitate family reunification and social reintegration of children separated during armed conflict, including child soldiers, street children and institutionalized children. The Agency's Child Blindness Program will provide eye health education, comprehensive vision screening, refractive error correction, sight-restoring surgery, and education for blind children.

In the past year, more than 137,000 children and adults in 17 countries benefited from DCOF activities, and more than 1 million received vision care through the Child Blindness Program.

Strengthening Health Systems

Achieving impact while investing in health systems is challenging, given the low levels of resources available in most countries with high fertility and mortality rates. USAID is recognized as a major contributor to approaches that strengthen key elements of health systems, while linking investments to improved health outcomes. Our efforts have made important contributions in several critical dimensions of health systems, including:

  • Quality improvement - USAID has been a global leader in the application of modern quality improvement approaches to health and family planning programs in developing countries. These approaches are being used to improve basic services, such as reducing delays in management of life-threatening obstetric complications and improving care of severely ill children; in hospitals in Nicaragua, this approach reduced child deaths from malaria by 86 percent, from diarrhea by 57 percent, and from pneumonia by 38 percent.
  • Drug and commodity supply and logistics - USAID is a major supporter of systems that provide, distribute, and track contraceptive, anti-malarial and other essential public health commodities. Technical assistance in pharmaceutical management and/or supply chain strengthening has been provided in 39 countries. For new products, like zinc for treatment of diarrhea, USAID works with the U.S. Pharmacopoeia to develop and improve quality and manufacturing standards needed to allow international procurement by UNICEF and countries, and also works with manufacturers to assure adequate quantity and quality of products required by programs.
  • Financing - USAID worked with WHO and the World Bank to develop "National Health Accounts," tools which for the first time allow country governments and their partners to see all the resources available for health - not just from government, but from donors and from families themselves. These important decision-making tools are now being utilized in approximately 70 countries, with direct USAID assistance to 26 of these. Another important approach is technical assistance to community-based insurance plans, or "mutuelles," which is an innovative way to finance health care in Africa. These community-based plans now exist in about a dozen African countries; in Rwanda alone, where USAID is providing assistance, by 2006 there were over 300 community-based plans serving over 3.1 million people (or 40 percent of the population).

We will further integrate health systems strengthening (HSS) approaches throughout programming to increase the capacity of partner countries to manage, implement, and eventually finance health systems. Also, we will continue to leverage our resources whenever possible and maximize the effectiveness of all programs we design and implement.


To build strong and cost-effective platforms for broader primary health care services, we implement integrated health programs, especially maternal child health and family planning programs in almost every country where we work.

One example is the delivery of antenatal, delivery, and post-partum care services. We know that good antenatal care - including promotion of adequate nutrition and anemia prevention, detection and treatment of infections and complications, and planning for adequate care at birth - can have important positive effects on outcomes for both women and their babies. It is also an important opportunity to begin discussing family planning options with women who want to delay pregnancy. In areas where malaria is prevalent, we promote antenatal care as a key opportunity to provide anti-malarial treatment and promote use of insecticide-treated nets, protecting women from anemia and illness, and protecting their unborn children from the low birth weight caused by maternal malaria infection. In areas where HIV is prevalent, antenatal care is one of the best opportunities to offer testing and counseling services and identify mothers requiring anti-retroviral treatment or prevention of mother-to-child transmission of HIV (PMTCT).

High quality care at delivery is one of the most critical interventions for the survival and health of mothers and newborns; it prevents or resolves life-threatening complications and provides essential immediate care to newborns who need it. It also provides a key opportunity for PMTCT. We are now increasingly extending care into the post-partum period, allowing for the detection and treatment of serious maternal and newborn complications and better promotion of breastfeeding and essential newborn care. It allows us the opportunity to conduct early infant diagnosis and start cotrimoxazole preventive therapy which has integrated benefits for HIV-exposed children of prevention of death from pneumonia, TB, and malaria. This post-partum period is also one of the most important opportunities to counsel women in voluntary family planning methods. Thus, in practice, our MCH/FP programs are delivered holistically, giving greater impact, greater sustainability, and greater support for other important health programs.

The same is true for the community-based program approaches that we support in areas where formal health services cannot meet all basic health needs. We support outreach programs that often deliver multiple interventions including immunization of mothers and children, vitamin A and iron supplements, insecticide-treated bednet distribution, and antenatal care. We support community health worker and social marketing programs that often deliver family planning advice and commodities, condoms, and information for HIV prevention, oral rehydration, and increasingly treatment for malaria and other child illnesses. We support these types of programs for women's groups which also often engage in income-generating and micro-finance activities that enhance their effectiveness and influence in their communities.

Such integrated approaches reap the benefits of synergies among specific interventions and parts of our health programs. They also maximize the potential for sustainability by making the most effective use of each contact of services with families.

Multilateral Engagement

USAID continues to provide technical assistance to the Global Fund to Fight AIDS, Tuberculosis, and Malaria. The U.S. Government is the largest donor to the Global Fund with more than $4.3 billion in (or more than 27% of total) contributions.

The Global Alliance for Vaccines and Immunization (GAVI) is a public-private partnership created in 2000 to save children's lives and protect people's health by increasing access to immunization in poor countries.GAVI is a model that shows us that through partnerships we can scale up simple and cost-effective interventions that can save millions of lives. The U.S. is one of the two original government donors that provided contributions to the GAVI Alliance through the GAVI fund and we expect to continue this collaboration in FY2011. Between 2000 and 2009, USAID has directed $569 million to the GAVI effort. Since the inception of GAVI in 2000, USAID has always represented the constituency that includes the United States of America, Australia and Canada, on the GAVI Alliance Board, except for a two-year period. USAID currently sits on GAVI's Board, the Board's Executive Committee, and the Board's program and policy committee. USAID shapes GAVI policy through its involvement on the GAVI Alliance Board and various committees and USAID provides technical guidance. Through GAVI, 250 million children have been immunized, saving 5.4 million premature deaths over the last decade.

Through the Global Alliance for Improved Nutrition (GAIN), USAID is directly supporting 22 programs in 19 countries around the world that fortify staple foods and condiments --such as fish sauce in Vietnam and cottonseed oil in Burkina Faso -- with iron, iodine, Vitamin A and other micronutrients. Food fortification is critical for health and is cost-effective. Every dollar spent on Vitamin A fortification returns $7 dollars in increased wages and decreased disability. A dollar spent on iodized salt returns $28 dollars, and on iron fortification, $84 dollars.

NGOs and FBOs

Nongovernmental, faith-based, and community-based organizations (NGOs, FBOs, and CBOs) have strong bases of operations in underserved, rural areas where formal health services are limited. The key to saving lives, especially children, is to expand proven approaches and interventions until they reach each and every child who needs them. USAID is expanding its reach through these organizations.

USAID Child Survival and Health Grants Program (CSHGP) focuses on innovative approaches and delivering operations research (OR) for high-impact maternal, newborn, and child health (MNCH) interventions. CSHGP currently supports 41 NGOs implementing 54 projects in 27 countries. Typical projects run 4-5 years with an average of 40,000 child beneficiaries in one district. Projects use a variety of integrated community-oriented strategies for household behavior change and improved service delivery.

Through support to these groups, PMI helps build local capacity and program sustainability and improves access to critical malaria prevention and treatment service at the community level. Due to their close contact with local residents, these organizations can facilitate behavior change communication activities to help families prevent and treat malaria. To date, PMI has supported nearly 200 nonprofit organizations; more than 45 of these are FBOs.

For example, PMI supported Senegal's National Malaria Control Programme (NMCP) to hold its first nationwide distribution of nearly 2.3 million free long-lasting ITNs to children under five in June and October 2009. This campaign involved nearly 20 different local and international organizations, including local and international NGOs, United Nations agencies, two different Red Cross affiliates, a manufacturer of long-lasting ITNs, and a World Bank-funded project. PMI contributed 380,000 nets and about 30 percent of the total operational costs. Advocacy by PMI attracted an additional 86,000 nets from the Canadian Red Cross, the Against Malaria Foundation, and the Sumitomo Chemical Company, as well as support for operations from World Vision and ChildFund Senegal.

PMI also artnered with local NGOs and FBOs to continue humanitarian services when the political crisis led to USG sanctions that prohibited direct support to the Government of Madagascar. During Madagascar's ITN mass distribution campaign, PMI supported two local FBOs to deliver 1 million long-lasting ITNs at the community level. PMI also partnered with and supported the Malagasy Red Cross to conduct indoor residual spraying in six health districts protecting more than 1,270,000 people.

Public-Private Partnerships

To maximize the impact of our health resources, USAID is leveraging monetary contributions, information, ideas and technology from the private sector. These public-private partnerships have dramatically increased our impact.

Through public-private partnerships, USAID estimates that over $1 billion worth of drugs have been donated by research-based pharmaceutical partners, including GlaxoSmithKline, Merck, Johnson & Johnson, and Pfizer, for integrated NTD control in USAID-supported countries. Moving forward, USAID will scale-up the proven approach to integrated, community-based delivery to the highest burden countries, sustaining high levels of population coverage and moving toward disease elimination for some of the targeted NTDs, including lymphatic filariasis globally and onchocerciasis in the Americas. USAID is exploring coordination with water and sanitation investments and links with malaria control programming to further accelerate progress toward elimination.

Top global companies and the PMI are working with the Government of Angola on an intensive technical training program to arm the country's malaria fighters with state-of-the-art mosquito surveillance and vector control techniques. This unique partnership between the private sector, Government of Angola and PMI provides an opportunity to build in country capacity to monitor malaria control interventions in Angola, building a foundation to develop an effective resistance management and monitoring strategy in Angola- areas in which the private sectors expertise can be leveraged.

The effort includes the Corporate Alliance on Malaria in Africa (CAMA), USAID's implementing partner Research Triangle Institute International (RTI) and the Global Business Coalition on HIV/AIDS, TB and Malaria. It is part of the Angola National Malaria Control Program's overall effort to scale-up malaria prevention and treatment services to reduce the health, social and economic burden resulting from the disease. Lead corporate sponsorship is by the Chevron Corporation, with additional private sector support from Halliburton, Bayer, Sumitomo Chemical, Cameron International and Vestergaard Frandsen.


USAID employs a "research to use" strategy to guide its investment in innovations of low-cost and effective health products. Through its product development plans USAID closely monitors and facilitates concurrent research and introductions activities to accelerate the process from research to field implementation. Illustrative of this effort is USAID's research investment in addressing sepsis. Of the estimated 8.8 million children under 5 that die each year - 3.7 million are newborn infants who die within the first four weeks after birth. Up to two-thirds of these deaths can be prevented through existing effective interventions delivered during pregnancy, childbirth and in the first hours, days and week after birth. A growing body of knowledge has shown that home visits by appropriately trained workers to provide newborn care can significantly reduce neonatal mortality even where health systems are weak.

USAID supported research documented in Bangladesh that Community Health Worker home visits involving a simple package of preventive and curative newborn care reduced newborn deaths by 34%. Few proven strategies to improve newborn survival have successfully been taken to scale in low-resource settings. This intervention, however, effectively used government and NGO infrastructures to facilitate a sustainable home-care approach. This study was honored as Lancet best paper of the Year. The three-year study in Sylhet, Bangladesh was conducted in partnership with Save the Children's Saving Newborn Lives program and Johns Hopkins University, a local NGO Shimantik, and the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR). The result of this research contributed to evidence base for a new WHO/UNICEF recommendation for home visits. We are working to scale up this approach in other partner countries.

Based upon these study findings, the Government of Bangladesh (GOB), USAID and others are already implementing a large-scale community-based project (ACCESS) in 7 sub-districts to improve preventative newborn health in rural areas of Bangladesh Within the next few months UNICEF in partnership with the GoB will begin to implement this approach in 14 districts. The new UNICEF program will also include a pilot of the community treatment approach of this study in 3 sub-districts with further plans to scale up in subsequent years.

In FY11, USAID will expand research into best practices, innovative technology, and other interventions that will allow for quick dissemination and scale-up of cost-effective services.


At USAID, we stand ready to bring to bear the full measure of our capabilities to the Global Health Initiative and its goal of achieving major improvements in health outcomes in the developing world. As you know, with the support of Congress, USAID has long track record developing and adapting appropriate health products and technical interventions, and supporting proof of principle field testing and effective and rapid introduction of new technologies in the field at scale.

And in addition to our extensive field experience and presence, USAID possesses in-house technical expertise in areas such as immunology, virology, nutrition, malaria, epidemiology, maternal health and child survival, HIV/AIDS, tuberculosis, influenza, family planning and reproductive health, water and sanitation, health systems strengthening, quality assurance, vulnerable children and behavioral change.

To address global health needs, we will continue to be strategic, but flexible and respond to programmatic gaps identified by a specific country. We will increase cooperation with governments, multilaterals, NGOs and the local private sector to assist host governments develop their own national health plans, identify jointly with the host countries and other donors places where our integrated resources can best support those plans, and contribute to collaborative monitoring of progress.

And we will strengthen the capacity of the private sector to provide community-based services/distributors to create sustainable service delivery and encourage social marketing and private sector providers to deliver community level curative and preventive services, including health franchising, individual health providers and pharmacies.

By doing so, the world can come closer to achieving the health Millennium Development Goals. Thank you.

FY2011 Global Health and Child Survival Budget Request
Subcommittee on State, Foreign Operations, and Related Programs; Committee on Appropriations