Distinguished ladies and gentlemen,
I would like to thank the president of Women Deliver, Jill Sheffield, for inviting me to speak at this session today, on poverty as an obstacle to improving maternal health.
Issues relating to women and girls are of especial importance to me, and I believe the conference message is fitting: women truly are the “economic heart of the developing world. And to do all this work, they need to be healthy.” This session goes to the heart of this message, given the intrinsic link between poverty, ill health and a nation’s economic prosperity. I would further add that beyond good health, the empowerment of women is central to the economic prosperity of a nation. This is further stressed through the Programme of Action of the International Conference on Population and Development (ICPD), which is the basis for achieving reproductive health, as well as population and development objectives within a framework of human rights and gender equality. Goals include universal access to reproductive health care, universal education and the empowerment of women and gender equality: these are pre-conditions in reaching a country’s development objectives, in reducing poverty and improving the health and social status of women. These objectives, as you are aware, have been incorporated in the Millennium Development Goals (MDGs).
I am pleased to be speaking specifically to MDG 5, improving maternal health, with its dual focus on reducing maternal mortality and ensuring universal access to reproductive health services, given its link with the other health MDGs. Namely, MDG 4 and 6: which among other issues, target reducing by two-thirds the mortality rate of children younger than five years; and halting and beginning to reverse the spread of HIV and AIDS by 2015 and other diseases respectively. However, it’s clear that the other MDGs, that of eradicating extreme poverty & hunger (MDG1); and achieving universal primary education (MDG 2); and the empowerment of women through the promotion of gender equity (MDG 3), are intimately linked with the attainment of MDGs, 4, 5 & 6.

Allow me to speak to the situation in Sub-Saharan Africa.
Africa’s population of over 980 million is young: with children and young people below the age of 15 constituting about 40 percent of the total population . Poverty is widespread with half of the population living in poverty, as compared to the worldwide average of 20%. In post-conflict countries such as Sierra Leone, Liberia, Angola, Burundi, and Eritrea, current levels of poverty and hunger have stagnated and in some even worsened. Poverty further disproportionately affects women in Sub-Saharan Africa. For example, countries such as Lesotho, Gabon and South Africa have large numbers of poor female headed households .
Poverty, inequality & Ill health
We know that conditions of poverty and inequality, including women’s’ unequal rights to household assets and decision making, the burden of care that HIV and AIDS imposes on women and girls’ and women’s exposure to gender based violence (including women who are refugees) make it more difficult to promote reproductive rights and health.
Furthermore, we also know how HIV has exposed, in the most dramatic of ways, the inter-sect between poverty or economic inequities and health. While HIV and AIDS does not discriminate from one social class to another, people who live in conditions of poverty, and in Sub-Saharan Africa, these are predominantly women, are more vulnerable to infection (accounting for over 60% of people living with HIV). People living in poverty are also less likely to be treated for their ailments, at the end of 2008, only 45% of HIV positive pregnant women received the necessary treatment in low- and middle-income countries. Loss of income and medical costs have driven families into new poverty spirals: where caring for people living with HIV and AIDS has increased the burden of women’s unpaid workload and reduced their options for earning income. This has led some women and girls to resort to high-risk work as commercial sex workers. Caring for a growing number of orphans has further put additional strain on the elderly and older siblings, which in turn has kept children, especially girls, out of school, magnifying the impact of poverty and reducing potential economic growth.
Maternal health & HIV
Given such a dire situation, it is encouraging to note that globally, there has still been a significant drop in the number of women dying each year from pregnancy and child birth. In a recent study published in the Lancet, researchers estimated that maternal deaths fell from 526 300 in 1980 to 343 900 in 2008. However, Sub-Saharan Africa still has the highest rates of maternal mortality with a Maternal mortality ratio estimated at 920 maternal deaths per 100,000 live births compared to only 20 per 100,000 live births for developed regions of the world. Estimates from an African Union Commission 2009 ICPD At 15 Africa Review indicated that the maternal mortality ratios had worsened in quite a number of African countries, such as Sierra Leone, Malawi, Angola and Niger. The maternal mortality ratios in these countries were in excess of 1,000 per 100,000 live births. Both Mauritius and Seychelles, reported very low levels of maternal mortality, justifiably so given their strong health infrastructure and management capacity.
However, overall across Sub-Saharan Africa, insufficient resources have been dedicated to maternal health. Clinics and hospitals are relatively inaccessible to the poor, especially in rural areas, and there are insufficient numbers of skilled medical staff who can be deployed to cover the gaps. While there has been an increase in the proportion of women with access to skilled health personnel, in countries such as Senegal and Swaziland, in countries such as Niger, Burundi, Sudan and Kenya, less than 50% deliveries were by skilled health personnel .
Progress in reducing maternal mortality has been slowed by the ongoing HIV epidemic. Nearly one out of every five maternal deaths— over 61,000 in 2008—can be linked to HIV, and many countries with large populations affected by HIV have had the most difficulty reducing their maternal mortality ratio. In 10 southern African countries, HIV causes up to one half of all maternal deaths, while in South Africa, from 2005-2007, the maternal mortality ratio was nearly 10 times higher in women known to be HIV positive. As Michele Sidibe, the UNAIDS Executive Director noted, this serves as a “powerful reminder that progress in maternal health efforts is hugely dependent on progress in the AIDS response in countries with the most severe HIV epidemics.”
The impact of HIV on maternal mortality, and as such the attainment of MDG 5 is further compounded by the fact that maternal mortality tends to be inversely proportional to women’s status in countries with similar levels of economic development. Furthermore, social cultural values continue to affect access to health services, especially sexual and reproductive health services. Thus while some countries have made strides towards improving the health and social status of women, overall there has been limited progress in reaching maternal health objectives across Sub-Saharan Africa.
The case of Zambia is instructive.
Findings from focus group discussions with women and children living with HIV, from a report that was conducted on the impact of the economic crisis on HIV programs for mothers and children living with HIV revealed that their biggest barriers around access to health services were: lack of adequate nutrition, lack of transportation, stigma and threat of violence, which had worsened due to increased levels of unemployment particularly in mining towns. (It should be noted that structural challenges to access to services for women, existed even before the start of the economic crisis). However, very few programs are designed in a way that comprehensively addresses these issues. In addition, in line with preliminary studies elsewhere across Africa on the impact of the economic crisis on health service delivery, the study further revealed that increased unemployment particularly in the mining sector and related jobs such as domestic work, coupled with high levels of out of pocket expenditure, has had a negative impact on the capacity of households to sustain themselves, and children within these households.
Strategies
Given such a situation, what more should we be doing to ensure that we make significant progress on maternal health by 2015. The principles on what needs to be done, while refined over the past few years are clear. The Partnership on Maternal and Child Health succinctly stresses five key areas, which I believe encapsulate much of the learning on effective strategies in Maternal and Child health. PMCH stresses the need for successful political will; sound health policies; effective financing; strong health systems and action to achieve equity. I will use these five tenants to form the basis of my remarks on recent developments in the MNCH area, which should give us reason for hope, but further act as a cautionary tale.
As UN Secretary-General Ban Ki-moon notes, “a health system that delivers for mothers will deliver for the whole community.” Beyond sound health policies, health systems strengthening and quality health care, the status of women in African societies should be elevated so as to ensure that their fundamental human rights are respected. “Despite the fact that human rights of women are inalienable, integral and indivisible part of human rights, violence against women continues as an intolerable violation to their rights, in addition to lack of basic needs such as food, water, shelter, clothing, education, education access to health services in general and reproductive health services in particular. Basic services are essential for women’s empowerment and pre-condition for the enjoyment of their rights, personal empowerment and access to equal opportunity. ”
I cannot over-emphasise that gender equity and respecting the rights of women and girls are central, for any MNCH interventions to be successful over the long-term.
This conference comes at a time of renewed hope on delivering on promises made on maternal and child health. UN Secretary-General Ban Ki-moon’s recent announcement of the development of a joint action plan for accelerating progress on maternal and child health which will be endorsed at the United Nations MDG Summit in September 2010, should certainly give us hope. This is in addition to the Obama Administration’s women and child centred development approach, the Global Fund’s landmark decision to reprogram resources from Round 8 and 9 towards PMTCT for 10 priority countries.
Leaders, at the imminent G8 summit, have in advance, announced a laudable maternal and child health initiative, which addresses “the continuum of care for both mothers and children, including training and support for frontline health workers; better nutrition and provision of micronutrients; treatment and prevention of diseases such as pneumonia, diarrhoea, and sepsis; screening and treatment for sexually transmitted diseases, including HIV; proper medication; family planning; immunisation; and clean water and sanitation.”
These landmark initiatives and financial commitments are truly a testament to the hard work of many present here, who through your tireless efforts, continue to ensure that governments, leaders and all of us present, live up to our promises to ensure that women and girls can live lives of dignity, good health and can more effectively contribute to their countries economic development.
However, it is clear that our overall universal access commitments will not be met in 2010. In addition, what we need beyond successful leadership, is sustained, successful leadership at all levels. Far too often, there is a strong disconnect between policy formulation, and pledging of resources and actions taken to implement them especially at the country level. It is essential therefore that the action plan on maternal and child health, and associated accountability framework be robust enough to follow-through with implementation at the country-level.
I further join with other African advocates and allies in urging African governments to increase domestic health financing through higher percentage allocations (minimum of 15%) to health and higher per capita expenditure on health. This would be to ensure long term and sustainable investment in overall health, social protection, greater investment in improving health systems as well as greater investment in the social determinants of health, including a strategic focus on achieving gender equity.
It is however clear that even if African countries were to meet the agreed upon Abuja 15% commitment of national budgets to health agreed by African Heads of State in May 2001, African countries require concerted global solidarity through greater long-term and sustained investment in health and HIV, especially in high HIV prevalence countries.
Let me very candid. We will not make progress on maternal health or HIV in Africa, without long-term, predictable and sustained external financing in support of efforts of national governments, networks of people living with HIV and civil society groups. That is why, as we approach the G8 summit, I urge G8 nations, to re-affirm their commitment towards the delivery of a concrete, time-bound, resource-backed plan of action to ensure universal access to HIV prevention, treatment, care and support; and strengthened health systems: all of which are critical for progress on maternal health.
In conclusion, I wish to thank you again for providing me with the opportunity to form part of this important dialogue. It reinforces our strength in working together across issue areas, as fundamentally, we are all advocating for the improved health, wellbeing and dignity of women and girls; and the attainment of all the Millennium Development Goals.