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Improving Health Outcomes for Women and Girls

This blog was cross-posted from FSG and written by David Garfunkel.

The cast at last week’s “No Ceilings: Not There Yet” event put on by the Clinton Foundation was impressive. Hillary Clinton, Chelsea Clinton, Melinda Gates, and America Ferrera all spoke eloquently, highlighting advances in gender equality and areas for continued improvement. But it was the speech of someone much less famous that caught my attention.

fsg blogGenette Thelusmond spoke only a handful of words in English before launching into a moving story in her native Haitian Creole of her journey as a midwife in Haiti’s Central Plateau. I had lived for a couple of years in Haiti, and her voice immediately transported me back to the beautiful, harsh mountains of the Plateau and the hours I had spent talking with families who lived there, particularly mothers – mothers holding their babies; mothers hunched over a meal they were cooking; mothers selling rice and oil in the local market to support their families.

Genette is thinking about these mothers too. She explained that in a country with over 10 million people, there are only 200 obstetricians and 100 midwives to serve the entire population. The lack of qualified health professionals is one reason that Haiti’s maternal mortality rate remains one of the highest in the world, at around 350 maternal deaths per 100,000 live births. Thankfully, through the work of organizations such as Genette’s Midwives for Haiti, more midwives are being trained and more women will have the ability to access lifesaving services.

Yet the supply of excellent healthcare services is only half of the equation when it comes to improving health outcomes. Women need to be empowered to demand and access those services. At FSG, we’ve been working with the Gates Foundation to study women’s empowerment and social norms. Social norms are rules of behavior that individuals conform to because they believe that others in their relevant groups either also conform to them or believe they ought to conform to them (Bicchieri, 2010).

It turns out that social norms often supersede individual beliefs and attitudes about a given subject, which has real implications for those who wish to design and implement programs to improve health outcomes for women and girls. There is increasing evidence that discriminatory social norms can disempower girls and women from making decisions that would otherwise benefit them and constrain their choices and capabilities. Social norms can actually serve as barriers to accessing health services that girls and women know exist. Take just one example from Ethiopia: despite the fact that nine out of 10 girls and women know about modern family planning methods, only 20% of women aged 15-49 and 5% of girls aged 15-19 are using contraception (DHS, 2011).

There is still much for the field to learn about how social norms constrain women’s agency, and how norms could be changed to lead to better health and development outcomes for women and their families. For example, how would one measure a change in social norms? How can efforts to change social norms be combined in with more traditional approaches to women’s empowerment, like self-help groups or village savings associations?

These questions are complex, which makes them challenging. But understanding how to increase the demand for services like the lifesaving maternal care Genette provides will lead to real impact on mothers across the world.

Finally, FSG would like to engage you on this issue. What are your thoughts on ways to influence social norms for women and girls in order to improve health outcomes? Which programs have been the most successful at changing discriminatory social norms impacting women and girls? How can we measure progress in this area?

Photo Credits: Photo by Every Mother Counts

GHC Launches Global Health Briefing Book for U.S. Congress

On March 16, 2015, Global Health Council (GHC) released, “Taking Stock: Why U.S. Investments in Global Health Matter,” an online briefing book for members of U.S. Congress and their staff. The briefing book comprises briefs on crucial global health issues, such as health systems strengthening, malaria, vaccines and immunization, and maternal and child health. Each brief includes an overview of the particular issue, a look at the progress made over the past few years, and the U.S. response and strategy through funding and programs. The briefs offer vital recommendations that the Administration and Congress should pursue for further success. Several of these briefs also include impact stories that highlight how U.S. support for global health programming has made a difference in the lives of people around the world.

Congresswoman Betty McCollum

Congresswoman Betty McCollum gives welcoming remarks at GHC’s Global Health Briefing Book launch event on Capitol Hill.

At the launch event on Capitol Hill for the Briefing Book, Congresswoman Betty McCollum (D-MN), who serves as a Co-Chair of the Congressional Global Health Caucus, provided keynote remarks on the United States’ strong support of global health. A panel discussion followed with a look at how U.S. investments in global health contribute to a healthy society, as well as economic growth in local communities. Dr. Craig Rubens of the Global Alliance to Prevent Prematurity and Stillbirth conveyed the significance of promoting research to avoid maternal and child deaths as well as preterm births. International Medical Corps’ Annie Toro focused on health in humanitarian response, particularly drawing attention to why strong health systems are crucial to preventing and controlling disease outbreaks like Ebola, while Bruce Wilkinson of the Catholic Medical Mission Board stressed the importance of training and retaining frontline health workers. Tiaji Salaam-Blyther from the Congressional Research Service provided background on U.S. funding for global health programs over the years and the challenges of maintaining that support in times of fiscal constraint. Panelists drove home the point that investing in global health allows developing nations to move toward aid independence and increase their participation in the global economy.

Later that day, members of GHC met with congressional staff to share the Global Health Briefing Book and to answer questions that they had about U.S. investments in global health. Many staff members were excited to learn about this important resource, especially that it is easily accessible online.

About the Global Health Briefing Book

Taking Stock: Why U.S. Investments in Global Health Matter” is a collaborative effort between GHC and the global health advocacy community. These briefs represent the work of a wide group of global health experts,



Improving Tuberculosis Care for Children

By Jeffrey Starke, MD, FAAP, liaison to the American Academy of Pediatrics Committee on Infectious Diseases

Despite the availability of inexpensive diagnostic tests, curative and preventive therapies, and the widespread use of the BCG vaccines, tuberculosis (TB) remains a major cause of morbidity and mortality among children, and its lack of control is one of our biggest public health failures.

A clinical diagnosis of childhood TB usually can be established using epidemiology (especially recent contact to a case subject), and clinical findings such as symptoms, radiography and a test for TB infection. However, TB in children is difficult to confirm microbiologically.  Given the reliance on microbiologic tests for diagnosis and reporting cases in most high-burden countries, the majority of childhood TB cases are not diagnosed, or not counted if they are diagnosed clinically, leading to woeful under-counting of cases. Although microbiologic confirmation of childhood TB remains elusive, we have effective and safe regimens for treating TB disease and infection, and we know that early detection via contact tracing and treatment can prevent many cases of childhood TB.

In most high-income countries, childhood TB has decreased remarkably over the past 30 years. But this has not occurred in many low- and middle-income countries. In 2013, only 275,000 cases of childhood TB were reported by national TB programs1. Based on techniques used to estimate adult TB case numbers, the World Health Organization (WHO) estimated that there were actually 600,000 TB cases among children under 15 years of age, and 80,000 deaths from TB among HIV-negative children. (No estimates of mortality in HIV-positive children were given, but TB is a leading cause of death in HIV-infected children.) However, a review of 97 papers on multidrug-resistant TB in children used setting-specific estimates and TB incidence to estimate that there were 999,792 cases of childhood tuberculosis in 20102. Finally, sophisticated mathematical modeling techniques on reported TB data and local household structure have estimated that in just the 22 WHO high-burden TB countries in 2010, there were: 15,319,701 children cohabitating with a TB case; 7,591,759 children who became infected with Mycobacterium tuberculosis; and 650,977 children who developed TB disease3. Unfortunately, the actual case detection rate was estimated to be only 35%. Cumulative exposure in these 22 countries meant that 53,234,854 children were infected and at risk for developing TB disease in the near or distant future. Clearly, the burden of childhood TB infection and disease is enormous, many cases are never discovered, and few cases are being prevented.

Childhood TB has not received adequate attention from child health and TB programs. The child survival movement has not embraced TB because of the lack of accurate estimates of TB morbidity and mortality in children. TB services in most low- and middle-income countries, including access to drugs and diagnostic tests, are restricted to national TB programs so child health programs have paid little attention to the disease and its prevention. As a result, there has been little advocacy for child TB services on the part of pediatricians and child health experts. Because childhood TB is difficult to confirm with a sputum smear and children with TB are rarely contagious, many national TB programs have paid little attention to children. A common but misguided perception has been that giving infants a BCG vaccine and controlling adult TB in a population would be adequate to prevent childhood TB. As a result, effective prevention measures that are standard in low-burden countries, such as treatment of TB exposure and infection, have not been implemented in most high-burden countries. For several decades, WHO has recommended that children living in a household with a TB case who have symptoms should be evaluated for TB disease and those without symptoms should receive 6 months of isoniazid. However, this simple, safe and effective approach is rarely utilized in high-burden countries. Finally, there have been missed opportunities to correctly diagnose and treat children with TB in programs focused on other health problems of children who also are at risk for TB.

Over the past 30 years there has been an explosion of studies and science related to the diagnosis, treatment and prevention of childhood TB. In 2013, the WHO published a Roadmap for Childhood Tuberculosis4 detailing the ten essential steps for preventing children from dying from this treatable, preventable disease. The technology and means exist now to bring this roadmap to life. Actions and advocacy need to occur at the national and local levels. We know what to do; what we are lacking is the motivation, political will and coordination of services to do it.


World Health Organization. Global tuberculosis report 2014. World Health Organization, 2014. ISBN 978 92 4 156480 9.

Jenkins H, Tolman A, Yuen C, et al. Incidence of multidrug-resistant tuberculosis disease in children: systemic review and global estimates. Lancet. 2014; 383:1572-1579.

Dodd P, Gardiner E, Coghlan R, Seddon J. Estimating the burden of childhood tuberculosis in the twenty-two high burden countries: a mathematical modelling study. Lancet Glob Health. 2014; Aug;2(8):e453-9. doi: 10.1016/S2214-109X(14)70245-1. Epub 2014 Jul 8.

World Health Organization. Roadmap for Childhood Tuberculosis. World Health Organization, 2013. ISBN 978 92 4 150613 7.


This blog post is adapted from a previous publication:

Starke JR. Improving tuberculosis care for children in high-burden settings. Pediatrics. 2014; 134(4):655-657


MPTs for Women’s Global Health
Making Broad-Spectrum Sexual & Reproductive Health Prevention A Reality Through Collaboration

This guest post was written by Bethany Young Holt, PhD, MPH

Imagine the global health impact if women who want to prevent a pregnancy had contraception that also prevented sexually transmitted infection (STIs) including HIV.  Not only would such products expand prevention options for women, they would simultaneously help reduce a myriad of related risks, including maternal mortality and morbidity, adolescent sexual and reproductive health (SRH) risks, under 5 mortality, cancers and infertility resulting from untreated STIs, and the human, economic and treatment costs of declining health from HIV/AIDS.

Multipurpose Prevention Technologies (MPTs) are products on the horizon that offer broad-spectrum SRH prevention. They promise to be a game-changer for women’s health around the world. A growing collaboration of researchers, women’s health advocates and funders from across the globe is shaping this field and making an array of comprehensive options a reality.

MPT Potential Impact

Today, if women want to protect themselves from unintended pregnancies and STIs, condoms are the only option for “all-of-the-above” prevention. Both male and female condoms require male partner cooperation. While condoms are extremely effective if used consistently and correctly, couples overwhelmingly forgo them once they are in a more committed partnership. In fact, only 8 percent of committed couples world-wide use condoms, leaving millions of women who use alternative kinds of birth control in danger of contracting HIV and other STIs.

Furthermore, there are many millions of women worldwide who want to avoid or delay having children but lack access to modern contraceptive methods—increasing their chances of unplanned pregnancy or, depending on the contraceptives available, STI infection.

Women agree, it is clearly time to create new, female-initiated products that offer multipurpose prevention of HIV, other STIs, and unintended pregnancy. Recently, researchers at Ipsos Healthcare released a study finding that ninety-three percent of women interviewed in Uganda, Nigeria, and South Africa who were given a hypothetical choice of methods preferred the one that offered broad spectrum prevention rather than simply an HIV prevention tool or a contraceptive.

Women’s lives are complex and their circumstances vary considerably; no single broad-spectrum product will meet most women’s needs. Rather than promoting a single method, researchers and advocates are advancing an array or suite of combination prevention methods so that women can find methods that suit their lives.

With MPTs in women’s hands, we can expect a decline in HIV rates in high-risk regions as preventing STIs becomes easier and prevention more accessible. In addition, we can expect reductions in the 86 million unplanned pregnancies worldwide and improvements in maternal mortality and morbidity.

When contraceptive efficacy increases, so does the quality of life for women and children: As women are better able to plan their children and stay healthy, they are more likely to attain higher levels of education and economic stability.

Women’s Input at the Heart of MPT Development

The development of MPTs has required a number of innovations that are made possible through an international collaboration of researchers, policymakers, and advocates known as the Initiative for MPTs (IMPT). To date the Initiative has succeeded in transcending a number of barriers to innovation, not the least of which are the silos traditionally separating HIV, contraceptive, and STI research. Until recently, funding for each of these fields, primarily from the governmental sectors and private foundations, was separate and disconnected—a great challenge for collaboration.

Through the collaborative structure of the IMPT, stakeholders are working together, some for the first time, to share findings, reduce redundancies, and create a more streamlined and efficient field. Noteworthy advances can be viewed in the MPT product development database, for example, where anyone can find details about products currently in development.

This work is putting women’s feedback at the heart of product development. Scientists, as they develop new products, traditionally have not sought women’s opinions and feedback until later-stage clinical trials. The IMPT is changing the funding priorities so that women’s input on acceptability and uptake issues is sought at the get-go and social-behavioral research that informs whether women will actually use a given product is meaningfully integrated into the biomedical research.

The progress made to date in the MPT field, in combination with the potential cost savings and efficiencies offered by MPTs, makes for a compelling case for funding innovation and the international collaboration approach. We invite readers whose work intersects with that of the IMPT to contact us to explore involvement.


Bethany Young Holt, PhD, MPH is the Executive Director of CAMI Health, a project of PHI, and Coordinator of the IMPT (Initiative for Multipurpose Prevention Technologies)


Women and Water in Kenya

This blog was cross-posted from International Medical Corps

In Kenya, a woman is burdened with the important chore of collecting, managing, transporting and storing water. This can be an incredibly challenging task in Samburu County in northern Kenya, one of the driest areas of the country often plagued by water shortages. Sometimes it will not rain for an entire year in the region. The land is desolate, exposed and sparsely populated. Without access to running water, a woman must walk to the closest natural water source many kilometers away, in fact the average distance a woman walks in Africa to collect water is six kilometers. Then, she must carry the heavy water all the way back, sometimes with a baby strapped to her back. Women in Africa on average carry 20 kg of water on their heads when they walk back from the water source.

Scola Letena, a housewife in Samburu County, only has access to one viable water source, the Nukutoto spring located in the mountains.  She must travel a great distance, particularly in the dry season, to fill up her jerrycans. However, when the water in the spring dries up she must go much further to another town 11 kilometers away with her donkey and eight children to fetch water. When this happens, her children miss school. Given the severe drought that is currently afflicting East Africa, the spring dries up often and the children miss more school. When the spring is producing water, Scola must make the arduous hike up the mountain while avoiding wild animals who also drink from the spring. Scola says, “I usually come early in the morning to fetch water. In the morning I can manage to fetch ten liters while in the evening only five liters can be found because of competition with wild animals.” Scola’s aging neighbor, Naonkota, complains that she cannot carry as much water as the younger women. Despite her age and weak knees, she is still responsible for the water in her household and she says, “Walking uphill is very difficult for me. Even if I make it to the source, I can only manage to carry back a… jerrycan (5 liters) of water.”

Not only must Scola and Naonkota avoid leopards and poisonous snakes on the trip to the spring, but the water could be contaminated. Elephants are known to muddy the water and baboons defecate in the water. Contaminated water leads to high risk of contracting waterborne diseases such as diarrhea, cholera and typhoid. A small-scale cholera outbreak resulted from this spring in 2013 because residents had no other choice than to drink this water. Diarrhea is responsible for almost 7.7% of all deaths in Africa.  Water is life, as the saying goes, and in Kenya when that water is contaminated, it can also mean death.

International Medical Corps, with funding from Brighton, has started to address the dire situation and access to water in Nkutoto by building a concrete shelter at the source to protect the spring from contamination and laying a series of pipelines to bring the water down the mountain and into the village for easy access.  With the newly constructed water tap, the women of Nkuoto village do not have to walk up the mountain, often with their livestock and children in tow, to collect water. A town elder, Situelia says, “This has ensured that our women are safe from wild animals while the water is also being used to sate our livestock.”

The lack of access to clean water affects women all over Samburu County. Silango is a remote village about 20 km from Wamba town that can only be accessed via unreliable public transportation on rough, unpaved roads. Silango, like Nkutoto, is burdened by chronic drought and disease. Recently, International Medical Corps spent about a month building the Silango sand dam, an innovative technology for harvesting rainwaters and providing a community with clean, reliable water. Previously, women of Silango had to walk seven km from the nearest road to the closest water source. The sand dam is now less than 500 meters to the village and saves women an enormous amount of time and energy. The sand dam collects and stores rain water and prevents the water from evaporating during dry season. The sand filters the water which helps prevent waterborne disease. The sand dam is also tapped and directed to the health center, the school and the outdoor market. International Medical Corps has installed a hand pump to provide access to potable water for the community and also built cattle troughs.

Susan, a mother living in Engilae, another village in Samburu county where International Medical Corps is working, says before International Medical Corps began its sanitation projects in Engilae, the maternity wing at the health center was not operating at optimum levels due to lack of an adequate water supply. The nationally recommended supply for a health center in Kenya is 10,000 liters per day. The women had to walk a distance of 2 km to the Ngeng’ river to fetch water and carry it uphill to use at the health center; bringing 10,000 liters from the river everyday was an impossible task. There was never enough water to treat patients properly and it was often contaminated. This was the water used to clean mothers on the delivery beds. Now, International Medical Corps, with funding from the Office of Foreign Disaster Assistance and Brighton, have establish a successful water and sanitation project at the health center including building latrines, promoting good hygiene practices, and most importantly creating access to a water supply, water storage and distribution facilities. Susan says that incidences of maternal and child health problems are decreasing thanks to the delivery of necessary services.

In an effort to unite women in Kenya in their shared burden over water chores, International Medical Corps has trained local women to form Mother to Mother Support Groups. Susan founded such a group in Engilae. In this group, Susan educates other mothers about important water and sanitation practices. She says, “International Medical Corps has shown us how to use baby pampers. Previously it was very embarrassing for us especially when the baby soiled its clothes. We usually dispose the Pampers by dumping in the pit latrines or burning,” she says. “We have also learnt how to use baby napkins. They are very good because one can use them several times after washing them.”