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Designing better solutions for maternal health

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By Bjorn Lomborg

Every two minutes, a pregnant woman dies from preventable complications related to childbirth, one of the most beautiful moments of human life. Mothers in developing countries are disproportionately affected by this tragedy, with a risk of dying in childbirth 80 times higher than their rich country counterparts. Infections, seizures caused by high blood pressure during pregnancy, and severe bleeding after childbirth are considerable risks for these mothers, many of whom give birth in their homes or in facilities with limited basic emergency care and poor hygiene.
Maternal health has long been a global priority, included in the Millennium Development Goals (MDGs) and the Sustainable Development Goals (SDGs). However, the objective of reducing the global maternal mortality rate (MMR) by three quarters from 1995 has not been achieved. Between 2000 and 2017, maternal deaths declined by 45%, from 451,000 to 295,000, but the decrease fell short of the global MDG target by approximately 135,000. Further still, the 2015-2030 SDGs establish a global MMR goal of 70 per 100,000 births in 2030. As recently as 2017, global health systems still don’t appear to be on track to meet this goal, with the actual MMR being three times higher.
Investing in maternal and newborn health has far-reaching consequences years and even decades into the future. The death of a mother weighs heavily on a family, and the lives of surviving children are bleak – their risk of dying before the age of 5 can be up to 51 times higher. Households also see a reduction in income following a maternal death, and children often need to support the family, which cuts their education short. Investments in maternal and newborn health can help lessen the instances of maternal deaths and contribute to a cycle of growth and progress for the women, their families and communities.
Something needs to be done. An analysis presented at the UN Population Summit in Nairobi in 2019 documented the cost of a package of interventions to end preventable maternal deaths, eliminate gender-based violence and meet the family planning needs of women in 120 countries. While this package is necessary and commendable, its additional global funding cost of more than $30 billion a year makes it implausible to be funded, either by cash-strapped governments or squeezed donor programs. Low- and middle-income countries with limited budgets need to strategically target interventions in a manner that helps them end preventable maternal deaths using the smartest policy options available.
A new report by the award-winning think tank Copenhagen Consensus, supported by funding from Merck for Mothers, uses the proven method of cost-benefit analysis to define the policies that would do the most good for every dollar spent, providing an evidence-based approach to end preventable maternal deaths. Using Johns Hopkins University and Avenir Health’s LiST model, the study analyzed the potential effect of more than 30 different targeted interventions in the 59 countries with the highest maternal and newborn mortality rates. These countries represent roughly half of the world’s population, including 970 million women of reproductive age.
The findings of the study revealed that a package of Basic Emergency Obstetric and Newborn Care (BEmONC), comprised of 15 primary health-based interventions including routine delivery care, administration of antibiotics, assisted vaginal delivery and neonatal resuscitation, was among the most cost-effective interventions packages. Scaling up the implementation of BEmONC to cover 90% of the unmet need would require an additional $2.2 billion per year in investments, but would help avoid an expected 93,000 maternal deaths, 870,000 newborn deaths and 810,000 stillbirths, generating $61.5 of benefits for every dollar spent.
The researchers also studied the effects of safe and inclusive family planning, which has the potential to save 87,000 women’s lives annually. This intervention would generate $27 worth of social benefits for every dollar spent by governments and beneficiaries, costing an additional $1.2 billion per year. Having fewer children also allows women to be more active in the labor market. Children will have more access to their parents and teachers and can become more productive as adults, fueling economic growth.
A combination of these two interventions, however, was the package with the greatest potential to save lives per dollar available. Basic emergency obstetric care together with family planning could lead to 162,000 fewer maternal deaths, 1.21 million fewer newborn deaths and 1.18 million fewer stillbirths each year. The combined package could be produced at a cost of $2.9 billion per year and has the potential to provide $71.5 in benefits per every dollar invested by governments. For resource-constrained nations, this intervention can provide the greatest benefit for each dollar spent.
The researchers also found that grouping interventions together increases their benefits and lowers the likelihood of complications throughout and following the pregnancy, as well as their cost of administration. While there is no magic bullet to reducing maternal mortality, these types of broad packages of interventions, especially those that include family planning, are a pathway to reaching the global goals in maternal health at a fraction of the cost usually projected. Investing in sexual and reproductive health care could help generate hundreds of billions of economic and health benefits to households and societies around the world and save millions of lives.

Bjorn Lomborg is President of the Copenhagen Consensus and Visiting Fellow at the Hoover Institution, Stanford University

With vaccine deliveries to Accra and Abidjan, the race for equity begins

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By Solomon Zewdu

On February 24, 600,000 doses of COVID-19 vaccine arrived in Accra, Ghana. Two days later, another 504,000 doses arrived in Abidjan, Côte d’Ivoire. These were the first international deliveries of COVID-19 vaccine through the COVAX Facility, and-with the first doses administered in both countries just days later-the first steps in what will be the largest immunization campaign in world history. Hopefully, these milestones represent a turning point in the world’s response to the pandemic.
A wide-ranging coalition of international public health organizations and other partners, COVAX aims to ensure that every nation, regardless of resources, gets the vaccines needed to protect its people from this devastating virus. A large part of the developing world, including most of Africa, has too often been forced to wait for lifesaving innovations and treatments. Because of this chronic lack of equitable access, disease and poverty linger. COVAX was created at the start of the pandemic to mitigate these inequities. It plans to deliver 2 billion vaccine doses all over the world in 2021, including 1.3 billion to low- and middle-income countries.
This ambitious international campaign is especially crucial given the deep disparities that have marked COVID-19 vaccine distribution so far. Until very recently, the world’s richest nations had received almost all of the vaccine supply. As a result, even as some high-income nations have already immunized more than 20% of their population with at least one dose, only a few African countries have reached even 1 in 1,000 people. It is frankly impossible to defeat the virus if these disparities persist. If everyone doesn’t have the chance to get immunized, the world economy could lose as much as US$9.2 trillion and twice as many people could perish needlessly.
Nonetheless, these first introductions in Accra and Abidjan coming less than three months after COVID-19 vaccines were first introduced in high-income nations represents proof that pooling resources can help shorten the time it takes to get vaccines to lower-income countries after they are developed. Before Gavi, the Vaccine Alliance, launched the Pneumococcal Advance Market Commitment in 2009, for example, it could take up to 15 years for life-saving vaccines to reach lower-income countries. Through donor commitments, this innovative funding mechanism has dramatically increased the speed with which vaccines reached lower-income countries and has helped 60 lower-income countries introduce pneumonia vaccines at more affordable prices.
Collaborations like COVAX and its Advance Market Commitment build on these successes and are similarly helping to narrow the gap in access to COVID-19 vaccines. To keep closing this deadly gap, however, additional resources from governments, donors, and the private sector will be needed. The commitment by G7 nations in mid-February to double COVAX funding is an excellent start, but more will be required to immunize everyone.
With that in mind, we must recognize that vaccines arriving at international airports-while an important and laudable logistical feat-is only the first step. The job will not be done until these vaccines get into people’s arms. Even some of the world’s wealthiest nations, with access to substantially more doses and with expensive health systems, have struggled with their vaccination campaigns, and the job could be exponentially harder in countries with far fewer doses and public health resources. That is why governments and public health organizations across Africa are working overtime to make sure their health care systems and workers are ready to get these vaccines moving.
Many African countries have expertise in conducting rapid and effective mass vaccination campaigns, often immunizing millions of people in a single week. In 2016, for example, 41,000 health workers and volunteers were recruited and trained to administer yellow fever vaccines to 14 million people in Angola and the Democratic Republic of the Congo (DRC) in just 10 days. The following year, Nigeria-despite political conflict-was able to immunize 4.7 million children against measles in only two weeks. And even amid the pandemic, Ethiopia was able to vaccinate 13 million children against measles and nearly 2 million people against cholera, thus averting the catastrophic consequences of missed vaccination campaigns.
These countries and many others in Africa already know firsthand what a successful mass vaccination campaign takes and have invested in many of the essential components, including detailed planning, real-time communication, building health worker capacity, and, critically, developing public trust in vaccines. Some nations, such as the DRC, even have experience with the ultracold temperatures needed for some COVID-19 vaccines, due to their efforts to inoculate more than 300,000 people against Ebola.
These experiences offer key lessons for vaccine delivery that the rest of the world can benefit from and will assuredly be helpful as African nations work to immunize their citizens against COVID-19. It will take enormous effort, resources, and dedication from everyone-both in Africa and around the world-to scale up vaccine delivery to the levels that are needed. Getting vaccines to Accra, Abidjan, and cities all over the planet is a vital first step in defeating this pandemic. Now the real test of whether we can achieve vaccine equity begins.

Dr. Solomon Zewdu is the Bill & Melinda Gates Foundation’s deputy director for health in Africa and its Africa COVID-19 response coordinator.

Ruth Hailu

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Name: Ruth Hailu

Education: University of Gondar, College of Medicine and Health Sciences

Company name: Haleta Mela Healthcare Services P.L.C

Title: MD

Founded in: November 2020

What it does: Clinical and Home to Home healthcare services

HQ: Kotebe Mesalemia, around Woreda 12 Main Office

Number of employees: 8

Startup Capital: 500,000 birr

Current capital: 500,000 birr

Reasons for starting the business: To meet the very high need for affordable and accessible healthcare

The biggest perk of ownership: To be able to participate in the decision making that will actually make a difference

Biggest strength: Forming a good rapport with our community

Biggest challenging: Trying to work and change a system that is broken

Plan: To expand our services to reach the unreachable

First career: General practitioner

Most interested in meeting: Dr. Lia Tadesse, Minister of Health

Most admired person: My Father

Stress reducer: Eating

Favorite past time: Watching movies

Favorite book: A stranger in the mirror by Sidney Sheldon

Favorite destination: Italy

Favorite automobile: Cadillac

Emerging market consumers in the global economy

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The newly emerged middle class are trailblazers in their own nations and represent, on a massive scale, agents of global economic transformation. Their effect on the global economy is already starkly apparent in the seismic shift in global economic gravity over the past few decades.
Due to a myriad of factors, greater trade and investment flows, urbanization, expanding labor forces, rising wages, infrastructure spending, rising life expectancies, political stability, prudent macroeconomic management and, of course, the emerging middle classes of many developing nations, the world has been turned upside down. As recently as 1980, the world economy beat to the tune of the United States in particular and the developed economies in general. The West towered over the Rest.
But, currently the tables have turned. According to the International Monetary Fund, where the developing nations accounted for roughly one-third of world GDP in 1980, this cohort now accounts for over 55% of the global total, with China, the world’s second largest economy, leading the way. By pumping millions of new workers into the global labor force over the past three decades, China and other developing nations have dealt both a supply-side shock (more workers) and demand-side shock (more consumers) to the world economy.
Much of the economic narrative over the past few years has been focused on the former, notably in many developed nations, the United States included, where the common refrain is that the rising supply of workers in the developing nations has undermined the jobs and incomes of workers in the West. To a degree, this is true, although many empirical studies suggest that more United States jobs have been lost to automation and technological advances than to low-cost labor in Mexico or China. The more salient point is that the millions of workers in the emerging markets are also consumers, with more disposable income than their parents or grandparents ever had.
While the spending power of the West has been diminished by the United States-led financial crisis and ensuing austerity in Euro zone area of the European Union, the purchasing power among developing consumers is on a secular upswing. Where in the past factory workers in Asia would trudge off to work on Saturday morning, today they are more likely to head for the local shopping malls for a day of socialising and shopping.
Any first-time visitor to the emerging cities of Shanghai, Dubai, Mumbai, Ho Chi Minh City, Istanbul and Sao Paulo is struck by the vigor and vitality of the local consumer, out in force and shopping in an air-conditioned mall that might be mistaken for a mall in suburban America. The size and scale of these urban buyers and their pent-up demand for electronic goods, appliances, automobiles, skin-care products, clothing and other goods are increasingly setting global trends. Emerging market consumers are leading in global fashion and driving global sales in a number of industries.
Indeed, in a seminal shift, global consumption is tilting toward the developing nations and away from the United States and the West. According to both the recent UNDP and IMF documents, the gap in global personal consumption is narrowing in favor of the developing nations. Where the spread was roughly 80:20 in favor of the developed nations in 1980, the spread has now narrowed to roughly 60:40. And the will have little doubt that in the not-too-distant future, the lines will cross, with the newly emerging middle class poised to take the global baton of consumption from consumers in the West.
And as the emerging market middle classes consume more, world trade flows are being altered. According to the IMF, a shift in world imports is well under way, with the developing nations’ share of world imports reaching a record 56% last year, totalling a record $10.5 trillion. Again, in just a matter of years, the lines are set to cross and imports from the developing nations, led by rising purchases of goods and services from the middle class are set to easily supersede those of the developed nations.
The aftershocks from the rise of the middle class in the developing nations are evident in various guises. Their pent-up demand for electronic goods, appliances, automobiles, skincare products, clothing and other goods has reached the point where emerging market consumers are now dictating the global revenues and profitability of these industries and others.
In addition, as the new global consuming class adopts and acquires Western lifestyles, moves from the village to the city, works in air-conditioned offices, drives to work, consumes more protein, there will be greater demand and higher prices for energy, water, agricultural goods and other natural resources. Put in another way, the monopoly the West has long enjoyed in devouring the world’s natural resources is over.
For much of the post-Cold War era, the equation was rather simple. The developing nations produced commodities and the West consumed them. Those days however, are past. Millions of the new middle class consumers are pressuring the global commodity infrastructure. There is a dramatic shift in underlying demand for global energy, with the developing nations clearly now the global drivers of energy demand and prices.
According to the IMF, the same holds true for the global consumption of meat, fruits and vegetables, with the developing nations, driven by a more affluent emerging market consumer, already out-consuming the developed nations. Pick virtually any commodity and the story is basically the same. Copper, silver, iron ore, meat, corn, wheat, soybeans, the future price of these commodities and others will increasingly reflect the rising per capita incomes and attendant jump in consumption among consumers in the developing nations. In the end, the world has changed. In the years ahead, the global economy will increasingly beat to the tune of millions of other middle-class consumers.