Substantial reductions in maternal and child deaths have been achieved worldwide in the last two decades. The global maternal mortality ratio reduced by 47% in 1990–2010 and the under-5 mortality reduced by 47% in 1990–2012.1, 2 However, this falls short of the rates of reduction needed by 2015 to achieve the Millennium Development Goals (MDGs) 4 and 5. Despite rapid economic growth in many Asian countries, south Asia still accounts for a third of child and maternal mortality (appendix). Communicable, maternal, neonatal, and nutritional causes account for 25% of deaths and remain dominant causes of premature mortality in sub-Saharan Africa.3 Maternal causes are a significant cause of death for women aged 15–34 years, accounting for 11% of deaths in 2010.3
Sustained global and regional efforts are being made to support countries to accelerate progress, including the UN Secretary-General's Global Strategy for Women's and Children's Health, and the Campaign on Accelerated Reduction of Maternal, Newborn and Child Mortality in Africa.4, 5, 6, 7 As part of these initiatives, much work has been done to calculate where additional investment is needed to improve health systems and service delivery in low-income countries.8, 9 Our analysis builds on this work, with particular focus on the substantial social and economic benefits that can accrue when a country invests in the health of its women and children.
The investment gaps are well known: insufficiently resourced health systems10 with low coverage of cost-effective interventions,11 and poor health information and management systems,12 making inefficient use of limited resources.13 This in turn leads to unacceptably high rates of preventable maternal and child deaths with significant social and economic losses.
The leading causes of maternal mortality—obstetric haemorrhage, hypertensive disorders of pregnancy, sepsis, and unsafe abortion14—are, to a large extent, preventable in most high-burden countries. Death from these causes can usually be prevented by well equipped health facilities, the presence of a skilled care provider (even at the lowest level of the health system), a functioning referral system, and a reliable supply of life-saving commodities. Some services are key interventions to prevent maternal deaths, such as contraception, antenatal care, skilled birth attendance, integrated reproductive health care in the postnatal phase, postnatal care, and a range of services for adolescents and women. However, access to them remains low, especially among the poorest in high-burden countries.15
Key messages
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Additional investments of US$5 per person per year in 74 countries, with 95% of the global maternal and child mortality burden, would yield high rates of return, producing up to nine times the economic and social benefit by 2035.
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Continuing historical trends of coverage increases is not sufficient. Accelerated investments are needed to bring health benefits to the majority of women and children.
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Compared with current trends, our accelerated investment scenario estimates that a total of 5 million maternal deaths, 147 million child deaths, and 32 million stillbirths can be prevented in 2013–35 in 74 high-burden countries.
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Expanding access to contraception will be a particularly cost-effective investment potentially accounting for half of all the deaths prevented in the accelerated investment scenario.
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More than a third of the additional costs required are health systems investments that are also required for services beyond those for reproductive, maternal, newborn, and child health. An ambitious scale-up would require an additional 675 000 nurses, doctors, and midwives in 2035, along with 544 000 community health workers.
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The new global investment framework could serve as a guide to countries to optimise investments in women's and children's health within national health and development plans over the next two decades.
Health systems investments are also required to prevent child mortality. WHO has estimated that 17% of deaths in children younger than 5 years are due to diseases that can be prevented by routine, cost-effective vaccination.16 Although coverage rates of immunisation are high compared with other maternal and child health interventions, many children still die from easily preventable diseases, including pneumonia and diarrhoea.17 New pneumococcal and rotavirus vaccines now exist to prevent these disorders. Coverage can be scaled up by strengthening existing supply chains and by training health workers to provide integrated care at facilities, and through outreach activities to rural communities. Robust health information systems and good management are also needed to ensure efficient and effective immunisation coverage.
High rates of malnutrition underlie more than 45% of all deaths in children younger than 5 years and are a significant factor in maternal mortality. For those children who survive, malnutrition jeopardises their potential for optimum growth and development, with important consequences later in life.18, 19
The economic and social consequences of poor health services coverage and outcomes to families and communities are substantial, particularly for the poor and other vulnerable groups.20, 21 Unexpected illness and associated health-care costs are leading causes of impoverishment in many low-income and middle-income countries.22 Poor health has a detrimental effect on school attendance and performance and future earnings.23 Children—not just newborn babies—whose mothers die, are, on average, more likely to die before the age of 2 years than children with mothers.24 If they do survive, they are also disadvantaged socially and economically.25
The analysis in this study estimates the costs and benefits of addressing the remaining gaps through health sector interventions. We show the potential effect on the economy and outline benefits for overall development.
In response to a recommendation in 2012 by the UN independent Expert Review Group on information and accountability for women's and children's health (iERG), WHO, the Partnership for Maternal, Newborn & Child Health (PMNCH), and The Lancet Commission on Investing in Health26 coordinated the development of a global investment framework for women's and children's health (“the investment framework”).27 This builds on the HIV/AIDS investment framework and previous investment cases for reproductive, maternal, newborn, and child health (RMNCH) and other initiatives.9, 28, 29, 30, 31 (appendix).
We have undertaken a new analysis that extends the earlier work by estimating the effects of investment on RMNCH across the continuum of care, including family planning, stillbirths, and newborn health (which have not always been included in previous studies). It also extends the timeframe to 2035 (this end date was chosen to align our analysis with the The Lancet Commission on Investing in Health) and analyses the economic and social returns on investment. The findings of this analysis will contribute to broader policy dialogue on effective health investments, including by being an input to The Lancet Commission on Investing in Health, which is expected to publish its report in December, 2013.
The analysis provides an updated estimate of the health, social, and economic benefits of investing in strengthening health systems to deliver RMNCH interventions in 74 low-income and middle-income countries that account for more than 95% of maternal and child deaths. It provides a global cost estimate of the level of investment required for the integrated delivery of a set of evidence-based RMNCH interventions. In modelling investment needs and health outcomes, the analysis supports an implementation approach that factors in equity and the social determinants of health—ie, by considering the effect of conditional cash transfers on increasing the proportion of women giving birth in health facilities. While recognising the intrinsic value of health and its role in meeting basic human rights, it also attempts to estimate the economic benefits of averting morbidity and mortality. This study analyses the broader, long-term health and nutrition gains to human capital development, and the substantial benefits of family planning for both health outcomes and socioeconomic development. The framework also emphasises the broader links to, and need for, health systems strengthening.