[Senate Hearing 110-]
[From the U.S. Government Publishing Office]


 
  STATE, FOREIGN OPERATIONS, AND RELATED PROGRAMS APPROPRIATIONS FOR 
                            FISCAL YEAR 2008 

                              ----------                              


                       WEDNESDAY, APRIL 18, 2007

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10:30 a.m., in room SD-138, Dirksen 
Senate Office Building, Hon. Patrick J. Leahy (chairman) 
presiding.
    Present: Senator Leahy.

           UNITED STATES AGENCY FOR INTERNATIONAL DEVELOPMENT

                        Bureau for Global Health

STATEMENT OF DR. KENT R. HILL, ASSISTANT ADMINISTRATOR

             OPENING STATEMENT OF SENATOR PATRICK J. LEAHY

    Senator Leahy. I apologize for being late. It's not often 
we have this distinguished a panel. We had votes that were 
supposed to have been earlier today, partly to accommodate this 
hearing, and then as sometimes happens in the Senate, things 
slipped.
    This hearing focuses on the aspects of our global health 
programs which address the core public health needs of the 
world's poorest people. I think of when children of people in 
my office, or my own grandchildren, get immunizations and it is 
a routine thing, and I think of so many children around the 
world where this does not happen, for them or their families.
    The chart on my right shows funding for HIV and AIDS, which 
has--for obvious reasons, and with bipartisan support of this 
subcommittee--increased dramatically in recent years, but 
funding for maternal and child health, and family planning and 
reproductive health, has languished.
    I don't want this to be an either/or thing, by any means. 
But, I am concerned, when you consider what a difference these 
programs make, and what we take for granted in our own country.
    Over the past 30 years, expanded immunization programs, 
often costing only pennies a child, have saved millions of 
lives. Family planning and reproductive health programs have 
also made enormous differences in child survival and women's 
health. USAID has been in the forefront of these efforts.
    But despite the great progress and countless lives saved, 
11 million children--11 million children under age 5--die each 
year, mostly from easily preventable and treatable causes, like 
diarrhea, pneumonia, or measles. Eleven million children each 
year--that's about 20 times the total population of my State of 
Vermont. Twenty times. That's each year.
    The administration's fiscal year 2008 budget request for 
these programs is $373 million, but that's compared to $420 
million in fiscal year 2007. An estimated 200 million women 
still lack access to family planning. Half a million yearly 
maternal deaths would be prevented with basic reproductive 
health services. The administration's budget request for these 
programs is $325 million, compared to $436 million in fiscal 
year 2007.
    What I worry about is we're short-changing the programs 
that have a proven and long history of success. We're also 
witnessing an alarming exodus of health professionals from 
developing countries, to higher-paying jobs in industrialized 
countries. The short- and long-term consequences of this brain 
drain, coupled with the deaths of countless health workers from 
AIDS, are staggering.
    I think of a country as great and powerful as the United 
States, and a country that has great economic means, that 
spends far less on maternal and child health, and on family 
planning and reproductive health for the world's 2 billion 
poorest people than we spend for the same purposes in the State 
of Vermont, with 625,000 people. We are far from being a 
wealthy State. I think most Vermonters would find that 
unacceptable, and I hope most Americans would find it 
unacceptable.
    Dr. Hill, who is the Assistant USAID Administrator for 
Global Health, will describe the administration's request.
    Dr. Helene Gayle is currently the President of CARE, one of 
the country's leading organizations fighting global poverty. 
She previously headed USAID's HIV/AIDS programs, and at the 
Gates Foundation she was the Director of HIV, TB, and 
reproductive health. Dr. Gayle and I have had discussions 
before, and my wife has, too, with her, and we consider that a 
privilege.
    Laurie Garrett is Senior Fellow for Global Health at the 
Council on Foreign Relations. Her Pulitzer Prize-winning book 
``The Coming Plague'', and her recent book ``Betrayal of Trust, 
the Collapse of Global Public Health'', should be read by every 
Senator, and every House Member, for that matter.
    Dr. Nils Daulaire is an old friend from my own State of 
Vermont, he's President of the Global Health Council, and after 
serving as USAID's Senior Health Advisor, he has been a friend 
and advisor to me and to others.
    So why don't we start with Dr. Hill, and place your full 
statement in the record. I wonder if you might sum up in 5 or 6 
minutes. Then we will go to Dr. Gayle, and Ms. Garrett, then 
Dr. Daulaire.

                   SUMMARY STATEMENT OF DR. KENT HILL

    Dr. Hill. Thank you, Chairman Leahy. I want to thank you, 
first of all, for holding this hearing, for your personal 
passion on these issues, which has been evident for so many 
years, and for the opportunity to testify with my esteemed 
colleagues and friends about these important issues.
    As you're well aware, over many years USAID has contributed 
to impressive reductions in child and maternal mortality, and 
in helping women and couples achieve the size of family they 
desire. In the process, we have strengthened health systems, 
built the capacity of developing countries to reduce maternal 
and child deaths, and provided basic health services.
    Maternal and child health, and family planning are often 
seen as separate and distinct, vertical and disconnected. But 
USAID is working very hard to integrate our programming, an 
approach that promotes efficiency and sustainability.
    I will talk about maternal and child health, and family 
health planning separately, but I do so only for ease of 
presentation--as they are, in fact, implemented in an 
integrated fashion in our country programs.
    Mothers and their young children bear a disproportionate 
share of the burden of diseases and preventable mortality in 
developing countries each year. More than 500,000 women die of 
complications of pregnancy and childbirth.
    Women in sub-Saharan Africa have more than a 150-times 
greater risk of dying in childbirth over a lifetime than women 
in the United States. Our programs focus on interventions 
targeting the high mortality complications of pregnancy and 
birth that account for two-thirds of maternal mortality; this 
would be hemorrhage, hypertension, infections, anemia, and 
prolonged labor.
    In USAID-assisted countries, skilled birth attendance has 
increased from an average of 37 percent in 1990 to 50 percent 
in 2005. Ten USAID-assisted countries have reduced maternal 
mortality by 33 percent on average over a decade, demonstrating 
that substantial progress is achievable.
    In this chart, which I won't detail for you, you can see 
all the lines going down; these are all countries that, over 10 
years, have seen a substantial decline in maternal mortality.
    But, every year, 3.7 million newborns fail to survive even 
the first month of life. Newborn mortality has not been reduced 
as much as mortality among older infants and children, making 
it the unfinished agenda of child survival.
    Let me now turn to child survival. Twenty years ago when 
USAID and UNICEF launched the Child Survival Revolution with 
the support of Congress, an estimated 15 million children in 
the developing world died every year. Without action, the 
number of deaths today would be more than 17 million each year.
    Instead, as a result of global child survival efforts, by 
2005, the number of child deaths was reduced to about 10.5 
million--still far too many, but representing more than 6 
million childrens' lives now being saved every year.
    Over the past 20 years, the United States has committed 
more than $6 billion to this effort, which has yielded public 
health successes at an unprecedented global scale. For example, 
almost 1 billion episodes of child diarrhea are treated with 
oral rehydration therapy each year, reducing deaths from 
diarrhea by more than half since 1990. More than 100 million 
children receive basic immunizations every year. More than 75 
million cases of child pneumonia receive treatment. Child 
malnutrition has been reduced by 25 percent, from 1 in 3 to 1 
in 4. An estimated 5 million children have been saved from 
death from paralysis through the polio eradication initiative. 
Finally, 500,000 children were saved last year by micro-
nutrition supplementation.
    These accomplishments are not attributable to USAID alone. 
Yet, as the graph to my left shows, in almost 30 countries with 
sustained USAID investment in child survival, we have seen 
significant reductions in mortality of children under the age 
of 5. The takeaway here is that the lines that are higher, in 
blue, are 1990, and the red shows what it's been reduced to. 
Wherever we've had a chance to work on these issues, we have 
been able to make a tremendous difference.
    These are great accomplishments. But even greater 
challenges remain, such as saving the lives of the more than 10 
million children who still die each year. I appreciate the 
chairman mentioning that fact--we must focus on the work left 
to be done.
    As the next graph shows, over two-thirds of the remaining 
child deaths--6.5 million--are preventable. Now, I want to make 
a point here. You saw the 15 million that were dying in the 
Eighties; you can see how many would be dying today if we did 
not act and that is 17 million. You see the number, the 10.5 
million that are still dying. Despite saving the lives of 6.5 
million, the point I want to make is the next one. Of that 10.5 
million, two-thirds of those deaths can be averted through 
proven interventions. Only 4 million of that 17 million 
represent things that would be very tough for us to get at.
    Now, to be sure, a lot of that remaining work is in remote 
areas and would cost a bit more, but it is what we ought to aim 
at. By replicating our best practices, I hope some of this came 
through. Anyway, by replicating our best practices and new 
approaches and interventions, we believe that it is possible to 
achieve reductions of 25 percent in under 5 years and maternal 
mortality in most of these countries by 2011.
    Now, let me turn to family planning for a minute. USAID and 
Congress's joint support for family planning has resulted in 
many successes since 1965. The use of modern family planning 
methods in the developing world has increased by a factor of 
four, from less than 10 percent to over 40 percent in the 28 
countries with the largest USAID-sponsored programs. The 
average number of children, per family, has dropped from more 
than six to less than four. Enabling women and couples to 
determine the number and the timing of their births has been 
crucial in preventing child and maternal deaths, improving 
women's health, reducing abortion, preserving often scarce 
resources, and ensuring a better life for individuals and their 
communities.
    To be sure, the United States is the largest bilateral 
donor and the acknowledged world leader in advancing and 
supporting voluntary family planning services.
    Because of our success, we are now able to address those 
countries with the greatest need for family planning and have 
strategically shifted our resources to do so. Many countries in 
Africa, for example, are characterized by low rates of 
contraceptive use, high fertility, and high unmet need for 
voluntary family planning.
    Between 1994 and 2000, there were nearly 39 million 
unintended pregnancies in Africa, and 24 percent of the women 
there expressed an unmet need for family planning. Nearly half 
of the world's maternal mortality occurs in Africa. As you can 
see in this particular chart, the unmet need is highest in sub-
Saharan Africa, but it is very great in areas of Asia, the 
Middle East, Latin America and Central Asia. To be sure, we try 
to graduate countries, and we have done so successfully.
    One final issue, perhaps, deserves our attention and that 
has to do with the ``brain drain.'' One challenge that faces us 
is the movement of trained healthcare providers away from the 
developing countries into more developed countries, commonly 
referred to as a ``brain drain.''
    USAID is trying to deal with this, and deal with health 
worker retention, in almost every country in which we work by 
strengthening in-service training, by reinforcing supervision 
systems so that they provide positive support to these workers, 
and by instituting quality improvement methods. This won't 
completely solve the problem, but this is what we have to work 
very hard on. There has been an increase in retention in places 
like Ghana, Namibia, and Uganda.

                           PREPARED STATEMENT

    USAID-supported maternal-child health programs and family 
planning programs have a proven success record. Our support has 
reduced under-5 mortality in almost 30 countries and maternal 
mortality in 10 countries. USAID-supported family planning 
programs have been successful in increasing access to and use 
of modern contraceptives in all regions of the world. We now 
have program approaches and interventions that will allow us to 
build on these successes. We have the experience to do it, and 
with the continued support of Congress, we will be able to 
contribute to further gains in maternal and child health, and 
family planning throughout the developing world.
    Thank you very much.
    [The statement follows:]
                 Prepared Statement of Dr. Kent R. Hill
                              introduction
    Chairman Leahy, Senator Gregg, and other distinguished members of 
the Committee, I would like to thank you for convening this important 
hearing and for inviting me to testify. U.S. development assistance has 
brought dramatic improvements in health, income advancement, and 
education to much of the developing world in the last 50 years. Average 
life expectancy in low and middle-income countries increased 
significantly during this same period. Good public health underpins 
these advances. Indeed, research findings and country experience have 
demonstrated an inextricable link between investments in improving 
individual and collective health status and a nation's economic 
development and performance. Many of these advances are due, in large 
part, to your continued support for maternal and child health and 
reproductive health programs.
    USAID has a proven track record that has contributed to impressive 
reductions in child and maternal mortality and in helping women and 
couples achieve the size of families they desire in all regions of the 
world. Our support has helped to reduce under-five mortality in almost 
30 countries and maternal mortality in ten countries. USAID-supported 
voluntary family planning programs have been successful in increasing 
access to and use of modern contraceptives in all regions of the world. 
In the process, we have strengthened health systems and built the 
capacity of developing country institutions to reduce preventable 
maternal and child deaths and provide basic health services. Your on-
going commitment and support for maternal and child health has been and 
is critically important. As I often remind my staff, it is a great 
privilege to have work to do which matters, which saves lives of 
children and mothers, and it is you in the Congress whose compassion 
and support makes this work possible. And I want to express my great 
appreciation to you for this.
    In talking to you about our work in improving maternal and child 
health (MCH) and family planning and reproductive health (FP/RH), I 
would like to focus on five key points:
  --Our programs have a proven record of success.
  --Despite real progress, our work is not done.
  --We have pioneered program approaches and continually develop new 
        interventions that have made and will make a difference in our 
        progress.
  --There are crucial opportunities to accelerate progress.
  --We can take advantage of these opportunities by capitalizing on 
        existing resources and by focusing on key countries.
    Maternal and Child Health and Family Planning are often seen as 
separate and distinct--vertical and disconnected. But USAID is working 
to integrate our programming to the fullest extent possible, an 
approach which increases the affordability and sustainability of our 
global efforts to tackle these important public health challenges. For 
example, we are making substantial progress integrating our programs 
for women and children and building consolidated platforms such as 
antenatal care and community-based distribution approaches for family 
planning, child vaccinations, and other important health interventions. 
Most of our missions already support integrated MCH/FP programs and 
help to build broad-based health systems. These programs strengthen 
drug management, supervision, community outreach, and other critical 
systems needed to deliver basic public health services.
    In all our health programs, including MCH and family planning and 
reproductive health, we work to build human and organizational 
capacity, including taking steps to address the so-called ``brain 
drain.'' Our programs help strengthen human resources to implement 
quality health care services through workforce planning, allocation, 
and utilization; strengthened systems for sustained health worker 
performance on the job; and training of health professionals. While, as 
a development agency, we cannot affect recruitment policies of the 
developed world, we are working on ways to keep health workers in their 
countries by working with governments on developing appropriate 
incentives, providing clear and equitable career paths, and offering 
continuing education and professional development. Other projects also 
work to strengthen management systems and increase leadership capacity.
    By strengthening and building upon common service delivery 
platforms, we help to support the specific goals of new high-intensity 
initiatives like the President's Emergency Plan for AIDS Relief 
(PEPFAR) and the President's Malaria Initiative (PMI), and therefore 
advance countries' ability to deliver the full range of health 
services.
    I will talk about MCH and FP in separate sections, but I do so only 
for ease of presentation, as they are implemented more and more in a 
fully integrated fashion in country programs.
    Using cost-effective tools and approaches, USAID and its 
international development partners have an unprecedented opportunity to 
accelerate progress in MCH and family planning, leading to further 
reductions in maternal and child mortality and unintended fertility.
            maternal, newborn, and child survival and health
    To achieve impact in maternal, newborn, and child health, USAID has 
consistently applied an approach that focuses on:
  --working with countries having high burdens of maternal and child 
        mortality and malnutrition;
  --developing and delivering high impact maternal and child health 
        interventions such as increasing skilled attendance at birth, 
        control of post-partum hemorrhage, oral rehydration therapy 
        (ORT), immunization, and vitamin A;
  --bringing these interventions as close as possible to the families 
        who need them;
  --supporting results-oriented research to develop new interventions 
        and strengthen programs;
  --monitoring progress; and,
  --strengthening the capacity of countries and communities to save the 
        lives of their own women and children.
                      maternal and newborn health
The burden of maternal and newborn mortality and disability
    Each year more than 500,000 women die of complications of pregnancy 
and childbirth. Indeed, this is the second most common cause of death 
of women of reproductive age. While the number of deaths is disturbing 
enough, it is estimated that an additional 15-20 million women suffer 
debilitating consequences of pregnancy. Pregnancy-related mortality 
shows the greatest inequity of all health indicators between the 
developed and the developing worlds. For example, the one-in-16 chance 
over a lifetime that a woman in sub-Saharan Africa has of dying as a 
result of pregnancy is more than 150 times greater than the one-in-
2,500 risk of a woman in the United States. In many Asian and Latin 
American countries, improved national averages often obscure the 
substantial risk of pregnancy that still remains for women living in 
poverty. 
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    In addition, 3.7 million newborns die annually, failing to complete 
even the first month of life. As noted, newborn survival is 
inextricably linked to the health and nutritional status of the mother 
before and during pregnancy, as well as her care during labor and 
delivery. For this reason, USAID's programs always link mother and 
infant. As we make progress in reducing under-five mortality in 
general, the deaths of newborns in the first 28 days of life comprise a 
greater proportion of under-five and infant deaths. Globally, newborn 
mortality represents over one-third of all mortality among children 
under age five; however, in countries which have made greatest progress 
in child survival, newborn mortality can be more than half of the 
remaining deaths of infants and children. Thus, further progress in 
child survival must emphasize reduction of newborn deaths as a 
critically important element.
We have shown that substantial progress can be made in reducing 
        maternal and newborn deaths
    Despite the challenges faced in reducing maternal mortality, USAID 
has helped demonstrate that real progress can be made. Because maternal 
mortality is normally measured every 5-10 years, the globally-accepted 
proxy for maternal mortality is coverage at birth by skilled 
attendants. Across all USAID-assisted countries, skilled attendance has 
increased from an average of 37 percent in 1990 to 50 percent in 2005; 
the greatest progress has been in the Asia and Near East region, where 
coverage has more than doubled, increasing from 21 to 47 percent. 
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    Most important, although global progress in reducing maternal 
deaths has generally been slow, ten USAID-assisted countries have 
achieved average reductions of maternal mortality of 33 percent over a 
decade. 
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    Family planning also makes a substantial contribution to saving the 
lives of women by reducing the number of unintended pregnancies (each 
of which exposes a woman to risk) and by reducing abortions.
    For newborn mortality reduction, USAID funded-research has 
documented a 33 percent decline in newborn mortality in Sylhet, 
Bangladesh with a package of home-based essential newborn care, and a 
50 percent decline in Shivgarh, India with a similar program. Such 
programs have the potential to produce widespread impact on newborn 
survival in settings where most births take place at home, and they are 
now being scaled-up. In large controlled trials, community-based 
programs for detection and antibiotic treatment of life-threatening 
neonatal infections have also demonstrated the potential to reduce 
newborn mortality by almost half. We and other partners are replicating 
these trials and--if they are successful--will work with countries to 
apply the results in MCH programs. Neonatal interventions are 
relatively new in such programs, so we do not yet have examples of 
national-level mortality reduction. However, very recent analyses 
suggest that, as these interventions are scaled-up, we are beginning to 
see overall declines in newborn mortality at the global level.
This success can be scaled-up through expanding the use of proven, low-
        cost interventions
    Our work demonstrates that many of the major causes of maternal 
death are substantially preventable and treatable with low-cost 
interventions. USAID has sharpened its focus on a set of highly-
effective interventions targeting specific high-mortality complications 
of pregnancy and birth--hemorrhage, hypertension, infections, anemia, 
and prolonged labor. Together, these complications account for two-
thirds of maternal mortality. Hemorrhage alone accounts for almost one-
third, and USAID has been in the forefront of promoting ``active 
management of the third stage of labor,'' a highly-effective technique 
for preventing postpartum hemorrhage.
    USAID has recognized that attention to the newborn is essential to 
success in our child survival programs. Increasing evidence and program 
experience indicate that we can significantly reduce newborn mortality 
by combining focused antenatal care, a package of essential newborn 
care that enhances the survival of all infants, detection and treatment 
of serious neonatal infections, and community and facility-based 
approaches to special care for low birth weight babies. These 
approaches especially target newborn infection and birth asphyxia, 
which together account for more than 60 percent of newborn deaths. 
USAID is presently supporting introduction or expansion of newborn care 
programs based on these elements in 20 countries.
Accelerating progress
    While we have been able to demonstrate important progress in 
maternal survival in a number of countries, we recognize that sub-
Saharan Africa has generally made little progress and represents a 
special challenge. In response to this stagnation of progress in sub-
Saharan Africa, USAID has initiated a new ``Safe Birth Africa'' 
initiative to increase skilled attendance at birth, beginning in Rwanda 
and Senegal. This initiative includes a focus on decreasing financial 
barriers for families so that they will be more likely to bring 
expectant mothers for skilled care at birth. It also involves expanding 
the mandate of frontline providers so that they can perform life-saving 
measures, along with quality improvement approaches to ensure that good 
clinical practice standards are systematically applied. USAID plans to 
expand this work to other high burden countries in order to increase 
skilled attendance at birth and coverage with life-saving care.
    In all countries where maternal mortality is high, as well as in 
countries where there is wide disparity in birth outcomes between rich 
and poor, USAID is intensifying its work to spotlight specific life-
saving interventions. To expand the use of ``active management of the 
third stage of labor'' to prevent postpartum hemorrhage, USAID launched 
the Prevention of Postpartum Hemorrhage Initiative in 2002. As of 2006, 
this approach had been introduced into MCH programs in 15 countries. In 
support of this intervention, we are working to get oxytocin, the drug 
that contracts the uterus to reduce bleeding after birth, into single-
use UNIJECT injection devices, so that it can be provided by skilled 
birth attendants to women in peripheral health centers and homes. 
Because oxytocin is sensitive to heat, we are also exploring a time/
temperature index to be put on the oxytocin vial, similar to the 
Vaccine Vial Monitor, to ensure that medication given to women is 
potent and that health workers do not unnecessarily discard oxytocin 
that has not been refrigerated.
    In addition to further expansion of essential newborn care at 
birth, USAID is applying research results on treatment of sick newborns 
with antibiotics in the community. One step is testing the delivery of 
antibiotics in UNIJECT devices, so that treatment can be administered 
easily and safely by frontline-care providers. These newborn activities 
represent the combination of technical leadership and program 
application that USAID brings to MCH programs, working in partnership 
with other donors and recipient countries.
Reversing maternal disability
    While our efforts continue to emphasize safe births and prevention 
of maternal mortality and disability, we are also providing 
compassionate care for women who suffer the devastating problem of 
obstetric fistula, a consequence of prolonged labor that can cause a 
woman to leak urine or feces, often resulting in divorce and social 
isolation. In 2004, USAID began a program to provide surgical treatment 
for such women. By the end of 2006, USAID was supporting eighteen 
fistula repair centers in eight countries of south Asia and sub-Saharan 
Africa. This support included physical upgrading of centers, training 
of surgeons, nurses and counselors, and mobilizing more than 5,000 
community agents to change norms to delay pregnancy, reduce stigma of 
affected women, and promote use of family planning and maternity 
services. Over 2,000 surgeries have been completed.
                             child survival
    Let me now turn to the child survival component of our MCH program. 
This is one of the cornerstone components of USAID's health 
programming. Arguably, the quantifiable, at-scale results generated by 
the child survival and family planning programs helped build the 
confidence that paved the away for later investment in other global 
health programs, from TB and malaria to HIV/AIDS and Avian Influenza.
    The child survival program has a proven record of success, achieved 
by delivering high-impact interventions. Twenty years ago, when USAID 
and UNICEF launched the ``child survival revolution'' with the support 
of Congress, an estimated 15 million children under age five in the 
developing world died from common, preventable diseases each year. 
Across the developing world, more than one in 10 children did not 
survive to see their fifth birthday; in some countries, it was one in 
five. If the same rates of infant and child mortality existed today, 
the number of deaths would be more than 17 million each year. In 
contrast, for 2005 WHO and UNICEF estimate the number of children under 
five who died to have been reduced by more than one-third, to 10.5 
million--this is still far too many preventable deaths, but it means 
that more than 6 million children's lives are now being saved every 
year through global child survival efforts.
    Over the past 20 years, the United States has committed more than 
$6 billion in support of USAID's global child survival efforts. In 
collaboration with international, national, and private sector 
partners, this effort has yielded public health successes on an 
unprecedented global scale:
  --Almost a billion episodes of child diarrhea are treated with 
        lifesaving ORT each year, reducing child deaths from diarrheal 
        disease by more than 50 percent since 1990.
  --More than 100 million children receive a set of basic immunizations 
        each year, and tens of millions more receive supplemental 
        immunizations against polio, measles, and other killer 
        diseases.
  --More than 75 million cases of infant and child pneumonia are taken 
        for treatment by trained health workers.
  --Malnutrition among children under age five has been reduced from 
        one in three to one in four, a 25 percent reduction.
  --The Polio Eradication initiative has saved an estimated five 
        million children from death or paralysis.
  --Half a million children are estimated to have been saved last year 
        alone by micronutrient supplementation programs.
    These accomplishments are not attributable to USAID alone. In 
virtually all countries where it carries out child survival and 
maternal health efforts, USAID invests its resources in ways that best 
interact with and leverage the contributions of other donors and of the 
country itself. Yet, as the attached graphic demonstrates, in almost 
all the countries where USAID made an average annual investment of at 
least $1 million of child survival and maternal health funds each year 
during 2003-2005, we have seen significant reductions in mortality of 
children under age five. 
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

Despite real progress, there is still a substantial job left to do
    Sustaining this progress is itself a challenge, especially in the 
poorest countries with the weakest governments and health systems. A 
greater challenge is saving the lives of the remaining 10.5 million 
children who still die each year. As shown in the graph from the 2003 
authoritative review of Child Survival in the medical journal The 
Lancet, the causes of most of these child deaths continue to be 
malnutrition, the common infections of newborns and young children--
diarrhea, pneumonia, infections of newborns, and, especially in Africa, 
malaria--and other life-threatening newborn conditions.\1\
---------------------------------------------------------------------------
    \1\ ``All other causes'' includes principally congenital anomalies, 
malignancies, all other infectious diseases, and injuries & accidents.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    The Lancet analysis indicates that over two-thirds of these child 
deaths are preventable with interventions that are available or in the 
pipeline, including Oral Rehydration Therapy for dehydrating diarrheal 
illness; basic treatment of serious infections including pneumonia, 
malaria, and newborn sepsis; improved nutrition through breastfeeding, 
better child feeding practices, and management of acute malnutrition; 
and delivery of micronutrients, especially vitamin A and zinc, which 
improve children's ability to resist infections or help them fight them 
off when they occur.
    Countries and the global community--with USAID playing an important 
leadership and program role--have been able to make substantial 
progress in delivering these high impact interventions. In addition to 
our substantial contributions to increased global coverage of 
interventions including immunization and oral rehydration therapy, 
there are several areas where USAID's contribution has been especially 
important. One of these is vitamin A. USAID supported a large part of 
the research demonstrating that vitamin A deficiency was widespread 
among young children in developing countries, and that preventing or 
repairing this deficiency could reduce overall mortality among children 
under age five by about one-fourth. Since then, integrating vitamin A 
supplementation into maternal, newborn, and child health programs has 
been one element of our work in most countries, working with UNICEF and 
the Canadian International Development Agency. One result is that by 
2004 (the latest year with complete estimates) almost 70 percent of 
children in the developing world had received at least one semi-annual 
dose of vitamin A supplementation, and almost 60 percent had received 
both doses needed each year for full protection. This achievement, 
combined with the increasing coverage of micronutrient fortification 
programs, of which we are also major supporters, means that tens of 
millions of children are receiving this important nutritional 
intervention.
    Another area worth special comment is breastfeeding, because 
malnutrition underlies over half of all under-five child deaths. 
Breastfeeding is one of the highest impact child survival 
interventions, but improving feeding practices and children's nutrition 
is one of the most challenging areas of child survival. The global rate 
of improvement in exclusive breastfeeding of children for the first six 
months of life is less than one percent annually. However, USAID 
demonstrated that this challenge can be effectively addressed through a 
multi-pronged approach that incorporates community workers, media, 
health services, and policy changes. Using this approach, seven USAID-
assisted countries have made at-scale improvements in exclusive 
breastfeeding of as much as 10 percentage points a year, well above the 
global trend. We are now working with partners to apply this experience 
in additional countries.
    A major challenge is that many of the remaining child deaths are 
occurring in places where existing services often do not reach: in the 
poorest countries and countries emerging from conflict (like Sudan, 
Afghanistan, and the Democratic Republic of Congo), in the huge rural 
areas of countries like India and Pakistan, and increasingly in the 
slums of the developing world's rapidly growing urban population.
We have new program approaches and new interventions that will make 
        additional impact
    Our response to these challenges is not just to do more of the 
same. Bringing high impact interventions to additional children who 
need them requires new approaches. One of these is our increasing 
emphasis on community-based programs, learning from our extensive 
partnerships with U.S. Private Voluntary Organizations and our 
experience working with countries that have pioneered these approaches 
as part of their national program strategies.
    One example is community treatment of pneumonia. At the end of the 
1990s, our analyses showed that progress in delivering simple oral 
antibiotic treatment to children with pneumonia--a treatment that 
research had shown reduces mortality by at least one-third--had leveled 
off, with only about 50 per cent of children needing treatment actually 
getting it. The reason was that in most countries, this treatment was 
restricted to formal health facilities. With the support of USAID and 
others, a few innovative programs in Nepal, Honduras, and Pakistan had, 
however, implemented treatment through trained community health 
workers. In Nepal, this approach more than doubled the number of 
children receiving treatment for pneumonia, and did so with excellent 
quality of care. We documented and presented this program experience to 
international partners including WHO and UNICEF, with the result that 
this is now the recommended approach to pneumonia treatment for 
countries where formal health services fail to reach many children. 
USAID itself has helped introduce this approach in Africa, beginning in 
Senegal; six additional countries are now implementing this community-
based approach, and several others are introducing it.
    Similarly, we helped pioneer ``Child Health Weeks,'' which are 
outreach approaches that bring vitamin A, immunization, insecticide-
treated nets, and other health interventions to underserved areas. The 
aim is to get basic interventions to all children possible now, while 
building countries' systems and capacities to do so through more 
systematic approaches in the future.
    Our program has also played a key role in developing, testing, and 
introducing new interventions and technologies that will save 
additional lives.
    One of these is zinc treatment for child diarrheal illness. 
Research--much of it supported by USAID--has clearly shown that zinc 
treatment reduces the severity and duration of these illnesses; as a 
result, zinc is now recommended by WHO and UNICEF as part of the 
treatment of diarrheal illness, along with oral rehydration. To 
implement this recommendation, we are supporting introduction of zinc 
treatment in countries including India, Indonesia, and Tanzania. We are 
also collaborating with UNICEF and potential zinc supplement producers 
to assure the availability of safe, standardized, high quality products 
to supply these new programs.
    Another example is ``point-of-use'' (POU) water disinfection 
technologies. These simple and cheap methods were first developed and 
used through collaboration of USAID and the Centers for Disease Control 
and Prevention (CDC) during cholera outbreaks in Latin America in the 
1990s. Subsequent research showed that ``POU'' water treatment can 
reduce diarrheal and other water-transmitted illnesses by one-fourth or 
more. Since then, we have collaboratively developed programs for their 
production and distribution in twelve countries. In some countries, 
like Indonesia, this is a purely private sector partnership, with the 
United States providing just the technical know-how. In poorer 
countries like Madagascar and Zambia, we are using social marketing 
approaches that involve some degree of subsidy to make sure they are 
available to low-income households (often most impacted by bad quality 
water). In emergencies--including the 2004 tsunami--these ``POU'' 
technologies have played an important part in reducing disease 
transmission, especially among children. Because over a billion people 
in the developing world still live without access to safe water, these 
simple technologies can play an important role in reducing the disease 
burden on young children.
    One other important new intervention is ``community therapeutic 
care'' (CTC), an innovative approach to therapeutic feeding and medical 
treatment of children with acute severe malnutrition in field 
environments with few human and medical resources. Many families 
impacted by emergencies cannot reach therapeutic centers, or cannot 
spare the family members needed to accompany a child in such a center 
for the days or weeks required to reverse malnutrition. In response, 
USAID has worked with non-government agencies and international relief 
organizations to develop this approach for children with severe acute 
malnutrition. A central innovation of CTC is the use of ready-to-use 
therapeutic foods such as Plumpy'nut, an energy-dense peanut paste. 
Plumpy'nut can be safely given by parents in the home, eliminating the 
need for a prolonged stay in feeding centers. CTC has already been 
introduced in several African countries as well as in Bangladesh. USAID 
is now working with WHO and UNICEF to endorse CTC as the standard of 
care in all countries for managing acute malnutrition.
    My testimony on child survival may best be summarized by the 
following graph. 
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    As I noted early in my statement, global efforts to improve Child 
Survival now result in the saving of over 6 million children's lives 
each year. This is a tremendous accomplishment, and one that needs to 
be sustained. At the same time, authoritative analyses tell us that we 
can save at least an equal number of those children who still are dying 
unnecessarily, using the tools and program experience that are already 
available to us. It is our intention to do our utmost with the 
resources provided to us to accomplish this important goal.
There is now an important opportunity to accelerate progress in 
        maternal, newborn, and child survival
    During the past few years, we have seen new commitments that we 
believe can lead to a ``second wave'' of global effort to improve 
maternal and child survival. There are new resources appearing from 
private sector partners like the Bill and Melinda Gates Foundation, 
from bilateral donors like the U.K. and Norway, and from multilateral 
partners including UNICEF. One of the largest increases is through 
funding from the International Funding Facility of the U.K. and Europe 
for immunization, through the Global Alliance for Vaccines and 
Immunization (GAVI). The European Union is providing substantial 
amounts of new funding to several countries to support maternal 
mortality reduction.
    The Millennium Development Goals (MDGs) are stimulating increased 
international attention to the need for accelerated progress to reach 
the child and maternal survival goals; this attention is producing new 
international cooperation, like the inter-agency ``Countdown 2015'' 
collaboration to monitor and report on progress toward these goals and 
the inter-agency ``Partnership for Maternal, Newborn, and Child 
Health.'' The African Union has recently developed and approved a new 
``Framework for Accelerated Progress in Child Survival'' as well as a 
new reproductive health regional strategy; work on a similar regional 
framework for maternal, newborn, and child health is beginning in Asia.
    Partly in response to the MDGs, and partly in response to their 
understanding of the need to accelerate social development, some 
countries themselves are substantially increasing their own investments 
in maternal and child health. One impressive example is India, whose 
Prime Ministerial ``National Rural Health Mission'' and new second 
stage Reproductive and Child Health Project represent the commitment of 
over $2 billion a year to improved health status among the underserved. 
There is also increasing public visibility, including ongoing attention 
by The Lancet to child survival, maternal and newborn health, and 
global public health in general.
Against this background, we have a strategy to use our existing 
        resources to substantially reduce maternal, newborn, and child 
        mortality and malnutrition in a focused set of high burden 
        countries
    To take advantage of this opportunity, we plan to focus resources 
on a set of countries which have the highest need, in terms of both the 
magnitude and the severity of under-five and maternal mortality; that 
is, countries that have the largest number of preventable deaths as 
well as the highest rates of mortality. We will focus on countries that 
have strong commitment to improving MCH and the capacity to program 
resources effectively, and wherever possible, offer the potential for 
interaction with other USG investments, including the President's 
Malaria Initiative and GAVI funding. We believe it is possible to 
achieve reductions of 25 percent in under-five and maternal mortality 
in most of these countries by 2011; and in many of them, we also 
believe it possible to achieve reductions of 15 percent in the number 
of children who are below weight-for-age.
    We will do this by applying our successful lessons from the past 
and the new approaches and interventions we now have. We will work with 
countries and partners to identify the most important maternal, 
newborn, and child health and nutrition problems, and the most 
important interventions that can be implemented at scale to address 
those problems. We will support those interventions through appropriate 
integrated delivery approaches, involving the public health system, 
private sector providers, NGOs, and community-based approaches. We will 
identify the best fit of our resources alongside those of other 
initiatives, partners, and the countries themselves. We will join with 
countries and partners to monitor progress in terms of improved 
coverage, and ultimately improved survival, health, and nutrition 
status. And we will identify and invest in developing the capacity of 
communities, health systems, and human resources to achieve and sustain 
progress.
    Our belief that such rapid progress is possible is not 
hypothetical. It is based on the real recent performance of a number of 
USAID-assisted countries, shown in the following table.

                        RAPID REDUCTION IN UNDER-5 MORTALITY BY USAID-ASSISTED COUNTRIES
----------------------------------------------------------------------------------------------------------------
                                                       Under-5                     Under-5
                                                      mortality                   mortality
                      Country                          (deaths/    Year    To      (deaths/    Year    Percent
                                                        1,000                       1,000             reduction
                                                       births)                     births)
----------------------------------------------------------------------------------------------------------------
Bangladesh.........................................          116   1996  [r-arr           88   2004           24
                                                                             o
Cambodia...........................................          124   2000  [r-arr           83   2005           33
                                                                             o
Ethiopia...........................................          166   2000  [r-arr          123   2005           26
                                                                             o
Malawi.............................................          189   2000  [r-arr          133   2004           30
                                                                             o
Madagascar.........................................          164   1997  [r-arr           94   2003           41
                                                                             o
Nepal..............................................          139   1996  [r-arr           91   2001           23
                                                                             o
Tanzania...........................................          147   1999  [r-arr          112   2004           24
                                                                             o
----------------------------------------------------------------------------------------------------------------

    Most of these recipient countries are still very poor. Yet they 
have demonstrated that through commitment to effective programs and to 
bringing needed services to children and families, rapid progress can 
indeed be achieved. These achievements, along with those I have already 
presented in maternal mortality reduction, give us confidence that our 
continuing work with countries and partners can produce equally 
important results during the next 5 years.
    Finally, the question comes up of determining when a country is 
ready to go on its own in MCH, without continued USAID support--the 
``graduation'' question. We plan to approach this process in a phased 
approach. By looking at past experiences and current conditions; 
progress on key indicators including under five and maternal mortality; 
and such factors as equity of health status, we will develop and apply 
graduation criteria and analyze each country receiving MCH assistance 
against these criteria. Based on this analysis, we will identify 
countries that have strong chances of successfully graduating in the 
near term. We will then work with the country to focus our program 
investments and to address institutionalization of health systems, 
including human resources, financing, drug management, quality 
improvement, and information systems and evaluation, that will promote 
sustainable capacity. This process will produce a 3- to 5-year phase 
down plan developed with the country. In this way, we plan to have a 
responsible process for dealing with countries that make good progress, 
while at the same time keeping our eye on the unmet need of countries 
with continued high burdens.
                family planning and reproductive health
    The United States is firmly committed to promoting the reproductive 
health and well-being of women and families around the world. Over the 
years, USAID has become the acknowledged leader in implementing the 
U.S.'s global voluntary family planning assistance program. Our 
portfolio of interventions strongly emphasizes method choice and 
includes a mix of contraceptives that are country appropriate and can 
include long-acting methods, injectibles, and fertility awareness 
options, sometimes known as natural family planning. We are fully 
committed to informed choice and to ensuring that family planning users 
know the risks and benefits of the method they choose. USAID supports 
these contraceptive options with a range of activities to advance 
service delivery, the quality of the medical care and counseling, and 
the effectiveness and sustainability of family planning programs. Our 
work includes helping to create an enabling environment for family 
planning programs, support for research on improved contraceptive 
methods, training of health care providers, and helping nations create 
a commodities logistics system.
    Since our program began in 1965, the use of modern family planning 
methods in the developing world, excluding China, has increased by a 
factor of four, from less than 10 percent to 42 percent. In the 28 
countries with the largest USAID-supported programs, the average number 
of children per family has dropped from more than 6 to 3.4. Moreover, 
abortion rates have declined in Eastern Europe and Eurasia. Using 
Romania as an example, abortion was the primary method of family 
planning through the early 1990s, with women having as many as four 
abortions in their lifetime. When modern contraceptive use more than 
doubled between 1993 and 1999, the abortion rate decreased by 35 
percent and abortion-related maternal mortality dropped by more than 80 
percent.
    USAID's program is unique in a number of ways: it is comprehensive 
in its support (with activities ranging from contraceptive development, 
to community-based delivery of FP/RH services), it works through 
multiple channels of delivery (including private sector and NGO 
sector--while other donors tend to focus on public sector and 
increasingly on basket funding), and it has on-the-ground health 
experts that direct, oversee, and manage bilateral activities. We have 
pioneered program approaches and continually develop new interventions 
that will accelerate progress.
  --Our efforts have made family planning services accessible to people 
        in hard-to-reach areas. These include door-to-door 
        distribution, clinic-based services and employee-based 
        programs.
  --USAID introduced contraceptive social marketing. These programs 
        privatize contraceptive distribution and marketing, using the 
        commercial pharmaceutical sector to reach more people at lower 
        cost, decreasing countries' dependence on the donor community 
        for supply and distribution of affordable commodities.
  --We support the world's largest information/education programs that 
        use in-country media and local entertainment outlets, 
        performers, and groups to educate millions of people about 
        contraception, child care, and health.
  --USAID created and standardized the largest repository of fertility 
        and family health information, the Demographic and Health 
        Survey, which is used by policy makers and program managers in 
        developing countries and the donor community to assess impact 
        and make informed decisions about program design and 
        management.
  --We are the major donor in developing new and improved contraceptive 
        methods and supporting research to improve existing 
        contraceptive technology. These innovations provide couples in 
        developing countries with superior and safe methods of family 
        planning. Americans also profit from USAID-supported 
        improvements, such as the introduction of low-dose oral 
        contraceptives and the female condom.
  --USAID has always given high priority to providing contraceptive 
        supplies and related assistance in logistics and quality 
        assurance. USAID provides 50 to 70 percent of all contraceptive 
        assistance in the developing world and nearly all logistics 
        management assistance.
    We have successfully graduated numerous countries and others with 
mature programs are on the road towards graduation from family planning 
assistance, allowing us to respond to countries where unmet need is 
still critical. Currently we are strategically shifting family planning 
resources towards sub Saharan Africa. The fiscal year 2008 budget 
request targets 43 percent of family planning resources to the region.
    Graduation of several countries from U.S. government assistance for 
family planning also is an indicator of USAID's success. In addition to 
the overall measures of lowering fertility and high levels of 
contraceptive use across income groups, successful graduation from 
family planning assistance requires that a number of specific elements 
are in place, including national commitment to family planning, 
adequate financing for programs, contraceptive security, sustainable 
leadership and technical skills, availability of high quality 
information, appropriate engagement of the private sector, and 
attention to access of underserved populations.
    The Asian countries of Indonesia, Thailand, and Turkey have 
graduated from family planning assistance. Egypt will graduate by 2010. 
In Latin America, Brazil, Mexico, Colombia, and Ecuador are no longer 
receiving family planning assistance. Family planning programs in the 
Dominican Republic, Jamaica, and Paraguay are on track to graduate from 
USAID family planning assistance in the next few years. In Europe and 
Eurasia, programs in Kazakhstan, Kyrgyzstan, Moldova, Romania, Russia, 
and Uzbekistan have successfully increased contraceptive use and 
thereby reduced abortion.
    As the world's largest bilateral donor, USAID delivers assistance 
in more than 60 countries through bilateral and regional programs. Each 
year, U.S. reproductive health programs deliver services to more than 
20 million women, including clinical services as well as non-clinic 
based approaches to deliver services to the hard-to-reach. The Agency 
works directly with hundreds of non-governmental organization partners, 
the majority of which are foreign NGOs, to provide technical assistance 
to family planning programs at the local level. Assistance is also 
provided through U.S.-based universities, and private sector companies 
and organizations.
    Despite our strong record of achievement, our work is not done. 
Women's health burden remains great:
  --More than 500,000 women die annually from maternal causes, almost 
        all of them in the developing world. Family planning helps 
        reduce maternal mortality by reducing unintended pregnancy and 
        the perceived need by many to resort to abortion, as well as by 
        ensuring that the proper spacing is achieved between wanted 
        pregnancies.
  --Of these annual pregnancy-related deaths worldwide, about 13 
        percent (or 78,000) are related to complications of unsafe 
        abortion. The United States believes one of the best ways to 
        prevent abortion is by providing high-quality voluntary family 
        planning services and providing assistance to prevent repeat 
        abortions through the use of family planning. As a result, 
        USAID-supported family planning programs in Eastern Europe have 
        resulted in significant declines in abortion as contraceptive 
        use has increased. 
        
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Unmet need continues to be a challenge
    There remains a great need--and desire--for family planning. While 
more than 400 million women in the developing world are now using 
family planning, there are an estimated 137 million with an unmet need 
and 64 million using traditional, rather than modern, contraceptive 
methods.
    Unmet need is particularly great in Africa. There, nearly half of 
the world's maternal mortality occurs and on average only 15 percent of 
married women use contraceptive methods. The desired fertility in the 
region is considerably lower than actual fertility, which remains high 
at 5-7 children per women in most countries. Although demographic and 
health surveys reveal that a high proportion of women and men--well 
more than half in many African countries--said they wanted to wait at 
least 2 years before having their next child or that they had the size 
family they wanted, there were, in fact, nearly 39 million unintended 
pregnancies in Africa between 1994 and 2000--clear evidence of the need 
for family planning. In too many African countries, attention to family 
planning has declined and donor and government funding has stagnated. 
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There are significant opportunities to accelerate progress
    Though family planning is primarily viewed through the prism of 
women's health, research has shown that the women themselves view 
family planning in broader terms. They believe that having smaller 
families and spacing births not only improves health, but increases 
opportunities for education as well as for greater domestic and 
community involvement. Their instincts are right--women are critical to 
achieving development goals.
    The impact of family planning on children's lives often is not 
considered. More than 10.5 million children under the age of 5 die 
every year in the developing world. Many of these deaths can be reduced 
by expanding access to family planning. Births that are spaced too 
close together, too early, or too late in a woman's life decrease both 
the mother's and infant's chances for survival. Children born too close 
together face increased risk of contracting and dying from infectious 
diseases and can suffer high rates of malnutrition. By helping women 
space births at least 3 years apart and bear children during their 
healthiest years, family planning could prevent many of these deaths. 
Research done in 2003 has shown that if women had not had any births at 
intervals less than 24 months, almost two million deaths to children 
under age 5 could have been averted. Additional deaths also would have 
been averted if mothers had spaced births at least 36 months apart. 
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    The education of women is critical. Research has shown a strong 
link between girls' literacy and many other development objectives. 
Women who start families before age 20 are less likely to finish school 
than those who wait even a few years. Early and frequent childbearing 
can limit women's education. The importance of family planning in 
allowing women to stay in school goes beyond the women themselves. 
Mother's education is an important predictor of children's educational 
attainment and therefore of their future earnings. Conversely, 
education also improves use of family planning services. Studies show 
that women with as little as 2 or 3 years of formal schooling are 
significantly more likely to use reliable family planning methods than 
women with no formal education.
    Employment allows women to earn income, which increases life 
options and involvement in the community. Family planning users often 
are more likely than non-users to take advantage of work opportunities. 
In addition, high levels of female labor force participation and higher 
wages for women are associated with smaller family size. As women enjoy 
greater economic opportunities and as family income rises, they spend 
more money on the education and nutrition of their children, continuing 
the cycle of opportunity. This in part explain why micro-finance is 
such a powerful tool today in development, both economic and social 
development.
    Working with key international partners, family planning has now 
come to embrace a broader mandate.
  --Ensuring that family planning is introduced into policies, 
        programs, and services whenever there is a natural link. At the 
        country level, this aims to ensure that there are no missed 
        ``good'' opportunities.
  --Recognizing that program development is situation specific, USAID 
        will draw on the best current programmatic evidence to 
        determine priority interventions and conduct further research 
        to identify the best approaches that can be scaled up.
  --Programming for impact: underscoring that opportunities and 
        challenges differ in each country, local data and experiences 
        will be used to help determine which approach to strengthening 
        family planning will have the greatest impact.
  --Exploring strategies to reduce the large inequities--among the poor 
        and hard to reach--in family planning access, method choice, 
        and information among population subgroups.
  --Promoting national ownership and responsibility for the 
        strengthening of family planning services despite current 
        shifts in priorities and economic environments.
  --Ensuring optimal allocation of resources and strengthening of 
        technical and managerial capacity as prerequisites for 
        sustainable family planning programs.
  --Multisectoral approaches: strengthening linkages between health and 
        other sectors so as to make use of all available entry points 
        and opportunities to introduce family planning and address 
        unmet need.
    USAID also has several special initiatives that broaden our work 
beyond ``bread and butter'' family planning programs. Among them:
  --Reproductive health programs can be effective partners in HIV/AIDS 
        prevention in developing countries. Incorporating education and 
        counseling to promote condom use and other HIV/AIDS prevention 
        methods in reproductive health programs can contribute to the 
        fight to stop the spread of the epidemic. In addition, research 
        shows that adding family planning into programs for the 
        prevention of mother to child transmission of HIV (PMTCT) can 
        greatly reduce the number of orphans while saving the lives of 
        thousands of women and children.
  --Slowing the rate of population growth gives nations time to develop 
        sustainable solutions to other development challenges. Access 
        to reproductive health programs can contribute to preserving 
        the world's endangered environments by conserving scarce 
        resources. Currently, more than 505 million people live in 
        areas already experiencing chronic water shortages, a number 
        that is expected to increase to 2.4 billion in the next 20 
        years. In addition, in the past 3 decades, growing populations 
        have caused 10 percent of the world's agricultural land to be 
        lost due to residential and industrial needs. When reproductive 
        health and family planning information are widely available and 
        accessible, couples are better able to achieve their desired 
        family size. This not only directly impacts the well being of 
        families, but also contributes to both better management and 
        conservation of natural resources.
  --The Office of Population and Reproductive Health has other special 
        initiatives that address women's health and status in society 
        in innovative ways. These include working to bring about the 
        abandonment of female genital cutting; increasing male 
        involvement in family planning; gender violence; health equity 
        which is how to ensure the poorest of the poor receive our 
        services and programs; the reproductive health of refugees; the 
        availability and sustainability of health commodities including 
        contraceptives and condoms; and repositioning family planning 
        as attention and resources to this crucial health intervention 
        are sometimes neglected because of the understandable focus on 
        such pressing health concerns as HIV/AIDS.
We can take advantage of these opportunities by capitalizing on 
        existing resources and by focusing on key countries
    USAID must address the great unmet need for family planning that 
continues to exist by:
  --Maximizing access to good-quality services;
  --Emphasizing communication;
  --Focusing on men as well as women;
  --Increasing our efforts to reach the very poor.
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    Also, family planning programs can develop better links with other 
services for new mothers and young children. Making common cause among 
such programs should be efficient because unmet need is concentrated 
among women who are pregnant unintentionally or who have recently given 
birth. We are developing approaches to address high levels of need in 
the poorest countries of the world. I have spoken of the profound need 
to expand our programs in Africa. Significant need also continues to 
exist in low contraceptive prevalence countries in Asia, such as 
Afghanistan, Cambodia, northern India, Pakistan, and Yemen, where 
prevalence is below 25 percent. In Latin America, USAID is 
concentrating its family planning resources in Guatemala, Bolivia, and 
Haiti where contraceptive use ranges from 22 to 35 percent.
    However, USAID's targeted countries, particularly those in Africa, 
face a number of challenges in their quest to meet the family planning 
needs of its population. Among these are weak health systems, poor 
access to family planning commodities, the non-involvement of men in 
family planning interventions, and inefficient utilization of 
resources.
    We also must employ interventions that will ensure family planning 
remains on the agenda of all sectors and continue improving access to 
all services. Other interventions include strengthening national 
capacity for sustainable programs, strengthening community 
participation, addressing family planning needs of vulnerable 
populations, and conducting operations research.
                  building capacity while saving lives
    Our programs are aimed at achieving impact in saving the lives and 
improving the health of mothers and children. At the same time, we are 
a development agency--we therefore believe that everything we do should 
also build the capacity of countries and people to improve their own 
situations. To do this, our program investments aim to build 
integrated, sustainable approaches and develop key components of the 
health systems countries need to deliver all basic health services. Let 
me touch on several specific areas of particular importance.
Integration
    As I noted in my introduction, we recognize the important positive 
connections among voluntary family planning and birth spacing, good 
maternal care, and child health and nutrition programs in terms of 
health outcomes for women and children. To achieve these synergies, and 
at the same time build strong and cost-effective platforms for broader 
primary health care services, we implement integrated maternal-child 
health and family planning programs in almost all countries 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 for women who want to delay a future pregnancy, 
which will help preserve their health and that of their infants. In 
areas where malaria is prevalent, we promote antenatal care as a key 
opportunity to provide antimalarial 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 high HIV environments, 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. 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 programs for women's groups that promote family planning, 
breastfeeding and child nutrition, and birth planning; these groups 
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.
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, and thus the huge number of potential claims 
on additional resources. As has been seen in some countries where a 
broad focus on health systems has replaced a clear focus on health 
outcomes (Zambia in the 1990s, Ghana recently), investment in systems 
not linked to outcomes will not necessarily improve the survival and 
health of women and children. USAID is recognized as a major 
contributor to approaches that strengthen key elements of health 
systems, while doing so in ways that link these investments to 
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. The Agency's 
``Maximizing Access and Quality'' initiative has impacted every country 
we assist and has even further reach. For example, quality improvement 
approaches have led to the development of a Global Handbook that 
documents protocols and best practices for family planning services. 
This document, which has been translated into eight languages, is 
published by the WHO and is used by USAID funded programs in more than 
60 countries through WHO's reach. Quality improvement approaches have 
led to the development of ``standards of care'' for maternal and child 
health services and the use of these standards to measure and improve 
quality of services. 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 by pneumonia by 38 
percent.
    Drug and Commodity Supply and Logistics.--USAID is a major 
supporter of systems that provide, distribute, and track contraceptive 
commodities and other essential public health commodities. Last year, 
shipments for contraceptives and condoms were provided to 52 countries 
and additionally, many of these countries also received anti-retroviral 
drugs and diagnostics. Additionally, technical assistance 
pharmaceutical management and/or supply chain strengthening was 
provided in at least 39 countries. For maternal and child health, where 
most drugs and commodities are parts of routine health systems, efforts 
have focused on making MCH drugs parts of ``tracer'' systems that 
evaluate the functioning of overall logistics systems by tracking the 
availability and use of selected drugs. For new products, like zinc for 
treatment of diarrhea, USAID works with the U.S. Pharmacopoeia to 
develop 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 that 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 area of USAID engagement 
is support for ``risk pooling'' approaches that remove cost barriers to 
care. One 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).
Human Resources and ``Brain Drain"
    One challenge which faces virtually all of our health programs is 
the movement of trained health care providers away from developing 
countries and into more developed countries--commonly referred to as 
the ``brain drain.''
    As a development agency, USAID has little influence on the policies 
of wealthy countries that receive emigrating health professionals, the 
demand side of this issue. Our strategy in this area focuses on 
retaining trained providers in their countries' health systems, the 
supply side of the issue.
    The in-country factors affecting the healthcare human resource 
supply are more than a shortage of workers or absentee-ism due to 
training. Low salaries and poor working conditions drive workers to 
other types of employment even within their own country. Weak human 
resource management systems do not support workers. The recruitment, 
deployment and promotion of workers are often politicized and not 
performance-based. Additionally, an inappropriate alignment of the 
workforce means that tasks are often assigned to the wrong types of 
workers causing overly burdensome workloads.
    USAID is actively engaged in multiple efforts within countries to 
increase retention and contribute to greater worker productivity. 
Specifically, in almost every country where USAID has programs, USAID 
is developing and/or strengthening in-service training systems to 
provide workers with the knowledge and skills needed to do their jobs; 
often utilizing innovative learning approaches, such as distance 
learning and self-directed learning, in order to minimize the time 
workers are out of post for training. USAID is collaborating with 
Ministries of Health to strengthen supervision systems so that they 
provide positive support to workers, and is instituting quality 
improvement methodologies that encourage workers to take an active role 
in ensuring the quality of the services they provide.
    Keeping workers on the job is essential to increasing the number of 
workers. In five African countries, several approaches are being tested 
and implemented in USAID programs, including: piloting financial and 
non-financial incentives; developing clear and equitable careers paths; 
offering continuing education and professional development. There has 
been an increased retention of workers in Ghana, Namibia and Uganda 
with improvements to the working environments and benefits such as 
transportation reimbursements.
    Improved management and modern quality improvement approaches are 
affordable and have the potential to improve dramatically the way 
health systems manage their human resources, helping to retain workers. 
USAID provides support for workforce planning and rationalization in 
six countries. Human resource (HR) managers are assisted to develop the 
skills needed to scan and analyze HR data, determine relevant policy 
questions, and make policies to ensure that workers with appropriate 
skills are available when and where they are needed. In several 
countries, HR Directorates in Ministries of Health are being 
strengthened through training of key staff and through secondments of 
HR experts who then share their knowledge and skills so as to create 
strong HR managers. In a number of countries, USAID is assisting MOHs, 
licensing and certification bodies, private-sector organizations and 
other stakeholders to develop the human resource information systems 
they need.
Sustainability
    Sustainability of MCH and family planning programs is a critical 
goal of USAID. To this end, we aim to:
  --Increase funding by host governments of national MCH/FP programs.
  --Increase diversification and long-term funding of MCH/FP activities 
        by donors and international organizations.
  --Improve the quality of national MCH/FP activities and establish 
        critical masses of health workers competent in MCH/FP 
        interventions.
  --Achieve high and sustained national coverage rates for MCH/FP 
        interventions.
  --Reduce inequities in access to health care and in health outcomes.
  --Involve community, voluntary and private sector organizations in 
        MCH/FP activities at national, district and community levels.
    With progress on each of these elements, MCH/FP programs will 
become more effective and sustainable. More importantly, national 
leaders, health managers, and the general population will expect and 
demand effective, nationwide MCH/FP programs and will help to make this 
happen. There will also develop an international mandate that no 
country will suffer stock-outs of essential MCH/FP commodities. This 
has already occurred for child vaccines. Finally, national governments 
and international donors and organizations will be judged by the 
quality and coverage of their MCH/FP programs.
    There is now evidence that USAID, other donors, and national 
governments are helping to make important progress on all these key 
elements of sustainability. For example:
  --There is evidence that host government contributions to MCH/FP 
        programs have increased in real dollar terms over the past 10 
        years.
  --Coverage rates for key MCH/FP interventions are steadily 
        increasing. For example, the worldwide coverage for the third 
        dose of the DPT vaccine is 74 percent and for vitamin A is over 
        50 percent.
  --As highlighted above, there are major new commitments of 
        international partners to MCH/FP and some new funding 
        mechanisms that promise long-term support for the sub-sector.
Complementary Funding and Global Development Alliances
    USAID funds have complemented over $4.6 billion from partners to 
advance development objectives worldwide.
    USAID provides leadership in the Reproductive Health Supplies 
Coalition (RHSC), a coalition of 21 members--multinational 
organizations, bilateral and private foundation donors, low and 
moderate income country governments, civil society, and the private 
sector--that works to increase political commitment and public and 
private financial resources, as well as more effective use of resources 
to ensure sustained access to quality reproductive health supplies 
through public, private, and commercial sectors.
    USAID supports the Global Alliance for Improved Nutrition (GAIN) to 
accelerate micronutrient fortification programs globally and to 
mobilize the private sector to deliver fortified products to the poor. 
The Alliance includes 14 governments; three donors; the United Nations; 
the private sector including Proctor and Gamble, Unilever, Danonoe, and 
Heinz; development agencies such as the World Bank; education and 
training institutions; and civil society. The Alliance has supported 15 
national food fortification programs projected to reach 446 million 
people.
    Between fiscal year 2001 and fiscal year 2006, USAID contributed 
$352.5 million to GAVI as one of the largest government donors 
representing nearly 20 percent of GAVI's funding. Since GAVI's 
inception in 1999, the Gates Foundation combined with a variety of 
donor governments has contributed a total of $1.9 billion.
                               conclusion
    USAID sees improved health for the world's poorest people not only 
as a moral imperative but also as a pragmatic investment of U.S. 
funding for peace, security, and world-wide economic growth. USAID-
supported MCH/FP programs have a proven record of success which is 
helping to save lives and build health systems. Our support has helped 
to reduce under-five mortality in almost 30 countries and maternal 
mortality in ten countries. USAID-supported family planning programs 
have been successful in increasing access to and use of modern 
contraceptives in all regions of the world. We now have program 
approaches and new interventions that will allow us to build on these 
successes and make additional progress. We also have valuable 
experience in delivering these interventions and approaches in a fully 
integrated and cost-effective manner at district, health center, and 
community levels so that these life-saving services can be affordable 
and sustainable. With the continued support of Congress, we will be 
able to contribute to further gains in maternal and child health and 
family planning throughout the developing world. Thank you for your 
support.

    Senator Leahy. Thank you very much. I read your testimony 
last night, and I know your personal commitment to this.
    Dr. Gayle, thank you for being here. I've heard you speak 
many times before, and I just appreciate you taking the time 
here.
STATEMENT OF DR. HELENE GAYLE, PRESIDENT, COOPERATIVE 
            FOR ASSISTANCE AND RELIEF EVERYWHERE
    Dr. Gayle. Thank you very much, Chairman Leahy, and thank 
you for having us here, and thank you for your consistent and 
passionate commitment to these issues.
    I'm really honored to be here in front of you, and with the 
other witnesses here who, also, as you said, bring a lot of 
experience, and are very distinguished in this area.
    I represent the organization CARE, which is committed to 
reducing global poverty, and have broadened from what I was 
doing in the past, focusing on health issues, because I believe 
strongly that poor health and poverty are very intertwined. And 
so, that's the context in which our work is done, where we feel 
that health has such an important contribution to our work in 
eradicating global poverty, and vice versa.
    I'm not going to go through a lot of the facts, I think 
people have put those on the table, and I think have very 
eloquently pointed out that there are very unacceptable gaps in 
maternal mortality and child health and child survival around 
the world, and important unmet needs in family planning and 
contraception.
    Also, I think the testimony that Dr. Hill gave pointed out 
the incredible advances that the U.S. Government, particularly 
through USAID, has made, and the real leadership role that we 
have played around the world on these important health issues. 
I think--if nothing else--I would say our message is that we 
would like to continue to see the United States play that kind 
of global leadership role in these issues, and that we have an 
opportunity to continue to build on these incredible advances 
that have already been made.
    So, important progress has been made, but I think as has 
been pointed out, there is still a lot that remains, and that 
in some ways, we've become complacent about basic public health 
issues, like maternal and child health, and family planning as 
we have moved to focus on very key, specialized issues, like 
HIV and malaria and others, where we have seen incredible, and 
important, growth. But, I think, in the meantime it means that 
we've kind of let our eyes off of some of these very basic and 
core issues, where we have such a basis for continuing to 
build.
    Let me just make a few points from our experience, and then 
some recommendations. I'll make first, four points. First of 
all, that technical solutions alone will not bring about 
lasting results. Obviously, it's important to continue to look 
for better and new technologies, but for health impacts to be 
sustainable, they must also address the underlying causes of 
poor health, and the reasons why people don't have access to 
these technologies to begin with, and making sure that we have 
a focus on that.
    So, for example, we had a project in Peru, in an area in 
rural Peru, where CARE found that only one-third of women who 
needed obstetrical services actually accessed them. I mean, 
this is in an area where mortality--maternal mortality was 
about 15 times higher than it is here in the United States.
    But, by working to understand the needs of the rural women, 
for example, giving respectful attention from staff to speak to 
women in local language, provide access to transportation, 
provide basic facilities that met the needs of those women, and 
by connecting health workers at various levels, and really 
looking at, how do you distribute health services at different 
levels, and removing blocks to emergency referral care and 
services, CARE was able to reduce maternal mortality by half.
    So, even if the services are there, if they're not 
appropriate, if they don't take local circumstances into 
consideration, the needs won't be met. And so, we have to look 
at coupling our technology with ways to get it to people that 
are appropriate.
    Second, we learn that by being marginalized and powerless 
within a society, is often closely linked to one's ability to 
access healthcare services, and is linked to overall health 
status of the most vulnerable. The--less power means that 
people have less voice, and often less access to services. In 
most developing countries, women and youth are the least 
powerful, and the roots of health problems they face are often 
hidden.
    An example, from our work in Bangladesh, where CARE is 
working on a Safe Motherhood Initiative, we found that domestic 
violence was really the--one of the greatest risks that women 
faced during pregnancy, and that if we didn't address the 
domestic violence issues, and look at women's needs in a 
holistic fashion, that our obstetrical care programs didn't 
work. We were able to modify our approach to incorporate 
efforts to prevent violence against women in our Safe 
Motherhood Work, and found that our programs were much more 
effective and were actually able to reduce maternal mortality.
    Third, and Dr. Hill mentioned this as well, we've learned 
that dividing public health into various categories--while it 
may be convenient for allocating donor funding--that it really 
doesn't, is not the most effective way to approach health 
services.
    So, for example, maternal mortality and child survival are 
not separate activities. In some countries, if the mother dies, 
the risk of death for her child and her children under 5 
doubles or triples. Sometimes, as with HIV/AIDS, and 
reproductive health, we not only pursue them as separate 
issues, but also build parallel systems to develop services, so 
that we're not wasting resources that make our services more 
ineffective.
    So, by providing HIV information and testing to reach 
women, within the context of reproductive health, we obviously 
have much more effective programs.
    Then finally, we at CARE are dismayed by what seems to be a 
tendency to move away from evidence-based programs within the 
U.S. foreign assistance programs, particularly as they relate 
to sex and reproductive health. So, for example, the abstinence 
until marriage earmark in the Global AIDS Act of 2001 is a 
concern, whether or not it impedes the ability to have 
comprehensive and evidence-based programs that focus on the 
best programs and the epidemiology within local circumstances.
    Let me just wrap up by saying a few things that we would 
like to recommend. First, investing more, and more 
strategically in reducing maternal mortality and enhancing 
child survival. Over the past 5 years, the commitment to 
maternal and child health funding has not kept pace with the 
unmet needs or growth in other international health accounts, 
as has been well outlined. We urge you to provide strong 
funding levels for international maternal and child health 
programs. In particular, CARE strongly supports the U.S. Fair 
Share levels that Nils Daulaire will outline shortly.
    Second, a recommitment to the importance of family 
planning. This is one of the most cost-effective investments 
the United States can make in the future of women, children, 
communities and nations. The administration's budget request 
proposes a 23 percent cut in family planning funding for 2008, 
noting that these efforts do not require as much U.S. 
investment, because they've been so successful. Well, this is 
obviously the case, and we urge you to, not only restore those 
cuts, but to increase funding levels for international family 
planning.
    Also like to draw attention to the reports that the World 
Bank's new Health, Nutrition, Population Strategy that's going 
to be discussed here in Washington, appears to diminish their 
commitment to family planning, and we see this as an area of 
great concern.
    Third, commit to evidence-based reproductive health 
programming for youth. With the impending youth bulge that is 
going to occur, that's anticipated by demographers, the needs 
for reproductive health services that are tailored to the 
conditions for youth are critical and important.
    Fourth, removing any legal barriers that get in the way of 
evidence-based, effective programming in reproductive health 
and HIV. As mentioned, our concerns about any particular 
earmarks that don't provide for comprehensive funding.

                           PREPARED STATEMENT

    Finally, investing more globally in global health and 
development, in ways that help to strengthen the health 
infrastructure. As is previously noted, the importance of 
building a workforce capacity, without that, and without a 
strong commitment to the overall health infrastructure, none of 
these individual programs will be successful.
    [The statement follows:]
                 Prepared Statement of Dr. Helene Gayle
    Chairman Leahy, Senator Gregg, Subcommittee Members. I am honored 
to be here, discussing issues that are vital to the future of millions 
of people. For the past 61 years, CARE has worked across a spectrum of 
poverty-fighting arenas--from child survival to clean water, and from 
basic education to HIV/AIDS. We believe that poor health and extreme 
poverty are intertwined, and that one cannot be overcome if the other 
is neglected. That is why we work on a broad range of health issues, 
including maternal and child health, infectious diseases, ranging from 
HIV/AIDS to avian influenza, and reproductive health. My testimony 
today reflects CARE's experience in thousands of poor communities 
throughout the world over the course of half a century.
    We are here today to consider some basic, yet heart-wrenching, 
questions. Why does one woman die every minute of every day from 
complications related to pregnancy and childbirth? (99 percent of these 
deaths occur in developing countries, and the reasons are basic: women 
hemorrhage to death, they lack access to antibiotics to prevent 
infection or they don't have the option of a cesarean section.) Why do 
10.5 million children die each year before their fifth birthday 
(greater than the number of adults who die from AIDS, malaria and 
tuberculosis combined), when most of these deaths are preventable? Why, 
at a time when contraception is cheap and effective, do 120 million 
couples have an unmet need for family planning? Why, when some 70 
percent of young women in Africa become sexually-active as adolescents 
and more than 20 percent have their first child by 18, do we hesitate 
to confront that reality?
    Despite the magnitude of unmet need that remains, the U.S. 
Government can be proud of the difference it has made in the global 
health arena.\1\ For example, American leadership in family planning 
has contributed to some impressive gains. In 1960, only 10 percent of 
married women in developing countries used modern contraception. By 
2000, this figure had risen to 60 percent--and the average number of 
births per woman had fallen from six to three. More broadly, in the 
past 50 years, life expectancy in the developing world has risen from 
40 to 65 years, and a child's chance of living to the age of five has 
doubled.
---------------------------------------------------------------------------
    \1\ A recent analysis of six projects funded by USAID's Child 
Survival and Health Grants Program indicates that mortality of children 
under 5 has been reduced by approximately 8 percent in project areas 
due to interventions supported by the program.
---------------------------------------------------------------------------
    We have learned that large-scale improvements in public health are 
achievable. We have seen the real difference made in lives saved and 
economies strengthened. Sri Lanka's long-term commitment to a range of 
safe motherhood services has, over four decades, decreased maternal 
mortality from 486 to 24 deaths per 100,000 live births. In Egypt, a 
national campaign that promoted the use of oral rehydration therapy 
helped reduce infant diarrheal deaths by 82 percent between 1982 and 
1987. China's national tuberculosis program helped reduce TB prevalence 
by 40 percent between 1990 and 2000, and translated directly into 
social and economic benefits: for each dollar invested in the program, 
$60 was generated in savings on treatment costs and increased earning 
power of healthy people.\2\
---------------------------------------------------------------------------
    \2\ Center for Global Development, Millions Saved: Proven Successes 
in Global Health, 2007 edition.
---------------------------------------------------------------------------
    Even though important progress has been made, the need remains 
enormous and urgent. The knowledge and experience we have already 
gained position us to invest resources more wisely--and the 
partnerships formed reflect greater capacity to turn resources into 
effective action. Yet, even as efforts to fight HIV and AIDS are 
receiving greater attention and resources (as they should), we are 
becoming too complacent about basic public health issues like maternal 
and child health, family planning, and adolescent reproductive health. 
And we are not paying sufficient attention to building the strong, 
accountable health systems (both infrastructure and workforce) required 
to support any health interventions, be it neonatal care, family 
planning or AIDS treatment. Ultimately, CARE's experience in poor 
communities strongly supports both the need for increased investment of 
resources, and better use of those resources.
    Our first, and most important, insight has been that ``technical 
solutions'' alone don't bring lasting results. For health impacts to be 
sustainable, they must address underlying causes of poor health, be 
tailored to each cultural context and be broadly owned by local 
communities. For example, emergency obstetric care is vital to reducing 
maternal mortality, but lasting improvements in maternal health are not 
achieved simply by making such care available.
    In rural Ayacucho, in Peru, CARE found that only one-third of women 
who needed obstetric services actually accessed them; and of every 
100,000 live births, 240 women died (by contrast, in the United States, 
this ratio is 17 of every 100,000 live births). CARE did not approach 
this challenge as an exclusively medical problem. Rather, we tried to 
understand the health system in Ayacucho as a unique social institution 
embedded in a specific community. We found that women did not seek care 
because health center staff often did not speak Quechua (the local 
language) and women did not feel welcome there. Health center staff 
felt inferior to regional hospital staff and often felt ridiculed by 
them when they referred an emergency case; they also did not have means 
to transport emergency cases. Hospital staff were frustrated that 
emergency referrals were often misdiagnosed or came too late to save 
women's lives.
    By working to understand the needs of rural women and health 
workers at various levels, and removing blocks in the emergency 
referral system, CARE has helped to reduce maternal mortality in 
Ayacucho by half. Now, all health centers in our project area and the 
regional hospital have Quechua-speaking staff, a friendly environment, 
and culturally-appropriate options for childbirth (such as vertical 
birthing chairs, preferred in Ayacucho). Emergency obstetric protocols 
were developed by collaboration among doctors, nurses, midwives and 
Ministry of Health staff, drawing from ideas and realities of rural 
health personnel. As a result of competency-based training provided to 
rural health personnel and cost-effective resources like two-way radios 
and ambulances, women's conditions can now be diagnosed more accurately 
and they can be transported to hospitals quickly. Currently, 75 percent 
of women who need obstetric services can access them. A key aspect of 
CARE's approach was building broad political will to address the 
exceedingly high maternal mortality rate. As a result of Ayacucho's 
success, in January 2007, the Peruvian Minister of Health established 
new national clinical guidelines for obstetric emergencies, based on 
those developed by this project.
    Second, CARE has learned that individual and collective empowerment 
has much to do with access to health care services, accountability of 
health systems and the ultimate health status of the most vulnerable. 
Less power means less voice and less access, and that inequity results 
in poorer health. In most developing countries, women and youth are the 
least powerful, and their needs are often neglected. The roots of the 
health problems they face are often hidden, but we must strive to 
uncover, understand and address them.
    In Bangladesh, where CARE had been implementing a safe motherhood 
initiative, we concluded that domestic violence was one of the greatest 
risks that women faced during pregnancy. Even the best prenatal, 
obstetric and post-partum care could not fully help these women, unless 
the phenomenon of rampant violence against women was also addressed. 
CARE's modified approach, of incorporating efforts to prevent and 
respond to violence against women into safe motherhood work, holds much 
more promise not only of helping women have healthier pregnancies but 
also of securing safer societies. In isolated southern Maniema 
province, in the Democratic Republic of Congo, local health systems 
were devastated by war and women had encountered brutal violence and 
rape in war-time. Many women had married young and had multiple 
pregnancies, and CARE's promotion of family planning and birth spacing 
was welcomed as a respite--a chance to control at least one aspect of 
their bodies and lives. A young woman named Anifa told us: ``Normally, 
I'd be pregnant again, and able only to concentrate on my new baby, and 
not my other children. Now that I can control my pregnancies, I can be 
sure that my kids go to school. I will see a better life through my 
children.''
    Third, we have learned that dividing public health into various 
categories may be convenient for allocating donor funding, but these 
inherently related issues have to be understood and addressed within a 
broader and more integrated context. For example, we talk about 
maternal mortality and child survival as separate issues, but we know 
that they cannot be separated. In some countries, if a mother dies, the 
risk of death for her children under 5 doubles or triples. When women 
cannot space the births of their children, both they and their children 
are less likely to be healthy. Sometimes--as with HIV/AIDS and 
reproductive health--we not only pursue them as separate issues, but 
also build parallel systems to deliver services. This is ultimately a 
less efficient investment of resources as well as a barrier to 
effectiveness--for example, HIV information and testing could reach 
many more women, in ways that are potentially less stigmatizing, if 
they were made available through family planning or prenatal care 
services. Even within CARE, which is considerably less complex than the 
U.S. government, maintaining a system-wide view and integrating across 
various sectors and technical specialties is a challenge. We are 
constantly trying to do better.
    Finally, we at CARE have been dismayed to witness the increasing 
politicization of U.S. foreign assistance related to programs that deal 
in any way with sex or reproduction.\3\ For example, the abstinence-
until-marriage earmark in the Global AIDS Act of 2003 requires that 
one-third of all HIV prevention funding be spent on abstinence 
programs. Administrative guidance issued by the Office of the Global 
AIDS Coordinator translates this earmark into a requirement that fully 
two-thirds of funding for preventing sexual transmission of HIV be 
spent on abstinence and fidelity programs. It also permits condoms to 
be provided only to sexually-active youth, with little recognition of 
the fact that those who are not sexually-active today may be so 
tomorrow (no matter how much we urge them to be abstinent) due to 
economic pressures driving transactional sex or vulnerability to sexual 
violence. Although the earmark governs only the U.S. Government's HIV/
AIDS responses, the message that A and B are the priorities have 
strongly influenced U.S. reproductive health programs--especially those 
working with adolescents. The spillover effect is that reproductive 
health programs targeting youth are increasingly constrained in terms 
of the information and services they can provide--as a result, U.S. 
funded programs are less effective at protecting young people from 
pregnancy, or HIV and other STDs.
---------------------------------------------------------------------------
    \3\ In addition to the abstinence-until-marriage earmark and the 
Mexico City Policy, increased politicization is also evident in the 
requirement of the Global AIDS Act of 2003 that organizations must 
adopt a policy opposing prostitution and sex trafficking in order to be 
eligible for HIV/AIDS funding authorized under the act.
---------------------------------------------------------------------------
    From CARE's perspective, family planning and women's reproductive 
health have become too politicized and are losing ground on the U.S. 
global health agenda. The Mexico City Policy, in particular, is 
symbolic of this politicization and has caused much difficulty for 
implementers of reproductive health programs. Much of the work of 
international NGOs like CARE is done in partnership with local 
organizations. In the reproductive health field, many of the best local 
organizations provide comprehensive family planning services, sometimes 
including counseling on safe abortion. The Mexico City Policy prohibits 
organizations like CARE from working with such organizations, and in 
some cases, prevents us from working with the only organizations that 
are capable of providing the most basic family planning services. Thus, 
it diminishes not just the availability of these services but also 
their quality.
    These are just some of CARE's experiences that are pertinent to the 
matters at hand today. Given what we have learned, I want to urge you 
to consider the following:
    First, invest more--and more strategically--in reducing maternal 
mortality and child survival. On this, the twentieth anniversary of the 
global safe motherhood movement, the slow progress on reducing maternal 
mortality undermines America's deeply-held commitment to strengthening 
health and well-being throughout the world. We must gather the will and 
do much better. Over the past 5 years, United States commitments to 
maternal and child health funding have not kept pace either with unmet 
needs or with increasing growth in other international health accounts. 
I urge you to provide strong funding levels for international maternal 
and child health programs in 2008. In particular, CARE strongly 
supports the requested United States ``fair share'' levels outlined by 
Nils Daulaire on behalf of the Global Health Council for maternal and 
child health, and I urge their adoption by this committee in the coming 
appropriations process.
    The vast majority of maternal deaths are due to hemorrhage, 
infection and obstructed labor and can be easily prevented or treated. 
For each of the half a million women who die of complications during 
pregnancy and childbirth, 30 others are injured, many of them in 
seriously disabling and socially devastating ways. Women with obstetric 
fistulas, for example, are often abandoned by their families and 
condemned to isolation. The lifetime risk of dying in pregnancy or 
childbirth is 1 in 16 for women in developing countries, as compared to 
1 in 2,800 in developed countries. In Afghanistan, where 95 percent of 
women deliver their babies at home, without a skilled attendant on 
hand, the lifetime risk of dying in pregnancy or childbirth is 1 in 6.
    We must invest more strategically, not only to strengthen and 
expand all levels of health care (particularly speed of emergency 
referrals and quality of emergency obstetric care) but also to remove 
barriers to women's access to health systems and services. We must 
strive to ensure that all pregnant women have a skilled attendant at 
delivery; this need not be a doctor, but must be someone who can 
diagnose complications, administer drugs to manage them, and (where 
possible) refer women to emergency obstetric care. Drugs like 
misoprostol, which are cheap and easy to administer, can help 
strengthen contractions and control post-partum haemorrhage, and could 
ultimately increase the effectiveness of skilled attendants and reduce 
maternal mortality.
    Maternal health and child survival go together--this is why funding 
to reduce maternal mortality is such a smart investment. Four million 
babies die each year in the first month of their life; that is roughly 
the equivalent of all babies born in the United States in 1 year. 
Simple interventions like promoting breastfeeding, oral rehydration 
therapy, vaccinations, clean water, and insecticide-treated bed nets 
could make a huge impact on child survival, even where health systems 
are weak. USAID's Child Survival and Health Grants Program has done 
excellent work in this area and deserves your increased support.\4\ In 
partnership with this program, CARE has worked in the extremely poor 
far-west region in Nepal to reduce under-5 mortality by 53 percent. A 
key approach in Nepal was community case management, whereby volunteers 
are trained to provide an antibiotic to treat pneumonia. This 
intervention effectively prevents pneumonia deaths in communities where 
many families do not have the money or means of transportation to see a 
doctor in time. In settings as diverse as Nepal, Mozambique and Sierra 
Leone, CARE has achieved significant reductions in under-5 mortality 
for a cost per life saved of between $740 and $980.
---------------------------------------------------------------------------
    \4\ The analysis referenced in footnote 1 indicates that these 
projects saved more than 16,000 lives of children under 5.
---------------------------------------------------------------------------
    Second, recommit to the importance of family planning. Access to 
family planning services represents one of the most cost-effective 
investments the United States can make in the future of women, 
children, communities and nations. Family planning returns enormous 
value in improved health outcomes, economic development and national 
security. Yet, the administration's budget request proposes a 23 
percent cut in family planning funding for 2008. I urge you to not only 
restore the cut, but also provide significantly increased funding 
levels for international family planning, as the request outlined by 
the Global Health Council indicates.
    The ability to decide when, with whom and how often to have 
children is key not only to the individual futures of women and girls, 
but also to the development of countries struggling to overcome 
poverty. Although methods for avoiding unwanted pregnancies are cheap 
and effective, every year, 80 million women have unintended 
pregnancies. The unmet need for contraception is closely related to 
maternal mortality: if every woman who needed contraception had access 
to it, an estimated 20-35 percent of maternal deaths could be averted. 
However, with other health priorities taking precedence, family 
planning seems to be declining in importance. Between 1995 and 2003, 
donor support for family planning (commodities and service delivery) 
fell from $560 million to $460 million.
    The rationale provided by the administration for the 23 percent cut 
in family planning funds for 2008 is that these efforts have been so 
successful that they don't require as much U.S. investment going 
forward. Unfortunately, that is hardly the case. Large pockets of 
substantial unmet need still remain, and gains are reversed all too 
quickly when they are not reinforced. Kenya, for example, had a 
fertility rate of about eight births per woman in the 1960s. After 
decades of investment in family planning services, the fertility rate 
had fallen to 4.8 births per woman in 1998. In the past few years, 
however, attention has shifted away from family planning. As a result, 
availability of contraceptives at health facilities declined, as did 
outreach services. Sadly, between 1998 and 2003, the proportion of 
births reported by mothers as unwanted rose from 11 percent to 21 
percent.
    On a related note, I also want to register our concern about recent 
reports that the World Bank's draft health, nutrition and population 
strategy omits any commitments to family planning. This strategy is 
under review as we speak today and, if approved, could deal a serious 
blow to reproductive health programs all over the world. CARE urges the 
United States, as the largest shareholder of the World Bank, to 
underscore the importance of family planning and reproductive health in 
achieving progress on multiple fronts, including economic development, 
basic education and public health.
    Third, commit to evidence-based reproductive health programming for 
youth that is grounded in sound public health practice. The impending 
``youth bulge'', anticipated by demographers, demands that we act 
effectively, realistically and rapidly. Sadly, the new strategic 
framework for U.S. foreign assistance fails to highlight the specific 
needs of youth, and places their critical needs underneath a broader 
umbrella. Although the intent to ``mainstream'' youth reproductive 
health is laudable, our observation is that fewer and fewer U.S. 
funding opportunities are addressing youth issues--and we believe this 
important issue may be falling through the cracks.
    Young people, especially girls and young women, are vulnerable on 
many fronts, but especially when it comes to pregnancy, STDs and HIV/
AIDS. They are less likely than older people to protect themselves, 
either because they are not aware of--or cannot access--the protective 
measures that can keep them safe or because they have less control over 
the terms of sexual relations. We must ensure that the needs and rights 
of the most vulnerable young people are protected: for example, 
adolescents at risk of inter-generational or transactional sex; girls 
at risk of child marriage; young people who are victims of gender-based 
violence; and youth in conflict or post-conflict settings. Many young 
people fall into the category of orphans and vulnerable children 
(OVCs), orphaned or made vulnerable due to HIV/AIDS, other diseases and 
conflict, and are left without parental guidance and are particularly 
vulnerable to sexual exploitation. These young people are at risk of 
unplanned pregnancies, HIV/AIDS and other STDs, and therefore, are 
badly in need of comprehensive reproductive health services.
    Fourth, eliminate legal barriers that impede evidence-based 
programming in reproductive health and HIV/AIDS, especially related to 
vulnerable women and adolescents. I urge Congress to repeal the 
abstinence-until-marriage earmark and request the Office of the Global 
AIDS Coordinator to revise its ABC guidance in a way that promotes 
(rather than discourages) comprehensive sex education. I also urge 
Congress to repeal the Mexico City Policy--there is no evidence that 
having this policy in place has reduced the number of abortions 
performed. In fact, by cutting off funds to foreign family planning 
organizations that reject its conditions, the Mexico City Policy has 
most likely increased the number of unplanned pregnancies and led to 
increased numbers of abortions sought.
    In some of the countries in which CARE works, we see the 
implementation of the ABC approach translating into the operational 
message that abstinence and fidelity are the most desirable and moral 
options, and positioning condoms as something used only by people 
engaging in risky sex or as a ``last resort''. When Uganda first 
developed the ABC approach, it was compelling because it demystified 
HIV/AIDS and communicated that individuals had the power to protect 
themselves by choosing among A, B or C options. Delaying sexual debut 
and partner reduction is absolutely vital to preventing HIV and other 
sexually transmitted infections, but that does not mean that A, B and C 
should be broken up into parts and promoted to different segments of 
the population. In settings where risk of HIV infection is high, it is 
a disservice to not provide comprehensive information and prevention 
methods to young people who are not yet sexually active. The young girl 
who we counsel today about abstinence may be married tomorrow (or 
coerced into transactional sex), and we have an obligation to prepare 
her for the future.
    Finally, invest more broadly and strategically in global health and 
development. The U.S. leadership on HIV/AIDS has been admirable, but it 
must be accompanied by broader investments that promote community-led 
development, strengthen health care systems and build workforce 
capacity. We cannot save babies from contracting HIV only to see them 
dying of diarrhea or languishing without access to basic health and 
social services. Our investments in drugs, tests and other health 
interventions will be constrained if there are not enough health 
workers to administer them. If all boats don't rise at similar levels, 
the bold investment in HIV/AIDS may fail to deliver on its promise--and 
other areas in which gains have been made over several decades may be 
undermined. We cannot let that happen.
    I want to thank you for inviting me here today and I look forward 
to answering your questions. CARE has been a partner in the fight 
against global poverty with the U.S. Government and the American people 
for more than half a century and we are grateful for what your support 
allows us to do in thousands of poor communities around the world. We 
look forward to a future of productive partnership and exchange.

    Senator Leahy. Thank you, and I think you understand, 
Doctor----
    Dr. Gayle. No, no, that's fine.
    Senator Leahy. No, I think you understand, also----
    Dr. Gayle. Yeah.
    Senator Leahy [continuing]. From my background that you 
preach to the converted on many of these issues.
    Ms. Garrett, again, as I said earlier, your writings have 
been extremely illuminating. It was recommended to me by my 
staff to make sure to read your testimony, which I did, but 
please, go ahead.
STATEMENT OF LAURIE GARRETT, SENIOR FELLOW FOR GLOBAL 
            HEALTH, COUNCIL ON FOREIGN RELATIONS
    Ms. Garrett. Thank you very much, Senator, and thank you 
very much for your interest and concern in this area.
    I was going to remark that most Senators don't have a 
constituency that provides them with an advantage to taking on 
these issues, they're not make or break issues, but I think 
that may be different for Vermont.
    I'm happy to say that, with my colleague here to the right.
    Speaking of my colleagues, the two prior talks----
    Senator Leahy. Dr. Daulaire is rarely to anybody's right, 
but please, go ahead.
    We don't need that--we don't need that in the transcript, 
I'm sorry. It was just too easy, it was just too easy.
    Go ahead.
    Ms. Garrett. Well, of course from your vantage point, he's 
to my left.
    Senator Leahy. There you go. In fact, Dr. Daulaire is one 
of the most respected health professionals I know--by Democrats 
and Republicans.
    Ms. Garrett. My colleagues have done a wonderful job of 
laying out some of the key issues. What I'd like to do is, you 
have the written text, let me just see if I can hit some key 
points here.
    We are in an age of such fantastic generosity, we have seen 
the amount of money, as your chart indicates, skyrocketed, as 
being dedicated to global health, but it isn't just U.S. 
Government funding, it is across-the-board in increase in the 
amount of generosity pouring into global health. This is a 
skyrocketing that, literally, has occurred in the 6 year's 
time.
    Six years doesn't provide us with a big window to reflect, 
to try to ascertain whether the way we're spending the money, 
whether it's coming from philanthropic sources, such as the 
Gates Foundation, or individuals with great celebrity cache, 
such as Bono and Angelina Jolie and Brad Pitt, or coming from a 
whole host of other Government agencies around the world, akin 
to our USAID.
    It is a phenomenal amount of money, but it has not been 
suddenly flooded in with some overview, with some perspective 
put behind it.
    So, what we're doing is, we're increasing charity, we're 
not building anything. We're increasing charity. One of the key 
pieces of why the charitable incentive has risen so much, is 
because we now have evidence that certain diseases can be held 
at bay with seeming quick-fix drugs, with medicines that can be 
applied to them, and of course, HIV is the big landmark turning 
point, with the 1996 innovation of antiretroviral combination 
therapy.
    But the problem here is that the notion that we can simply 
flood a treatment modality on top of a very, very weak public 
health infrastructure, and suddenly medicalize a public health 
infrastructure overnight, this is--6 years is overnight--and 
turn it into a medical delivery system, that can 
instantaneously get antiretrovirals out to people in rural 
areas all over sub-Saharan Africa, get tuberculosis drugs out 
all over Haiti, get malaria bed meds out all over West Africa, 
this is an absolutely asinine notion. We cannot, overnight, 
scale up, switch our public health format into a medicalized 
treatment intervention format, without having casualties, all 
along the way.
    What are the big casualties? Women and children. Because 
the safety and survival of children under 5 is really, 
absolutely a public health mission. What kills children? Dirty 
water. Getting into their bodies through water, a whole host of 
microbes that shorten their poor little lives.
    What kills those mothers? Not having any kind of health 
delivery infrastructure, so that when they're in labor, and 
when all of the crises of childbirth hit, there's nobody to 
help, there's no where to go. Or, they get there, and because 
it's so grossly underfunded, they are treated with unwashed 
hands, non-sterile instruments, and succumb to infectious 
outcomes from that childbirth.
    We, just, we've talked about the brain drain, but let's 
just really think carefully about what this means. You put that 
much more money overnight into global health, you make the 
priorities of that money about getting pills out the door for a 
variety of different things, or quick-fix technologies, just 
shove them out there, but you don't have enough healthcare 
workers to do any of it.
    Indeed, we have a shortage of well over 4 million 
healthcare workers--sub-Saharan Africa alone is short 1 
million. By the way, I'm not just talking about doctors, this 
is doctors, nurses, lab technicians, health administrators, 
people who know how to do drug procurement, process supplies, 
the logistics, the whole infrastructure that is the essence of 
both public health and medical delivery. That is so weak, it 
was already fragile to the point of breaking, and now all of a 
sudden we put this surge of funding in, but it is funding with 
the priorities set in the wealthy world, not in the poor world, 
with the sense that it's all about ``we'' in the rich world, 
we'll have bragging rights and feel terrific, because we saved 
X number of lives by shoving these pills out the door.
    What's happening in practice, on the ground, is that 
because the healthcare worker crisis is so acute, we're seeing 
healthcare workers skewed towards the places where the money 
is.
    So, I am here wearing a red ribbon, which--as everybody 
knows--is the insignia of the fight against HIV/AIDS. I'm 
wearing that, partly, because I don't want anyone to misread 
what I'm saying to indicate that I somehow oppose the largesse 
that the American taxpayers have put behind PEPFAR and other 
HIV efforts--I am all for it, I think we need more money 
directed to HIV/AIDS.
    But, in the absence of sufficient health systems, of real 
training of people who know how do to health management, and 
corral these meager, weak resources, and fragile 
infrastructures as wisely as possible, what we're going to end 
up doing, and we're already seeing it in some countries, is see 
an increase in child death. An increase in maternal mortality, 
even as we're saving millions of people suffering from HIV/AIDS 
and malaria. Because we're just skewing the programs the way we 
want that money spent.
    So, finally, my main message is, we really need to step 
back and think--how do you fund systems management? We're not 
going to instantly, overnight, get 4 million healthcare 
workers, it's impossible. We do need to be grossly increasing 
the amount of money we put into healthcare worker training, but 
we're not going to fill that gap overnight.

                           PREPARED STATEMENT

    What we need to do is think, how do you train those people 
who are on the ground, in the skill set that is about managing 
meager resources, and doing it wisely to save all lives? Lift 
all boats at once, not just those targeted disease-specific 
boats.
    [The statement follows:]
                  Prepared Statement of Laurie Garrett
    Senator Leahy, Distinguished Members of the Senate Appropriations 
Subcommittee on State, Foreign Operations and Related Programs, and 
Committee Staff: It is a distinct honor to be invited to address you 
today on the subject of global health priorities. I would especially 
like to thank the Committee for expressing interest in this matter. I 
recognize that few of you have constituents clamoring for your 
attention regarding the general health needs of people living far away, 
in desperately poor countries. These are not electoral make-and-break 
issues. It is, therefore, all the more laudable that you are devoting 
time today to their consideration. Again, I thank you.
    My esteemed colleagues preceding me today have done an excellent 
job in describing exactly who is currently under-served by U.S. foreign 
aid and investment, as well as the generous philanthropic, private 
support of the American people. I will not reiterate. I will build on 
their comments, highlighting some critical fault lines in current 
global health funding and directions, and offering some suggestions for 
fresh directions for the Committee's consideration.
    Some of the basic principles, and data, I will mention are 
delineated in a piece I authored for Foreign Affairs \1\ earlier this 
year.
---------------------------------------------------------------------------
    \1\ Garrett, L., ``Do No Harm: The Challenge of Global Health,'' 
Foreign Affairs Jan/Feb 2007, pp 14-38.
---------------------------------------------------------------------------
 age of generosity commences: still not enough, but rapidly increasing
    We are in an age of fantastic generosity. Globalization has brought 
the plights of the world into every living room, and onto every 
computer. As the world public's response to the 2005 Tsunami 
illustrated this internet-driven sense of the immediacy of 
catastrophe--even in places as remote as Aceh, Indonesia--spawns 
remarkable outpourings of finances, donations and goodwill. As little 
as 6 years ago global health commitments totaled a few hundred million 
dollars: Today--combining all government and private sources--we see 
donations exceeding $18 billion. This is not enough, but it constitutes 
a dramatic, even astounding, increase in generosity, realized over a 
short period of time.
    But there are dangers in throwing billions of dollars about in 
emotionally-driven responses to news events, and disease-specific 
campaigns that capture the collective imagination of the wealthy world 
citizenry.
    First, let's be blunt: most of this generosity reflects our 
interests: causes we care about, our national security, and our moral 
concerns.
    Second, for obvious political and, in the case of the private donor 
sector, self-promotion reasons, we want bragging rights. We want to be 
able to say that X amount of money, after 2 years, saved Y amount of 
lives. Most of the health-related legislation signed by President Bush 
and created by the House and Senate is rife with short term, mandatory 
timelines. In order to achieve measurable health targets in 1 or 2 
years, we necessarily have to set extremely narrow, pinpointed goals. 
And on the ground, to achieve such goals, U.S. supported programs must 
corral all available resources, funneling them into one channel of 
health.
               treatment, yes: but not without prevention
    Let me give you an example. About a year ago I was in a small town 
in Haiti. The people in this town were overwhelmed with infectious 
diseases. Their illnesses swamped the beleaguered clinics, where long 
lines of mothers and children stood in the tropical sun for hours on 
end, waiting to see a doctor. The children's growth was stunted; 
mothers couldn't produce enough milk to feed their babies; long-
infected teenagers fought to keep their eyes open in class. In the 
parking lot of the town's main hospital sat two rusted-out, broken 
USAID jeeps, the American insignias clearly evident. Though American 
charities were helping to subsidize the medical training and services 
in the hospital, nobody--no Haitian government agency and no foreign 
donor, looked at this town and asked the obvious question: ``Why are so 
many people sick with dysentery, typhoid fever, and intestinal 
problems? Why are so many children in this town dying before they hit 
their fifth birthdays?''
    The answer: Water. The colonial-era water filtration and pumping 
system had long ago broken down. For about $200,000 the system could be 
fixed, children would drink safe water, and the disease and death rate 
would plummet. But no donor chose to take on that water problem. 
Instead, at the cost of far more lives, and dollars, the donors--
including USAID--funded treatment of entirely preventable diseases, and 
supported the operation of a very busy morgue.
    The emphasis my colleagues placed on maternal and child health is 
wise. What is killing babies and toddlers? The lack of essential public 
health services: clean water, mosquito control, basic nutrition, 
healthy moms.
    What is killing their moms? The lack of medical systems: No safe C-
sections, no sterile equipment for episiotomies, no prenatal care.
    Public health systems keep babies and children alive. Medical 
delivery systems keep their moms alive.
    Systems: Not individual, disease-specific programs--health systems 
are the key. Those targeted programs, such as PEPFAR (the President's 
Emergency Plan for AIDS Relief), are terrific, but without functioning 
public health and medical systems in place, PEPFAR and its like are 
just big band-aids that barely cover gaping wounds.
    We--Americans and the wealthy world, generally--have given, and 
given, and given for decades. Yet the gap between longest and shortest 
lived societies has widened, now a full five decades long. And despite 
mountains of foreign aid from the OECD nations, basic health markers 
such as life expectancy and child survival have barely budged over the 
last 60 years in any sub-Saharan African country--except, thanks to 
HIV, to go backwards in a few.
               going backwards on half a trillion dollars
    Senators, your counterparts in the Canadian Senate recently issued 
a startling report, entitled, ``Overcoming 40 Years of Failure: A New 
Road Map for sub-Saharan Africa.'' The report estimates that over the 
last 45 years the United States, Canada and the rest of the wealthy 
world has spent more than half a trillion dollars in aid and investment 
in sub-Saharan Africa. Yet the World Bank Office in Nairobi estimates, 
``that in 1948 Africa had a 7.5 percent share of world trade; in 2004 
that share had decreased to 2.6 percent. A single percentage decrease 
represents United States $70 billion.''
    ``Africa is diverging from the rest of the world at the rate of 5 
percent per capita income each year,'' The Canadian Senate report 
concludes.\2\
---------------------------------------------------------------------------
    \2\ Canadian Report by the Standing Senate Committee on Foreign 
Affairs and International Trade, ``Overcoming 40 Years of Failure: A 
New Roadmap for sub-Saharan Africa,'' Feb 2007.
---------------------------------------------------------------------------
    Even in parts of the world we have credited as economic success 
stories--where the Asian Tiger roars, and the Latin miracle twinkles--
health remains a striking challenge. The world nervously watches the 
spread of H5N1 influenza--``bird flu''--in Asia, largely in the same 
locations that featured SARS in 2003. Yellow fever, dengue, and malaria 
have all returned to Latin America. Indeed, Jamaica is at this moment 
battling the first malaria outbreak on that Caribbean island in more 
than 60 years, spiraling out of control right in the capital city. That 
is a public health failure. And as the previous speakers told you, 
maternal health is going backwards in much of the poor world--women are 
dying in childbirth in many of these countries at a far greater rate 
than they were half a century ago. Recent United Nations findings on 
maternal mortality show that a woman living in sub-Saharan Africa has a 
1 in 16 chance of dying in pregnancy or childbirth. This compares with 
a 1 in 2,800 risk for a woman from a developed region, and a more than 
1:28,000 risk for a mother in Scandinavia.
    Every effort to battle diseases--from bird flu to HIV--comes up 
against the same set of problems. Congress has, over the last 3 years, 
approved some $8 billion of spending--about 5 percent of it overseas--
to make Americans safer in the face of threatened pandemic influenza. 
But in the big picture the danger has over that time only increased, 
both because of mutations in the evolving H5N1 virus, and because 
quick-fix approaches to disease surveillance and control won't work in 
countries that have no adequate systems of public health and medical 
care.
    Even the Bush administration's laudable PEPFAR program, which 
started out with a fairly minimal mission of providing prevention, care 
and treatment for a single disease, now finds itself forced to build 
medical delivery systems simply to get anti-HIV drugs to the patients 
who need them.
    A just-published critique of the Global Fund to Fight AIDS, 
Tuberculosis and Malaria \3\ charges that unless the Fund starts to 
directly underwrite the salaries of healthcare workers, including 
minimally-educated community providers, the effort will become nothing 
more than ``medicines without doctors,'' an unsustainable program for 
tossing out drugs without providing any actual healthcare.
---------------------------------------------------------------------------
    \3\ Ooms, G., Van Damme, W., and Temmerman, M., ``Medicines without 
Doctors: Why the Global Fund Must Fund Slaries of Health Workers to 
Expand AIDS Treatment,'' PLoS Medicine 4:0001-0004, 2007.
---------------------------------------------------------------------------
                   the world needs healthcare workers
    The world is desperately short of health professionals, and the 
severity of that gap promises to increase sharply in coming years. The 
World Health Organization estimates the shortage breaks down currently 
as follows: \4\
---------------------------------------------------------------------------
    \4\ World Health Organization, ``The global shortage of health 
workers and its impact.'' Fact sheet No. 302, April 2006. http://
www.who.int/mediacentre/factsheets/fs302/en/index.html
---------------------------------------------------------------------------
  --In 57 countries the deficit is labeled by WHO as ``severe'';
  --The world needs, immediately, 2.4 million medical service 
        providers;
  --1.9 million laboratory workers, health managers, and 
        administrators;
  --A total of 4.3 million healthcare workers are needed at this 
        moment.
    Sub-Saharan Africa faces the greatest challenges. While it has 11 
percent of the world's population and 24 percent of the global burden 
of disease, it has only 3 percent of the world's health workers.\5\
---------------------------------------------------------------------------
    \5\ ibid.
---------------------------------------------------------------------------
    The World Health Organization says:

    ``There is a direct relationship between the ratio of health 
workers to population and survival of women during childbirth and 
children in early infancy. As the number of health workers declines, 
survival declines proportionately.''

    This is going to get much worse. Why? Because the wealthy world is 
aging, therefore requiring more health attention. At the same time, 
wealthy nations are trying to reduce rapidly inflating health costs by 
holding down salaries, and increasing work loads, making the practices 
of nursing and medicine less attractive. Unless radical changes are put 
in place swiftly in the United States and other wealthy nations the gap 
will soon become catastrophic. Studies show that the United States will 
in 13 years face a shortage of 800,000 nurses and 200,000 doctors.
    How are the United States and other wealthy nations filling that 
gap? By siphoning off doctors and nurses from the poor world. We are 
guilty of bolstering our healthcare systems by weakening those of 
poorer nations.
    Here is an example: due to healthcare worker shortages, 43 percent 
of Ghana's hospitals and clinics are unable to provide child 
immunizations and 77 percent cannot provide 24-hour obstetric services 
for women in labor. So the children die of common diseases, like 
measles, and the mothers die in childbirth. In all of Ghana there are 
only 2,500 physicians. Meanwhile, in New York City, alone, there are 
600 licensed Ghanaian physicians.\6\
---------------------------------------------------------------------------
    \6\ Krestev, N., ``World: Maternal-Mortality Numbers Still 
Climbing,'' Radio Free Europe July 2006. http://www.rferl.org/
featuresarticle/2006/07/10d24de4-cc8d-459c-9eed629ee1bccc4c.html
---------------------------------------------------------------------------
    There are a number of bills pending in both the House and Senate 
that seek, in various ways, to increase domestic education and staffing 
of healthcare workers, and bolster training in poor countries. Though 
this committee deals with foreign operations, it is vital that you 
concern yourself with the progress of measures that would decrease the 
drive to drain the health brain power of the poor world by enhancing 
education and incentives here in the United States. In the House, for 
example, H.R. 410, the United States Physician Shortage Elimination Act 
of 2007, seeks to create incentives for physicians to serve in under-
allocated areas of America.
    Senate Bill 805, sponsored by Sen. Richard Durbin, is the ``African 
Health Capacity Investment Act of 2007.'' It seeks to amend the Foreign 
Assistance Act of 1961 to provide funding for medical training, and 
retention of healthcare staff in sub-Saharan African countries. I urge 
the Senate to pass S.805.
Fund Programs for Systems Development
    But let's be clear: Even if we put the brakes on the brain drain 
this instant, and the United States of America no longer imported 
foreign doctors, nurses, and lab technicians, there would still be a 
crisis. And even if Senator Durbin's bill passed, fully funded, there 
would still be a crisis.
    We are in an ugly mess. If we want to do the right thing, and get 
millions more people in poor countries on anti-HIV medications, our 
U.S. tax dollars have to be put to use skewing health services towards 
AIDS, and away from general maternal health and child survival. Why: 
Because there aren't enough healthcare workers to do both.
    If we want to spend U.S. taxpayer dollars--as we should--on 
campaigns to wipe out malaria-carrying mosquitoes and get children 
under insect-barrier nets at night, then the public health workers who 
will implement such programs have to come from somewhere. Perhaps there 
will be fewer of them trying to clean the children's drinking water or 
teaching teenagers how to avoid getting infected with HIV. Why? Because 
there aren't enough trained public health experts.
    The only way American tax dollars can save lives, across the 
board--without robbing healthcare workers from one disease area to 
implement disease combat in another area--is if we start funding 
systems management. The expertise for disease prevention and treatment 
is sparse: the talent pool, along with their supplies and patient 
loads, must be carefully managed. Novel incentive systems to defy 
corruption and bring quality health to vast constituencies must be put 
in place.
    At the request of Prime Minister Tony Blair, this question of the 
relationship between wealthy world priorities, and the health--or the 
lack thereof--in Africa was studied by Lord Nigel Crisp. His recently-
released report \7\ concludes that single-disease-specific programs can 
damage other health interests. He calls for direct funding of systems 
development and management, with far longer-term commitments than had 
been the norm for the UK. The Crisp recommendations are now being 
implemented.
---------------------------------------------------------------------------
    \7\ Lord Nigel Crisp. ``Global health partnerships: the UK 
contribution to health in developing countries:'' February 2007. http:/
/www.dh.gov.uk/en/Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_065374
---------------------------------------------------------------------------
    But what about the United States? Well, we do have a health systems 
management program nested inside USAID. It is working to 
professionalize health management in poor countries. It's budget? Just 
over $3 million.
             fiscal year 2008 budget: international affairs
    As you look over the White House fiscal year 2008 budget requests--
for a total Foreign Operations request of $20.3 billion--please pay 
close attention to the following:
  --More than half of all funding for Africa will focus on 8 strategic 
        states.
  --Overall health spending in designated African countries would more 
        than double compared to fiscal year 2006 actual spending.
    Of the nearly $4 billion requested for health in Africa, $3.4 
billion would go for HIV/AIDS in 12 countries (under the Global HIV/
AIDS Initiative or GHAI, formerly known as PEPFAR). The remaining $700 
million would be spent on the President's Malaria Initiative, 
Tuberculosis and a host of modest child survival and health 
initiatives.
  --Nearly all programs are heavily ear-marked, with little or no 
        monies designated for general health threats or health systems 
        management and support. Health management and personnel 
        training is not stipulated clearly in any budget lines, either 
        under disease-specific programs, nor in overall global health 
        budgets.
  --Only $34 million is requested for water systems, sanitation, or 
        general public health threats.
  --Under the Global War on Terror 2007 supplemental the President 
        requests $161 million, in additional to the general budget $100 
        million, for pandemic influenza surveillance and control, 
        through USAID. The supplemental request is listed under Child 
        Survival and Health Programs.
    I do not believe that we are guilty of over-spending in any global 
health initiative. Rather, we are guilty of under-valuing the necessity 
of building genuine, well-managed public health and medical systems. 
The paltry $3 million now spent on USAID's Management Sciences for 
Health program should increase dramatically, reflecting this gap. 
Further, current caps \8\ on human resources development and training 
that exist for PEPFAR funds should be lifted, for training of 
indigenous--not American NGO or FBO--personnel.
---------------------------------------------------------------------------
    \8\ Under PEPFAR, spending to train local healthcare workers cannot 
exceed $1 million per country per year. That is absurd.
---------------------------------------------------------------------------
                           what is the goal?
    I think the appropriate goals for U.S. foreign aid in support of 
global health ought to be twofold:
  --Build sustainable infrastructures in poor countries that shift the 
        paradigm towards fantastic improvements in maternal health, 
        child survival and overall extension of life expectancy.
  --And, second, ensure the safety and security of the American people 
        by lowering the global disease burden, both in terms of 
        infectious threat and detrimental impact on nations' and global 
        GDP and economic growth.
    The current channels of spending, though in the billions of 
dollars, will not accomplish either of these goals.
    Systems and infrastructure aren't sexy, cannot be built in short 
funding cycles, and are tough to brag about to constituents. But 
without viable systems of medical delivery and public health 
infrastructures all we will manage to do with our billions of dollars 
is save some lives, at the expense of others; achieve short term 
targets without fundamentally leaving anything in place that allows 
nations ultimate dignity and self-reliance.
    Let me close with this final story. During the 1960s, at the height 
of the Cold War, the global community committed to the astonishing goal 
of completely eradicating smallpox. The virus had killed more people 
during the first six decades of the 20th Century than all wars, 
combined. In order to accomplish this remarkable feat the World Health 
Organization and our Centers for Disease Control set up an 
unprecedented worldwide infrastructure of community health workers, 
public health advocates, disease detectives, laboratories, vaccine 
manufacturing, specialized infectious diseases clinics and hospitals 
and international-scale leadership and management. It was a 
breathtaking scale of effort. And it worked. By the end of the 1970s 
smallpox was eradicated.
    But then a tragic, inconceivable mistake was made: The entire 
worldwide smallpox infrastructure was simply shut down. Unable to find 
funding, or international interest, the infrastructure that defeated 
smallpox was, itself, eradicated at precisely the same time as a new 
scourge emerged: HIV. Since 1981 AIDS has killed more people, in 25 
years, than smallpox did in the 20th Century.
    As the late, great Kurt Vonnegut would say ``So it goes.''
    Thank you for your time, attention, and concern.

    Senator Leahy. I was discussing your testimony with my wife 
who is a registered nurse, now retired, except for children and 
grandchildren, she's traveled with me to a number of places 
around the world where we've used the Leahy War Victims Fund. 
She's been in some of these places, and she said our first-year 
nurse's training 40 years ago was more advanced than what they 
had available. We've brought thousands of sterile disposable 
gloves and needles.
    We're not trying to build the Mayo Clinic in these places. 
We're not talking about major surgery, we're talking about the 
preventive measures that we take for granted.
    I'm glad you raised the brain drain. I worry, also, though, 
that we don't have the basic--very, very basic--infrastructure. 
Where I see medications that are supposed to be refrigerated, 
there's no ability or knowledge of doing it. A pill a day for 
20 days, but, well, why not take 20 today and get it over with, 
and that kind of thing.
    Dr. Daulaire, as I said before, you and I have been friends 
for decades, and I'm delighted you're here. I'm delighted the 
Global Health Council is based in Vermont. There's some days 
when I'm down here I'm envious of you being back home.
    Please go ahead, sir.
STATEMENT OF DR. NILS DAULAIRE, PRESIDENT, GLOBAL 
            HEALTH COUNCIL
    Dr. Daulaire. Thank you, Senator Leahy, in turn I'm 
delighted to be one of your enthusiastic constituents, as are 
our staff, headquartered in Vermont, some of whom are Senator 
Gregg's constituents as well, right across the river.
    But I'm here today, not as a Vermonter, but as the head of 
the Global Health Council, an organization representing health 
professionals and service organizations working in more than 
100 countries. This is the issue of the moment, and I'm more 
delighted than I can tell you that you are hosting this hearing 
today.
    As you well know, I'm a doctor and a scientist, I've worked 
in the field for over 3 decades, and I believe deeply, as Dr. 
Gayle mentioned before, that what we do in global health has to 
be evidence-based. So, both in the submitted testimony and what 
I'm going to talk about over the next few minutes, we have hard 
facts to back up everything that we're talking about.
    I'd like to make five points--first, this is a huge issue; 
second, we have done an enormous amount, we, the United States, 
to improve the situation, and we know what to do; third, over 
the last 10 years, our investments have lagged; fourth, we can 
make a world of difference with modest additional investments, 
starting this year; and fifth, this would be good, not only for 
the women and children of the world, but it would be good for 
America.
    So, let me take those five points in order. We've already 
heard quite a number of the statistics, let me just put one 
chart up here--this is a huge issue. In many of the countries 
where I've personally worked, 1 out of 5 children do not 
survive to their fifth birthday. Take a classroom of 16 
adolescent girls, one of those girls is not going to make it 
through her fertile years, because of a death due to pregnancy 
or childbirth, and 1 out of 4 regnancies around the world is 
unintended.
    These are staggering statistics, when we consider our own 
lives and our own children and our own families, and they're 
simply unacceptable. Sitting in the Dirksen Building, I'm 
reminded that he once said, ``A million here, a million there, 
pretty soon you're talking about real money.'' In this case, 
you're talking about real lives. You've heard the lives--over 
10 million child deaths, over half a million women dying in 
pregnancy and childbirth--and as well, more than 200 million 
women living around the world with an unmet need for family 
planning.
    Some people have asked, why does the Global Health Council 
concern itself about family planning? That's a population 
thing, not a health thing. But, family planning is 
fundamentally a health intervention. It prevents abortion--I 
don't need to make that argument with you, sir, you've been 
clear on that, and you understand that well--but in addition, 
we know from the data that it saves the lives of young 
children, the older siblings. A child born more than 3 years 
after the prior birth has a one-third lower chance of dying 
than a child born within 2 years.
    Children born to teen mothers have a 30 percent higher rate 
of infant and child mortality than do children born to older 
mothers, so--family planning saves mothers' lives, and it saves 
childrens' lives.
    But this is not only about death, but also about lives. I 
have to say that, in addition to the ones dying, there are 40 
million children living stunted lives physically and 
intellectually each year. There's more than 20 million women 
who suffer lifelong consequences of complicated deliveries, and 
there are 60 million women a year making agonizing choices 
about pregnancies that they did not intend.
    The second issue, we've learned a lot, and we know what to 
do. We've talked about that already, and Dr. Hill, I think, 
made the case beautifully, that this has been an area of 
enormous scientific growth and operation growth, but it didn't 
just happen. It happened because of considerable U.S. 
Government investments in maternal and child health, and in 
family planning. Investments led to knowledge, led to 
application, and led to millions of lives saved.
    Why have our investments lagged over the past decade? We 
have this chart up here that your staff prepared, let me take 
those bottom lines that you can barely see, and show you that 
in maternal and child health in nominal dollars, the line has 
been more or less flat. Adjusted for inflation, we're actually 
spending 22 percent less than we were 10 years ago, and that's 
in a world that has 19 percent more children.
    In family planning, the situation is also very sobering. 
Again, adjusted for inflation, our investment in the past 10 
years has declined by 14 percent, and that's in a world with 30 
percent more women in need of family planning services.
    So, this is critical in terms of making an important change 
in the delivery of services. What do we need today? What U.S. 
leadership is called for? Well, analysis has shown that it 
would take $5.1 billion of global investment, not just United 
States, to save 6 million children's lives, the figure that Dr. 
Hill pointed to before. Another $3.9 billion to save, to 
provide family planning services for 200 million women, so 
we're talking about a global need of $9 billion in which the 
United States fair share would be about $1.6 billion for child 
health, $2 billion for maternal health, and about $1.3 billion 
for family planning.
    Now, as much as our community would love to have that 
investment made this year, we recognize that you have to deal 
with a difficult appropriations process. So, I'm going to tell 
you what you can buy for every $100 million that this 
committee, in its wisdom, decides to invest in maternal and 
child health and family planning.
    If you invest $100 million in child health and survival, 
you will save 113,000 to 200,000 lives every year. Nearly a 
million children will be provided with the 16 essential 
interventions that programs like CARE and others carry out.
    If you invest $100 million in mothers, you will prevent 
12,000 maternal deaths, 15,000 newborn deaths, you'll provide 4 
million women with basic, essential care, and 140,000 women 
will be treated for life-threatening conditions.
    Last but certainly not least, if you invest $100 million in 
family planning, there will be another 3.5 million additional 
family planning users, 2.1 million fewer unintended 
pregnancies, fewer infant and maternal deaths, and not 
incidentally, 825,000 fewer abortions around the world.
    Senator Leahy. So, as you're talking about that chart, the 
amount of money--it's a large amount of money--but its almost 
as much as we had spent by Tuesday morning of this week in 
Iraq.
    Dr. Daulaire. There we go.
    Senator Leahy. Not to put too fine a point on it.
    Dr. Daulaire. I----
    Senator Leahy. Or to indicate my feelings on that, but 
really, starting Sunday morning, we spent more than that by 
Tuesday noon in Iraq. We did last week, and the week before, 
and the week before, and we've been there for 5 years, longer 
than we were in World War II.
    Dr. Daulaire. Mr. Chairman, this is indeed a matter of 
making decisions about national priorities.
    Let me wrap up--Laurie Garrett has talked about the 
importance for health systems. What builds health systems 
capacity is the delivery of routine services on a daily basis, 
and what does that the most effectively and efficiently is 
maternal and child health services, and family planning, 
because those children and those mothers come through the door 
every single day. You can build other programs on top of that 
infrastructure, but that is the core of daily activities that 
is essential for infrastructure.
    Finally, I think it's self-evident, I'm preaching to the 
converted here, but this would be good for America, not only 
because healthy families lead to more stable societies, less 
turmoil, and fragmentation in the world, but because the United 
States desperately needs a more positive face overseas. United 
States programs invested in maternal and child health and 
family planning have been among the most effective and 
appreciated around the world.
    Senator, I know your children, you know mine, I know your 
wife, you know mine--we would not tolerate these levels of 
risks in our own family, and this is our family writ large. 
Women and children are at the center of global health and it's 
time for us to take action.

                           PREPARED STATEMENT

    I call on you and your committee to boldly re-establish 
that commitment, with real dollars measured in the hundreds of 
millions. Thank you very much.
    [The statement follows:]
                Prepared Statement of Dr. Nils Daulaire
    Chairman Leahy, Ranking Member Gregg and members of the 
subcommittee, thank you for inviting me to testify before you today on 
Maternal and Child Health, Reproductive Health and Family Planning. I 
am Dr. Nils Daulaire, President and CEO of the Global Health Council, 
the world's largest membership alliance of health professionals and 
service organizations working to save lives and improve health 
throughout the world.
    Before I begin my remarks, let me thank you, Chairman Leahy, for 
your service to our home State of Vermont and your longstanding 
commitment to global health. You have been a proponent and champion of 
U.S. investment in global health for more than 30 years. Long before 
PEPFAR, the Global Fund, PMI and other welcome global health 
initiatives, you fought for basic health services in developing 
countries, committed to meeting the needs of the poor and most 
vulnerable. I applaud you, Chairman Leahy and you, Senator Gregg, for 
your bipartisan collaboration, recognizing that saving lives knows no 
party lines. On behalf of the Council's 350 member organizations 
working in over 100 countries across the globe, and the millions whose 
lives are improved by U.S. Government investments, we thank you.
    The Global Health Council's members include non-profit 
organizations, schools of public health and medicine, research 
institutions, associations, foundations, businesses and concerned 
global citizens who work in global health--delivering programs, 
building capacity, developing new tools and technologies and evaluating 
impact to improve health among the poor of the developing world. Our 
members work in a wide array of areas, including child and maternal 
health, family planning, HIV/AIDS, other infectious diseases, water and 
sanitation, primary health care and health systems strengthening. The 
members of the Council share a commitment to alleviating the great 
health disparities that affect the world's most vulnerable people. The 
Council serves its members and the broader community of global health 
stakeholders by making sure they have the information and resources 
they need to fulfill this commitment and by serving as their collective 
voice.
    It has been my privilege to be part of the global health movement 
for over 30 years, and much of my career has been spent as a physician 
and program manager in some of the world's poorest countries. Working 
in countries such as Nepal, Mali and Haiti, I have had the good fortune 
to participate in the development and introduction of some important 
child survival interventions, notably in treating childhood pneumonia 
and Vitamin A deficiency. I have also had the honor of serving in 
Government as a senior policy advisor in USAID. My remarks today derive 
from these different perspectives and experiences, as well as the 
evidence and experience of our membership.
                      the world's women & children
    The link between the health of the world's women and children is 
well-established, as is the link between their health and the well-
being of the larger community. Because of these connections, we must 
view the challenges, interventions and investments as contributing to a 
continuum of care that has mutually reinforcing benefits from the 
individual all the way through global society.
Child Health
    Today, as every other day, nearly 30,000 children under age five 
will die--1 every 3 seconds. In many countries, 1 of every 5 children 
born won't live to see their fifth birthday. If death rates of this 
magnitude were happening to the youngest and most vulnerable here in 
the United States, we would declare a state of national emergency. It 
is happening, perhaps not in our backyard, but in our world, and we 
must do more.
    This year, more than 10 million children under 5 will die, mostly 
from preventable and treatable conditions--about the same as the total 
number of American children under 5 living east of the Mississippi 
River. Almost 4 million of these deaths will occur during the first 
month of life. Two million children will die from pneumonia; 1.8 
million from diarrhea; nearly another million from malaria and almost 
half a million from measles. Virtually all of these deaths can be 
prevented--easily and cheaply.
    As American parents, we take for granted that our kids will live 
and thrive. We recall when a skilled medical provider coached us 
through the stages of labor. We remember when our babies were whisked 
away to be dressed with head caps and swaddled to keep them warm. We 
have all taken our children in for their immunizations to protect them 
against measles, diphtheria, pertussis, tetanus and polio, diseases 
which, as a result, are today practically unknown in our country. If my 
daughter developed diarrhea, she was hydrated and her risks were very 
low. If my son developed pneumonia, rapid cure was ensured through 
antibiotics. These are all simple, basic practices that kept our 
children alive, and we are blessed to be able to take them for granted.
    In the developing world, however, too many parents live with the 
very real fear that death will take their children. The interventions 
that I have named are neither difficult to administer nor expensive. 
The cost of some, such as oral rehydration salts, vitamin A supplements 
and even antibiotics, are measured in cents, not dollars. Breastfeeding 
and kangaroo care, where mothers hold newborn babies to their breasts 
to keep them warm, cost nothing at all beyond educating parents. Yet 
children are still dying because these basic interventions are not 
reaching them. I couldn't imagine that expectation when my children 
were born. No parent should have to.
Maternal Health
    In the United States and other developed nations, the risk of death 
from complications of pregnancy and childbirth is extremely low. 
Although the risk of a woman in a developed country dying is about 1 in 
2,800, the lifetime risk of sub-Saharan African women dying from 
complications in pregnancy or childbirth is 1 in 16. Over half a 
million women die each year from pregnancy-related causes, and up to 20 
million develop long-term physical disabilities each year because of 
complications or poor management of pregnancy or childbirth. Almost 4 
million newborn deaths are closely linked to poor maternal health care, 
especially the absence of a trained provider during and immediately 
after birth. And each year, more than 1 million children are left 
motherless.
Reproductive Health/Family Planning
    Notwithstanding the progress in making family planning services 
available, over 200 million women still have an unmet need for family 
planning. These are women who are at risk of becoming pregnant, who 
wish to delay or end childbearing and yet do not have effective access 
to family planning. This is a denial of the basic right of every woman 
to decide if and when she will become pregnant. It is utterly 
meaningless to declare support for the human rights of women and yet 
fail to provide them with the information, services and commodities 
that will allow them to make a free, informed and safe decision about 
whether and when to become pregnant. Women cannot fulfill their 
potential or assert their rightful place in economies and societies 
unless they have such access. The decline in United States support for 
family planning flies in the face of our stated national commitment to 
overcoming the second class status of women in much of the world.
    What is less well understood but equally important is that family 
planning is essential to protecting the health of mothers and their 
children. Family planning helps young women delay or space pregnancies. 
Family planning helps all women avoid high risk pregnancies; 
approximately 215,000 maternal deaths will be averted this year alone 
thanks to the family planning that is available.
    Debate over abortion continues to create stark political divides. 
Yet, there is one thing we can agree upon--family planning reduces 
recourse to abortion by enabling women to avoid unintended pregnancies. 
Every year, there are more than 46 million abortions. 68,000 will also 
end in the death of the mother. Increasing access to family planning is 
the surest path to decreasing the number of abortions.
    Speaking as a physician who has devoted years to improving 
children's health worldwide, let me make this clear: family planning is 
also critical to saving children's lives. Closely spaced births and 
births to young mothers dramatically raise the risk that the infant 
will die. A child born less than 2 years after a sibling is 67 percent 
more likely to die than a child born after a 3 year interval. The child 
of a teenage mother is 30 percent more likely to die than that of a 
woman aged 20 to 29. Between 20 percent and 40 percent of all infant 
deaths could be prevented if all women had access to family planning.
Lives, Not Just Deaths
    I should point out that the issues of maternal and child health as 
well as reproductive health are not limited to averting deaths. They 
are also cause for diminished lives. For every woman who dies during 
pregnancy, childbirth or immediately following, another 30 suffer 
debilitating life-long consequences. Each year, nearly 40 million 
children who suffer early childhood illnesses but do not die become 
physically or mentally impaired. All of this contributes to the cycle 
of poverty and the failure of poor countries to develop.
                 u.s. investments--progress undermined
    The United States is a tremendously important force in global 
health. Its decisions about priorities, resource allocation, policies 
and technical leadership have profound consequences--that is the 
privilege and burden of our country's unique role. It is widely 
acknowledged that the United States has made very important and 
enduring contributions to global health. Yet today, U.S. global health 
policy is marked by two trends that are in stark opposition and 
mutually inconsistent. On the one hand we see the rapid expansion of 
U.S. programs in HIV and malaria; on the other we witness the neglect 
of maternal health, child health and family planning. This makes no 
sense.
Contradictory Trends
    The U.S. Government (USG) investment in global health has grown and 
evolved dramatically in just a decade. In fiscal year 1997, USG 
spending on global health sat just below $1 billion. Ten years later, 
global health spending is well over $5 billion from the foreign 
operations budget alone, with additional investments from the 
Department of Health and Human Services and the Department of Defense. 
However, the devil is in the details.
    Most of the exponential growth in global health spending over the 
past decade is due to USG investments in HIV/AIDS--over $14 billion 
since the advent of the PEPFAR, the President's emergency program for 
AIDS relief--an important commitment that the Council applauds. More 
recently, the President Malaria Initiative (PMI) has joined PEPFAR as a 
priority program of this administration, with a $1.2 billion pledge 
over 5 years. PEPFAR and PMI speak to the USG's generosity and ability 
to make a difference and, through these programs, many lives are being 
saved. The USG deserves tremendous credit for its global leadership.
    But the U.S. Government has not seen fit to increase in a similar 
way its historic leadership in maternal and child health and family 
planning. Once the investment in AIDS and malaria is subtracted from 
current spending totals, investments in child health, maternal health, 
family planning and the remaining infectious diseases remain at about 
$1 billion, roughly where they were a decade ago. There has been level 
funding in most program areas and cuts in others, which means a 
decrease in programming power once adjusted for inflation and the 
increase of the number of people in need. This is most notable in the 
areas of child health and reproductive health and family planning 
which, when adjusted for inflation, have declined 22 percent and 14 
percent, respectively, over the past decade. To this must be added the 
impact of a 19 percent increase in the number children under five and a 
30 percent increase in the number of reproductive age women in the 43 
least developed nations. So while the dollars have gone down, the need 
has gone up. Reduced investment translates into lives--millions lost 
unnecessarily.
Complements not Contradictions
    Let me say again, the Council enthusiastically applauds the growth 
in spending for AIDS and malaria and the leadership President Bush and 
the Congress have shown in these areas. But while funding flows through 
independent and issue-specific channels, these health threats do not 
occur in isolation. The same communities where individuals are living 
with AIDS are also those in which non-HIV infected women are at very 
high risk of dying during child birth from lack of family planning and 
basic obstetric care. The same young children who now sleep under bed 
nets to guard against malaria are no less likely to die from diarrhea 
or pneumonia. We have confused the laudable objective of fighting 
disease with the fundamental goal of saving and bettering lives, and 
our investment is undermined by an excessively narrow perspective. 
Fortunately, relatively modest increases in USG investment in these 
neglected areas can save millions of lives through simple, cost-
effective interventions.
    That is the good news--solutions are within easy reach at low cost. 
In the past 30 years, thanks to the investments and efforts that have 
been undertaken, the child mortality rate in the poorest parts of the 
world has declined by 40 percent. Because of family planning efforts, 
birth rates have also declined by 40 percent. What an incredible 
moment: For all of human history, people have lived with the 
expectation that many of their children will die young and that women 
will endure one pregnancy after another, regardless of the impact on 
their health and survival. The 40 percent decline in birth and death 
rates is a stunning change. The advent of simple, inexpensive vaccines, 
antibiotics, oral rehydration salts, anti-malarials, micronutrients and 
contraceptives have radically changed expectations and reality in many 
parts of the world. What a tragedy it would be not to finish a job so 
well begun.
    This progress makes the choice not to increase our investment in 
women and children intolerable. Allowing women and children to die from 
easily preventable causes is just that--a choice. We are at a loss to 
understand how this administration, so generous in the response to HIV/
AIDS and malaria, now proposes substantial cuts in maternal and child 
health and family planning.
                     improving health, saving lives
    As I have described, U.S. support for basic maternal health, child 
health and family planning services has been declining. This must be 
reversed. The United States must reassert its historic and essential 
leadership in saving the lives of women and children. Providing these 
basic interventions for women and children is the cornerstone for 
securing improved health and is at the heart of building sustainable 
public health systems. The record is clear. Every time the United 
States has approached a major global health problem with tenacity and 
at the requisite scale, our country has had a tremendous positive 
impact.
    On the scale of global need, the amount needed to achieve important 
gains in child health and family planning is manageable. Six million 
children could be saved every year if the global budget for child 
health were increased by $5.1 billion. Providing essential obstetric 
care to 75 percent of women in 75 countries would cost an additional 
$6.1 billion; 200 million women with an unmet need for family planning 
could receive these services for an additional $3.9 billion per year. 
So the math is simple. If--from all sources: United States, other 
donors, developing nations--the world devoted an additional $15 billion 
per year, 6 million children would be saved annually, most women would 
have maternal health care and 200 million more women would have access 
to family planning. I urge this committee and the Congress to move the 
United States into the same leadership role on family planning, 
maternal and child health that it has shown in AIDS and malaria.
                   modest investments, maximum impact
    To illustrate the potential impact of a heightened U.S. commitment, 
I'd like to reflect on what even a modest ramp-up in investments could 
return. The U.S. share of the additional global investment needed to 
reduce child mortality is roughly $1.6 billion. The United States 
should add $2 billion per year to its spending on maternal health. The 
United States should increase its contribution to family planning by 
$1.3 billion per year. We have a long way to go. However, we can take 
modest steps and still see great gains. The projections I share with 
you are based on solid scientific analyses by the Council and others.
Investment Scale-Up
    Every $100 million in attacking the most common causes of child 
death with the most cost-effective interventions would have the 
following impacts:
  --At least 113,000, and perhaps as many as 200,000, young children's 
        lives saved
  --Over 812,000 children provided with 16 essential interventions, at 
        an average cost of just over $12 per child
    Every $100 million devoted to maternal health programs would:
  --Avert nearly 12,000 maternal deaths
  --Avert more than 15,000 newborn deaths
  --Provide basic and essential care for 4 million women
  --Treat 140,000 women with life-threatening conditions
  --Treat an additional 880,000 women with serious pregnancy and 
        childbirth-related conditions
    Every $100 million invested in family planning would have the 
following impacts:
  --3.6 million more family planning users
  --2.1 million unintended pregnancies avoided
  --825,000 abortions prevented
  --970,000 fewer births
  --70,000 fewer infant deaths
  --4,000 maternal deaths averted
    These are remarkable outcomes for relatively moderate additional 
outlays. Each increment of $100 million would yield proportionate 
gains, the virtuous cycle writ large. We therefore urge this committee 
to approve a significant increase in the budgets for maternal and child 
health and family planning with investments on par with the other 
global health priorities.
                  building capacity while saving lives
    There is the misperception in some quarters that U.S. assistance 
for maternal and child health has been an example of charity or created 
dependency. This is far from the truth. Improving health is not merely 
a matter of delivering pills and vaccines, though pills and vaccines 
are essential. It's about improving health equity by putting in place 
sustainable systems for delivering essential care. Improving health 
means supporting educational programs to foster new attitudes and 
behaviors; building community leadership and organizations committed to 
improved health; strengthening the capacity of health providers and 
institutions; better measurement of what programs accomplish; and, 
adopting better health policies and health financing schemes. The 
United States role has been to strengthen the capacity of national 
health systems to deliver essential maternal and child health care. 
Achieving long term sustained change requires patience and sustained 
investment, but the record of building capacity while achieving gains 
in health outcomes is clear.
    Another invaluable U.S. contribution has been to invest in 
technical leadership and research and development, areas where the 
United States has historically excelled. These core functions support 
the development of new technologies and innovative means of delivering 
services, which have enduring impact. The overall decline in resources 
has seriously affected these core functions, a consequence exacerbated 
by the declining percentage of available resources devoted to technical 
leadership and research and development. I am greatly concerned that 
the technical leadership role of the United States has been starved of 
resources and I urge the committee to be sure it is adequately funded.
                          in the u.s. interest
    The United States has a compelling national interest in saving the 
lives of the most vulnerable women and children. The stated goal of 
U.S. foreign assistance is ``To help build and sustain democratic, 
well-governed states that respond to the needs of their people, reduce 
widespread poverty and conduct themselves responsibly in the 
international system.'' There is no more dramatic marker of this goal 
than saving the lives of millions of women and children.
    Poor maternal and child health indicators are viewed by many as 
evidence of the failure of governments to provide basic services. 
Conversely, alleviating the burden of disease among women and children 
is clear evidence of improving governance through concrete, specific 
gains. Even low income societies can achieve dramatic gains by 
providing widespread access to essential services and information. 
Improving access to basic health care for women and children is an 
exercise in good governance, meets a basic need, redresses pervasive 
inequities and creates a model for other essential services.
    Poor maternal and child health also brings economic ruin to 
families and households. What truly marks poor households is 
vulnerability. A childhood illness or complications from pregnancy 
force a poor family into excruciating choices, when they must choose 
between buying seeds or paying for basic health care. Preventable 
illness and death can tip a poor family over into destitution as they 
divest themselves of meager savings and borrow money to pay for health 
care or funerals. Efforts to alleviate poverty must address this 
underlying cause of household vulnerability.
    Mr. Chairman, it is no secret that the international reputation of 
the United States is at low point. Multiple surveys reveal the 
widespread negative perceptions of our country. One could argue whether 
these perceptions are justified, but there is no arguing with the 
urgent need for effective public diplomacy. But public diplomacy is 
more than words and promises, it is deeds. The most powerful statement 
our country could make is to save the lives of the world's most 
vulnerable women and children. This is an enormous opportunity for 
constructive engagement with much of the world. Most importantly, a 
renewed commitment to saving women and children will express the values 
of a decent and generous American people, who invariably support 
effective efforts to alleviate needless suffering.
                            a call to action
    Chairman Leahy, Senator Gregg, members of the subcommittee and 
colleagues, my most fundamental message to you today is of hope and 
possibility. We know how to save millions of women and children through 
simple, inexpensive means. We know what works. We know how to deliver 
the interventions. We know what they will cost and we know what will 
happen once these services are provided: lives will be saved; 
communities strengthened; futures built and countries developed.
    The responsibility for improving maternal and child health does not 
rest principally with the United States. That responsibility for 
meeting basic needs rests with national governments. Non-governmental 
organizations, faith communities, multilateral institutions and other 
donors all have a role to play. As I speak before you today, global 
partners are gathered in Tanzania under the invitation of the 
Partnership for Maternal, Newborn and Child Health. An increasing 
global commitment guarantees that the United States is not in this 
alone. But there is no substitute for U.S. leadership or for active 
U.S. partnership in a global compact for women and children.
    Mr. Chairman, we need a bold commitment on the part of the U.S. 
Government and the American people--a commitment to the world's most 
vulnerable families so that they may enjoy the same expectation we have 
for our children's survival, planned pregnancies and mothers' safe 
deliveries. We simply must decide that this is the right thing to do in 
partnership with other governments and the communities in need. 
Relatively modest yet sustained increases in resources will make a 
significant difference in the lives of millions of women and children. 
And this clear commitment to the well being of families also will make 
a significant difference in popular perceptions of the role of the 
United States abroad.
    I appeal to you to boldly reestablish that commitment with real 
dollars, measured in the hundreds of millions. It's time to act.
    Thank you for your time and for hosting this hearing. I look 
forward to addressing any questions you have, and to working with you 
to continue to save and improve lives.

    Senator Leahy. Dr. Hill, let's go into this a little bit. 
The Millennium Development Goals. I read that one of the goals 
is to reduce by two-thirds the mortality rate among children 
under 5 by the year 2015. That's 8 years from now. You pointed 
out a half a million women die in pregnancy and childbirth each 
year. That's one per minute. Ninety nine percent of those are 
in the poorest countries. Another one of the Millennium 
Development Goals is to reduce by three-quarters the maternal 
mortality rate by the year 2015.
    The United States has affirmed these Millennium Development 
Goals--how does the fiscal year 2008 budget request, which 
doesn't increase resources for either child health, maternal 
and reproductive health, fit into a strategy to reduce child 
death by one-half, and maternal deaths by two-thirds by 2015, 
realizing as Dr. Daulaire, and others, have pointed out, the 
world's population is increasing?
    Dr. Hill. You raise important issues, and it's very clear 
that you don't make the kind of progress towards reaching those 
MDG goals as you would like without sufficient funds.
    One of my problems, of course, is that I wear a very 
partisan global health hat, and I tend to view things as my 
colleagues on this committee do, thinking about what we could 
do with money and do with more money. Yet, I must acknowledge 
that we're part of a bigger budget process. That process is 
trying to limit resources that they're willing to ask Congress 
for, to make very tough decisions, and get at the same table at 
the same time all of these different sectors--peace and 
security, economic growth, and democracy.
    Senator Leahy. What you're saying is that you've lost the 
OMB battles.
    Dr. Hill. We've won some battles. I doubt if there's any 
part of the budget process that is fully satisfied with the end 
product. But there are a lot of tradeoffs. I do have to 
acknowledge that, as has been said by my colleagues, malaria 
and HIV have huge increases, avian influenza is in the budget 
at $100 million, and you folks are considering a $161 million 
supplemental. I know that overall health money being spent and 
being asked for by the Congress is more than in the past. But, 
it is certainly true that the way that it is prioritized within 
the health portfolio has left these two units upon which we're 
testifying today with less money than they have had in previous 
requests or appropriations. Those are very difficult tradeoffs.
    Senator Leahy. But, on these tradeoffs, for example, the 
World Bank has 54 countries designated low-income countries, 
and USAID has programs in many of these.
    Let me give you an example. In the fiscal year 2008 budget, 
where some of these tradeoffs are, there's an increase in funds 
for Liberia, and I strongly support that.
    Dr. Hill. Right.
    Senator Leahy. But, Mali, which also has similar problems, 
receives less. So, is this robbing Peter to pay Paul?
    Dr. Hill. I think you have pointed out an issue that's come 
up in this first year of the new system, which is problematic, 
and it's been noticed, and we're going to address it in two 
ways.
    As you know, the budget was put together by country teams, 
looking at and trying to prioritize within their countries. But 
when you look at the final product, you've got some inequities 
where some countries with greater need had less money than was 
being spent in the countries that needed the money, but not as 
much. Therefore, I think we're going to have to look at these 
2008 appropriations by country, and make some adjustments, but 
that's only part of the answer.
    The second part of the answer is to ask the question, what 
can you do about the process for 2009 that would make fewer 
adjustments necessary? The answer seems to be this--to ask the 
three pillar bureaus at USAID to look globally at big issues 
and give some input to the Office of the Director of Foreign 
Assistance and say: ``If you have to spend X amount of dollars 
on, say, child and maternal health, this is the priority of the 
countries you ought to spend it in.'' That will affect the 
amount that they set for the country team to consider. They 
will say to the country team: ``Be aware that we are setting 
this amount,'' partly keeping in mind that they have an unusual 
global need in this area. So, that may help us some.
    Senator Leahy. May help some, but you still have a 
limited----
    Dr. Hill. A limited pot.
    Senator Leahy. Yes.
    Dr. Hill. Now, there's one other thing I should say, and 
that is that it's probably inaccurate to describe the work in 
HIV or malaria, not suggesting you did this, but some might 
conclude this, that there's no connection to these other 
interventions. Eighty-five percent of the malaria deaths are to 
children under 5, so if we succeed there, it will actually help 
in child survival as well.
    Senator Leahy. But, it's not 85 percent of the children. 
For example, we've--I understand that USAID has cut funding for 
the oral rehydration salt program, which stops diarrhea----
    Dr. Hill. Right.
    Senator Leahy [continuing]. I mean, that doesn't seem 
right. Should the HIV/AIDS and malaria initiatives, which I 
strongly support, should they be the foundation of our global 
health strategy?
    Dr. Hill. I think it's fair to ask questions about how a 
pot of money for health ought to be divided up. I can tell you 
the experts at USAID and elsewhere strongly disagree with each 
other from time to time about what those priorities ought to 
be, measuring how many people will die in a particular 
intervention. The experts don't always agree, so it's always a 
tough process, even among the health experts to decide, with 
limited money, where you'll get the most bang for your buck.
    On HIV, the argument often goes, if that gets out of 
control, you get a lot more parents dying. This fact that a 
parent is alive is a huge factor in whether a child lives, and 
the quality of their life, so they argue that you don't have 
the children to work with if you fail, so these are the kinds 
of arguments----
    Senator Leahy. I understand.
    Dr. Hill [continuing]. Of these people.
    Senator Leahy. I've visited a number of these countries, 
and I've encouraged improvements in HIV/AIDS programs, but, I 
worry that Secretary Rice spoke of the U.S. health strategy as 
primarily being implemented through the HIV/AIDS and malaria 
initiatives, and there is much more to public health than those 
two diseases.
    Dr. Gayle, how would you respond on that?
    Dr. Gayle. Yeah, well, I think, you know, people have made 
the, several points about how we have to look at this in a much 
more integrated fashion. So, for instance, if we do a much more 
comprehensive approach in our HIV work that really looks at, 
what are some of the underlying reasons why some people are 
more at risk than others? Women, particularly who oftentimes 
are at risk for HIV because of sex, gender-based violence, or 
lack of economic opportunities. If we address some of these 
underlying causes as well, I think we will go a much longer way 
towards helping strengthen health and the root causes of poor 
health to begin with.
    So, I think, first and foremost, it's looking at these 
things in a much more integrated fashion. We do HIV testing in 
the context of reproductive health programs, and treat other 
sexually transmitted diseases for women who come for 
reproductive health services. I think we can do this in a way 
that supports building a much broader, and more comprehensive 
approach to poor health and poor nations.
    But we can't do it only by focusing on specialized 
programs. We have to do it in a way that looks at both the root 
causes, what are some of the things that are in common, 
including access to services, a strong health infrastructure, 
and do it in a way that recognizes that we can't let go of our 
core competency in programs that save the lives of children and 
women and families around the world, while we're continuing to 
focus on these other programs. It has to be integrated, or else 
in the long run, we're not doing service for HIV, malaria or 
any of the other issues, if we don't do it in a way that builds 
the platform upon which we can make health better overall.
    Senator Leahy. Ms. Garrett, do you want to add to that, and 
then I'm going to ask Dr. Daulaire the same question.
    Ms. Garrett. I think if we have two strategic targets for 
our global health/foreign aid, they would be to create 
sustainable infrastructures that can address a broad range of 
disease issues, and not be too narrowly focused, and that they 
would--in the process--ensure the safety and security of the 
American people by lowering the disease threat burden external 
to the United States. I think that we can accomplish both, but 
that the way we're going about it right now, we will fail to 
accomplish either goal.
    It is appropriate that we elevate the level of funding 
directed to H5N1, or Avian flu. That is an elevated risk, and I 
do very strongly believe that the odds are reasonably high, 
that this particular bird flu strain may make, what we now 
know, is only two amino acid changes necessary in its entire 
genome to turn into a rapid human to human transmitter.
    It is appropriate that we very heavily address concerns 
about HIV and that we have this PEPFAR, or now GHAI 
infrastructure in place to deal with specifically HIV. But, 
they--each one of them comes up against the same identical 
problem. If you talk to the people dealing with flu, and we've 
put out--I think our total expenditure now is if the fiscal 
year 2008 are approved, is going to top $8 billion, domestic 
mostly. But, if you look at the flu problem, and you talk to 
those people, they all say, you know, ``Our problem is that we 
can't find human cases of flu on the ground fast enough because 
there isn't a health infrastructure. There aren't people there 
watching, and there aren't places for the patients to go.''
    Senator Leahy. You also have some countries that don't want 
the information to come out, and you don't want----
    Ms. Garrett. Well, that's a separate issue, transparency is 
obviously a huge problem. HIV tells us the story of the lack of 
transparency, because country after country after country 
denied that they had an HIV problem, or then said, ``Oh, it's 
only foreigners,'' or ``It's only homosexuals,'' or it's only 
this or that, until they had a generalized threat.
    But I don't think that--and I know that this is going to 
come up when you hit the appropriation on the PEPFAR funding--I 
don't think that the PEPFAR infrastructure can be scaled up to 
become ``the'' infrastructure we're all looking for. I'd be 
happy to go through all the reasons why, it's a very long 
story, but bottom line is, it is an infrastructure that is 
primarily designed to address the health needs of a small 
population of adults, ranging between roughly 15 and 35 years 
of age. It is not--though it has a pediatric component--it is 
not a child health program. Though it deals with women of 
pregnancy age, it is not a maternal health program.
    In fact, you have this odd possibility that as you enhance 
PEPFAR, a woman can get Nevirapine to prevent her from 
transmitting HIV to her child, but the next time she's 
pregnant, she will die in childbirth, because she can't get a 
cesarean section.
    Senator Leahy. Dr. Daulaire?
    Dr. Daulaire. Well, let me first endorse what Laurie 
Garrett just said. There is no question that these programs for 
HIV/AIDS and malaria are, have an impact on the health of 
children and the survival of children, and of some women, but 
they are not the first and primary route for making a change in 
terms of their lives. They are, in a sense, necessary, but not 
sufficient.
    I think the question here that we often get trapped into in 
the social sector in international development, is run a first 
assumptions. If we had accepted the assumption in 2001 that the 
cap on U.S. Government spending in global health was going to 
be, as it was then, about $1 billion, we would be having 
arguments today about whether we could possibly do anything at 
all with HIV.
    You've made the case that we spend lots of money on things 
that we consider to be important National priorities, so the 
argument made that, by Secretary Rice, that this addresses the 
issues of child health and maternal health do not hold water. 
They certainly are supportive of children's health and women's 
health, the kinds of programs that we're talking about today 
are the ones that are fundamentally important to make this 
change.
    Senator Leahy. Let me ask about some of those fundamental 
things. We keep going back to this question of safe water, 
especially for child and maternal health. Now--and you've 
spoken, Dr. Gayle, about CARE and the broad things it does, all 
the various aspects, you're basically saying there's no magic 
bullet, it's everything.
    What has been the impact of USAID's Safe Water and 
Sanitation Programs?
    Dr. Gayle. Thank you, and I don't have the specific numbers 
offhand, clearly there has been a major impact. We've been very 
supportive of the Safe Water Act in Senator Simon's name that 
we feel really ought to be strengthened and supported even 
more. Clearly, having safe water where a sixth of our 
population today does not have access to clean and safe water, 
means that not only will basic hygiene not be available for 
much of our world population, but it also means that things 
like diarrheal diseases are only going to continue to be 
prevalent.
    I've been in village after village in our work, where I've 
seen what it means to a family to have clean, safe water, where 
not only does it cut down the diarrheal diseases, and the 
under-5 mortality, but it means that children can go to school 
for the first time in their lives, and start to think about a 
different kind of future for themselves and for their families 
and communities.
    So, yeah, I think the basic ability to supply clean and 
safe water, while some don't think of it as a health 
intervention, is one of the most basic interventions, and is 
something we feel is one of those cornerstones upon which a 
health--looking at improving health is critically important, 
and needs to be build upon. We think that there is more that 
needs to be done, and it is one of those areas that gets second 
shrift, because it isn't seen as one of the visible issues that 
is currently on the front lines.
    I would just say, with some of the concerns around climate 
change, we think that the issues of clean and safe water are 
only going to become more and more urgent, and particularly for 
the poor, who will be facing more erratic climate conditions, 
more drought affecting agricultural productivity and nutrition, 
et cetera. So, this issue of safe water, clean and safe water, 
is a critical one.
    Senator Leahy. Dr. Hill, and I might say, when I ask some 
of these questions, I'll be the first also to say that USAID 
has done some tremendous things around the world, and I'm just 
trying to figure out how to make it even better. What do you 
say about the importance of clean water?
    Dr. Hill. We agree with Dr. Gayle, that those who insist on 
separating water projects from health miss the point. For 
example, we have a three-part response to the question of small 
kids who die from diarrhea, and the first part of the strategy 
has to do with point-of-use water projects, second, the 
sanitation message about washing your hands; and third, dealing 
with feces. Much of this has to do with water; so we view the 
water projects as integral to what we need to do to have a big 
impact on under-5 mortality.
    Senator Leahy. Ms. Garrett, you talked about direct funding 
for systems development and management, and you say USAID is 
doing that, but they're doing it on a budget of $3 million a 
year. Do you want to address that? I'm going to follow up with 
another question, but go ahead.
    Ms. Garrett. I keep forgetting to push the button, so 
sorry. Yeah, we, if you were a CEO of a major corporation, and 
the revenue for your corporation suddenly jumped, from say, 
$800 million to, say, $18 billion. You wouldn't want to imagine 
that your $800 million management infrastructure was up to 
snuff to handle $18 billion appropriately.
    You would be even more concerned about that jump, if you 
knew that you had almost no health personnel to execute this 
giant new corporate venture. Worse yet, it's projected that by 
2013, we will have a deficit here in the United States of 
800,000 nurses, and 200,000 doctors. I, you know, I want to say 
a little on the side here, that I know that we're here dealing 
with foreign relations, but if there's one place where I feel 
that there is a need to see a conversation between--
conversation between foreign operations and domestic--it is on 
this healthcare issue, healthcare resources issue.
    Senator Dick Durbin has a bill that would try to rapidly 
increase the number of healthcare workers we're training in 
developing countries----
    Senator Leahy. In fact, Senator Durbin was going to be here 
but he was not able to because of what's happening on the 
floor.
    Ms. Garrett. Understood.
    Senator Leahy. He's a whip, and you're talking about his 
African Health Capacity Investment Act----
    Ms. Garrett. Exactly.
    Senator Leahy. I'm co-sponsoring that and we've all touched 
on this a bit. As doctors and nurses leave for better paying 
jobs, and I think of our own country when I see the ads for 
nurses. Bringing them here from other countries to make up for 
our failure as a Nation compounds the problem.
     To go back to my earlier comment, I'm not suggesting the 
Mayo Clinic in these countries, but I am asking why can't we 
have nurse practitioners? Why can't we have people who have at 
least basic skills, and the kind of infrastructure to handle 
basic health needs.
    Ms. Garrett. Right.
    Senator Leahy. There are certain things we do almost 
unconsciously, for hygene, but they need to be taught. How do 
we do this?
    Ms. Garrett. Well, I'm so glad you're asking that, because 
it goes back to your original question to me, how do we get to 
reasonably managed health systems?
    As I was saying, I really think there needs to be a 
conversation between your counterparts dealing with domestic 
health funding, and international on this question. Because if 
we reach the point where we are trying to suck away from the 
poor world 200,000 doctors, to offset our deficit--I'm not even 
sure there are 200,000 out there--but if we go after everything 
we can get, sure, we might be able to deal with our health 
problem, but at the expense of killing people in poor 
countries.
    So, I see that----
    Senator Leahy. Is there a way we can do both? To take care 
of our health problem and also help take care of theirs?
    Ms. Garrett. Well, actually, as it turns out, with the 
nursing crisis and the physician crisis here, in terms of our 
really mediocre level of domestic production of our own 
indigenous personnel, so that we don't need to suck the talent 
away from the poor world, it turns out the disincentives are 
less about pay, salaries at the, once you are a professional, 
than they are about access to the actual training.
    We've had bills come consistently before this body and the 
House, requesting subsidies for State support of nursing 
training and physician training, and they have consistently 
failed to even get out of committee.
    One of the biggest problems that we have right now in 
nursing training is that a typical nurse earns more as a 
practicing nurse than she can earn as a Professor of Nursing. 
Most nursing training is done by land grant and State-supported 
institutions, they are underfunded, and their faculty are 
underpaid. Most of the States, a State like Michigan, for 
example, which has quite a number of nursing schools, as you 
know, Michigan is a hard-hit State right now. Its economy is in 
deep trouble. They cannot afford to even match the salary level 
that a nurse can make as a nurse, versus as a professor, 
without Federal support.
    We need to really say, I think, in no uncertain terms, that 
the foreign operation side of the Senate is saying to the 
domestic operations side, ``Unless you create the incentives 
for us to produce sufficient healthcare personnel, 
domestically, so that we do not need to absorb the talent from 
the outside, we're in an immoral position.''
    Senator Leahy. Dr. Daulaire, Dr. Gayle and Dr. Hill on 
this?
    Dr. Daulaire. Senator Leahy, there's two sides to this 
question, there's the push side, and there's the pull side. And 
the pull side is what goes on here in the United States in 
terms of our healthcare deficits, and in Europe for that 
matter.
    I think it's appropriate for this Committee to particularly 
focus its attention on the push side--why is it that healthcare 
workers are leaving, or not getting trained to begin with? 
There are a number of different issues here. One is very often 
the wrong kinds of people are being trained in these countries. 
As a physician myself I hate to say it, but what the world does 
not need more of is lots more doctors, what the world needs 
lots more of is nurses, paramedics and auxiliary health workers 
who can address the healthcare needs at the communities where 
they're taking place. My own experience in the field has 
reinforced this many times over. So, that needs to be a focus 
in terms of both National priorities and donor assistance from 
the United States.
    Second, if the United States in its donor-assisted 
programs, HIV/AIDS, malaria, TB and all of the rest, if it 
simply recognizes the fact that there has to be a health 
systems overlay, you don't just say, ``Well, you do the health 
system, and you train the people, and then we'll give you the 
money or the drugs for specific interventions,'' there has to 
be incorporated into the framework of international assistance 
in healthcare. Third, on a very practical basis, in Africa 
where this crisis is at its worst, recently a group of African 
leaders got together and established a 15 percent target--they 
decided it themselves--of their national budgets to be used for 
their health systems. We need to encourage and reinforce this. 
This is not just a United States problem, but we can help by 
providing incentives through our international assistance for 
those countries that are actually moving forward on getting to 
that 15 percent, which, I would note, I believe no African 
country has currently reached.
    Senator Leahy. Dr. Gayle?
    Dr. Gayle. Yeah, just to basically support, I think, the 
issue--in addition to thinking about how we can make sure that 
we're not being a drain on the workforce in poor countries, but 
also that we look at what are the needs? That we are very, that 
we reinforce the kinds of health workers that will have the 
greatest impact on the lives of people in poor countries.
    As Nils said, it's not necessarily doctors or even 
sophisticated nurses, it really is, developing a core of people 
who are the auxiliary health workers, on the ground people who 
come from those communities, and understand those communities, 
who are really, the cornerstone of health interventions. By 
supporting the interventions, they are much more focused on the 
preventative side of health services, the public health 
approaches, I think we will get a lot--much more bang for the 
buck than by supporting tertiary care focus and technology 
fixes that oftentimes lead to short-term fixes, but not looking 
at the longer-term impact on lives.
    We also would like to endorse the Durbin workforce bill, 
and be happy to help in any way as that continues to move 
forward, and think about what are the best ways in which to 
build that kind of health capacity on the ground that meets the 
needs of people where they are.
    Senator Leahy. Senator Durbin and I feel very strongly, I'm 
following his leadership on it, but we feel very strongly about 
that.
    Dr. Hill?
    Dr. Hill. Three quick points--there is one piece of good 
news here. When I travel to Africa or talk to doctors here who 
came from Africa, I've been pleased to find that the 
overwhelming majority did not come here primarily because they 
would get a higher salary. They often report that they came 
here because they had a chance to work in the field they were 
trained in, and they didn't have the chance at home. It is 
generally only a secondary motive--that is they did have the 
chance, they couldn't feed their family and do it.
    Which leads me, and leads us, to the conclusion that we 
need to focus as Nils said, Dr. Daulaire said, on making sure 
that out there in the field the systems improve, so they can 
hold onto the people that are trained.
    There is also a second point that addresses some of the 
points that Dr. Garrett was bringing up about infrastructure 
and health systems, because it's all related. I think as good 
as the CBJ may be in terms of communicating some things, at 2 
inches thick you would think it could communicate a lot, but 
there's an awful lot it doesn't communicate.
    There aren't a lot of projects. There's not a category for 
infrastructure or health systems, et cetera. But as a matter of 
fact, at USAID--and at PEPFAR too--there's a strong sense that 
these issues that have been raised simply have to be dealt 
with. The surge is a big problem, and they know that we have to 
work on systems.
    But the way it tends to get done is that it is a component 
within a project that might be HIV or malaria or tuberculosis 
or contraceptive health or whatever it is, and any good program 
is going to have a component to it that specifically deals with 
this issue.
    Now, there are two questions that Ambassador Tobias always 
asks at a review of programs. One, ``Show me how this 
correlates with the work of other donors, so I know it's not 
duplicative.'' Number two, ``Show me how this is going to 
produce sustainability,'' which means it has to get at the 
issue of health systems, et cetera. So, we're aware this is a 
problem.
    The third simple point is that we are trying to ramp up, 
within all of the specific interventions, a component that will 
address precisely the question about what can you leave in 
place there that will allow them to do this work when we are 
gone.
    Senator Leahy. You know, in the article Challenge of Global 
Health, that Ms. Garrett wrote in Foreign Affairs, she quoted a 
Zambian doctor who said maternal death is the biggest challenge 
in strengthening health systems, if we get maternal health 
services to perform then we're nearly perfecting the entire 
health system.
    Without going into great detail, let me start, Dr. Hill, 
with you. Would you agree with that?
    Dr. Hill. Sorry, that there's a health systems problem in 
Zambia? Is that----
    Senator Leahy. No, that maternal death is the biggest 
challenge in strengthening health systems. If we can get 
maternal health services to perform, we're nearly perfecting 
the entire health system--that's what a doctor in Zambia said.
    Dr. Hill. Yes, my health experts would probably disagree 
and have a big debate about that. It is certainly a critical 
component, and one of the most important. Whether it's the very 
most important, I don't think I'd be prepared to say, but it is 
a lynchpin, a critical piece of the puzzle.
    The problem with a lot of this is that--however you decide 
to prioritize, the bottom line is, if you're not basically 
doing them all, just the top ones, whatever you choose is going 
to be undermined by what you didn't do. So, you almost have to 
find a way to take the top three, four or five, and find a way 
to do them, and to do them as well as you can, or you're going 
to undermine your successes wherever you did work.
    Senator Leahy. Which goes back to my prior 
oversimplification, my concern about robbing Peter to pay Paul, 
and making them all work.
    Dr. Gayle, how would you----
    Dr. Gayle. I wouldn't add a lot to that, only to say that 
while it may not be the thing that can fix the overall system, 
it is something that we know we can do a lot about, there's a 
lot of examples of making a difference, and I think it is 
totally unacceptable that today with all that we know and all 
that we can do that we continue to let 500 million women die 
every year from maternal mortality--something that ought to be 
a normal part of life, and that we continue to have 150 times 
greater mortality rates in poor countries, than we have here. 
So, it is one of those issues that we can do something about, 
that would strengthen the infrastructure.
    I would just go back to the point, the chart that Nils 
Daulaire showed earlier, when we look at, and the point that 
you made--when we look at talking about $100 million and what 
that does in terms of saving lives--$100 million is a small 
amount of money for a huge return in lives saved.
    So, I think, again it is a choice of where do we put our 
resources, what do we want to be known for as a Nation, where 
do we want to show our leadership, and start making some of 
those choices?
    When I headed the program for USAID program for, or Global 
AIDS Program, we at that time had $250 million in our total 
program. You know, we are now in the billions of dollars. It is 
possible, with the right kind of leadership and the right kind 
of commitment to take the cap off and stop making unnecessary 
limitations for things that we know can make a huge difference 
in people's lives around the world, and put us back in the 
global world as a compassionate Nation that does care about 
these things.
    Senator Leahy. You talk about the $100 million. It's just 
about noon, we spent that much today in Iraq.
    Whether one is for or against the war, just so we 
understand where the money is being spent.
    Ms. Garrett, did you agree with the Zambian doctor you 
quoted?
    Ms. Garrett. I did. I think that we use the phrase 
``canaries in the coal mine'' to refer to what is the marker of 
a potential risk or threat.
    To me, the big canary in the coal mine for whether or not 
you have a public health infrastructure is dying children under 
5, and a big canary in the coal mine for whether or not you 
have a functioning health delivery system is dying mothers in 
childbirth, and childbirth-associated deaths.
    I'll give you an example from a few years ago, when I was 
in a rural clinic in Zambia, probably about an hour's drive 
from Lusaka. A woman came in with two children, one strapped to 
her back, and one trying to walk at her side. She had had to 
walk for 2 days to get to this clinic, and was doing so because 
the baby on her back was terribly sick. But, along the way the 
child became sick as well, the one that was ambulatory, and she 
ended up, for the last mile or so, carrying both children.
    When she staggered in, the doctor felt that the larger 
child looked like the more crisis case, so she left her baby 
with me, on a straw mat on the floor, and went in to see the 
doctor with the larger child. As I held the baby, it died in my 
arms, and its cause of death was measles--completely 
preventable. The larger child died of malaria, and the mother 
broke out sobbing, describing how hard it had been for her to 
give birth both times, and how frightening it was, the prospect 
of what she would have to go through just to have two children 
to replace the two she had just lost.
    To me, that anecdote has lived with me my entire 
professional life, it has been a guiding anecdote. I can't 
think of any better way to look at what we're trying to do with 
U.S. foreign aid than to focus on how we could save both of 
those babies, and make it safe for that mother to give birth to 
future children.
    Senator Leahy. Have both the mother and the child live.
    Dr. Daulaire. The question that you asked, Senator Leahy 
is, I think, a very important one, and it underlines some of 
the challenges that we have in addressing all of these issues 
in a substantive way.
    I can certainly create for you a model in which maternal 
mortality could be dramatically reduced in which other major 
causes of illness and death probably wouldn't be affected. You 
can design a health delivery system that focuses on that. So, 
the point is that you should not confuse cause and effect. A 
well-functioning medical care delivery system will reduce 
maternal deaths, but a maternal death-reducing system will not 
necessarily be a good medical system, and I reinforce what 
Laurie Garrett just said about keeping some distinction between 
public health and medical care.
    On the other hand, an awful lot of children who die around 
the world, die not only because they lack preventive services, 
but because they don't have access to the basic care that would 
get them antibiotics for their pneumonia, that would get them 
treatment for their malaria, where you actually need a trained 
healthcare provider, so there's a mix in all of these. I think, 
though, that the bottom line is, if we made the kinds of 
investments that each of our panelists has been talking about, 
it is a reasonable presumption that we would see dramatic 
reductions in both child death and maternal deaths.
    Senator Leahy. Thank you. I want to thank each of you for 
being here. Some of the questions I asked may have seemed self-
evident, but I'm also trying to prepare a record for other 
Senators.
    I don't want to leave the impression that I simply feel 
that more money cures all things. there are very dedicated men 
and women who are out in the world, from the United States as 
well as a whole lot of other countries. Some very dedicated men 
and women from those countries, that are trying to make a 
difference. Sometimes in areas with no infrastructure, or in 
the midst of civil war.
    I think of one African country where I went with my wife 
where we were using the Leahy War Victims Fund. She had helped 
the nurses to bathe and care for a boy who was probably 10 
years old, with terribly distorted limbs. As she was bathing 
him, she didn't see a mark on him, she asked why, they said he 
had polio. She asked the obvious question, ``Why polio?'' She 
knew that we'd sent polio vaccine to that country, making it 
available? They said the people who would do the polio 
immunization could not get to his village because there were so 
many landmines around, they couldn't.
    I mention that only because too often--and I think Dr. Hill 
you were trying to point this out, there is no magic thing that 
we can do, but we should start with the health needs of women 
and children.

                     ADDITIONAL COMMITTEE QUESTIONS

    There will be some additional questions which will be 
submitted for your response in the record.
    [The following questions were not asked at the hearing, but 
were submitted to the witnesses for response subsequent to the 
hearing:]
                Questions submitted to Dr. Kent R. Hill
               Questions Submitted by Senator Tom Harkin
                           polio eradication
    Question. Polio Eradication efforts are clearly working as we have 
seen the number of countries with indigenous polio drop to four, 2 
billion children have been immunized, 5 million have been spared 
disability and over 250,000 deaths have been averted from polio. 
However, until the world is polio-free, every child, even those in the 
United States, is at risk.
    In fiscal year 2007, both the House and Senate included $32 million 
for polio eradication in their respective Foreign Operations 
Appropriations bills.
    What amount is included for polio in your fiscal year 2007 
projections?
    Answer. USAID intends to provide $31,680,000 for polio eradication 
in fiscal year 2007, which meets the House and Senate report level 
minus a 1 percent rescission.
    Question. What is included for polio in your fiscal year 2008 
budget submission?
    Answer. The administration will fund polio eradication but specific 
funding levels are still under consideration.
                                 ______
                                 
            Question Submitted by Senator Richard J. Durbin
                           maternal mortality
    Question. The statistics are devastating--1 in 6 women in Angola or 
Afghanistan is likely to die from the complications of pregnancy or 
childbirth. UNFPA has a strong track record in this area, but the 
administration has refused to provide the funding for them that 
Congress has allocated. Women giving birth alone without access to the 
most basic care or life-saving drugs that could prevent post-partum 
hemorrhage should not be a hallmark of the 21st century, but in too 
many countries it is all too common. What are the most effective ways 
to reduce maternal mortality?
    Answer. Maternal mortality can be reduced in two major ways: (1) 
reduce the number of high-risk and unintended pregnancies and (2) 
address the life-threatening consequences of pregnancy, which can 
include hemorrhage, infection, eclampsia, obstructed labor, and unsafe 
abortion. By promoting healthy timing and spacing of births, reducing 
unintended pregnancy, and reducing abortion, voluntary family planning 
is one of the most effective ways to decrease the number of maternal 
deaths. Once a woman becomes pregnant, USAID's strategy focuses on 
high-impact interventions. These include active management of the third 
stage of labor to address post partum hemorrhage; tetanus toxoid 
immunization during pregnancy, clean delivery practices, and treatment 
by antibiotics to address infection; administration of magnesium 
sulfate for eclampsia; monitoring the duration of labor and taking 
action in the event of prolonged labor; and provision of post abortion 
care. The over-arching strategy to deliver these and other maternal 
interventions (such as nutritional support and intermittent presumptive 
treatment for malaria to address indirect causes of maternal death) is 
to increase women's access to skilled attendance at birth, emergency 
obstetric capability to deal with complications, antenatal care and 
post-partum care, and family planning information and services. 
Essential to successful maternal care programs are reduction of 
financial barriers for families, appropriate deployment and retention 
of skilled frontline workers, and institutionalization of quality 
improvement systems. USAID has a very strong track record in maternal 
mortality reduction, including demonstration of effective approaches in 
community mobilization and behavior change, policy formulation, 
financing of maternity services, effective life-saving skills training, 
quality improvement, and contribution to reduction of maternal 
mortality by 20-50 percent within 10 years in 10 countries.
                                 ______
                                 
               Question Submitted by Senator Patty Murray
          healthtech and the child survival and health account
    Question. Under current funding levels, successful programs such as 
HealthTech have been cut to the skeletal remains. The administration's 
proposed budget calls for further cuts to the Child Survival and Health 
account, which funds HealthTech. These cuts are proposed while the 
administration comes to the Hill and touts HealthTech's successes such 
as the UNIJECT injection device and thccine Vial Monitor. The Senate 
budget resolution recognizes how important these programs are, and has 
added additional funding. That being said, please explain how further 
reductions could inhibit USAID's ability to fund such proven programs 
with demonstrable successes at the full obligated level?
    Answer. Reduction in funds to HealthTech is not due to Agency 
funding cuts, but due to completion of certain activities. Further, 
sufficient money is already obligated to HealthTech for current needs. 
USAID is currently funding HealthTech to help develop several 
technologies--including antibiotics in UniJect and newborn 
resuscitation devices--which will improve the health of impoverished 
people.
    In this and other key health investments, USAID focuses its 
programs and efforts on the highest impact activities, works closely 
with other donors, and continues public-private collaborations to help 
fill gaps. By these means, we expect to meet our objectives with 
requested Child Survival and Health account levels.
                                 ______
                                 
                  Question Submitted to Laurie Garrett
                Question Submitted by Richard J. Durbin
                  african health capacity/brain drain
    Question. The issue of health capacity is critical to addressing 
all of the problems raised today. The whole world, including the United 
Stats is experiencing a shortage of health personnel, but in Africa the 
shortage is far more dire. The math is devastatingly clear: as you 
testified, ``As the number of health workers declines, survival 
decreases.''
    Along with Senator Coleman, Senator Leahy, and others, I have 
introduced legislation to authorize a concentrated effort to help 
Africa build the health capacity that it so desperately needs, from 
personnel--doctors, nurses, and community health workers--to 
infrastructure. Africa needs both health systems and the ability to 
train and retain personnel. Our legislation is also part of an effort 
to combat the brain drain of health professionals, including the need 
to train more nurses here in the United States so that we are not 
dependent on the poorest countries in the world to supply our health 
workforce. Ethiopia has 3 physicians per 100,000 people but there are 
more Ethiopian physicians in Chicago than in all of Ethiopia (Tobias).
    What are the most effective ways to build health capacity AND fight 
this brain drain? This is an enormous problem--where can a U.S. 
contribution add the most value?
    Answer. Thank you very much for posing this critically important 
question. I am, of course, well aware of your important initiative, and 
praised it in my testimony, and during Sen. Leahy's questioning. When 
you initiated the process of drafting this bill there were few 
analogous efforts going on in the world, and the U.S. leadership in 
this area was desperately needed.
    I am happy to report that several potentially blockbuster efforts 
are underway, augmenting your efforts in this area. I will try to 
briefly describe the status of this situation, and suggest some efforts 
the United States can, and should, make.
    First of all, in the last few months there has been a striking 
sense of global recognition of this problem. Recognizing a problem, and 
understanding its roots and nuances, is always the first step. Two real 
heroes in this aspect of the situation are Mary Robinson and Tim Evans. 
Robinson, the former President of Ireland and former head of the U.N. 
Commission on Human Rights, is now heading an international group that 
is trying to find ways to slow the exodus of health care workers from 
poor countries to the rich, without violating their individual human 
rights. Her group is meeting as I write these words in Geneva, in 
tandem with the 59th World Health Assembly.
    Dr. Tim Evans, a leading Canadian health expert, now holds a top 
position in the office of WHO Director-General Margaret Chan. Together 
with Harvard's Dr. Lincoln Chen, Evans authored the groundbreaking 
analysis of the global health care workers situation, publishing 2 
years ago, that estimated current deficits at 4.3 million. Evans' high 
level position in WHO's new leadership signals Chan's appreciation of 
the dire severity of the situation, reflected in her marvelous remarks 
at the opening of the Health Assembly this week. Chan is clearly the 
sort of Director General the global health community has been waiting 
for, and I have no doubt that she will take this health crisis issue by 
the horns.
    On an entirely different front, the Prime Minister of Norway 
instigated a high-level meeting of foreign ministers, which convened in 
Oslo earlier this spring. The goal of the meeting was to better 
understand the links between national security and health, and the 
elevate discussion and action in the arena far beyond mere financial 
commitments. There is a growing recognition, as I outlined in my 
Foreign Affairs piece in January, that simply throwing billions of 
dollars at targeted global health problems, without any structural 
framework or support for public health systems development, will kill 
more people than are saved. (The one-page Oslo Ministerial Declaration 
is attached below.) The Oslo Summit promised a series of actionable 
steps.
    The first of those steps will be launched this September in New 
York, during the U.N. General Assembly: ``A Business Plan to Accelerate 
Progress Towards MDG 4 and 5''. It's not a pretty title, but the 
concept is important. The Plan recognizes that the real victims of 
health care worker and health system deficits are mothers and children, 
and seeks to create an out-put based business strategy for investment 
in developing country health systems. The Oslo declaration estimates 
that 10.5 million mothers and children die annually from preventable 
causes, nearly all of them directly resulting from lack of sufficient 
medical care or basic public health services, such as water filtration 
and sewage treatment.
    The Oslo group seeks to find business solutions to the crisis, 
creating better management of available personnel and resources, 
linking standards of care to financial rewards for providers, and 
moving the global community away from single disease targets for 
support and financial aid.
    Secretary General Ban ki-Moon is also interested in finding ways to 
move the entire U.N. system towards a health systems approach for 
achievement of the MDGs (Millennium Development Goals), hoping to bring 
the health targets of various agencies into greater harmony.
    Angela Merkel has signaled that she wants the G-8 to look at this 
issue in its upcoming Summit in Germany. Merkel has also instructed 
Germany's current leaders of the EU to examine EU foreign aid to global 
health, with an aim of building sustainable health systems.
    Meanwhile, the World Bank and its IFC are moving in a very 
different direction--at least, for now, under Wolfowitz's imperiled 
leadership. Thought the IFC recognizes the crisis in healthcare workers 
and paucity of health systems, it is not interested in building local 
capacity. Rather, it has announced a $200 million program that would 
bring massive healthcare corporations from the wealthy world into poor 
countries, providing fee-for-service healthcare delivery to the 
nations' elites. The notion is that quality care for the elites will 
have a trickle-down effect, setting a standard that the entire Ministry 
of Health operation will strive to achieve for the population, as a 
whole.
    As my tone may reveal, I do not accept this thesis. I was in Moscow 
when the U.S. Government built such an elite care facility inside the 
Kremlin Hospital, specifically to ensure that Boris Yeltsin received 
state-of-the-art cardiac care without having to leave Russian soil. The 
fantastically expensive effort was described in precisely the 
``trickle-down'' terms now used by IFC. But in the years following 
construction of the elite facility, the Russian healthcare system 
deteriorated further, life expectancy for Russian men spiraled 
downward, drug resistant TB and HIV spread across the region, the live 
birth rate reached an all-time low for Russia and the overall health 
status of the country plummeted: So much for ``trickle-down''.
    Here is the problem with how the United States funds these issues 
(to be followed by some suggested solutions):
    (1.) Nearly the entire foreign aid budget for health and 
development is earmarked for disease-specific programs. Under the 
President's fiscal year 2008 State Department ``Strategic Framework'' 
funding is further funneled according to global political exigencies, 
targeting specific countries that the Administration believes play 
crucial roles in maintaining regional stability or in the War on 
Terrorism. Funding does not reflect on-the-ground needs.
    (2.) The Administration (and many AIDS activists) argues that 
PEPFAR has created a health infrastructure in the 15 targeted countries 
that may now be solely for provision of HIV-related services, but can 
serve as a template for all health needs. In debates over 
reauthorization of PEPFAR this argument will be made. PEPFAR has become 
sensitized to the negative impact the massive AIDS-specific health 
program is having on other health services in targeted countries, and 
hopes to convince Congress to reauthorize PEPFAR, giving it more money, 
and a larger mandate.
    (3.) The United States is not now engaged in the multilateral 
efforts to address the healthcare worker and health systems crisis, 
such as Mary Robinson's plans or the Oslo Declaration. As you well 
know, the Bush Administration has not played on the global health stage 
in partnership with other wealthy nations, and has set moral standards 
for execution of health programs (e.g. sexual abstinence, faith-based 
solutions, etc.) We are not part of the global efforts to solve these 
problems.
    (4.) Overall, the U.S. foreign aid budget shares with other wealthy 
nations the problem of having been designed as a massive charity 
program. We have failed to invest in health, though we consistently use 
the term, ``invest''. Therefore, nothing is sustainable. There are no 
local profit centers, no genuine stakeholders.
    (5.) The Republican-controlled Senate, under the leadership of 
surgeon Bill Frist, favored solutions to the healthcare worker and 
health systems crises that flowed from the fundamentally charitable 
view of U.S. foreign aid. Frist introduced bills that would underwrite 
the costs of faith-based and medical societies-run programs that 
dropped American doctors (and maybe nurses) into foreign countries for 
short time periods, during which they would theoretically perform 
surgeries, and supplement the services of indigenous healthcare 
workers. Criticized as ``Safari Medicine,'' such vacation programs for 
American doctors tend to do more good for the Americans than for those 
they seek to serve, opening their eyes to the needs of the poor. 
Successes are limited to a handful of healthcare needs that are truly 
amenable to one-stop interventions, such as removal of cataracts, heart 
surgery, or limb replacement. Even acute humanitarian care 
interventions suffer if the health professionals limit their 
participation to time periods too short to allow them to learn some 
basic elements of the local language and culture.
    (6.) There is no linkage in our government currently between the 
dire healthcare worker situation overseas and our shortages of doctors, 
nurses, lab technicians and other health professionals domestically. 
Government functions as if the two issues were entirely unrelated. 
There is no official recognition that American companies and hospitals 
actively recruit doctors and nurses from poor and middle income 
countries to offset our gaps in training of domestic personnel. 
Institutionally, the federal agencies and Congressional committees that 
have oversight of the domestic and overseas issues share no lines of 
communication, whatsoever.
                               solutions
    (1.) A joint session should be convened of the Senate Foreign 
Relations Subcommittee on Foreign Operations and the Senate Committee 
on Health, Education, Labor and Pensions. This should be a well-
orchestrated, and well-publicized full day joint session, aimed at 
revealing:
    a. Twenty year forecast on U.S. healthcare worker needs and 
shortfalls for all health professionals.
    b. Twenty year forecast on developing country healthcare worker 
needs and shortfalls for all health professionals.
    c. Recruitment and immigration trends of foreign healthcare 
workers, filling United States needs, and estimated damage done in home 
countries.
    d. Policies enacted by other wealthy countries to address brain 
drain.
    e. Reasons the United States is currently unable to fulfill its 
domestic healthcare worker needs through training and employment of 
Americans.
    f. Identification of legal instruments and budget initiatives that 
could be enacted by the House and Senate to radically enhance both the 
training of Americans and their conditions of employment, domestically.
    g. Identification of legal instruments and budget initiatives that 
could be enacted by the House and Senate to provide incentives to poor 
country healthcare workers for remaining in-country, based on the 
identified reasons for their departures to rich countries. (For many 
doctors, dentists, pharmacists, technicians and nurses, money is not 
the primary driver: The lack of coordinated health systems, reliable 
supply chains of medical equipment and drugs, lack of meritocracy 
within Ministries of Health and general political conditions rank far 
higher as reasons for immigration.)
    (2.) As a result of above Joint Session, corrective bills should be 
forwarded that seek not only bipartisan support, but also support that 
bridges the gap between domestic and foreign committee and agency foci.
    (3.) The Senate should push the State Department to radically 
increase its currently mere $3 million commitment to training in 
overseas health systems management. Even if your healthcare workers 
bill is passed, and fully funded, a surge in the numbers of community 
healthcare workers will have little positive impact if these 
individuals are not managed properly within an overall system of public 
health and clinical care.
    (4.) Attention should be given to the remarkable successes of BRAC, 
the Bangladeshi micro-financing program that has deployed vast networks 
of paid, trained community healthcare workers to villages in pursuit of 
cholera, tuberculosis, failures in child immunization and maternal 
health. BRAC has proven that community healthcare workers, including 
semi-literate individuals, can save thousands of lives if they are (1.) 
given a finite and clear mission to accomplish, backed by adequate 
training, and (2.) paid for their work at a rewarding scale, linked to 
success, and (3.) are part of a transparent, well-organized health 
system, in this case independent of the government.
    (5.) The foreign aid budget needs to move away from charity, 
towards support of business models and financial incentives of health. 
America cannot afford to put 20 million people on anti-retrovirals for 
HIV care, and foot the bill for their continued treatment for the next 
30-to-40 years. Even if we were, as a Nation of taxpayers, interested 
in underwriting the healthcare needs of the world, we could not afford 
to do so. Therefore, we have no choice but to move away from the 
charity model of foreign aid, towards a model that provides incentives 
for creation of local business solutions. This should not follow the 
apparent IFC model of providing support to foreign health corporations, 
to go into poor countries, and extract profits from their health needs. 
Rather, the Senate should look to the BRAC model and consider how 
providing low-interest seeds can lead to the blossoming of genuine, 
sustained health businesses in poor countries.
    (6.) The Senate should put pressure on HHS to radically speed up 
approval of appointments of federal employees for overseas health 
positions. Currently the majority of CDC overseas positions, and 
deployment of health personnel from other agencies within HHS, is mired 
in Secretary Leavitt's office, pending political litmus tests aimed, 
apparently, at finding scientists, experts and physicians who meet the 
Bush Administration's moral and political standards. At the very time 
when the world is, as a community, trying to hammer out radically new 
approaches to these health crises, America's voice on the world stage 
is diminishing. This should stop, immediately.
    (7.) When considering large initiatives for healthcare worker 
training, such as is envisioned in your bill, the Senate should also 
imagine the toolkit that these workers will draw from. With what 
supplies will these new healthcare workers execute their efforts? No 
doubt supplies will, in early days, also require outside support. To 
minimize such costs and build in incentives for performance standards 
and sustained commitment to maintaining community health practices we 
have favored exploration of franchise models, a la MacDonald's: Each 
community health worker, after some identified set of training and work 
excellence have been achieved, is given very low interest micro-finance 
loans for purchase of his or her own franchise, which would include a 
physical clinic and basic tools and supplies. All of the franchises 
would be overseen by the hub of the network, monitored closely for 
performance quality; volume of services provided and inventory needs.
    Senator, we are at your service for any further clarifications, 
brainstorming or information needs you may require. We are honored to 
be of service.
oslo ministerial declaration: global health--a pressing foreign policy 
                           issue of our time
    Under their initiative on Global Health and Foreign Policy, 
launched in September 2006 in New York, the Ministers of Foreign 
Affairs of Brazil, France, Indonesia, Norway, Senegal, South Africa and 
Thailand issued the following statement in Oslo on 20 March 2007:
    In today's era of globalisation and interdependence there is an 
urgent need to broaden the scope of foreign policy. Together, we face a 
number of pressing challenges that require concerted responses and 
collaborative efforts. We must encourage new ideas, seek and develop 
new partnerships and mechanisms, and create new paradigms of 
cooperation.
    We believe that health is one of the most important, yet still 
broadly neglected, long-term foreign policy issues of our time. Life 
and health are our most precious assets. There is a growing awareness 
that investment in health is fundamental to economic growth and 
development. It is generally acknowledged that threats to health may 
compromise a country's stability and security.
    We believe that health as a foreign policy issue needs a stronger 
strategic focus on the international agenda. We have therefore agreed 
to make ``impact on health'' a point of departure and a defining lens 
that each of our countries will use to examine key elements of foreign 
policy and development strategies, and to engage in a dialogue on how 
to deal with policy options from this perspective.
    As Ministers of Foreign Affairs, we will work to:
  --increase awareness of our common vulnerability in the face of 
        health threats by bringing health issues more strongly into the 
        arenas for foreign policy discussions and decisions, in order 
        to strengthen our commitment to concerted action at the global 
        level;
  --build bilateral, regional and multilateral cooperation for global 
        health security by strengthening the case for collaboration and 
        brokering broad agreement, accountability and action;
  --reinforce health as a key element in strategies for development and 
        for fighting poverty, in order to reach the Millennium 
        Development Goals;
  --ensure that a higher priority is given to health in dealing with 
        trade issues and in conforming to the Doha principles, 
        affirming the right of each country to make full use of TRIPS 
        flexibilities in order to ensure universal access to medicines;
  --strengthen the place of health measures in conflict and crisis 
        management and reconstruction efforts.
    For this purpose, we have prepared a first set of actionable steps 
for raising the priority of health in foreign policy in an Agenda for 
Action. We pledge to pursue these issues in our respective regional 
settings and in relevant international bodies. We invite Ministers of 
Foreign Affairs from all regions to join us in further exploring ways 
and means to achieve our objectives.
   new initiative seeks practical solutions to tackle health worker 
                               migration
    Geneva.--The health worker migration policy initiative held its 
first meeting today at the headquarters of the World Health 
Organization (WHO) in Geneva. The initiative, led by Mary Robinson, 
President of Realizing Rights: the Ethical Globalization Initiative, 
and Dr. Francis Omaswa, Executive Director of the Global Health 
Workforce Alliance (GHWA), is aimed at finding practical solutions to 
the worsening problem of health worker migration from developing to 
developed countries.
    WHO Director-General Dr. Margaret Chan said, ``International 
migration of health personnel is a key challenge for health systems in 
developing countries.'' The new initiative has a Technical Working 
Group housed at WHO.
    The Health Worker Migration Policy Initiative is made up of two 
groups that will work closely together over the coming months to 
develop recommendations. The Migration Technical Working Group, which 
is being coordinated by WHO, brings together the International 
Organization for Migration, the International Labour Organization, 
professional associations, experts and academics.
    The Health Worker Global Policy Advisory Council, under the 
leadership of Mary Robinson and Francis Omaswa and with Realizing 
Rights serving as its Secretariat, is made up of senior figures from 
developed and developing countries, who will develop a roadmap and a 
framework for a global code of practice for health worker migration and 
seek high-level political backing for its recommendations.
    A recent study has shown that the number of foreign-trained doctors 
has tripled in several OECD countries over the past three decades. The 
number of foreign-trained doctors from countries with chronic shortages 
of health workers is relatively small (less than 10 percent of the 
workforce) in developed countries. However, for some African countries, 
the migration of a few dozen doctors can mean losing more than 30 
percent of their workforce, even as basic health needs remain unmet.
    Other health professions are also affected by this phenomenon. The 
study showed that in Swaziland, 60 to 80 nurses migrate to the United 
Kingdom each year, while fewer than 90 graduate from Swazi schools. 
GHWA partner and member Save the Children UK estimates that the United 
Kingdom saved [brit-pound] 65 million in training costs between 1998 and 
2005 by recruiting Ghanaian health workers.
    Mary Robinson summarized the need for urgent action: ``We cannot 
stand alone as individual countries continue to address their own 
increased needs for health workers without looking beyond their shores 
to the situation these migrating workers have left behind in their 
homelands. We cannot continue to shake our heads and bemoan the 
devastating brain drain from some of the neediest countries on the 
planet without forcing ourselves to search for--and actively promote--
practical solutions that protect both the right of individuals to seek 
employment through migration and the right to health for all people.''
    One of the initiative's first priorities will be to support WHO in 
drafting a framework for an International Code of Practice on Health 
Worker Migration, as called for by a resolution of the World Health 
Assembly in 2004. This framework will promote ethical recruitment, the 
protection of migrant health workers' rights and remedies for 
addressing the economic and social impact of health worker migration in 
developing countries. The Code of Practice will be the first of its 
kind on a global scale for migration.
    The initiative will also promote good practices and strategies to 
enable countries to increase supply and retain their health workers 
more effectively. The new tools and policy recommendations developed by 
the initiative will support better management of migration through 
North-South collaboration.
    Dr Francis Omaswa emphasized the importance of addressing both the 
``push'' and ``pull'' factors simultaneously. ``Health workers are a 
valued and scarce resource. Demand is increasing worldwide, but not 
enough are being trained--in the developed or the developing world. 
Developing countries must prioritize health and health workers, with 
better working conditions and incentives so its workforce can stay and 
be more efficient, while developed countries must train more of their 
youth and try to be self-sufficient.''
    The Health Worker Migration Policy Initiative is due to make 
initial policy recommendations by the end of 2008. Its operations are 
co-funded and coordinated by Realizing Rights, the Global Health 
Workforce Alliance, and the MacArthur Foundation.
              health worker global policy advisory council
    Co-Chairs: Hon. Mary Robinson, President, Realizing Rights
    Dr. Francis Omaswa, Executive Director, GHWA
                                members
    Hon. Major Courage Quarshie, Minister of Health, Ghana; Hon. Erik 
Solheim, Minister of International Development, Norway; Hon. Patricia 
Aragon Sto Tomas, Minister of Labor and Employment, the Philippines; 
Hon. Rosie Winterton, Minister of State for Health Services, United 
Kingdom; Dr. Lincoln Chen, Director, Global Equities Initiative, 
Harvard University; Dr. Anders Nordstrom, Assistant Director General, 
Health Systems and Services, WHO; Ms. Janet Hatcher Roberts, Director, 
Migration Health Department, IOM; Mr. Ibrahim Awad Director, 
International Migration Programme, ILO; Lord Nigel Crisp, co-Chair, 
GHWA Task Force on Scaling up Education & Training; Dr. Percy Mahlati, 
Director of Human Resources, Ministry of Health, South Africa; Huguette 
Labelle, Chancellor, University of Ottawa; Dr. Titilola Banjoko, 
Managing Director, Africa Recruit; Prof. Ruairi Brugha, Head, 
Department of Epidemiology & Public Health, Ireland; Ms. Sharan Burrow, 
President, International Confederation of Free Trade Unions; Ms. Ann 
Keeling, Director, Social Transformation Programs Division, 
Commonwealth Secretariat; Mr. Markos Kyprianou, Director General, 
Health & Consumer Protection, European Commission; Mr. Peter Scherer, 
Directorate for Employment, Labour and Social Affairs, OECD; Prof. Anna 
Maslin, Nursing Officer, International Nursing & Midwifery Health 
Professions Leadership Team, Department of Health, United Kingdom; Dr. 
Mary Pittman, President, Health Research & Education Trust, American 
Hospitals Association; and Dr. Jean Yan, Chief Scientist for Nursing & 
Midwifery, WHO, chair of the Migration Technical Working Group.
        health worker global policy advisory council secretariat
    Ms Peggy Clark, Managing Director, Realizing Rights
    Dr. Ita Lynch, Health Advisor, Realizing Rights

                          SUBCOMMITTEE RECESS

    Senator Leahy. So, I thank you all very much for being 
here. The subcommittee will stand in recess.
    [Whereupon, at noon, Wednesday, April 18, the subcommittee 
was recessed, to reconvenne at 10:30 a.m., Thursay, May 10.]