USAID’s Rajiv Shah: ‘End preventable child deaths in a generation’

Rajiv Shah, administrator for the US Agency for International Development (USAID), spoke with GlobalPost’s John Donnelly on the eve of the Child Survival Call to Action, held in Washington on Thursday and Friday. Shah talked about the need to focus efforts on five countries that have 50 percent of all preventable child deaths. But he said this new effort will not mimic the US global AIDS initiative, which focused efforts on 15 countries, and instead will rely on many governments’ commitments to saving the lives of children. Currently, experts estimate that 7.6 million children die needlessly each year from preventable causes.

Q: What are your hopes for the Child Survival meeting in Washington?

A: The goal for this gathering, which will have more than 80 countries and nearly every major international partners represented, with more than 56 countries on a ministerial level coming, is to recommit ourselves to accelerate the rate of reduction in child death and getting to a place where we can fully eliminate preventable deaths. For the first time, that is now possible. It’s possible because we really collectively believe there are new technologies, new solutions, and new examples of success to allow us to plan how we can double or triple the rate of reduction of child deaths on an annualized basis and thereby eliminate preventable child deaths in a generation.

Q: What are some examples?

A: There are three or four big shifts in how the world works against this task. The first is recognizing nearly half of all preventable child deaths are in five countries. Having those five countries really present their own country-led plans and how they are going to measure themselves and report on progress, and why this effort in their countries is part of their political and operational priority, will be a major outcome.

We expect India, Pakistan, the Democratic Republic of the Congo, Nigeria, and Ethiopia all will make strong commitments and back up those commitments with strategies and plans. That’s important because frankly, the global community hasn’t previously said we are going to have a much more strategic approach in countries that account for nearly half of all child deaths.

The second big advance that I hope comes out of it is a renewed set of public-private partnerships that help alleviate some of the critical bottlenecks we are facing – whether they are related to oral rehydration therapy and zinc, or the ability to get mobile phones in the hands of community health workers and have those phones be tools they can use to refer back to clinic services or to transfer or collect data, or to present information to consumers in a more advanced and effective way. Achieving success requires a much better commitment from private sector partners and much more creativity in public-private partnerships.

The third big shift is recognizing that if you are really want to drive down the child death numbers, you have to reprioritize the urban poor and rural communities as the absolute target focus markets for expanded efforts to address child survival. Part of how we do that is partner with institutions that are present in providing services to those communities, and in particular, faith-based communities.

Finally, having a recommitment to the Millennium Development Goals (MDG) and a strategic plan that has a new way to measure and report on results, and to drive more resources into this sector, are going to be more important. 

This is bringing the world together under the leadership of the Indian government, the Ethiopia government, UNICEF, ourselves, and others to have a real effort here to eliminate preventable child deaths. It’s possible. We’re seeing it in some places. But we’re not seeing a global reduction that is fast enough to achieve elimination within a generation, and we need to step up our efforts.

Q: Why hasn’t it happened before?

A: There has been a push in the past, both around the MDGs, and the original child survival movement, that resulted in the kind of progress that got us here. So we have seen these real reductions, which is why the Economist recently wrote that the performance in this space was a real development success story that you can build on.

The core answer to your question is we have not done enough to just recognize that in order to achieve the goal we have got to seriously implement what we are calling some major strategic shifts. One is a recognition that five countries account for 50 percent of all child deaths, and we need country-led partnerships that are effective, that are at scale and that are business-like in their ability to tackle that challenge in those five countries, and that hasn’t materialized to date.

Second, I think one of the strategic shifts is recognizing that a lot of health case service delivery in countries around the world is geared toward middle- and upper-class urban communities, but if you want to tackle child death, you need to work in urban slums and rural communities. Making sure that recognition is guiding the operational importation of programs has not fully taken hold. It has in some places such as parts of Bangladesh and parts of Ethiopia, but it hasn’t taken hold as a global concept because it’s politically difficult.

A third strategic shift is the recognition, over time, that the percentage of child deaths attributable to neonatal causes has gone up. To reverse that trend, we need to get more women into birthing clinics and have more skilled service providers present at childbirth. 

Q: Do you see a parallel to the beginning of PEPFAR, which named 15 focus countries to fight AIDS? Is this five focus countries for child survival in terms of putting that kind of resources and people into it?

A: Certainly in terms of strategic and diplomatic focus and technical partnership. But keep in mind this is a different era and a different problem. India is a great example. It is a country that has 22 percent of all child deaths, but has enough resources and technology and innovation within their system to tackle that problem should they choose to do so. I expect (senior Indian officials) will lay out a profound vision to do that. They are not dependent on aid to be effective or successful at that task and, in fact, they do not seek aid. They are an emerging economy and power that is standing on a global stage and is taking on a regional responsibility to be leaders in tackling child survival. 

(The child survival initiative) is a more modern and a more future-looking interpretation of PEPFAR, but in terms of our commitment in achieving the goal and to recognize we want every country around the world, including the United States … to be getting engaged and committing themselves to this task, using local ingenuity and resources.

Q: The top three killers of children are pneumonia, diarrhea, and malaria. The first two have relatively new vaccines now being rolled out with assistance from the GAVI Alliance. The third one has a vaccine entering the final stages of clinical trials. How critical will be it to your goal to get vaccine delivery right?

A: Vaccines are a huge piece of the solution. They are essential to this effort and that’s a major priority. But I just had a conversation in a public forum with Andrew Witty, the CEO of GlaxoSmithKline, and the maker of a lot of these vaccines, including potentially the malaria one, and his point was that vaccines can be an entry point to service delivery. They can be the reason you get interface with a baby, but when you are at that point of interface with the baby, if they don’t get nutritional supplements, if they are not getting bed nets, if they are not getting simple diagnosis for other issues that they face, then you are missing an opportunity to have a more integrated approach. So absolutely vaccines are the tip of the arrow, but there’s a whole lot more to the arrow that can be dragged along with vaccine delivery that can actually save that child from a number of different causes of death. 

Q: One of the key areas you have cited in the past in reducing child deaths is more education for women and girls. Why is this so important?

A: Data that comes from Chris Murray at the Institute for Health Metrics and Evaluation show that maternal education is the most powerful social determinant of outcomes in terms of preventable child deaths. When women are more literate and have a higher level of education, children survive. There’s a whole effort here to be more data driven in how we identify priorities and make investments.

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