 Good morning and welcome. We're going to get started. I'm Steve Morrison, Senior Vice President at CSIS and head of our Global Health Policy Program. And we're really thrilled today to be able to host this event. It's a very momentous point here, a milestone in the development of this very ambitious initiative and we'll hear much more about it from all of our speakers. We're blessed by having such a remarkable array of speakers here today to reflect on where we are at the end of this first phase and where do we move forward. A special thanks to Janet Fleischman, my colleague and close friend who has really pioneered our side of this and the work that we've undertaken along with Alicia Kramer. Many thanks to those at CSIS who have contributed. Ryan Sickles, Annie Anderson, Comm Quinn, Jesse Simpson, Joe Jordan, many of the folks on our staff who weigh in on the logistics and the preparations. Dr. Rutha Chang from Uganda and Dr. Carolyn Fury from Zambia made the special commitment to come here to be with us today as our particularly honored guests from those two partner countries. Thank you both for coming and we're very honored to have Rod Shaw, Dr. Rod Shaw, the Administrator of USAID and Dr. Thomas Frieden who will be here with us. Our friends at CDC, AID, Merck and Ogack have all been great partners in pulling the initiative together but also incorporating with us. We know this is a big moment. We know this is a point of celebration and reflection about looking forward into the future in terms of mustering the political will, the resources, the knowledge and operating plan for moving forward into the next phase and we know much more about that. So thank you all for being with us. I think this is going to be a terrific morning of discussion and I'm going to turn the floor over to Janet. Thank you. Thank you all again and special thanks to Steve Mars in the director of the Global Health Policy Center for his extraordinary leadership of our efforts here at looking at US Global Health Policy. It's wonderful to see so many champions of maternal mortality here in the audience today. I think it highlights the interest in this field and the importance, the dynamism of this area of global health and the fact that women's health really is the cornerstone of global health. We have all seen in different ways the tragedy of maternal mortality particularly in the developing world, the impact, the human impact on families, on communities and of course on the women. When I was in Zambia in 2012, I interviewed Professor Chamba from the Zambian Ministry of Community Development, Women and Child Health. She, by the way, was going to come today but had an illness in her family so we send them best wishes. But Professor Chamba told me, quote, in Zambia, when women have delivered, we say, oh, you have survived. She said we want to get to the point where women can look forward to labor and not say I may die. This really is a chilling reminder of the impact of maternal mortality around the world. Nearly every day 800 women die from complications of pregnancy and childbirth. 99% of these are in the developing world. We know that these deaths are largely preventable with interventions and training to prevent and treat complications such as hemorrhage, infection, obstructive labor and with increased access to reproductive health services and emergency care. Maternal mortality really is the ultimate indicator of a country's health system. Saving Mother's Giving Life as we know is a five-year, $200 million initiative that seeks to reduce maternal mortality by up to 50% in eight districts of Zambia and Uganda. It uses an innovative approach, a public-private partnership, and it was launched by then Secretary of State Hillary Clinton in 2012 with partners beyond the U.S. government with the Norwegian government, the Zambian government, the Ugandan government, Merckfer Mothers, the American College of Obstetricians and Gynecologists, and every mother counts. New partners include Project Cure and other partners are coming on board. Many representatives of these partners are here today and we welcome you and thank you for your efforts. All of this built on the U.S. government's investments in women's health through PEPFAR, through USAID, through the CDC, and other USG agencies, the Department of Defense and Peace Corps included. SMGL has generated great excitement, but all who are involved know that there's no quick fix and there's no magic bullet. SMGL has shown that you really can move the dial on maternal mortality, but the programs face many challenges. It's complicated. There are many partners and multiple components to be implemented. It's costly, it requires resources and in the current budgetary environment it remains unclear how the short and long-term financing can be secured, and moving forward it will be essential to transition to greater country control, country ownership underpinned by high-level political will. And that's why we're here today to reflect upon the first phase of SMGL's results and to look ahead to the next phase. We hope to address the questions of what needs to happen to make SMGL sustainable and scalable? And how do we get there? What are the components for a viable program and how can the partnerships support the achievement of these goals? We have a wonderful program today. We are going to open up with a keynote by Dr. Shah, the administrator of USAID, and then we'll be followed by two panels. The first featuring representatives of the host governments from Zambia and Uganda, and then we will move to a discussion about the SMGL partnership and examining how it has delivered. And we will end with remarks by CDC director Tom Frieden. So now it's my honor to introduce Dr. Shah, the administrator of USAID. He has just passed his four-year anniversary at USAID. Many of you remember that he entered with the crisis in Haiti just days later, and it has been a turbulent time with challenges to USAID's mandate and support. And Dr. Shah has worked to reform and revitalize the agency, leading reforms of USAID's business model under USAID Forward, building bipartisan confidence in health and development, and key milestones of his tenure include the Child Revival Call to Action Summit in 2012, the Feed the Future Initiative, and advancing USAID's leadership in maternal and child health with SMGL being a prime example of these initiatives. His work on engaging the private sector, on interagency collaboration, and on being results-driven have been hallmarks of his leadership, as well as moving forward with the development needs in areas of conflict and humanitarian crisis. So we welcome you, Dr. Shah, and look forward to your comments. Good morning. First a special thank you to Janet for that kind introduction and for reminding me that it's now been four years in this role. A special thank you to Stephen for hosting us today and for your committed leadership on behalf of CSIS and Global Health. A special thank you to CSIS's donors that made this wonderful building happen. We're thrilled to be here to celebrate this great facility, and I also want to recognize, and part of why I'm so excited that everyone has gathered today is that we are celebrating and learning from a genuine partnership today, and I'd like to recognize Tom Frieden, who will of course be here later, but sent me a note and I know that he will, even though he's going at the end of the day, he's going to run through all the data for you, so you'll get that from him as you always do. And Tori Gadal from Norway we are very hopeful that as Norway continues its own political transition, it maintains its very strong leadership in global health because the Norwegians have always had a unique and significant commitment to that particular goal. I too am pleased that Dr. Firi is here from Zambia and Dr. Acheng is here from Uganda. We value your partnership and are very much celebrating today the results of your work, so thank you. And I want to take a moment just to recognize there's so many wonderful USAID colleagues here, but in particular Claudia Morisset and Robert Clay if you two could just stand up and wave for a moment who on behalf of Arielle and Katie and myself and so many others carried the torch forward for this important initiative and I can assure you raise it regularly with me and with everybody else to keep us informed and supportive. It really is hard to believe that it's almost, it's only been just over a year since Secretary Clinton launched this partnership with our friends in Norway and at the time it seemed ambitious she was insisting that the entire US government get together to support this effort. I know my colleague Tracy Carson from OGAC is here with CDC while represented and certainly USAID as an example of coming together to take on a difficult challenge and try to see it through. But it wasn't just about the US government working in a coherent way, although that's important, but genuine partnership between the public and private sector and today we recognize the role and the leadership of Merckfer Mothers. Every mother counts Project Cure and the American College of Obstetricians and Gynecologists that have all lent their expertise and their unique capabilities to the extraordinary results we will be discussing this afternoon and this morning. The reality is we know that it is unacceptable and heartbreaking that nearly 300,000 mothers and 3 million newborns continue to die each year from causes we know how to prevent. Without access to a skilled birth attendant who provides life-saving care in rural settings, a mother's risk of dying at what should be the most joyous moment of her life is 120 times higher than it is in medical settings here in the United States. That's why Saving Mothers was specifically designed to target the three big delays that put the lives of women and newborns at risk every day. The delays in seeking, reaching, and receiving good care. In many cases something as simple as knowing the danger signs during pregnancy or arranging for transportation to a clinic ahead of time is all it takes to save a mother's life. In Uganda and Zambia, for example, we focused on the challenge of getting women to the help they needed during an emergency. We used geospatial technology to map travel time to clinics, helped form district committees to coordinate transportation for mothers, and provided travel vouchers to pay for it. In Uganda in one year alone nearly 30,000 transportation vouchers were actually redeemed and used. In Zambia where distances are vast and roads sometimes perilous motorcycle ambulances now connect women to facilities that can provide emergency services in the two hour window around birth when the risk to women and their newborns is greatest. Now, after a year after we launched this pioneering effort, we've begun to see real evidence of progress and the results are inspiring. In just one year maternal mortality declined by roughly one third in the districts we worked in in Zambia and Uganda. The number of women who delivered in healthcare facilities shot up by 62% in Uganda. And the number of women who received the care they needed to protect their children from being born with HIV rose by 28% in Uganda and 18% in Zambia. These are extraordinary results achieved in just one year of real change and effort. They are remarkable and we know that they can be scaled to larger levels. We know this because in order to even gather the data to be able to make these claims we had to help build robust measurement systems to document our progress. In Uganda officials carried out a reproductive age mortality study to identify the baseline and track actual results. In Zambia where information was too sparse to measure maternal mortality by district we reviewed the medical records in each facility independently. As a result we now have a strong foundation for continuing to monitor and report on what's actually happening as a result of your great efforts. And as a result we're confident that we can see similar results when these programs are implemented nationwide in both Zambia and Uganda. But we're not stopping here, not with these promising results. In the next five years we plan to bring saving mothers to at least three more countries because we know just what a difference this approach can make on the ground. When you save the life of a mother you create ripples of change that echo outwards transforming not only the health of her family and the strength of her community but also the stability and economic prosperity of her society. A mother's survival resonates across borders and through generations. Every life we save, Secretary Clinton said when she first launched this program, is a step towards a more peaceful prosperous planet. Today we know exactly just how big a step forward this represents. For centuries birth rates across the world remain stubbornly high and dangerous hedge against the awful reality that many children die young and often right at the moment of birth. But as countries began investing in child survival family planning, neonatal health and education something surprising happened. Their economies started to take off. Armed with data from the World Bank and the United Nations and visualization software that became the envy of technology companies like Google the world-renowned analyst and my favorite YouTube subject Hans Rosling has traveled the world to demonstrate the close connection between healthy children and prosperous economies. As they trace across decades his animated graphs show how the distribution and rate of child mortality in numerous countries has changed over time and the conclusion is quite clear child survival underpins strong economic growth. Take Thailand as just one of many many examples. 50 years ago the average citizen made under a dollar a day and the average family had over six children. But with our support and partnership the country expanded access to voluntary family planning to immunize children, fought malaria and made educating girls a priority. Birth rates fell quickly. The average family now has fewer than two children and retrospective economic analysis showed that a major part of Thailand's economic rise was the demographic dividend they experienced from the changing structure of their population in the early 90s. This phenomenon is far from unique. In fact this is the rule not the exception. In country after country we've seen birth rates go down, population growth slow and that serves as an underpinning for what the World Bank has identified as a 2% demographic dividend that supports accelerated growth rates in those countries for nearly two decades. The truth is that maternal and child mortality are not only a stain on our conscience but also anchor our global prosperity. Hans Rosling says it best when he says the moral obligation of providing health services hides the fact that healthy children are also one of the best economic investments you can make in your country. That's why nearly two years ago we did join UNICEF at Ethiopia in India in hosting a call to action for child survival here in Washington D.C. It was a powerful moment and I see many of you were there then and are still with us now as more than 176 countries and more than 450 civil society and faith organizations from around the world step forward to join that call to action. Together we committed to a new approach to global health that's not about excluding the poorest of the poor populations or deprioritizing specific individual diseases. In fact it's the opposite by setting a single comprehensive goal that we can end preventable child death within two decades. We focused on the core interventions, the core target populations and the core health commodities that need to be delivered at much larger scale in order to achieve this basic result. With a greater emphasis on science, business and innovation as you've demonstrated through this partnership, we're seeing new solutions emerge that can help us achieve and even accelerate the deadlines we've set for ourselves. By partnering with the private sector, saving and just giving life is getting affordable new maternal health technologies into the hands of community health workers. With Merck for Mothers in the lead, I think Navin Rao is here and we thank him for his leadership. We're testing the design of community shelters where women can stay and receive care in advance of their due date. And by working closely with local leaders we're strengthening the capacity of our partner countries and partner communities to one day manage the care of their communities without our assistance. That's exactly what we saw happen in Uganda this past year. When a member of the parliament recognized the success that saving mothers had in recruiting health workers by paying them higher salaries he encouraged the government to introduce a wage bill. Today that bill has increased the salaries for health care workers across the entire country. Around the world countries are taking real concrete steps to dramatically improve the odds for women, newborns and children. Since the call to action, 18 to 20 months ago, more than a dozen countries have launched their own local calls to action. They've developed evidence based plans and clear data driven report cards. They've identified target districts and target communities where the highest rates of child death occur and maternal death occur and try to focus resources and energy at reducing those rates of child mortality and maternal mortality in those places. And that includes countries like India, the DRC and Nigeria that still together account for a very large proportion of the nearly 6.6 million children who die every year under the age of 5. Now at the end of the day we know that our efforts will only succeed when we work together to identify these vulnerable communities and target and scale the kinds of solutions that you've developed here to those communities at real scale. And we know from what you've done here that we're going to have to invest in measuring and reporting on results not just so that we can all talk to our colleagues in Congress or the British Parliament or any other donor country community. But more importantly, so that leaders like that parliamentary leader in Uganda can see the value of these investments and can make the connection for themselves that when they invest local resources and local capacity in their own health systems they're building the basis for a sounder economy and a more prosperous nation. You know, just before the holiday break I had a chance to visit the Democratic Republic of Congo. And I spent a day in the eastern part of that country which is just experiencing the potential for some improvements in socioeconomic conditions based on a recent peace deal that was negotiated as part of the Kampala Accords. And I met with young children who had either been the subjects of violence, too often young girls, who had been severely injured and traumatized from sexual violence during the conflict. And young, mostly boys who had spent too many years of their young life in rebel groups with machetes or machine guns in their hands. And I just take great pride in the fact that each of you by coming together to develop this kind of a program and approach, and by your willingness to extend the reach of these efforts to the places where people suffer the greatest are going to do more to save more lives and to create the basis for stability in places that really need the fruits of your labors. So I accepted the invitation to come here and really say thank you because all too often people will thank military leaders that win victories on the battlefield or presidents that sign peace agreements. But at the end of the day I think this partnership shows that when you can bring this kind of excellence commitment to mission and commitment to outcome to the toughest parts of our planet, you can both help us build a better safer world and you can serve as the best and most profound expression of American values often in the farthest corners of the globe. So thank you for your leadership and thank you for having me this morning. Thank you so much Dr. Shaw. Can you all hear me? Dr. Shaw agreed to take a couple of questions before he has to run out and maybe I can just start it off. And we have microphones can you hear me better now? Can you hear me better now? Thank you. So Dr. Shaw will take a couple of questions. We should have microphones so raise your hand and we will be able to take just a couple. Maybe I can start out first of all by thanking you for your remarks and for all your amazing work and leadership at USAID. And maybe you can elaborate a little bit more on the lessons of a public-private partnership. Why do this not as a bilateral program? What are the benefits of doing it as a public-private partnership? Well I hope you will discuss this and I know you will through the rest of today. But it's quite clear that the power of coming together across these different communities both brings different points of view, new ideas and technologies a sort of shared commitment to measure the results in this setting. And a sense for the rest of us that as this has been succeeding this can now scale. And it can now scale because the United States government is fully committed through all of our different global health entities that can now scale because great significant companies and countries are standing behind it. It can now scale because it's generating data and changing laws on the ground. And all too often we talk about building health systems in the abstract when if we focus on the results and build the right partnerships and then just really in a results oriented way insist that we take these things to scale and end up building that health system we've been talking about in a more coherent and more results oriented manner. Okay we have time for a couple of questions. I'm going to ask that you identify yourself and keep your questions brief in the back. Hi my name is Jean Arcadis from the Results for Development Institute. Thank you so much for your comments. I was really interested in what you were saying about results monitoring and data. I work on impact evaluation currently working on maternal and newborn health. I was just wondering I know evaluation has been a signature part of your tenure at USAID and wondered what role impact evaluation has played in this effort if any. Thank you. Well thank you and impact evaluations have played a huge role in this effort. I think over the last several years we've literally put hundreds of third-party evaluations with no rewriting elements involved on a public system so that people can download that. I keep the app on my iPhone and you can go to the app store and download it but it's just the USAID evaluation app and it has hundreds of evaluations. Some of those are impact evaluations and what we found is about 40% of our projects that undergo those types of evaluations, people end up using the data in a mid-course correction exercise to make adjustments in those programs and I just think that's ultimately the goal. The goal is not necessarily although it's fun for some of us to thumb through these things on long flights but the reality is the real use of this information needs to be those of you that are running these programs and thinking every day how do we make this more effective and optimizing the results we generate through the efforts we've put in place. I hope we see more of these efforts. I think this project and the reason we're all here today is because we have robust data. Robert and I spent a lot of time mostly him explaining this to me but discussing how hard it would be to collect valid data in this situation because at the end of the day district level maternal mortality is a difficult thing to measure and so changes in that level is also a difficult thing to attribute to a specific initiative but the seriousness with which you've undertaken that task allow us all to learn from it today and we just wouldn't be here had you not done that so thank you. I think we have a question in the back over here. Thank you Dr. Shaw for your excellent presentation Keith Martin from the consortium of universities for global health. Can you share with us your views on how MCH can be used as a springboard to actually building up the primary care plus public health initiatives that can be used to address 80% of what comes through your door medically but also to deal with the social determinants of health and how that can be used to build up the primary surgical capabilities that are needed essential to deal with the causes of perinatal mortality morbidity. Well thank you and I think underlying that question is the reality that you know this answer and everyone else here knows this answer and the thing we all have to do is keep reminding ourselves that when we build a service platform that allows us to reach vulnerable people who have unnecessarily high rates of mortality and morbidity for whatever cause we ought to be able to use that platform to do as much as we can to save lives and reduce mortality and morbidity and you know I was thrilled I see CHIP lines right behind you I was thrilled to see the data on the HIV transmission reduction from this effort as well and I think the more we can show that these relatively straightforward efforts to expand the quality of health care services at a primary care level and the integrated capacity to do everything from ending mother child transmission to providing better delivery support to immunizing those kids to ensuring people go home with bed nets I mean whatever it is y'all are doing to make sure that those things come together that's the path forward to ending preventable child death and that's why everyone no matter what specific disease you're most committed to studying and is the source of the funding that drives your work we are stronger if we stick together and stay focused on that big goal of ending preventable child and maternal death in a fixed time frame. Do you have time for one more question? Sure. Alright one last question from the audience and then Dr. Shell will have to go Wait Jill can you wait for the microphone Jill Gay what works association how do you plan to align USAID's work on maternal health with your goals on gender equity? Well that's a good question and the good news is you have Katie Taylor and a number of other of our leaders here today Robert included to help answer that in more depth but I think the two big observations I'd make are number one we found from the call to action analysis and work that when we target that we don't often our global health expenditures do not often target the places and the communities that have the largest gender equity gaps and have the highest rates of maternal and child mortality and so I think first it's about effective targeting of specific communities within the countries where we work and I think everyone here knows this and it's the spirit of this program you know we don't have to target 42 different outcomes in order to make progress here the idea that you all have demonstrated which is let's focus on saving mothers lives and do it in a way that's inclusive and builds an effective health system appears to both improve dramatically service access for women and achieve all of these other health goals that we all are so committed to so efforts to bring those two things together are shining examples of what's possible and we should do more of this across our work all around the world. Thank you very much please join me in thanking Dr. Schell. Can I invite the first panel to come up. Thank you so the first panel is going to focus on the country level and we are very honored to have Dr. Ruth Acheng the director general of the Uganda Ministry of Health and Dr. Carolyn Peary the director for maternal and child health at the Zambian Ministry of Community Development Women and Child Health each of these speakers is going to give a short presentation and then we are going to sit down and have a discussion before opening up opening it up to Q&A so let us begin with Dr. Acheng. Good morning to you all I bring you greetings from Uganda and particularly from my ministers of health and I want to thank you for this opportunity to share with you the results of an undertaking of a very noble program in Uganda that has very promising results and Uganda has always had a strategy to address maternal mortality and the evidence in this is shown in our national health policy and the health sector strategic and investment plan which define maternal child and newborn mortality reduction as three key outcomes of our health sector. In 2007 we developed a roadmap for accelerating reduction of maternal and maternal mortality which has been running to date and in 2010 we also committed to the campaign for accelerated reduction of maternal, newborn and child mortality in Africa and also to the UN Global Health Strategy that addresses the continuum of maternal and newborn care. In 2012 we undertook this ambitious program of saving mothers giving life with the aim of reducing maternal mortality by 50% in four pilot districts in western Uganda The interventions focused on three areas to reduce maternal and newborn mortality and this were increasing awareness hence creating demand for maternal and newborn health services throughout the communities. The second was to enhance quality maternal health services by improving communication and transportation systems and the third was to improve the quality of maternal and newborn health care including emergency care in the event of pregnancy related complications. I am now pleased to share with you some of the results of the achievements that we had. We had improved health outcomes in a number of areas and I will start with the area of maternal mortality and HIV treatment Overall there was significant reduction in maternal mortality observed at both facility and community level. Prior to the saving mothers giving life the ratio in the four pilot districts was 452 per 100,000 life births and this was reduced to 316 deaths per 100,000 life births. The 452 is not very different from the national average which is about 438 per 100,000 life births. This reduction from 452 to 316 constituted a 30% reduction overall. The real number of deaths also decreased between baseline and end line dropping to 247 from 342. Delivery at the facilities also increased. As I mentioned before we used community health workers that we popularly know as village health teams to work throughout the saving mothers giving life districts to encourage women to seek maternal health services and to give birth in the health facility. This effort led to a 62% increase in the number of women giving birth in the health facility. The baseline was at 46 and it rose to 72%. Deliveries in the referral facilities decreased as a proportion of this total increase indicating that the lower level facilities were absorbing much of this higher demand and this also allowed our referral facilities which is only one in this area to focus on managing complications that require emergency obstetric care. The number of women that were enrolled on treatment for prevention of mother to child transmission increased by 28%. And also the number of infants that were able to access treatment, prophylaxis for prevention also rose by 27%. And this definitely built on the existing PEPFAR platform with the aim to further integrate maternal and child health with HIV treatment and prevention. The next improved health outcome was in the area of managing maternal complications. As I mentioned before, the numbers of women seeking maternal health services increased by 62%. And therefore the demand for treatment of life-threatening obstetric complications increased as well. Saving mothers made a concerted effort to hire, train and mentor health workers to provide emergency obstetric and newborn care. We recruited a total of 147 health workers of different categories to work in these districts. We had more women with major complications were able to be treated. However, there was a minimal increase of 10%, as you can see, from 39 to 49%. There is room for improvement in this area. There was also an increase in the number of women who were able to access cesarean section. This increased from 5.3 to 6%, 6.5, which was a 23% increase. The proportion of women who died from obstetric complications decreased despite the significant increase in the number of facility deliveries. And this was from 2.6 to 2%, which was a 25% drop. There was also an increase in the number of facilities that were practicing active management of third stage of labor, which is an effective intervention to treat postpartum hemorrhage, one of the leading causes of maternal death. And this showed an increase of 100%. The other improved health outcome was in the area of cause-specific maternal mortality rate. There was an observed reduction overall in the leading causes of maternal mortality across the serving mothers giving life districts with the largest reduction in obstetric hemorrhage, which is the number one killer of mothers. These reductions reaffirmed that emergency services in the serving mothers giving life facilities are improving and providers are therefore able to provide life-saving emergency obstetric care. Significant reductions were also registered in the areas of obstetric labor and uterine rupture line as well as postpartum sepsis as you can see from that graph where the uterine rupture line from 71 to 33 and for postpartum sepsis reduced from 33 to 17. Under health system strengthening we had remarkable improvement in health facility capacity. The number of facilities that we are able to offer services 24-7 and this is looking at our health centre threes. The health centre threes are at the sub counties. The structure, the referral structure in Uganda is that you move from health centre two which is at the village level or the parish to health centre three at the sub county to health centre four which is at the health sub district. And at that time very few health centre threes were able to offer services 24-7. There was a significant increase of 24%. The health centre threes also offer basic emergency obstetric and neonatal care. At the baseline we only had three facilities offering these services but at the end line this had increased to nine facilities offering the services which is a 200% increase. The health centre four general hospitals and the referral hospitals offer comprehensive emergency obstetric and neonatal care. And at baseline we had only seven offering these services. At the end line all the health centre fours, the general hospitals and the referral hospitals were all offering comprehensive emergency obstetric and neonatal care which was a 129% increase. One of the strategies we employed to increase this facility coverage was the introduction of the transport vouchers to enhance access to services. This system had a tremendous impact on increasing accessibility and it contributed to the overall increase in number of women seeking maternal services. There was an 11 fold increase in the uptake of the transportation vouchers during the project period. We distributed vouchers in three of the saving mothers giving life districts and these were given to women both in public and private facilities. 75% of the women who delivered in the facilities in the districts had transport to facilitate the move to the different facilities and this transport was either by way of motorcycles or tricycles or ambulances that was made available for this purpose. Finally I'll discuss the overall expenditure that went into this very noble venture. We spent about 10.5 million US dollars over 17 months. 8.3 million went into support services delivery and 2.2 went into systems support. Building on the existing PEPFAN maternal health platforms we documented expenditures for strengthening district health services and systems to reduce both maternal and neonatal mortality. There were a number of partners that were involved in this venture and it was interesting to have all the partners well coordinated all aiming to achieving one goal. We believe that this expenditure was worth it. Each district was driven by unique context and the gaps were addressed based on the challenges in each of the districts. As I mentioned before the majority of the expenditure went to improve service delivery and the remaining was spent on system support. What are our next plans for scale up? Moving forward we plan to expand to six districts in northern Uganda and these are particularly districts that were affected by the war or the Lord resistance army insurgency and these are districts that have very high maternal mortality rates. We also plan to maintain the program of progress in these learning districts, the four districts in western Uganda and we plan to continue to implement and scale up high impact interventions that have been documented in the recently launched promise renewed document and we also plan to collaborate with other partners to ensure that the proven interventions from saving mothers giving life are implemented throughout Uganda. I thank you all for listening to me. Thank you very much Dr. Acheng. I should also have mentioned that their full bios are available with the papers when you came in. So I did not read them for you but you can find that at the papers at the front. So now it is my pleasure to introduce Dr. Carolyn Peary of the Ministry of Community Development Women and Child Health in Zambia. Good morning ladies and gentlemen. I know it's a cold day but sometimes in Zambia we like a responsive, good morning everyone. Thank you very much for giving me this opportunity to come and share the experiences in Zambia and the progress that we have made in terms of maternal health and also that what we have learned, the lessons that we have learned from the saving mothers giving life. Firstly I just want to convey apologies from my permanent secretary in the Ministry of Community Development, Mother and Child Health, Professor she would have loved to be here and unfortunately that at the last minute she had family illness and so you just have to make do with myself. So to start my presentation I would like to show you this girl who is actually on this picture. This woman is on her way to the health center and she is going for antenatal care. The reality in Zambia is she most probably have started, this could be her first antenatal visit because despite having a high first antenatal care of 91%, we actually have most women attending antenatal care quite late. Apart from that, maybe she was even a person who didn't have access to family planning. We've got a very high and met need of 27%. What are her chances of survival? Will she be able to attend all four antenatal care visits? We have a very, very low number of antenatal care visits. So women usually go for antenatal care to get the book so that if there is any complication at least they have the antenatal book. They do not value the quality of care that is being provided. So she might be one of the 60% women who actually go for all four antenatal care visits. Our maternal mortality is also quite high. It's 440 per 100,000 live births. So what are her chances of survival? A woman has a 23 lifetime chance of dying from pregnancy or child birth. Her baby has survived. We find that the neonates actually have a much lower survival chance. So we find that we have a one chance in 26 of dying in the first month for most of these women. Despite these statistics, Zambia embarked on a very vigorous maternal newborn and child health campaign. We were partied to the campaign on accelerated reduction of maternal mortality. We also developed the roadmap to see how we can improve maternal health in Zambia. With all these interventions, with all these high impact interventions we needed support from partners. We needed to work government and partners to see how we can actually achieve these results. So Seven Mothers Giving Life actually joined us in this same roadmap that we had developed and was able to implement high impact interventions which I won't go through because I think they were well elaborated and they are in your documents. So what are the results of that one year? I think that's what I'm going to present to you. So this first slide shows us the improved health outcomes and we actually saw some dramatic improvements in these same sad statistics I have mentioned. In the four Saving Mothers Giving Life supported districts we saw a very significant reduction in maternal mortality and 35% maternal mortality within one year was actually something which we had a lot of pessimists including myself but it is actually something that is positive and has taught our government that we should be able to collaborate and use these strategies that have been used to improve maternal mortality in the rest of the districts. You look at facility deliveries that woman you saw on that picture only 47% of the women actually deliver in health facilities. Most of our women do not come to the health facility for delivery unless there is a complication or unless they think they are at high risk. So we actually saw a dramatic increase in facility delivery. How has this done? I think it was really improving the community awareness we have women being encouraged to deliver in the health facilities we have a program where we train community health workers traditional better attendance in what we call the Safe Motherhood Action Groups. They work together with the community. They encourage the women to deliver in the health facilities. They teach the women on dangerous signs. We even have a campaign where we target the traditional leaders and the chiefs that they should be able to come to the health facilities that they should encourage women to health facilities. Some communities go to the extent of actually even charging a woman to charge the husband because usually it's the husband's fault. Charge the husband for actually allowing the wife to deliver in the health facility and to deliver at home. So you have to pay that a go to two chickens if your wife delivers at home. So that actually encourages women to come to the health facilities. We also had looking at a birth plan which shows a woman any dangerous signs they are taught using the community health workers. They are taught on what the dangerous signs they should look for and how to come to the facility early and how to even plan for transport to go to the health facilities. The other indicator which we looked at and this was actually building on what PEPFA and what other HIV programs we have. We have actually seen an increase in ART which has been given to pregnant women who are HIV positive by 18% and prophylaxis to the baby to the newborns was increased also to 29%. Other improved health outcomes looked at the management of maternal complications. I think we are all aware that despite having the best facilities you cannot prevent a complication in pregnancy and 15% of all the pregnancies result in a complication. So you need to have facilities available to provide comprehensive emergency and obstetric care. So in Zambia SMGL was able to train 200 health workers including the nurses, midwives and doctors to be able to provide emergency obstetric care both at the health facility and the comprehensive EMOC at the hospitals. And this led to an increase in 24% for those facilities which were able to provide emergency services. We do not have enough health workers and that's one of the challenges that we have. So the SMGL was able to provide, they hired health workers skilled better attendance in these health facilities and these were now able to operate 24 hours because some clinics were actually closing at 16 hours. So they were able to provide these services and it increased by 44%. The caesarean section rate increased because we trained women in comprehensive EMOC and we also saw a reduction in the case fatality rate. So looking at the cost specific maternal mortality like the obstetric hemorrhages, this reduced by 35% from 110 to 72 and the deaths from obstructed labour also reduced from 59 to 13 and this was a quite a drastic reduction of 89% and this also reduced the number of obstetric fistulas that we had. Other direct causes indirect causes like maternal deaths from HIV and malaria were 28% lower and all this was because we were able to provide comprehensive and basic EMOC training and skilled health workers equipment infrastructure and to those four districts. One of the things that we really also benefited was sorry, thank you, it moved on my paper. One of the things that we also benefited from okay, thank you, sorry about that was maternal death reviews. We had 100% maternal death reviews being done in the health facilities. This was using the VABO autopsy concept. We had launched this as government in 2009 in all the districts where every maternal death in the facility and in the community was reviewed but because it wasn't really done, we didn't really give so much effort. We found that the health facilities or the health workers were a bit reluctant thinking it would actually be a police type of maternal audit but what SMGL did in the four districts was to reintroduce the VABO autopsies where they work with the district commissioners. We also trained health workers and the community to be able to provide, to be able to assess any death that is done in the community and if there's a death they register this death report to the health facility and then it can be reviewed. The review also included the district commissioners, other departments like engineering, the transport and the roads so that people should understand that it's not only the health worker who causes a death but it's the whole line of the three delays that causes the death. All this, what has it cost us? You cannot improve, you cannot improve maternal health without a cost. You cannot conduct a delivery in the home without having to, without it resulting in a death. So maternal death can only be prevented if we put in funds and looking at this we actually spent 8.1 million over 20 months and this was broken into in the first initial 20 months for the four districts and most of the expenditure went to 56% of the expenditure was for service delivery and 44% was spent on system support which included monitoring and evaluation which included supporting the health system to be able to provide these services. I put in this slide just to show what the government is doing in terms of partnerships and this slide shows the different partners who have come on board ever since we launched the Kama campaign to be able to work well together. The government coordinates the partner so that the different geographical locations are covered by a partner and that we don't have duplication. This is important as we might, if we work together, concerted efforts together, government and partners I think we'll be able to achieve much. I thought maybe I could just include this. So for us to actually have this woman coming early enough and being aware that she should come in the first trimester when she's pregnant we need to ensure that we invest in this woman and I think saving mothers giving life has given us lessons and opportunities to increase community awareness, provide facilities which are equipped which have health workers and provide transport to take a woman when there's a complication for Caesarean section. Thank you very much. Thank you very much for those excellent presentations that really set the stage for what we want to talk about today. There's so much data, so many lessons that have been learned and so much of this relies on the countries themselves and the levels of political commitment, political will to really move this forward at the country level. So I wonder if we could start out and I could ask you perhaps Dr. Acheng if you could talk about the change in terms of political will in Uganda to support this kind of program. I hope I'm audible. Well thank you very much for that question. From the beginning there has been very good political will and as was mentioned before, one of the steps that was taken was in the recruitment of health workers. We recruited about 7,200 health workers in a period of six months of all categories and they are available in all those health facilities at the Law Health Center and a wage bill was provided for them as well as an increase in salary at least for the doctors. There is now a program to increase the salaries for the midwives and also to recruit more health workers, about 3,000 health workers this particular year. Apart from that there has been a plan by government to mobilize all women to deliver in the health facilities using the village health teams. Registers have been bought for the village health teams, bicycles have been bought by the government and the village health teams have been trained and right now they are mobilizing government to deliver in the health facilities. Government has also procured equipment for basic emergency obstetric care as well as comprehensive and distributed them to all the facilities in the country and right now training is ongoing for the health workers that have been recruited so that they are able to handle every mother who comes to the facilities. There is a committee in parliament that is concerned with maternal and child health and advocacy committee that has meetings with us in ministry of health every quarter and they have really been advocating for more funding for maternal health and this is evidenced by what government has increased to the ministry for handling maternal health. Thank you. Thank you very much. Mary, I know that the issue of recruiting health care workers has been a huge challenge in Zambia. Perhaps you can speak a little bit about that issue and some of the other challenges you faced in scaling and sustaining this program. Thank you, Janet. Yes, health workers are a challenge for Zambia. I think one of the challenges that the availability of the health workers in the health facilities and also our training schools are not able to spill out enough health workers for the government to absorb and because of that you find that even if the districts, even if the women do come to the health facilities, they might be delivered by a card called an environmental health technologist who does water and sanitation and environment, some health centers are even being managed by a maid or a guard. We are aware of that as government and because of that we have also recruited health workers. All those who are graduating, we actually put in funds, the government put in funds to recruit health workers. We recruited 1,900 health workers in 2013 but this is still not enough because of the attrition. So one of the things that we have thought of is task shifting. We thought that if this, the health worker who could be two or there could only be one midwife in the health facilities, if they were, and they do everything, outpatient, data collection, water and sanitation, everything, if there could be task shifting where certain tasks could be done by the community health workers. For example growth monitoring and promotion, community based distribution. If the task could be transferred to them then they can concentrate on delivering a woman and providing the basic emergency services. The other thing that we want to address is also looking at the community health assistant and we did see what Ethiopia is doing and this community health assistants, we've trained some with support from partners, we have trained and we've put in the health facilities to work with the community to encourage them to come to the health facilities but they are also able to manage a certain outpatient like management of childhood illnesses as well as simple deliveries. But I think the challenge of transport is also there. We have a very vast and sparsely populated country. Distances to the clinics are very, very far. Most women have to work more than maybe five hours just to get to a health facility. So mobile services are some of the things that we are doing and also when they do get to the health facilities provision of maternity waiting homes are also some of the things that we are doing. So saving mothers giving lives has given us these lessons and as new partners are coming on board to be able to provide services, we want to use these concepts which are proven interventions which have quite high impact to provide these services. Thank you. Dr. Acheng you spoke about scaling up to some of the provinces and districts in the north. And I wonder what are some of the key elements of the saving mothers giving life program in the districts where it now is operating that you want to transfer to those areas in the north. Some of the key learnings from those first districts. One of the very important undertakings that was carried out in the saving mothers giving life was empowering the community health workers that we call village health teams to mobilize the mothers to deliver in the health facilities. These village health teams moved from door to door you know to talk to the mothers physically and to encourage them to deliver in the health facilities. This is one of the very important concepts that we have to move to northern Uganda and to get these mothers to deliver in the health facilities. In Uganda right now we have nearly every district has village health teams that have been trained and as I mentioned before they have been empowered with a bicycle and a register. And so we believe that when we empower them with information to give to the mothers about the importance of delivering in the health facility this will encourage mothers to move and deliver in the facilities. The second and the most important is the use of the voucher systems. There is definitely difficulty with the transportation of the mothers moving from where they are to get to the health facilities. The health center tools which are at the village level are able to offer services for delivery but they are not at the level of the health center threes which are the parishes sorry at the sub counties. It is there for pertinent that the mothers are facilitated to move to these facilities to get their services. And therefore the voucher system will work and not only will it work for transportation and delivery we also plan to scale it up for family planning because as you are very much aware the fertility rate in Uganda is quite high. It is about seven children per woman and if we are able to scale up family planning and cover the unmade need for family planning then we shall also be able in a way to address the high maternal mortality that is already in that area. As I mentioned before recruitment is still ongoing and we hope to break the gap and also to make sure that at least in the referral facilities there are obstetricians to cater for the mothers. Thank you. Dr. Piri, can you tell us what are the next steps for your government and what do you want to see from other partners and other donors? Thank you. We are planning to scale up the saving mothers giving life to four more districts and we've learned the lessons that I think let us do the districts which are adjacent to the already existing districts that are providing this service because it was quite costly to actually implement it in the almost four corners of the country. And then we also as a government we are as I said we have lessons that we have learned. One of the very important ones is the maternal death surveillance review. This has been incorporated in the back in the government and we have trained the province and the districts to be able to do the maternal death surveillance. So this is one of the things that we want to all partners who come into the MNCH arena that that should be part of the things that they are doing in their district. That we actually use the same tools we use the same collection format and we review the deaths that are done. It is quite costly but I think it's something which if we start with using the community as well as the health workers we can be able to achieve it. We also plan to as government we are buying equipment and transport to the district to give to the districts to improve on management of complication of the referral system. One other thing which we have want to introduce is the mama kits which were done in some of the SMGO districts. So we want to actually scale that up to the other districts because it does incentivize the women to deliver in the facilities and also the TBAs when they bring the women to the clinic they are given an incentive with the mama kits so that will also be quite helpful. So we want to scale up the whole package and consider it a whole package to other districts. When partners come in we use the same interventions to scale up to other parts. I think it would be great since we have such an engaged audience here to open it up to questions from the audience. When you ask your question please identify yourself and we will take as many as we can. Maybe we'll do it in groups of three and then we will get responses and do another round. And there are microphones So first let's start on this side of the room. We'll begin over here on the right. Thank you. Loretta Kakuza with Plan International and I want to thank you both for sharing your early successes and wish you much more success in this endeavor. My question is for Dr. Acheng. I'm really happy to hear you'll be scaling up family planning in Uganda. And I just needed a little bit of clarification. I had the pleasure of being in Uganda in November and my colleagues there said that girls under 18 were not able to access contraception through the public health system. Is that actually the case? And if so is there any movement towards making contraception available to the very large youth population? Take another question. Over here on the far right. Good morning. My name is Erin Emel with the American Academy of Pediatrics. Thank you very much. These are wonderful results. I'd like to hear a little more about the slight increases in neonatal mortality and what can be done about that. Thank you. And we'll take one last question. We'll go to the middle here. Thank you very much for presenting those results. They're very noteworthy. Rick Berzon with the National Institutes of Health. My question really focuses on the issue of long term sustainability of the programs that are in place within your country. While you are training up quite a lot of community health workers to learn these skills around obstetrics and gynecology, my question really is is your country committed to an effort to training up nurses, nurse midwives, clinical officers that can go out into the countryside and into areas where needed that are better able and better trained to deliver these kinds of services and is there an effort within your country to expand the way you train up your physicians so that they are encouraged to go out into areas where they're most needed. We have a similar problem of maldistribution in our own country here in the United States which is often perceived as an under-availability of clinicians but it's really a maldistribution and I was wondering how you were planning on offering incentives to your clinicians that you train up to actually go into areas where they're most needed. Thank you. I think we'll start with those three. Maybe Dr. Acheng, you could begin with the family planning question. Well the question was whether it is true that girls under 18 are not able to access family planning or contraception through the public health system. Well this is not true. The truth is that there are challenges in the public health system with health workers to offer the contraception to these girls and therefore they prefer to go to the private facilities where they already readily access services but nobody denies them services. It is available and the commodities are available. There was a question about a slight increase in neonatal mortality. I don't think we talked about that. What we said was that there was improvement in the number of infants that were able to access treatment or prophylaxis for HIV especially those who are exposed. There was definitely no increase in neonatal mortality although the saving mothers giving life did not actually focus a lot on the neonate. There was a lot done to make sure that they stayed alive and this will now be addressed in the scale up. Talking about the long term sustainability and training of nurses and midwives Uganda in particular no longer considers traditional birth attendants or you know task shifting to non-medical people. We did this several years ago and it was banned. We now particularly look at the professionals to offer services to the mothers and it is true that we have had a shortage of midwives more so because along the way we decided to train the comprehensive nurses and this was done because we thought if we made comprehensive nurses available to the lower health facilities they would be able to handle delivery as well as attend to the other class of patients who also need treatment. But right now training is ongoing for midwives in nearly all the schools and the challenge with Uganda is not the production the challenge is the absorption into the system. We have health workers available. Thank you. Dr. Peary do you want to take those questions too about the whatever you'd like to say about family planning availability as part of the program as well as the neonates and the availability of healthcare workers. Thank you. For Zambia the access to family planning is available for all but I think it's the attitude of the health workers and also the fear by the young people to go to the health facility especially the public health facility to access the services. We have identified this as a challenge and what we do is that we have actually also developed what we call a family planning scalar plan an eight year plan and in there there's a target we are targeting adolescent girls. We're also targeting the community, the health providers and the traditional leaders to tell them about the challenges that we are having especially with the high teenage pregnancies. The girls if they want to access family planning they can go and get it from the public health institutions. In smaller areas most probably the health worker is your aunt or is a friend to your mother so that is where the challenge is and they can't afford to go and get the services from the private because it's quite expensive. So yes it is a challenge we've actually noted it but the guidelines say that we should provide family planning to all those who request for it. And I think as Dr. Cheng has said that I don't think we mentioned an increase in neonatal mortality but what we said was that we did not see a drastic reduction in neonatal mortality. So I think we have actually noted that and as a country what we are trying to do is we are providing the essential newborn care services management of the newborn complications especially at delivery as well as the first one month management of the newborn. So that is something which we are doing and training the health workers in the health facilities. Looking at the human resource yes our government does have a plan to scale up the number of health workers that we are producing. We have a training plan that we have developed and there's a training school that we are actually renovating which used to provide maybe only graduate about 70 to 80 per year. So this one now will be able to manage nurses, midwives, clinical officers, a card called medical licentias and we want to be producing at least 3,000 a year. That is a plan that we have and we want to see if we can increase this number. To ensure that we expand the physicians to the rural areas we have what we call rural posting. Once a physician, a medical doctor finishes the internship they have to go to the rural, they are posted to the rural areas where they work for one and a half to two years before they can be accepted into the training schools for postgraduate. So that is something that we have put in place and once they graduate they are bonded for the time that they are sponsored by government so that they can go back to the rural areas and they work for a period of time then they can move to wherever they are. When we said task shifting we do not task shift the skilled birth attendants. We task shift those things like growth monitoring and promotion for immunization, for child health. We task shift things which the health worker seems to be so busy doing. Certain outpatient management of children. So we train the community health workers in what we call integrated community case management so that they can manage certain conditions and then refer to the health facility. This reduces the burden on the midwife who has to do everything so we don't task shift delivery. That is still being done by the skilled birth attendant. Though in reality we still have a very big gap. Thank you. Okay we can take one more round of questions. We'll do three more. We'll start over here in the front row. A mic is coming. Reading them Koki Agarwal with MCHIP, Jepaygao. I'd first like to congratulate both the countries in demonstrating these results because I think it's really important for the maternal health community to see that when you put money and resources and a public-private partnership behind initiatives like this we can demonstrate the results that we've been waiting for for a long time. My question was for either one of you or both of you if you'd like to answer is as we scale up and as more women are coming into the system to have deliveries in the facility, could you say a little bit about how we are making sure that we provide them with the best quality of services. And we'll take one from the middle back here. Thank you very much. My name is Manas Harrison and I'm with Project 216. My question is to both of Madam Presenters and that is about, you're talking both about need for more skilled workers and what have you. Either one of the countries have the capacity for e-learning that's sort of a two-fold and if yes what is being done about it and if no, what can be done about it to make your programs both sustainable in terms of your skilled workers. Thank you. Thank you and one last question. We'll go over here. Hi, my name is Alex and I'm from PATH and I'm working on a tuberculosis focused project and we're working on integration of tuberculosis screening with maternal and child services and also given that tuberculosis is accountable for about 15% of all maternal mortality and up to 34% of maternal mortality if indirect causes are considered. I was wondering if I could hear from either of you about if your health centers or health workers right now were trained in tuberculosis screening and if you thought that that was something that you could integrate into your health clinics. Okay, thank you. We'll let you answer this round of questions and then give you a chance to make a final comment and then we'll have to wrap it up. Well thank you very much for the questions. The question on provision of quality services as we plan to scale up yes. We are focusing a lot on provision of quality services and as I mentioned before part of this was to ensure that we actually have obstetricians in those places and support supervision continues and training as I said is ongoing for especially the newly recruited health workers in comprehensive emergency obstetric and neonatal care and also training is ongoing in the areas of neonatal resuscitation and helping babies breathe to ensure that the babies stay alive. Equipments have generally been provided and of course there is a lot of support supervision that will be undertaken. On the question of e-learning, well this has not yet started so I will not comment a lot on it but I'm hopeful that it will be considered. Health workers screening for TB. In Uganda nearly all health workers are trained to screen for TB especially in women who are HIV positive or those who have TB and are not HIV positive and vice versa so there is routine screening for all these groups of people. Thank you. In addition to what Dr. Cheng has said for us to be able to provide quality of care we've also included mentorship which is at district level so there are mentors who have been trained who go and supervise the health workers so that they're able to provide quality of care and as well as the technical support supervision which is done. The question on e-learning, yes, Zambia has introduced e-learning in the nursing schools and in the schools which are training clinical officers. This is just starting, we started it last year and we want to see how it will evolve but otherwise we are interested to be able to increase the number of health workers being put out in the field. We also have e-learning for certain programs like integrated management of childhood illnesses and so this is being done so that we can increase the number of skills, improve the skills of the health workers at the district and health center level. Tuberculosis screening in maternal health yes for those who are HIV positive unfortunately we still have to do the separate screening, I think that's the question you're asking, separate screening for all pregnant women in terms of tuberculosis. They are asked the questions but we don't do active screening so they do, there are certain questions that are asked when they come for antenatal at booking time and those who are found that they need to be referred to the TB corners they are referred but I think it is more of the HIV screening that is done and syphilis screening which is actually more active. So there was a lot of questions and I'm sure we could continue to ask many more but I'd like to give you a chance to just offer any final thoughts things that we didn't cover or that you'd like to convey to us as we wrap up this session. Well as a wrap up I just want to say the loss of a mother in childbirth is very painful and the loss of a neonate is as well very painful it is therefore very important that mothers should be kept alive while giving birth as well as the neonates. Let us not focus on the amount of money that is spent in these interventions rather let us focus on the number of lives we have saved to make the world better. Thank you. Thank you. I think to wrap up I just want to say that these efforts need to be done in partnership with the governments and with all partners who come on board. I think the saving mothers giving lives in Zambia showed a very strong partnership within the US government organizations. Why I say this is sometimes we have parallel programs within the US government and as government you will find that we have to deal with the US government parallel programs and then the other partners as well and it's quite a lot so and everyone wants to achieve so if we are going to go for achievements we won't achieve anything a personal achievement but if we want to save the woman we need to work together and as government we are actually willing to work together and we appeal that let's come and buy into what government is doing and we have the interventions we know what we're supposed to do. Let's just sit together at the table and put in our funds together and save one woman and one child. Thank you very much. Thank you all very much I think you'll agree that we have been very honored to have these distinguished guests from Zambia and Uganda to join us today and to share with us their experiences in this very important first phase and we will look forward to welcoming you again to hear about phase two so thank you all we'll move to the second panel now.