THE PMNCH 2012 REPORT ANALYSING PROGRESS ON COMMITMENTS TO THE GLOBAL STRATEGY FOR WOMEN S AND CHILDREN S HEALTH *****

Transcription

1 THE PMNCH 2012 REPORT ANALYSING PROGRESS ON COMMITMENTS TO THE GLOBAL STRATEGY FOR WOMEN S AND CHILDREN S HEALTH ***** ONLINE QUESTIONNAIRE International Diabetes Federation 1. Does the above statement accurately reflect your commitment(s) to the Global Strategy? Yes 1.1 Please specify in the text box below what is your actual commitment(s) to the Global Strategy. 2. Please select from the following list the countries and/or regions (in capital letters at the end of the list) that your commitment(s) to the Global Strategy target(s). Select all that apply. (If your commitment does not have any specific geographical targets, please select none ). India, SOUTH AMERICA, CENTRAL AMERICA, NORTH AMERICA, CARIBBEAN, WESTERN EUROPE, CENTRAL EUROPE, EASTERN EUROPE, MIDDLE EAST, NORTH AFRICA, SUB- SAHARAN AFRICA, CENTRAL ASIA, SOUTH ASIA, EAST ASIA, SOUTH-EAST ASIA, OCEANIA 3. In the implementation of your commitment(s) to the Global Strategy, have you been prioritizing specific reproductive, maternal, newborn, and child health (RMNCH) intervention areas? Yes 3.1 Please select these RMNCH interventions from the following list. Select all that apply. Other (please specify):: gestational diabetes screening and care 4. In the implementation of your commitment(s) to the Global Strategy, have you been focusing on any specific health systems strengthening and/or service delivery areas? Yes 1

2 5. Please select from the list below areas of health systems strengthening and/or service delivery supported through your commitment(s). Select all that apply. Recruit and/or train other health workers, Establish new/improve existing health facilities, Reinforce community systems, Inform and educate the public about RMNCH to promote healthy behaviours and build demand for commodities and care 5.1 You selected "Other". Please specify in the text box below. 6. How would you rate the progress in implementing each of your health systems strengthening and service delivery commitment(s)? Recruit and/or train other health workers: In the inception phase Establish new/improve existing health facilities: In the inception phase Reinforce community systems: In the inception phase Inform and educate the public about RMNCH to promote healthy behaviours and build demand for commodities and care: In the inception phase 7. Please provide details of progress achieved in the implementation of your health systems strengthening and service delivery commitment(s). Examples: What specific decisions or planning processes have you put in place to implement your commitments? How many health workers have you trained? In whi Gestational diabetes (GDM) is associated with several perinatal complications, and women with GDM and their offspring are at increased risk of developing type 2 diabetes later in life. IDF has identified a number of critical gaps with relation to gestational diabetes in lowresource settings. These include: - insufficient focus on GDM risk factors and on prevention (including insufficient preconception planning and support) - lack of consensus on diagnostic/screening criteria of GDM - lack of early-detection/diagnosis soon after onset of GDM - lack of sufficient initial support immediately following diagnosis - lack of follow-up post-partum, and of longer-term monitoring of both mother and child - lack of interdisciplinary coordination at the health system level IDF has thus selected Chennai, India, as the site for a 3 ½ year translational research pilot project that will address some of the aforementioned gaps. It will be implemented in collaboration with IDF s in-country partner, the Madras Diabetes Research Foundation. The project seeks to improve the health outcomes of women with GDM and their newborns in the target area, and strengthen the capacity of selected health facilities to address GDM. Its intervention strategy consists in: 2

3 - establishing a comprehensive baseline view of GDM in the target area - developing a model of GDM care that can be integrated into the existing package of RMNCH services - building the capacity of facility-based and outreach health workers to address GDM - documenting the impact of the project through a research study As the project is still in the inception stage, no concrete actions have been taken yet to strengthen health system and service delivery. The project has identified multiple entry points for integration of GDM-specific interventions along the lifecycle dimension of the continuum of care (not all of which will be directly addressed in the context of this project): - preconception planning and care: awareness-raising and prevention; education targeting all women of reproductive age, with specific attention to women with a pre-existing diabetes condition and those at increased GDM risk) - antenatal care: awareness-raising; screening of high-risk pregnancies and monitoring of fetal well-being; early detection/diagnosis of both diabetes and GDM; ongoing monitoring, education, and support (including self-management and medicine) for women diagnosed with GDM - postnatal and post-partum care: continued monitoring and support (including nutritional counseling, breastfeeding counseling and support, and screening of infants for complications)for women diagnosed with GDM and their newborns - ongoing health promotion beyond the post-partum stage, in order to prevent future complications (namely, onset of type 2 diabetes) and linkage with diabetes health professionals GDM-specific interventions along this second dimension of the continuum of care (places of care-giving) and that are in accordance with existing diabetes models of care and the expanded chronic care model, include: - individual/household: education of pregnant women and their partners/families, who access health services at an earlier stage of pregnancy are benefit from early screening and are better able to self-monitor and access appropriate health services - community/outreach: community awareness (among women of reproductive age and their partners, among community health outreach agents) around GDM risk factors and promotion of screening among high-risk groups, health promotion/prevention, development of peer support networks - health facilities: prevention, promotion, and early diagnosis of GDM and GDM-related complications by primary and referral-level health professionals; coordinated management by interdisciplinary teams (primary, obstetric/pediatric, diabetes specialists including nutritionists and other paramedical professionals) to optimize initial and longer-term management 8. Which constraints have you encountered in the implementation of your health systems strengthening and service delivery commitment(s)? Select all that apply. 3

4 Financial constraints (for example, lack of funding for recurrent costs), Social and cultural barriers to providing access to services for women and children, Gender inequalities, Other (please specify):: The major difficulty faced by this project is the lack of coordination between different facility-based services: healthcare workers providing antenatal, labour & delivery, and postpartum care services do not coordinate care with healthcare workers treating diabetes. A woman diagnosed with GDM will receive care from two separate and parallel systems of care, increasing the burden on herself, the health system, and increasing the risk of conflicting advice and care. 8.1 Please provide in the text box below details of any constraints you have encountered in the implementation of your health systems strengthening and service delivery commitment(s). See above 9. What opportunities do you see for strengthening health systems and service delivery at both the global and the country level? Please provide information in the text box below. Despite the growing need to address GDM in order to promote mother and child health and well-being, GDM remains a neglected issue. Major initiatives underway globally, such as the Helping Babies Breathe and Saving Newborn Lives initiatives, do not look specifically at GDM, which can be a major underlying factors in neonatal deaths. Likewise, integrated packages of services that promote a coordinated approach to maternal, newborn and child health within the continuum of care framework are now the norm (although actual implementation varies); yet these packages of care do not, for the most part, incorporate GDM-specific aspects or offer linkages with countries diabetes models of care (where they exist). Opportunities exist for the integrated service provision model that has been standardized and promoted within the field of RMNCH be expanded to incorporate non-communicable diseases (as is being done to strengthen the links between RMNCH, HIV/AIDS, and nutrition). Globally, health systems strengthening and service delivery should focus on case management and referral mechanisms. Some aspects we have identified as key gaps include: a) from the community to the health system: clearly identifying and maintaining the primary point of contact for a pregnant woman who may need to receive care from multiple services within the health facility b) within the health system: there should be increased support to interdisciplinary coordination within health facilities. This should include promoting increased links between RMNCH and other services (be they surgical, rehabilitation, or to specialized services such as diabetes care). A case management system could be promoted and would be highly beneficial for certain types of issues that require inter- and multi-disciplinary care. 10. In the implementation of your commitment(s) to the Global Strategy, have you been focusing on any specific policy and advocacy areas? 4

5 Yes 11. Please select from the list below areas of policy and advocacy supported by your commitment(s). Select all that apply. Policy on specific RMNCH interventions (for example, adoption of integrated management of childhood illness (IMCI) guidelines), Advocacy for political/policy support (for example, support from ministries, parliamentarians or media) 11.1 You selected "Other policy commitments". Please specify in the text box below You selected "Other advocacy commitments". Please specify in the text box below. 12. How would you rate the progress in implementing each of your policy and advocacy commitment(s)? Policy on specific RMNCH interventions (for example, adoption of integrated management of childhood illness (IMCI) guidelines): In the inception phase Advocacy for political/policy support (for example, support from ministries, parliamentarians or media): In an advanced stage of implementation 13. Please provide details of progress achieved in the implementation of your policy and advocacy commitment(s). Examples: Which policies have you already developed, enacted, or implemented? How have you advocated for women s and children s health? Policy on Specific RMNCH interventions: IDF has been working to address critical gaps with relation to the prevention and management of gestational diabetes (GDM) in low-resource settings. GDM is associated with several perinatal complications, and women with GDM and their offspring are at increased risk of developing type 2 diabetes later in life. Inconsistent diagnostic criteria and lack of awareness among health professionals and pregnant women mean that identifying and appropriately treating women with GDM is challenging in many contexts and can lead to poor outcomes for mother and child. When existing guidelines and standards are implemented, this can significantly improve the health of women with GDM, pregnancy outcomes for mother and child, and reduces future risk of diabetes. The gaps IDF is working to address include: 5

6 - insufficient focus on GDM risk factors and on prevention (including insufficient preconception planning and support) - lack of consensus on diagnostic/screening criteria of GDM - lack of early-detection/diagnosis soon after onset of GDM - lack of sufficient initial support immediately following diagnosis - lack of follow-up post-partum, and of longer-term monitoring of both mother and child - lack of interdisciplinary coordination at the health system level IDF has made the following progress: - Initiated a 3 ½ year translational research pilot project in Chennai, India, to improve the health outcomes of women with GDM and their newborns in the target area, and strengthen the capacity of selected health facilities to address GDM. (further details in health system strengthening section) - IDF has co-chaired a WHO expert group on GDM diagnosis and screening. This will result in global recommendations for GDM diagnosis and screening that can be feasibly adopted by all resource settings. - IDF is taking a leading role in developing international best practice for GDM prevalence studies by developing an IDF Model Approach to GDM Prevalence which is aligned with the outcomes of the WHO GDM Consultation. In doing so, IDF will catalyse a consistent approach to generating GDM prevalence estimates throughout all its regions, and ensure that data are comparable and reliable going forward. This initiative will support the inclusion of a GDM chapter in future editions of the IDF Diabetes Atlas, and raise this neglected maternal health issue on the global health agenda. Advocacy for political support: The International Diabetes Federation used the opportunity of the UN High-Level Summit on Non-Communicable Diseases (NCDs) to elevate diabetes and NCDs onto the global political agenda, and led a movement to increase recognition of the linkages between diabetes/ncds and women and children s health. IDF was one of the earliest voices calling for a UN Summit on NCDs, as these four diseases (diabetes, cancer, cardiovascular disease and chronic respiratory disease) have been a neglected and silent killer for too long. No longer diseases of the rich and elderly, NCDs increasingly affect women and children in developing countries and across the reproductive, maternal, newborn and child health (RMNCH) continuum. We joined forces with visionary NCD champions and our sister federations in the NCD Alliance in calling for the Summit, and in record time we achieved a unanimous decision amongst governments to hold the Summit in September IDF and the NCD Alliance were instrumental in the preparatory months leading up to the Summit. We build a NCD civil society movement from scratch, growing the NCD Alliance into the leadership vehicle for civil society. By the time of the Summit, the NCD Alliance represented a network of 2,000 organisations, including four federations, 1,000 member associations, 9 supporting NGO partners and their organisations, 11 private sector partners and 350 NGOs from a range of disciplines. It was through this extensive network, and our strategic alliances across the UN, governments, NGOs and the private sector, that we were 6

7 able to leverage the opportunity and outcomes of the UN Summit for women and children s health. Outputs: IDF Chaired the NCD Alliance Women and NCDs Working Group, which brought together experts from the NCD and MNCH community to develop an influential publication on Women and NCDs. Entitled NCDs: A Priority for Women s Health the publication was the first of its kind to focus on the specific challenges and needs of girls and women at risk of or living with NCDs. It outlined the evidence and provided policy recommendations for action. It built on the UN Global Strategy for Women and Children s Health which refers to NCDs as a key element of improving the health and lives of girls and women worldwide. Launched at a side event at the UN Commission on the Status of Women (CSW) in February 2011, it stimulated policy dialogue on the particular issues related to girls and women and NCDs in the lead up to the UN Summit on NCDs, and reached policy makers in key UN agencies and multilateral agencies including UNFPA, UN Women and the World Bank. IDF used the publication to increase recognition of the linkages between NCDs and MNCH among NGOs working in the field of MNCH, including by becoming a member of the WHO Partnership for Maternal and Newborn Child Health (PMNCH) and promoting the publication to its 400+ members. Building on this, IDF joined forces with the WHO Partnership for Women and Children's Health (PMNCH) to produce a knowledge summary on NCDs and the reproductive, maternal, newborn and child health (RMNCH) continuum. The Global Strategy for Women and Children s Health recommends that healthcare for NCDs be provided as part of an integrated approach to promote women and children s health, and this Knowledge Summary was a synthesis of the scientific evidence into a user-friendly format to inform policy and practice on this issue. Launched at the World Health Assembly in 2011, this Knowledge Summary has been widely disseminated. IDF produced a policy brief series, with a particular focus on women s health. We produced a policy brief entitled Diabetes in pregnancy: protecting maternal health and one entitled Early origins of diabetes. The Diabetes in Pregnancy policy brief specifically focuses on gestational diabetes - the evidence on the increasing scale of the problem, the short and long-term complications it can cause, the challenges that remain in diagnosis and data collection, and the need to integrate diabetes into maternal health initiatives. The Early Origins of Diabetes policy outlines the compelling body of evidence that suggests that type 2 diabetes originates in the early stages of life, influenced by maternal under- and overnutrition, diabetes in the mother and the fetal and post-natal environment, and the implications for policy makers. We disseminated these widely to UN agencies, particularly UNFPA and UN Women, governments, NGOs working in the MNCH field, and the private sector. Another element of IDF s advocacy has been promoting gender-responsive approaches to diabetes/ncds. IDF produced a fact sheet together with the Gender, Diversity, and Human Rights Office of the Pan-American Health Organization (PAHO) on Gender and NCDs, and consequently led the organisation of a NCD Alliance, PAHO, the Commonwealth Secretariat, 7

8 and the WHO Partnership for Maternal and Newborn Child Health (PMNCH) co-hosted a side event on Gender Responsive Approaches to Non-Communicable Diseases (NCDs). The event was held concurrently with the UN Summit on Prevention and Control of NCDs. A high profile panel explored the different dimensions associated with NCDs for men and women and the gender-related disparities in NCD treatment outcomes. The panellists, drawn from Mexico, Nicaragua, Trinidad and Tobago, and Rwanda discusses gender integrated approaches to NCDs and provided recommendations to change NCD policies and interventions to respond to the specific needs of men and women. The event provided practical solutions and best practice examples for governments. Outcomes: As a result of the work of IDF, the NCD Alliance and the leadership of Caribbean Heads of State, world governments convened at the UN High-Level Summit on NCDs in New York from September 2011 to agree to a set of actions to address the growing NCD crisis. Heads of State unanimously adopted a Political Declaration on NCDs at the Summit that firmly position diabetes and NCDs as a global development issue. It is the strongest statement of intent for action to date by governments, encompassing 22 action-oriented commitments covering the spectrum of prevention, care, health systems, research and development, monitoring and resourcing required for accelerated action. It defines a united global response to stem the tide of NCDs, and critically, demonstrates consensus by the world s governments that NCDs are everybody's business and therefore require a collective response. Significantly, due to IDF and the NCD Alliance s advocacy during the negotiations of the Political Declaration, it includes specific paragraphs on women s vulnerability to NCDs, maternal and child health, gender inequalities and the socio-economic determinants of health. The Political Declaration acknowledges the gender differences in the NCD epidemic, particularly with regard to vulnerability; acknowledges that maternal and child health is inextricably linked with NCDs and their risk factors, including the early origins of diabetes/ncds; promotes a gender-based approach for NCD prevention and control and sex disaggregated data; and calls for the inclusion of NCDs within sexual and reproductive health and maternal and child-health programmes, especially at primary care level. The Political Declaration is not only a major milestone in the journey to elevate diabetes and NCDs onto the global agenda and as a women and children s health issue, but it is also a major step forward in promoting the integration of health services, as recommended by the UN Global Strategy for Women and Children s Health. 14. Which constraints have you encountered in the implementation of your policy and advocacy commitment(s)? Select all that apply. Other (please specify):: The absence of diabetes/ncds in the MDGs resulting in multilateral and bilateral agencies focusing on the priorities within MDG 4 and 5, and neglecting diabetes/ncds 8

9 14.1 Please provide in the text box below details on constraints you have encountered in the implementation of your policy and advocacy commitment(s). 15. What opportunities do you see to strengthen policy and advocacy commitments at the global, regional and country levels? The Political Declaration on NCD Prevention and Control, adopted unanimously at the UN Summit on NCD, represents an unprecedented commitment. Now we have to ensure that the promises made by governments are turned into action and use the declaration to accelerate national action on diabetes and promote integration within existing health services, including MNCH. We will continue to build the political momentum from the Summit in emphasising the links between NCDs and MNCH. IDF and the NCD Alliance saw progress earlier this year at the UN Commission on the Status of Women in 2012 when a Resolution on maternal mortality and morbidity was adopted, emphasising the linkages between NCDs and maternal health, as well as making specific references to gestational diabetes. In 2010 a similar Resolution on maternal mortality was adopted at CSW with no mention of NCDs or GDM. Post-Summit, diabetes and NCDs are now on the global and maternal health agenda. The 2012 Resolution states that prenatal malnutrition and low birth weight create a predisposition to obesity, high blood pressure, heart disease and diabetes later in life. It also states that maternal obesity and GDM are associated with an increased risk of contracting NCDs. After the UN Summit on NCDs, the next major opportunity is the end date of the Millennium Development Goals (MDGs). We have always given our full support to the MDGs, but the absence of diabetes/ncds has been a major obstacle to mobilising leadership and resources. As the official process to review the MDGs and plan for the post development framework gets underway, we have a unique opportunity to ensure diabetes/ncds are fully embedded in the future development agenda and the linkages across health (including NCDs and MNCH) are fully captured in the framework. The UN Conference on Sustainable Development (Rio+20) and the process to define Sustainable Development Goals are open opportunity, as is the MDG High-Level Review in 2013 in the countdown to Does your commitment(s) include support for research? No 16.1 Have you established or participated in any research networks in connection to your commitment(s)? 9

10 16.2 Have scientific publications, policy briefs and/or program evaluations been developed in relation to your commitment(s)? 16.3 What barriers, if any, have you encountered in implementing support for research? 17. Does your commitment(s) support the development of any RMNCH innovations? No 17.1 Please describe what kind of innovations are supported through your commitment(s), how these innovations have contributed to improving RMNCH Have related patents and guidelines been developed? 17.3 What barriers, if any, have you encountered in implementing support for innovation? 18. Does your commitment(s) include support for monitoring and evaluation? No 18.1 Which monitoring and evaluation areas have you targeted in the implementation of your commitment(s)? Select all that apply Do your monitoring and evaluation mechanisms produce data disaggregated as recommended by the Commission on Information and Accountability for Women s and Children s Health, for example by socioeconomic status, gender, age, geographic location and ethnicity? 10

11 18.3 Please give an example of a significant achievement in your support to monitoring and evaluation. If you have made any efforts related to information and communication technologies, or vital registration systems, please focus your answer on this type of support What barriers, if any, have you encountered in implementing support for monitoring and evaluation? 19. Please specify in the text box below the amount (in US$) of your financial commitment(s) to the Global Strategy which had been disbursed by the end of If this data is currently not available, when would you likely be able to provide overall disbursement data (if at all)? 21. Below is the list of countries/regions you selected at the beginning of the questionnaire. Please include what amount has been committed to each of these countries, and for which timeframe. 22. Do you channel any part of your financial commitment(s) to the Global Strategy through multilaterals organizations, and/or global health partnerships? 22.1 Please provide information on the amount committed to these organizations, and the progress in disbursing the funding to these organizations. 23. Was your financial commitment(s) additional to what you would have spent in 2011 on women's and children's health in the absence of the Global Strategy? 11

12 23.1 Please describe. 24. Please provide in the text box below additional information on progress made in implementing your financial commitment(s) to the Global Strategy, and on related barriers and constraints. 25. Please upload document here (maximum 1): 26. Please upload document here (maximum 1): 27. Please upload document here (maximum 1): 28. Please indicate your level of agreement with the following statements. At the global level, global oversight and monitoring systems for tracking progress towards the Global Strategy s goals are sufficient: Disagree At the regional level, oversight and monitoring systems for tracking progress towards the Global Strategy s goals are sufficient: Disagree At the national level, countries have made significant progress in recent years to improve national RMNCH monitoring and accountability systems: Agree 29. Which opportunities do you see to strengthen accountability mechanisms at global, regional and country levels? Accountability is essential for assessing progress on the prevention and treatment of NCDs. A key commitment in the Political Declaration from the UN High-Level Meeting on NCDs in September 2011 called upon WHO to develop a comprehensive global monitoring framework to assess progress made in the implementation of national strategies and plans for NCDs. Member States of WHO are preparing the framework including voluntary global targets and indicators; the framework will be finalized at the World Health Assembly in May 12

13 2013. The global process to define the accountability framework for NCDs needs to draws lessons from accountability mechanisms from other global health priorities, especially the healthrelated MDGs, including HIV/AIDS, and the recommendations of the Commission on Information and Accountability for Women s and Children s Health. And in the long-term, should aim to be integrated. 30. Do you take any specific actions to monitor and assess the impact of your commitment(s)? Yes 30.1 Please specify them in the text box below. Progress on advocacy is monitored at the global level through decisions, resolutions, declarations, media coverage; and at the national level through policy decisions taken by governments and feedback from member associations. Progress on the GDM project in India will be monitored through on-going reporting by the team on the ground, and 2 external evaluations (mid-term and final). A logframe and indicators are also being developed. 31. Are you aware of the recommendations of the Commission on Information and Accountability for Women s and Children s Health (COIA)? Yes 32. Are there any feedback mechanisms that allow women to assess the implementation of your commitment(s)? No 33. Are there any provisions in your commitment(s) to improve equity of access and outcomes, and/or to reach the poorest and most vulnerable (for example, people in the lowest socio-economic status quintile; young girls aged 15 to 19, with low levels of education and from the poorest rural households)? Yes 33.1 What steps have you taken towards improving equity of access and outcomes, and/or what progress have you made in reaching the poorest and most vulnerable? 13

14 34. Has your financial commitment(s) to the Global Strategy led to increased health and/or RMNCH expenditures in 2011 compared to previous years? 34.1 Please provide information on your expenditures using the table below. 35. Does your financial commitment(s) to the Global Strategy rely on external funding? 35.1 Please select your source(s) of funding from the list below. Select all that apply Please provide information on the extent to which your financial commitment(s) to the Global Strategy rely on external funding sources? 36. Are you aware of the recommendations of the Commission on Information and Accountability for Women s and Children s Health (COIA)? 36.1 Which of the following COIA recommendations are you implementing or do you plan to implement, and what is the implementation status? 36.2 What are the major barriers to implementing the recommendations? Select all that apply. 37. Are there any feedback mechanisms that allow women to assess the implementation of your 14

15 commitment(s)? 38. Do you take any other actions or are there any other existing mechanisms (for example, annual reports to parliament) to monitor and assess the impact of your commitment(s)? 38.1 Please describe which ones in the text box below. 39. What opportunities do you see to strengthen accountability mechanisms at the global, regional and country levels? 40. Are there any provisions in your commitments to improve equity of access and outcomes, and/or to reach the poorest and most vulnerable (for example, people in the lowest socio-economic status quintile; young girls aged 15 to 19, with low levels of education and from the poorest rural households)? 40.1 What steps have you taken towards improving equity of access and outcomes, and/or what progress have you made in reaching the poorest and most vulnerable? 41. Do you have a national RMNCH strategy/roadmap? 41.1 For which timeframe? 41.2 Which are the RMNCH priority areas within the national RMNCH strategy/roadmap? 15

16 41.3 Please describe how the implementation of your commitment(s) is aligned with and supports the national RMNCH strategy/roadmap Please describe how your development partners support the implementation of the national RMNCH strategy/roadmap Is the national RMNCH strategy/roadmap costed? 41.6 Does it include a joint financing framework, which commits donors to one commonly agreed reporting format and to one single financial review, and which is aligned with your budget and review cycles? 41.7 Please provide comments if any on this joint financing framework To what extent is the national RMNCH strategy/roadmap funded, and which areas are underfinanced (if any)? 42. Please indicate your level of agreement with the following statement. The Global Strategy has provided additional support to our efforts to improve the health of women and children (for example, increased levels of funding; targeted technical assistance to improve service delivery): Agree 43. If relevant, please give examples of how the Global Strategy has supported your efforts to improve the health of women and children. 16

17 44. What kind of support do you need to more effectively implement your commitment(s)? 17