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12 posts categorized "Millennium Challenge Account"
Get ready. Next month Bread for the World and Concern Worldwide will team-up with other partners to celebrate the first 1,000 days of a global movement to make nutrition a key development goal. To update everyone on where our “Sustaining Political Commitments” event sits in “nutrition history,” we’ve put together an interactive timeline (above) that highlights some of the biggest moments since 2008. Use the side arrows to click through the slide-view, or click the "timeline" tab on the top left corner for a more linear perspective. Click on each event for videos, images, links, and a detailed description.
A lot has happened since September 2010, when developing countries founded the Scaling Up Nutrition (SUN) movement and donors—led by the United States, Ireland, and the United Nations—launched the 1,000 Days call to action to support it. What started as the recommendations of a scholarly series in a British medical journal has morphed into a global partnership. To date, 35 countries with high rates of maternal and child malnutrition have joined SUN. The movement has grown rapidly as governments and civil society leaders increasingly recognize the irreversible damage that early childhood malnutrition can inflict on whole generations—and conversely, the tremendous return on national investment in preventing this damage.
The 2013 Hunger Report is chock-full of stories on maternal and child nutrition, stunting, the 1,000 Day window, and the SUN movement. It’s all related to our recommendation for a bull’s-eye goal of ending mass hunger and extreme poverty by 2040.
Download the report at www.hungerreport.org to get the full story on Bread for the World’s recommendations regarding nutrition in the first 1,000 days.
Posted by Bread on May 20, 2013 in Africa, Agriculture, Asia, Assets for the Poor, Climate Change, Development Assistance, Economic Development, Food Aid, Food Prices, Foreign Aid Reform, Global Hunger, Good Governance, Hunger Hotspots, Hunger Report, Immigration, Inequality, Latin America, Malnutrition, Maternal and Child Nutrition, Millennium Challenge Account, Millennium Development Goals, Religion and Hunger, Trade, U.S. Hunger, Weblogs | Comments (0) | TrackBack (0)
Good news for data nerds: The OECD has just released its latest disposable income, poverty and inequality numbers for all of its 34 member states. You can access the entire data set here, but don't miss the the fun interacive tools that were released along with it. OECD was kind enought to make them embeddable:
So what are the key stories in this beautifully arranged chart? You may not find them all that surprising:
- Poverty and inequality have grown in OECD countries since the global recession of 2007-2008.
- The United States still has greater-than-average inequality and relative poverty than the typical OECD country.
- The United States has less pre-tax/transfer poverty than most other countries.
- The overall OECD unemployment rate has eased slightly to 8.0%.
- Iceland, Slovenia, Norway and Denmark shared the lowest poverty rate of member countries, while Israel bore the highest at 21%.
This data release is well timed, just before the 39th G-8 summit to be held in Lough Erne, Northern Ireland between June 17-18. As member states gather to focus on shared global development goals like advancing trade, ensuring tax compliance, and promoting greater transparency, the OECD offers a humbling reminder that poverty, hunger, and inequality are on the rise across the developed world. A global committment to solving the poverty problem will require committment from all countries, regardless of income level. This is still everyone's problem.
Posted by Bread on May 16, 2013 in Asia, Assets for the Poor, Development Assistance, Economic Development, Food Prices, Foreign Aid Reform, Global Hunger, Good Governance, Hunger Report, Inequality, Malnutrition, Maternal and Child Nutrition, Millennium Challenge Account, Millennium Development Goals, Trade, U.S. Hunger, Weblogs | Comments (0) | TrackBack (0)
Developed and developing, north and south, rich and poor—these are some of the dichotomous terms we use to categorize a country's quality of life. Does any country, or any person, fit neatly into one category or another?
Increasingly, though, people are finding that development is more a continuum than an all-or-nothing condition, an up or down vote. Every country whether it’s been labeled “developed” or not, falls somewhere along that continuum. The 2013 Hunger Report acknowledged this point in its recommendation for continued universal ownership of goals after the expiration of the Millennium Development Goals (MDGs) in 2015. All countries face the same threats to their development to varying degrees.
The momentum behind this more inclusive way of looking at development and quality of life has been helped along by new concepts and tools. The old standards such as gross domestic product (GDP) or income per capita offer limited insight. Indices such as the Human Development Index (HDI) and the Multi-dimensional Poverty Index (MPI) point out the need for a more diverse set of indicators to complete the development picture, expanding it to include less obvious but equally important measurements like access to education, gender equality and greenhouse gas emissions.
Transparency is one of the more recent additions to the expanding development concept. It has only been a major priority of U.S. foreign assistance for a relatively short time. The Millennium Challenge Corporation only made “fighting corruption” an absolute requirement for funding recipients in 2002.
Short clip explains how Transparency International guages corruption and why it matters.
More recently, the push for open government has gained rapid momentum as citizens across the world discover promising new ways to track their leaders’ actions, their use of public resources, their campaign contributors, their vested interests in legislation, and more.
Organizations such as Transparency International and the Sunlight Foundation are leading a growing grassroots movement to open government data to public scrutiny. They’re ranking countries by degree of corruption, tracking political ad spending, and crowdsourcing to fill in missing information gaps. Perhaps most important, they’re collaborating internationally as they never have before. For example, Sunlight recently held its first Transparency Camp International, where members of civil society and government employees from 25 countries (of all income and “development” levels) gathered to join the global open government network and absorb the experiences and solutions of others.
The 2013 Hunger Report, Within Reach: Global Development Goals, links open government and transparency to the end goal: good governance. “Improving governance is essential to progress on development,” it explains. “The corrosive effects of government corruption are just one example of how governance problems undermine progress. Good governance, on the other hand, is an enabling condition and a prerequisite to lasting change. Good governance includes many elements, but the most relevant for reducing poverty have to do with creating space for a strong civil society that can hold governments accountable for making progress; building effective institutions to manage and deliver public services; and respecting the rule of law—for example, by protecting the rights of minorities and ensuring that people have recourse to redress for injustices.”
“Most of the work to put these elements in place must be done by national governments and by civil society in developing countries. What the United States and other countries can do as a partner is set high expectations for levels of accountability and transparency. Additionally, they can provide technical know-how, strengthen global institutions that foster good governance, and support leaders who want to govern well. The United States itself must be an example of good governance and continue to work towards becoming more transparent and accountable.”
For more on the importance of transparency in the fight to end hunger, visit hungerreport.org.
Posted by Bread on May 13, 2013 in Africa, Asia, Assets for the Poor, Climate Change, Development Assistance, Economic Development, Food Prices, Foreign Aid Reform, Global Hunger, Good Governance, Hunger Report, Inequality, Latin America, Millennium Challenge Account, Millennium Development Goals, Trade, U.S. Hunger, Weblogs | Comments (0) | TrackBack (0)
On February 11, Senator Christopher Coons (D-DE) treated his constituents yet again to his annual Opportunity: Africa Conference. The half-day conference looked at how Delaware’s businesses, faith communities, and individuals can engage in Africa amid the opportunities and challenges on the continent. The residents of Delaware had the opportunity to interract with some of the nation’s leading voices on sustainable development issues- food security and nutrition, child health and trade in Africa.
Africa today offers the promise for a return on investments. During the previous decade (2001-2010), six of the world’s 10 fastest-growing economies were in Africa. The continent has shown consistent growth, a trend that is expected to continue. A number of factors account for this growth, including technological innovations, political stability, trade, and investment. Robust growth rates, a new commitment to health and agriculture, and significant advances in science and technology are creating new investment opportunities. The United States has played a role in this progress. Senator Coons reminded participants that through life-changing assistance programs such as the President's Emergency Plan for AIDS Relief (PEPFAR), for example, HIV/AIDS infections have significantly declined in Africa.
But challenges remain. Today, half the population in sub-Saharan Africa (an estimated 400 million people) live on less than $1.25 a day. We know that the main driver of poverty reduction in the world is the hard work of poor people themselves. Given the opportunity to improve their communities and provide a better life for their children, they seize it. It is this recognition that makes Senator Coons a champion for foreign assistance. As Chair of the Senate Foreign Relations Subcommittee on African Affairs, Coons echoes President Obama’s view that a strong foreign policy rooted in American values must aim to promote democracy and freedom, protect human rights, defend U.S. interests abroad, while also increasing U.S. investment and trade through mutual partnerships. He stresed that today more than ever, development assistance is critical in reducing poverty and bringing greater stability to our interconnected world.
This conference gave Bread for the World the opportunity to remind participants that moving the aid effectiveness agenda to achieve the MDGs is a complex task, but a necessary one. While more work lies ahead, efforts to achieve the MDGs have already saved lives, helped to lift millions of people out of poverty, and ensured that more children attend school. By investing in local capacity and building strong institutions and infrastructure, U.S. development assistance can help promote good governance, stability, and prosperity. Even as difficult fiscal choices are before Congress, Bread for the World maintains that U.S decision makers should lead the way by protecting and speaking out for investments that build resilience in communities. Making resources available through well-planned programs such as Feed the Future will enable African countries to develop their agricultural infrastructure in sustainable ways and diversify their economies. The 1,000 Days initiative takes advantage of a unique window of opportunity – the 1,000 days between pregnancy and a child’s second birthday – to create a healthier future for an entire generation. This is because the right nutrition during this period is critical to a child’s ability to grow, learn, and ultimately rise out of poverty.
In his keynote address, Kenyan Ambassador to the U.S, His Excellency Elkanah Odembo also urged that U.S. leadership and commitment to Africa’s development are necessary and that the recent gains on the continent be supported and sustained. The Ambassador stressed that at a time of intense debate over budget cuts, it is helpful to remember that not only do investments save lives, improve livelihoods and promote stability- they also save money in the long run and create markets for local communities as well as strong trading partners for the U.S market. Partnering for development, he noted- would help to identify common ground between different actors and to combine their skills, resources and expertise and engage in win–win relationships around development objectives such as food security, poverty reduction, health, education and access to opportunities.
Sustaining this commitment and others like it, is what will create the future we want for all—a future grounded in prosperity, dignity and mutual respect.
Posted by Faustine Wabwire on February 22, 2013 in Africa, Agriculture, Assets for the Poor, Climate Change, Development Assistance, Economic Development, Food Prices, Foreign Aid Reform, Global Hunger, Good Governance, Malnutrition, Maternal and Child Nutrition, Millennium Challenge Account, Millennium Development Goals | Comments (0) | TrackBack (0)
Posted by Bread on January 09, 2013 in Africa, Agriculture, Asia, Assets for the Poor, Climate Change, Development Assistance, Economic Development, Food Aid, Food Prices, Foreign Aid Reform, Global Hunger, Good Governance, Hunger Hotspots, Hunger Report, Immigration, Inequality, Latin America, Malnutrition, Maternal and Child Nutrition, Millennium Challenge Account, Millennium Development Goals, Religion and Hunger, Trade, U.S. Hunger, Weblogs | Comments (1) | TrackBack (0)
Sometimes the best way to communicate information is through pictures instead of text. And our new 2013 Hunger Report, Within Reach: Global Development Goals, offers a good balance for the eyes. Enjoy this colorful gallery of photos that tells the graphical tale of hunger and the ongoing struggle to end it across the world (I fully endorse viewing it full screen). Then maybe dive deeper into the Report to encounter the incredible stories and struggles waiting just behind the faces. Maybe download it to your e-reader?
On Twitter? Follow @BreadInstitute and stay current on hourly hunger-fighting news, data, stories, and solutions.
Posted by Bread on December 14, 2012 in Africa, Agriculture, Asia, Assets for the Poor, Climate Change, Development Assistance, Economic Development, Food Aid, Food Prices, Foreign Aid Reform, Good Governance, Hunger Hotspots, Hunger Report, Immigration, Inequality, Latin America, Malnutrition, Maternal and Child Nutrition, Millennium Challenge Account, Millennium Development Goals, Religion and Hunger, Trade, U.S. Hunger, Weblogs | Comments (0) | TrackBack (0)
The road that gets you in and out of Accra the fastest is called the Bush Motorway in honor of President George W. Bush. The Millennium Challenge Account, one of President Bush's signature development assistance programs, provided the funding to build the road.
Roads and other physical infrastructure projects are some of the best investments in development assistance donors can make. The Bush Motorway runs all the way to Accra's main port and has been a boon to importers and exporters. But the farther away from the city the less impact it’s had on development.
My Bread for the World Institute colleague Faustine Wabwire and I rode the Bush Motorway on our way out of Accra to visit rural areas of Ghana. One has to get off of paved roads and onto rougher terrain to get to the communities that Faustine and I had come to Ghana to visit. Slow, bumpy and dusty: these are the roads in Ghana I expect I will remember far longer than the paved ones.
Faustine and I spent two days with Lydia Sasu, Executive Director of the Development Action Association, a Ghanaian NGO that works with some of the poorest women farmers in the country. Lydia is a dynamic organizer, and I will write more about her in my next blog post, but I want to focus on one community she took us to meet in Sege, an area east of Accra by about 100 kilometers.
Lydia had organized a meeting for us to talk with some women from the community. We met them in a Spartan building they use mainly as a church. It was scorching hot outside and some of the women had walked for miles to be there. Lydia had brought them food and fresh water, incentives to ensure we got a good size group. These women don't have much to eat or drink, so there was more drawing them to come than a couple of researchers from Bread for the World Institute.
It was still the dry season so they were doing little farming, tending to livestock mainly. They raise piglets which I had seen running around the hamlet where the church was located. The sell the animals in nearby markets. The ones they slaughter for themselves provide a vital source of protein. Some of these women have buried children who've died from malnutrition.
They have always battled dry conditions but over the last two decades periods of drought are more protracted. For anyone who doubts climate change, I challenge them to come to this community and see what climate change has wrought. The hungry season in this community now lasts from January to June, so we had come to visit them when one meal a day is all they are eating. Most of men had left to find work in salt mines, or they’d gone to find work in Accra.
I asked them why they stay in a place where the conditions are so harsh. The women are illiterate, they haven't got many options. Poverty and hunger in a place you know is preferable to poverty where you feel like a stranger. One woman stood up and explained she plans to abandon the community and move to Accra. Her prospects there may be no better, but perhaps her children's will be. She expects to earn a living as a porter, meaning she will carry goods on top of her head to sell on the street.
Climate change is driving people like this woman out of rural areas into cities. In 1950, the rural population in Africa outnumbered its urban counterpart by eight to one. By 2030, the number of urban residents is expected to surpass the number of rural. People are leaving rural areas not only because of climate change but it has accelerated the pace of the outmigration.
Infrastructure development is just as important in rural areas. Roads are a good place to start. Everyone in Ghana knows about the Bush Motorway. One of the things we heard wherever we went was please ask the U.S. government to help us to build roads.
When we talked with government officials in the Ministry of Agriculture, they emphasized what the agricultural sector needs is storage infrastructure to cut down on post-harvest losses. Ghana, like other sub-Saharan countries, loses up to 40 percent of crop harvests due to spoilage. You think about the need to increase agricultural production to keep up with growing populations. Africa’s population alone will grow by nearly a billion people by the middle of the century. We all love a good technology challenge but African countries could do a lot to improve productivity by using boring old technologies like asphalt to put down roads or concrete and steel to build storage facilities to prevent crop loss.
Secretary of State Hillary Clinton is poised to sign a five-year Millennium Challenge Corporation (MCC) compact with Indonesia—the first such compact to include a nutrition component, “Community-Based Nutrition to Reduce Stunting.”
More than 35 percent of Indonesia’s babies and toddlers under age 2 are stunted, meaning they have a highly visible sign of malnutrition--being significantly shorter than average children of their age. There is growing global attention to this age group, often called the 1,000 day window between pregnancy and age 2, because the consequences of malnutrition for such young children are death for some and lifelong, largely irreversible damage to the health and development of those who survive. A higher risk of death in infancy and early childhood, increased susceptibility to infection and illness, and impaired cognitive abilities caused by early nutritional deficiencies have been well documented in a growing body of scientific evidence, dating to 2006 with the Copenhagen Consensus and followed by studies done by the World Bank and by a series of studies by the respected medical journal The Lancet. Research has also found that survivors of early childhood malnutrition complete fewer years of school and are less productive on the job, which causes countries long-term economic loss.
The 1,000 Days Partnership, on which Bread has reported previously, champions new investments and partnerships to improve nutrition during this critical period. Indonesia recognized that taking action against malnutrition during the 1,000-day window must be a top national priority. Its five-year national development plan called for a program of prevention.
Indonesia is the fourth most populous country in the world, with more than 140 million people living on less than $2 a day. The country’s high prevalence of stunting is a legacy of a health service delivery system that lacks capacity at the local level. The Community-Based Nutrition to Reduce Stunting project will work with communities and health systems to “strengthen the demand for and supply of appropriate services to reduce chronic malnutrition among children.” Designed with the participation of local governments, civil society, and the private sector, it will build on an existing program that involves communities in taking action to improve targeted health, education, and nutrition indicators. Stunting will be reduced by strengthening community engagement, nutrition and sanitation services delivery, and national awareness and advocacy. The project proposes to reach 1.4 million beneficiaries in rural Indonesia.
The MCC administers Millennium Challenge Account funding. Back in 2002, Bread members were instrumental in persuading Congress to establish the program, which makes multi-year grants to promote inclusive economic growth that reduces poverty. To qualify for MCC funds, countries must be low-income or lower-middle-income (meaning that their per capita incomes are less than about $4,000 a year), and they must satisfy set criteria such as investing in the well-being of their people and fighting corruption.
Bread for the World Institute has long been a champion of increased focus on improving maternal and child nutrition. In our 2009 briefing paper, New Hope for Malnourished Mothers and Children, the Institute noted that the Millennium Challenge Corporation was under-investing in nutrition—especially given the importance of nutrition to economic growth. We are encouraged by Indonesia’s plan for this compact and applaud MCC for taking this important step forward. We look for additional countries to improve nutrition outcomes, especially in pregnant women and children.
The Institute’s 2011 Hunger Report, Our Common Interest: Ending Hunger and Malnutrition, has just become available online at www.hungerreport.org. The 2010 Hunger Report, A Just and Sustainable Recovery, which had been the default landing page till today, remains available on the site along with the 2009 report, Global Development: Charting a New Course.
Who will feed the future? Nepal is one country where the U.S. will increase investments in agriculture. Photo: Richard Lord
At the 2009 G-8 Summit in L’Aquila, U.S. leadership was instrumental in gaining the commitment of member nations to $22 billion to improve global food and nutrition security. For its part, the Obama administration developed its own initiative, Feed the Future. Bread for the World, along with several U.S. civil society groups, provided input into the design of the program. The 2011 Hunger Report is concerned with events that led to the establishment of Feed the Future and with what it will take for the initiative to succeed.
The report argues that Feed the Future is a bold step forward in U.S. foreign assistance, possibly the best opportunity to come along in decades for the United States to contribute to lasting progress against global hunger and malnutrition. Feed the Future stands out with its dual focus on boosting incomes of smallholder farmers and improving the nutritional status of mothers and children, the groups most at risk of hunger and malnutrition.
The report starts with the spike in food prices in 2007-08 that pushed the number of people who suffer from hunger to more than a billion for the first time in history. Prices have fallen since then and so has the number of undernourished people, but as we are seeing in 2010, grain markets are still quite volatile, and so food prices remain a great concern.
For children born in the poorest parts of the world during the 2007-2008 food-price crisis, higher food prices meant that their families could not afford staple foods let alone the more nutritious foods. A series of articles in the British medical journal, the Lancet, published in early 2008 had immediate relevance, as it pointed out that malnutrition during the window of opportunity during pregnancy and in the first two years of life has irreversible consequences for a child. For children who survive early childhood malnutrition, the physical and cognitive setbacks are lifelong, leaving children more prone to illness throughout their lives and reducing earning potential.
The 2011 Hunger Report includes several recommendations to strengthen Feed the Future and U.S. foreign assistance more broadly. Feed the Future must take a comprehensive approach to fighting hunger and malnutrition, adopting the following elements: increase the productivity of smallholder farmers, help them reach markets, take advantage of the links between agriculture and nutrition while scaling up evidence-based nutrition interventions (especially for pregnant women and young children), empower women, strengthen safety nets, and respond quickly to hunger emergencies.
Dr. Rajiv Shah, USAID administrator, described "Our Common Interest" as "The best report I've seen in years on this issue" in remarks at the National Press Club.
Moreover, the report argues, Congress should rewrite the 1961 Foreign Assistance Act to make clear that poverty reduction and development are key elements of U.S. foreign policy and reduce earmarks to ensure that U.S. development assistance has the flexibility to respond to realities on the ground. U.S. food aid should be improved to allow for a greater focus on nutritional quality, especially to reach infants and young children. In addition, the United States should take the lead in strengthening international institutions that are complementary to U.S. bilateral assistance in fighting hunger and malnutrition.
After decades of underinvestment in agriculture, Feed the Future is a refreshing throwback to when agriculture held a much more prominent place in U.S. foreign assistance. But Feed the Future has the potential to be much stronger than earlier U.S. programs. Its focus on country-led development is encouraging, but this must include building the capacity of national governments to sustain the progress begun with foreign assistance, and should also include building the capacity of civil society to hold national governments accountable for what they do with this assistance.
The 2011 report is available online and in print and anybody who wants to order a copy can do so via the website. The online edition includes everything in the print edition and several other features. The Hunger Report has always been a comprehensive source for data on hunger, poverty and other development indicators. The Hunger Report website allows you to visualize these data. An assortment of information covered in the report is displayed in eye-catching graphics.
Enjoy the report. Tell us what you think of it. And please, get the word out about it.
Posted by todd post on November 22, 2010 in Africa, Agriculture, Assets for the Poor, Climate Change, Development Assistance, Economic Development, Food Aid, Food Prices, Foreign Aid Reform, Global Hunger, Good Governance, Hunger Hotspots, Hunger Report, Immigration, Inequality, Latin America, Malnutrition, Maternal and Child Nutrition, Millennium Challenge Account, Millennium Development Goals, Trade, U.S. Hunger | Comments (0) | TrackBack (0)
In April, The New York Times reported that a Lancet study on global maternal mortality—deaths resulting from the complications of pregnancy or childbirth—had caught the international community by surprise. Looking at new data, researchers from the University of Washington and the University of Queensland found that maternal mortality had declined far more than previously estimated—from 526,300 deaths in 1980 to 342,900 in 2008.
Maternal Health / With the right interventions and resources, maternal mortality can be reduced dramatically.
A couple days ago, on September 15—just ahead of next week’s Millennium Development Goals Summit—the World Health Organization, UNICEF, the World Bank, and the U.N. Population Fund released their own updated analysis, which reinforced this new information. Their study found that since 1990, maternal mortality has declined by 34 percent, from 546,000 in 1990 to 358,000 in 2008. Putting the two studies together, it is clear that since 1990 the world has made much more progress in reducing maternal mortality.
Reasons for this progress include increased family incomes that allow for better, lower pregnancy rates, increased education among girls, and better access to healthcare. That’s the good news.
The bad news is that the international community is not on track to achieve the fifth Millennium Development Goal (MDG), to reduce by three-quarters the maternal mortality ratio. According to the World Health Organization/UNICEF analysis, the annual rate of decline in maternal mortality, even with the gains since 1990, is half what it should be—2.3 percent instead of the 5.5 percent that is needed.
The 2010 Millennium Development Goals Report indicates that half of all maternal deaths in developing countries are a result of hemorrhage and hypertension. Indirect causes such as HIV/AIDS, malaria, and heart disease account for 18 percent of maternal deaths.
According to the report, a vast majority of these deaths could be avoided with the help of skilled healthcare providers. But less than half the childbirths in South Asia and sub-Saharan Africa are attended by skilled healthcare attendants. Unsurprisingly, the report points out the huge disparities between rich and poor communities in developing countries in accessing health care, especially in South Asia and sub-Saharan Africa. In these regions, the richest women are five and three times more likely, respectively, to have access to a trained healthcare attendant.
There are also big urban-rural disparities. Only 33 percent of rural women have access to the recommended care in developing countries. In South Asia, that figure drops to 25 percent of rural women.
Education also plays a big role. Women with a secondary education are more likely to delay and space pregnancies, which substantially improve their chances of survival.
There are reasons for hope. The Lancet and WHO/UNICEF studies suggest that progress is possible. With the right interventions and resources, maternal mortality can be dramatically reduced. At the 2010 G8 Summit in Muskoka, Canada, on June 25-26, leaders launched the “Muskoka Initiative,” an effort that will invest $5 billion over five years in maternal and child health, focusing on MDG 4 (child mortality) and MDG 5 (maternal health).
The Obama administration has also launched the Global Health Initiative (GHI), which complements the Muskoka Initiative’s focus on strengthening health systems and on reaching women and girls. It is a new approach that builds on existing successes in the area of HIV/AIDS through the PEPFAR program. The GHI aims to help developing countries build healthcare networks that can focus on the prevention and treatment of specific diseases, but also on addressing crosscutting issues such as malnutrition and risks associated with pregnancy and childbirth.