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The Lancet 2007; 370:1383-1391
Practical Lessons from Global Safe Motherhood Initiatives: Time for a New Focus on Implementation
The time is ripe for a shift in focus
Global initiatives and local actors: lessons for implementation
Summary
The time is right to shift the focus of the global maternal health community to the challenges of effective implementation of services within districts. 20 years after the launch of the Safe Motherhood Initiative, the community has reached a broad consensus about priority interventions, incorporated these interventions into national policy documents, and organised globally in coalition with the newborn and child health communities. With changes in policy processes to emphasise country ownership, funding harmonisation, and results-based financing, the capacity of countries to implement services urgently needs to be strengthened. In this article, four global maternal health initiatives draw on their complementary experiences to identify a set of the central lessons on which to build a new, collaborative effort to implement equitable, sustainable maternal health services at scale. This implementation effort should focus on specific steps for strengthening the capacity of the district health system to convert inputs into functioning services that are accessible to and used by all segments of the population.
Introduction
The safe motherhood
movement reaches its 20th anniversary as the global health field embarks on
ambitious new efforts to transform its practice. With the Millennium
Development Goals (MDGs), the Paris Declaration on Aid Effectiveness, and the
launch of the Global Campaign for the Health MDGs,1 the principles of country ownership, aid
coordination, and results-based financing will create a new approach to
national policymaking and financing. The success of these initiatives depends
on the ability of countries to steadily expand their capacity to implement
integrated programmes for service delivery while progressively advancing
coverage and equity.
Four major global
safe motherhood implementation and evaluation initiatives of the past
decade—Averting Maternal Death and Disability (AMDD), Immpact, the Skilled Care
Initiative (SCI), and ACCESS (panel 1)—call
for a renewed and intensified focus on implementation. In this paper we use our
complementary experiences in the field to offer a set of central lessons on
which to build a new, collaborative effort to initiate change on the ground,
where women live and die.
Panel 1:
Global Maternal Health InitiativesGlobal initiatives
can generate and synthesise evidence, develop instruments, create links for
learning across countries, and provide technical guidance and support.
The Averting Maternal Death and Disability
(AMDD) Program at the Mailman School of Public Health, Columbia University, is
a global programme of research, advocacy, policy analysis, and programme
support that is dedicated to the reduction of maternal mortality and morbidity.
AMDD and its UN, non-governmental, and governmental partners have worked in
some 50 countries in Asia, Africa, and Latin America with a focus on expanding
availability, quality, and use of emergency obstetric care and addressing
health systems factors that constrain or facilitate equitable access at scale.
Immpact is a global research
initiative to strengthen the evidence-base on the effectiveness and cost
effectiveness of intervention strategies for safe motherhood, and is
coordinated by the University of Aberdeen, UK. It consists of a collaborative
network of scientists spread across seven research institutions, and has
developed measurement methods for robust evaluation of strategies, which were
used to undertake major assessments in its first phase (2002–06) in Burkina
Faso, Ghana, and Indonesia.
The Skilled Care Initiative (SCI) is a
5-year programme of Family Care International that aimed to increase the
availability, quality, and accessibility of skilled maternity care in four
rural, underserved districts in Burkina Faso, Kenya, and Tanzania through a
multifaceted approach of health facility and community interventions.
The ACCESS Program works to expand coverage, access, and use of key maternal and neonatal health services across a continuum of care from the household to the hospital. The 5-year global programme is sponsored by the US Agency for International Development (USAID) and works with USAID missions, governments, non-governmental organisations, local communities, and partner agencies in developing countries.
The time is ripe for a shift in focus
For much of its
history, the Safe Motherhood Initiative focused largely on global debates about
strategies and priorities. Little attention was devoted to expanding the
capacity of countries with high mortality rates to implement and sustain any
such strategies or to learning from the few local-level initiatives that did
exist. New attention to implementation is now needed.
Several factors are
already in place. First, the safe motherhood community has coalesced around
three key elements that are crucial for reduction of maternal mortality—family
planning, skilled care for all deliveries, and access to emergency obstetric
care for all women with life-threatening complications—all of which are firmly
grounded in a sustainable health systems approach that engages communities and
facilities.
Second, in many
countries, national plans to accelerate progress on maternal and neonatal
health have set overall priorities for implementation and monitoring and, in
the process, generated political will and national ownership.
Third, virtually
every country has committed to the MDGs, and leading donor and recipient
countries have endorsed the new global initiatives being brought together under
the Global Campaign for the Health MDGs to accelerate progress in reaching
these goals. Lastly, promising mechanisms have been created for carrying
advocacy messages, maintaining the public profile of maternal health, and
strengthening coordination and collaboration in the discipline of maternal,
newborn, and child health overall, in particular the Partnership for Maternal,
Newborn and Child Health.
With these factors in place, we call for renewed energy, attention, and resources for implementation at the district or local level. However, the importance of generating political will, increasing funding, or launching advocacy campaigns that keep the issue in the public eye should not be discounted nor dismissed. Of course, national policy work should continue. But implementation of maternal health services on the ground has been woefully neglected in the global safe motherhood community. We believe that the time is right to change the balance and provide new priority to implementation.
Global initiatives and local actors: lessons for
implementation
Although each of
the four initiatives focuses primarily on a different aspect of maternal health
efforts, on the basis of these varied experiences we believe that
implementation efforts aimed at service delivery at scale, and thus achievement
of MDG5, should be firmly embedded in a health systems approach. Ultimately,
this tenet means that the following needs to be addressed: both the supply and
demand side; both home and community dynamics and facility-based services in a
home-to-hospital continuum of care; and both obstetric emergencies and routine
deliveries.
But a health
systems approach does not mean that every district in every country has to do
everything all at once or use exactly the same strategy. Instead, countries or
the relevant subnational planning and implementation units (usually states or
districts), or both, should start where they find themselves, and proceed
through a process of assessment, planning, progressive implementation, and
monitoring, while keeping in steady focus the operational result they seek:
equitable use of functioning, good quality services, and measurable health
improvements.
To plan for
implementation at scale needs prioritisation and vision. Selected elements of a
plan might be put into operation immediately, whereas other elements need a
longer timeline but demand immediate investment to set into motion progress
along that timeline. Of course, plans need to be financially realistic and
sound, but the approach of simply postponing serious attention to any crucial
elements of a maternal mortality reduction plan, until a time when poor
countries are prosperous, is not acceptable. Maternal mortality reduction is a
global responsibility that is codified in international law2 and endorsed repeatedly in policy
statements.3 For MDG5 to be achieved, support has to
be available to responsibly implement all the essential elements of an
evidence-based strategy to reduce maternal mortality.
In this paper we
focus on interventions that are designed to avert deaths and injuries to women
around the time of delivery and in the immediate postpartum period, when the
risk to mother and baby is greatest.4 The number of maternal deaths can and should
also be reduced through access to family planning, which enables women to
control the number of times they become pregnant and thus risk maternal death.5
Furthermore, the risk of dying when pregnant can also be reduced through safe
abortion services when legal, and treatment of abortion complications. Good
intrapartum care has other important health effects. For example, it can reduce
the risk of chronic morbidities, such as fistulas or uterine prolapse.
Interventions for the mother at the time of delivery also have a substantial
effect on perinatal mortality—an estimated 30–45% of newborn deaths6 and 25–62% of intrapartum stillbirths7 could be averted through good obstetric
care.
Equally importantly, maternal health programmes that are well implemented strengthen the broader health system with collateral benefits for many other health disorders. For example, referral systems help victims of road accidents reach emergency care; blood transfusion services supply blood for all surgeries; improvement in facility management benefits the whole site; and community engagement can change accountability dynamics across all health services.
Needs assessments and the importance of contextual variation
We are not
advocating a single universal approach to implementation, but neither are we
suggesting that every situation is so unique that it has to start from scratch.
In short, we know what to do,5 but how to
do it varies by context. Understanding context entails an appreciation of the
relation between supply and demand within the district level health system—ie,
the continuum from home or community, up through health posts and health
centres, to the first referral level facility.8 In many countries where political and
bureaucratic decentralisation has taken place, the district is also the level
at which budgets are decided and authority over the direct functioning of the
health system is lodged.
The ultimate goal
is to ensure that every birth is attended by a skilled health professional (panel 2)
and that every woman who has an obstetric complication receives care either in
a basic emergency obstetric care facility (typically a health centre) or in a
comprehensive emergency obstetric care facility (typically a district or
subdistrict hospital; panel 3). Although there is not just one right strategy for
attaining this goal, a strategy is crucial to guide implementation. This
strategy should be based on evidence and on relevant information about the
local context. For example, the recent Lancet series on
maternal survival5 presented evidence to suggest that, if
maternal survival is the outcome sought, then the best strategy for delivering
intrapartum care at scale is one that enables women to routinely give birth in
health centres, private clinics, or maternity homes that can assist with
healthy births but which also include basic emergency obstetric care for
managing complications and which provide ready access to well-functioning
referral level care. Health centres would be staffed by fully qualified
midwives as principal providers working in teams with midwife assistants or
their equivalents, who can safely handle routine deliveries.
Panel 2:
WHO, International Confederation of Midwives, and International Federation of Gynaecology and Obstetrics definition of a skilled birth attendant“A skilled
attendant is an accredited health professional—such as a midwife, doctor, or
nurse—who has been educated and trained to proficiency in the skills needed to
manage normal (uncomplicated) pregnancies, childbirth, and the immediate
postnatal period, and in the identification, management, and referral of
complications in women and newborns”.9
Panel 3:
Signal functions for basic and comprehensive emergency obstetric care10Basic
emergency obstetric care
1Parenteral
antibiotics
2Parenteral
oxytocic drugs
3Parenteral
anticonvulsants
4Manual
removal of placenta
5Removal
of retained products
6Assisted
vaginal delivery
Comprehensive
emergency obstetric care
All of the above
plus:
7Surgery
(eg, caesarean delivery)
8Blood
transfusion
To develop and then
plan for implementation of this strategy or any other evidence-based one, the
following questions are crucial for every district: where do women give birth
and under what circumstances (ie, what proportion receives skilled care)? Where
is basic and comprehensive emergency obstetric care now available and which
signal functions (panel 3)
are missing? What is the profile of human resources—both clinicians and
managers—that is now available compared with what is needed? What is the
present pattern of and capacity for referral (ie, emergency transport, patterns
of bypassing, etc)? Who is and who is not accessing care—ie, what is the equity
profile? What are the demand-side barriers to use and what is their relative
importance? This information will be expanded through the health management
information system and through operations research as implementation and
scale-up proceed.
Instruments already
exist for many aspects of needs assessments for both supply-side and
demand-side. For example, information about place of delivery and present
status of skilled care can usually be identified in population-based data sets
such as the Demographic and Health Surveys and in facility surveys such as the
Service Provision Assessments. Instruments for needs assessments for emergency
obstetric care have been developed by AMDD in partnership with UNICEF, UNFPA,
and WHO, and have been used in some 48 countries (panel 4).
Panel 4:
Needs assessments with the UN process indicators for emergency obstetric care10Over the past
decade, the UN process indicators for emergency obstetric care have been used
in over 48 countries to assess the status and to monitor progress in the
provision of emergency obstetric services. Findings from needs assessments with
the UN process indicators have shown:
•Per
population, most countries have enough comprehensive facilities for emergency
obstetric care but very few basic facilities.11 Quality of care, however, needs to be
improved at all levels
•Geographic
distribution of facilities for emergency obstetric care is a challenge,
especially in rural areas12
•Met
need for emergency obstetric care is low. National needs assessments in nine
countries in sub-Saharan Africa showed that met need was on average 28%
(ranging from 12% in Mali to 48% in Benin), suggesting that too many women in
these countries are not receiving treatment for their obstetric complications12
•Caesarean
delivery rates in surveyed African and Asian countries were less than 3% and
therefore below the UN recommended range of 5–15%10,12
On the demand side,
research undertaken by Family Care International (FCI), Immpact, and others
confirms that there is substantial variation in the relative importance of
different barriers, such as financial and geographical obstacles. This work
also shows great variation in the relative importance of different cost
elements—such as user fees, transport costs, and supplies purchased outside the
facility—that together could restrict access. Understanding such variation is a
prerequisite to efficient and effective policies to alleviate financial
barriers (panel 5).
Panel 5:
Contextual variation in barriers to financial accessConventional
strategies to reduce financial barriers tend to focus largely on the costs of services
at the facility by abolishment or reduction of user charges.13 Yet in
some contexts, the costs that households incur outside the facility—eg, drugs
and supplies purchased as well as payments for transport to reach care—might
represent a more important barrier than formal payments for the care itself.14 The size of these costs varies
enormously by context. In Nepal, demand-side costs represent at least 60% of
the costs of a healthy delivery. In Ghana, spending on non-facility cost
accounted for almost half the cost of delivery, and this proportion hardly
changed after the introduction of free delivery care.15 In
contrast, in the Immpact study districts in West Java, Indonesia, which are
densely populated, without topographical barriers, and with good roads,
transport and other demand side costs represented less than 10% of the total
costs of a routine delivery. Demand side costs are an especially important
issue in countries where distances or topography make facilities physically
difficult to access.
Finally, an often
neglected area for needs assessment relates to equity across several dimensions
of social disadvantage, including wealth, locality, religion, and ethnic origin.
Techniques exist for showing the magnitude of inequity in the maternal
mortality ratio with use of data from the Demographic and Health Surveys.16 Other indicators focus on specific
services such as Unmet Obstetric Need, which provides an equity-sensitive
measure of access to caesarean sections.17 New methods are being developed to
assess equity in service use at the facility level.18 In maternal health, both the barriers
to skilled care for routine deliveries and those to access emergency obstetric
care in the event of life-threatening complications are especially important.
Not only is the amount of the costs incurred for these services and the effect
that these costs have on households very different, but the distinction between
a planned event, such as routine delivery, and an unpredictable emergency has
implications for the effectiveness of different financing mechanisms and policy
initiatives such as targeting (panel 6).
Panel 6:
TargetingThe research of
Immpact and other studies suggest that targeting services to poor groups is of
little use since identification of poor individuals is usually inadequate,
targeting stigmatises, and providers frequently prefer to deliver services
largely to those who are able to pay high fees. Furthermore, and of great
importance for emergency obstetric care, many more households than those
defined as poor are at risk of impoverishment from the high costs of care. For
example, the selective insurance for the poor people in Indonesia has almost
been abandoned at a public hospital level for these reasons, where most women
now receive highly subsidised emergency obstetric care.19
Geographical targeting can be beneficial in extending access to services in the
poorest areas first. Such services include access to skilled delivery care,
basic emergency obstetric care, and transport or transport subsidies to get to
hospitals. This idea receives extensive support in published work, which
reports that geographic targeting, especially if focused on fairly small areas
(eg, district, subdistrict), is a cheap and effective way of reaching the
poorest groups.20
From the bottom-up
approach that begins with this type of needs assessment at the district level,
issues will emerge that should be addressed at a centralised level of the
health system, such as overall financing, procurement systems, and human
resource strategies including employee posting and transfer policies. But
implementation efforts at the district level should not wait until all such
central issues are resolved. Implementation efforts—the transformation of
existing and new inputs into functioning equitable services—can and have to
begin immediately in the periphery and feed information and experience back up
to the centre where, simultaneously, health systems structure and financing are
being addressed.
In practice, the
interplay between change at the service provision level and policymaking at the
central level is rarely so straightforward. Incentives created by specific
centralised decisions (eg, about compensation or career paths) or by the
structure and financing of the system itself (eg, privatisation, decentralisation)
can either ease or undermine local efforts to improve service delivery.
Conversely, in the process of implementation, service providers and local
managers can subvert even the best-intentioned policies created at the central
level.21,22
Competent, committed managers at the district level—skills often absent in
newly decentralised or weak health systems—are needed to ensure that policy
change initiated from the top down and information generated in needs
assessments from the bottom up do indeed come together to help produce
equitable services of good quality.
Thus the new focus on implementation that we call for here is as much about management as it is about clinical care.
From inputs to functioning
Arguments about the
effectiveness and theoretical impact of specific clinical interventions, such
as misoprostol or active management of third stage of labour for postpartum
haemorrhage, often mask the fact that none of the interventions in question,
whether community-based or facility-based, will actually reach people in an
equitable and sustained way without the infrastructural support of the health
system. The field of maternal health has many examples of projects in which an
intervention that is enthusiastically pursued ultimately has little effect on
health outcomes because of failure to address the necessary health system support.
Inputs alone are
not enough. The mere presence of health workers, drugs, supplies, and physical
infrastructure does not necessarily produce functioning, responsive services.
The results—ie, functionality and use—are what matter, not just the existence
of the inputs. But understanding and tracking the relation between inputs,
processes, and results will ultimately be an essential part of managing for
results.
For example, within AMDD, a simple method—the emergency obstetric care building blocks—has effectively helped planners and managers break down the task of implementation for results into manageable pieces (figure 1). With this type of step-by-step approach, hundreds of facilities over the course of 3 to 4 years were able to more than double the met need for emergency obstetric care and substantially reduce case fatality rates, often by 50% or more.23
Figure 1. AMDD building blocks
framework for emergency obstetric care
Additional
instruments exist for almost every block in the pyramid. Adaptations of
EngenderHealth's COPE method were used to improve management in both FCI's
Skilled Care Initiative in facilities managing routine deliveries24 and in the AMDD programme in facilities
providing emergency obstetric care.25 Other methods such as criterion based
audits,26–28
verbal autopsies,29 forms of confidential enquiry,30 and appreciative inquiry31,32
have also been successful in assessment and maintenance of quality and
functionality in facilities.
Such management instruments
emphasise perhaps the most challenging area of implementation: human resources.
Implementation at scale needs a sound human resource plan: a health workforce
framework that considers planning, recruitment, education, deployment, and
performance support of health workers.33
As in other areas
of implementation, no universal solution for human resources exists. For
example, in Nepal, a new skilled birth attendant policy focused on upgrading
existing workers. On the basis of an analysis of all cadres of health workers
involved in maternal health care, policymakers assigned resources and attention
to selected groups for standardisation and upgrading to become skilled
attendants. Conversely, in Afghanistan the situation clearly needed immediate
production of new workers, since less than 500 midwives existed in the country
in 2002. Therefore, a massive national effort to train and appropriately make
use of midwives was launched in 2003.34 A national policy to expand skilled
attendance, especially in rural areas, strong donor support, and clear
technical leadership and resources led to a rise in the number of midwifery
schools from six in 2003, to 23 in 2006, and the production of more than 1100
new competent midwives in 3 years. Skilled birth attendant coverage in the
Herat province increased from 4% in 2003, to 43% in 2006.
Maternal mortality
reduction also needs appropriate skilled human resources to treat
life-threatening complications when women with obstetric emergencies are
referred. Studies have shown that scale-up for results often requires
fundamental changes in both inservice and preservice curricula to emphasise
competency (rather than simply knowledge) in a core set of essential skills and
to ensure that training fits the infrastructural realities of high-mortality,
low-resource settings.19,35,36
But no one right combination of professional credentials exists. In many
countries, delegation to lower cadres of workers—usually midlevel providers
such as clinical officers or surgical technicians—has become a crucial strategy
for health system functioning.37 In Mozambique, for example,
non-physician surgical technicians posted to rural areas had an 88% retention
rate after 7 years compared with 0% retention of physicians, resulting in 92%
of all major obstetric surgeries being done at district hospitals in Mozambique
by surgical technicians.38
None of these
training approaches can be effective without careful planning for the
deployment and support of trainees. For example, in the Afghanistan midwifery
system supported by ACCESS and JHPIEGO, the focus of these new schools was on
the midwifery service to the community, not simply on midwifery education.
Recruitment of students was connected with planned deployment, with the
student, their family, and local authorities committed to a 3–5 year rural work
contract. Initial deployment success in provincially-based community midwifery
schools was more than 80%, whereas government schools whose recruitment
policies were less tied to planned employment had deployment rates lower than
50% on average.
Immpact's research
has explored the effects that health financing schemes39 can have
on health worker performance, sometimes with substantial consequences for
equity. For example, its assessment in Indonesia showed that although the
government had trained and placed a sufficient number of midwives in the study
districts, midwives' reliance on incomes from private practice means that women
not able to pay for services are still disadvantaged in accessing them.40 Similarly
in Burkina Faso, the absence of career progression including salary increase is
probably an important factor behind the challenge of retaining experienced
staff.41 The Ghana assessment showed that when
user fees were eliminated, the willingness of staff to shoulder increased
workloads was partly linked to a general rise in public sector pay and
allowances, even though most staff did not receive direct incentives to provide
free delivery care.42
Such findings help
to emphasise the important links between micro dynamics at the level of service
delivery and macro dynamics at the level of health system structure and
financing. Furthermore, they remind us that the health system is a core social
institution made up of many different sets of social relations43—ie, among health system staff, between
health providers and the communities they serve, and within communities
themselves. Implementation efforts cannot avoid addressing these relations and
the power dynamics, including culturally specific gender and class or caste
hierarchies, on which they are frequently based.
Accountability is
the notion that has in recent years been regarded as the key to ensuring that
this system of relations yields an equitable and efficiently functioning health
system.44 Although accountability is often
approached strictly as top-down enforcement of laws and regulations, experience
in our initiatives support a so-called constructive accountability approach45 that encourages accountability to
clients and other members of the full team who are associated with delivery
care within the district health system, rather than solely to distant managers
and supervisors.
Building
constructive accountability into implementation programmes often means
integration of community members or community-based institutions into the
management of health services. Many techniques are able to achieve this effect.
For example, in FCI's work in Kenya, initially there was friction and mistrust
between facility staff and community health committee members. A training
programme helped to clarify the roles and responsibilities of the management
committee and to strengthen members' awareness about maternal health issues,
their ability to serve as health ambassadors to and from the community, and
their skills in key areas such as community mobilisation and fundraising.
In Burkina Faso,
FCI worked extensively with local chiefs and traditional leaders in the
Ouargaye district to heighten their awareness of and concern about maternal
mortality. In one community, the local chief began to regularly attend
antenatal clinics to urge women to return to the facility for delivery care.
The use of skilled care increased from 25% to 56% between 2003 and 2006, partly
because of the positive social atmosphere created by the local chiefs and
partly because quality services were made available at health centres that were
closest to where women lived.46
Although formal legal and regulatory mechanisms should, of course, be used to enforce some types of accountability (such as financial corruption), rights-based approaches have also been used effectively in implementation of programmes to create a responsive dynamic that is focused on teamwork for best possible client care. For example, the organisation CARE used an explicitly rights-based approach in its AMDD-supported programme in Ayacucho, Peru, to tackle a failing referral system in which poor clinical decisionmaking and slow action were reinforced by mistrust and condescension across different levels of providers. The introduction of a referral/counter-referral system, as well as training, clear protocols, two-way radios, and ambulances helped improve the situation, ensuring that staff at all levels saw themselves as part of a team which was working to improve maternal-health outcomes. With improvements in performance at both health centres and the referral hospital, and in their interactions with the community, met need for emergency obstetric care rose from 30% to 84% in 4 years.47,48
Monitoring and evaluation
Monitoring and
evaluation is a fundamental part of a well-functioning health system, and thus
it is an essential element of any implementation initiative. At a programmatic
level, the rationale for tracking inputs, processes, and outcomes is clear: to
improve performance, enhance effectiveness, and achieve results.49 Over the past 20 years, a large amount
of experience has accumulated on many aspects of the monitoring and evaluation
of programmes for maternal health.50–52
As the interdependence between health systems strengthening and initiatives for
the reduction of maternal mortality has become increasingly apparent, so has
the overlap in their monitoring needs.
Indeed, as global
health policy and development aid move increasingly toward results-based
financing as a means for improvement of overall management of the health system
and service delivery at the operational level, monitoring and evaluation have
become very important.53 The challenge is to define a small
number of indicators that will not overwhelm fragile reporting systems, but
that capture district level programme inputs and management appropriately,
which is necessary for both health system strengthening and maternal health
specifically. One of the lessons learned in our and others' initiatives, is the
importance of linking coverage indicators to quality and equity.40,54,55
In Ghana, for example, Government removal of user fees was associated with an
increase in the proportion of deliveries with health professionals, but the
reduction in out-of-pocket payments for care was only 14% for the poorest women
compared with 22% for the richest.15
These developments
in global health policy and financing mechanisms imply an increased commitment
to strengthening district level reporting and data collection systems, and
commitment to analysis, interpretation, and use of data. In the maternal health
field, many measurement methods and techniques are now available, although
further improvement is still needed.56 Some of these methods rely on the
routine information system, like the UN process indicators for emergency
obstetric care57 and quality of care audits,58 whereas others use secondary analysis
of data from major survey programmes—eg, the Demographic and Health Surveys,59 and some need specific data collection
activities such as key informant interviews.42 Measurement of health outcomes, such as
maternal mortality, continues to present challenges for weak routine information
systems, but several novel methods have emerged from AMDD60 and Immpact.61 Experience with the measurement of
non-fatal outcomes, such as obstetric fistulae62 and psychological morbidities,63 is slowly increasing, and efforts are
underway to improve analysis of perinatal outcomes.64
Remaining
challenges
The inputs needed for maternal mortality reduction are
within the reach of all countries over the next decade if the necessary rises
in aid and budget allocations are forthcoming. Recognition of the deficits in
human resources and infrastructure that hamper maternal health programmes has
been growing. But attention to the poor capacity of the overall organisational
system to convert these inputs into functioning, equitable services is now
urgently needed.65
Efforts to strengthen capacity should focus on the organisational system that “is composed of a network of programmes of services, staff, facilities, structures (forums for discussion and collective decisionmaking such as management boards, committees, etc), and processes of supervision, decisionmaking, information passing, financial flows, and so forth.”65 When systems capacity is ignored, inputs are often wasted and results scarce (figures 2 and 3). The challenge will be to address these elements of systems capacity not as mechanical cogs in a wheel, but as human interactions. Effective management of these interactions needs a continual, open-minded search to understand what incentives from inside or outside any particular health system drive people—eg, providers, patients, managers—to act as they do. The work of our four initiatives has shown the feasibility of eliciting context-specific information about the motivating factors that drive service quality and use, which can then help adapt policies and practices to address these factors directly.
Figure 2. Pyramid of effective
capacity building65
Reproduced from reference 65 by permission of Oxford University Press.
Figure 3. Suboptimum capacity
building65
Technical training and equipment are supplied, but
they are fairly ineffective because staff are overstretched, facilities are
dilapidated, and powers to refurbish remain centralised. Reproduced from reference 65
by permission of Oxford University Press.
Clearly these many
dimensions of health-system functioning do not exist in isolation from the
wider political economy that prevails in high-mortality countries and in the
global system. Our call is not to ignore such issues. We recognise that
maternal health is linked in profound ways to poverty and wider issues of
socioeconomic development. Yet social and economic dynamics are not only
questions for contributors to global policy. They also have tangible
consequences in the actual functioning and use of these most basic services on
which the lives of millions of women and neonates depend. Our call is to bring
the fight for these services to the local level, and to support the efforts of
those inside and outside the health system at that level who are able to
initiate real and lasting change.
This leaves the
question of what will it cost to implement this aim at scale? Here there are
some known and unknown factors. Known factors encompass the various global
costs on scaling-up maternal and newborn services. Although these costs vary
according to model assumptions, the additional budget needed is clearly
substantial—in the range of US$5·5–6·1 billion per year by 2015, for the 75
priority countries.13,66,67
Present investment at a global level is insufficient, and donors will greatly
need to increase financial contributions.68 The Global Campaign for the Health MDGs
is hoped and expected to be the catalyst and mechanism for achieving this
increase. Projections suggest that such funding requirements could be met if
countries invested 15% of their national budgets in health (the Abuja target
set by and for Africa), and if official development assistance rose further
towards 0·7% of gross national income for countries in the Organisation for
Economic and Co-operative Development.
The unknown factors
in the scale-up costs lie at a country level. The global estimates are too
crude for national planning, and there is an urgent need for context-specific
budgets to be produced—ie, budgets which also need to cover improved resource
tracking, so that both country and donor commitments are held accountable.
Crucial information gaps67 exist on the costs of health sector
reforms, and costs of recruiting, training, and retaining sufficient numbers of
skilled health personnel, who are vital to saving women's lives. Strong
evidence exists in support of major reform in the financing of maternal health
services, and specifically the removal of user fees, which disadvantage the
poorest women and exaggerate the poor-rich gap in terms of use and outcomes.39,69
For this bold move to succeed, governments have to replenish the income lost
from the abolition of user fees, and should ensure rather than assume that the
benefits reach disadvantaged groups and regions.
Conclusions
The focus of the global maternal health community needs
to shift. Instead of energy spent on the fine points of precisely which
effective interventions theoretically fit best into generic packages, we now
need to address the health system that must deliver them. Yet virtually nothing
in the maternal health field has been prepared or set up to address the type of
systems capacity-building for scale that is the over-riding lesson of the
diverse experiences of our four initiatives. To change this pattern will take
creativity and courage. Creativity is needed to build political commitment and
forge strong coalitions across programmes, sectors, professions, and countries,
and to tap the expertise and local knowledge—so often hidden from the global
view—to design and implement the new initiatives, incorporating the best of
what is already known. Courage is needed not to confront what is wrong in
health systems that do not function for people, especially those who are
poorest, despite huge infusions of cash and development aid, and to demand and
support a transformation.
Conflict
of interest statement
We declare that we
have no conflict of interest.
Acknowledgments
LPF is supported
through the AMDD programme at the Mailman School of Public Health of Columbia
University, funded by the Bill & Melinda Gates Foundation and Irish Aid.
WJG is supported partially by the University of Aberdeen. TE is partially
supported by the Oxford Policy Management Group. WJG and TE are also partially
supported through Immpact, funded by the Bill & Melinda Gates Foundation,
the Department for International Development, the European Commission, and
USAID. EB and ET are supported through the Skilled Care Initiative of Family
Care International, funded by the Bill & Melinda Gates Foundation. JMS, SC,
and KA are supported through the ACCESS programme funded by USAID. VF is funded
through UNFPA by a grant from the Government of Luxemburg. The funders have no
responsibility for the information provided or views expressed in this paper.
The views expressed herein are solely those of the authors
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Affiliations
a. Averting Maternal Death and Disability Program, Mailman
School of Public Health, Columbia University, New York, USA
b. Immpact, University of Aberdeen, Aberdeen, UK
c. Family Care International, New York, USA
d. JHPIEGO, Maryland, USA
e. UNFPA, Geneva, Switzerland
f. ACCESS Program, JHPIEGO, Maryland, USA
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