September 22, 2014

Preventing Needless Deaths and the Intergenerational Costs of Inaction

Written by Dr. Koki Agarwal, MD, MPH, DrPH, Director Maternal and Child Survival Program

This blog originally appeared on Medium. For the best viewing experience, please visit the blog here.

The Maternal and Child Survival Program enters its inaugural year with 2015 on the horizon and the world engaged in a discussion of the post–Millennium Development Goal (MDG) agenda. This new flagship, USAID-funded program carries forward the momentum and lessons learned from the Agency’s Maternal and Child Health Integrated Program (MCHIP), which made significant progress in improving the health of women and children in over 50 developing countries throughout Africa, Asia, Latin America and the Caribbean.

And yet, with the 500-day deadline for the MDGs now behind us, we realize how much more there is to do to end preventable maternal, newborn and child deaths. Under no circumstances can we afford to lose the momentum in the days leading to the culmination of the MDGs. At the core of this stalled progress is equity: the ability to reach those most in need, especially in low-resource settings, with high-quality services.

The Maternal and Child Survival Program is motivated by a vision of self-reliant countries equipped with the analytical tools, effective systems, and technical and management capacity to improve the health of mothers and families. But to truly improve health care and reach the MDGs—and achieve the post-MDG goals in the process—we must recommit our efforts in ways that address equity and general health systems strengthening.

To keep the promise we made to the world’s mothers and children in 2000, we must ask ourselves five questions:

What can be done to promote equity?

• We must reach every pregnant woman, delivery and childbirth — as well as newborns and children — with a minimum package of interventions.
• This extended reach will be built on developing and strengthening community health worker systems/cadres to reach the most remote and vulnerable populations with key services. This includes reaching rural populations, adolescents, the very poor, and those facing the highest disease burden.
• To direct programs and resources to hard-to-reach populations, we must use data — including epidemiological profiles, coverage data, GIS mapping, and community mapping — to identify gaps in availability and delivery of services.
• And to ensure the involvement of partners, we must improve the process of shared responsibility, accountability and community empowerment.
• Throughout our work and across interventions, we must ensure improved quality of care, including respectful maternal and newborn care, with the full engagement of the community.

How should we measure equity to ensure that we are reaching all those who need services?

• It is key to leverage technology and partnerships! To ensure universal health coverage and care for all, we must push for universal enrollment in a strengthened civil registration system, and linkages with census systems routine service delivery data.
• It is critical to promote analysis by geographical areas to identify which areas are not being covered. And we must empower health care workers with the necessary tools to help with this analysis and to take action. This includes promotion of the use of subnational data visualization tools (such as dashboards and scorecards) to facilitate the use of data for decision-making.
• Ultimately, we must also integrate this community data to have a comprehensive picture of services and related gaps, and present it in ways that best help decision makers take action. The ability to paint a complete picture from routinely monitored maternal and newborn care data lags behind that in child health.

In what ways can we improve measurement, ensuring that we have more proximate measures than simply maternal mortality ratio or skilled birth attendant rate?

• We need to test the validity and feasibility of new indicators of the content and quality of maternal and newborn care.
• Monitoring & Evaluation training must be a component of every clinical training conducted on maternal and newborn health. This will ensure that the right people have the skills to record and report accurately and timely data.
• Using data is one of the best ways to understand and improve data quality and will raise attention to the need for better measurement. However, we must not work alone; promoting data sharing and use of data by subnational and national stakeholders is essential. This includes building consensus on a core set of indicators.
• Measuring and making progress requires target setting. Therefore, mapping of vulnerable populations must be done in order to establish targets.

How do we ensure mutual accountability within the health system?

Accountability is a process of data analysis, review, shared responsibility, and action taking. We cannot talk about accountability without a process of shared responsibility between partners. It is not the sole role of ministries of health to ensure services are delivered; all partners — including nongovernmental organizations, civil societies, the community, and private sector — have to take responsibility and act in a coordinated manner under national plans.

What is the role of the community in promoting equity?

Communities are crucial in promoting equity, and they must be educated and empowered. Through heath volunteers, peer groups, and advisory boards, communities help to ensure that the right people are getting the right services at the right time. For instance, we know that it’s feasible to achieve high coverage of uterotonic use — even in low-resource and post-conflict settings — by distributing misoprostol in advance of birth during home visits. And that community plans for emergency transportation and obstetric care are critical to saving lives. Many countries have also taken up the challenge of scaling up integrated Community Case Management programs for the main killers (pneumonia, diarrhea and malaria) of children under five, with the idea of extending services to those without current access. We must continue to improve the performance of village health workers to meet these needs.

Above all, we cannot assume that our efforts will increase equity. We must monitor not only the quality of services, but also their equity, tracking performance and taking corrective actions where necessary. Ensuring gender equity here — outside of the formal health system, in the most remote areas — is critical to improving care for the most vulnerable women and children.