July 1, 2014

Success factors for women’s and children’s health: Poverty does not always block health-care progress

Written by Carole Presern

This post originally appeared on The Lancet’s Global Health blog here.

Social and economic development is a mysterious business. In some low- and middle-income countries, economic growth brings very little change to the lives of women and children, especially those in the poorest communities, while other countries achieve near-miracles on very little. What makes the difference?
Since 2011, the Partnership for Maternal, Newborn & Child Health (PMNCH), WHO, the World Bank, and the Alliance for Health Policy and Systems Research have been trying to figure this out, working closely with ministries of health, academic institutions, and other partners.

A series of multicountry, multidisciplinary studies explored the reasons why some countries have made fast progress to reduce maternal and child deaths. The survey was part of a global stocktaking in the run-up to 2015, the deadline governments set in 2000 for achieving eight Millennium Development Goals (MDGs). Some low- and middle-income countries are on track to get there; others with comparable income aren’t and challenges remain. Why?

We focused on MDGs 4 and 5, reducing child mortality and improving maternal health, which many studies have called key to achieving all the other goals. We looked at more than 250 health and development indicators for 144 low- and middle-income countries. We examined data and research literature, field reports, government policies, non-governmental involvement, and other factors such as governance and leadership.

In 2012, we had found ten countries punching well above their spending weight in this area: Bangladesh, Cambodia, China, Egypt, Ethiopia, Laos, Nepal, Peru, Rwanda, and Vietnam. In our report, Success Factors for Women’s and Children’s Health, we call them “fast-track countries” because they are reducing maternal and child mortality at rates that will achieve the two MDGs ahead of comparable countries. What can be learnt from these countries? What strategies have they used to make these improvements? What are these countries doing that others aren’t?

First, there is no standard formula for success. Each fast-track country has developed strategies suitable for its unique context, challenges, and strengths. However, fast-track countries have acted in three main areas to reduce maternal and child mortality.

The first area is investment across various sectors. Fast-track countries’ investments tackle a range of problems, not just health. Targeted investments create synergies that have improved gender equality, education, nutrition, energy and pollution management, and general economic growth. Vietnam, for example, achieved universal primary school enrolment in 2000 for both girls and boys. In Rwanda, 64% of parliamentarians are now women, in part from new quota and ballot requirements.

The second common area involves strategies to make the best use of available resources. One strategy is to spread the issue around, with actors across society playing leadership roles and working in partnership. Fast-track countries break down the “silos” that often keep educators, health-care providers, funders, business owners, sanitation experts, religious authorities, and so on from talking to each other. Women’s and children’s health involves all those areas and more, it turns out. In Egypt, for example, a group of university professors formed a “happy family society” back in 1937 and worked with religious leaders to obtain a fatwa, or declaration of doctrine, that Islam did not oppose family planning. Demand for contraception rose.

Another strategy uniting fast-track countries is use of up-to-date evidence to support decision-making and accountability for results. In Ethiopia, scorecards are used at all levels of the health system—community, regional, and national—to monitor progress on women’s and children’s health. Fast-track countries also use a “triple planning” approach, focusing on both quick wins and longer-term gains and adapting fast to sustain progress.

For example, after the genocide in 1994, Rwanda deployed community health workers and volunteers to meet urgent health needs, but also invested in long-term efforts to build its professional health workforce with medical colleges and international collaborations. To sustain its progress, Peru made a concerted effort to address the unequal access of the rural poor and the urban wealthy to quality obstetric care.

Most of the fast-track countries used principles of human rights and development effectiveness to guide action. New laws and policies addressed gender and economic inequality by guaranteeing rights for all to quality health care and legal standing. Nepal’s interim constitution explicitly names health care as a human right, and Supreme Court rulings based on that right have expanded service delivery and community involvement. Laos set up policies and programmes to improve women’s rights and participation at all levels of society.

In many fast-track countries, government interacts with health and development partners to align their work with country priorities. For example, Rwanda holds a monthly Joint Action Development Forum in every district, where all partners review data on their progress, coordinate, and plan next steps. Each district has an annual performance contract with the president’s office.

None of these countries made constant progress. Most still lag in one area or another. But together they demonstrate that improved health outcomes can be achieved with relatively few resources if investments are used strategically. While further collaboration across interest areas is needed in all countries, our studies confirm that if the political and social will to take action is present, poverty alone cannot stop progress on women’s and children’s health.

This blog is part of a series linked to the Success Factors for Women’s and Children’s Health studies presented at this year’s Partners’ Forum. PMNCH, WHO, World Bank, and the Alliance for Health Policy and Systems Research, worked closely with Ministries of Health, academic institutions, and other partners on a three-year multidisciplinary, multicountry initiative that aimed to understand what factors enabled some low- and middle- income countries to achieve rapid reductions in maternal and child mortality.