Memorandum submitted by Immpact[43]
1. KEY MESSAGES
— The burden of maternal mortality
is borne disproportionately by the poor;
— Financial barriers to skilled delivery
and emergency care are major reasons for this inequity;
— A window of opportunity has opened
for reducing these barriers by abolishing user fees;
— Enabling governments to reduce these
barriers is an evidence-based way to catalyse progress towards
MDG5.
What needs to be done is clear: the poorest
women must have access to timely and effective care, particularly
in the event of obstetric emergencies. A focus on the poor and
on the reduction of financial barriers to skilled care can act
as a hub for efforts, but with many wider spin-offs and benefits.
We set out below further material from Immpact
in support of our key messages, and in response to specific questions
posed by the Select Committee.
2. BACKGROUND
Our "key messages" emerge from Immpact
research and are also supported by other sources of evidence.
Immpact is an international research initiative
for maternal mortality programme assessment. It was set up in
2002 to improve the evidence-base for decision makers on cost-effective
strategies to reduce maternal mortality.
Immpact developed innovative means to conduct programme
evaluations; used these to assess maternal mortality reduction
strategies in Burkina Faso, Ghana and Indonesia; and built capacity
in these countries to gather and use evidence for decision-making.
Investment in Immpact was in direct response
to donor and country concern about slow progress towards MDG5.
There was recognition that gaps in evidence on effective strategies
were significant bottlenecks. DFID played a crucial role in catalysing
and sustaining Immpact. Many other research and programme initiatives
in recent years have also contributed to strengthening the evidence
base.
In our view, the bottlenecks have now shifted
to communicating and acting upon the evidence, at country and
international levels. In particular, the four[44]
new major global enterprises relevant to MDG5 must make use of
the available evidence in order to progress towards action.
3. Question: How can donors—and DFID
specifically—catalyse progress towards MDG-5?
We urge DFID and other donors to champion explicitly
the needs of the poorest women by focusing on the removal of financial
barriers to delivery and emergency care, and so catalyse wider
improvements in the demand and supply side of health systems in
low-income countries.
We base our case around 4 key messages.
3.1 Message 1: The burden of maternal
mortality is borne disproportionately by the poor.
An equity lens is essential to monitoring all
indicators relevant to maternal health.
The poor-rich gap has been clearly demonstrated
in many studies (Figure 1).
In relation to maternal mortality the gap is
a reflection of wider inequities: in education, gender, and nutrition,
for instance, and particularly in access to care. Poor women have
limited access to care, especially for obstetric emergencies.
The lifetime risk of maternal death for poor
women is further increased by the markedly higher fertility rates
for women in the lowest income quintile in developing countries—these
rates are typically 2-3 times higher than for women in the highest
income quintile.
The disproportionate burden on the poor has
not been adequately revealed or communicated, in part owing to
data constraints and use of insensitive indicators.
We know, for example, that uptake of antenatal
and delivery care with a health professional shows 2-6 fold differences
between the rich and the poor. It is only recently that the gap
for caesarean sections—a life-saving surgical intervention,
was shown to be substantially greater in many low-income countries
(Figure 2).
The burden does not stop at the death of a mother.
Young children lose the parent who makes the
biggest difference to their survival and well-being (Figure 3).
Figure 3
A study in Indonesia of over 2,500 children aged 6-10 showed that maternally orphaned children are approximately four times more likely to die compared to non-bereaved children, and twice as likely to drop out of school.
Source: id21 Insights 2007: 11:4
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Families disintegrate with the loss of the key person who
feeds and cares for members. Societies and economies lose women
in their prime of life and when most productive.
Better indicators are needed to quantify and communicate
these broader aspects of the burden of mortality. Immpact, for
example, is working on ways to estimate the number of children
who lose their mothers during childbirth or whilst they are still
young (Motherhood Method).
3.2 Message 2: Financial barriers to skilled delivery
and emergency care are major reasons for the disproportionate
burden of maternal mortality borne by the poor.
Even with existing knowledge gaps regarding the true burden
from maternal mortality, it is clear that the costs of care help
explain the wide and widening poor-rich gap.
Surgical interventions related to pregnancy and childbirth,
especially caesarean sections, are amongst the most common and
expensive operative procedures that families face. The costs of
complicated deliveries are often "catastrophic""—a
term used where costs are in excess of 10% of yearly household
income. The consequences for the poorest groups are particularly
devastating (Figure 4), plunging them further into irrecoverable
debt.
Figure 4
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In Burkina Faso on average, a normal delivery costs US$ 124 for a caesarean section, and with transport costs to reach health facilities in addition. Delivery costs are estimated to constitute 43% of per capita income in the poorest households and as much as 138% for a caesarian section.
Source: Immpact
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For women who survived obstetric complications, Immpact's
anthropological research in Burkina Faso and Indonesia also found
adverse social consequences (Figure 5) arising from the costs
of care.
Figure 5
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Social tensions arising from catastrophic payments were felt very strongly in women's daily lives according to research in Burkina Faso and Indonesia. These tensions were reflected in women's efforts to cut back on their own spending to avoid being blamed for being "too expensive", increased work activities to replenish depleted funds—even when they were still unwell, and increased perceived dependency and guilt. In some cases marital or other social relationships disintegrated as a direct result of the financial burden of emergency care.
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3.3 Message 3: A window of opportunity has opened for reducing
these barriers by abolishing user fees.
The universally adverse effect of user fees on the poor is
now widely accepted. Many countries, particularly in sub-Saharan
Africa, are taking the bold move to abolish fees. There is now
a "head of steam" behind such a move, and many agencies—including
DFID, are endorsing this. Advocates for maternal health should
take special advantage of such an opportunity.
Our research provides evidence to support removal of fees
for delivery and emergency obstetric care. But benefits in terms
of reduced mortality will not be realised unless two further barriers
are addressed—out of pocket expenses and poor quality of
care.
Figure 6
Care made "free"" at the point of service
may still not reach the poorest women. Out-of-pocket expenses
are still significant obstacles, including costs of transport,
food, drugs and supplies, and informal charges. In Ghana, for
example, although the Government's fee exemption policy was shown
by Immpact to have increased overall uptake of delivery care in
health facilities (Figure 6), the fall in out-of-pocket payments
was only 14% for the poorest households but almost double this
for the richest. In other words, special consideration needs to
be given to the equity dimension of free care.
It is often assumed that financing schemes to reduce barriers
to care will automatically be of greatest benefit to the poor.
Our research shows that, particularly for obstetric emergencies,
free care without transport subsidies (as in Ghana) or social
insurance for the poor without tackling referral costs (as in
Indonesia), will undermine prospects for reducing maternal mortality
(Figure 7).
Figure 7
In Indonesia, women covered by the Government's social insurance for the poor still had the lowest uptake of delivery with a health professional (%) and the highest level of mortality (630 maternal deaths per 100,000 live births). This compares with the equivalent figures of 31% and 410 for women without any insurance, and 81% and 235 for those with other insurance.
Source: Immpact
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The second additional barrier is poor quality of care.
Increased workload facing health professionals is a threat
to the effectiveness of fee removal, with implications for staff
motivation and quality of care.
These problems are particularly acute where there is already
a massive shortage of skilled health professionals and functioning
facilities (Figure 8).
Figure 8
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In Burkina Faso, for example, the community mobilisation component of an intervention to increase uptake of institutional delivery helped to explain the increase in uptake observed by Immpact, over time and in comparison with a control district. However, improvement sin the supply of care were constrained by the lack of facilities: 77% of births within 1 km of the health centre took place in a facility, compared to just 19% for births further than 10 km from the health centre. Access to life-saving interventions remained extremely low in the intervention area, with only 0.4% of all births being delivered by caesarean section. It is generally accepted that caesarean section rates of less than 1% indicate an unmet need for life-saving care.Source: Immpact.
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3.4 Message 4: Enabling Governments to reduce financial
barriers to delivery and emergency care is an evidence-based way
to catalyse progress towards MDG5.
There is now an enabling international environment to push
forward a concerted effort to do what needs to be done: the poorest
women must have access to timely and effective care, particularly
in the event of obstetric emergencies.
A focus on the poor and on the reduction of financial barriers
to care can act as a hub for efforts, but with many wider spin-offs
and benefits for the health system and for other health problems
in low-income settings.
The way to achieve this cannot be a "one-size-fits-all"
approach. The options and phasing for removing financial barriers
need to be context-specific, and built into national plans. These
plans are now being called for by the four[45]
new major global actions relevant to MDG5. The Innovative Result-based
Financing, for example, can provide a stimulus for tackling financial
barriers to delivery and emergency obstetric care, with equity-sensitive
indicators used to track progress.
It is important that these plans also mobilise interim funds
whilst Governments seek to establish mechanisms for replenishing
income lost from the abolition of user fees.
Immpact is now using evidence to help design strategic alternatives
for reducing financial barriers in specific country contexts.
We refer to these as FreeD strategies—a term which captures
the primary aim—for women to be freed from the financial
barriers to delivery and emergency care.
We urge DFID and other donors to prioritise FreeD strategies
within and through the new international initiatives to catalyse
progress towards MDG5.
4. Question: How effectively DFID is working with recipient
countries to resolve EmOC and HR issues?
We sought a view on this from a senior colleague who was
attached to the project for a year but who previously had been
Deputy Director-General of the Ghana Health Service. The response
is based in part on Immpact experience and in part on his and
colleagues experience within the Ghana Health Service and Ghana
Ministry of Health. The full report is included as an appendix,
but the key messages in response to this question are:-
1) DFID has contributed about £7-10m annually to
the programmes of work agreed with the Ghana Ministry of Health
through flexible funding arrangements for the sector. However
the release of funds has been unpredictable and erratic in recent
times.
2) DFID closed its health office in Ghana without discussion.
This has created a vacuum in the policy dialogue in Ghana. It
has also deprived the health sector of good quality technical
support in health as a whole and in dealing with MDG5 in particular.
3) DFID and other donors can support Ghana's effort at
achieving MDG5 by:
(i) Providing more flexible funding especially as they
move into multi-donor support.
(ii) Providing technical support for policy, human resource
development, evaluation and research.
(iii) DFID especially can assist in exchange programs
with NHS UK in service delivery support and training of skilled
personnel.
(iv) DFID needs to revisit its policy of closing down
its country office for health.
5. Question: How achieving MDG5 is being prioritised and
integrated into countries' overall health provision?
Achievement of MDG5 is not simply a matter for Ministries
of Health and health provision. The findings of our project are
that education, nutrition, employment and transport all have major
impacts on maternal health. The Public Services Agreement (PSA)
approach by DFID in sub-Saharan Africa provides flexible funding
where this is feasible, but the temptation to target resource
through vertical initiatives, experienced by our Ghanaian colleagues,
needs to be resisted by DFID and as far as DFID can influence
them, by other donors.
6. Question: How effectively DFID works with bilateral
and multilateral donors, NGOs and other stakeholders to promote
maternal health?
DFID have provided very effective leadership through the
substantial contribution of Dr Stewart Tyson as Chair of the group
of Funders for this project which is an example of donors (the
Bill and Melinda Gates Foundation, USAID and DFID) working together
for maternal health.
We do observe, however, in working with DFID colleagues both
in the UK and in developing countries that they are frequently
overstretched by the volume and range of work they must undertake,
so that their potential for providing leadership and influence
cannot always be realised. The experience of our colleagues in
Ghana where DFID interests are looked after by another national
agency, demonstrates the dangers of this overstretch.
7. Question: What leadership the UN is providing and how
well coordinated its agencies are?
In our experience and opinion this has, and continues to
be, a problematic issue for maternal health. The absence of a
clear and unequivocal technical lead agency for this important
target group has resulted in tensions and duplication of efforts
at country and international levels. By comparison, the example
of UNICEF's lead for child health shows what can be gained within
and beyond the UN family by such clarity of mandate. The recent
creation of the Partnership for Maternal, Newborn and Child health
(PMNCH), on which the Immpact Principal Investigator sits as a
Board Member, cannot be expected to provide leadership on maternal
health, since its remit is the MNCH continuum. We understand that
three agencies—WHO, UNICEF and UNFPA—are now being
regarded as the triad of leaders within the UN. Our hope is that
this succeeds, though history would suggest otherwise.
APPENDICES
1) Stopping Women dying during childbirth; how are the
Commonwealth countries doing? (submission to Commonwealth govt
conference, O. Campbell, W. Graham, Aug 07)
2) "Dear Minister"—an open letter
to developing country ministers urging action on maternal health—Wendy
1graham and others, Reproductive Health Matters 2007; 15 (30)
3) Dying Mothers—from the evidence to political
will—news article in Real Health News May 2007
4) Delivering Safer Motherhood—Sharing the Evidence—Policy
Brief from Immpact February 2007.
5) Comments for the Committee from Dr Sam Adjei, former
Deputy Director-General of the Ghana health Service and Dr Eddie
Addai, Director of Policy, Planning, Monitoring and Evaluation
for the Ministry of Health, Ghana
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Professor Wendy J Graham, Mr David Braunholtz, Mr Alec Cumming,
Dr Tim Ensor, Ms Sue Fairburn, Dr Julia Hussein (all of University
of Aberdeen), Dr Eddie Addai, Ghana Ministry of Health and Dr
Sam Adjei, Ghana Health Service Back
44
International Health Partnership; Women and Children First;
Catalytic Initiative to Save a Million Lives; Innovative Result-based
Finance. Back
45
International Health Partnership; Women and Children First;
Catalytic Initiative to Save a Million Lives; Innovative Result-based
Finance. Back
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