Lessons for Implementation
The findings from the CEA indicate potential health gains and the reduced burden that may be achieved by implementing selected packages of interventions. Such implementation assumes, first, that decision makers accept the evidence and are willing and able to act and, second, that an enabling health system environment exists within which the requisite scale and quality of care can be effectively delivered. These factors are not peculiar to safe motherhood, but they undoubtedly help explain the significant gap between evidence and action that many argue is one of the main obstacles to progress (Godlee and others 2004; Villar and others 2001). The gains from bridging this gap would be significant: the MDGs for child survival and maternal health might become more than mere rhetoric for poor regions if intervention packages of the scope and nature described here were implemented. The most cost-effective of the packages averted nearly 50 percent more direct maternal deaths than the base package. This gain would be encouraging, but the prospects for achieving it by 2015 are weak (Johansson and Stewart 2002).
At the macro level, a supportive policy environment clearly is crucial, as noted earlier. At the micro level, an enabling health system implies a reduction in the disequilibrium between the demand and supply sides (Williams 1987), with particular attention to three interrelated issues: access, quality, and finance. The CEA reported in this chapter emphasizes the potential benefits to mother and baby of improved access to care, particularly the importance of entry to the health system through primary-level services. The increases in coverage could be achieved by a variety of mechanisms but clearly require both demand- and supply-side interventions.
On the supply side, this chapter has shown that improved quality of care at both the primary and the secondary levels encompassing technical, infrastructural, and human resource dimensions (Pittrof, Campbell, and Filippi 2002) is a particularly cost-effective option. The widespread call for all women to deliver with skilled attendance immediately raises major questions about quality of care and capacity, because much of the developing world faces an acute shortage, as well as an unequal geographic distribution, of health professionals.
Our CEA assumes that redistributing human resources within countries will accommodate the increased uptake of care by women, although the most effective mechanisms for achieving this goal, such as incentives, use of nonphysicians, and increased private sector involvement, have not yet been established (De Brouwere and Van Lerberghe 2001). What is clear, however, is the importance of the interplay between supply and demand, with the supply of quality care stimulating demand for care and vice versa. Quality care includes an effective referral system (Murray and others 2001) to ensure the required match between the various levels of care different women and their babies need at different times (De Brouwere and Van Lerberghe 2001). Such systems require not only financial resources to support transportation, communications, and feedback mechanisms, but also structured fee and exemption strategies to reduce both inappropriate self-referral to hospitals and financial barriers to access on the part of the poor.
The financing of prenatal and delivery care services at an adequate and sustainable level is a subject of much debate and uncertainty, given the difficulty of distinguishing these elements from broader health expenditure categories (De Brouwere and Van Lerberghe 2001). Given the low level of overall per capita expenditure on health in developing countries—estimated at US$13 in 2002 for the poorest 49 countries (Bale and others 2003)—attaining our base intervention package (costing approximately US$0.41 per capita in South Asia and US$0.60 in Sub-Saharan Africa) does not sound unrealistic at current resource levels (see table 26.8, and divide by base population of 1 million people).
The effects of health sector reforms, particularly decentralization of management and budget holding, appear to be mixed in terms of increasing resource flows into maternity services, with both apparent positive benefits, as in Bolivia (De Brouwere and Van Lerberghe 2001), and negative effects through the exacerbation of inequities (Russell and Gilson 1997). Effective management decisions on finance, access, and quality require information, an essential ingredient for stimulating action. To allocate scarce resources where they are likely to achieve the greatest gain, countries need information to assess the burden of ill health, evaluate the performance of current intervention strategies, identify the scope for improvement and implement changes, and close the loop by evaluating effects and cost-effectiveness (Lawn, McCarthy, and Ross 2001).
Even though the challenges that the poorest countries face today clearly differ in many respects from those that developed or transition countries experienced in the past, six historical lessons provide particularly relevant insights. First, examples abound of supportive policy contexts and individual champions of progress in addressing maternal and newborn health, such as those reported by De Brouwere and Van Lerberghe (2001). Second, historical data on the uptake of prenatal care demonstrate that community-based providers and advocates played a crucial role. Third, the role of various professionals and professional bodies has not always been positive, particularly as regards the "war" between advocates for home and institutional deliveries (Koblinsky and Campbell 2003). Moreover, good historical evidence indicates that excessive rates of forceps deliveries and other interventions were significant contributors to maternal mortality in countries such as the United Kingdom and the United States (Buekens 2001). Fourth, primary-level care depends on an effective referral system being in place to maintain the confidence of both women and providers (Loudon 1997). Fifth, to reduce the burden of maternal and perinatal conditions, the system of health care financing must facilitate access for the poorest groups and guarantee service quality (De Brouwere and Van Lerberghe 2001). Finally, the role of population-based information on births and maternal deaths was crucial in ensuring that actions were locally relevant (Sorenson and others 1998), in demonstrating progress, and thus in stimulating further action. This crucial role is particularly apparent in the literature on several European countries in the past century (Graham 2002; De Brouwere and Van Lerberghe 2001).
