Cost-Effective Interventions Aimed at Building Health Systems
Vaccines will halt some diseases, and larvicides will wipe out some vectors, but such approaches have no bearing on prenatal care and childbirth. For these, a robust, functioning health system with equitable access is crucial for good results. The experience of Sri Lanka shows how this can be achieved.
" if a woman is in poor health because of, malnutrition, malaria, immune deficiency, TB, or heart disease, she can face serious risks during pregnancy and childbirth."
Pregnancy and childbirth are natural events and typically require little or no medical intervention for either mother or baby (DCP2, chapter 26). However, if a woman is in poor health because of, say, malnutrition, malaria, immune deficiency, TB, or heart disease, she can face serious risks during pregnancy and childbirth. Reducing maternal and infant mortality requires preventive measures, such as proper nutrition and screening for possible risks. It also requires a sanitary environment for giving birth and swift, effective care in case of emergencies, such as obstructions at birth or hemorrhaging. Unsafe abortions are another major risk factor for women's health. Where health systems are poor and populations consequently lack appropriate care, a much higher proportion of pregnancies can result in complications, illness, permanent disability, or death of the mother or child. Millions Saved notes that "interventions to detect pregnancy-related health problems before they become life-threatening, and to manage major complications when they do occur, are well known and require relatively little in the way of advanced technology. What is required, however, is a health system that is organized and accessible—physically, financially, and culturally—so that women deliver in hygienic circumstances, those who are at particularly high risk for complications are identified early, and help is available to respond to emergencies when they occur" (Levine and others 2004, p. 48).
Despite its poverty, this is what Sri Lanka has provided. In the 1950s, estimates indicated that Sri Lanka's maternal mortality ratio was 500 to 600 per 100,000 live births. By 2003 it had plummeted to 60, and skilled practitioners were attending 97 percent of births. This was an outcome of continued, dedicated efforts by the government to extend health services, including essential maternal health care, equitably. Sri Lanka has pursued its goal of building a system accessible to all in many different ways: it has purposely located facilities in rural areas, made care universally free, provided transportation networks, and strengthened referral systems. In developing human resources, it has paid particular attention to midwifery. Other basic attributes of the Sri Lankan system have been making good use of information for monitoring and planning, improving the quality of care, and targeting underserved populations.
"In the 1950s, Sri Lanka's maternal mortality ratio was 500 to 600 per 100,000 live births. By 2003 it had plummeted to 60"
The country's step-by-step strategy to provide broad access to specific clinical services, to encourage the use of those services, and to systematically improve quality has been facilitated by its excellent civil registration system and reinforced by a good education system notable for its gender equity (89 percent of Sri Lankan women are literate, compared with the South Asian average of 43 percent). Moreover, its dedication to providing social services for all has been sustained and predates independence in 1948.
Sri Lanka has been and remains a poor country. It has achieved its exemplary performance in maternal health not only without major technological innovations but also without high levels of spending. Indeed, it accomplished all this on a spartan budget. Absolute national spending on maternal health was almost the same in the 1990s as it had been in the 1950s; but income growth over that interval meant that the share of gross domestic product (GDP) fell from 0.28 to 0.16 percent. Furthermore, financing was mostly domestic, coming from government revenues. Millions Saved suggests that "others can take inspiration from the country's record: In the late 1950s, when the first efforts were made to address the problem of maternal deaths, the GNP [gross national product] of Sri Lanka was equivalent, in constant dollars, to the national income of Bangladesh, Uganda, or Mali today and far lower than that of Pakistan, Egypt, or the Philippines. In relative terms, Sri Lanka has spent far less on health—and achieved far more—than any of these countries" (Levine and others 2004, p. 54).
"The success of Sri Lanka is related to maternal health specifically, but it could not have been achieved without building a robust, equitable health system overall."
The success of Sri Lanka is related to maternal health specifically, but it could not have been achieved without building a robust, equitable health system overall.
