REGIONAL COMMITTEE
Provisional Agenda item 14
Sixty-third Session Bangkok, Thailand 7–10 September 2010
SEA/RC63/13 16 July 2010
Accelerating the achievement of MDG 5: Addressing inequity in maternal and neonatal health Improving maternal and neonatal health continues to be the major challenge for many countries in the WHO South-East Asia (SEA) Region. Overcoming the challenge would require an effective and efficient health-care system that allows all women to plan for their pregnancy and to get skilled care during antenatal, childbirth and postnatal periods, as well as neonatal care, and that these are backed up by referral services. Providing such healthcare services is an important element of implementing human rights that governments are obliged to provide for all their citizens without discrimination. Countries in the SEA Region contribute to about 27% of the global population; however, they contribute to approximately 33% of the global maternal and neonatal deaths. In absolute numbers, the Region contributed to more than 170 000 maternal deaths, 1 million still-births and more than 1.3 million neonatal deaths in 2008. The health inequities across and within countries are the major issues in the Region. The attached paper highlights the inequities among and within countries in accessing skilled care at birth and in utilization of modern family planning methods. Among the causes of inequity in maternal and neonatal health (MNH) care, a few of the key issues that are emphasized are: (i) inadequate commitment and low budget allocation for the MNH programme at national and subnational levels; (ii) social and cultural barriers in accessing MNH care; and (iii) inadequate quality of MNH care. The recommendations proposed to address the inequities in MNH care are: (i) strengthen commitment and ensure adequate budget allocation for the MNH programme; (ii) improve leadership and management of the MNH programme at all levels; (iii) ensure women and community empowerment for MNH care and community-based actions; (iv) forge multisectoral collaboration/partnership in achieving universal access for MNH/reproductive health; and (v) facilitate exchange of information and experience within and among countries. The High-Level Preparatory (HLP) meeting held in the Regional Office in New Delhi from 28 June to 1 July 2010 reviewed the working paper and made the following recommendations:
Actions by Member States (1) (2) (3) Leadership and management of the MNH programme should be strengthened at all levels through capacity building. Women and community empowerment for MNH care and community-based actions should be ensured. Multisectoral collaboration and partnership should be forged for achieving universal access for MNH/reproductive health.
Actions by WHO-SEARO (1) (2) (3) To facilitate resource mobilization for the MNH programme in collaboration with other UN agencies and potential donors. To provide support for exchange of information and experience within and among countries. To support programmes responsible for MDGs 4, 5 and 6, in preparation for AsiaPacific Ministerial MDG Summit in August 2010, and the UN MDG Summit meeting to be held in September 2010.
The working paper and the HLP meeting recommendations based on it are submitted to the Sixty-third Session of the Regional Committee for its consideration.
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1. Background 1. Improving maternal and neonatal health continues to be the major challenge for many countries in the WHO South-East Asia (SEA) Region. Overcoming the challenge would require an effective and efficient health-care system that allows all women to plan for their pregnancy and to get skilled care during antenatal, childbirth and postnatal periods, as well as neonatal care for their newborns, and that these are backed up by referral services. Maternal and neonatal health (MNH) care is an important element of implementing human rights that governments are obliged to provide for all their citizens without discrimination. 2. During the past decades, many initiatives have been taken by governments of countries of the SEA Region in order to improve maternal and neonatal health. Some encouraging progress has been made in most countries of the Region. However, the overall progress has been too slow towards reaching the targets of the Millennium Development Goal (MDG) 5 by 2015, including universal access to skilled care for birth and reproductive health. 3. The poor and other socially and culturally marginalized people usually suffer the most as access to MNH care is limited for them. This leads to inequity in MNH outcomes. The gap is usually wider in countries with a low level of MNH service coverage. Inequities in other social and cultural factors, such as economy, education, ethnicity and religion, as well as geography lead to a wider gap in accessing and utilizing MNH care.
2. Situational analysis 4. The health inequities across and within countries is the major issue in countries in the Region. The work of both the Commission on Social Determinants of Health and the Conference on Revitalization of Primary Health Care (PHC), in its thirtieth anniversary of PHC, addressed this issue with the aim to closing the health gap between the rich and the poor over the next generation. The social determinants of health indicate the importance of non-health sectors in both generating and addressing the health concerns in collaboration with the health sector. On the other hand, the PHC approach indicates the importance of health system strengthening. 5. Countries in the SEA Region contribute to about 27% of the global population; however, they contribute to approximately 33% of the global maternal and neonatal deaths. In absolute numbers, the Region contributed to more than 170 000 maternal deaths, 1 million still-births and more than 1.3 million neonatal deaths in 2008. Of those, more than 80% occurred in five countries, namely Bangladesh, India, Indonesia, Myanmar and Nepal, simply because of the high numbers and/or the high level of mortality of their respective populations.
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2.1 Inequity in accessing skilled care at birth 6. Countries in the Region are at different stages of development in achieving universal access to skilled care at birth (see Table). For countries with a very low level of proportion of deliveries assisted by skilled health personnel (less than 50%), the major problem is the lack of skilled attendants at the primary care level. Health-care facilities often lack essential equipments, medicines and back-up for referral services. Moreover, health-care providers are often busy with other health-care services, which prevent them from devoting sufficient time to provide appropriate maternal and newborn care, especially during childbirth. Table: Maternal health indicators for Member States of the SEA Region Reported number of maternal deaths, 2005 Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste 21 000 280 1 300 117 000 19 000 12 3 700 6 500 190 1 100 190 Maternal mortality ratio (per 100 000 live births) 1990* 574 560 105 (1996) 437 390 500 232 515 92 36 NA Latest (year)* 320 (2004) 255 (2009) 87 (2006) 254 (2004-2006) 228 (2007) 72 (2005) 380 (2002-2003) 281 (2005) 47 (2001) 41 (2006) 420-800(2002) MDG 2015* 143 140 30 109 102 125 63 134 36 9 252 % deliveries assisted by skilled birth attendants** 2000-2006 20 51 97 52.6 (2007-2008) 66 84 57 19 97 97 19 Progress towards the MDG target Insufficient Insufficient On track Insufficient Insufficient On track Insufficient Insufficient On track On track Insufficient
Source: WHO, UNICEF, UNFPA, WB: Maternal mortality ratio in 2005. *WHO-SEAR: 11 health questions about 11 SEA Region countries, New Delhi 2007. **World Health Statistics 2008. MDG=Millennium Development Goal, NA=Not available. For MMR: country data for Bangladesh, India (DLHS III), Indonesia and Thailand (DRI).
7. In countries with a medium level of proportion of deliveries assisted by skilled health personnel, there are usually adequate numbers of skilled attendants deployed at primary care level. Governments usually make efforts for skilled attendants to be well accepted so that they can stay in the community they serve. They are, as far as possible, given an adequate and appropriate incentive system, including career development schemes to help them stay in the community. However, these countries usually need to also ensure that the technical quality of the care provided at the first referral unit is adequate, i.e. basic equipment and supplies, especially emergency drugs, equipment for surgery, safe blood transfusion and laboratory services; and effective supervision and monitoring system. Countries providing outreach services to the poor and disadvantaged groups, and in remote areas usually display less inequity in the provision of MNH services.
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8. In countries with a high level of proportion of deliveries assisted by skilled health personnel, some areas still suffer from low access – usually disadvantaged groups/remote areas, and areas of conflict. At the same time, there is a growing tendency in urban areas of these countries for over-medicalization of normal pregnancy and childbirth, such as overuse of ultrasound screening and high rate of caesarean sections. This may also create inequity in the distribution of resources between urban and rural areas, while it causes unnecessary morbidity and mortality for mothers, as well as their foetuses/newborns.
2.2 Inequity in MNH care within countries 9. Figure 11 highlights inequities between the poorest and the richest in respect of the proportion of deliveries assisted by skilled health personnel. For countries with universal access to skilled care at birth, such as Sri Lanka and Thailand, the inequalities between the poorest and the richest are narrow. In Indonesia in 1997-1998, the inequities were wide, which became narrower in 2003, although the poorest still had a low coverage of 36%, while the richest had coverage as high as 93%. In countries with a low level of proportion of deliveries assisted by skilled attendants, such as Bangladesh and Nepal, the richest have a low level of skilled attendance at birth, while the poor have a very low (almost non-existent) level of skilled attendance. Also, the progress in this area over the years has been very slow. Figure 1: Inequities between the poorest and the richest in skilled birth attendance
Source: Health Inequities in the South-East Asia Region, WHO-SEARO, 2007
10. Figure 2 shows inequities in the proportion of deliveries assisted by skilled health personnel taking into account mother’s education (no education, and secondary education). For countries with universal access to skilled care at birth, such as Sri Lanka, the inequity between mothers with secondary education and those with no education is narrow. In Indonesia, the inequity has grown wider over the years, while the proportion of deliveries assisted by skilled attendants has increased in both groups. The gaps in Nepal were wider than in Bangladesh, although the 1 Although the source of data of Figure 1-4 was published in 2007, some have outdated data that might have been changed overtime. It is suggested for countries to produce updated information on inequities in MNH.
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average figures were about the same. The analysis therefore shows that the level of education may influence the decision to go in for skilled birth attendant in different ways in different countries. Figure 2: Inequities in skilled birth attendance, by mother’s education and by country
Source: Health Inequities in the South-East Asia Region, WHO-SEARO, 2007
11. Figure 3 highlights inequities in the proportion of deliveries assisted by skilled health personnel by urban-rural residence. Both Sri Lanka and Indonesia have made progress in narrowing the gaps in coverage between urban-rural settings. However, the progress in Bangladesh has been slow, while in Nepal the inequities seem to have been stagnant over the years. Figure 3: Inequities in skilled birth attendance, by urban-rural residence (%)
Source: Health Inequities in the South-East Asia Region, WHO-SEARO, 2007
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Figure 4: Inequities between the poorest and the richest regarding the use of modern contraceptive method
Source: Health Inequities in the South-East Asia Region, WHO-SEARO, 2007
12. Figure 4 shows inequities in the use of modern contraceptive methods between the poorest and the richest. Bangladesh, Indonesia and Thailand are shown to have made progress in narrowing the gap in access to the use of modern contraceptive methods between the poorest and the richest, although each country has different levels of contraceptive use. Sri Lanka exhibits an unusual pattern, in that the poor and less educated have higher usage rates for modern contraceptive methods than the rich and the more educated. This distinctive profile stems from the fact that in Sri Lanka, the poor, less educated and rural women are more likely to be sterilized than their wealthier, more educated, urban counterparts. Another possible reason for this is that the rich people can afford for a third child and not that keen to limit to two children, which is the norm in Sri Lanka.
3. Causes of inequity 13. Inequity in access and utilization of MNH service is often the result of unfair treatment, discrimination or neglect of the human rights to health of the disadvantaged community. Overall, the causes of inequity can be categorized as follows.
3.1 Inadequate commitment and low budget allocation for the MNH programme at national and subnational levels 14. In general, governments are very committed to achieving the MDG 5, including universal access to skilled care at birth and for reproductive health. However, the commitment is not always translated by putting MNH high on the agenda among other priorities in countries. While it is accepted as a priority, often the MNH programme is not provided with sufficient funding at national and subnational levels. The overall health expenditure is also low.
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15. The low level of national health expenditure indicates that health budget is not adequately spent towards promotive and preventive measures, including MNH care. It is estimated that the lowest level of per capita public health expenditure at which it is at least possible to achieve universal access to skilled attendance at birth is about US$ 352. 16. Access to effective treatment for major obstetric complications, while life-saving, is a major equity issue. The high cost of emergency obstetric care can easily translate into catastrophic expenditure for poor women who utilize private health care because of unavailability of public health services. Barriers in accessing emergency obstetric care and special care for the sick newborns, especially for the poor, often include a mix of causes, such as ignorance of danger signs, lack of financial resources and transport facility for referral, and shortage of qualified human resources at referral facilities.
3.2 Social and cultural barriers to accessing MNH service 17. Social and cultural barriers may lead to general deprivation of the basic rights of women to seek MNH care. Women are often treated as subordinates to men and do not have an equal decision-making power, i.e. inability to make decisions regarding their own health, inability to negotiate for family planning, safe sex and are vulnerable to gender-based violence. Power relations within families and communities, as well as male dominance in society can create situations that jeopardize the physical and psychological welfare of females. When this occurs during pregnancy, it may threaten the lives of both the mother and her unborn child. 18. Girls are often deprived of equal opportunities for getting adequate attention for their basic needs, such as nutrition and schooling, and for their overall growth and development. They are often forced to get married at a very young age, which puts them at unnecessary risks of teenage pregnancy. This increases the risks of having unsafe abortions, which may threaten their lives. 19. Inequities in MNH care may also spring from poverty and disparities in education, dwelling, caste, ethnicity and religion. Population dynamics, such as urbanization and demographic changes, such as higher dependency ratio, migration and displacement, may expose more people to poverty, which may lead to a low living standard with its consequences, such as living in a crowded housing with poor hygiene and sanitation, and poor nutrition. Poverty is also related to limited access to education and information, which can lead to practices that may endanger lives and well-being. 20. Health providers who serve poor and marginalized communities often have little understanding of the socio-cultural background of their clients. This coupled with poor quality of service and delay in provision of services form strong impediments to the use of health services, including MNH services. Lack of transparency, accountability and civil society engagement often create mistrust with health systems.
2
WHO Making Pregnancy Safer Department. Priority public health conditions: Social Determinants of Health and Women’s Pregnancy Outcomes. Unpublished. Geneva 2008.
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3.3 Inadequate quality of MNH service 21. Inequity in MNH is also caused, among others, by poor quality of MNH service that is not acceptable to the clients for many reasons. The technical quality of MNH care and its availability for 24 hours a day and 7 days a week, including its referral back-up at times of emergency, are crucial. However, the utilization of MNH services is also influenced by the interface between the health system and consumers at all levels. Low responsiveness of the health system to the legitimate needs of the population has been identified as one of the important factors for low utilization of health care. It can manifest as providing care that is not people-centred, and as lack of respect to and neglect of the social and cultural backgrounds of the disadvantaged and marginalized groups. 22. The organization of health services, including MNH services, is often not tailored to the needs of the community they serve. The need for appropriate timing of service delivery, privacy and preference of female health providers for MNH care are often neglected in health service delivery planning. The outreach services are often scheduled at times when women are in the field.
4. Recommendations 23. Addressing the inequity in MNH in order to accelerate the achievement of MDG 5, and to contribute to the achievement of MDG 4 requires emphasis on bringing the basic intervention package for MNH to the poor, disadvantaged and marginalized communities. This should be in the context of strengthening the health system under the revitalized primary health care approach. The following are the actions proposed:
4.1 Strengthen commitment and ensure adequate budget allocation for the MNH programme •
Ensure adequate allocation of funds at national and subnational levels for delivering the basic intervention package for MNH, with special attention to the poor, disadvantaged and marginalized communities. Strengthen policies and strategies to reduce out-of-pocket expenditures, i.e. through implementation of maternity scheme for the poor, national health insurance or taxbased health insurance and other promising interventions, in order to achieve universal access to skilled care at birth and reproductive health. Implement strategies that contribute to reduce inequity in MNH, i.e. address human resources issues for MNH, especially for countries with a low level of proportion of deliveries assisted by skilled health personnel.
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4.2 Improve leadership and management of the MNH programme at all levels •
Scan and analyse national and sub-national MNH situation in order to provide direction on strategic interventions considering the level of MNH programme development in countries. Implement coordinated plans with relevant public and private sectors, as well as development partners in addressing inequity in MNH. Improve access to MNH service, including its referral back-up, and ensure provision of quality and client-centred MNH service that considers the social and cultural backgrounds of clients, especially the poor and marginalized groups. Disadvantaged and marginalized community members are identified and given special attention and proactive service. Strengthen the monitoring and evaluation system to ensure the achievement of MNH targets.
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4.3 Empower women and community members for MNH care and community-based actions • • •
Improve awareness, knowledge and skills in respect of self-care for mothers and their newborns, and regarding when and where to seek professional care. Strengthen community actions for MNH, including those related to birth and emergency preparedness. Advocate for women’s rights and gender equality, and prevent teenage marriages and pregnancies.
4.4 Forge multisectoral collaboration/partnership in achieving universal access for MNH/RH •
Address the key social and cultural factors that influence MNH, i.e. delay the age of marriage, improve female education, balance urban and rural development, strengthen commitment of local government to MNH, and work for income generation for disadvantaged groups, etc. Mobilize resources for MNH, including collaboration with UN agencies (H-4 Initiative for MNH i.e an initiative for MNH initiated by WHO in collaboration with UNFPA, UNICEF and World Bank), development partners and donor agencies. Coordinate with key players.
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4.5. Facilitate exchange of information and experience within and among countries • •
Document and share success stories. Exchange local champions and benchmarking activities, etc.