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Equity in maternal healthcare: Going beyond the low hanging fruits

In September 2015, the world adopted the Sustainable Development Goals (SDGs) with increasing focus on equity and inclusiveness in the post-2015 period. There is a global consensus that significant strides were made during the preceding Millennium Development Goal (MDG) era, albeit achievements varied across goals and geographical regions. An evaluation of the eight MDGs, however, showed that the maternal health-related goal was one of the most off-track goals. Furthermore, there were remarkable differences within and across social strata, especially across income groups and between rural and urban regions.

CMNH is conducting a multi-stakeholder PhD study in five countries across two continents (Bangladesh, India, Kenya, Malawi and Nigeria). This study seeks to explore ways to improve the availability of and access to maternal and newborn healthcare to the underserved rural population, through community health worker programmes.

Formal and informal discussions, within and across countries and stakeholder groups, suggest that there is a need to focus more on community-based approaches, and incorporate equity into maternal health policy and practice during the post-2015 era. Early recommendations emerging from these preliminary findings include:

  1. Empower women in the community
    Socio-economic empowerment programmes, through income generating schemes, directed at women can help break the close link between poverty and poor maternal health outcomes. This is particularly important for women who have no academic qualification to enable them to seek skilled employment. Similarly, a sustained focus should be placed on girl child education as this will not only empower them, but will also influence their maternal health-related choices when they attain the reproductive age.
  2. Build synergy through collaboration and harmonisation of programmes Community-based programmes that address various thematic areas in maternal health and socioeconomic determinants of health need to be coordinated and harmonised. This has a great potential to unlock synergy for a multi-faceted approach to addressing maternal health challenges and produce a greater impact e.g. coordination and harmonisation of various community-based programmes focusing on the continuum of maternal healthcare and income-generating social enterprise schemes. It may be possible to identify women with economic needs during maternal healthcare service delivery and refer them to income-generating programmes.
  3. Equity-sensitive maternal health indicators (or proxies) and targets
    It is often said that “what gets measured, gets done”. Therefore, it will be rewarding to emphasise reporting of maternal health indicators using “social stratifiers”, like income status and geographical location (rural-urban). This will provide an equity-sensitive maternal health profile within and across geographical regions. These reports need to be supported by robust qualitative and quantitative data that provide a rich description of the various contexts while explaining the maternal health determinants, outcomes and impact.
  4. Incentives to encourage utilisation of formal health service delivery
    At community level, informal healthcare providers offer competitive, often cheaper, culturally-sensitive but not scientifically verified alternative services to women. Incentives that encourage utilisation of formal health services through targeted free/subsidised services provide a viable option for increasing demand for formal health services.
  5. Invest additional resources to reach the underserved population
    Going the extra mile to reach the underserved population will often require additional resources, including transportation cost for service delivery and supervision. The provision of services to the underserved population is often overlooked when the requisite resources are not set aside during programme planning and implementation.
  6. Encourage use of multi-cadre health teams
    While the human resources for health crisis continue to persist with its in-country variations, stakeholders propose that equity-sensitive distribution of the limited number of health workers within the country will help alleviate some of the challenges. Subsequently, it may be possible to constitute health teams made up of professional and lay health workers that will ensure quality health service delivery in the communities. Additionally, incentives should be provided to attract professional health workers to work in hard-to-reach communities that lack basic infrastructure.
  7. Implement sustainable, fit-for-purpose and appropriate programmes
    Many communities complain of a sharp decline in health indices following the expiration of donor-funded health programmes. Existing community structures and systems need to be strengthened, to sustain implementation beyond the lifespan of these donor-funded health programmes. Similarly, donors need to consider the community context in providing appropriate technologies, as many of the underserved communities have an erratic power supply, inadequate internet access and poor road network. Use of fit-for-purpose equipment that require minimal maintenance cost and resources will be more sustainable at the community level.

Conclusion

Efforts to close equity gaps during the MDG era need to be sustained. As the world journeys on the “road to dignity by 2030”, it will be critical to implement context-sensitive recommendations from key stakeholders in underserved communities.

About the author:

Dr Abimbola Olaniran is a PhD candidate at CMNH, LSTM. He has keen interest and expertise in improving health systems, especially in developing countries.