“Even in a weak system without a quality improvement structure, it is possible to support district managers and facility providers to measure and improve quality care,” said Eliane Razafimandimby, Chief of Party of USAID’s flagship Maternal and Child Survival Program (MCSP) in Madagascar, at a recent Wilson Center event on improving the quality of reproductive, maternal, newborn, and child healthcare (RMNCH).
Madagascar is currently in the early stages of improving the quality of its RMNCH care. After failing to meet the maternal and newborn Millennium Development Goals by 2015, the government created a roadmap to achieving the maternal and newborn MDGs by 2019 and mandated MCSP to support the Ministry of Health in strengthening its health system to reduce maternal and newborn mortality.
In order to have an impact on quality, “we needed to engage with the health system at different levels,” said Razafimandimby. A systems approach required emphasis on policy at the national level, capacity-building and data usage at the district/regional level, and targeted service-delivery support and community engagement at the facility level.
The ambitious task of assessing quality of care and implementing change involved nearly two-thirds of the country, across 16 regions and 80 districts. Quality care indicators monitored at more than 600 facilities showed promising reductions in maternal and newborn mortality.
Health facilities implemented preventative measures to improve quality. Having a newborn station in the operating room after a C-section allowed midwives to care for the baby without having to carry him or her to the neonatal unit for care, which was often located in another building. This small change facilitated more immediate newborn care as well as greatly reduced the risk of infection. Other improved outcomes were linked to significant increases in antenatal screening for preeclampsia and the adoption of postpartum family planning methods before discharge from a facility. “These improved outcomes were not only seen at the primary facility level but also at district and regional hospitals,” said Razafimandimby.
Despite success at the facility, district, and regional levels, national progress is slow. “Development of a national quality strategy and structure remains a high priority for Madagascar,” said Razafimandimby. “To be able to sustain and continue improvement work, national level leadership is really essential.”
“A lot of the advocacy of family planning has been built around establishing a long list of the many ways in which family planning can be relevant” to other development goals, says Parfait Eloundou-Enyegue of Cornell University in our latest Friday Podcast. While comprehensive accounts of the ways family planning access benefits communities, these “laundry lists” are not “clear, synthetic, or integrative,” he says.
Instead, Eloundou-Enyegue proposes that development planners focus instead on four “bottom lines” to more clearly communicate the importance of family planning across all sectors.
The first bottom line is financial: “Take people through the savings that they are going to achieve with each dollar that is invested in family planning,” said Eloundou-Enyegue.
The second bottom line is equity, which appeals to stakeholders who seek to promote justice in communities. Inequalities in fertility, income, and family structure “translate into very large inequality among children that will lead to even wider, larger inequality in the next generation,” Eloundou-Enyegue says. “Family planning can play an important role in breaking this intergenerational cycle.”
The third bottom line Eloundou-Enyegue proposes is durability, which appeals to visionary leaders through the dividends that family planning offers over multiple generations. In addition to the immediate benefits, there is a second dividend, when the current working age population reaches retirement with greater savings, and then a third dividend comes from greater investment in the early childhood development of the next generation.
The final bottom line is demand, particularly from youth: “There is actually a very large demand for family planning among youth if we return to the full meaning of ‘family planning,’” says Eloundou-Enyegue, focusing not just on births but on the course of one’s entire life. “Planning families for youth, and African youth, today, who are very concerned about their futures, is to think about how to plan their transition into work,” including developing skills and leadership.
“There is room there to incorporate family planning in a large vision which is concerned about planning futures, planning families, naturally, and planning lives,” says Eloundou-Enyegue.
Healthy Women, Healthy Economies is a global initiative that aims to unleash the “economic power of women by bringing governments, private sector, and other civil sector actors together to improve women’s health,” says Jocelyn Ulrich of EMD Serono, the U.S. branch of Merck KGaA, Darmstad, Germany, in our Friday Podcast. Providing for women’s health needs enables them to “join, thrive, and rise” in the economy, “bringing prosperity home to their families and communities.”
This partnership was established in 2014 within the Asia-Pacific Economic Cooperation (APEC) forum by the 21 APEC economies, led by the United States and the Philippines, and members of the private sector. The project sought to address significant barriers to women’s full participation in the workforce, which include non-communicable diseases related to reproductive health and the dual responsibility of the workplace and caregiving for children and elderly parents.
The partnership engaged in a comprehensive literature review and created a toolkit for governments and private sector actors to address these hurdles, with specific recommendations:
• Improve access to sexual and productive health services
• Increase awareness of services for voluntary family planning
• Provide high-quality maternal, sexual, and reproductive health services
• Protect against discrimination
Since 2015, the project has convened workshops to track progress against the toolkit’s policy goals. One of the advantages to working under the auspices of APEC is engaging high-level ministers in women’s health.
The toolkit’s policy recommendations align with the Sustainable Development Goals. “Sustainable economic growth really can’t be achieved if we’re leaving half of the population behind,” says Ulrich.
Africare’s work has been built on a “strong belief that community mobilization and local capacity building and innovation are the cornerstones of successful development, and that, for us, includes resilience,” says Franklin Moore, Chief of Programs for Africare, in a podcast from a recent Wilson Center event. “Community engagement, capacity building, and looking at locally driven behavior and social change is what empowers communities.”
Africare organizes community committees to identify innovations and behavior changes to make themselves more prosperous and resilient, including climate-smart agricultural techniques and women’s empowerment.
In Niger, agro-pastoral communities rehabilitated land through the use of zai pits and half-moons, traditional farming techniques that retain rainwater for crops. Along with planting drought-resistant cowpea and forage sorghum, these steps enabled the communities Africare worked with to stockpile 57,000 tons of animal forage. During the 2011 drought, these communities were able to feed their livestock using the stored forage even when grazing land was degraded. Livestock death rates dropped 14 percent, and communities that might have otherwise had to sell off their livestock were able to keep them.
Engaging women is key. “In Niger, food security committees are required to have at least 30 percent of their members [be] women,” says Moore, and in Zimbabwe, women make up 80 percent of Africare’s food distribution committees, because in these communities, “food distribution is really something females know a whole lot more about than males.”
Child spacing also contributes women’s empowerment by improving women’s health and ability to participate in livelihood activities. Africare’s “husband schools” teach men about the importance of reproductive healthcare. “When we talk about child spacing, it is critically important that the men know as much or more about this as the women do,” Moore says.
Community-based capacity building programs can change lives. “The organization of the community affects what the community is doing, who the community is, and in fact the size of the community,” says Moore.
“This is a woman who did exactly what she was supposed to do; she did exactly what we encourage pregnant women to do,” said Amy Dempsey of the Population Council at a recent Wilson Center event on World Preeclampsia Day. The Ethiopian woman was suffering from preeclampsia—a preventable condition—but like many pregnant women in low- and middle-income countries, she did not receive the treatment needed to stop it. “Pregnancy was the first time she had ever stepped foot in a health facility,” said Dempsey.
Preeclampsia is characterized as the rise of blood pressure during pregnancy. Symptoms include (but are not limited to) headaches, nausea, abdominal pain, changes in vision, and shortness of breath. “She had constant headaches and blurry vision…At each visit, her providers measured her blood pressure but none of them told her that it was high or why they were measuring it,” said Dempsey. “She was told that what she was feeling was normal for a pregnant woman.”
Although magnesium sulfate is commonly used to prevent seizures (eclampsia) later on in pregnancy, the patient did not receive treatment for her preeclampsia symptoms. “After one contact point with the health system, she was sent home with paracetamol to treat her headaches,” said Dempsey.
In her eighth month of pregnancy, she collapsed. Her husband drove her to their church, where he hoped faith would heal her. “When her condition did not improve, he took her back to their local healthcare facility,” where she was referred to a hospital, treated with magnesium sulfate for her seizures, and given an emergency Caesarean section, said Dempsey.
Fortunately, the woman was able to deliver a healthy baby boy. But five months later, she still experiences the same symptoms of headaches and abdominal pain, and has not been back in contact with her health providers since her initial postpartum visits.
“She was never told that what she was experiencing were symptoms of preeclampsia,” said Dempsey. “What she went through is fairly common for women in low- and middle-income countries, where challenges that they encounter are quite different from the barriers that women in high-income countries deal with.”
Sources: Healthline, Population Council, Preeclampsia Foundation
“How do our interventions provide an opportunity to really work at some of the core drivers of instability or lack of resilience?” said Larry Cooley from Management Systems International at a recent Wilson Center event on scaling up reproductive, maternal, newborn, child, and adolescent health interventions.
In fragile settings—countries in conflict or crisis—scaling up healthcare is increasingly complex, yet incredibly urgent. Maternal mortality in fragile states is almost quadruple that of other low- and middle-income countries, and infant mortality is double. And 60 percent of the countries with the highest maternal and neonatal mortality rates are classified as fragile, conflict, and violence impacted by the World Bank.
Understanding the context in fragile states is key, said Cooley. “Governments and markets”—the two main platforms for scaling up health interventions—“are both compromised.” Interventions and programs are often politicized along battle lines.
Countries experiencing conflict or instability often cannot rely on public financing, and international support is inconsistent. “Resources tend to flow in very quickly around a crisis,” said Cooley, “and they flow out equally quickly.” Consequently, financing organizations such as the Global Financing Facility (GFF) invest in non-governmental organizations and humanitarian aid programs to secure stable ground.
“Always—even within fragile systems—there are people and points of strength that can be built upon,” said Laura Ghiron, vice president of Partners in Expanding Health Quality and Access. “For example, there are those who know the limitations of the system,” said Ghiron, “but are trying…to work around them.”
Most importantly, scaling up in fragile settings requires a heavy focus on the system, and not the details of the intervention in and of itself. “We need to be giving appropriate attention to the system that is going to have to deliver that intervention,” said Dr. Stephen Hodgins, associate professor for Global Health at the University of Alberta and editor-in-chief of Global Health: Science and Practice.
“Sometimes the interventions that we are introducing make relatively heavy demands,” said Dr. Hodgins, “and we need to make a determination whether that is realistic given the system that we actually have to work with.”
At the end of the day, scaling up interventions should be doing no harm, said Cooley, and should be seen as “a chance to really advance some of the building blocks of peace and stability.”
Sources: Global Financing Facility, World Bank
“Climate is unquestionably linked to armed conflict,” says Halvard Buhaug, Research Professor at the Peace Research Institute Oslo, in the latest Wilson Center podcast.
“If we produce a map of the world with locations of ongoing and recently entered armed conflicts, and we superimpose on that map different climate zones or climatic regions, we would very easily see a distinct clustering pattern of armed conflicts in warmer climates.”
Since 1950, countries that have experienced at least one civil conflict have been an average of 8 degrees Celsius warmer than countries that have remained peaceful, reports Buhaug. Furthermore, rates of conflict are 10 times higher in dry climate zones than in continental climate zones.
While these statistics show a clear correlation between climate and conflict, they do not prove that severe climates or changes in climate can cause conflict. Does such a causal connection exist? Maybe, says Buhaug: “There is emerging evidence that climate changes can affect the dynamics of conflict,” including duration, likelihood of a peaceful ending, and the severity of conflict. Extreme weather in particular “can make conflict resolution harder [and] can make it easier for rebel organizations to recruit soldiers.”
However, there is yet “no scientific consensus that climatic changes can cause the outbreak of new conflicts,” he says. To identify causal mechanisms, we need more research: We “need to study dogs that don’t bark: societies that regularly experience extreme weather events…but where we do not observe a violent outcome.”
Whether or not climate causes conflict, “adaptation and development can be very important in lessening the human costs of that conflict,” he says, especially because “conflict is an important cause of vulnerability to climatic changes.”
“Ending armed conflict is the most effective strategy to lower the human consequences of climate change and to create facilities compatible with sustained growth,” says Buhaug.
“As many as 865 million of our mothers, daughters, [and] sisters across the globe are not reaching their full potential to contribute to their national economies,” said Dr. Belén Garijo, CEO for healthcare and executive board member of Merck KGaA, Darmstadt, Germany, at a recent Wilson Center event. The act of caregiving, and the physical and mental health impacts that accompany it, often disproportionately rest on the shoulders of society’s women.
These negative health impacts often hold women back from achieving their full potential, according to Dr. Garijo. “When health costs rise, households may not tighten the belt as much for men as for women,” she said. “We are advocating for policies that enhance productivity, and most importantly, advance equity.”
Merck KGaA has been investigating their own employee productivity and retention of female workers. According to Dr. Garijo, the pharmaceutical company has implemented policies to support career pathways for women, such as unconscious bias trainings for senior executives, sponsoring high-potential women within the company, and flexible work arrangements.
The “Healthy Women, Healthy Economies” toolkit, developed in partnership with the Asia-Pacific Economic Cooperation and other partners, analyzes “traditional healthcare access barriers, as well as broader topics, like the impact of unpaid work,” said Dr. Garijo, and relates these issues to “economic impact and success in the workplace.”
Accompanying the toolkit is “Embracing Carers,” a global initiative launched by EMD Serono, the branch of Merck KGaA in North America, which is “actively engaging in quantifying the impact of the role of caregiving and advocating for progress on behalf of those filling these rewarding and challenging roles,” said Dr. Garijo.
With the support of progressive policies, private and public sector leaders, and male counterparts, we can not only achieve gender equity, but also create a more productive workplace. “We are very committed to addressing the challenges,” said Dr. Garijo, “but we cannot do this alone.”
“We need to think differently about how we invest in our country programs, and what outcomes we are interested in,” said Dr. Koki Agarwal, director of the U.S. Agency for International Development (USAID)’s flagship Maternal and Child Survival Program (MCSP) and a Vice President with Jhpeigo, at a recent Wilson Center event.
USAID’s “Acting on the Call” report recommended 29 evidence-based maternal health interventions, though Kelly Saldaña from USAID’s Bureau of Global Health said that with enough research and data, there are likely many more. “There’s a need to study further interventions…to have a better understanding of how we can link health systems directly to the outcomes we are trying to achieve.”
To improve maternal, child, and adolescent health systems globally, we need to “have the ability to use that data to make changes within a health system,” said Dr. Agarwal.
Strategic partnerships are essential to building stronger health systems. Donors, in tandem with their country partners, have to bring all the players together, said Dr. Agarwal: “Bringing in that partnership, understanding what is happening across the country at the onset, is a much more successful way of building a sustainable program at the country level.”
Supporting country leaders to strengthen health systems is a crucial part of development partners’ jobs, said Mary Taylor, a professor at the Arctic University of Norway. “Country leadership is a process.”
Every day, 7,100 babies are stillborn. A tragic, complicated problem, stillbirth—which the WHO defines as a baby born with no signs of life at or after 28 weeks' gestation—remains difficult to control and to assess. Some hospitals hide data on stillbirth, due to the shame and stigma associated with it. However, as White Ribbon Alliance CEO Betsy McCallon said at a recent Wilson Center event marking the 30th anniversary of the Safe Motherhood Initiative, stillbirth “had been hidden and neglected, but that is changing.”
Distinguishing a stillbirth from a neonatal death can be challenging, particularly when the lack of a skilled birth attendant prevented adequate resuscitation. Despite the complexity, “we need to measure it,” said Barbara Kwast, one of the pioneers of the Safe Motherhood Initiative.
While stillbirth was not included in the original SDGs, after strong advocacy by the international global health community and bereaved families, stillbirth is now part of the SDG’s Every Woman Every Child framework. UNFPA’s Petra ten Hoope-Bender cited a new “people’s movement” that is bringing “dynamism, new energy into that agenda.”
To reduce the rate of stillbirths, Kwast urged the maternal health community to decrease the rate of birth asphyxia and to use a partograph to help make decisions during labor. “The international community has done an extraordinary amount of work around third stage [of labor] to prevent postpartum hemorrhage,” but now “we need to pay more attention to the first and second stages of labor,” where 50 percent of stillbirths occur.