“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.
“Women still die…and they die preventable deaths,” said Address Malata, vice chancellor of the Malawi University of Science and Technology, at a recent Wilson Center event honoring the 30th anniversary of the Safe Motherhood Initiative. Malata—a midwife and the former vice president of the International Confederation of Midwives—told the heart-wrenching story of a pregnant woman who, like so many others, died waiting for transportation.
“[Her mother] asked me…‘why was it that we waited for two days before my daughter was transferred to a decent hospital, but it only took a short time to take my daughter back home, and this time she was dead?’” said Malata. “My life has never been the same.”
Malawi’s government has started to build new maternity waiting homes, develop community-based interventions, and provide family planning, as well as other programs intended to improve health outcomes for women and mothers. “At the end of the day,” Malata said, “the question is: Is this good enough progress?”
Malawi still struggles with retaining an adequate health workforce, especially when it comes to midwives. Malawi needs to increase not only the quantity of midwives that stay in the country, but also the quality of their training and working conditions. “Do they have adequate time to practice when they are going through a midwifery program?” Malata asked. “As an advocate for midwifery, I would like to start protecting the profession,” she said.
“There is so much money going to maternal health…but why are women still dying?” she asked, “We are not addressing the core issues that can change women’s lives.” By holding leaders accountable for fulfilling the needs of people on the ground, Malawi can address issues of quality, equity, and dignity for mothers.
“If your dreams don’t scare you, they are not big enough.” Malata’s dream—that no woman dies while giving life—is big. “It is scary,” she said, “but it can be done.”
Peter Yeboah, Executive Director, Christian Health Association of Ghana, offers his perspective on faith-based approaches to global health
Dr. Tonny Tumwesigye, Executive Director, Uganda Protestant Medical Bureau, gives his remarks on faith-based approaches to global health.
As a child growing up in Nepal’s mountainous Upper Mustang region, Ghana Gurung understood that his survival depended on the mountains and his community. Today, as senior conservation program director at World Wildlife Fund-Nepal, he works to protect the endangered and elusive snow leopard by improving local communities’ livelihoods and the mountains’ ecosystem.
“Survival of the snow leopard is…important for our own survival,” Gurung says in a podcast of his remarks at a recent panel discussion, “Securing the Third Pole: Science, Conservation, and Community Resilience in Asia’s High Mountains,” at the Wilson Center. He didn’t always believe this. As he herded his families’ goats, Gurung knew that in the harsh mountain climate, livestock is livelihood. When a snow leopard attacked and ate his goats, he was angry: “A loss of one animal is a loss of your economy, cash in the bank,” he says. But through his Buddhist faith and his ecological education, he came to see the important role played by snow leopards; as an umbrella species, the leopards are a top predator and indicate the overall health of the ecosystem.
Climate change also threatens the snow leopard and its habitat, says Gurung. The tall grasses of his youth are now degraded, as are the habitats that support wild blue sheep, the snow leopards’ primary prey. “It’s not only wildlife and ecosystem that suffers; it’s people [that] suffer a lot,” says Gurung. To adapt to the changing climate, people are resettling alongside riverbeds that are vulnerable to flooding. And more catastrophically, water from melting glaciers could potentially impact billions of people downstream. Just a few months ago, one day of rain flooded 300,000 households.
Climate change knows no political borders, and neither do snow leopards. They can travels more than 2,000 kilometers between countries, said Gurung. Twelve countries have joined together to create the Global Snow Leopard and Ecosystem Protection Program, a global forum that brings together “countries that don’t normally sit side-by-side to talk too much in political terms,” says Gurung. But the snow leopard—acting as an “ambassador”—brings them together, he says.
“You can call it adaptation, or you can call it mere survival strategies,” Gurung says of community-based efforts to protect snow leopards. For example, citizen scientists from local Sherpa communities set up camera traps, collect scat for DNA analysis, and help put radio collars on the the cats. “It’s not all about ecology of conservation for snow leopards, it’s about community,” he says. “The community holds the key to the survival of the species.”
Climate change poses an undeniable threat to small island states, but many islanders do not even know what climate change is, says Camari Koto, an indigenous Fijian academic and educator at the University of the South Pacific and member of the Resilience Academy, in our latest podcast. “They know it’s happening, they are unconsciously [taking] adaptive responses,” and certainly feel the brunt of its effects, she says. “But they don’t see climate change as an immediate threat.”
As Fiji presides over the 23rd UN Climate Change Conference of Parties (COP-23), perspectives in the South Pacific are beginning to shift. The first island nation to host the conference, Fiji is showcasing its leadership on climate change issues for both the global community and Fijians themselves, Koto says.
“Our government was able to engage right [at] the grassroots level in creating awareness” within Fijian communities, says Koto, an advocate for building sustainable livelihoods and community resilience. It is especially important for the younger generation to be sensitized to climate risks “to start thinking about the threats that we have now,” she says, “and about ways in which they can help to make things better.” We must “prompt them to think about ways forward.”
“It’s the community working together, collaborating, and valuing their relationship” to one another that is at the core of livelihood resilience, says Koto. Community is “the platform of our forefathers.”