Assessing results-based financing in reproductive health

Article: Salome Donkor (published on 20/11/2010
THE Millennium Development Goals (MDGs) Summit attended by world leaders, along with the private sector, foundations, international organisations, civil society and research organisations, in New York in September this year kicked off a major concerted world-wide effort to accelerate progress on women and children's health.
Reports from that summit indicate that child mortality (MDG 4) has been reduced, but not significant enough to reach the target, while maternal mortality (MDG 5) remains high in much of the developing world.
Deliberately ambitious, the MDGs have provided a global agenda that has galvanised international action towards agreed indices of change, including a specific target of reducing the number of women dying during pregnancy and childbirth by three-quarters by 2015.
The MDGs give a central place to maternal health and gender equality and MDG 5 — improving maternal health — is often called “the heart of the MDGs” because if it fails, the other goals will also fail.
According to the World Health Organisation (WHO) 2006 report, while women in northern Europe have a one in 4,000 likelihood of dying from pregnancy-related causes, for those in sub-Saharan Africa the chance is one in 16.
Available evidence shows that 75 per cent of these deaths are preventable and that the timely provision of blood transfusion, caesarian section, oxytocin and antibiotic therapy and the timely management of pre-eclampsia/eclampsia are sufficient to reduce maternal mortality rates by 50 per 100,000 without the need for advanced technology and safe support mechanisms.
The problem of maternal mortality causes more anxiety and uneasiness, considering the fact that the factors that jeopardise maternal and new-born survival are preventable or treatable with essential services and, the most effective, affordable public health interventions.
Maternal mortality is defined by health experts as the death of a pregnant woman during her pregnancy or within 42 days of pregnancy termination. According to the experts, an obstetric emergency is not a situation where the expectant mother involved could be asked to come back the next day, since that can result in her death.
Evidence from 20 years of research and pilot interventions has identified five primary causes of deaths among pregnant women. Pregnancy-related conditions, also known as obstetric complications, include post-partum haemorrhage (bleeding), eclampsia (high blood pressure in pregnancy), sepsis (infection), prolonged or obstructed labour, as well as complications of abortion, and these are the leading causes of death among women of reproductive age in many developing countries.
Maternal mortality is a global issue and the concern for reducing it stems from the fact that at least 583,000 women die each year from the complications of pregnancy and childbirth. The alarming situation is that almost 90 per cent of these deaths occur in sub-Saharan Africa and Asia.
The situation in Ghana is equally gloomy, with an institutional maternal mortality rate of 250 per 100,000 live births. Reducing maternal and neonatal mortality has been a challenge in Ghana over the past decades, as many more women continue to fall prey to this problem, in spite of the efforts by the government, the development partners, the private sector and civil society.
Attaining MDGs 4 and 5, still remains a big challenge to most developing nations, Ghana included. For this reason, the World’s Children Report for 2009 prepared by UNICEF called on political leaders, governmental and non-governmental organisations (NGOs) to generate action at all levels to address the problem of maternal and neonatal deaths.
The MDGs Summit also expressed grave concern over the slow progress being made in reducing maternal mortality and improving maternal and reproductive health and the summit indicated that progress on the other MDGs was fragile and must be sustained to avoid reversal.
Similarly, the Vice President, Mr John Dramani Mahama, in an address read on his behalf at the 52nd annual general meeting of the Ghana Medical Association in Koforidua recently, on the theme, “Maternal Health Care in Ghana: The Realities Beyond the Policies”, said there were numerous challenges facing the health sector which could only be addressed through collaboration between the government and the GMA to reduce maternal and infant mortality.
He said such an initiative would also enable the country to attain its MDGs in the health sector and expressed the hope that the GMA would embrace the slogan, “Zero Tolerance for Maternal and Infant and Childhood Deaths”, and work in that direction to find solutions to the problems associated with such deaths.
The situation has been attributed to several factors, and with such growing concerns, the Ghana office of the World Bank (WB) is taking the initiative to hold deliberations with relevant players, especially in the public sector, as part of an identification mission being undertaken in preparation of a pilot project to implement results-based financing in the area of reproductive healthcare delivery in the country.
In line with the programme, a round-table discussion on the issues, the challenges and the way forward to identify possible actions was organised in Accra on Wednesday on the theme, “Reducing maternal and neonatal mortality through dialogue and action”.
The programme brought together a number of core practitioners and policy makers and other stakeholders to brainstorm on the problems, challenges and possible actions that can be taken to address the neonatal and maternal mortality issues confronting the country.
The programme, from the World Bank’s perspective, seeks to explore the extent to which civil society organisations, through civic engagement, could contribute to the bank’s regular programmes/projects on improving maternal health.
In his opening remarks, the World Bank Country Director for Ghana, Mr Ishac Diwan, said there was the need to keep searching for more solutions and explore the usefulness of results-based financing.
An extended term consultant on financial management of the World Bank, Mrs Elizabeth Alluah Vaah, said the meeting was aimed at getting everybody’s view on the way forward, stressing, “We don’t have to throw our hands in despair.”
Discussion on the subject was generated after a documentary on maternal healthcare delivery in Ghana, produced by the Alliance for Reproductive Health Rights (ARHR) and titled, “The lights have gone our again”, had been shown.
It showed that lack of facilities, delay in accessing health facilities, acute shortage of skilled staff working under severe pressure, unsafe abortion, anaemia, lack of family planning services, as well as dissatisfaction on the part of some patients with the services provided by health service staff, negatively affected maternal healthcare delivery in the country.
Participants asserted that the problem was multi-dimensional and required effective public/private sector partnership to come up with a solution.
One issue that cropped up was the phasing out of traditional birth attendants (TBAs) and the role of faith-based groups in the provision of maternal healthcare delivery.
While some maintained that TBAs and faith-based groups could not be done away with in maternal healthcare delivery, since those in the rural areas preferred patronising their services to visiting health facilities, others insisted that receiving antenatal care from a skilled provider, mostly a nurse or a midwife, and going through supervised delivery by a trained health official, was necessary to dealing with obstetric complications.
For her part, Madam Florence Okra, the Founder/Chief Executive Officer of Eve’s Foundation, an NGO that offers education on safe motherhood, suggested that TBAs and community-based attendants
should be trained and certified to team up with private midwives to offer the needed maternal health care to people, mostly in the rural communities where health facilities are inaccessible.
Ms Petra Vergeer, Health Specialist, made a presentation on the Concept of Results-Based Financing as a vehicle to achieve accountability for results and said the concept involved focusing on maternal and child health, increasing quantity and quality of selected health services provided, increasing health worker motivation, as well as providing financial incentives for health facilities for more quantity and quality services, in addition to providing financial incentives for pregnant women to deliver in health facilities.
A social development specialist of the World Bank, Ms Beatrix Alla-Mensah, said every year the bank selected a theme under its small grant programme and that was used to apply for funding and then advertised for civil society organisations (CSOs) to put in applications.
She said the theme for the small grant project in the coming year was on maternal health and that the bank, through its small grants programme, was looking to engage CSOs to identify innovative ways by which they could engage the public, sensitise and educate them as a way of addressing the demand side of the problem of maternal and neonatal mortality at the community, district and national levels.
Like the observation made by participants at the MDG Summit in New York, those who attended the focus group discussion in Accra realised key areas where CSOs could begin some civic engagement work in achieving “Zero Tolerance for Maternal and Infant and Childhood Deaths”.