Informing humanitarians worldwide 24/7 — a service provided by UN OCHA

Ethiopia + 7 more

Learning from Maternal and Child Health Successes in Africa

- In Africa, many countries are making progress on mother and child health

- The World Bank has supported many key reforms and projects in these countries

- Progress needs to be replicated quickly to close the gap on the health MDGs in Africa

----------------------------

KAMPALA, July 23, 2010-As African policymakers gather in Kampala this week to focus on maternal and child health as a high priority challenge, it's important to look beyond Sub-Saharan Africa as a whole being largely off-track on the Millennium Development Goals (MDGs), which include targets for major reductions in mother and child deaths by 2015. To step up the pace of progress, the region at large could learn valuable lessons from countries that have made extraordinary progress despite the odds.

Substantial progress has been made in many countries, including Tanzania, which is on track to meet the MDG targets related to infant and child health; Senegal, which has made great strides forward in improved nutrition; and Niger, where early data shows that modern contraceptives may now be used more widely than before. Also, Malawi, Ethiopia, and the Gambia have all reduced child mortality by 25 to 40 percent in the past ten years, while in Rwanda the decline has been even greater, at 47 percent.

Better results are a combination of many things: equitable access to health services, evidence-based decision making, health systems reforms, resource availability, education, behavior change, country ownership, and donor coordination, to name a few. With these changes adopted more widely, Africa could reach the maternal and child health goals-perhaps not by 2015, but in the not too distant future.

Rapid progress in infant and child survival in Tanzania

Infant mortality fell by over 40 percent in Tanzania, from 99 deaths per 1,000 live births in 1999 to 58 in 2007-08. This suggests that the country can reach the MDG target by 2015. Under-five mortality has also declined, from 146 deaths per 1,000 live births to 91, again bringing the MDG target within reach.

"Tanzania's reductions in infant and child mortality are among the greatest seen in Sub-Saharan Africa," said Dominic Haazen, Lead Health Policy Specialist in the World Bank's Tanzania office. "But that's not all. Access to health services has improved, especially among the poorest-that is very encouraging."

More equitable access to health services is related to the government's focus on improved primary health care; and to the growing volume of 'health basket' funds from many partners, including the World Bank, going to frontline health services. An independent evaluation of this coordinated approach (called a Sector-Wide Approach or SWAp) concluded that it could be linked to better health outcomes and quality of services, and in turn to MDG progress, especially that relating to infant and child survival.

A recently implemented campaign to protect children under age five from malaria-bearing mosquitoes (to which the World Bank contributed 2.4 million bed nets); and the increased emphasis on immunization coverage, make Tanzania's child health related MDG targets look even more attainable.

Reversing negative trends in infant and child survival in Kenya

After a period of stagnation during which infant and child mortality rates deteriorated and life expectancy dropped, Kenya has recently made very significant progress. The negative trends seen between 1993 and 2003 were reversed between 2003 and 2007. The 2008 Kenya Demographic and Health Survey (DHS) reveals remarkable declines in infant and under-five mortality rates in this period (from 77 to 52, and from 115 to 74, per 1000 live births, respectively).

"It's hard to pinpoint the causes of Kenya's improved infant and child survival rate from 2003 to 2007, but the probable factors were strong economic growth during the period, as well as various successful health programs, including against malaria with a rapid increase in bed net use, considerable progress in the immunization program, and the strengthening of the HIV/AIDS program with enhanced prevention of mother to child transmission," said Michael Mills, Lead Economist and Human Development Sector Leader in the World Bank's Kenya office. "Increases in immunization rates were particularly impressive."

Recently, the Bank approved a further $100 million to support Kenya's health sector-wide program.

Results-based financing goes a long way in Rwanda

After the 1994 conflict, which took a great toll on the health sector, Rwanda entered the 21st century with one of the weakest health systems in the world. Yet today it shows some very strong health results. Assisted childbirths rose from 39 percent in 2005 to 52 percent in 2008; while under-5 mortality fell by a third, from 152 deaths per 1,000 live births in 2005 to 103 in 2008. And the use of modern contraception has increased from 10 percent to 27 percent in just three years.

These widespread successes can be attributed to Rwanda's innovative health sector reforms, particularly its results-based financing for health facilities and more decentralized decision-making. The World Bank has supported the Government of Rwanda's strong commitment to these reforms.

A rigorous evaluation (using a randomized control trial) has shown that results-based financing-a type of financing through which health facilities receive performance bonuses based on services provided, for example, the number of children immunized-has made a large contribution to improving health service delivery.

More than half of Ghana's population now covered by health insurance

Since the inception of the World Bank-financed National Health Insurance program in 2006, Ghana has made a strong effort to extend health insurance coverage to people employed in the informal and rural sectors. More than half of Ghana's population is now covered.

About 70 percent of the insured, including children and pregnant women, are exempt from paying premiums. The 2009 DHS shows at least 90 percent of pregnant women use antenatal care services, and births attended by skilled health staff rose from 40 percent (1990) to 59 percent (2008).

The World Bank provides technical assistance to Ghana's National Health Insurance Authority, to consider, among other interventions, the introduction of performance-based payment mechanisms to create incentives for improved quality of care. Such incentives have worked well in other countries, including Rwanda.

Senegal's under-five years stunting rate is now the lowest in Sub-Saharan Africa

In Senegal, the Bank has supported nutrition policy reforms and implementation. The Senegal Nutrition Enhancement Project, supported by the World Bank, now reaches about 40 percent of the population-with a focus on remote areas with high malnutrition rates.

Pre-natal consultation coverage-important for both mothers-to-be and the babies they bear-climbed from 52 percent to 67 percent. The percent of mothers who breastfeed exclusively for the first six months has nearly doubled-from 30 percent to 58 percent. Counseling women on the ill effects of sugar water, formula, and other substitutes has had an impact in Senegal.

Bed net use also improved, doubling from 28 percent to 59 percent in the target communities. Reduced malaria prevalence is important from a nutrition perspective because malaria can aggravate or cause anemia, which reduces labor productivity in adults and affects cognitive function in children.

Senegal has also made strides in institutional capacity. The Comite de Lutte contre la Malnutrition (Committee for the Eradication of Malnutrition) acts as a central coordinating agency for all nutrition activities, increasing the visibility of nutrition as a policy priority. Senegal's stunting rate is now the region's lowest, at 19 percent.

Ethiopia expands health posts and health extension workers, with broad benefits

Ethiopia is making a major effort to strengthen primary health care and provide basic health services to poor people and those in remote areas through its Health Extension Program (HEP). Starting in 2002, through this program, the country plans to build one health post and assign two health extension workers in each administrative village.

Over 31,000 health extension workers have been recruited and trained so far, and about 15,000 health posts have been built. The HEP has greatly improved access to health care. The coverage of basic health services-including bed nets, immunization, HIV testing and counseling-has contributed to decreased child mortality as well as lower malaria and HIV incidence.

Preliminary results from the World Bank-financed National Nutrition Program in Ethiopia show a rapid reduction in malnutrition in children aged 6-24 months. About 17,000 community health workers were trained to lead the delivery of key nutrition activities.

Possible increase in the use of modern methods of contraception in Niger

While there has been only slow progress in reducing the fertility rate in most of the region-a key factor in maternal mortality-some countries have sharply increased their contraceptive prevalence rate (CPR) for using modern methods, the latest example of which may be Niger.

Niger began from a low base, with its CPR for using modern methods growing from 2.3 percent in 1992 to 4.4 percent in 2006 (DHS). But preliminary results from various sources, including a 2010 sample survey done for the Ministry of Public Health, show that the CPR using modern methods may now be as high as 15 to 16 percent in Niger which, if validated, could be an impressive increase in just a few years.

While it is as yet early days, factors contributing to this possible increase could include free health services, increased knowledge about family planning through media such as the radio, television, and from health care facilities; availability and affordability of modern family planning methods, particularly the pill; and some degree of women's empowerment.

Zambia pays attention to malaria prevention as well as supply chains for key drugs

In Zambia, where the Bank was one of the key partners supporting the successful scale-up of the National Malaria Control Program, child mortality for the country as a whole dropped by 29 percent between 2002 and 2007 and the prevalence of severe anemia among children dropped by almost 10 percent during the period 2006 and 2008. This is linked to prevention efforts such as more bed net use and insecticidal spraying in homes.

On the treatment side, a major weakness has been faulty supply chains. A recent study supported by the Bank and other partners found that simple improvements to the supply chain for essential drugs, if rolled out nationwide, could save 27,000 children from malaria deaths between now and 2015. Stronger supply chains could mean the difference between life and death for a great many children and adults across Africa.