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The myth of the meager maternal health market

2015 April 6
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By Deepti Tanuku, Program Director, USAID-Accelovate

This post originally appeared on the Maternal Health Task Force blog.

pakistan mother maternal health quality care facility smile woman pakistani

Mother in Sindh, Pakistan receiving quality care. Photo: Jhpiego.

When I first entered this line of work, I often heard one thing: the maternal health market is way too small to be sustainable, much less lucrative. Naturally, one can only expect market failure for maternal health drugs and, by extension, a chronic situation of limited access to lifesaving medicines among those most in need.

However, I disagree.

The maternal health market is, of course, comparatively small when looking at the parallel markets for reproductive health, HIV, TB, malaria and even child health.

Take malaria for example. Prepared technical guidance provided by the President’s Malaria Initiative states that the unit cost for delivery of long-lasting insecticidal nets (LLINs) provided free of charge through antenatal clinics in four countries ranged from US $1.61 to $2.35 – which is roughly equivalent to the unit cost of US $1.50 for a delivery package of the three essential maternal health medicines: oxytocin, misoprostol and magnesium sulfate. However, in 2014 an estimated 214 million long-lasting insecticidal nets were delivered to malaria-endemic countries in Africa, while only 36 million women gave birth in the same region that same year. As any business school student can tell you, applying the formula of Price x Quantity = Revenue means that the maternal health market simply doesn’t compare in size.

This is the origin of the myth. For those of us committed to the goal of improved maternal health, we cannot confuse a small market with an unhealthy market – small can still mean healthy. Small can and should still mean a consistent and sustainable supply of high-quality and affordable maternal health drugs to all mothers in all settings.

There is a catch. The maternal health community cannot wait for market realities to drift toward our favor – we must actively and purposefully shape them. This begins with strong political will at both global and national levels. The creation of the UN Commission on Lifesaving Commodities for Women and Children is an excellent start, as is the inclusion of maternal health within the Reproductive Health Supplies Coalition (RHSC) agenda. These actions complement the ongoing efforts of other groups in this space, including the Maternal Health Task Force, itself.

The good news is that in the context of strong political will, there is plenty of research to shape evidence-based next steps. Together, we have built a clear understanding of market access barriers and we even know ways to incentivize around them. We also have market shaping strategies from other priority health areas, such as family planning, that serve as blueprints that we can adapt for our own purposes. As the maternal health community, it is up to us to use these tools to advocate for and help ourselves.

Finally, it’s good to revisit why this issue is critically important. Several studies and reports have demonstrated time and time again that healthy mothers strengthen families, societies and a nation’s economic development, which, in turn, strengthen a nation’s markets. Let’s say that again: Healthy mothers strengthen markets. It’s time markets returned the favor.

Resources used in the writing of this post:

This post is part of the blog series “Increasing access to maternal and reproductive health supplies: Leveraging lessons learned in preventing maternal mortality,” hosted by the Maternal Health Task Force, Reproductive Health Supplies Coalition/Maternal Health Supplies CaucusFamily Care International and the USAID-Accelovate program at Jhpiego which discusses the importance and methods of reaching women with lifesaving reproductive and maternal health supplies in the context of the proposed new global target of fewer than 70 maternal deaths per 100,000 births by 2030. To contribute a post, contact Katie Millar.

Changing incentives: Creating a market for high quality oxytocin

2015 March 31
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By Celina Schocken and Courtney Chang, Jhpiego

This post originally appeared on the Maternal Health Task Force Blog, as part of the series “Increasing access to maternal and reproductive health supplies: Leveraging lessons learned in preventing maternal mortality,” hosted by the Maternal Health Task Force, Reproductive Health Supplies Coalition/Maternal Health Supplies CaucusFamily Care International and the USAID-Accelovate program at Jhpiego which discusses the importance and methods of reaching women with lifesaving reproductive and maternal health supplies in the context of the proposed new global target of fewer than 70 maternal deaths per 100,000 births by 2030. To contribute a post, contact Katie Millar.

 

Oxytocin is the first-line drug for the prevention and treatment of postpartum hemorrhage (PPH) and is widely available in developing countries. There is a large market for oxytocin and there are many manufacturers of the drug; however, there are growing concerns that products are not in good condition when they are injected, either because of poor manufacturing or degradation along the supply chain.

oxytocin

Issues with inconsistent oxytocin quality

In 2012, a study by US Pharmacopeia and the Ghanaian Food and Drug Authority found that only 8% of oxytocin samples in Ghana had market authorization. The majority (97.5%) of samples failed either assay or sterility testing and over 55% of samples failed their physio-chemical assay. Even when a product is properly manufactured, storage and labeling of the drug along the supply chain and in facilities varies: in fact, only 8% of oxytocin samples were stored in the proper temperature (2°-8° C). The study ultimately concluded that 65.5% of oxytocin sampled in country did not meet quality standards, severely impairing the ability to prevent and treat PPH.

In most countries, we lack clear information about the quality of oxytocin administered to postpartum women. More studies are underway, as it is critically important to ensure that quality oxytocin is administered.

Limited product choices for quality oxytocin

In order to regulate quality, the WHO prequalification process helps identify quality drugs for countries. Currently, there are no WHO-prequalified oxytocin products; the only regulated products currently in the market are approved by Stringent Regulatory Authorities (SRAs), which are national bodies like the US Food and Drug Administration. This less stringent regulation is present despite a high volume market for oxytocin; globally, 100 million doses per year are used for prevention and treatment of PPH. There are at least 300 different oxytocin products manufactured by at least 100 manufacturers, creating a market that is difficult to regulate.

Most oxytocin in developing countries is procured by national procurement agencies, and most do not require WHO prequalification of oxytocin. These agencies are very resource-constrained and tend to focus on procuring high volume for low cost.

Current market structure threatens quality

For manufacturers, the low price of oxytocin—ranging from about $0.15 to $0.20 per 10 international unit (IU) dose—paired with a large number of competitors, creates a highly price-sensitive market. Achieving prequalification requires a manufacturer to upgrade its factory or improve manufacturing processes, likely adding 5-12% to the cost of products: a cost that makes thriving in the current market too difficult.

In a market where procurers do not require regulatory approval, prequalified or SRA-approved drugs simply will not be competitive against non-quality assured drugs and manufacturers will have no incentive to go through WHO prequalification. Instead, in order to stay competitive in the market, manufacturers will compromise the quality of their products order to keep prices low, boost sales and sustain profits.

Promoting a market shaping strategy for improved oxytocin

As the market for oxytocin grows, national governments and international partners must work together to ensure that manufacturers are incentivized to produce quality oxytocin. National governments and international partners should rally around a market shaping strategy that involves the following components:

  1. International partners working with national procurement agencies to improve procurement guidelines and procedures to ensure that only quality drugs are accepted into countries
  2. International partners working with National Drug Regulatory Agencies and others to increase awareness about quality issues with oxytocin
  3. Stricter enforcement of national guidelines and routine quality audits of drugs

For more information on quality oxytocin, please read the Business Case: Investing in Production of High Quality Oxytocin for Low-Resource Settings

Photo: “DSC_0096″ © 2009 Colin, used under a Creative Commons Attribution license: http://creativecommons.org/licenses/by/2.0/

Improving Access to Maternal Health Commodities through a Systems Approach: Where are we now?

2015 March 27
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By Beth Yeager, Principal Technical Advisor, Management Sciences for Health & Chair, Maternal Health Supplies Caucus, Reproductive Health Supplies Coalition. This post originally appeared on the Maternal Health Task Force Blog.

This post is part of the blog series “Increasing access to maternal and reproductive health supplies: Leveraging lessons learned in preventing maternal mortality,” hosted by the Maternal Health Task Force, Reproductive Health Supplies Coalition/Maternal Health Supplies CaucusFamily Care International and the USAID-Accelovate program at Jhpiego which discusses the importance and methods of reaching women with lifesaving reproductive and maternal health supplies in the context of the proposed new global target of fewer than 70 maternal deaths per 100,000 births by 2030. To contribute a post, contact Katie Millar.

Nearly three years ago, I blogged about a systems approach to improving access for a Maternal Health Task Force (MHTF) series on maternal health commodities:

Increasing access to essential medicines and supplies for maternal health requires a systems approach that includes: improving governance of pharmaceutical systems, strengthening supply chain management, increasing the availability of information for decision-making, developing appropriate financing strategies and promoting rational use of medicines and supplies.

It was an exciting year for maternal health. The UN Commission on Life-Saving Commodities for Women and Children (UNCoLSC) had just released its report with 10 recommendations for improving access to 13 priority commodities that included 3 for maternal health: oxytocin, misoprostol and magnesium sulfate.  The UNCoLSC report also reflected the idea that a systems approach was necessary and included recommendations related to both upstream and downstream supply chain bottlenecks, information, financing and appropriate use. That same year, the Maternal Health Supplies Caucus of the Reproductive Health Supplies Coalition held its first membership meeting in October for the purpose of joining the maternal health and family planning communities to “draw on existing approaches to address the bottlenecks undermining commodity security across health systems.”

Since then, great progress has been made in identifying the bottlenecks to access, raising awareness of the complexity of addressing these challenges and increasing global commitment to ending preventable maternal deaths as part of the post-2015 development agenda.

Improving governance

With respect to governance, through the efforts of the UNCoLSC to promote coordinated national strategies for Reproductive, Maternal, Newborn and Child Health (RMNCH), the need for coordinated planning among all stakeholders, including measures of accountability, has come to the forefront.

Reviewing national policies — such as the essential medicines lists and standard treatment guidelines — and advocating for the inclusion of the three priority maternal health medicines in these policies has raised awareness of both the need to harmonize policies at the national level and the challenges to implementing these policies.

Recognition of the importance of the regulatory role governments play in ensuring the quality of products in circulation in the public and private sectors has also grown. In a recent study conducted by the USAID-funded Systems for Improved Access to Pharmaceuticals and Services program (SIAPS) in Bangladesh, we found that over 40% of the oxytocin in circulation at the district level was procured from local wholesalers.

Strengthening supply chain management

In terms of supply chain challenges, resources are now available to assist countries in more accurate forecasting for maternal health medicines. The Estimation of Unmet Medical Need for Essential Maternal Health Medicines developed by SIAPS (a project led by Management Sciences for Health with partners) presents an approach that allows national program managers and other key stakeholders to assess a country’s theoretical need for the three maternal health commodities and compare this with actual procurement data from past years in an effort to make more evidence-based decisions. The RMNCH quantification guidance developed by the Supply Chain Technical Resource Team of the UNCoLSC also includes the three maternal health medicines.

Information for decision making

Over the past three years, we have also learned how little information is readily available about these commodities and the conditions they are meant to treat at the country level. In many cases, logistic management information systems do not capture these three products (and many others necessary for maternal health). Likewise, health information systems do not necessarily capture the number of women who develop post-partum hemorrhage and are successfully treated. Efforts are currently underway in a number of countries to address this problem.

The global community has learned a lot these past three years and made great progress in further revealing the actions required to increase access to quality medicines and supplies for maternal health. With the current proposed target of ending preventable maternal deaths by 2030, global and national stakeholders need to continue their coordinated efforts to build stronger, more responsive systems.

Beth Yeager, MHS, is Principal Technical Advisor, SIAPS program, at Management Sciences for Health (MSH), Chair Maternal Health Supplies Caucus, Reproductive Health Supplies Coalition

Making connections: Ensuring access to reproductive and maternal health supplies

2015 March 24
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Shafia Rashid is Senior Program Officer for Global Advocacy at Family Care International. This post originally appeared on the Maternal Health Task Force blog.

This post is part of the blog series “Increasing access to maternal and reproductive health supplies: Leveraging lessons learned in preventing maternal mortality,” hosted by the Maternal Health Task Force, Reproductive Health Supplies Coalition/Maternal Health Supplies CaucusFamily Care International and the USAID-Accelovate program at Jhpiego which discusses the importance and methods of reaching women with lifesaving reproductive and maternal health supplies in the context of the proposed new global target of fewer than 70 maternal deaths per 100,000 births by 2030. To contribute a post, contact Katie Millar.

The past ten years have witnessed impressive gains in the availability and use of reproductive health supplies like condoms and oral contraceptives that allow men and women to safely and effectively prevent or space pregnancies. As a result of concerted efforts by many partners, contraceptive prevalence rates have risen over 60% in countries around the world.

These dramatic successes in improving access to reproductive health supplies can shed important lessons and guidance for those working to ensure that life-saving maternal health medicines — including, oxytocin, misoprostol and magnesium sulfate — are available to all women, when they need them and wherever they give birth. These medicines — which can save lives by preventing or treating the leading causes of maternal death — remain out of reach for many women, particularly for poor, rural, indigenous and other vulnerable women. Many countries lack clear, supportive policies and adequate budgets to make essential maternal health medicines widely available, or have weak supply chains and logistical systems. Inadequate regulatory capacity, poor quality of medicines and lack of information and guidance on correct use are other barriers to access.

In order to summarize lessons learned and provide concrete tools to improve access to maternal health supplies, the Reproductive Health Supplies Coalition tasked Family Care International to create seven policy briefs that show policy makers and program managers real-world examples of successful interventions. Importantly, there is a brief dedicated to each of the three most critical maternal health supplies: oxytocin, misoprostol and magnesium sulfate. Other briefs cover the cross-cutting issues of policy and financing, supply and demand generation.

Lessons learned from successful efforts to improve access to family planning commodities can help to effectively address the challenges related to maternal health medicines. Family planning advocates have, for example, tracked government expenditures on reproductive health supplies: in Indonesia, budget analysis and concerted advocacy led the mayors of five districts to increase their family planning budgets by as much as 80%. Similarly, many countries — including Bolivia, the Dominican Republic, El Salvador, Honduras, Nicaragua and Paraguay — have established contraceptive security committees that bring together multiple supply chain stakeholders to support coordination, address long-term product availability issues and reduce duplication and inefficiencies. These committees have advocated for increased financial support for contraceptives, improved inventory management, developed standard operating procedures, published reports and provided technical assistance. These efforts to increase budgets and ensure commodity security for contraceptives can be effectively adapted and expanded to improve financing and security for maternal health supplies as well.

A wide range of tools and resources can support countries in strengthening their forecasting, procurement and other supply chain functions. Tools originally developed with a sole focus on reproductive health supplies now include or can be adapted to apply to maternal health supplies as well and can be used by country managers working to improve the supply of maternal health medicines.

Finally, many countries are moving toward integrating their supply chains to include family planning commodities and other essential medicines, including medicines for maternal health. In Ethiopia, for instance, the government (with the support of in-country partners) integrated their supply chain to include all health commodities and to connect all levels of the supply chain with accurate and timely data for decision-making. In Nicaragua, where the supply chain was separated vertically by health issue and type of commodity until 2005, the health ministry has integrated the essential medicines system with the contraceptives’ supply chain and has now fully automated the system and expanded it to include all essential medicines.

There are many parallels and potential synergies between reproductive and maternal health supply chains and processes. The reproductive and maternal health communities must take the following actions to address the interrelated barriers that prevent access to and use of life-saving commodities:

  • Advocate for development and implementation of supportive policies at the national and sub-national levels,
  • Advocate for dedicated budget lines to enable monitoring and evaluation of policy implementation
  • Improve government systems and procedures for procuring high-quality medicines and maintaining their quality throughout the supply chain
  • Invest in a streamlined, coordinated supply chain across sectors and levels, reducing inefficiency and duplicative efforts
  • Strengthen the knowledge and skills of health providers so that they are aware of evidence-based policies and guidelines and can effectively administer these essential medicines

More information can be found in Essential Medicines for Maternal Health: Ensuring Equitable Access for All, a set of briefs that highlight challenges and strategies for increasing the availability of these maternal health medicines and identify linkages with reproductive health supplies. You can download the Essential Medicines for Maternal Health policy briefs in English, French and Spanish.

Three barriers to delivering maternal health supplies and the solution

2015 March 18
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By Katharine McCarthy and Saumya RamaRao

Katharine McCarthy is Research Coordinator and Saumya RamaRao is Senior Associate at Population Council. This article originally appeared on the Maternal Health Task Force blog.

This post is part of the blog series “Increasing access to maternal and reproductive health supplies: Leveraging lessons learned in preventing maternal mortality,” hosted by the Maternal Health Task Force, Reproductive Health Supplies Coalition/Maternal Health Supplies Caucus and Family Care International, which discusses the importance and methods of reaching women with lifesaving reproductive and maternal health supplies in the context of the proposed new global target of fewer than 70 maternal deaths per 100,000 births by 2030. To contribute a post, contact Katie Millar.

How can we use the lessons learned by the reproductive health community to advance the maternal health supplies issues?

Each year more than 180,000 women die during pregnancy or childbirth from hemorrhage or pre-eclampsia/eclampsia. Many of these deaths can be prevented with appropriate access to oxytocin, misoprostol and magnesium sulfate. A delivery package containing these medicines is estimated to cost less than US $1.50 per person, and is predicted to save 1.4 million lives over ten years, if available to all women. Current barriers in markets for maternal health drugs, however, cause these drugs to remain largely inaccessible for many women. As the maternal health field refocuses priorities for the SDGs, the importance of building healthy markets for essential medicines is evident.

What are the Major Barriers in Accessing Maternal Health Drugs?

In 2012 the UN Commission on Life Saving Commodities for Women and Children identified key barriers that limit access to lifesaving maternal health drugs:

  1. Market failures leading to an insufficient supply of quality drugs
  2. A weak regulatory environment leading to variability in drug formulation and quality
  3. Lack of provider and consumer awareness of drugs and/or their appropriate use

The interrelated nature of supply and demand challenges makes addressing them difficult. But, there may be a solution. As seen in other health commodity markets, market shaping strategies involving the “total market” may best address these challenges by capitalizing on the potential of all market players to achieve a coordinated approach.

The Solution: What is Market Shaping?

Like many markets, the maternal health drug market is made up of actors from different sectors, including the public (e.g., government), private commercial (e.g., manufacturers, distributors, midwives and oby-gyns), and private non-profit sectors (e.g., faith-based health care providers). Two main reasons for inefficiencies in markets are (1) lack of information and (2) an unbalanced sharing of risk.

Incomplete information or gaps in information flows can be a barrier to market entry. For example, manufacturers and suppliers of drugs may lack information on many aspects of the market such as volume of demand, timing of demand, prices and profitability. Such information gaps can be addressed by high quality demand forecasts, a schedule of when orders are likely to be place, and data on stock-outs, prices, and drug quality. With wider availability of information, new manufacturers and suppliers can be encouraged to enter the market, expanding the supply of available drugs.

To address unbalanced market risk, another strategy is volume guarantees. Unbalanced risk can occur in uncertain markets when a manufacturer or distributor bears the majority of upfront costs with an unforeseeable future profit. A volume guarantee, or an agreement by buyers to purchase of a certain quantity of a product, can offset the risk to suppliers and encourage drug production. Volume guarantees can also aid in negotiations to strengthen the quality and reduce the cost of drugs by achieving purchasing power not previously possible in fragmented developing country markets. Such leverage can also aid in identifying opportunities for innovations in product improvement and financing, further encouraging product purchase and use.

What Else Will it Take?

While capitalizing on market opportunities can facilitate access to drugs and save lives, these strategies alone are likely not sufficient. Complementary programmatic investments are needed to strengthen the supply chain and service delivery, as well as to generate demand by raising awareness on the need and appropriate use of maternal health drugs, and to advocate for the importance of women’s lives. As maternal health researchers, policy planners, advocates and program leaders, we all have our role to play in ensuring women have access to resources for a safe and healthy delivery. We must now turn to moving what we know can work to those in most need.

To learn more about how market shaping lessons from the HIV and reproductive health commodity markets can be applied to scale-up access to maternal health drugs, please see a recent commentary by McCarthy et al., published in Maternal and Child Health Journal.

Resources used in the writing of this post:

Call for posts: How to increase access to maternal and reproductive health supplies

2015 March 16
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By Milka Dinev, Beth Yeager, and Katie Millar

Milka Dinev is the Latin America and Caribbean Forum Regional Advisor for the Reproductive Health Supplies Coalition. Beth Yeager is the principal technical advisor for maternal, newborn and child health for Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program, led by Management Sciences for Health (MSH). Katie Millar is a technical writer for the Maternal Health Task Force (MHTF), where this article originally appeared

The Maternal Health Task Force (MHTF), the Reproductive Health Supplies Coalition (RHSC)/Maternal Health Supplies Caucus (MHS) and Family Care International (FCI) share the goal of increasing awareness of the key role that reliable access to quality maternal and reproductive health supplies plays in reducing maternal mortality. To this end, we’d like to invite you to contribute a post to our blog series, Increasing access to maternal and reproductive health supplies: Leveraging lessons learned in preventing maternal mortality.

women-mobile-clinicOur goal for this blog series is to create a platform for sharing innovative interventions, lessons-learned and opportunities for collaboration across various organizations and communities in terms of what can be done to ensure availability of quality maternal health supplies. The new global target of fewer than 70 maternal deaths per 100,000 births by 2030 makes timely access to quality maternal and reproductive health medicines and supplies for women even more critical.

Two of the major causes of maternal deaths are post-partum hemorrhage (PPH) and pre-eclampsia/eclampsia. Both conditions can be successfully managed with proven interventions that include administration of oxytocin and misoprostol in the case of PPH, and magnesium sulfate for pre-eclampsia and eclampsia.

Unfortunately, many health systems face challenges that limit access to these life-saving commodities. For example, in some cases there is insufficient funding for these medicines in national budgets, driving increased out-of-pocket spending. Likewise, regulatory agencies are sometimes unable to assure the quality of products circulating in the market due to funding and human resource constraints. Storage conditions remain inadequate for medicines with special storage requirements, like maintaining the cold chain. Lack of information systems that provide up-to-date, reliable data on supply availability further complicates the issue as managers are unable to make evidence-based decisions regarding supplies. Finally, demand side barriers exist as providers often lack appropriate guidance on the use of these life-saving supplies.

These challenges are not insurmountable. Indeed, many of these challenges have been successfully addressed in ensuring access to reproductive health commodities. The reproductive health community has worked for more than three decades to improve the quality of their supplies, strengthen the supply chains that deliver these supplies (mainly contraceptives) and create information systems that help managers make decisions regarding these supplies. Many of these lessons could well apply to increase accessibility and availability of quality maternal health supplies.

Questions and topics for potential guest posts:

  1. What are the barriers you face in ensuring mothers get the supplies they need? How has your work addressed the complicated interplay between contributing factors that attribute to a mother not receiving the life-saving medicine she needs?
  2. Are governments assuming responsibility for and taking the necessary actions to address maternal health supplies issues? What strategies have been successful to increase involvement of government in ensuring maternal health supplies?
  3. What have been successful strategies to reduce financial barriers to access maternal health supplies?
  4. What are lessons learned regarding supply chains for maternal health and information systems for their monitoring?
  5. How can we best prepare health providers to both use maternal health supplies correctly and advocate for their use?
  6. What strategies can be used to raise awareness of the importance of quality assurance among governments, health providers and women?
  7. How can we use the lessons learned by the reproductive health community to advance the maternal health supplies issues?

If your work involves other factors related to supplies, please feel free to propose an original topic.

General guidelines for guest blog posts:

  • Please include the author name, title, and photo
  • Goal: Guest posts should raise questions, discuss lessons learned, analyze programs, describe research, offer recommendations, share resources, or offer critical insight
  • Audience: The audience for this series is health and development professionals working in maternal and newborn health around the world, primarily in resource-constrained settings
  • Tone: Conversational. Does not need to meet professional publication standards
  • Feel free to choose your own style or approach. Q/A and lists (e.g. top ten lessons) can often be effective ways of organizing a blog post
  • Length: 400-600 words
  • No institutional promotion
  • Please include links to sources such as websites and/or publications
  • May also include photos and videos, please include a caption and a credit for the photo

To contribute a post to this series, please contact, Katie Millar, at kmillar@hsph.harvard.edu.

Submissions to this series will be reviewed and accepted on a rolling basis, but preference will be given to posts received by March 30th, 2014.

Posts in this series will be shared on the MHTF blog and may be cross-posted on other leading global health and development blogs.

Thank you for considering contributing to our series. We look forward to hearing from you soon!

Photo credit: Mobile Clinic Medical Day in Azbat Jarrad © 2010 Physicians for Human Rights – Israel, used under a Creative Commons Attribution license: https://creativecommons.org/licenses/by/2.0/

Tracing the money: A new tool to impact the budget process

2015 March 4
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Kathleen Schaffer is senior program officer for Anglophone Africa at Family Care International.

A dilapidated clinic, falling tiles, a never-ending leak. Barren and disorganized medicine shelves. An overcrowded maternity ward with desperate, soon-to-be mothers crying out for help. One nurse scrambling to meet the needs of the many patients who have come through the doors. When clients lament the clinic’s disrepair, or doctors request more supplies and personnel, they’re met with the same hopeless reply: “There’s no money.”

Through Family Care International’s (FCI) Mobilizing Advocates from Civil Society (MACS) project in Kenya, international, national and grassroots organizations as part of the Reproductive, Maternal, Newborn, and Child Health (RMNCH) Alliance are demanding better facilities, adequate and respectful maternity care, and especially, more health personnel. Kenya has only 11.8 health workers per 10,000 people–more than 40% fewer health workers than the World Health Organization’s minimum recommendation of 22.8 health workers per 10,000 people.

Of course any effort to increase the quantity and quality of health workers will have to be paid for, and that means dealing with the budget. For many of us, budgets seem abstract and intimidating, but it’s vital to engage with them since they reflect the government’s priorities and determine where the public’s money goes.

In order to make realistic demands, we need access to information about Kenya’s budget. However, over the last few years Kenya decentralized many decision-making processes, including budgeting, to the county-level. This recent decentralization has made it difficult for us to intervene effectively during the budget process.

Kenya calendar 2

But now, civil society organizations in Kenya can engage with budget decision-makers at the right moments thanks to a new Annual Budget Cycle Calendar, developed by the MACS project.

This new easy-to-read calendar shows the key dates for the Kenyan Annual Budget Cycle at both the national and county levels, enabling citizens to participate in both the setting of priorities and in accountability processes.

It is a great resource not only for maternal health advocates but also for the broader health community and county government officials, such as those from the Health and Finance Committees. The RMNCH Alliance will distribute the calendar in counties all over the country, and we hope to see it on many office walls as a constant resource for advocacy opportunities.

Ultimately, by being able to participate in and monitor the budget process more effectively, we will ensure that the government fulfills its commitments to maternal, newborn, and child health, and that the budget reflects the needs and priorities of the community and not just politicians.

Budget accountability in the midst of the Burkina Faso revolution

2015 January 26
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By Manuela Garza

Manuela Garza is an independent consultant and is co-founder of Colectivo Meta. She is currently engaged as a consultant to FCI’s Mobilizing Advocates from Civil Society (MACS) project, on which she works to build the budget analysis skills of health-focused civil society organizations in Burkina Faso.

For the past seven years, it was my good fortune to work at a job that allowed me to work with brave and committed activists in interesting and beautiful places. As a staff member of the International Budget Partnership, I found myself in Mombasa, Kenya, where ordinary citizens conducted ‘social audits’ to claim their communities’ fair share of government financial resources; in Abbottabad, Pakistan, where 500 women and men voiced their priorities for spending of earthquake rehabilitation funds; in Beijing, where civil society groups were trained to pursue budget transparency and accountability in a context where silence rules; and in Abbra, a remote region in the Philippines, where rural villagers have advocated for and achieved truly participatory budgeting.

In recent months, FCI’s MACS initiative has been working in Burkina Faso to strengthen the capacity of civil society groups to effectively advocate for more and smarter spending of public funds to improve reproductive, maternal, newborn, and child health in their communities. Last October, I was engaged, together with my Malian colleague Boubacar Bougodogo and Burkinabé budget researcher Hermann Doanio, to develop and facilitate a weeklong workshop to train grassroots advocates to understand and engage with public budgets. We arrived in Ouagadougou, Burkina’s capital, on a calm and warm West African evening, all of us ready with our slides on the budgeting process, our spreadsheets, our budget calculation formulas, and our case studies. Business as usual, or so we thought.

Little did we know that, in the course of that week, the citizens of Burkina Faso would overthrow the dictator who had been ruling the country for the past 27 years. Thousands of people (young people, mostly) took to the streets with a very clear message for President Blaise Campaoré: they wanted him out, for good. They were no longer willing to tolerate corruption and abuse of power, they declared: Burkina is ready for democracy.

In the midst of these historic events, you may be wondering, what did our Burkinabé colleagues, who had put this week aside for budget training, do? Was the workshop still relevant during these revolutionary days? Of course, every participant was closely watching the dramatic events taking place outside the training venue; each participant was concerned and worried about what they would mean for their families and their country. At the same time, however, they remained committed to take full advantage of this unique opportunity to learn about a new tool that will enable them to carry out evidence-based advocacy. They stuck around, they learned, and they questioned; they talked about their country, about change, and about what these new skills could help them achieve. They discussed the potential for how things could change, including in the way that the government sets priorities and spends public money— that is, the people’s money!

Civil society plays a key role in ensuring that governments prioritize spending on women’s and children’s health.

Civil society plays a key role in ensuring that governments prioritize spending on women’s and children’s health.

Is budget accountability still relevant in a context of earthshaking change? My experience says that it is. Revolutions are tricky things: countries and their institutions can change either for better or for worse, and conditions may take a long time to stabilize. If change is managed wisely and stability returns quickly, as seems to be happening in Burkina, revolution can provide an opportunity for a fundamental shift in the balance of power—toward the people. This can vastly increase the possibility of reshaping inefficient and corrupt institutions, of fostering new structures that institutionalize transparency and accountability. In a country like Burkina Faso, accountability for public resources is an essential element of overall accountability.

In this context, investing in building the skills of civil society groups is crucial, because the significance and sustainability of positive change largely depends on a well-organized and well-prepared civil society. These are the times when advocates and grassroots organizations most need support, when citizens most need to develop new knowledge and skills in civic participation, when accountability and participation-related processes are more necessary than ever. The MACS project is doing just that, and FCI’s local partners in Burkina Faso will continue to arm themselves with new tools such as budget analysis, so that their advocacy has more impact, their voices are heard, and they can be effective forces for real, sustainable change.

Good luck to them and to Burkina Faso–a country that many people cannot even locate on a map but which has a lot to teach us when it comes to citizen power!

 

MamaMiso: A simple medicine provides hope to Uganda mothers

2015 January 6
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By Andrew Weeks and Shafia Rashid

Andrew Weeks is Professor of Women’s and Children’s Health at the University of Liverpool and the Principal Investigator of the MamaMiso study. Shafia Rashid is a senior program officer at Family Care International (FCI). Through research and advocacy, FCI works with Gynuity Health Projects and other partners to support increased access to and availability of misoprostol for prevention and treatment of postpartum hemorrhage. 

Sarah Nerima was working on her banana plantation when she went into labor. Unable to reach a health center – the nearest was 6 miles away – Sarah gave birth in the fields, attended only by her mother-in-law. Already a mother of two, she had bled heavily in each of her previous deliveries, and she was afraid that a hemorrhage could take her life, leaving three motherless children.

For the 50% of women in rural Uganda who, like Sarah, give birth outside a health facility, a simple, safe and effective medicine, called misoprostol, can prevent or stop life-threatening bleeding. Misoprostol is a medicine that comes in tablet form, can be stored without refrigeration, and be administered without any specialized skills. The World Health Organization (WHO) recommends misoprostol for the prevention and treatment of postpartum hemorrhage (PPH) in settings where the standard of care, oxytocin – which requires cold storage and is administered by injection – is not available or cannot safely be used. WHO also recommends that misoprostol can be administered by community health workers for PPH prevention when skilled health providers are not present.

Some countries with high rates of non-facility births distribute misoprostol at antenatal care visits to women directly (a strategy called ‘advance distribution’), but WHO – citing unanswered questions about the safety and effectiveness of self-administered misoprostol in home births – has held off on recommending advance distribution, calling for additional research.

In Uganda, a research team from the University of Liverpool, Gynuity Health Projects, and Makerere University has tested the safety and feasibility of this community-based distribution model. MamaMiso, as this 2012 study was aptly called, provided misoprostol tablets to pregnant women for self-administration immediately after childbirth to prevent bleeding. Working in 200 villages in Mbale district, Eastern Uganda, the research team recruited women who came for antenatal care at Mbale Regional Referral Hospital or 3 large health centres (Busiu, Lwangoli and Siira) nearby.

Every pregnant woman at more than 34 weeks of gestation living in the recruitment villages was eligible to participate. Each participant was given a small purse, with a string that could be hung around the neck, containing 3 foil-packed tablets (600 micrograms misoprostol or placebo). Women were told to bring the purse home, to keep it with them, and to swallow the pills immediately after birth if they delivered at home. They were given an instruction sheet with written and pictorial instructions on how to take the tablets. Women were advised not to take the tablets if they went to a health facility for their delivery. Each participant was visited at 3 to 5 days after birth to check whether she had taken the medicine and to collect clinical outcomes.

MamaMiso’s results showed that self-administration of misoprostol is safe, and that advance distribution during antenatal care has the potential to increase the number of women who receive a medicine to prevent PPH. Of the women who enrolled in the research study, 57% gave birth at a facility and 43% delivered at home. Of those women who delivered at home, almost all (97%) took the study medicine after childbirth. Only 2 women (0.3%) took the medicine prior to delivery, and neither suffered adverse effects. Women who took misoprostol did experience fever and shivering, but they found these side effects to be acceptable.

These findings, together with results from other studies examining community-level use of misoprostol, have spurred national stakeholders to take action. The national Ugandan ob-gyn society has called for updating the national guidelines on PPH prevention to recommend community use of misoprostol, specifically enabling women to receive misoprostol as part of antenatal care. ‘We cannot continue to let women die when we have the solutions,’ said Dr. Charles Kiggundu, vice president of the Association of Obstetricians and Gynaecologists of Uganda. ‘The hindrance to using scientifically proven drugs is with health workers, not the women.”

Sarah Nerima was one of the women included in the MamaMiso study. After delivering her baby daughter among the banana trees, she opened her MamaMiso purse, and took the pills. “The bleeding was very, very little this time”, she said, “As you see, I am already very strong.”

Sarah had her MamaMiso purse with her when she gave birth, and took the misoprostol pills. In contrast to her 2 previous deliveries, she did not experience heavy bleeding, and she and her baby came through the childbirth safely.

Sarah had her MamaMiso purse with her when she gave birth, and took the misoprostol pills. In contrast to her 2 previous deliveries, she did not experience heavy bleeding, and she and her baby came through the childbirth safely.

Breaking the silence on gender-based violence in Mali

2014 December 18
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Adama Sanogo is Program Officer at Family Care International in Mali, working at the national office in Bamako and supervising FCI’s programs in Mopti. Adama authored a post on gender-based violence last year.

Samira [not her real name], a married Burkinabe woman, took a vacation to Mali to visit her sister. One evening, they attended the Balani Show, a cultural festival of traditional music and dance, in Mopti. Samira’s sister decided to go home early, but Samira opted to stay out a little later. Later that evening, Samira walked back to her sister’s house alone when a group of young men—residents in her sister’s neighborhood—attacked and gang-raped her. The next morning, Samira contacted Family Care International for care and took her case to the police. Her attackers and their families immediately began to pressure her to drop the case. As the social intimidation mounted, even Samira’s own sister, afraid of conflict with her neighbors, advised Samira to stop pursuing the case. Despite encouragement from social workers and legal counsel provided by Family Care International (FCI), Samira eventually abandoned the case against her rapists. Although Samira wasn’t able to pursue justice, she found support, and allies, at FCI.

Since 2012, Mali has endured drought, armed rebellion, and a political coup and French military intervention, all of which have undermined the country’s stability and security and left a population especially vulnerable to gender-based violence (GBV). GBV is a glaring indicator of persistent inequality between men and women and represents a breach of fundamental rights to life, liberty, security, dignity, non-discrimination and physical and mental integrity. GBV exists in all forms but the most severe and common include: rape, sexual assault, assault physical, forced marriage, denial of resources/opportunities/services, and psychological/emotional violence. Responding to and preventing GBV requires the prioritization of the survivors’ best interests and strict compliance with four guiding principles: security, respect, confidentiality and non-discrimination.

FCI-Mali is committed to ensuring women and children who have suffered GBV have access to medical care, psychological support, and legal counsel. In Mopti and the surrounding villages, we have formed protection teams–consisting of village and community leaders and often, an FCI-trained ‘youth leader’–to identify women and children survivors of GBV. These protection teams refer survivors to FCI for medical or psychological support and educate communities about GBV in order to prevent further violence against women and children. Sometimes, GBV survivors seek out FCI without a referral, because of our reputation as a safe place. FCI is also working with the Malian government through the Regional Directorate for the Promotion of Women, Children and Family Mopti (DRPFEF) to create the Women’s House of Mopti, in which women survivors have access to social workers and psychological counseling. The social workers also organize activities for children and coordinate theater company performances. This center primarily serves to strengthen the resilience of GBV survivors.

FCI-Mali works with communities to prevent GBV and provide support to survivors of GBV.

FCI-Mali works with communities to prevent GBV and provide support to survivors. (Pictured: Participant in a Bamako-based program that educates youth on GBV prevention.  Photo credit: Catherine Lalonde)

FCI also hosts a radio program to broadcast information about GBV, and our efforts to deal with it, to an even wider audience. Due to limited airtime, we only have a few minutes to explain that GBV exists and that it is a violation of human rights and the rights of women. We encourage survivors of GBV to break their silence, take back their bodies and rights, and request care–even anonymously–from FCI.

Unfortunately, in Mali, social attitudes tend to direct shame and blame on the victims of rape and sexual violence, deterring many GBV survivors from pursuing justice in court. Although we recommend that survivors fill out an incident report, the first step towards holding the aggressor responsible, many women decline. Of the most severe rape cases that I have seen in Mopti (on which FCI has assisted), only eight victims have chosen to pursue the case with the police. If a survivor decides to complete a police report and it arrives in the courts, the parents, the family, and the relatives of the accused–and sometimes of the accuser–will create social pressure to dissuade the accuser from seeing the case through. In one case, a 10-year-old girl suffered a brutal rape, but her parents decided not to pursue the case. They wanted to protect their daughter from further shame and social abuse she might endure if her identity as a rape victim became public.

At FCI, we are working to change traditional societal ideas about rape and sexual violence which stigmatize women victims, because these attitudes make it nearly impossible for us to prevent women from suffering. For instance, aggressors in Mali don’t fear the state justice system because they know that victims rarely persist in bringing charges through court. Therefore, we adapt our GBV strategy to our particular cultural setting. We focus on changing social and cultural ideas around gender-based violence through education and awareness training. We are one of the few organizations in Mali undertaking this type of community education and awareness work through radio programs, protection teams and myriad other peer education programs in order to catalyze holistic change in the communities in which we work.

We hope our work will lead to a Mali that does not disparage survivors of GBV, diminish women’s rights, or tolerate social, economic, or emotional violence toward women. It is challenging, arduous work, but we believe that with our current strategies–with every peer education program, with every education workshop, with every radio program–we are changing the cultural and social expectations in Mali for the better.

——-

Briser le silence sur la violence basée sur le genre au Mali

Adama Sanogo est agent de programme à Family Care International au Mali qui travaille au bureau national à Bamako et supervise des programmes de FCI à Mopti, une ville sur le fleuve Niger à plus de 8 heures de route au nord. Adama a écrit un autre témoignage sur le travail de FCI au Mali en matière de violence basée sur le genre l’année dernière.

Samira, une Burkinabée mariée, a pris des vacances au Mali pour visiter sa sœur. Un soir, elles ont assisté à une soirée culturelle de masse (appelé « BALANI SHOW ») à Mopti ou elles ont passé la soirée à écouter de la musique et à danser. La sœur de Samira a décidé de rentrer à la maison tôt, mais Samira a choisi de rester un peu plus tard. Plus tard ce soir, Samira se dirigea toute seule vers la maison de sa sœur quand un groupe de jeunes -résidents du même quartier que sa sœur – l’ont attaquée et l’ont violée. Le lendemain matin, Samira a pris contact avec Family Care International pour les soins médicaux et psychosociaux et a aussi porté l’affaire à la police. Après être allée à la police, ses agresseurs et leurs familles ont immédiatement commencé à faire pression sur elle d’abandonner l’affaire. Vu que la pression sociale devenait forte, même la sœur de Samira craignait sa relation sociale avec ses voisins, finit a conseillé Samira d’abandonner l’affaire. Malgré les encouragements de l’assistante sociale de FCI et du conseiller juridique, Samira a finalement décidé d’abandonner l’affaire contre ses violeurs présumés. Bien que Samira ne était pas en mesure de poursuivre la justice, elle a trouvé soutien et alliés, au Family Care International.

Depuis 2012, le Mali a subi la sécheresse, une rébellion armée et un coup d’Etat politique, qui sont entre autres des facteurs qui ont compromis la stabilité et la sécurité du pays et a laissé une population particulièrement vulnérable à la violence basée sur le genre (VBG). La VBG est un indicateur flagrant de l’inégalité persistante entre les hommes et les femmes à cause des considérations sociales et représente une violation des droits fondamentaux à la vie, une atteinte à la liberté, et à l’intégrité physique et mentale. La VBG existe dans toutes les formes, mais selon la classification universelle de l’outil GBVIMS du Comité de Pilotage en matière de VBG, on retient les six types suivants en fonction de la gravité : le viol, l’agression sexuelle, l’agression physique, le mariage forcé, le déni de ressources/d’opportunités/ou de services et la violence psychologique/émotionnelle. Travailler pour la réponse et la prévention des VBG nécessite le respect strict des 4 principes directeurs à savoir, la sécurité, le respect, la confidentialité et la non-discrimination. Cette intervention doit être centrée sur l’intérêt supérieur des survivants(es).

FCI-Mali s’engage à assurer que les femmes et les enfants qui ont souffert de la VBG aient accès aux soins médicaux, au soutien psychologique et aux conseils juridique. Dans la commune de Mopti et des communes environnantes couvrant plusieurs quartiers et villages, nous avons formé des équipes de protection – composés des chefs de village, de leaders femmes au sein des communautés et souvent de jeunes leaders – qui font l’identification des femmes et enfants ayant subit des VBG pour leur référencement afin de bénéficier d’une prise en charge. Ces équipes de protection réfèrent les survivantes vers les assistantes psychosociale et la psychologue de FCI pour le soutien psychologique et médical – Ces équipes de protection font également la sensibilisation des communautés sur les VBG, afin de prévenir de nouvelles violences contre les femmes et les enfants. Parfois, les survivantes de VBG s’adressent à FCI directement sans référencement, grâce à notre réputation comme un lieu sûr.

FCI-Mali travaille avec les communautés pour prévenir la VBG et apporter un soutien aux survivantes de VBG. Crédit photo: Catherine Lalonde

FCI-Mali travaille avec les communautés pour prévenir la VBG et apporter un soutien aux survivantes. (Photo: Participant à un programme basé à Bamako qui éduque les jeunes sur la prévention VBG. Crédit photo: Catherine Lalonde)

FCI travaille également avec les radios pour la diffusion des messages de prévention des VBG et de la séparation familiale mais aussi pour des messages d’orientation des survivants sur la prise en charge holistique. Cette collaboration avec les radios du cercle de Mopti et la radio régionale a pour but d’atteindre un plus grand public. Ces émissions radio permettent d’encourager les survivants(es) à aller vers les services de prise en charge et renforcer la prévention des cas de VBG au sein des communautés.Nous encourageons les victimes de VBG à briser le silence, à renforcer leur résilience, reprendre la vie normalement et avoir accès à leurs droits, et de demander des soins-même de façon anonyme-de FCI.

Pour faciliter ce travaille, FCI collabore avec le Gouvernement malien à travers la Direction Régionale de la Promotion de la Femme, de l’Enfant et de la Famille de Mopti, (DRPFEF) pour animer un espace filles/femmes à la Maison de la Femme de Mopti, dans le quel une psychologue met son service à la disposition des femmes surtout les survivantes, une animatrice sociale assure la mise en œuvre des activités ludiques à l’intention des enfants, coordonne la prestation d’une troupe de théâtre forum. Ce centre permet surtout aux survivantes de VBG de renforcer leur résilience.

Malheureusement, au Mali, les attitudes sociales, les croyances, etc. ont tendance à renforcer le sentiment de honte chez les survivantes de VBG, surtout le cas de viol ou autres violences sexuelles et amener la communauté à blâmer ces victimes, un fait qui démotive, décourage de nombreuses survivantes de GBV à poursuivre les auteurs présumés à la justice ou au tribunal. Bien que nous informons les survivantes et les oriente pour les plaintes à la police et la poursuite judiciaire, la première étape pour responsabiliser l’agresseur présumé, de nombreuses femmes refusent de faire ces plaintes et poursuite judiciaire. Des cas de viol les plus graves que j’ai vu à Mopti (sur lequel FCI a aidé), seulement huit victimes ont choisi de poursuivre l’affaire à la justice. Si une survivante décide de porter l’affaire à la police et engager la poursuite judiciaire dès que l’affaire arrive dans les tribunaux, les parents, la famille et les parents de l’accusé – et parfois de l’accusateur – vont exercer une pression sociale pour dissuader la survivante (la plaignante) au maintien du processus juridique, voir à abandonner l’affaire. Un autre exemple du cas d’une fille de 10 ans qui a subi un viol brutal, mais ses parents ont décidé de ne pas poursuivre l’affaire. Ils voulaient protéger leur fille des regards sociaux à cause de la honte et d’abus social qu’elle pourrait subir si elle a été publiquement identifiée comme une victime de viol.

A FCI, nous travaillons avec la communauté à la base pour changer des perceptions sociales, les idées traditionnelles de la société par rapport au viol et d’autres violences sexuelles qui mettent la vie de la femme et des enfants en danger, qui contribuent à développer le sentiment de honte chez les victimes. Nous travaillons pour changer les comportements et attitudes de la communauté qui blâment les femmes qui sont victimes, parce que ces attitudes rendent presque impossible nos efforts d’empêcher les femmes victimes de souffrir. Par conséquent, nous adaptons notre stratégie de lutte contre la VBG à notre contexte culturel particulier. Au Mali les agresseurs ne craignent pas le système judiciaire de l’Etat parce qu’ils savent que les victimes maintiennent rarement leur plainte au niveau des tribunaux. Donc, ici au Mali nous nous concentrons d’abord sur l’information surtout la communication pour un changement de comportements et des idées sociales et culturelles autour de la VBG à travers l’éducation, la formation et la sensibilisation. C’est pourquoi les programmes de radio de FCI, les équipes de protection au niveau communautaire pour le dialogue social et nos autres programmes d’éducation sont en fait plus importants et pérenne pour mieux lutter contre les VBG.Nous sommes l’une des rares organisations au Mali qui entreprennent une stratégie ciblant la communauté à la base pour qu’elle soit au centre de l’intervention, en mettant l’accent sur la pérennisation de nos actions tout en apportant une réponse efficace à la situation en vue. Ce type de stratégie d’enseignement de la communauté et de sensibilisation à travers des programmes de radio, les équipes de protection et d’autres programmes d’éducation variés favorise la prévention des VBG mais aussi la réponse pour une prise en charge holistique. Nous espérons que ces activités permettront pour le Mali d’être un pays qui ne supporte ni la stigmatisation de victimes de la VBG ni les comportements et attitudes entravant les droits des femmes. C’est un engagement difficile à relever qui demande beaucoup de travail dur, mais avec les stratégies que nous développons pour nos projets et programmes, nous sommes sûr d’être en train de contribuer favorablement pour le changement de comportement social, culturelle au Mali pour le bonheur de tous.

 

Maternal health supplies ARE reproductive health supplies

2014 December 2
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Shafia Rashid is senior program officer for global advocacy at Family Care International.

In late October, the Reproductive Health Supplies Coalition (RHSC) held its annual membership meeting in Mexico City. Representatives from governments, international organizations, pharmaceutical companies, and civil society came together to press for greater and more equitable access to reproductive health supplies. The RHSC’s focus includes family planning commodities, such as condoms, oral contraceptives, and other methods that allow men and women to safely and effectively prevent or space pregnancies.

MH supplies briefs coverThis was my first time attending the annual RHSC meeting. I was there because the Coalition has expanded its mandate to explicitly address maternal health supplies. Earlier this year, it commissioned FCI to develop a series of seven policy briefs, Essential Medicines for Maternal Health: Ensuring Equitable Access for All, which were launched at the Mexico City meeting. These briefs highlight challenges and strategies for increasing the availability of three maternal health medicines – oxytocin, misoprostol, and magnesium sulfate – and:

  • Make the case for increasing priority and investment in these medicines
  • Provide examples of successful strategies from around the world
  • Highlight linkages with reproductive health supplies

A special plenary session addressed this crucial question: How are maternal health supplies reproductive health supplies? This sparked a wide-ranging, engaging, and very interesting discussion. Here are some of the key points that emerged:

  • Many countries can already see clear value in linking reproductive and maternal health supplies, and are moving toward integrating their supply chains to include family planning commodities and essential medicines, including medicines for maternal health. In Ethiopia, for instance, the government (with the support of in-country partners) integrated their supply chain to include all health commodities and to connect all levels of the supply chain with accurate and timely data for decision-making. In Nicaragua, where the supply chain was vertical until 2005, the health ministry has integrated the essential medicines system with the contraceptives’ supply chain, which has now been automated and expanded to include all essential medicines.
  • The RHSC and other partners have developed a wide range of tools and resources to support countries in strengthening their forecasting, procurement, and other supply chain functions. Tools originally developed with a sole focus on reproductive health supplies now include or can be adapted to apply to maternal health supplies as well, so they can now be used by country managers working to improve the supply of maternal health medicines.
  • Lessons learned from successes in improving access to family planning commodities can help us to effectively address the challenges related to maternal health medicines. Family planning advocates have, for example, tracked government expenditures on reproductive health supplies: in Indonesia, budget analysis and concerted advocacy led the mayors of five districts to increase their family planning budgets by as much as 80%. Similarly, many countries — including Bolivia, the Dominican Republic, El Salvador, Honduras, Nicaragua, and Paraguay – have established contraceptive security committees that bring together multiple supply chain stakeholders to support coordination, address long-term product availability issues, and reduce duplication and inefficiencies. These committees have advocated for increased financial support for contraceptives, improved inventory management, developed standard operating procedures, published reports, and provided technical assistance. These efforts to increase budgets and ensure commodity security for contraceptives can effectively adapted and expanded to improve financing and security for maternal health supplies as well.

Many parallels and potential synergies exist between maternal and reproductive health supplies, and the reproductive and maternal health communities must take action to address the interrelated barriers that prevent access to and use of life-saving commodities. These actions include:

  • Advocating for development and implementation of supportive policies at the national and sub-national levels, and for dedicated budget lines to enable monitoring and evaluation of policy implementation
  • Improving government systems and procedures for procuring high-quality medicines and maintaining their quality throughout the supply chain
  • Investing in a streamlined, coordinated supply chain across sectors and levels, reducing inefficiency and duplicative efforts
  • Strengthening the knowledge and skills of health providers so that they are aware of evidence-based policies and guidelines and can effectively administer these essential medicines

→ For more information, you can download the Essential Medicines for Maternal Health policy briefs here.

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Panelists at the plenary session, RHSC annual meeting, October 2014 Photo: RHSC

Health workers in many Kenyan clinics brave community health care alone

2014 November 18
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By Melissa Wanda

Melissa Wanda is Advocacy Program Officer for FCI Kenya. This article originally appeared on the blog for the Frontline Workers Health Coalition

In a village in rural Kenya, a woman in labor travels miles along rutted dirt roads to get to the nearest health center. She wants to give herself and her baby the greatest possible chance of surviving childbirth and returning home to begin new and healthy lives. When she arrives however, the gates are locked; the nurse has gone home.

Kenya, with only 11.8 health workers per 10,000 people (more than 40% below WHO’s recommendation of 22.8 per 10,000), is one of 57 countries — including 36 in Sub-Saharan Africa — with a critical shortage of health workers.

Many local health facilities have only one health worker, often a nurse, to provide all patient care. This puts a heavy strain on the health worker, and means that many intended 24-hour health facilities are often closed for extended periods of time. Kenya’s news media has also reported recent health worker strikes in reaction to late or non-payment of wages.

The Government of Kenya has committed to strengthening human resources for health in the public health system. Several civil society organizations (CSOs) working to improve reproductive, maternal, newborn, and child health (RMNCH) have come together to advocate for the fulfillment of this urgently important promise. This alliance, co-led by Family Care International (FCI) and the African Women’s Development and Communication Network (FEMNET) under FCI’s Mobilizing Advocates from Civil Society (MACS) project, is conducting advocacy at the county level in Kenya, since counties are responsible for making many health spending decisions in Kenya’s recently decentralized administrative structure and health system.

With support from the MACS project, Deutsche Stiftung Weltbevoelkerung (DSW), a member of the advocacy alliance in Kenya, has surveyed community perceptions of the need for more health workers, and explored how effectively county governments have invested in addressing those needs. Working in two urban and two rural counties, DSW conducted research at various levels of the health system, including outpatient dispensaries, health centers, and hospitals. DSW found that counties are not budgeting or investing spending adequately enough to ensure that facilities have enough health workers to provide high-quality services. Although special funding has been set aside nationally to hire new health workers, counties have mainly been spending this money to pay current staff. DSW is sharing these findings with MACS and county health authorities, leading to one county already committing to hire an additional 72 nurses.

Kenyan health workers share frustrations and challenges of working at understaffed health centers.

Kenyan health workers share frustrations and challenges of working at understaffed health centers.

DSW also brought together community members and health facility staff to discuss the state of care at local health facilities. Community members complained that lack of staff meant an absence of essential services, especially at night and on weekends. Health workers expressed the frustrations of working alone, often lacking the drugs and supplies they need to treat their patients, and the low morale that comes from working under those conditions. For example, one nurse described a recent evening when she was the lone nurse caring for six women in labor!

These community meetings opened new channels of communication, fostering greater understanding and accountability between health workers and the communities they serve. This enabled health system users and health workers to join together in search of practical solutions.

Peter Ngure, DSW’s project lead, shared with me a story about one community in which participants said they prefer to come to the hospital — a long distance from their homes —in the afternoon, so they have time in the morning to travel there. In response, the hospital rearranged staff work schedules, deploying more nurses in the afternoon than morning hours. Similarly, community members learned that the hospital holds Monday afternoon staff meetings, helping to explain why appointments are often unavailable at that time, which had been a repeated source of frustration and confusion.

“This dialogue between community members and health workers helped to build much-needed goodwill during these very challenging times,” said Mr. Ngure.

FCI, DSW and the members of the civil society advocacy alliance will use these findings and experiences to hold county governments accountable for addressing the health worker shortage. When the Kenyan Ministry of Health releases its upcoming human resources for health strategy, which will provide specific guidance on exactly how many health workers should be assigned to each health facility, alliance members will work to make sure that counties follow that national policy, so that every Kenyan mother, seeking care for herself and her baby, will be greeted by open gates and a health worker with the skills and resources to ensure their survival and good health.

 

The true cost of a mother’s death: Calculating the toll on children

2014 October 23
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By Emily Maistrellis

Emily Maistrellis is a policy coordinator at Harvard University’s FXB Center for Health and Human Rights and a research study coordinator at Boston Children’s Hospital. This article originally appeared on Boston NPR station WBUR’s CommonHealth blog. 

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A health worker interviews a client at a health care facility in Tharaka, Kenya. (Photo: Family Care International)

Walif was only 16 and his younger sister, Nassim, just 11 when their mother died in childbirth in Butajira, Ethiopia.

Both Walif and Nassim had been promising students, especially Walif, who had hoped to score high on the national civil service exam after completing secondary school. But following the death of their mother, their father left them to go live with a second wife in the countryside. Walif dropped out of school to care for his younger siblings, as did Nassim and two other sisters, who had taken jobs as house girls in Addis Ababa and Saudi Arabia.

Nassim was married at 15, to a man for whom she bore no affection, so that she would no longer be an economic burden to the family. By the age of 17, she already had her first child. Seven years after his mother died, Walif was still caring for his younger siblings, piecing together odd jobs to pay for their food, although he could not afford the school fees.

In all, with one maternal death, four children’s lives were derailed, not just emotionally but economically.

More than 1,000 miles away, in the rural Nyanza province of Kenya, a woman in the prime of her life died while giving birth to her seventh child, leaving a void that her surviving husband struggled to fill. He juggled tending the family farm, maintaining his household, raising his children and keeping his languishing newborn son alive.

But he didn’t know how to feed his son, so he gave him cow’s milk mixed with water. At three months old, the baby was severely malnourished. A local health worker visited the father and showed him how to feed and care for the baby. That visit saved the baby’s life.

As these stories illustrate, the impact of a woman’s death in pregnancy or childbirth goes far beyond the loss of a woman in her prime, and can cause lasting damage to her children — consequences now documented in new research findings from two groups: Harvard’s FXB Center for Health and Human Rights, and a collaboration among Family Care International, the International Center for Research on Women and the KEMRI-CDC Research Collaboration.

The causes and high number of maternal deaths in Ethiopia, Malawi, Tanzania, South Africa, and Kenya — the five countries explored in the research — are well documented, but this is the first time research has catalogued the consequences of those deaths to children, families, and communities.

The studies found stark differences between the wellbeing of children whose mothers did and did not survive childbirth:

  • Out of 59 maternal deaths, only 15 infants survived to two months, according to a study in Kenya.
  • In Tanzania, researchers found that most newborn orphans weren’t breastfed. Fathers rarely provided emotional or financial support to their children following a maternal death, affecting their nutrition, health care, and education.
  • Across the settings studied, children were called upon to help fill a mother’s role within the household following her death, which often led to their dropping out of school to take on difficult farm and household tasks beyond their age and abilities.

How do we use these new research findings to advocate for greater international investment in women’s health?

At a webcast presentation earlier this month, a panel of researchers, reproductive and maternal health program implementers, advocates and development specialists discussed that question.

Central to the discussion was the belief that the death of a woman during pregnancy and childbirth is a terrible injustice in and of itself. The vast majority of these deaths are preventable, and physicians and public health practitioners have long known the tools needed to prevent them. And yet, every 90 seconds a woman dies from maternal causes, most often in a developing country.

The panelists expressed hope that these new data, which show that the true toll of these deaths is far greater than previously understood, can help translate advocacy into action.

It’s important to recognize that, beyond the personal tragedy and the enormous human suffering that these numbers reflect — some hundreds of thousands of women die needlessly every year — there are enormous costs involved as well. -Panelist Jeni Klugman, a senior adviser to the World Bank Group and a fellow at the Harvard Kennedy School of Government.

“So quantifying those effects in terms of [children’s] lower likelihood of surviving, the enormous financial and health costs involved and the repercussions down the line in terms of poverty, dropping out of school, bad nutrition and future life prospects are all tremendously powerful as additional information to take to the ministries of finance, to take to the donors, to take to stakeholders, to help mobilize action,” said Klugman.

Just what does “action” mean? Currently, the countries of the world are debating the new global development agenda to succeed the eight Millennium Development Goals, an ambitious global movement to end poverty. Advocates can use this research to make the case that reproductive, maternal, newborn, and child health should play a central role in this agenda, given that it reveals the linkages between the health of mothers, stable families, and ultimately, more able communities, according to Amy Boldosser-Boesch, Interim President and CEO of FCI.

Panelists also called for more aggressive implementation of the strategies known to prevent maternal mortality in the first place; as well as for the provision of social, educational, and financial support to children who have lost their mothers; and for continued research that outlines the direct and indirect financial costs of a woman’s contributions to her household, and what her absence does to her family’s social and economic well-being.

But action is also required outside of the realm of health care, said Alicia Ely Yamin, lecturer in Global Health and Population at the Harvard School of Public Health and policy director of the FXB Center.

In fact, the cascade of ill effects for children and families documented by this research doesn’t begin with a maternal death. The plight of the women captured in these studies begins when they experience discrimination and marginalization in their societies: “It [maternal death] is not a technical problem. It’s because women lack voice and agency at household, community, and societal levels; and because their lives are not valued,” she said.

Klugman added that this research adds to work on gender discrimination, including issues like gender-based violence, which affects one in three women worldwide.

It’s a tall order: advancing gender equality, preventing maternal, newborn, and child death, and improving the overall well-being of families. But panelists were hopeful that this research can show policy makers, and the public, that these issues are intertwined, and must be addressed as parts of a whole.

As Aslihan Kes, an economist and gender specialist at ICRW and one of the researchers on the Kenya study concluded, this research is “making visible the central role women have in sustaining their households.”

This is an opportunity to really put women front and center, making all of the arguments for addressing the discrimination and constraints they face across their lives. -Aslihan Kes

 

Making a human-rights and socioeconomic case for preventing maternal mortality

2014 October 22
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By Katie Millar
Katie Millar is a technical writer for the Maternal Health Task Force (MHTF), where this article originally appeared. 
Panel at Women's Lives Matter

Photo: MHTF

On October 7, 2014, a panel of experts in maternal health—moderated by Dr. Ana Langer, the Director of the Maternal Health Task Force—gathered at the Harvard School of Public Health to discuss the socioeconomic impact of a maternal death on her family and community. Several studies were summarized and priorities for how to use this research were discussed by the panel and audience at “Women’s Lives Matter: The Impact of Maternal Death on Families and Communities.”

What does the research say?

In many countries around the world, the household is the main economic unit of a society. At the center of this unit is the mother and the work—both productive and reproductive—that she provides for her family. A study in Kenya, led by Aslihan Kes of the International Center for Research on Women (ICRW) and Amy Boldosser-Boesch of Family Care International (FCI), showed great indirect and direct costs of a mother losing her life. This cost is often accompanied by the additional cost and care-taking needs of a newborn. “Once this woman dies the household has to reallocate labor across all surviving members to meet the needs of the household. In many cases that meant giving up other productive work, loss of income, hiring an external laborer, girls and boys dropping out of school or missing school days to contribute [to household work],” shared Kes. In addition, the study done in Kenya determined that families whose mother died used 30% of their annual spending for pregnancy and delivery costs; a proportion categorized by the WHO as catastrophic and a shock to a household.

Similar research was conducted in South Africa, Tanzania, Ethiopia, and Malawi by Ali Yamin and colleagues. In addition to similar socioeconomic findings to those in Kenya, Yamin found that less than 50% of children survived to their fifth birth if their mother died compared to over 90% of children whose mothers lived. An even more dramatic relationship was found in Ethiopia with 81% of children dying by six months of age if their mother had died. In South Africa, mortality rates for children whose mothers had died were 15 times higher compared to children whose mothers survived.

Increasing the visibility of maternal death

While a family is grappling with grief they are also making significant changes in roles and structure to meet familial needs. Dr. Klugman emphasized this point when she said, “Quantifying [the] effects [of maternal death]… and the repercussions down the line—in terms of poverty, dropping out of school, bad nutrition, and future life prospects—I think are all tremendously powerful. [This] additional information [is] very persuasive—to take to the ministries of finance, to take to donors, to take to stakeholders—to help mobilize action for the interventions that are needed.”

Apart from the economic and social costs, is a foundation of human rights violations and gender inequalities. The high rate of preventable maternal mortality is no longer a technical issue, but a social issue. “Maternal mortality it is a global injustice. It is the indicator that shows the most disparities between the North and the developing world in the South. It’s not a technical problem, it’s because women lack voice and agency at household, community, and societal levels and because their lives are not valued. Through this research of showing what happens when those women die, it shows in a way how much they do [and how it] is discounted,” said Dr. Yamin, whose research focuses on the human rights violations in maternal health.

Leveraging this research for improved reproductive, maternal, newborn, and child health

The research findings are clear: prevention of maternal mortality is technically feasible, the right of every woman, and significantly important for the well-being of a family and a community. Boldosser-Boesch provided three reasons why making the case for preventing maternal mortality is critical at this time.

  1. These findings strengthen our messaging globally and in countries with the highest rates on the importance of preventing maternal mortality, by increasing access to quality care, which includes emergency obstetric and newborn care.
  2. This research supports integration across the reproductive, maternal, newborn, and child health (RMNCH) continuum to break down current silos in funding and programs.
  3. “We are at a key moment… for having new information about the centrality of RMNCH to development, because… the countries of the world are working now to define a new development agenda, beyond the MDGS, post-2015. And that agenda will focus a lot on sustainable development… and we see in these findings… , connections to the economic agenda…, questions of gender equality, particularly what this means for surviving girl children, who… may experience earlier marriage or lack of access to education,” shared Boldosser-Boesch.

In order to move the agenda forward on preventing maternal mortality and ensuring gender equality, ministries of health and development partners must be engaged. In addition, donors can fund the action of integration to address a continuum approach and media outlets should be leveraged to disseminate these findings and hold governments accountable for keeping promises and making changes. The prevention of maternal mortality is a human rights-based, personal, and in the socioeconomic interest of a family, community, and a society.

This panel included:

  • Ana Langer, Director of the Maternal Health Task Force
  • Alicia Yamin, Lecturer on Global Health at the Harvard School of Public Health
  • Amy Boldosser-Boesch, Interim President & CEO, Family Care International
  • Jeni Klugman, Senior Adviser at The World Bank Group
  • Aslihan Kes, Economist and Gender Specialist, International Center for Research on Women

Watch the webcast here.

UNGA week shows maternal and newborn health are central to development challenges

2014 October 10
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Amy Boldosser-Boesch is the Interim President and CEO at Family Care International. This article originally appeared on the Healthy Newborn Network (HNN) blog.  

CD cover 2This year’s UN General Assembly was full of high-profile moments that reinforced the need for investment and action to improve reproductive, maternal, newborn and child health (RMNCH): the launch of a Global Financing Facility to Advance Women’s and Children’s Health; the release of reports tracking stakeholders’ fulfillment of commitments to Every Woman Every Child; new data on maternal, newborn and child survival from Countdown to 2015; and a plethora of side events focusing on strategies and country progress toward MDGs 4 and 5. For Family Care International, which advocates for improved reproductive, maternal, and newborn health, this unprecedented level of attention to women’s and children’s health is a welcome sign that our advocacy is having an impact, and that global commitment to ending all preventable maternal and child deaths is stronger than ever.

RMNCH was a key theme in many other important discussions during the week, demonstrating the centrality of the health of mothers and newborns to a range of development challenges.

  • Events began with a Climate Summit that brought together leaders from more than 120 countries. The Partnership for Maternal, Newborn & Child Health noted during the Summit that “women and children are the most vulnerable to the effects of a changing climate, and those who are more likely to suffer and die from problems such as diarrhoea, undernutrition, malaria, and from the harmful effects of extreme weather events such as floods or drought.”
  • There was a special session to review progress towards achieving the International Conference on Population and Development Programme of Action. The ICPD agenda highlights the importance of ensuring universal access to sexual and reproductive health and rights and the importance of quality and accessible maternal health care, recognizing that healthy girls and women can choose to become healthy moms of healthy babies.
  • The UN Security Council held an emergency meeting where President Obama called for swift action on the Ebola epidemic that is destroying lives and decimating African health systems. This crisis highlights already-fragile health systems that lack sufficient health workers, supplies, and essential medicines–the same failures that contribute to maternal and newborn mortality. A recent news story details how pregnant women who are not infected with Ebola risk dying in West Africa due to lack of access to maternal health services, and the same risk exists for newborns and young children. The loss of skilled healthworkers, particularly midwives, could have enormous long term impacts on the ability of women, newborns and children to access life-saving care.
  • Finally, the UNGA week included high-level meetings on humanitarian crises in Syria, South Sudan and many other countries. According to the State of the World’s Mothers 2014 report, more than half of all maternal and child deaths occur in crisis-affected places. Discussions of humanitarian response in crisis settings included recognition of the disproportionate impact on women and children of violence, including gender-based violence, displacement, lack of access to food and lack of access to crucial maternal health services and early interventions for newborns. These crises and fragile health systems make achieving the Every Newborn Action Plan recommendations on ensuring quality care for mothers and newborns during labor, childbirth and the first week of life more difficult, but also more critical.

While this long list of world crisis may seem overwhelming, there is some good news on maternal, newborn and child survival. As the UN Secretary-General reminded us, the world is reducing deaths of children under the age of five faster than at any time in the past two decades and significant declines in maternal mortality have occurred in the past 10 years. As the world works together to shape the post-2015 development goals, these experiences during UNGA show that the new agenda must prioritize continuing to address maternal, newborn and child mortality which is linked to many of the world’s pressing development challenges, including poverty. As a recent editorial in The Lancet says, “As governments slowly come to an agreement about development priorities post-2015, it is clear that maternal and newborn health will be essential foundations of any vision for sustainable development between 2015 and 2030.”