Maternal health equity is a urgent problem that can be solved

Maternal health equity is a urgent problem that can be solved

Worldwide, we are losing ground on maternal health outcomes. 

Maternal deaths are rising in many parts of the world, and we are not on track to meet SDG 3.1: Reduce the global maternal mortality ratio (MMR) to less than 70 per 100 000 live births by 2030. In February 2023, the WHO released a report indicating that nearly 800 women died every day in 2020 – about one woman every two minutes. 

More importantly, maternal deaths are not distributed equally. On a global scale, most maternal mortality is concentrated in sub-Saharan Africa (69%), particularly West Africa. Pregnancy-related causes are still the leading cause of death among African women aged 15-29. In the US, black women are 2.6 times more likely to die due to childbirth than white women. 

This significant equity challenge is being overlooked; the deaths of mothers deserve more attention and more resources. Within Mali, even though pregnancy is deadlier than armed conflict, the world pays far more attention to

At the same time, nearly every maternal death could be prevented. Though there is no standardized global data, studies from sub-Saharan Africa routinely show that over 90% of the causes of maternal deaths could be avoided with access to basic, quality maternal healthcare. In the US, more than 80% of maternal deaths could be avoided.

This contradiction is important and revealing – maternal mortality is mostly preventable, but we are still failing to prevent it. African women, and black women in the US, are dying at significantly higher rates. We must confront this truth, and its origins. We know what interventions work to improve maternal health outcomes. Our focus must stay on why all women and all communities don’t have access to them, and fix it.

Our current systems, strategies, institutions, and financing are not reaching the women most in need, because the women most in need are not represented in our current systems, strategies, institutions, and financing. In our current approaches, marginalized women and communities are usually rendered as passive recipients of services, not as actors with agency who are essential participants in the development of remedies to these deep and historic inequities.

To fix this problem, as Dr. Mary-Ann Etiebet noted, it is not just about what we do. It is about how we do it. We will not fix it by continuing to use the same approaches that have created and are maintaining these gaps in maternal health equity. It won’t be solved from the top-down, which is still how most of the world’s global public health systems work. What’s required is not developing a new technology or innovation.

If we are going to stop and reverse the increasing trend in maternal mortality, the women and the communities most affected must be at the heart of solutions.

If we do not change our approach, the result would be disastrous. By one estimate, if the reduction of maternal deaths continues at its current rate, SDG 3.1 would not be met in the African Region until 2100, after 125 million mothers died from a cause related to childbirth.

So what does it mean to change the how of our sector? What would it mean to dismantle entrenched systems designed to retain power and decision-making in certain hands? How do we prioritize and center the voices, experiences, and knowledge of those whose needs are not being met?

Instead of continuing to operate through our existing institutions and structures, and building interventions around their capacity to deliver or distribute solutions to a population, it means turning our focus to the mother who needs access to those solutions and starting to address the problem from her perspective.

 It requires a complete shift towards a more fundamental question of who is invited to participate in the solving – who is invited to participate in the how.  It means being willing to give up control and to pursue solutions that put power and resources into local hands.

We are trying to put this shift into practice every day. Whether it is adapting traditional quality improvement processes so they can be led by local teams of women and stakeholders, or redefining local health financing to ensure that women have the ability to build and manage their own health-financing resources, we strive to use a women-centered approach in every strategy. We convene and support women, community members, and providers in the community health system to work together to identify and solve obstacles to quality maternal healthcare in their communities.

Ending preventable maternal mortality is a problem that can be solved, but only if we’re willing to change how we try to solve it.

Investir dans les agents de santé au niveau communautaire

Investir dans les agents de santé au niveau communautaire

Veuillez trouver ce message en anglais ici.

Dirigée par le Frontline Health Workers Coalition et partenaires, la Semaine mondiale des agents de santé/World Health Worker Week (WHWW) rassemble des défenseurs, des agents de santé, des dirigeants et des communautés pour demander plus de ressources pour soutenir les agents de santé.

S’adressant principalement aux décideurs politiques et aux dirigeants mondiaux, l’objectif de cette semaine est d’exhorter les décideurs à donner suite aux engagements mondiaux et à investir, protéger et soutenir le personnel de santé, en particulier les femmes. 

Le thème 2024 est  Sur et Soutenu : Investir dans les agents de santé /Safe and Supported : Invest in Health Workers. Les arguments en faveur d’un investissement dans les agents de santé communautaires sont clairs et prouvés. Bien qu’il ait été démontré que le retour sur investissement financier pour le personnel de soins de santé primaires atteint 10 :1, le déficit de financement actuel des programmes de santé communautaire est estimé à 5,4 milliards de dollars par an.

Sur le continent africain, il existe de nombreux contextes dans lesquels les dirigeants et les décideurs ont pris des engagements politiques liés à l’investissement dans la santé, mais ne les ont pas encore mis en œuvre. En 2001, les pays de l’Union africaine se sont fixé pour objectif d’allouer au moins 15 % de leur budget national annuel au secteur de la santé, connu sous le nom de Déclaration d’Abuja. Mais atteindre cet objectif est resté insaisissable. Au Mali, avant la COVID-19 et les dernières transitions de gouvernance, les dépenses du Mali dans le secteur de la santé étaient d’environ 4 %.

Combien de temps faudra-t-il pour qu’un plus grand nombre de pays soient en mesure d’atteindre les objectifs de la Déclaration d’Abuja ?

S’il est nécessaire d’augmenter les dépenses consacrées aux soins de santé primaires, investir dans les agents de santé ne peut pas simplement se résumer à une augmentation des dépenses nationales ou à une augmentation du financement des donateurs internationaux.

Quelle qu’en soit la cause, il est clair qu’il n’y a pas eu d’investissements nationaux et internationaux plus importants dans les systèmes de santé et les agents de santé. Au Sahel, même avec des décideurs politiques et des trésors volontaires, les conflits armés et les gouvernements militaires de transition constituent un problème croissant à l’augmentation des investissements nationaux dans la santé. En outre, dans les systèmes de santé décentralisés, l’augmentation des investissements nationaux n’atteint pas nécessairement les systèmes de soins primaires, dans la mesure où les systèmes de santé communautaire ne sont pas principalement financés par le gouvernement national.

Si ce n’est les décideurs politiques et les dirigeants, qui peut investir dans les agents de santé comme tant de patients et de communautés ont-elles désespérément besoin ? Existe-t-il d’autres stratégies et investisseurs possibles ? Surtout dans les systèmes de santé décentralisés ?

Les communautés sont négligées en tant que partenaires essentiels pour investir dans les programmes de santé communautaire.

Les appels à une augmentation du financement et des investissements dans le domaine de la santé se terminent généralement au niveau national. Même les termes « financement local » et « mobilisation des ressources intérieures » sont principalement utilisés pour désigner les budgets nationaux. Mais si nous terminons notre plaidoyer à ce niveau, nous négligeons un éventuel financement de la santé qui serait plus localisé, notamment au niveau du district, de la communauté, des ménages et même du financement individuel de la santé.

N’oublions pas non plus l’initiative de Bamako de 1987, dont le but était d’accroître la participation de la communauté non seulement à la prise de décision et à la gouvernance du système de soins de santé primaires, mais également à son financement.

Au cours des dernières années, Mali Health a cherché à mieux comprendre qui peut investir et soutenir les agents de santé. Dans le système de santé décentralisé du Mali, nous cherchons à contribuer à l’élaboration de solutions communautaires pour investir et soutenir les agents de santé communautaires, notamment dans les communautés périurbaines.

Bien entendu, il ne s’agit de dire que les agents de soins primaires ne devraient pas être une priorité en matière de politique de santé pour chaque gouvernement national, comme c’est le cas au Mali. Mais alors que nous continuons de plaider en faveur d’investissements accrus et de la réalisation des ambitions de la Déclaration d’Abuja, les femmes et les enfants ont besoin d’agents de santé dès maintenant, et nous pouvons travailler dès maintenant sur des solutions locales pour soutenir les agents de santé.

Par exemple, il existe déjà une source de financement de la santé très localisée, en grande partie grâce à l’Initiative de Bamako. Outre le financement des donateurs externes et les dépenses intérieures, les paiements directs constituent une source importante de financement de la santé dans la plupart des pays africains – correspondant et dépassant dans de nombreux cas d’autres types de dépenses. Malheureusement, les frais d’utilisation sont inéquitables et onéreux, mais ils constituent aujourd’hui un élément essentiel du financement des systèmes de soins primaires, en particulier dans les systèmes de santé décentralisés.

Mais ces stratégies ne représentent qu’une méthode parmi d’autres pour impliquer la communauté dans le financement des services de santé. Alors que nous plaidons pour le remplacement des paiements directs et des frais d’utilisation, nous avons l’opportunité de les réaffecter, ainsi que d’autres ressources communautaires, à des stratégies plus équitables, abordables et durables qui pourraient canaliser les ressources locales dirigées par la communauté pour investir dans le personnel de santé. Le Rwanda offre un excellent exemple de la manière dont les stratégies de financement communautaire de la santé peuvent mobiliser les ressources communautaires et locales pour un accès plus équitable à des soins de santé de qualité, parallèlement aux investissements nationaux et des donateurs.

 Pour améliorer l’équité en santé, répondre aux besoins urgents en matière de santé et surmonter la pénurie attendue de personnel de santé, nous ne pouvons pas dépendre seuls de l’augmentation des budgets nationaux ou de l’augmentation du financement des donateurs. Même s’ils font partie de la solution, ils ne constituent pas la solution complète. Alors que nous travaillons avec les décideurs politiques et les dirigeants, n’oublions pas non plus ceux qui sont proches de ces défis et qui travaillent dur pour soutenir les agents de santé de leur communauté au quotidien. Ils ont des perspectives et des idées précieuses, non seulement en tant que bénéficiaires des services des agents de santé, mais aussi en tant qu’investisseurs dans ces services.

Commençons par réfléchir aux investissements afin que tous les agents de santé puissent bénéficier d’un soutien et d’une sécurité assurés, non seulement de haut en bas, mais également de bas en haut.

 

 

 

Investir dans les agents de santé au niveau communautaire

Investing in health workers, from the ground up

Veuillez trouver ce message en français ici.

Led by the Frontline Health Workers Coalition and partners, World Health Worker Week (WHWW) brings together advocates, health workers, leaders, and communities calling for more resources to support health workers.

Directed primarily at policymakers and global leaders, the goal of this week is to urge decisionmakers to follow through on global commitments and to invest in, protect, and support the health workforce, especially women.  The 2024 theme is Safe and Supported: Invest in Health Workers.

The case for investing in community health workers is clear and proven, with immense health, social, and economic returns. Though the financial return on investment for the primary health care workforce has been demonstrated to be as high as 10:1, the current funding gap for community health programs is estimated to be $5.4 billion annually.

Across the African continent, there are many contexts in which leaders and decisionmakers have made policy commitments related to investing in health, but have not yet implemented them.  In 2001, African Union countries set a target of allocating at least 15% of their annual national budgets to their health sectors, known as the Abuja Declaration. But achieving this goal has remained elusive. In Mali, before COVID-19 and the latest governance transitions, Mali’s spending on its health sector was around 4%.

How much longer will it take for more countries to be able to reach the Abuja Declaration targets?

While increasing spending on primary healthcare is necessary, investing in health workers cannot simply be a matter of increasing national spending, or increasing international donor funding.

Whatever the cause, it is clear that greater domestic and international investments in health systems and health workers have not been forthcoming. In the Sahel, even with willing policymakers and treasuries, armed conflict and transitional military governments are a growing obstacle to increased national investment in health. Furthermore, in decentralized health systems, increased national investment may not even necessarily reach primary care systems, as community health systems are not principally financed by the national government.

If not policymakers and leaders, who can do the investing in health workers that so many communities desperately need? Are there other strategies and possible investors? Especially in decentralized health systems?

Communities are being overlooked as essential partners for investing in community health programs.

The calls for increased health financing and investment usually end at the national level. Even the terms “local financing” and “domestic resource mobilization” are mostly used to refer to national budgets. But if we end our advocacy there, we neglect possible health financing that is more localized including district, community, household, and even individual health financing. 

Let us also not forget the Bamako Imitative of 1987, whose purpose was to increase the participation of the community not only in the decision making and governance of the primary care health system, but in its financing as well.

For the past several years, Mali Health has been seeking to expand the understanding of who can do the investing and supporting of health workers. In Mali’s decentralized health system, we are seeking to help build community-led solutions for investing in and supporting community health workers.

To be sure, we do not mean to suggest that primary care workers should not be a health policy priority for every national government, as they are in Mali. But as we continue to advocate for greater investment and the fulfillment of the ambitions of the Abuja Declaration, women and children need health workers now, and we can work on local solutions to support health workers now.

For example, there is already a source of health financing that is highly localized, largely due to the Bamako Initiative. In addition to external donor funding and domestic spending, out of pocket payments (OOPs) are a significant source of health financing in most African countries – matching and exceeding other types of spending in many cases. Regrettably, OOPs and user fees are inequitable and burdensome, but they are a critical component to how primary care systems are financed today, especially in decentralized health systems.

But user fees and OOPs represent just one method for community involvement in the financing of health services. As we advocate for replacements to OOPs and user fees, we have an opportunity to reallocate them and other community resources into more equitable, affordable and sustainable strategies that could channel local, community-led resources to invest in the health workforce. Rwanda provides an excellent example for how community-based health insurance can mobilize community and local resources for more equitable access to quality healthcare, alongside national and donor investments.

To improve health equity, meet urgent health needs, and overcome the expected health workforce shortage, we cannot depend alone on increased national budgets or increased donor funding. While part of a solution, they are not the whole solution. As we work with policymakers and leaders, let us also not forget those with proximity to these challenges, and who work hard to support health workers in their community every day. They have valuable perspectives and insights, not simply as the recipients of health worker services, but as investors in them.

Let us begin to think about investment so that all health workers can be safe and supported, not just from the top down, but also from the bottom up.

Meet Aïssata, SHARE manager

Meet Aïssata, SHARE manager

While reflecting on progress, accomplishments, and goals yet to be achieved after her 15 years of community health and development work, Aïssata Touré, Mali Health’s SHARE project manager, tentatively says, “we’re doing the maximum, but we can still do more.” SHARE is a component of our savings group program aimed specifically at bolstering perinatal care and assisted births among pregnant women.

As a lifelong resident of Sikoro, the community where Mali Health was born, Aïssata has been an intimate witness to, and a driver of social transformation within her community. While growing up, her mother founded L’Association Muso Kalanso, The Association of Women’s Education. It was a grassroots community savings and education group in Sikoro, and simultaneously ran a nearby kindergarten. So working directly with pregnant women as Mali Health’s SHARE project manager, Aïssata feels right at home.

At only 26-years old, experience and ambition don’t fully describe the path Aïssata has blazed thus far. “Since I was the first child in my family,” she explains, “I had to believe that I could do anything boys could do.” Aïssata’s parents frequently tasked her with chores and errands usually associated with boys, so she quickly developed a thick skin and personal resolve with which she navigates complicated gender norms today. “The worst,” she laughs, “was carrying huge batteries across Sikoro to get recharged for nighttime electricity. I think those experiences pushed me to do more, to expect more,” she says.

Mali ranks among the countries with the highest gender discrimination in the world. Aïssata consciously lives her life as a positive example for other young girls in Sikoro, especially her own 9-year old daughter. She was the first in her family to attend university, receiving a degree in Economics from the University of Bamako. “Women can do anything. We just have to be brave.”

Since I was the first child in my family, I had to believe that I could do anything boys could do…Women can do anything. We just have to be brave.

– Aïssata Touré

At 13 years old, Aïssata volunteered as a peer-educator throughout her district’s school system to perform theater skits about about HIV prevention and treatment. “Oh yeah! I was terrified before my first performance,” she remembers. Within a few years she was running health advocacy radio programs throughout Bamako as assistant director.

By 2013, Aïssata was already on a list of community surveyors that Mali Health contracted to conduct various impact evaluations of our programs in Sikoro. At the time, she was working on her radio program, women’s savings groups, and maternal health volunteer work with the Red Cross. When she saw a job posting for Mali Health’s Assistant to the Advocacy and Radio Program, she took the opportunity. From then on, “every year I wanted more. In my performance reviews I would push for more responsibility.” The following year Aïssata transitioned to Communications and Public Relations Assistant, and the year after to become project manager for SHARE, her current position.

What’s the connection between her mother’s lifelong work with women’s groups and Aïssata’s own career choices? “Just a coincidence.” And between Aïssata and her own daughter: “I’m not sure, we’re very different—she’s super ambitious!”

The apple never falls far from the tree.

Meet Mah

Meet Mah

Mah Diarra lives in Lassa, a small community that feels remote, even though it sits in the hills on the western edge of Bamako, Mali’s bustling capital. 

Last year, nearly four months into her pregnancy, Mah hadn’t yet seen a doctor because she couldn’t afford to. One day, a friend told her about Mali Health’s new SHARE savings groups, which help women during their pregnancy. SHARE, or Savings for Health And Reproductive Empowerment, helps mothers to save for all the costs associated with their pregnancy, including prenatal care and delivery at a community health center. 

Mah met with one of Mali Health’s animateurs, the community members who support and coordinate the savings groups. She enrolled and immediately started to save money to pay for the costs associated with her maternal care and delivery.

Women in savings groups save and lend their own money for group activities. Mali Health encourages them to use funds for health purposes and offers health education sessions at each meeting. Women learn about the most common and dangerous diseases, including malaria, malnutrition, diarrhea, and respiratory infections, plus effective techniques to prevent them. They learn about the benefits of prenatal and postnatal care, and of giving birth in a health center. Women also learn financial management skills that can help them to build greater financial independence.

Today, Mah is the mother of a beautiful, happy little girl. Mah knows that her daughter’s health is due in part to her ability to receive all her maternal care. She was relieved to deliver safely in the health center, but knows most women do not have the same experience. In fact, only 56% of women in Mali have a skilled attendant when giving birth.

Because of her experience, Mah now reaches out to other women in Lassa, encouraging them to enroll in SHARE. She speaks proudly of her experience, with her daughter at her side:

Following my prenatal care sessions with a doctor, I carried my pregnancy to term in good health! Before I joined my savings group, I had no knowledge about my pregnancy, the danger signs, and everything else that comes along with motherhood. 

I joined the SHARE group four months into my pregnancy. The doctors advised me to attend all of my prenatal care (ANC) visits. With the help of other women in my group, I saved 750 CFA (~$1.30) every other week to help pay for my care. Meanwhile, Mali Health gave me a grant of 5,000 CFA (approximately $8-9 USD) to support my delivery in a health center.

These many benefits of the Savings for Health program allow all of us to be satisfied, happy mothers.

Mah speaking about SHARE, before she gave birth
Mah encourages other women in her community to join SHARE