91294
H N P D i s c u s s i o n P a p e R
MATERNAL AND CHILD SURVIVAL:
Findings from five countries’ experience in addressing
maternal and child health challenges
Rafael Cortez, Seemeen Saadat, Sadia Chowdhury and Intissar Sarker
May 2014
MATERNAL AND CHILD SURVIVAL:
Findings from five countries’ experience
in addressing maternal and child health
challenges
Rafael Cortez, Seemeen Saadat,
Sadia Chowdhury and Intissar Sarker
May 2014
Health, Nutrition and Population (HNP) Discussion Paper
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© 2014 The International Bank for Reconstruction and Development / The World Bank
1818 H Street, NW, Washington, DC 20433
All rights reserved.
ii
Health, Nutrition and Population (HNP) Discussion Paper
Maternal and Child Survival:
Findings from five countries’ experience in addressing maternal and child health
challenges
Rafael Corteza Seemeen Saadatb Sadia Chowdhuryc Intissar Sarkerd
a
Human Development Network, The World Bank, Washington DC, USA
b
Human Development Network, The World Bank, Washington DC, USA
c
Human Development Network, The World Bank, Washington DC, USA
d
Human Development Network, The World Bank, Washington DC, USA
This paper was prepared as part of a Joint initiative on Maternal and Child Health
undertaken by the World Bank, the Partnership for Maternal, Newborn, and Child Health
(PMNCH), the World Health Organization (WHO), United States Agency for
International Development (USAID), Alliance for Health Policy and Systems Research
(AHPSR), Johns Hopkins University, Global Health Insights, London School of Hygiene
and Tropical Medicine, University of St Gallen, Cambridge Economic Policy Associates
and MamaYe– Evidence for Action. Details about this initiative are available at:
http://www.who.int/pmnch/knowledge/publications/successfactors/en/
Abstract: Considerable progress has been made towards the achievement of the
Millennium Development Goals (MDGs) since 1990. Although advances in improving
MDG 4 and MDG 5a (reducing child and maternal mortality, respectively) have been
made, progress is some countries have been insufficient. While some countries have
made substantial gains, others have not. This paper is part of a larger study that aims to
address this gap in knowledge. The paper discusses the findings from qualitative case
studies of five countries that are either on track to meet MDGs 4 and 5a by 2015 or have
made significant progress to this end (Bolivia, China, Egypt, Malawi and Nepal).
Although they have different socio-economic characteristics, all have made significant
advancements due to a strong commitment to improving maternal and child health. To do
this, strong political commitment, through policies backed by financial and programmatic
support, was critical. In addition, focusing on the most vulnerable populations helped
increase access to and use of services. Empowering women and families through
education, employment, and poverty reduction programs have led to better health
outcomes. These countries still face challenges, however, in terms of the evolving health
system, and changes at the economic, social and political levels. Future qualitative and
quantitative analyses on the returns of health investments, the political context and
institutional arrangements at the country level could help deepen the understanding of the
ways in which various countries, with their unique conditions, can improve MCH.
iii
Keywords: Reproductive, Maternal, Child, Neonatal, Health, Fertility, Adolescent,
Family Planning, Immunization, Childhood Illness, Survival, Mortality, Community,
Health Workers, Skilled Birth Attendance, Service Delivery, Healthcare Financing,
Insurance, Empowerment, Leadership, Poverty
Disclaimer: The findings, interpretations and conclusions expressed in the paper are
entirely those of the authors, and do not represent the views of the World Bank, its
Executive Directors, or the countries they represent.
Correspondence Details: Rafael Cortez, World Bank, 1818 H Street, NW,
Washington, DC 20433; telephone: (202) 458-8707; fax: (202) 522-3234; e-mail:
rcortez@worldbank.org; website: http://www.worldbank.org/hnp.
iv
Table of Contents
ACKNOWLEDGMENTS .............................................................................................. VI
INTRODUCTION............................................................................................................. 7
METHODOLOGY ............................................................................................................... 7
COUNTRY CONTEXT ......................................................................................................... 8
FACTORS THAT REDUCED MATERNAL MORTALITY .................................... 11
AFFORDABLE SERVICES FOR THE POOR........................................................................... 11
GEOGRAPHICALLY-ACCESSIBLE SERVICES ..................................................................... 13
MONITORING OUTCOMES TO EVALUATE ACCOUNTABILITY AND GOVERNANCE .............. 18
SETTING POLITICAL AND PROGRAM PRIORITIES (RMNCH) ............................................ 19
ENABLING ENVIRONMENT .............................................................................................. 21
Education ................................................................................................................... 21
Women’s empowerment ............................................................................................. 22
Social inclusion.......................................................................................................... 23
Poverty reduction ...................................................................................................... 24
CONCLUSIONS ............................................................................................................. 24
RECOMMENDATIONS AND NEXT STEPS ........................................................................... 27
REFERENCES ................................................................................................................ 28
ANNEX: COUNTRY PROFILES ................................................................................. 33
ANNEX 1: BOLIVIA’S PROGRESS ON MDGS 4 AND 5 ...................................................... 33
ANNEX 2: CHINA’S PROGRESS ON MDGS 4 AND 5 ......................................................... 44
ANNEX 3: EGYPT’S PROGRESS ON MDGS 4 AND 5 ......................................................... 55
ANNEX 4: MALAWI’S PROGRESS ON MDGS 4 AND 5 ..................................................... 66
ANNEX 5: NEPAL’S PROGRESS ON MDGS 4 AND 5 ......................................................... 77
v
ACKNOWLEDGMENTS
This report was prepared by a team of World Bank staff and Consultants composed of
Rafael Cortez (Task Team Leader), Seemeen Saadat, Sadia Chowdhury and Intissar
Sarker.
The report is part of a larger collaboration with the Partnership for Maternal, Newborn,
and Child Health (PMNCH) on understanding the factors behind countries’ performance
on MDGs 4 and 5. The authors would also like to thank Nicole Klingen (Practice
Manager, GHNDR, World Bank); and Carole Presern (Executive Director, Partnership
for Maternal, Newborn and Child Health, PMNCH), Shyama Kuruvilla (Senior Technical
Officer, PMNCH) and Jennifer Franz-Vasdeki (Economist, PMNCH) for their continued
support and feedback. The report benefitted from the literature review and quantitative
mapping conducted at the Alliance for Health Policy and Systems Research Secretariat in
collaboration with the World Health Organization.
The findings presented in the report are based on case studies conducted on five
countries. The authors would like to thank Susan Harmeling, Deborah Neveloff, Guo
Yan, Badri Raj Pande, Werner Christian Valdez Romero, Adamson Muula, and Gehan
Beltagy for background research and stakeholder interviews. The case studies also
benefitted from contributions from the following World Bank GHNDR staff: Alaa
Mahmoud Hamed Abdel-Hamid, John Paul Clark, Amparo Gordillo-Tobar, Fernando
Lavadenz, Akiko Maeda, Andre Medici, Gandham NV Ramana, Albertus Voetberg,
Shiyong Wang and Shuo Zhang.
A special thanks goes to Daniela Hoshino (GHNDR) and Karen Lorena Hoyas (GHNDR)
for providing all the necessary administrative support; and Diane Stamm and Barbara
Koppel for providing excellent editorial support.
The authors are grateful to the World Bank for publishing this report as an HNP
Discussion Paper.
vi
INTRODUCTION
1. Since 1990, progress has been made towards the achievement of the Millennium
Development Goals (MDGs), which include, among others, reducing extreme poverty,
attaining universal primary education, and promoting gender equality. Despite some
success in Reproductive, Maternal, Newborn and Child Health (RMNCH), progress on
MDG 4 and MDG 5a (reducing child and maternal mortality, respectively) has been
limited in many high burden countries. Of the 75 countries with the highest rates of
maternal and child mortality (identified by the Countdown to 2015 Initiative 1), 23 are “on
track” to achieve MDG 4, and 9 to meet MDG 5a (WHO and UNICEF 2010; UNICEF
2012; WHO 2012). Of these, only 8 are on track for both, including Bangladesh,
Cambodia, China, Egypt, Eritrea, the Lao People’s Democratic Republic, Nepal, and
Vietnam. This list has been updated since 2010 when the project was first launched. At
that time, Bolivia was also on track to meet MDG 5, but new estimates indicate that
Bolivia is “making progress.”
2. Progress in improving RMNCH varies. While some countries have made
substantial gains, others with similar socio-economic conditions and demographic
markers, have not. Also, and as this study highlights, countries with different socio-
economic characteristics have reduced maternal and child mortality and morbidity.
Unfortunately, there are only a few cross-country analyses of policies to identify the
factors contributing to successful RMNCH results (Goodburn and Campbell 2001). This
study is part of a larger project that aims to address this gap in knowledge.
3. This paper reviews qualitative case studies of five countries (Bolivia, China,
Egypt, Malawi and Nepal) that are either on track to meet MDG 4 and MDG 5a by 2015
or have made significant progress to this end. The paper compares the main findings
across the five countries, presents the methodology and country contexts, and
conclusions.
METHODOLOGY
4. Five countries were selected for in-depth studies due to the progress that they
have made in improving RMNCH outcomes. The cases were selected to maximize the
quality and amount of data collection and analysis through other sources. They were built
on primary and secondary information collected through (a) interviews with key
individuals; (b) statistical data from secondary sources such as demographic health
surveys, world development indicators, and the World Health Organization (WHO)
global observatory; and (c) analytical reports, journal articles, and policy/program
documents on health and related fields.
5. Criteria for selecting the countries included: (a) progress on MDG 4 and/or MDG
5a as noted by the Countdown to 2015 Initiative, (b) availability of information, and (c)
1
“Countdown to 2015 tracks coverage levels for health interventions proven to reduce maternal, newborn
and child mortality. It calls on governments and development partners to be accountable, identifies
knowledge gaps, and proposes new actions to reach Millennium Development Goals 4 and 5 to reduce
child mortality and improve maternal health” (http://www.countdown2015mnch.org/).
7
capacity to conduct stakeholder interviews in the countries. When the countries were
selected in 2010, only five were on track to meet both MGDs, including Bolivia, China,
Egypt, Eritrea, and Equatorial Guinea (WHO 2010 2). While both Eritrea and Equatorial
Guinea were considered possible, they did not completely meet the criteria at that time.
Malawi and Nepal were included to provide a broad geographic representation. Although
the Countdown and United Nations inter-agency maternal mortality data indicate that
Nepal is “making progress” on MDG 5, data from the Nepal Maternal Mortality and
Morbidity Survey 2008–2009 show the country will meet its MDG 5a goal. 3 Malawi has
made significant progress in improving child health, as shown by a decline in the under-
five mortality rate from 209 deaths per 1,000 live births in 1990 to 92 deaths in 2010;
however, although not on track for MDG 5, the country has made significant progress in
reducing maternal mortality from 1,100 deaths per 100,000 live births in 1990 to 460
deaths in 2010, indicating a 4.4 percent annual decline.
6. Interviews were held with key stakeholder groups: (a) governments (eg.
Ministries of health, finance, and planning), (b) multilateral organizations (eg. WHO,
World Bank, United Nations Population Fund [UNFPA], and UNICEF), (c) donors (eg.
Bilateral agencies and foundations), (d) health professional associations, (e) academic
and research institutions, (f) NGOs and civil society, and (g) the private sector.
7. Studies focused on: (a) MCH programs and related policies; (b) service delivery
methods, financing, and other sector factors as they apply in each country; and (c) socio-
economic factors such as education, women’s empowerment, social inclusion, and
poverty reduction in lowering inequities and creating an enabling environment for better
MCH.
COUNTRY CONTEXT
8. The countries reflect five different contexts. Each has a unique social, economic,
and political history that has shaped the way they address MCH. For example, China is
an emerging market with a strong socialist government. Nepal is a post-conflict country
that was a monarchy until 2006. Egypt, due to social and political upheaval, still faces
challenges to accelerate gains in maternal and child health. Bolivia’s policies, since 2005,
have changed the social and political climate. Malawi held its first multi-party elections
in 1994.
9. All have reduced poverty in the last two decades. In China, the proportion of
people living under US$1.25 a day dropped from 60 percent in 1990 to 11.8 percent in
2009. Nepal almost halved the number of those in extreme poverty from 53.1 percent in
2003 to 24.8 percent in 2010. In Malawi, with the highest proportion of people living in
poverty of the five countries, the figure dropped in the last 10 years from 83 percent to 61
percent. Bolivia, where extreme poverty in the 1990s grew from 5 percent to 26.9
percent, reversed the trend, with 15.6 percent now living on under US$1.25 a day
2
Interagency Maternal Mortality Estimates with data from 2008, which were available during the design of
the study.
3
Nepal also received the 2010 MDG Award for Improving Maternal Health and for being on track to
achieve MDG 5.
8
10. Labor force participation is moderately high in all five countries (70 percent or
above). While it is slightly lower for females than males, nearly half the labor force is
comprised of women and participation rates range between 64 and 80 percent. The only
exception is Egypt, where the female rate of participation is extremely low at 25 percent,
and is likely reflective of a combination of factors such as labor market opportunities,
occupational segregation, limited mobility, and social norms (see for example Assaad and
Arntz 2005; Assaad 2007).
11. Although gaps exist between male and female literacy, over half the population in
all of the countries is now literate. Their investment in basic education has ensured
universal primary schooling; however, differences emerge at the secondary level. In
China, secondary enrollment is about 80 percent, while in Nepal it is about 40 percent.
What is clear though is that in each country, gender parity in enrollment at the secondary
level is high. Thus, although the number for Nepal is low, almost the same proportion of
boys and girls attend.
Table 1: Socio-economic and Human Development Indicators
Indicator Bolivia China Egypt Malawi Nepal
GNI per capita, PPP (constant 2005 int’l $) 2011-12 4251 7917 5654 650a 1289
Population (Total, in millions) 2012 10.5 1351 80.7 15.9 27.5
Population growth (annual %) 2012 1.7 0.5 1.7 2.9 1.2
Poverty headcount ratio at $1.25 a day (PPP) (% of
15.6d 11.8c 1.7d 61.6b 24.8b
population) 2008-10
Age dependency ratio (% of working-age
67 36 58 95 68
population) 2012
Labor force, female (% of total labor force) 2012 45 44 24 51 51
Labor force participation rate, female (% of female
64 64 24 85 80
population ages 15+) 2012
Literacy rate, adult female (% of females ages 15+)
86.8c 92.7b 66 51.3b 46.7a
2009-12
Literacy rate, adult male (% of males ages 15+)
95.8c 97.5b 82 72.1b 71.1a
2009-12
Ratio of female to male primary enrollment (%)
98a 100 96 104 108
2011-12
Ratio of female to male secondary enrollment (%)
100a 102 98 90 104
2011-12
Human development index rank (out of 186
108 101 112 170 157
countries) 2012
Gender inequality index rank (out of 186 countries)
97 35 126 124 102
2012
Source: UNDP 2013; WDI 2014. Accessed 4-24-14
Note: GNI = Gross national income; a =Year 2011, b =Year 2010, c =Year 2009, d =Year 2008
12. In short, the five countries either created equal opportunity for men and women or
took steps to include women in the social and economic development of the country.
Countries with higher per capita income and economic growth, of course, show higher
levels of literacy, enrollment, and completion rates, as well as greater female
9
participation. Table 1 presents the key socio-economic and human development
characteristics of these countries (Annex provides more details).
13. Each country has also made considerable progress in achieving its MDG 4 and
MDG 5 targets. Malawi and Nepal, both low-income countries, experienced the largest
absolute declines in maternal and child mortality (Figures 1 and 2) among the five
countries. As of 2012, four of the five countries have achieved and exceeded the targets
set for reducing child mortality (Figure 1). The only exception is Bolivia, which is just
shy of meeting its target for under-five mortality, having reduced its child mortality by
three-folds between 1990 and 2012.
Figure 1. Achieving MDG4 - Exceeding Targets for in Under-Five
Mortality in Five Countries, 1990-2012
300
Dealths per 1,000 live births
244
250
200
142 1990
150 123
2012
86 76
100 71 Target
54 45
41 40 29 42
50 21
14 16
0
Bolivia China Egypt Malawi Nepal
Source: UNICEF 2013.
Maternal mortality ratio (MMR) for Bolivia has also declined considerably based on
current projections. 4 China’s gains are also impressive: In 1990, the country had a MMR
of 120 per 100,000 live births, but it showed high level of inequalities across geographic
areas. By 2010, health sector interventions focused on the poor and hard-to-reach
populations, and on facility-based births (requiring high levels of resources). China had
reduced its MMR to 32 deaths per 100,000 live births by 2013, which is comparable to
high-income countries. Egypt focused on the gaps in service coverage to reduce its MMR
by 71 percent and is expected to achieve its MDG 5 target. Malawi and Nepal have also
made impressive gains, with maternal mortality declining by more than three times of
what it was in 1990 (Figure 2).
4
DHS 2008 data for Bolivia show a higher MMR. The results of the survey contradict interagency-
modeled estimates for Bolivia’s MMR. The general consensus seems to be that the decline in MMR has
slowed. In the absence of a follow-up DHS or data collected through other sources such as a census, it is
difficult to accurately assess maternal mortality information.
10
Figure 2. Achieving MDG 5 - Reduction in the Maternal Mortality Ratio in
Five Countries, 1990-2013
1200
1100
Deaths per 100,000 live births
1000
790
800
510 1990
600
510 2013
400 Target
200 280
190 190
200 120
110 97 45 57
32 31
0
Bolivia China Egypt Malawi Nepal
Source: WHO 2014.
FACTORS THAT REDUCED MATERNAL MORTALITY
14. All five countries sought to eliminate barriers to access and use of services to
improve MCH. Their investments to strengthen or expand health infrastructure, human
resources, and subsidized or free maternal and child healthcare were the key factors to
reducing maternal and child mortality.
AFFORDABLE SERVICES FOR THE POOR
15. Several studies have found that financial support for MCH is vital, as it increases
access to and use of services, especially among the poor (eg. Amazou et al 2012;
Liljestrand et al. 2012; Sousa et al. 2010). Other studies on countries as diverse as Niger,
Uganda, Thailand, and Brazil also found that eliminating user fees, either for women and
children, or population wide, was linked to reducing child and maternal mortality (eg.
Vapattanawong et al. 2007; Sousa et al. 2010; Mbonye et al. 2012; Amazou et al. 2012).
All five countries have some form of health insurance or incentive for MCH, which have
helped lower the households’ financial burdens and empowered women and mothers to
seek care.
16. Programs in the countries have targeted specific populations—the poor, those in
rural areas, women, and children—to maximize gains. In China, for example, health
insurance offered to poor, rural populations through the New Rural Cooperative Medical
Scheme (NCMS) eased some of the burden associated with the high cost of health care.
In the rural, western provinces the NCMS included MCH components, and as a result
there was an increase in institutional deliveries from 45 percent in 2002 to 80 percent in
2007 (Long et al. 2010). Similarly, incentives under China’s Two Reduction Program
(Safe Motherhood Program) supported facility-based births for the rural, poor;
subsequently, 95 percent of total deliveries are now in institutions. During the same
period, the MMR declined from just under 120 per 100,000 live births to approximately
11
60, and neonatal mortality dropped from approximately 20 to just under 12 deaths per
1,000 live births (Feng et al. 2010; Wang and Liu 2011). Egypt’s student health
insurance, introduced in 1993, helped bring school children into the public health
insurance system, and in 1997, extended it to children under one through a ministerial
decree. The program has been linked to increased use of child health services across all
income groups for school going children, although the largest gains seem to have been
made among middle-income groups (World Bank 2009; Nandakumar et al 2000; Yip and
Berman 2001).
17. Nepal introduced cash incentives to encourage poor women to seek pregnancy-
related care, with women in the poorest and more remote regions receiving the highest
amounts in cash transfers.. Conditional cash transfers were introduced under the Safe
Motherhood Incentives Program (SDIP) in 2005. The program pays women to attend four
pre-natal visits, have skilled delivery care, and attend one post-natal session, after the
program is completed. Cash transfers are based on the region’s income level, and range
from Nepalese rupees (NPR) 500 (US$5.6 at the current exchange rate) in the plains
(Terai) districts (richer regions) to NPR 1,500 (US$16.9) in the mountain districts
(poorest regions). After the program was in operation for one year, deliveries with trained
birth attendants increased from 20 to 30 percent, and women who knew about the SDIP
are now 26 percent more likely to deliver in a public health facility compared to those
who did not receive the incentives (Ensor, Clapham, and Prasai 2009; Hanson and
Powell-Jackson 2010).
18. Besides health insurance and conditional cash transfers, some countries offer free
health services to women and children so as to increase their use. Bolivia has provided
free MCH care through their maternal and child health insurance program
(SUMI/SAFCI) since 1996. From 1994-2003, use of skilled birth attendants grew, and
assisted deliveries rose from 5.3 percent to 21.1 percent among the poorest households,
due to the programs. Institutional deliveries further increased from 57.1 percent to 67.5
percent during the Seguro Universal Materno Infantil period (2003–08) (Coa et al. 2008).
Malawi removed user fees through an Essential Health Package, which included 11 free
health interventions (including reproductive health and, prevention and treatment of
HIV/AIDS and sexually transmitted infections). Once fees for MCH services were
removed, outpatient visits rose from 0.8 to 1.2 per capita annually (Vaillancourt 2009). In
2009, Nepal also removed user fees for delivery-related care, and institutional deliveries
soared from 17 to 33 percent the next year (Upreti et al. 2012).
19. In general, higher per capita health expenditures are positively associated with
reducing maternal and child mortality. Quantitative mapping in the larger study identifies
this association (Figure 3). Not surprisingly, countries with high maternal and child
mortality generally have lower per capita health expenditures (AHPSR 2012). In fact, per
capita health expenditures increased in all five countries, with differing spending levels
(Figure 4). For example, Nepal and Malawi have significantly lower per capita
expenditures compared to the other three. Conversely, China’s per capita expenditure
increased exponentially in the past decade, partly due to the rapid socio-economic
development, the type of health systems investment, and the rising cost of health services,
indicating that other factors are also associated with improving health outcomes. As seen
in figures below, some outliers were able to reduce the rates with relatively low per capita
12
total health spending It is important, therefore, to explore how these outlier countries
improved health outcomes with low per capita spending.
Source: Alliance for Health Policy and Systems Research (AHPSR) and Partnership for Maternal,
Newborn, and Child Health (PMNCH) 2012
Figure 4. Per capita health expenditure in all 5 countries has increased
(1995-2012)
500
Health Expenditure per capita, PPP
450
(constant 2005 international $)
400
350
300
250
200
150
100
50
0
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Bolivia China Egypt Malawi Nepal
Source: WDI 2014. Accessed 4-25-14
GEOGRAPHICALLY-ACCESSIBLE SERVICES
20. To improve MCH outcomes, it is vital to adapt services to specific needs and
invest in the health system. Data from the Countdown to 2015 countries also shows
positive correlations between service delivery and low maternal and child mortality
(Figure 5) (AHPSR 2012).
13
21. There has also been a strong focus on providing primary health care and
promoting skilled or facility-based births among the five countries. Although countries
pursued slightly different strategies and models, based on the resources available and
country context, the aim was to maximize coverage, focusing particularly on MCH.
Source: Alliance for Health Policy and Systems Research (AHPSR) and Partnership for Maternal,
Newborn, and Child Health (PMNCH) 2012
22. In China and Egypt, the cornerstone of improved services has been a well-
developed and organized system offering wide coverage. In China, to improve the weak
health system of the 1950s, the government built a three-tier system that extensively
covers both rural and urban populations. It also established special MCH hospitals and
township centers to provide specialty care, focusing on facility-based births in the 1990s.
Along with the Safe Motherhood Program, which aims to reduce maternal and neo-natal
mortality, this has helped increase the number of facility-based births. In Egypt, where 60
percent of the population live in the Nile Delta, the high population density and well-
developed infrastructure of roads and facilities (in Lower Egypt) mean most live close to
health services (Campbell 2003; MoHP 2003). In fact, both rural and urban residents live
within five kilometers of health facilities (El-Zanaty and Way 2006). More recently,
through the Healthy Mother/Healthy Child Project, the government has increased
14
coverage to remote areas such as Upper Egypt. The World Bank also supported this
endeavour through the Population Project (1996-2005), which encouraged family
planning and smaller families, offering these services in rural, Upper Egypt. A key
component of the project was the use of social change agents selected from the
community. They conducted outreach to raise awareness about population issues,
educated the population on behaviour change, and accompanied women to health clinics.
On average, contraceptive prevalence rates (CPR) increased from 45 to 55 percent at the
village level between 2000 and 2005, with improvements also at the district level (World
Bank 2005).
23. Bolivia and Nepal also launched services in poor and rural areas. Both have
substantial indigenous, remote, and/or poor populations, and have an increased need for
social sector investments in these areas. By using community-based approaches, they
brought services to people in settings where they would be most comfortable. In Nepal,
authorities created village-level health posts and encouraged communities to use them,
especially child health services (e.g., the integrated management of childhood illness,
nutrition and, more recently, newborn care), a strategy similar to China’s in the 1960s
and 1970s. In Bolivia, when it expanded the acute respiratory infections program into
indigenous areas, it drew on local slang in its Information, Education and Communication
(IEC) campaign, and adopted some beneficial traditional practices (such as drinking
herbal tea) into the program (Hudelson et al. 1995). The EXTENSA program brought an
essential health services package, including immunizations and pre-natal and post-natal
care to rural areas through mobile clinics. However, it did less well creating links
between these communities and the formal health system (for follow-up care) which
needed to be fostered. The Salud Familiar Comunitaria Intercultural Policy (Family,
Intercultural and Community Health) also promoted outreach services for women and
children, encouraging community engagement, particularly with indigenous populations
(GHI 2012).
24. To improve coverage in underserved areas, authorities have met with civil society
groups. In Malawi, where there are still gaps in the health infrastructure, the government
engaged in a public-private partnership. In 2002, it signed Service Level Agreements
with the Christian Health Association of Malawi, the second-largest provider of health
services after the public sector, to provide free care to pregnant women and children in
catchment areas not covered by public health services. In addition, a key component of
Nepal’s community-based approach has been to engage NGOs to deliver services in
remote, rural regions.
25. For those developing health care programs, it is important to understand potential
barriers to access. Often there are hidden costs to seeking health care, such as transport or
the opportunity cost of time away from home (for deliveries at facilities). In Nepal,
authorities addressed these costs by encouraging skilled and facility-based births. Its
SDIP, and later the Aama Surakshya Karyakram or “Aama” program (Maternal Well-
being Program), included a stipend to cover travel, which could sometimes cover as
much as 50 percent of the transportation costs (Hanson and Powell-Jackson 2010).
Similarly, by creating birthing centers at village-level health posts, it eased the burden of
long trips over prolonged periods of time. Several other countries around the world, such
15
as Haiti, Indonesia, and Nicaragua, have pursued similar strategies to promote healthier
births for rural women.
26. Countries have also invested in health workers, midwives, and a medical staff at
the community level to provide essential MCH services. In Nepal, a large cadre of female
community health volunteers carry out most of the local education and delivery services,
functioning alongside health workers to provide education and outreach in areas such as
health education, family planning, immunizations, and the integrated management of
childhood illnesses. In Malawi, community-based workers such as Health Surveillance
Assistants and distribution agents have been important, especially in rural areas. In
China, authorities relied on “barefoot doctors” (community health workers) to reach the
population.
27. To strengthen MCH services in villages in the 1980s, China created positions
called Maternal and Child Health Clinicians; this staff worked part-time providing pre-
natal services at the township level, and supervised village doctors and midwives. Since
then, however, the country has developed professional cadres, and the midwives’ role has
diminished. Whether this is the appropriate strategy remains to be seen as China has a
shortage of health workers, especially in poor, rural areas. In fact, all of the countries
studied need more health workers. The shortage is especially severe in Malawi, where the
Emergency Human Resources Program has used salary top-ups, incentives, and training
to increase the number, along with international volunteers as a short-term strategy. .
Box 1: Key Reproductive, Maternal, Newborn, and Child Health Programs in Bolivia, China,
Egypt, Malawi, and Nepal
Bolivia: In addition to the health insurance programs targeting demand for services, critical to improving
child health was continuous coverage under the Expanded Program of Immunization (EPI), launched in
1979 and revamped in 2000. Through its awareness campaign, mobile brigades and coordinated efforts to
reach all populations, the EPI was successful in increasing immunization coverage from under 20 percent
to nearly 80 percent between 1989 and 2008. Other important programs launched, and later merged into
the Integrated Management of Childhood Illness (IMCI), – namely, the National Program to Combat
Diarrhea and the Acute Lower Respiratory Infection Program – addressed some of the leading causes of
child mortality in the 1980s. These programs incorporated local practices such as the use of herbal teas for
coughs and fever with WHO recommended treatments as a strategy to gain acceptability among
indigenous populations; and helped to reduce under-five mortality due to diarrhea and acute respiratory
illnesses from 35.7 percent and 20.5 percent to 15 percent and 16 percent, respectively, between 1989 and
2008. More recently, to improve the nutritional status of women and children, Bolivia began the Zero
Malnutrition Program. Between 2007 and 2010, under-two mortality due to severe malnutrition declined
by 80 percent, while the proportion of women receiving a complete iron supplement treatment -
increasing from 50.8 percent to 69.9 percent (DHS 1989, 2008; CIDA 2012; USAID 2010; World Bank
2008).
China: China’s Two Reductions Program, launched in 378 counties with high MMR in 2000 and later
expanded to the whole country, aimed to reduce the high burden of maternal mortality and neonatal
tetanus by promoting facility-based births. In addition to providing subsidized care to pregnant women,
the program also builds the capacity of health workers. Between 2000 and 2006, facility-based births
increased by 28 percent in counties where the program was implemented, and MMR due to hemorrhage
dropped from 68 to 30 deaths per 100,000 live births. Neonatal tetanus also declined from 0.5 to 0.1 case
16
cases per 1000 live births. China’s immunizations program has also helped to boost child health by
reducing risk of serious illnesses like measles, diphtheria, and pertussis. To stimulate demand, and close
coverage gaps, in the 1990s, China began to fund the program centrally and provide free coverage.
Between 1995 and 2010 immunizations increased from 80 to 99 percent (Feng et al. 2010, Liu et al. 2010,
Chen et al 2010; WDI 2013).
Egypt: A strong family planning program and childhood immunizations were critical in improving
maternal and child health in Egypt. The family planning program, launched in the 1970s, focused on
raising awareness, increasing contraceptive choices, developing local leadership, and generating
ownership of service provision among health service providers to improve services. The program is
credited with saving 3.8 million infants, more than 7 million children, and 18,000 maternal lives between
1980 and 2008. Immunizations also increased from 35 percent in 1988 to 80 percent children fully
immunized by 1995, under the Child Survival Project. The project also supported programs to address
leading causes of under-5 mortality in Egypt and is associated with a 59 percent decline in child mortality
between 1985 and 1995. More recently, the Healthy Mother/Healthy Child Project, and Population
Project have been important in addressing MCH in underserved and poor areas in Upper Egypt. Under the
population project, contraceptive prevalence increased from 44 to 55 percent in target areas, whereas the
Healthy Mother/Healthy Child project led to a 100 percent increase in facility based births, and
contributed to the halving of national maternal mortality (USAID 2011; Campbell et al. 2005; Cobb et al.
1996; JSI 2005; World Bank 2005).
Malawi: Malawi has focused on child health since the 1970s, introducing the EPI, under which health
surveillance assistants have played a critical role vaccinating children in rural areas, with nearly 81
percent of all children fully immunized as of 2010. The Child Lung Health Program (2000) addressed the
problem of severe pneumonia, and is credited with reducing pneumonia related fatalities by 55 percent.
The country also adopted the Emergency Triage Assessment and Treatment Program to address
weaknesses in recognizing and managing the care of severely ill children. The program was simplified so
it could be adopted by health workers who only have basic skills. Community based delivery of family
planning in recent years has helped to raise contraceptive prevalence rate (CPR) from 23.5 to 36 percent
during 1992-2000 in pilot districts – double the increase in control districts. Malawi’s focus on malaria,
nutrition, safe motherhood, and HIV/AIDS services, provided as part of community based package of
interventions for MNCH, has also helped improve maternal and child health. The malaria program has
been attributed with decreasing anemia in women aged 15 to 49 from 47 to 29 percent between 2001 and
2010, and according to data from sentinel surveys, the median HIV prevalence in pregnant women
declined from 12.6 percent in 2007 to 10.6 percent in 2010 ( (World Bank 2004; Soto et al. 2005; GoM
2012, 2013; Zimba et al. 2012).
Nepal: Safe motherhood has been an integral part of Nepal’s health and development agenda. The
Government of Nepal has invested in a comprehensive approach to addressing maternal and child health.
This includes investment in infrastructure and equipment, training health personnel, monitoring and
behavior change, promoting prenatal and postnatal care, skilled delivery, and emergency transport Since
the launch of the program, skilled birth attendance has increased from 7.4 percent in 1991 to 36 percent in
2011, and prenatal/postnatal visits have gone from 15.4 to 58.3 percent during the same time. On the
demand side key interventions included subsidized MCH services. The family planning program,
originally rooted in population concerns, and evolving within a framework of human and reproductive
health rights, has helped to reduce fertility from 5.9 to 2.7 births per woman between 1976 and 2011. The
program focuses on birth spacing, preventing unplanned pregnancies, managing adolescent reproductive
health, and infertility. The government has also ensured coverage by providing health facilities at all
levels, outreach clinics, and mobile voluntary surgical contraception camps. The Community-Based
Integrated Management of Childhood Illness (CB-IMCI) program supports regular immunizations, and
prevention and management of diarrhea and acute respiratory infections. Through nearly sustained
coverage immunization rates in Nepal have reached 87 percent, and 69 percent of the under-five
17
population has coverage for pneumonia (Ghimire et al. 2010; Suvedi 2003; WDI 2013; Barker et al. 2007;
HMG/N 2004).
MONITORING OUTCOMES TO EVALUATE ACCOUNTABILITY AND GOVERNANCE
28. All of the countries studied have relied on surveillance, surveys, censuses, and
other regularly collected data to design MCH policies and programs. Each has adopted
and adapted surveillance and other systems to generate data, using it to set priorities and
build accountability into their health information systems. China and Egypt have strong
data collection systems that were initially linked to programs such as family planning and
EPI, and later merged into an integrated Health Management Information System. In
Bolivia, data collection on MCH was initially done for the health insurance programs and
later combined with their information systems. The two low-income countries in this
group—Nepal and Malawi—also adapted surveillance systems to monitor MCH
outcomes. Nepal leveraged its polio surveillance system to monitor neo-natal tetanus,
while Malawi used its HIV surveillance system to also monitor pregnant women (with
surveillance at ANC stations).
29. Research has also helped guide programs and policies. In Egypt, authorities began
targeting MCH in the Upper Egypt region after a 1992–1993 maternal mortality survey
revealed the magnitude of maternal deaths. In Malawi, the Prevention of Mother to Child
Treatment program was based on a pilot that led the country to adapt WHO guidelines to
meet its own constraints—Option B+ which does not require a CD4 count and provides
lifelong anti-retroviral therapy to pregnant women who test positive for HIV. Due to its
success, the approach has been adopted and implemented in Uganda.
30. Surveillance and audits have also improved accountability, especially for maternal
mortality. Egypt established a Maternal Mortality Surveillance System in 1998 to monitor
deaths. Further, safe motherhood committees at the district and governorate levels meet
regularly to review maternal deaths and identify ways to prevent them, such as sharing
information with health staff (USAID 2010). In China, authorities have shown strong
interest in reducing maternal and child mortality. Maternal death reviews began in 2000
with support from local governments, which has helped provide detailed information on
these cases, identifying causes and encouraging accountability.
31. Other mechanisms, such as contractual agreements, have been used to set goals
and encourage accountability, most notably in China, where the “contract responsibility
system” and “target responsibility agreements” were introduced in the 1990s to improve
and monitor supply-side performance. The systems mainly focus on the Expanded
Program of Immunization (EPI) and prenatal care, and target agreements are signed
between county health bureaus, township health centers, and county maternal and child
health hospitals to monitor their performance on delivering services. These agreements
have been effective in achieving top-down accountability. However, as they are designed
to evaluate processes, they do not address quality issues, which would require that
performance also be measured against other criteria, such as maternal death audits. In
Malawi, service-level agreements with the Christian Health Association have been
applied in the same manner.
18
SETTING POLITICAL AND PROGRAM PRIORITIES (RMNCH)
32. Political priorities have been critical for reducing maternal mortality (Koblinsky
1999; Shiffman 2007; Shiffman, Stanton, and Salazar 2004). For example, with MCH-
specific policies, China has achieved MDG 4 and MDG 5, by financing specific services
(safe, facility based deliveries, immunizations, integrated management of childhood
diseases, and more recently, Prevention of Mother to Child Transmission), allocating
resources (including doctors) for poor and remote areas and creating a structure to
coordinate efforts to improve the indicators. In 1994 it passed the Law on Maternal and
Infant Health Care, which laid the foundation for comprehensive coverage and facility-
based births (Box 2). The successful Safe Motherhood Program (Two Reductions
Program) is rooted in this policy.
33. A change in government can also shift policies. In Malawi, prior to 1994 family
planning was only allowed within the context of “child spacing,” so as to reduce the risk
for maternal and child mortality when births were too close. In 1994, the country held its
first multi-party election, which ushered in a new government that shifted away from the
earlier pro-birth policy and passed a new National Population Policy that year. As a
result, contraceptive use increased from 13 percent in 1992 to 21 percent in 1996, and is
now at 46 percent (World Bank 2013). In Nepal, MCH has been on the development
agenda since the 1970s but gained momentum with the election of a pro-poor coalition
government in 2004. Indeed, it is one of the few areas that experienced strong political
consensus (Ensor, Clapham, and Prasai 2009; Smith and Neupane 2011). The Safe
Delivery Incentives Program, launched in 2005, subsidized care for pregnant women,
offering higher incentives to women in remote, mountainous regions (Ensor, Clapham,
and Prasai 2009; Hanson and Powell-Jackson 2010).
34. Constitutional support and new laws on reproductive health rights, especially for
indigenous populations and marginalized ethnic groups have garnered support from MCH
programs. In Bolivia, for example, the 2009 constitution guaranteed the right to health
care, including reproductive health, and is the basis for two new plans—the National
Strategic Plan for the Improvement of Maternal, Perinatal and Newborn Health (2009–
2015) and the National Sexual and Reproductive Health Strategic Plan (2009–2015).
Both aim to reduce maternal and infant mortality, improve the quality of care, and foster
sexual and reproductive health for all men and women with a focus on human rights,
gender equality, and multi-culturalism (MoHS Bolivia 2009a; 2009b). Similarly, in
Nepal, the 2007 interim constitution and 2009 constitution offered guarantees to women,
children, and ethnic minorities that have created an enabling environment for MCH
especially for marginalized ethnic groups.
35. Champions of reproductive health and MCH have helped prioritize
programs/policies in each of the five countries. In Egypt, the government was a strong
force behind the Student Health Insurance Program, which covers health care for children
one year of age and older. It has also been the driving force behind the Family Planning
program, which focused attention on reproductive health. The secretary general also
helped bring the landmark 1994 International Conference on Population and
Development to Cairo. In Malawi, the current president has championed MCH and
19
women’s rights, and influenced the direction of programs. When she was vice president,
she was Malawi’s Goodwill Ambassador for Safe Motherhood and supported the
Campaign on Accelerated Reduction of Maternal and Child Mortality (UNFPA Africa
Regional Office 2011). As president, she has also established the Presidential Initiative
for Maternal Health and Safe Motherhood to improve access to reproductive health
services (Banda 2012). Most recently, she supported the 2012 Gender Equality and
Women's Empowerment Agenda program (UNFPA Malawi 2012).
36. In Nepal, leaders in the Ministry of Health and Population focused on MCH,
launching broad campaigns for measles immunization and the community-based
Newborn Care Program, while introducing new financing strategies to provide safe
deliveries (e.g. the SDIP).
Box 2: MCH Policies in Bolivia, China, Egypt, Malawi, and Nepal
Bolivia: Two important MCH policies were the 1989–1993 National Plan for Child Survival and
Maternal Health and the 1993–1997 Plan Vida/Life Plan. Both stressed the need to reduce maternal and
child mortality. Due to Plan Vida, the first Insurance Program for Women and Children (Seguro Nacional
de Maternidad y Niñez) was created. Also, the Salud Familiar Comunitaria Intercultural Policy was
adopted in 2008 to improve outreach to indigenous populations, providing primary health care through
home visits. The model emphasizes community health and integrates the traditional health care practices
of the indigenous and Afro-Bolivian populations.
China: The 1994 comprehensive Law on Maternal and Infant Health Care requires that MCH be included
in “plans for national economic and social development.” The law also made sex-selected abortions
illegal and drew attention to service standards through the Safe Motherhood Program. Further, it promotes
better access to information, along with nutrition, reproductive, maternal, and newborn services for
adolescents, mothers, and infants (see also Hesketh and Zhu 1997). In addition, it introduced the one-
child policy, based on the authorities setting population growth and high fertility priorities.
Egypt: Recognizing that population growth was a concern for development, the first National Population
Policy, created in 1973, aimed to reduce birth rates from 34 per 1,000 in 1973 to 24 in 1982. It recognized
that socio-economic development and family planning services were key to reducing fertility. This policy
paved the way for Egypt’s strong family planning program. After the 1994 International Conference on
Population and Development, family planning was integrated into broader reproductive health care
services and linked with MCH. The 1998–2002 Five-Year Plan emphasized MCH, providing the
framework for successful projects such as the Healthy Mother Healthy Child and the Population Projects
in Upper Egypt, which has helped reduce regional disparities in MCH outcomes.
Malawi: The 1994 National Population Policy made MCH a priority. Other efforts, such as the EPI, the
Integrated Management of Childhood Illness (IMCI) strategy, the Child Lung Health Program, and the
Emergency Triage Assessment and Treatment program, helped prioritize services for childhood diseases.
More recently, the community-based maternal and newborn care package was adopted. It is an integrated
approach that includes maternal, newborn, and child health, HIV/AIDS, and malaria services. With the
Prevention of Mother to Child Transmission of HIV/AIDs program, Malawi is pioneering a new approach
in which lifelong anti-retroviral therapy is provided to all pregnant women who test positive for HIV
(Option B+). Other actions include the 1995 Safe Motherhood Strategic Plan (which led to the National
Safe Motherhood Program in 1996), the 2002 Reproductive Health Policy (which led to,the National
Reproductive Health Program), the Post-Abortion Care Strategy (2004), the National Road Map for
Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity (2005), the National
Reproductive Health Strategy (2006–2010), and the Sexual and Reproductive Health and Rights Policy
20
(2009). Malawi also adopted regional strategies such as the African Union Commission’s Maputo Plan of
Action on Sexual and Reproductive Health and Rights (2006) and the Campaign to Accelerate the
Reduction of Maternal Mortality in Africa (CARMMA) (2009).
Nepal: An early focus on population growth and poverty alleviation led to family planning and MCH
projects under Nepal’s Third Five-Year Plan (1965–1970). MCH was also an integral part of the First
Long-Term Health Plan (1975–1990). The 1991 National Health Policy was a turning point for Nepal, as
it was the first to adopt an integrated approach to health services that ultimately abolished vertical
programs. In 1997, the government adopted the National Reproductive Health Strategy to further the
concept of integrated services for the entire population. It also led to several, more specific policies/plans,
targeting family planning, safe motherhood, and adolescents.
ENABLING ENVIRONMENT
37. Socio-economic factors such as poverty reduction and education play an
important role in improving MCH. As noted in Section 3 (Country Context), poverty was
reduced in all five countries, and social and human development indicators improved.
Higher incomes have led to increased consumption and the demand for services,
including health. Investments in education, empowerment, and social inclusion have
further improved reproductive and MCH. This section describes the actions that created
an enabling environment for improving MCH.
Education
38. Education is linked to better health. Educated women are more likely to invest in
their children’s education (Filmer 2006; De Walque 2007) and participate in household
and community decision making compared to those with no or little education (Sen 1999;
UNESCO 2000). An analysis of 175 countries from 1970-2009 showed that of the 8.2
million under-five lives that have been saved, about half were attributed to increased
educational attainment in women of childbearing age (Gakidou et al. 2010).
39. All of the countries in the study invested in education, offering free primary
education, which helped them achieve universal or near universal coverage at the primary
level. However, outcomes vary for the secondary and tertiary level due in part to different
policies. In China, free, compulsory education is provided for the first nine years, with a
special focus on the poor, ethnic minorities, and rural areas. The government also focused
on gender parity at the primary level, and the ratio of girls to boys enrolled (the Gender
Parity Index) increased from 98 percent in 1991 to 106 percent in 2006. At the secondary
level, enrolment is at 80 and 83 percent respectively for boys and girls. In contrast, in
Nepal, secondary enrolment is only at 46 and 40 percent respectively for boys and girls.
These differences are driven by policies as well as socio-economic factors. In Malawi,
significant strides were made in improving the quality of and access to education, due to
government efforts, such as the Free Primary Education policy passed in 1994:
Enrolments rose from about 2 million in 1993 to 3.2 million in 1994, for a gross rate of
108 percent (Avenstrup et al. 2004).
40. Countries have also focused on improving access to education for girls, the poor
and marginalized—an important factor for improving their status and opportunities. In
21
Bolivia, the Educational Reform Act of 1994 advanced equal opportunities in education,
promoting gender and multi-cultural/multi-ethnic equality, with a focus on bilingual
education. It also mandates the state to provide free education (Lisandro 2007). Today,
secondary enrolment is relatively high in Bolivia — around 80 percent for both boys and
girls. In Nepal, the 2002 Education Regulation mandated free education to the poor,
disabled, girls, Dalits (a caste in Hinduism). In 2003, under the Tenth Plan, education
policy also stressed functional and income-generating literacy and post-literacy programs
to improve women’s lives. The policy also contains special provisions for their access to
education to achieve the "education for all" (by 2015) target. Nepal has achieved gender
parity at both the primary and secondary levels (World Bank 2013).
41. Within the last decade, the countries studied have led efforts to improve female
education. In Egypt, various projects, including those of UNESCO 5 and the National
Council for Childhood and Motherhood, 6 focused on improving girls’ education through
girl-friendly schools, recruitment and training of female teachers, and teaching girls
marketable skills beyond the standard primary education, especially in rural areas.
Improved access to and equity in education were also supported by the Community
Schools Initiative (1992), which was designed to bring quality education to hard-to-reach
and rural areas. Enrolment, therefore, increased from 121 in 1992/93 to 3,000 in 2000,
mainly due to the added numbers of girls attending (from 89 in 1992/93 to 2,000 in
1995/96) (World Bank 2003). In Malawi, the government took steps to improve
adolescent education, now allowing girls who become pregnant to return to school once
they have delivered. However, in practice, few return due to various factors, including
what the girls see as being stigmatized (Maluwa-Banda 2003). Further support, including
community education and financial incentives, is needed to encourage girls to return to
school.
Women’s empowerment
42. All of the countries have taken steps to mainstream gender equality into the
development process, but in varying degrees. Nepal has been involved in this since the
1990s through affirmative action laws, policies, and programs, especially within some
major sectors including agriculture, education, health, and local development. Its
community-based approaches to reducing poverty have supported local empowerment
and helped improve health. China’s socialist ideology has contributed to laws that
promote gender equality by providing equal franchise, abolishing old feudal marriage
customs, giving women and men equal rights in marriage, and protecting female workers’
rights. Although biases still exist, especially in rural areas, the laws have helped raise
women’s status. In Egypt, the Family Tribunal Law, the Nationality Law, and the Family
Court Law have built stronger legal rights and privileges for women and children.
Women’s rights in the workplace are protected in the 2003 Labor Law, which includes
provisions for a 90-day paid maternity leave, and prohibits gender-based wage
discrimination and dismissal of a woman while on maternity leave. The law also includes
5
http://www.unesco.org/education/wef/countryreports/egypt/rapport_3.htm.
6
National Council for Childhood and Motherhood’s Girls Education Initiative: http://www.nccm-
egypt.org/e11/e3151/index_eng.html
22
some controversial provisions that limit the hours a woman can work in paid employment
and control the types of occupations in which women can be hired (Freedom House 7).
43. In Egypt, the Social Fund for Development (SFD) has been pivotal in addressing
equity and empowerment. Established in 1991, it aims to (a) reduce poverty by
supporting community-level initiatives, (b) encourage small-enterprise development and
(c) increase employment opportunities through community development, public works,
micro-credit and small enterprises (Abou-Ali et al 2009). For example, the Population
Project and Social Change Agents, in cooperation with the Ministry of Health, hire young
women as agents to provide health education to families (e.g., family planning, the risks
of female circumcision, etc.), and accompany women to health clinics. The agents also
encourage married women with one or two children to participate in the micro-credit
program established through the social fund. In fact, an estimated 32 percent of Egyptians
benefited from the Social Fund from 2001-2008, most of whom are in lower-income
groups; this has also produced positive outcomes in health, education, and poverty
reduction (Abou-Ali 2009).
44. In Malawi, laws that have made gender a priority have increased women’s
political participation—which contributes to improving their status. The 50–50
Campaign, launched in 2008, increased female representation in the government. As a
result, the share of women in parliament rose from 14 percent in 2004 to 27 percent in
2009 (Karim 2010). The National Gender Programme further integrated gender into eight
areas, including institutional strengthening, poverty reduction and economic
empowerment, education, health and HIV/AIDS, agriculture, food, and national security.
Malawi also passed laws against gender-based violence with the Prevention of Domestic
Violence Act in 2006 (GoM 2005; MoGCS Malawi 2004).
Social inclusion
45. In countries with large indigenous populations, governments have focused on
social inclusion. In Bolivia, the 1994 Law of Popular Participation promoted the
participation of men and women in municipal development plans. It empowered
municipalities, especially the poorest, by giving them access to and control over the use
of government funds for development purposes (World Bank 2004). This helped
empower indigenous groups, rural communities, indigenous associations, and agrarian
unions because it gave them legal status (Hall and Patrinos 2004).
46. In Bolivia, equity of health services has been a guiding principle, especially to
accommodate the needs of indigenous groups, which constitute about 62 percent of the
population. The 2002 Pregnant Woman’s Rights Charter was another effort to empower
women, especially indigenous ones. The Charter establishes the rights of pregnant
women to information, education, and related health services. It also requires that
facilities honor the cultural preferences for birthing practices and for taking home the
placenta (World Bank 2004). In addition, the Salud Familiar Comunitaria Intercultural
Policy empowers indigenous communities, and helps them take control of their health.
7
http://www.freedomhouse.org/sites/default/files/inline_images/Egypt.pdf.
23
47. In Nepal, caste and gender barriers are being addressed through legislation.
Nepal’s 2007 interim constitution guarantees human rights for all, including the
“untouchables” (lowest castes). It also guarantees the right to health, including
reproductive health, 8,9 and is training women from the lowest castes to serve as
volunteers in their communities in order to reduce access and use barriers to services for
MCH.
48. In China and Egypt, the main focus is on reducing regional disparities in MCH.
China’s western provinces are poor compared to those in the east. Similarly, in Egypt, the
Lower Egypt region is much more developed than Upper Egypt.
Poverty reduction
49. Poverty reduction has also played an important role in improving the health of
women and children (as discussed in the Country Context section). In Nepal, increased
remittances have been associated with increased consumption, including basic services
such as education and health (MOHP Nepal 2012; Khatri 2010). In China, it is likely that
smaller family size has contributed to children’s well-being. Also, rapid socio-economic
development (an average annual GDP growth rate of 10 percent from 2000-2011)
contributed to increased consumption of basic health services. In addition to investments
in the health sector, and specifically for reproductive, maternal, and child health, the
countries have benefited from more inclusive social policies and poverty alleviation
strategies, which have helped reduce maternal mortality and improve child health.
However, further in-depth, multivariate analyses are needed to understand the different
paths adopted in the various countries to improving MCH.
CONCLUSIONS
50. The main themes of the study are:
• Country contexts matter. Services and programs that ensure coverage and
improve MCH must be adapted to a country’s specific needs and limitations;
• Clear policies and legislation, supported by strong political will and programmatic
interventions create a much needed enabling environment for providing MCH
services, as well as creating demand for these services.
• Scaling-up existing programs or piloting new ones that use mechanisms such as
insurance or demand-side, results-based financing are important to remove
financial barriers for the poor;
• Good quality human resources are needed to reach women and children, including
for skilled deliveries;
• Data collection must be improved and program outputs/outcomes better
monitored. Maternal death audits should be implemented to ensure better
8
http://www.rti.org/pubs/31_nepal_assessingimplementation.pdf.
9
http://www.idea.int/resources/analysis/upload/Women-s-Caucus-Book-Final-version-eng.pdf.
24
monitoring of maternal deaths, and their causes, as well as to build accountability
into the health systems.
51. The countries in the study have made remarkable progress on MDG 4 and MDG
5. Although they have different socio-economic characteristics, all have advanced
because they were committed to change—identifying the key issues and addressing them.
To do this, strong political commitment, through policies backed by financial and
programmatic support, was important. In addition, a focus on the most vulnerable
populations helped increase access to and use of services. Empowerment of women
through education and employment was also needed to raise their status in the family and
provide them with a voice and choices, which are critical for making decisions about
childbirth and use of health services. Finally, poverty reduction and economic
development contributed to improving health outcomes through increasing household
income and consumption.
52. The countries face several challenges. A shortage of human resources is a
common problem, especially in remote and rural areas. To address this, China has
focused on recruiting and training professional staff; while in Nepal volunteer workers
with appropriate qualifications are being trained as midwives. In Malawi, the shortage is
being addressed through training and recruitment of international staff to fill vacant posts.
Bolivia and Nepal also contract out services to address coverage gaps.
53. Gaps can still be seen in the use of services, due to income and ethnicity, but
progress has been made to address them. Countries have introduced subsidized or free
care, especially for more vulnerable groups, but there is room for improvement. New
laws/constitutions in Bolivia and Nepal create the space for inclusive growth. The next
step is to ensure effective implementation of programs.
54. While strides have been made to empower women, barriers persist that affect their
access to reproductive, maternal, and child health. In Nepal and Egypt, for example,
women have limited say in household decision-making. In China, the household
registration system, known as Hukou, prohibits migrant workers from accessing social
services other than in their primary place of residence; in this respect, female migrant
workers face the greatest challenges because pregnancies and childbirth mean they must
return to their towns or villages to deliver, and in many cases, raise their children to
ensure that they and their children have access to public services such as health and
education.
25
Figure 6: Lower adolescent fertility is correlated with lower maternal mortality
Source: PMNCH 2013
Note: Data for adolescent fertility available between 2000 and 2008. There was a positive correlation
between the adolescent fertility rate and MMR [r=.56]. Data source: WHO World Health Statistics, 2011;
Trends in maternal mortality: 1990-2010 (WHO, 2012).
55. Although adolescent fertility declined from 2000-2011, it is still relatively high in
Malawi, Nepal, and Bolivia, where it is 108.3, 89.6, and 75.4 births per 1,000 women
aged 15-19 respectively. Interestingly, while adolescent fertility is low in China, it is
estimated to have increased from 7.7 births to 9 births per 1,000 women aged 15-19
during the same time period (World Bank 2013). This remains an important MCH issue,
as adolescent pregnancies are linked to both high maternal mortality and poor economic
outcomes, and early parenthood is linked to reduced future opportunities for education
and employment for both boys and girls. It is also linked to reduced status in households
and communities (UNFPA 2009; Raj et al. 2009; World Bank 2007; World Bank 2010;
Chiavegatto Filho and Kawachi 2012). Evidence indicates that girls in lower income
groups are more likely to become pregnant than their richer counterparts, and are less
likely to use maternal health services. This is also reflected in poor health outcomes: 65
percent of obstetric fistulas occur in adolescents globally, and girls are two to five times
more likely than older women to die due to pregnancies. Quantitative mapping also
shows a positive correlation between adolescent fertility and maternal mortality (Figure
6). Further investigations are needed in each country to understand and address the causes
of high adolescent fertility, which would require multi-sectoral approaches (e.g.
opportunities for higher education and employment for girls; or vocational training for
pregnant women and young mothers) to get the most optimal outcomes.
26
56. In Egypt, Nepal, and Malawi, donor financing has been critical for sustaining
MCH programs. China has benefitted from technical and financial support from
multilateral donors, while USAID has provided substantial resources to Egypt. Although
the case studies looked at donor financing, it is an area that requires further analysis in
order to provide answers to questions of sustainability.
57. Other issues, such as low contraceptive use in Nepal, and HIV/AIDS in Malawi,
contribute to the challenges the countries face in maintaining current gains and achieving
their MDG targets. Addressing these challenges will require a continued focus on
reproductive, maternal, and child health by both government and donors. This includes
financial and technical support for expanding coverage of health services, and
investments in other sectors that enhance equity and improve the socio-economic status
of women and the poor.
RECOMMENDATIONS AND NEXT STEPS
58. Caution should be taken in interpreting the study’s findings, as further
quantitative analysis is needed to determine causality and the influence of various factors.
As this paper uses findings based largely on qualitative analyses, it does not assign
weight to the different factors such as education, legislation, family planning, insurance,
gender equality, for example. Instead it notes the similarities and differences in the
approaches used to reduce maternal and child mortality. Where impact evaluations are
available, especially in relation to programs, the results have been included.
59. Although the case studies have gathered information on various issues linked to
the decline in child and maternal mortality, and note the relevance of multi-sectoral
factors such as education, poverty reduction, and social inclusion and demographics such
as adolescent fertility, all of these areas deserve further attention. Future qualitative and
quantitative analyses on these topics would deepen the understanding of the ways in
which the various countries, with their unique conditions, can improve MCH.
60. To understand the effect of the health and non-health factors, new data collection
at the country level could improve multivariate, in-depth analyses. This could involve
expanding existing routine surveys, such as the demographic, health or household budget
surveys, to add questions about the use of particular programs or access to facilities, to
ultimately determine what is feasible and beneficial.
27
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32
ANNEX: COUNTRY PROFILES
ANNEX 1: BOLIVIA’S PROGRESS ON MDGS 4 AND 5
Key Messages
• Bolivia made considerable gains in reducing maternal and child mortality from 1990 to date.
The maternal mortality ratio declined from 510 to 200 deaths per 100,000 live births between
1990 and 2013, and under-five mortality also declined from 120 to 41 deaths per 1,000 live
births from1990 to 2011. Bolivia also reduced its under-2 child mortality rate due to severe
malnutrition by 80% in the same period
• The three key drivers of this reduction are: (i) structural reforms in the health delivery model,
including profound changes in programs and health systems governance, new health
infrastructure, and policies for expanding coverage from 1990 to 2003; (ii) financial
protection reforms with a pro-poor provision of free maternal and child services through the
creation of a public health insurance program, using results based financing to pay providers
since 1996, and (iii) cultural adaptation to ensuring greater access and acceptance of health
services from indigenous population.
• Over the last five years, progress has stagnated, and Bolivia needs to continue working on the
three lines developed to achieve next round of gains. The health delivery model will need to
improve quality and address shortages of staff, inadequate facilities and equipment in rural
and remote areas. Financial protection requires changes on payment mechanisms towards
increase quality of services, and is needed more culturally-friendly focus on indigenous
population.
1. Introduction
Bolivia, a lower-middle-income country, is one of the poorest, least-developed countries in
South America. It had a per capita GNI (PPP) of US$ 4,251 in 2012 and an average GNI growth
rate of 4.4 percent during the last ten years. A multi-ethnic society, Bolivia has one of the largest
proportions of indigenous people in Latin America (62 percent). According to 2011 estimates,
Bolivia has a population of 10.09 million, of which 35.7 percent are aged 0 to 14. Two-thirds of
the population—66.8 percent—lives in urban areas, and one-third—33.2 percent—lives in rural
areas.
Bolivia is ranked 108th out of 187 countries in the Human Development Index and 88th out
of 146 countries in the Gender Inequality Index. The current primary education completion
rate is 95 percent for both males and females. The gross secondary enrolment ratio is 80 percent
for females and 82 percent for males. Female labor force participation is 64 percent compared 81
percent for males, and women are primarily employed in the services sector.
Bolivia has made great progress in improving maternal and child survival. According to the
most recent interagency modelled estimates, child mortality declined from 123 deaths per 1,000
live births in 1990 to 41 deaths per 1,000 live births in 2012, just shy of its Millennium
Development Goal (MDG) 4. Maternal mortality has also declined from 510 deaths per 100,000
live births in 1990 to 200 deaths per live births in 2013, a 61 percent decline.
2. Key Maternal and Child Health Policies
National Plan for Child Survival and Maternal Health (1989–1993): Established specifically
to improve the health of women and children the plan focused on three main strategies : social
33
management, primary health care, and the development of local health systems. Under this plan, a
National Reproductive Health Committee was established, and the first norms on contraception in
Bolivia were introduced. In addition, emphasis was placed on training birth attendants and
several health system strengthening projects were initiated (Save the Children 2002).
Figure 1. Child Mortality (1990-2012) Plan Vida(1993-1997): The plan
Estimated Deaths per 1,000 Live Births aimed to reduce maternal mortality
140
by 50 percent and neonatal mortality
123 by 30 percent. It emphasized the
120
101 development of comprehensive local
100
78 health care services for women, and
80 for children under five. Bolivia
58
60 introduced its first maternal and child
45 41 40
40 health insurance program, the Seguro
20 Nacional de Maternidad y Niñez
0 (National Maternal and Child
1990 1995 2000 2005 2010 2012 2015 Insurance, SNMN) under this plan. It
(MDG provided free health care to pregnant
Target)
women and children and was
effective in increasing utilization of
Figure 2. Maternal Mortality Ratio (1990-2013)
Estimated Deaths per 100,000 Live Births
services. The Bolivian Health Norm,
600 with protocols for the care of women
510 and newborns, and the Committee for
500 Safe Motherhood were also
420
400 330
established under this plan (Save the
270 Children 2002).
300
230 200 Salud Familiar Comunitaria
200
110 Intercultural (SAFCI - 2008 to
100 Present): Initiaited in 2008 to
0
improve the provision of primary
1990 1995 2000 2005 2010 2013 2015 health care services and promote
(MDG social inclusion. The policy
Target)
emphasizes social participation in
Sources: WHO 2014; UNICEF 2013. health management, includes social
workers as part of the community-
based health service delivery system, and integrates traditional health care practices of Bolivia’s
indigenous, and Afro-Bolivian populations with modern medicine. New national plans enacted
under the policy to improve maternal and child health include the National Strategic Plan for the
Improvement of Maternal, Perinatal and Newborn Health (2009–2015) and the 2009–2015
National Sexual and Reproductive Health Strategic Plan (Ministry of Health and Sports 2009;
Global Health Initiative 2012; PAHO 201310).
3. Main Maternal and Child Health Programs – Transforming health delivery
To reach the majority of the population, Bolivia’s maternal and child health programs re-focused
attention on primary health care in the 1990s, expanding the public health system in rural and
peri-urban areas. This included (i) the construction of more than 300 hundred primary health care
facilities in around 100 defined networks during a ten years period and (ii) prioritizing key
programmatic interventions:
10
http://www.paho.org/saludenlasamericas/index.php?id=24&option=com_content
34
Immunizations: Introduced in 1979, the Expanded Program of Immunization (EPI) aimed to
reduce child mortality and morbidity from measles, pertussis, tetanus, diphtheria, poliomyelitis,
and tuberculosis. It was launched as a permanent and closely coordinated effort to replace
previous isolated and sporadic activities. The program coupled static facilities with mobile
brigades to address coverage gaps, with each health facility responsible for managing vaccination
operations for the population living within its 5-kilometer radius. This was accompanied by a
public awareness campaign. While immunizations increased initially, by the mid-1990s, coverage
had begun to wane due to both demand and supply side constraints (World Bank 2001). Under
the health sector reform (1996), the EPI was revamped and expanded as EPI II, which included
the pentavalent vaccine, a combination of five vaccines: diphtheria, tetanus, whooping cough,
hepatitis B and Haemophilus influenza type b (the bacteria that causes meningitis, pneumonia and
otitis). A new complete health cold chain was developed, and the new vaccines were included in
the package of services covered by maternal and child health insurance. Although coverage gaps
still persist, Bolivia successfully eradicated polio by 1987 (Gavi Alliance 2010), and the
proportion of fully immunized children increased from 18.8 percent in 1989 to 78.6 percent in
2008 (Figure 3).
Management of Childhood Illnesses: Figure 3. Trends in Childhood Immunization
Critical in addressing the two leading (1989-2008)
causes of childhood mortality –
diarrhea and pneumonia – were the 100
National Program to Combat Diarrhea 80
(NPCD) and the Acute Lower
60
Respiratory Infection (ALRI) Program,
both introduced as vertical programs in 40
the 1980s. Key to success of the NPCD
20
was the distribution of oral rehydration
therapy (ORT) through health facilities 0
and community volunteers, with 76 1989 1994 1998 2003 2008
percent of distribution attributed to % of children fully immunized
community volunteers (Mendizábal Immunization, DPT (% of children ages 12-23 months)
Lozano 2002). The ALRI program
Immunization, measles (% of children ages 12-23 months)
went a step further and incorporated
culturally acceptable traditional Source: DHS 2008/WDI.
practices appropriate for the treatment
of respiratory infections into the program such as the use of herbal teas for cough and fever in
conjunction with treatment prescribed by World Health Organization (WHO) guidelines, and
advice against harmful practices (use of kerosene and mentholated balms). The programs were
brought under Integrated Management of Childhood Illness (IMCI) in 1996. Under five deaths
due to diarrhea and acute respiratory illnesses declined from 35.7 percent and 20.5 percent in
1989 to 15 percent and 16 percent in 2008 respectively (DHS 1989, 2008).
Maternal Health: Early efforts to improve maternal health adopted the WHO-recommended
“risk approach” for pregnancy screening beginning in 1983. Other strategies, including the
promotion of prenatal and delivery care and postpartum care, were also supported. This approach
was replaced by 18 evidence-based best practices for maternal and newborn care mandated by
Ministerial Resolution 0496 including active management of third stage labor, birth preparedness
and counseling for complications to improve quality of services and maternal outcomes. On the
demand side, provision of free maternal health services as part of health insurance has been
critical in increasing utilization of services (more details in Section 4). Data show a considerable
increase in skilled birth attendance between 1994 and 2008 from 47.2 percent to 71.1 percent
(Table 1).
35
Family Planning: Family planning began rather late in Bolivia. Attempts were made to introduce
family planning in the 1970s and 1980s but were met with opposition, mainly from the Catholic
Church. Not until the 1989 National Plan for Child Survival and Maternal Health were family
planning services allowed to be provided through public facilities, at which time the total fertility
rate was at 5 births per woman. Since then, there has been a steady decline in total fertility and an
uptake in contraceptive use (Table 1).
Addressing Communicable Diseases: Maternal and child health outcomes in Bolivia are also
impacted by diseases such as Chagas, Tuberculosis (TB), and Malaria. In 1999, with support from
the Department for International Development (DFID) and the Inter-American Development
Bank (IADB), the government of Bolivia launched the Epidemiological Shield (ES). Its main
components are (a) EPI II; (b) a series of stand-alone programs to tackle highly prevalent diseases
such as Chagas, malaria, tuberculosis, leishmaniasis, and dengue; and (c) the establishment of an
epidemiological surveillance system to monitor the overall status of endemic diseases. The
program has been linked to strong improvements in outcomes. For example, between 1998 and
2008, the incidence of malaria declined from 24 to 4.2 cases per 1,000 people. Similarly, the
incidence of TB has declined from 251 to 131 cases per 100,000 people between 1990 and 2011
(Global Health Initiative 2012; USAID 2012; World Bank 2004).
Zero Malnutrition Program: Malnutrition is a serious concern in Bolivia, resulting in high
levels of stunting in the country. As recently as 2004, over 30 percent of population was stunted.
The Zero Malnutrition Program (ZMP) was established in 2007 with the aim of eradicating
malnutrition. The program focuses on pregnant and lactating women, and children under age two.
Its main activities include (a) food fortification; (b) literacy and Information, Education and
Communication activities; (c) the development of Rural Integral Nutritional Networks (RINN)
based on a preventive approach in coordination with health networks; and (d) expanded access to
drinking water and sanitation. Between 2007 and 2010, there was an 80 percent reduction in the
under-two child mortality rate due to severe malnutrition. There was also an increase in the
proportion of pregnant women receiving a complete iron supplement treatment - increasing from
50.8 percent in 2008 to 69.9 percent in 2010 (CIDA 2012; USAID 2010; World Bank 2008).
Table 1: Trends in Reproductive Health, 1989–2008
Indicator 1989 1994 1998 2003 2008
Total fertility rate 5 4.8 4.2 3.8 3.5
Contraceptive prevalence rate (any method) 30.3 45.3 48.3 58.4 60.6
Unmet need for family planning — 28.9 26.6 22.8 20.1
Births attended by skilled health staff (% of total) 42.6 47.2 59.3 66.8 71.1
Percentage of live births delivered at a health facility — — 53.2 57.1 67.5
Sources: DHS2008/WDI.
Note: — = not available.
4. Health System strengthening
Decentralization: In 1994, the Law of Popular Participation transferred 20 percent of central
government revenues to the municipalities, which became responsible for the provision of health
services (including facilities and financing of equipment and basic inputs). Management of
human resources for health was made the responsibility of the sub-national autonomous
administrations. In 1995, the Law of Administrative Decentralization, further supported local
governance through the creation of the “Prefectura” - an administrative body at the regional level
that would be responsible for policy -making at the regional and local levels and managing
human resources. Changes in governance from 1997 to 2003 increased accountability, with the
36
use of performance agreements between National and sub-national authorities for achieving
results in exchange of additional funds.
Since the mid-1990s, there has been a doubling of health expenditure per capita (in terms of
purchasing power parity) while out of pocket costs have remained low – underscoring the low
burden of healthcare on the population.
Financial coverage: The 1996 Health Sector Reforms, initiated in the country with support of the
World Bank, aimed to reduce maternal and child mortality as one of the main goals. Free
coverage for maternal and child health care was first introduced as part of this reform through the
Seguro Nacional de Maternidad y Niñez (SNMN) health insurance package. Since then, Bolivia
has provided free maternal and child health care services through evolving insurance programs
that are discussed below:
Figure 4. Health expenditure per capita, Figure 5. Out-of-pocket health expenditure
PPP (constant 2005 international $) (% of total expenditure on health)
350 40
305 35
300
30
250
25 28
200 23
20
150 15
100 10
50 119
5
0 0
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Source: WDI 2014
Seguro Nacional de Maternidad y Niñez (SNMN): SNMN, introduced in 1996, was Bolivia’s
first health insurance scheme. It provided coverage of 32 basic interventions including prenatal
care, emergency obstetric care, and newborn care; and treatment of diarrhea, pneumonia, and
respiratory infections in children under five. There was a significant growth in utilization of
services from the 18-month period prior to implementation to the 18-month period after
implementation with antenatal visits increasing by 39 percent and total births increasing 50
percent. In addition, utilization of services was strongest among the low socioeconomic clients.
Utilization of services among adolescents was also high (Dmytraczenko et al. 1999).
Seguro Básico Salud (SBS): In 1998, the SNMN was replaced by a broader health insurance, the
Seguro Básico Salud (SBS or Basic Health Insurance), to provide free coverage to poor and
vulnerable populations. Supported by the World Bank and rooted in the government’s Strategic
Health Plan (1998), SBS was open to everyone, but specifically aimed at the poorest segments of
the population in both urban and rural areas. It included a package of 102 basic health
interventions for maternal and child health and key endemic diseases (Chagas, cholera, malaria,
and tuberculosis). Additional reproductive health components were also included in the package
including post-abortion care, family planning, transport for emergency obstetric care, and
prevention of sexually transmitted infections. It also included child nutrition and development
screening. However, the program suffered from some drawbacks including a lack of incentives
37
for health workers to enroll eligible Table 2: Utilization of Public Services for
populations, and poor marketing and Births by Wealth Quintile (%)
enrollment in rural areas (Silva and Batista Year
Income
2010; Rivera et al 2006; GTZ 2000).
Group 1989 1994 1998 2003
Both the SNMN and SBS focused on first Lowest 6 5.3 11.6 21.1
and second levels of care, and during the
time of implementation maternal and child Second 14.5 19 21.1 35.7
mortality declined rapidly. This has been Middle 23.7 35.6 41 52.3
attributed to the increase in uptake of
maternal and health services between 1998 Fourth 41.5 48.3 53.7 76.6
and 2003 - the percentage of mothers Highest 68.3 78.8 73.6 92.3
utilizing health services through insurance
grew from 3.6 percent to 53.4 percent. TOTAL 29 34.4 37.1 53.4
However, gaps still remained between the Source: UDAPE and UNICEF 2006.
poorest and the richest households (Table 2).
Box 1: Mixed Results in Reaching the Vulnerable
The road to improving maternal and child health outcomes in Bolivia has also hit some bumps along the
way. Two well intentioned but poorly planned and excuted programs aimed at reaching vulnerable
populations highlight the supply side challenges still faced in Bolivia.
In 2002, the EXTENSA program was initiated to extend packages of essential health services (through SBS
and SUMI) to rural areas through mobile units that travelled to outlying communities. By 2007, EXTENSA
was providing services to over 300,000 people in 2,500 villages. However, the program was terminated in
the same year for various reasons including a two-month time lag between visits to a community, meaning
that care was not always available when needed, and inadequate referral services and ambulatory support.
In 2009, Bolivia introduced a conditional cash transfer program for maternal, newborn, and child health
titled Bono Juana Azurduy. The program provides a lifetime stipend of US$260 per pregnant woman, paid
in installments for regular prenatal visits, skilled birth attendance, and postnatal visits until her child is two
years old. According to government estimates, within a year of implementation nearly 350,000 eligible
women received cash payments through the program, and the number of prenatal visits to health facilities
around La Paz quadrupled. Recently, however, the once-promising program has experienced several
challenges, with demand outstripping supply. Major supply side constraints, including lack of facilities,
supplies, and personnel, have halted the expansion of the program into rural areas, where it is most needed,
and there are complaints of delays in beneficiary payments. Whether the program will be able to overcome
these challenges remains to be seen.
Sources: World Bank 2009; Maloney 2010
Cultural adaptation of health services –Indigenous Health Insurance: Created by the
Ministry of Health Resolution 26350 in 2001, the insurance aimed to improve indigenous
populations’ access to health facilities during the SBS period. It included an additional portfolio
of ten services that adapted maternal health services to indigenous traditions, such as “soul
rescue” by a traditional practitioner, devolution of placentae, painting facilities yellow, while
avoiding white which is associated with death among indigenous communities, and creating
“wilaqunas” or indigenous health defenders. Rural services increased in coverage by 15% within
one year. However, with the creation of SUMI, the next government ended this indigenous
insurance program.
Seguro Universal Materno Infantil (SUMI): In 2003, the Government of Bolivia, with World
Bank support, introduced SUMI. Unlike its predecessors, SUMI incorporated primary, secondary,
and tertiary levels of care, and focused specifically on pregnancy-related care and under-five
38
child health. Many services that had been covered under the SBS were no longer covered—a
strategic decision by the government to ensure focus where it was most needed, that is, on
reducing maternal and child mortality. By 2004, SUMI reached 74 percent of its targeted
population. Institutional deliveries increased from 57.1 percent in 2003 to 67.5 percent in 2008.
While initially SUMI did not cover family planning, in 2006, the program was expanded to cover
family planning and screening and prevention of cervical cancer for women up to age 60 (PAHO
2008). It should be noted that DHS data for 2008 also show an increase in maternal mortality
between 2003 and 2008. While there is some debate on the accuracy of the data, one of the
potential reasons for this is a decline in the quality of service provision. However, more
information is required to confirm the mortality data and the reasons behind it.
5. Creating an Enabling Environment
Besides health sector interventions, empowerment and equity are necessary to improving health
outcomes. Broad support for improved equality in gender and education is evidenced by a
number of policies in Bolivia.
Constitutional Rights: Bolivia’s new Constitution, promulgated in 2009, has been a key
development for maternal and child health and for indigenous rights. It guarantees the right to
health and health care for all citizens, including all indigenous groups (Articles 1 and 18), the
right to reproductive and sexual rights (Articles 14 and 15), and the right to gender and cultural
equality.
Women’s empowerment: The 1992 Women in Development Conceptual Framework was a
turning point for women’s empowerment in Bolivia. It was the first time that the government
acknowledged disparities between outcomes for men and women. It focused on health, education,
and social services and targeted two specific groups: minors in particularly difficult
circumstances and women in general. Also important to equity and empowerment of women was
the 1994 Law of Popular Participation, which promoted the participation of men and women in
municipal development plans. Supreme Decree 26350 established the following key government
policies relating to gender: the National Gender Equity Plan (the first gender mainstreaming
plan), the National Plan for the Prevention and Eradication of Gender-related Violence, and the
Programme for the Reduction of Poverty in Relation to Women 2001–2003.
Education: Bolivia’s 1994 Educational Reform Act was key to advancing equal opportunities in
education and the role of the state to provide universal free education. It promoted gender and
multicultural/multiethnic equality in education and focused on bilingual education. Today, gross
secondary enrollment in Bolivia is relatively high at around 80 percent for both males and
females. However, there are concerns about dropouts and absenteeism, especially among the
indigenous populations.
39
6. Challenges and Priorities for Future Action
While Bolivia has improved maternal and child health since the 1990s, progress has stagnated.
Areas that need attention include the following:
Bolivia is still struggling with the shortage of staff and adequate facilities in rural areas,
where the need for maternal and child health services is most acute. Rural health centers face very
high turnover of health personnel, particularly physicians.
The quality at rural health centers is cause for concern. Many health centers have deficient
equipment, and many rural areas lack services altogether. A health post may exist, but it is not
staffed by clinicians on a permanent basis. Transport and access are poor, making it difficult for
rural women to receive appropriate emergency obstetric care.
Unsafe abortions account for a significant number of maternal deaths. Abortion in Bolivia is
illegal except in cases where there is harm to a woman’s health or rape. Making post-abortion
care available can help mitigate some of the dangers of unsafe abortion. While this service is
covered under health insurance, more needs to be done to ensure women have access to it, and
that there is greater awareness regarding unsafe abortions.
Bolivia also has the highest rate of teen pregnancy in the Latin America region, with over 17
percent of girls aged 15 to 19 having experienced a pregnancy. Although the adolescent fertility
rate has declined from 87 per 1,000 births to 75 per 1,000 births for women aged 15 to 19, during
the last 15 years (1989-2008), the pace of decline has been very slow. Problems associated with
teen pregnancies include poor knowledge, as well as financial, physical, and psychosocial barriers
to accessing reproductive health services. These barriers can be addressed through ensuring the
availability of youth-friendly services, especially for the indigenous populations, and improving
communication on safe sex and family planning.
In Bolivia, addressing cultural challenges is important in stimulating demand for maternal
and child health services. A growing priority is to provide culturally appropriate services for
indigenous populations who often rely on traditional medicine. Communal decision making is
central to the culture, which means that the whole community decides whether the mother should
access health care. Low use of health services has been directly related to the lack of education
and inforation within these rural communities.
Quality of data is another area that requires improvement. Health information systems and
epidemiologic surveillance need to be improved to enable better monitoring and evaluation.
Figure 6 provides a timeline of interventions and indicators related to MDGs 4 and 5. 11
11
Caution should be taken in inferring any causality since multiple factors contributed to the decline of
U5MR and MMR as the discussion highlights.
40
Figure 6. Bolivia: Timeline of MDG 4 and 5 Interventions
MDG 4: Under 5 Mortality
120 200
deaths per 1,000 live births
100
84 150
80 169
80
% 60 100
40
13 50
20
41
0 0
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
DPT Measles U5MR
MDG 5: Maternal Mortality
80 600
deaths per 100,000 live births
70 510 71.1
500
60
60.6 400
50
42.6
40 300
%
30 200
20
23.6 200 100
10
0 0
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
Contraceptive Prevalence Rate Skilled Birth Attendance Maternal Mortality Ratio
1979–1990 1991–2000 2001–2012
1979: Expanded Program of 1993–97: Plan Vida/Life Plan 2002–07: EXTENSA program
Immunization (EPI)
1994: Law of Popular 2003: Seguro Universal Materno
1980s: National Program to Participation Infantil (SUMI)
Combat Diarrhea and Acute 2006: Zero Malnutrition
Lower Respiratory Infection 1994: Education Reform Act Program (ZMP)
Programs
1996: Integrated 2008: Salud Familiar
1983: “Risk approach” Management of Childhood Comunitaria Intercultural
adopted for maternal health Illness strategy (SAFCI) policy
2009: Bono Juan Azurduy
1989–93: National Plan for 1996–98: Seguro Nacional de incentive program
Child, Survival and Maternidad y Niñez (SNMN)
Development and Maternal 2009: New constitution
Health 1998–2003: Seguro Básico guaranteeing health and
Salud (SBS) reproductive health rights;
National Strategic Plan for the
1999: Epidemiological Shield Improvement of Maternal,
Perinatal and Newborn Health;
and National Sexual and
Reproductive Health Strategic
Plan
41
Selected References
Bolivia Beijing Report Questionnaire. 2004. Member States Responses to the Questionnaire on
Implementation of the Beijing Platform for Action (1995) and the Outcome of the
Twenty-Third Special Session of the General Assembly.
Camacho, S., N. Schwab, and R.P. Shaw. 2003. “Bolivia’s Reform to Improve Maternal and
Child Mortality.” World Bank, Washington, DC.
http://documents.worldbank.org/curated/en/2003/12/7356308/bolivias-reform-improve-
maternal-child-mortality.
CIDA (Canadian International Development Agency). 2012. “Project Profile for Support to Zero
Malnutrition Program – Ministry of Health and Sport. http://www.acdi-
cida.gc.ca/CIDAWEB/cpo.nsf/vWebProjByNumEn/8BEF3E3734B8D48C85257443003
7249C.
Coa, R., L.H. Ochoa, and MEASURE DHS, Macro International, Inc. 2008. “Bolivia Encuestas
de Demografía y Salud.” Calverton, Maryland, USA.
Cordero, D., R. Salgado, and C. Drasbeck. 2004. “An Analysis of the IMCI Implementation
Process in Four Countries of Latin America.” Arlington, VA: BASICS II for the United
States Agency for International Development and the Pan American Health Organization.
http://www.basics.org/documents/pdf/FINAL%20Short%20Program%20Review.pdf.
Coupal, F., L. Johnson, and W. Gutierrez. 2009. “Mid-Term Evaluation of the Bolivian Health
Support Programme (PASS).” UNICEF. http://origin-
www.unicef.org/evaluation/files/Mid-
Term_Evaluation_of_the_Bolivian_Health_Support_Programme_(PASS)_(ERD).pdf].
Dmytraczenko, T., S. Scribner, C. Leighton, and K. Novak. 1999. “Reducing Maternal and Child
Mortality in Bolivia.” Abt Associates, Partnerships for Health Reform, Resource Center,
Bethesda, Maryland, 7: 1. (PHR Executive Summary Series).
GAVI Alliance. 2010. “Second Gavi Evaluation Supporting Paper 4.4: Bolivia Country Study
Report.” Submitted by CEPA LLP, September 13.
Global Health Initiative. 2012. “Bolivia Global Health Initiative Strategy 2012.”
GTZ. 2000. “Evaluación del Seguro Básico de Salud en Bolivia con la Metodología InfoSure.
Roberto Böhrt and Jens Holst, Proyecto Sectorial, “Seguros Sociales de Salud en países
en vías de desarrollo.” Germany: GTZ. (In Spanish)
Hudelson, P., T. Huanca, D. Charaly, and V. Cirpa. 1995. “Ethnographic Studies of ARI in
Bolivia and their use by the National ARI programme.” Social Science & Medicine 41
(12) (December): 1677–83.
Martin, L. 2007. “Derechos, asignaciones garantizadas y política social. Caso de estudio:
Bolivia.” Unpublished. Adapted by Lisandro Martín from the original report: Gover
Barja y Jorge Leiton.
Mendizábal Lozano, G. 2002. “Historia de la Salud Pública en Bolivia: De las Juntas de Sanidad
a los Directorios Locales de Salud.” La Paz, Bolivia.
http://www.ops.org.bo/textocompleto/nhs18852.pdf.
Ministry of Health and Sports. 2009a. “Plan Estratégico Nacional para Mejorar la Salud Materna
Perinatal y Neonatal en Bolivia: 2009–2015.” Series: Regulatory Technical Documents,
La Paz, Bolivia.
———. 2009b. “Plan Estratégico Nacional de Salud Sexual y Reproductiva: 2009 – 2015”.
Series: Regulatory Technical Documents, La Paz, Bolivia.
Ministry of Social and Public Health. 1989. “National Plan on Infant and Child Survival and
Development and Maternal Health, Executive Summary” (Plan nacional de
supervivencia-desarrollo infantil y salud maternal, Resumen ejecutivo). Dirección
Nacional de Salud Materno Infantil, Ministry of Social and Public Health, La Paz,
Bolivia, November 6.
42
Ministry of Social and Public Health. 1989. Plan Nacional de Supervivencia Infantil y Salud
Materna. La Paz, Bolivia.
Moloney, A. 2010. “Difficulties Hit Bolivia’s Programme for Pregnant Women; Commentary.”
The Lancet 375 (9730): 1955.
Save the Children. 2002. The State of Newborns: Bolivia.
Rivera, AM, K. Xu, and G. Carrin. 2006. “The Bolivian Health System and its Impact on Health
Care Use and Financial Risk Protection.” World Health Organization, Geneva.
UDAPE and UNICEF. 2006. “Bolivia: Impacto de los Seguros de Maternidad y Ninex en Bolivia
1989–2003.” UDAPE/UNICEF, La Paz, Bolivia.
USAID (United States Agency for International Development). 2003. “Contraceptive Security in
Bolivia: Assessing Strengths and Weaknesses.” United States Agency for International
Development, Washington, DC.
World Bank. 2004. “Health Sector Reform in Bolivia: A Decentralization Case Study.” A World
Bank country study. Washington, DC: The World Bank.
———. 2013. “Bolivia’s Progress on Maternal and Child Health”. Washington DC: The World
Bank (mimeo)
43
ANNEX 2: CHINA’S PROGRESS ON MDGS 4 AND 5
Key Messages
• Since the 1950s, China has recognized the importance of improving maternal and child
health outcomes. Maternal mortality has declined from a staggering 1,500 deaths per 100,000 live
births in 1949 to 37 deaths in 2010, and infant mortality has gone from 200 deaths per 1,000 live
births to 13 deaths during the same period.
• Early “low-cost, high-impact” investment in clean deliveries, improved hygiene, and
immunizations led to considerable gains in reducing maternal and child mortality. The
government trained and deployed midwives in rural areas, organized mass immunization
campaigns leveraging its commune network, and, in the long term, invested in a three-tier health
system, including maternal and child health stations and, later, specialty hospitals.
• In 1994, the government passed the Law on Maternal and Infant Health Care. This is
widely seen in China as a critical turning point in refocusing on maternal and child health after a
decade of diffused attention.
• To reduce gaps in access to service due to income disparities, China reintroduced health
insurance in rural areas under the New Cooperative Medical Scheme in the 2000s. Where the
package of services has included maternal and child health, improvements have been observed in
utilization rates.
• The Safe Motherhood Program (the “Two Reductions Program”), which was mandated
by the Law on Maternal and Infant Health Care, has also been pivotal in recent years in reducing
maternal mortality and neonatal tetanus through subsidizing hospital-based deliveries.
• Socioeconomic development, which accompanied higher education and incomes, greater
female employment, and improved women’s status, has also contributed to improvements in
maternal and child health outcomes.
• Challenges remain including ensuring quality of care and integrated service delivery,
improving access to health and other social services for migrant populations, and addressing the
effects of population aging in the context of the one-child policy.
1. Introduction
China is a lower-middle-income country with a per capita GNI (PPP) of US$ 7,917 in 2012
and an average GNI growth rate of over 10 percent during 2000–12. In the last few decades,
China had gradually transitioned from a closed, centrally planned economy to a market-oriented
economy. Nearly half of the population lives in urban areas (45 percent). According to national
data, 3 percent of the population, or 40 million people, live under the poverty line. Given growing
urbanization and a rapidly growing economy, disparities among income groups are expected to
grow.
As of 2010, China had a population of 1.3 billion and a population growth rate of 0.6
percent. Seventy-two percent of the population is in the working-age group (15–64), with an age
dependency ratio of 11 percent. With a fertility rate of 1.6 births per woman and an aging
population, the dependency ratio is expected to increase over the next two decades, putting
disproportionate pressure on the working-age population, with potential socioeconomic
implications.
Between 1990 and 2010, China’s maternal mortality ratio (MMR) declined from 120 deaths
to 37 deaths per 100,000 live births, roughly halving twice in 20 years (figure 1). Currently, it
is well on track to meet its MDG 5 target of 31 maternal deaths per 100,000 live births by 2015
(WHO 2012). Skilled birth attendance is high, since most births take place at health facilities.
44
Table 1: Key Intermediate MCH Indicators, 1992–2010
Indicator 1992 1995 2000 2006 2010
Contraceptive prevalence (% of women ages 15–49) 84.6 90.4 83.8 84.6 —
Births attended by skilled health staff (% of total) 84.1 89.3 96.6 97.8 99.6
Pregnant women receiving prenatal care (%) 69.7 78.7 89.4 89.7 94.1
Immunization, measles (% of children 12–23 months) 87 80 84 93 99
Source: WDI.
Similarly, China made significant
Figure 1. Maternal Mortality Ratio (1990-2013)
gains in reducing under-five and Estimated Deaths per 100,000 Live Births
infant mortality (figure 2). As of 120
2012, China has exceeded its MDG 4 97
target of reducing under-five 100
mortality to 16 deaths per 1,000 live 76
80
births by 2015. Its under-five 63
mortality rate is 14 deaths per 1,000 60 50
live births, and its infant mortality 36
40 32 31
rate is 12 deaths per 1,000 live births.
Immunizations are nearly universal 20
and provided free of cost. Great 0
strides have also been made in 1990 1995 2000 2005 2010 2013 2015
(MDG
controlling childhood illnesses such Target)
as pneumonia (table 1).
Figure 2. Infant and Child Mortality (1990-2012)
Estimated Deaths per 1,000 Live Births
2. Key Maternal and Child
Health Policies 60
54
47
Provision of basic health services 50
42
and prevention of illness were the 38 37
40
cornerstone of earlier policy, with 30
30 24
special attention to MCH (Box 1). 20
16 16
The government also focused on 20 14
14 12
establishing standards and protocols 10
for provision of MCH care to address
0
quality of care issues. decades has 1990 1995 2000 2005 2010 2012 2015
contributed to the low levels In more (MDG
recent years, the Law on Maternal Target)
and Infant Health Care has given a U5MR IMR
boost to improving maternal,
newborn, and child health in the Source: WDI; UNICEF 2013; WHO 2014
country.
Law on Maternal and Infant Health Care: Passed in October 1994, this law is the most
comprehensive law on maternal and infant health in China and represents a turning point for
MCH in the country. Article 3 of the law places maternal and infant health at the center of
development, requiring that it be included in “plans for national economic and social
development.” The law provides better access to information, nutrition, and reproductive,
maternal and newborn services for adolescents, mothers, and infants. The law also made sex-
selective abortions illegal. While some provisions of the law have been criticized for being
disrespectful of human rights, overall it has been critical in signalling the importance of women’s
and children’s health and well-being at the policy level. It was also important in creating space
45
for continued attention at the programmatic level for maternal and child health (Ministry of
Health, China 1995; Hesketh and Zhu 1997; Stakeholder Interviews).
Box 1. China’s Early Interventions to Address Maternal, Newborn, and Child Health
At the time of China’s founding, it had one of the highest levels of maternal and child mortality in the
developing world.a During 1949–50, the leading causes of maternal and newborn death were postpartum
sepsis and neonatal tetanus. Most births took place in the home, with the help of traditional birth attendants.
The Ministry of Health prioritized reduction of postpartum infection, tetanus incidence, and mortality rates
through promoting safe and clean deliveries and improving hygiene.b The Patriotic Health Campaign called
for people to “be mobilized, pay attention to hygiene, reduce disease and improve health,” and focused on
sanitation, waste management, and disease control. This was aligned with the overall health policy, which
focused on greater access to care, preventive medicine (both traditional and western), and mass public
health campaigns to ensure a high level of outreach in rural areas and health personnel training (Ma and
Sood 2008; Zhang and Kanbur 2005). The policy supported creation of service teams consisting of
midwives, physicians, and administrative personnel to serve in rural areas, which helped to provide targeted
care for maternal and child health.c
The government initiated midwifery training and invested in Maternal and Child Health (MCH) Stations as
part of its clean delivery campaign. The Ministry of Health provided necessary disinfection equipment to
villages and created MCH service teams consisting of birth attendants, doctors, and administrative
personnel to improve service provision in rural areas. The ability for mass organization through communes,
production brigades, and production teams facilitated large campaigns for mass immunizations and health
personnel training (Zhang and Kanbur 2005).
“Twinning,” which paired urban and rural health workers and doctors for training, was introduced. Primary
care health workers from urban, developed areas worked in rural areas, while their rural counterparts
traveled to urban areas to learn best practices (Li et al. 2009).d By the late 1970s, every village had a clinic
staffed by health personnel also known as “barefoot doctors.” In village clinics with more than two barefoot
doctors, at least one would be female to provide basic MCH services. At the township level, all health
centers were required to have at least one MCH staff. This staff was also responsible for supervision and
training of village health workers/barefoot doctors, especially when high-risk cases were identified.
These efforts led to significant improvements in China’s health outcomes. By 1960, more than 810,000
traditional midwives had been trained, and clean delivery rates had reached 85 percent (Ling Xuezhen
Collection 1995). Infant mortality declined from 235 to 83 per 1,000 live births, and life expectancy
increased from 34 to 63 years between 1950 and 1970 (Blumenthal and Hsiao 2005;
MoH/WHO/UNFPA/UNICEF 2006; Wang and Liu 2011; Zhang and Kanbur 2005). According to the
National Health Services Survey of 2008, the proportion of safe drinking water in urban and rural areas had
reached 98.2 percent and 85.8 percent, respectively, and use of sanitary latrines reached 93.8 percent and
43.3 percent, respectively
Note: a. The MMR was 1,500 and the infant mortality rate was about 235; b, c, d, e. Stakeholder interviews
China’s One Child Policy: Established in1979, this policy has had a profound influence on both
Chinese society and maternal and child health. The policy limits households to one child, with
some exceptions. Rural households and ethnic populations were allowed more than one child
under certain circumstances. The policy aimed to reduce pressure on the country’s resources
through controlling population growth, which had already reached 969 million by 1979. Although
fertility rates in China had been declining due at least in part to earlier population policies and
social unrest, concern over a high population growth rate prompted the government to implement
the one-child policy. At the same time, it had provisions for families to use maternal and child
health services, through making reproductive health services available, including for adolescents.
The policy contributed to the already declining fertility rate by further halving it from 2.8 to 1.9
births per woman between 1978 and 1998. However, the policy has been strongly criticized for
being coercive and disrespecting human rights. It has also had some unintended negative
46
consequences, such as the skewed gender ratio in favor of boys (Doherty et al. 2001; Hesketh et
al. 2005; Short et al. 2001; Fengying 1998; Ni and Rossignol 1994).
3. Main Maternal and Child Health Programs
The “Two Reductions” Program (Safe Motherhood): In 2000, China introduced the Program
to Reduce Maternal Mortality and Eliminate Neonatal Tetanus, aimed at reducing maternal and
infant mortality by promoting hospital delivery. Initiated in 378 counties, it now covers the entire
country. The program focuses on health education, affordable care, quality of care, and social
mobilization to reduce maternal and infant mortality. It provides subsidies to mothers in national
poverty counties with a maternal mortality ratio (MMR) and neonatal tetanus incidence that are
high compared to the average provincial rate. Obstetric experts from provincial tertiary hospitals
are also assigned to primary maternal care centers for at least two weeks each year to build local
capacity through direct support and training, and to facilitate communications and referral
networks among the different tiers of service delivery. Effort has also been made to improve the
specialized capacity of pediatric workers by sending experts to counties for on-site training, and
conducting health education and social mobilization.
The program is associated with an increase in prenatal visits and facility-based births, and in
contributing to declines in maternal and neonatal mortality. Between 2000 and 2006, facility-
based births increased by 28 percent in counties where the program was implemented, and A
MMR due to hemorrhage dropped from 68 to 30 deaths per 100,000 live births. During the same
period, the overall MMR declined from just under 120 per 100,000 live births to approximately
60 per 100,000 live births. A decline was also observed in neonatal mortality, from approximately
20 per 1,000 live births in 2000 to just under 12 deaths per 1,000 live births in 2006. The
incidence of neonatal tetanus also declined from 0.5 cases to 0.1 cases for every 1,000 live births.
In 2012, the World Health Organization declared China free of maternal and neonatal tetanus
(Feng et al., 2010; Liu et al. 2010; WHO 2012).
Childhood Immunizations: China established the Expanded Program for Immunization (EPI) in
1978 covering tuberculosis, polio, whooping cough, diphtheria, measles, and tetanus. Routine
immunizations were organized through the health system under the supervision of China’s Center
for Disease Control (CDC) for children under seven years of age. In 1992, the MoH added
hepatitis B to EPI and later, in 2007, 15 additional immunizations were added including grubella,
mumps, encephalitis, epidemic cerebrospinal meningitis, hepatitis A, epidemic hemorrhagic
fever, anthrax, and leptospirosis (Zhang et al. 1999).
Over the next two decades, immunization rates averaged between 60 and 80 percent. Gaps in
immunization began appearing along socioeconomic lines, with maternal education, health
insurance coverage, and cost of vaccines as the main determinants of child immunization (Xie
and Dow 2005; Zhang et al. 1999). Other inherent problems of the health system such as uneven
distribution of resources (health workers, supply chain, and financing) across counties and
provinces also contributed to gaps in immunization, especially in remote and rural areas (Chen,
Lei, and Zhou 2010; WHO 2008).
To stimulate an increase in immunization rates, in 2007, the Chinese government took steps to
address both demand- and supply-side constraints. On the supply side, it began to centrally fund
the immunization/EPI program, which included vaccines, syringes, and allowances for health
workers to encourage greater coverage in rural areas. On the demand side, EPI services were also
made free. These efforts have helped increase immunizations, which are now nearly universal at
99 percent for both DPT and measles.
Control of Childhood Diseases: In the 1990s, acute respiratory infections (ARI) and chronic
diarrheal disease were identified as major causes of child ill health and mortality in China. To
47
address this, the MoH introduced the National Children's Respiratory Infection Control Program
(1992–1995) and the Diarrheal Disease Control Program (1990–1994). The programs promoted
the use of appropriate technology, systematic training, health education, management, and
monitoring to prevent and manage illnesses, especially in rural areas. A follow-on program in 10
counties from Guangxi, Inner Mongolia, Qinghai, Shandong, Shanxi, Sichuan, Xinjiang, and
Yunnan provinces targeted both health workers and mothers to reduce the incidence of mortality
due to ARI and diarrheal disease.
4. Health System Responsiveness
Service Delivery System: One of the most critical pillars of successful improvements in MCH
has been its well-organized service delivery system, with wide geographic coverage. Beginning
from a very weak base in the 1950s, especially in the rural areas, the government created a three-
tier health system consisting of county hospitals, township health centers, and village clinics in
rural areas, and of street clinics, district hospitals, and city hospitals in urban areas.
In rural areas where maternal mortality was highest, the government established Maternal and
Child Health (MCH) Stations, in addition to village clinics, to improve access and encourage
facility-based clean deliveries following standardized protocols. In 1986, MCH received a
further boost when the MoH and Ministry of Labor co-published standards for MCH service
delivery. The role of MCH stations was expanded to include both primary and secondary levels
of MCH services. Further, in the 1990s a separate Department for Maternal and Child Health
was created within the Ministry of Health, and all counties were required to have MCH specialty
hospitals, completing the three-tier MCH structure from village to county level with roles and
responsibilities clearly articulated. This helped create a clear chain of command, linking all
levels of service provision (Eggleston et al. 2008; Li 2004; MOH China 2011).
Health Insurance Coverage: In the rural areas, where major gaps in access to and provision of
health services appeared in the 1980s due to market reforms, the Government of China
reintroduced health insurance to reduce financial barriers to inpatient care in rural areas by
subsidizing the cost of inpatient care. Although rural populations had previously been covered by
the Rural Cooperative System, which provided free health care, with the collapse of the commune
system, rural populations lost this coverage.
Between 1988 and 2001, out-of-pocket payments rose significantly, increasing from 38 percent
to 61 percent, which have since declined to pre-1988 levels due in large part to health insurance
(figure 3). At the same time, with greater investments in health, the per capita health
expenditure has increased, and this is most likely related to the burden of non-communicable
diseases (figure 4).
In 2003, the New Rural Cooperative Medical Scheme (NCMS) was piloted in some counties,
and expanded to all rural counties by 2010. This scheme differs from its predecessor in that it is
organized at the county level and enrollment is voluntary (Wagstaff et al. 2009; Yip and Hsiao
2009; Zhang et al. 2010). 12
12
While its main focus is on subsidizing inpatient care, in some counties catastrophic illnesses requiring
outpatient care are also covered (Wagstaff et al. 2009). Under the cooperative medical scheme, citizens
make a small contribution to a pool and the community funds a local health worker, who provides basic
clinical services and referral for more specialized needs via a three-tiered network from village to township
to county (stakeholder interview).
48
The NCMS includes a maternal health care benefits package, which varies by county. It
generally provides reimbursement for specific services including both facility-based normal
delivery and caesarean section. Since the design of the package is left to the counties, coverage
for MCH under this scheme is not automatic and is limited to a few counties. Subsidies under
the NCMS helped reduce out-of-pocket costs, although at 14 percent of total household
expenditure, they are still substantial for the poorest households, and the scheme has been
criticized for its high deductibles and focus on hospital care. However, in the rural western
provinces of China where MCH components are available, NCMS is associated with an increase
in institutional deliveries—from 45 percent in 2002 to 80 percent in 2007 (Yip and Hsiao 2009;
Zhang et al. 2010; Long et al. 2010).
Figure 3. Out-of-Pocket Health Expenditure Figure 4. Health expenditure per capita, PPP
(% of total expenditure on health) (constant 2005 international $)
70 600
60 480
46 500
50
400
40
300
30
34 200
20
52
10 100
0 0
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Source: WDI 2014
Investment in Human Resources: In China, early focus on training health personnel including
midwives at the community level was pivotal in providing MCH services to the masses. The
aim was to build up a cadre of health personnel trained in Western medicine and to increase
staffing. At the rural level, “twinning” and the ability for mass organization through communes,
production brigades, and production teams facilitated health personnel training (Box 1). By the
late 1970s, “barefoot doctors” had been deployed in every village to provide basic health
services (Zhang and Kanbur 2005).
To strengthen delivery of MCH services in villages, the government created the position of the
Maternal and Child Health Clinician in the 1980s. These were part-time clinicians that provided
prenatal services at the township level, and supervised village doctors. Along with the village
doctors, they were responsible for identifying and keeping track of pregnancies in their area to
ensure proper care, especially of high-risk cases.
Over time, the role of midwives in China has also declined, as greater emphasis has been placed
on hospital-based deliveries. However, there are shortages of qualified staff. This is part of the
overall shortages in the health sector. In the rural and poor areas, these shortages are more acute,
because health workers have become concentrated in urban areas and higher-income counties,
where they can earn more. At the national level, skilled birth attendance remains high, as do
postnatal care visits, but at the county level there are coverage gaps due to inadequate qualified
human resources. While the Government of China has initiated training as part of its 2009 health
sector reforms, there needs to be greater discussion on how to ensure that underserved areas are
covered and whether trained birth attendants including midwives can fulfill this role (WHO
2008; Harris et al. 2009; World Bank 2010).
Monitoring of Health Inputs and Outcomes: China has one of the largest networks of
women’s and children's health surveillance in the world. Several surveillance networks including
the National Birth Defects Surveillance Network (1986), the National Maternal Mortality
Network (1989), and the Under-five Child Mortality Surveillance Network (1991) were
49
integrated into a single information system in1996, to form this system. To improve performance
and enhance accountability, maternal death reviews were initiated in 2000 with the strong
support and involvement of local governments.
In the 1990s, the Government of China also introduced the “contract responsibility system” and
“target responsibility agreements” to improve and monitor supply-side performance. The
contract responsibility system primarily focuses on the EPI and prenatal care, while the target
agreements are signed among the county health bureau, the township health center, and the
county MCH hospital to monitor their performance on delivery of services.
5. Creating an Enabling Environment
Education: Education is an important factor influencing maternal and child health. Educated
women are more likely to invest more in their children’s education (Filmer 2006; De Walque
2007), and they are more likely to participate in household and community decision making
compared to women with no or little education (Sen 1999; UNESCO 2000). After the Cultural
Revolution, universal primary education in China was one of the major targets pursued by the
government. Early efforts, which included mass adult literacy campaigns, helped reduce illiteracy
from 80 percent in 1950 to 52 percent in 1964. To further improve education status, the
Government of China introduced free compulsory education for the first nine years of schooling,
with particular focus on poor and ethnic minority areas (The Compulsory Education Law of the
People’s Republic of China, 1986). The government also set a target of “eliminating gender
inequities in primary and secondary education by 2005.”
By 2007, net primary education enrollment ratios reached 99.52 percent for girls and 99.46
percent for boys. Adult literacy rate has increased to 94 percent, with a 91 percent adult female
literacy rate in 2009. Secondary school enrollment has also increased significantly for both boys
and girls, increasing from 32 percent in 1990 to 83 percent in 2010 for girls, and from 43 percent
to 80 percent for boys.
Women’s Empowerment: Women’s empowerment is important for their uptake and utilization
of reproductive, maternal, and child health services. Improvement in women’s social and family
status is associated with more freedom and decision-making authority, especially in relation to
their own health and that of their children. Although gender discrimination still exists, China
legally recognizes men and women as equal. This is enshrined in several laws and the
Constitution of the People’s Republic of China (1954). The Marriage Law of the People’s
Republic of China (1949), which grants women equal rights in marriage, and the Electoral Law of
the People’s Republic of China (1953), which gives women equal right to hold political office,
have helped improve women’s status.
China has introduced a number of laws and regulations protect female workers’ rights and
establish health standards for female workers and protect their rights to social insurance such as
the Regulations Concerning the Labor Protection of Female Staff and Workers (1988), the Law of
the People’s Republic of China on the Protection of Women’s Rights and Interests (1992), and
the Measures for Implementation of the Law of the People’s Republic of China on Maternal and
Infant Health Care (2001).
Political Leadership: Political leadership has played an important role in shaping the
socioeconomic landscape in China. Directives from the Central Government have been important
in the Chinese context, with its one-party rule in signaling policy directions. Programs to promote
MDGs 4 and 5 have been successful in China due to strong support from the government,
including financing of MCH services and the creation of a three-tier structure to support
coordinated efforts to improve MCH indicators. Safe delivery, immunizations and, more recently,
50
preventing mother-to-child transmission, have been prioritized with strong political backing.
Similarly, maternal death audits were institutionalized with strong support from the government.
6. Remaining/Future Challenges
While China has 8.2 million health care providers, challenges remain in ensuring the
availability and quality of health care providers. The ratio of doctors and nurses to the
population is still low at 1.79 doctors and 1.52 nurses per 1,000 population (Chinese Health
Statistical Digest 2011). Human resources are also unequally distributed in favor of urban and
higher-income counties and provinces. The capacity of health workers also needs attention.
Health sector reforms were initiated in 2009, which aim at addressing these challenges including
training for health workers at the township and city levels and village doctors.
With facility-based births, one issue that has emerged is the high rate of cesarean sections,
with 70 percent of births being performed via C-section. Evidence suggests that the majority of
the C-sections are demanded by women for personal reasons, especially those with higher
education and those who live in urban area and higher-income regions (Sufang et al. 2007; Anand
et al. 2008; Harris et al. 2009). Demand-side interventions such as information and education
campaigns are needed to address this issue.
Although major strides have been made to reduce gender disparities, some gaps remain due
to income, residential status, and culture. Most women still work in the agricultural sector as
unpaid family workers. Wage differentials and other practices such as stronger enforcement of
penalties for violation of family planning regulations and forced early retirement due to
pregnancy put women at a disadvantage. Employers are often reluctant to hire women, and may
hire them on the condition that that they will not become pregnant, or fire them due to a
pregnancy. This also affects their insurance coverage and other benefits that depend on
employment status or length of employment. Women are considered primary caregivers within
Chinese society, and there is greater pressure on them to leave the labor force when they start a
family. This is especially relevant for female migrant workers. (Burnett 2010; Tolhurst, Standing,
and Qian 2004; Fan 2003). While major strides have been made in improving the status of
women, such practices persist and will require greater effort to address.
Migrant workers constitute a particular challenge since they do not have access to the
urban medical insurance system or other basic services. Floating migrant populations in
China’s urban areas have increased considerably, skyrocketing from 31 million in 1990 to 221
million in 2010. Household registration in China, known as Hukou, determines where household
members can access basic services such as health care and education, putting rural inhabitants
who migrate to urban centers at a disadvantage According to the United Nations Development
Program’s China Human Development Report 2007–08, the maternal mortality rate among
permanent urban residents is 25 per 100,000 births compared to 71 per 100,000 among migrant
workers (Chan 2009; Liang and Chen 2004).
Social services such as health and education are not easily accessible to these populations.
The problem is especially acute for female migrant workers from rural areas who, lacking safety
nets similar to those of urban residents may have to return to their villages for marriage,
childbirth, and even their children’s education, or face an uncertain future in urban centers
(Burnett 2010; Fan 2003). Those migrants who stay in urban areas face additional challenges
because their children do not qualify for free public health services such as routine immunizations
outside of their county of residence (World Bank 2006). Yet, these workers are critical to the
continued growth of China’s economy. It is a challenge to manage health and other social
services for a transient population. Some steps are being taken with towards providing better
coverage to these populations.
51
One of the key concerns in China has been regional disparities in MCH indicators due to
income differentials. Indicators of child health demonstrate particularly strong disparities: the
prevalence of stunting is 5.3 times higher in rural compared to urban children, and the prevalence
of underweight is 4.6 times higher in rural children (Liu et al. 2008). While the rural-urban gap in
infant and under-five mortality has declined, the pace of decline has been slow (Brixi et al. 2010).
Decentralized financing and administration has provided more autonomy to the counties,
but also makes it difficult to ensure that the poor have access to services especially when
counties do not have the resources to provide services. Local governments allocate resources
based on their development and health priorities, and may lack sufficient funds to cover MCH
services appropriately. This has translated into variations in service provision (see World Bank
2005, 2006). Programs such as the Safe Motherhood Program have been very useful in addressing
some of the barriers created due to changes to the economy and health system reform. In addition,
poverty alleviation programs and monitoring initiated by the Government of China are showing
positive results. Between 1990 and 2010, the percentage of people living under US$1.25 a day
declined significantly from 60 percent to 14 percent. While household consumption has
increased, at the regional level, disparities persist, especially in access to health services. For
example, out-of-pocket expenditures in rural areas continue to be twice as high as those in urban
areas, overall (Brixi et al. 2010). Generally speaking, richer coastal provinces in the east perform
significantly better than those inland (that is, the Western province), and this is starkly reflected
in MCH progress (see, for example, Fang et al. 2009). The Government of China has made
poverty alleviation and reduction of maternal and child mortality its priority, and continued effort,
focusing on local- and provincial-level inequalities, is needed to ensure continued improvements
in outcomes.
China’s also faced with an increasing age dependency ratio due to an aging population and
the one-child policy. Currently, China enjoys a low age dependency ratio, but this is expected to
reverse over the next 20 to 30 years due in part to the continued implementation of the one-child
policy and the resulting low fertility rate of 1.6 births per woman, the population growth has
slowed. In tandem with advances in medicine and an increased life expectancy of 73 years, the
elderly are living longer in China, and their proportion of the population is expected to grow over
the next few decades. In essence, this would translate into four grandparents and two parents per
person born today (the 1:2:4 ratio). This will also have implications for social safety nets and per
capita productivity. Addressing this challenge will require not only an assessment of social safety
nets but also the one child policy.
Figure 5 provides a timeline of interventions and indicators related to MDGs 4 and 5 in China. 13
13
Caution should be taken in inferring any causality since multiple factors contributed to the decline of
U5MR and MMR as the discussion highlights.
52
Figure 5. China: Timeline of MDG 4 and 5 Interventions
MDG 4: Under 5 Mortality
120 70
deaths per 1,000 live births
99 60
100
61
50
80
78 40
% 60
58 30
40
20
20 10
14
0 0
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
DPT Measles U5MR
MDG 5: Maternal Mortality
120 120
deaths per 100,000 live births
97 99.1
100 100
80 80
89.3
69.5
% 60 60
32
40 40
20 20
0 0
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
Contraceptive Prevalence Rate Skilled Birth Attendance Maternal Mortality Ratio
1950–1989 1990–1999 2000–2012
1950s onwards: Training of 1990–94 Diarrheal Disease 2000: Program to Reduce
midwives initiated; focus on Control Program Maternal Mortality and
improving hygienic conditions; Eliminate Neonatal Tetanus
1992–95 National Children's
and mass immunizations (“Two Reductions” or Safe
Respiratory Infection Control
Motherhood Program)
1965: "June 26 Directive" calls for Program
scientific methods in healthcare 2000: Maternal death reviews
1994: Law on Maternal and
initiated
Mid-1970s: Barefoot doctors in Infant Health Care
every village 2001: Implementation
1996: Integrated Health
Guidelines of the Law on
1978: Expanded Program for Information System for MCH
Maternal and Child Health
Immunization (EPI) initiated established through merger of
existing data collection 2003: NCMS to subsidize health
1979: One-Child Policy
channels care costs in rural areas
1980s: Position of Maternal and
Mid-1990s: MCH department 2010: NCMS expanded to
Child Health (MCH) clinician
created; all counties required cover all counties
created
having an MCH specialty
1984: Operational protocols to hospital
standardize maternal
healthcare provision
1986: Ministries of Health and
Labor co-formulate standards
for MCH
53
Selected References
Anand, S., V. Y. Fan, J. Zhang, L. Zhang, Y. Ke, Z. Dong, and L. C. Chen. 2008. “China’s
Human Resources for Health: Quantity, Quality, and Distribution.” The Lancet. Health
Systems Reforms in China Series (October).
Brixi, H., Y. Mu, B. Targa, and D. Hipgrave. 2010. “Equity and Public Governance in Health
System Reform: Challenges and Opportunities for China.” Policy Research Working
Paper Series, No. 5530, World Bank, Washington, DC.
Eggleston, Karen, L. Ling, M. Gingyue, M. Lindelow, and A. Wagstaff. 2008. “Health Service
Delivery in China: A Literature Review.” Health Economics 17 (2): 149–65.
Fan, C. C. 2003. “Rural-urban Migration and Gender Division of Labor in Transitional China.”
International Journal of Urban and Regional Research 27 (1): 24–47.
Fang, P., S. Dong, J. Xiao, C. Liu, X. Feng, and Y. Wang. 2009. Regional Inequality in Health
and its Determinants: Evidence from China. Health Policy 94: (1): 14–25.
Hesketh, T., and W. X. Zhu. 1997. “Maternal and Child Health in China.” BMJ 314: 1898–1900.
Koblinsky, M. A. 2003. Reducing Maternal Mortality: Learning from Bolivia, China, Egypt,
Honduras, Indonesia, Jamaica, and Zimbabwe. World Bank, Washington, DC, xiv, p.
132.
Liu, X, H. Yan, and D. Wang. 2010. “The Evaluation of ‘Safe Motherhood’ Program on Maternal
Care Utilization in Rural Western China: A Difference in Difference Approach.” BMC
Public Health 2010 10:566.
Long, Q., T. Zhang, L. Xu, S. Tang, and E. Hemminki. 2010. “Utilisation of Maternal Health
Care in Western Rural China under a New Rural Health Insurance System (New Co-
operative Medical System).” Tropical Medicine & International Health 15 (10): 1365–
3156.
MoH China/UNICEF/WHO/UNFPA. 2006. Joint Review of Maternal and Child Survival
Strategies in China. Ministry of Health, China/WHO/UNICEF/UNFPA, Beijing, China.
Sufang, G., Sabu S Padmadas , Zhao Fengmin , James J Brown , R William Stones. 2007.
“Delivery Settings and C-Section Rates in China.” Bulletin of the World Health
Organization 85 (10) (October): 733–820.
Short, S. E., and Z. Fengying. 1998. “Looking Locally at China’s One-Child Policy.” Studies in
Family Planning 29 (4): 373–87.
Wagstaff, A., M. Lindelow, G. Jun, X. Ling, and Q. Juncheng. 2009. “Extending Health
Insurance to the Rural Population: An Impact Evaluation of China’s New Cooperative
Medical Scheme.” Journal of Health Economics 28 (1): 1–19.
World Bank. 2003. Comprehensive Maternal and Child Health Project (Health VI).
Implementation Completion Report, No. 25239, World Bank, Beijing, China.
_______. 2011. Health Nine Project. Implementation Completion and Results Report, No.
0000480. World Bank, Beijing, China.
_______. 2013. China’s Progress on MDGs 4 and 5. World Bank, Washington DC (mimeo)
Xie, Jipan, and William H. Dow. 2005. “Longitudinal Study of Child Immunization Determinants
in China.” Social Science & Medicine 61 (3) (August): 601–11.
Yip, W., and W.C. Hsiao. 2009. “Non-evidence-based Policy: How Effective is China’s New
Cooperative Medical Scheme in Reducing Medical Impoverishment?” Social Science and
Medicine 68 (2): 201–9.
Zhang, L., X. Cheng, R. Tolhurst, S. Tang, and X. Liu. 2010. “How Effectively Can the New
Cooperative Medical Scheme Reduce Catastrophic Health Expenditure for the Poor and
Non-poor in Rural China?” Tropical Medicine & International Health 15 (4): 1365–
3156.
Zhang, X., and R. Kanbur. 2005. “Spatial Inequality in Education and Healthcare in China.”
China Economic Review 16: 189–204.
54
ANNEX 3: EGYPT’S PROGRESS ON MDGS 4 AND 5
Key Messages
• Child mortality has declined from 86 deaths per 1,000 live births in 1990 to 21 deaths per
1,000 live births in 2012. Maternal mortality has also declined from 120 deaths per 100,000
live births in 1990 to 45 deaths per 100,000 live births in 2013 – achieving its MDG 4 and 5
targets.
• Egypt has had a long standing family planning program which has contributed to the
improvement of women and children’s health.
• Programs for childhood immunizations and control of diseases have been an important
component of Egypt’s response to child ill health
• After ICPD 1994, integrated approaches to maternal and child health have been critical in
reducing maternal and child mortality further, especially through increased focus on the poor
and marginalized areas. Between 1992 and 2000, Egypt saw a 52% in reduction of maternal
mortality. This is due in part to the success of the Healthy Mother/ Healthy Child Project
which operated in the Upper Egypt region.
• While Egypt has done a great deal to improve maternal and child health, challenges remain
especially in relation to women’s autonomy. Egypt has seen political and social unrest since
2011 which has escalated in the past year with negative consequences for economic growth
and social development.
1. Introduction
Egypt is a lower middle-income country with a GNI per capita (PPP) of US$ 5,654in 2012
and an average GNI growth rate of 4.4 percent between 2001 and 2010. Following political
unrest (the Arab Spring) in 2011, Egypt’s economy has taken a downturn with growth slowing to
2.2 percent in 2012 (World Development Indicators 2014). With continued instability in the
country, there is growing concern regarding the socio-economic conditions in the country.
Although extreme poverty in Egypt is low (with only 25 percent of the population living on
US$ 1.25 per day or less), it is largely concentrated in the Upper Egypt (the southern) region,
which is home to 80 percent of the extreme poor. Half of Egypt’s 82.54 million people live in
rural areas. . It is the largest, most densely populated country among the Arab States. Most of the
population is concentrated in the Nile Delta (in the North) or in the Nile Valley (south of Cairo) –
which makes up the Lower Egypt region, which has been an advantage in providing coverage of
basic services to majority of the population as the government could concentrate in these two
regions.
Egypt is ranked 112th on the Human Development Index, and 126th on the Gender
Inequality Index (out of 186 ranked countries). The female labor force participation rate is 24
percent compared to 74 percent for males. The primary school completion rate is high for both
females and males at 99 percent and 102 percent, respectively. Gross secondary enrollment is 71
percent for females and 74 percent for males. However, only 60 percent of the women are literate
compared to 80 percent men.
Egypt has made considerable progress in improving maternal and child health. According to
interagency estimates, child mortality declined from 86 deaths per 1,000 live births in 1990 to 21
deaths per 1,000 live births in 2012 - a 75.4 percent decline, that has allowed Egypt to exceed its
target for MDG4. Egypt has also successfully reduced neonatal mortality by 65 percent during the
same period. Similarly, the maternal mortality ratio (MMR) has declined from 120 deaths per
55
100,000 live births in 1990 to 45 deaths per 100,000 live births in 2013 – a 62 percent decline,
that also exceeds the targets set for MDG 5 for Egypt. Recent political events in the country,
however, bring into question how long the results can be sustained if conditions do not improve.
Figure 1. Child Mortality (1990-2012) Figure 2. Maternal Mortality Ratio (1990-2013)
Estimated Deaths per 1,000 Live Births Estimated Deaths per 100,000 Live Births
90 140
86 120
80
64 120
70 96
60 100
50 45 75
80
62 57
40 31 50
23 29 60
30 45
21
20 40
10 20
0
1990 1995 2000 2005 2010 2012 2015 0
(MDG 1990 1995 2000 2005 2010 2013 2015
Target) (MDG
Target)
Source: WHO 2014; UNICEF 2013
2. Maternal and Child Health Policies
Child Health: Focus on immunizations and control of childhood diseases was an important
aspect of early prioritization of child health. In 1989 Egypt further focused attention on child
related issues by declaring a “Decade of the Egyptian Child” from 1989 to 1999, and then again a
second decade from 2000 to 2010. Investment in children was promoted as the best investment
for the future of Egypt. In 1996, the Law of the Child was passed, which aimed to use an
integrated approach to address childhood issues including health. Provisions in the law are guided
by the Qur’an, the Shari'a (the code of law based on the Qur’an), the principles of the Egyptian
Constitution, and the provisions of the Convention on the Rights of the Child. In 2008, the law
was amended to include a rights-based approach. 14
Reproductive and Maternal Health: Early family planning efforts in Egypt were grounded in
concern over population growth and the quality of life. The first National Population Policy was
promulgated in 1973 with the goal of reducing the crude birth rate from 34 births per 1,000 in
1973 to 24 per 1,000 in 1982 emphasizing the link between family planning, fertility reduction,
and socioeconomic development. By 1994, there was a marked shift in policy with family
planning being rooted firmly within comprehensive reproductive and maternal health after the
landmark International Conference on Population and Development (ICPD) conference which
was held in Cairo (Zohry 1997). In 1988, the National Council for Childhood and Motherhood
(NCCM) was created to coordinate policymaking and programs on children and safe motherhood
in Egypt (National Council for Childhood and Motherhood 2000). After ICPD 1994, family
planning was merged with maternal and child health under the Ministry of Health and Population
(MoHP). The 1998–2002 Five Year Plan of the MoHP adopted a comprehensive approach
integrating family planning and maternal and child health into a general women’s health program.
It focused improving the quality of delivery care and encouraging appropriate care-seeking
behavior to reduce maternal mortality. Greater emphasis was also placed on improving the quality
of care in Upper Egypt to reduce regional disparities in maternal mortality outcomes between the
region and Lower Egypt (Sharma et al. 2005; World Bank 2008; Campbell et al. 2005).
14
Child Rights/Legislation. National Council for Childhood and Motherhood. http://www.nccm-
egypt.org/e7/index_eng.html
56
Constitution of 2012: In 2012, Egypt adopted a new Constitution which guarantees healthcare
including free maternal and child health services and free healthcare for the poor. Article 10 of
the constitution states that “The State shall ensure maternal and child health services free of
charge, and enable the reconciliation between the duties of a woman toward her family and her
work.” Article 62 guarantees the right to health of every citizen and makes provisions for free
healthcare for the poor15. In guaranteeing these rights, it continues to support existing MCH
programs. However, there are concerns that overall it does not go far enough in preserving
women’s rights, including that for family planning, especially amid reports that the government
has begun to scale back the family planning program16, which in part is due to a phasing out of
donor support.
3. Maternal and Child Health Programs
Immunization: Improvements in child health in Egypt are largely attributed to the focus on
vaccinations and treatment of childhood illnesses. The immunization program in Egypt started in
1956, when DPT immunization was made compulsory, followed by poliomyelitis in 1968, BCG
in 1973, and measles in 1977. Initiated as vertical programs, these were later incorporated into the
Expanded Program of Immunization (EPI).17 In late 1985, President Mubarak set a national goal
of achieving universal coverage by 1987, resulting in a series of national campaigns that led to a
high level of complete immunization coverage in many areas. The overall immunization coverage
against childhood illness increased from 35 percent in 1988 to 92 percent in 2008. The World
Health Organization declared Egypt free of neonatal tetanus (NT) in 2006 based on the outcomes
of the national campaign against NT from 1995 to 2006 (UNDP 201018). The percentage of
children immunized increased from 35 percent in 1988 to 91.5 percent in 2008. Overall DPT and
measles immunizations have also increased, despite a minor decline between 2005 and 2008
(Table 1).
Table 1: Childhood Immunizations in Egypt (1988-2008)
Indicator 1988 1992 1995 2000 2005 2008
% of children fully immunized 35 67.4 79.1 92.2 81.1 91.5
Immunization, DPT (% of children 12-23 months) 87 79 88 98 98 97
Immunization, measles (% of children 12-23
months) 85 89 89 98 98 92
Sources: WDI, DHS
Childhood Illnesses: In the late 1970s and early 1980s, dehydration from diarrhea had emerged
as one of the leading causes of death in Egypt. To address this, the Control of Diarrheal Disease
Program (CDD) was begun in 1982 to address this issue. Oral rehydration salts (ORS) were
introduced through both the public and private sector. Media campaigns were also launched to
raise awareness and teach mothers how to use ORS. Diarrheal mortality decreased 62 percent in
children and 82 percent in infants between 1982 and 1987. Overall, the program helped reduce
child diarrheal deaths by 300,000 between 1982 and 1989. 19
15
http://www.egyptindependent.com/news/egypt-s-draft-constitution-translated
16
http://www.economist.com/news/middle-east-and-africa/21568394-if-approved-egypts-new-constitution-
would-be-step-back-mubarak-era
17
https://jscholarship.library.jhu.edu/bitstream/handle/1774.2/848/WP94-10.pdf;
http://www.benthamscience.com/open/tovacj/articles/V002/77TOVACJ.pdf
18
http://www.undp.org.eg/Portals/0/MDG/2010%20MDGR_English_R5.pdf
19
http://www.cgdev.org/doc/millions/MS_case_8.pdf
57
During the 1980s, there were high levels of morbidity and mortality associated with acute
respiratory infections (ARI) in children under five, particularly pneumonia. Egypt established a
national ARI program in 1989 to respond to this threat. To increase utilization, communication,
and education, efforts were made through counseling of families by doctors and nurses. The
program also focused on training of health personnel and securing equipment and a regular
supply of essential drugs. Research and monitoring also played an important part in this program
as it has informed key implementation areas such as policy making and the improvement of
guidelines. By 1994, access to standard case management was 85 percent (Khallaf and Pio 1997).
By the mid-1990s, the ARI, CDD, and EPI vertical programs were folded into the nationwide
Integrated Management of Childhood Illness (IMCI) program with an aim to provide cost-
effective and comprehensive child health services. The IMCI strategy was adopted by the MoHP
in 1997 as part of its health sector reform (WHO 1999). The IMCI in Egypt aims to improve the
quality of child health services, develop health information system, strengthen referral system,
and improve family practices by combining curative, preventive and development aspects of child
care, for the under 5 years age group. IMCI improved the quality of primary health care services
offered to children with universal coverage at public health care facilities, and evidence shows
that it is associated with doubling the rate of reduction of U5MR in districts implementing IMCI.
Despite progress in reducing childhood illnesses, disparities are evident between Upper Egypt
and Lower Egypt. According to the 2008 DHS, under-5 mortality in Lower Egypt is 25.3 deaths
per 1,000 live births compared to Upper Egypt which is 42.7 deaths per live births. Infant
mortality is also higher in Upper Egypt with 36.3 deaths 1,000 per live births versus Lower Egypt
with 21.3 deaths 1,000 per live births.
Family Planning: The national family planning program began in 1973 with the establishment of
the first National Population Policy, which focused on population growth and economic
development. Campaigns were launched and choice of contraceptives increased over the 1980s
and 1990s. The government also invested in developing local leadership and generating
ownership of service provision among health service providers to improve quality of services
through the Leadership Development Programme (LDP), which has shown positive results. After
ICPD 1994, family planning was integrated into the MCH program. The family planning program
can be associated with the increase in contraceptive prevalence from 23 % in 1980 to 60% in
2008. Total fertility also declined from 5.6 to 2.7 during the same period. The family planning
program is credited with contributing to 3.8 million fewer infant deaths and over 7 million fewer
child deaths, and for saving 18,000 maternal lives between 1980 and 2008 (USAID 2011).
Population Project (1996-2005): This World Bank supported project has also been instrumental
in encouraging utilization of family planning through women’s empowerment. One of the
objectives of the project was to stimulate demand for smaller families and family planning
services in high-fertility areas of rural Upper Egypt through socioeconomic improvement (micro
credit, literacy eradication activities, and home visits using a network of Social Change Agents).
On average, in participating areas CPR increased from 44 to 55 percent between 2000 and 2005
at the village level. There were also improvements at the district level. Anecdotal evidence from
the project suggests that the project had a positive impact on the women’s status and their
families. Positive changes in male attitudes were also noted, especially because of microcredit
(World Bank 2005).
Child Survival Project: In 1985, the MoHP, with the assistance of USAID, started the Child
Survival Project, which aimed to reduce maternal and child deaths by 1995. The project
comprised four vertical programs: EPI, ARI, child spacing, and nutrition. Data show that over the
next 10 years there was an average 35 percent decline in infant mortality and a 59 percent decline
in child mortality. At the same time, maternal mortality declined from 220 maternal deaths per
100,000 live births in 1988 to 174 maternal deaths per 100,000 live births during 1992–93,
58
accounting for a 21 percent reduction in the MMR. This reduction surpassed the project goal of a
15 percent decline (Cobb et al. 1996).
Box 1: Generating Consensus among Stakeholders on Family Planning in Egypt
In Egypt, a predominantly Muslim country, wide uptake of family planning is in part supported by the
efforts to ensure acceptability and wide access. To generate consensus, religious leaders were involved
early in the family planning policy making process to gain their support and encourage cultural
acceptability. Earlier advocacy by the Happy Family Society, a non-profit organization, led to an official
FATWA (religious decree) being issued in 1937 that declared that Islam was not against the use of family
planning under specific conditions. Later, with the government taking on family planning as part of its
policy, support was sought and gained for family planning through additional fatwas supporting the use of
modern contraception. These fatwas became part of the government’s education and information
campaigns on family planning.
Despite Egypt’s remarkable successes in family planning, the programming has traditionally adopted a top-
down approach. Amid concerns that uptake of family planning is stagnating, there is now an emerging
consensus among policy makers in Egypt that a different approach is needed in order to continue improving
results. Evidence points towards a relatively high unmet need for contraception (25 percent) coupled with
misinformation about contraceptive use. To address these issues it is important that there is a shift away
from a top-down program with targets for family size and fertility rate towards a rights-based and person-
centered approach. The essence of a rights-based approach is the focus on individuals taking control of
their lives. Such an approach would also support a greater voice for the poor and marginalized in exercising
their rights to better health.
The Healthy Mother/Healthy Child Project: Aimed at reducing regional disparities, the project
began operating in Upper Egypt in 1998 and incorporated a wide array of critical initiatives. It
enhanced the infrastructure of maternal and neonatal wards in the hospitals; improved services
via extensive training of physicians, nurses, and obstetricians/ gynecologists; developed
standardized national guidelines and disseminated them nationally; trained nurses to be qualified
nurse midwives; improved the referral network from the primary level to the tertiary level; and
developed an integrated maternal mortality surveillance system.
HM/HC has improved access to essential obstetric and neonatal care for an estimated 22,934,908
million people in nine Upper Egypt governorates and two slum areas. It has also improved
utilization and quality of maternal and child services. Urban births attended by a trained health
provider increased 45 percent between 1998 and 2003. In 2003, 77 percent of urban births and 50
percent of rural births were attended by a trained health provider, and the proportion of rural
births delivered in a health facility increased by 100 percent. Neonatal care unit admissions
increased from 6,149 cases in 1999 to 15,355 cases in 2003, representing an increase of 150% in
55 NCUs. The utilization rate tripled from between 1999 and2003 from 11.6/1000 live births to
27.9/1000 live births (JSI 2005).
By 2000, maternal mortality had declined 52 percent since 1992–93 with significant gains made
in Upper Egypt. Interestingly, the magnitude of change was significantly greater in Upper Egypt
(59 percent) than in Lower Egypt (30 percent). In addition, for the first time, the maternal
mortality ratio was lower in Upper Egypt than in Lower Egypt (MOHP 2000; Campbell et al.
2005).
4. Health System Responsiveness
Service Delivery System: Egypt’s health care system is characterized by widespread geographic
coverage of both public and private providers. The high population density and well-developed
infrastructure of roads and facilities means that most people live within close reach of health
59
services. In most cases, both rural and urban residents have access to a health facility within 5
kilometers of their home. Health services in Egypt are currently managed, financed, and provided
by the public and private sector as well as parastatal agencies. The public health care
infrastructure in Egypt is quite strong, with approximately 5,000 public primary care facilities and
1,100 public hospitals located across the country.
Health Insurance: In Egypt, half the population is covered by health insurance through the
government sponsored Health Insurance Organization (HIO), which includes public sector
workers, infants, school children, pensioners, and widows (WHO 2010). The government funds a
package of primary health care services. All Egyptians can receive free basic care through the
public health system; however, certain services, such as laboratory services, must be paid out-of-
pocket. While per capita health expenditure has increased, so have out of pocket costs (see figures
3 and 4). Private insurance is only utilized by 1 percent of the population. Fifty percent of the
population is uninsured and must pay out-of-pocket at public and private facilities for health
services. This includes the poor and those in the informal sector who rely on the free care
provided by the MOH. Out of pocket expenditures represent 60 percent of health care expenses
and 60 percent of this are for hospital and outpatient clinic services with spending on
pharmaceuticals making up the balance (World Bank 2009; WDI 2014).
In 1993, the government introduced the Student Health Insurance Program, to ensure
comprehensive preventative and curative coverage to address gaps in service among school aged
children. This increased the total beneficiary population from 5 million in 1992 to 20 million in
1995. In 1997, a ministerial decree extended insurance coverage to children under age one, which
by 2002 had increased the eligible beneficiary population to more than 30 million. The program
has been linked to increased utilization of child health services across all income groups although
the largest gains seem to have been made among the middle income groups (World Bank 2009;
Nandakumar et al 2000; MoHP 2005; Yip et al. 2001).
Health Care Reform (1997-2005): In 1997, Egypt took a step toward universal health coverage
with its Health Sector Reform Program (HSRP). The reforms aimed to extend health services to
poor populations by restructuring the primary health care delivery system to be based on the
Family Health Model (FHM). Under the FHM, families rather than individuals are registered with
specific doctors and facilities in their home neighborhood. Uninsured beneficiaries would be
registered through Family Health Funds (FHF), which were to function as insurance entities – a
precursor to national universal insurance. This program was targeted at women, children and
other disadvantaged population groups. Services would be provided through Family Health
Facilities which are accredited following staff training, upgrading of facilities, and ensuring
standard practice guidelines including essential drug lists, clinical information and referral
systems. An impact evaluation on the HSRP pilot found that HSRP improved maternal health
regarding nutrition and family planning but did not have an impact on prenatal and natal care. In
addition, the child vaccination rate and access to medical treatment also improved under the
HSRP (Grun and Ayala 2006).
60
Figure 3. Health expenditure per capita, PPP Figure 4. Out-of-pocket Health Expenditure
(constant 2005 international $) (% of total expenditure on health)
350 70
323 60
300 60
250 50
200 40 48
150 30
100 20
110
50 10
0 0
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Source: WDI 2014
Outcomes Monitoring: Most surveillance systems were established as part of the different
vertical programs, such as family planning, EPI, and ARI. As the programs matured and were
integrated within the overall health system, their surveillance systems were integrated into the
national health information system maintained by the MoHP. This system collects data at the
local, regional, district, and governorate levels. Egypt also established a Maternal Mortality
Surveillance System (MMSS) in 1998, which is based on death notification data at the district
level and expanded to all levels of the health system by 2001. These systems have allowed
practitioners to track diseases; determine causes of maternal deaths; and respond to the changing
environment and needs. It has also helped build accountability into the system, which has been
crucial in reducing maternal and neonatal mortality.
Monitoring outcomes through surveillance has been very influential in guiding government
response, projects and determining the areas of greatest need in Egypt especially for maternal
health. In 1992–93, the first Maternal Mortality Study was carried out under the Child Survival
Project. The study identified huge disparities in MMR between Lower and Upper Egypt. In
response, the government convened an expert panel and then released obstetric/gynecological
clinical guidelines and protocols nationally to ensure a high and consistent standard of care. The
government also focused its attention on Upper Egypt through the Mother Care and Healthy
Mother/Healthy Child Projects, which have been successful in addressing the regional disparities
in maternal mortality outcomes. 20
5. Creating an Enabling Environment
In addition to health sector interventions, empowerment through education and integrative
projects has also been important to improving maternal and child health in Egypt. Poverty
reduction has also played an important role in increasing demand and utilization of services.
Education: Literacy levels are moderately high in Egypt, with 72 percent of the population being
able to read or write. However, only 60 percent of the women are literate compared to 80 percent
men. Improved access and equity in education in Egypt has been strongly supported by the
Community Schools Initiative launched by the Ministry of Education. Launched in 1992, this
project was designed to bring quality education to hard to reach and rural areas. The number of
students enrolled increased from 121 in 1992/93 to 3,000 in 2000. Girl’s enrolment increased
from 89 in 1992/93 to 2,000 in 1995/96, reflecting the majority of the overall enrolment (World
Bank 2003).
Another project – the “One Classroom” was initiated in 1993 to encourage the re-enrolment of
girls in disadvantaged and remote areas aged 8-15 who have previously dropped out of school. It
aimed to reduce the large gender disparities in these areas by providing free education and
20
http://pdf.usaid.gov/pdf_docs/PNACA168.pdf
61
employing only female teachers. The project provided primary education and courses that teach
marketable skills for income generation. The number of schools increased from 313 in 1993/4 to
2,260 in 1998/9 and the enrolment increased from 2926 to 44,820 in the same period. 21 The Girls’
Education Initiative, initiated in 2000, also aimed to reduce the gender gap in primary education.
The Initiative has opened 1,076 girl-friendly schools and enrolled 24,413 girl students.22
At the primary school level, Egypt has achieved near universal enrolment as well as gender
parity. The primary completion rate is high for both females and males at 99% and 102%
respectively. Secondary school enrolment is also high and near parity (at 71 and 74 percent
respectively) for boys and girls (World Development Indicators 2013).
Empowerment: In 2000, the National Council for Women was established as a government
institution that aims to enhance the status and participation of women (United Nations 2004). The
Family Tribunal Law, the Nationality Law and the Family Court Law have built stronger legal
rights and privileges for women and children (World Bank 2005). The Egyptian Social Fund for
Development (SFD) has also been important in addressing equity and empowerment. It was
established in 1991 to reduce poverty and increase employment opportunities through community
development, public works, microcredit and small enterprises (Abou-Ali et al 2009). In support
of the goals of the Population Project, Social Change Agents, included population and family
planning into their outreach. With cooperation from the Ministry of Health, it hires young women
as social change agents who provide health education to families (family planning, the risks of
female circumcision etc.), and accompany women to health clinics. The social change agents also
encourage newly married women with one or two children to participate in the micro-credit
program established through the social fund. As estimated 32 percent of Egyptians have benefited
from the Social Fund between 2001 and 2008, majority of who are in the lower income quintiles
with positive outcomes for health, education, and poverty reduction (Abou-Ali 2009).
Employment: Women’s rights in the labor force are protected in the 2003 Labor law. The law
guarantees all provision of the labor code apply to women and mandates a 90 day paid maternity
leave. It also prohibits gender based wage discrimination and dismissal of a woman while on
maternity leave. While the law protects women’s rights in the workplace in many ways, it also
includes some discriminatory provisions. For instance, there are articles that allow government
ministers to establish conditions where it is inappropriate for women to work from 7pm to 7am.
Further, ministers are also able to determine is an area of work is morally inappropriate for
women.23 Overall, female labor force participation remains low with only 25 percent of women
ages 15-49 actively participating in the labor market. Female participation in waged or salaried
work is 48 percent – a decline from its peak at 67 percent in 2002 (World Development Indicators
2013).
Role of Political and Programmatic Leadership: Political and programmatic leadership has
played an important role in Egypt by maintain focus on maternal and child health. Senior
Egyptian policymakers have been instrumental in moving the country forward in terms of health
outcomes, health insurance coverage, MCH programs, and family planning, as well as bringing
ICPD 1994 to Egypt. Child health has been a critical focus of the first ladies.
6. Challenges and future priorities
While facility based births have increased considerably, quality of services need further
attention. For example, according to the 2004 Egypt service provision assessment, only 17
percent were in facilities equipped with newborn respiratory support and only 8 percent are by
21
http://www.unesco.org/education/wef/countryreports/egypt/rapport_3.htm
22
National Council for Childhood and Motherhood. Girls Education Initiative. Available at:
http://www.nccm-egypt.org/e11/e3151/index_eng.html
23
http://www.freedomhouse.org/sites/default/files/inline_images/Egypt.pdf
62
staff trained in neonatal resuscitation, with implications for neonatal survival. Moreover, while 65
percent of all mothers received a post-partum check-up within two days of birth, only 31.2
percent of newborn children received a check-up within two days of birth. Attention to these gaps
in provision is needed to further reduce incidence of maternal and child ill-health and mortality,
while ensuring that gains made in reducing under-5 mortality are maintained.
Despite gains disparities exist in access and utilization of health care due to income,
education and/or place of residence. For example, 57 percent of pregnant women in rural areas
received regular ante-natal care as compared to 80 percent of pregnant women in urban areas
during 2007-08. Similarly, 40 percent of women in the lowest income quintile received regular
ante-natal care compared to 90 percent of the women in the highest income quintile; and while 55
percent of the women in the lowest income quintile had a skilled attendant at birth, nearly all
women (97 percent) had skilled attendance at birth in the highest income group.
Although the contraceptive prevalence rate is high at 60 percent, long term use is limited.
According to the 2008 Egypt demographic and health survey, a quarter of the women stopped
using contraception within 12 months of starting during 2003-08. Of these, 3 out 10 women cited
health concerns as a reason for discontinuing contraceptive use (Cleland and Sinding 2000). As
highlighted in Box 1, there are now efforts to explore different approaches to encourage uptake
that focus on individual rights.
Emerging maternal and child health challenges relate to behavioural risks associated with
chronic diseases - a leading cause of death in Egyptian adults. Focus on control of such diseases
is needed due to complications from maternal obesity, hypertension and diabetes. This is already
evidenced in the increased share of neonatal and post-neonatal complications causing under-5
deaths e.g. 30 percent of infant deaths in Egypt are due to pre-term birth, whereas congenital
anomalies make up another 21 percent.
One of the issues that presented some challenges is women’s autonomy over their own
health care. Often husbands or other decision-makers such as mothers –in-law have to be
convinced of the need to seek medical help for women’s own illnesses and pregnancies. Although
the percentage of women who have some say in decision making about their own health has
increased from 60 to 87 percent between 2000 and 2008, the remaining 13 percent still had no say
in decisions about their health. Women with higher education, four or more children (possibly
reflective of status within the household), and those working for cash had more control over
decision-making regarding their health and other household issues. Rural women, especially from
Upper Egypt and the frontier governorates were less likely to make decisions alone or jointly. In
order for further inroads to be made towards reducing maternal and child mortality, it would be
important to reach this pocket of households.
Continued political commitment is important for ensuring that both maternal and child
mortality remain low. This support is also essential for further improving the quality of services,
maintaining momentum, and ensuring universal coverage of maternal and child health services.
Figure 5 provides a timeline of interventions and indicators related to MDG 4 and 5 in Egypt. 24
24
Caution should be taken in inferring any causality since multiple factors contributed to the decline of
U5MR and MMR as the discussion highlights.
63
Figure 5. Egypt: Timeline of MDG 4 and 5 Interventions
MDG 4: Under 5 Mortality
120 180
deaths per 1,000 live births
100 93 160
165 140
80 120
57 100
60
% 80
40 60
41
20 21 40
20
0 0
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
DPT Measles U5MR
MDG 5: Maternal Mortality
100 140
120
deaths per 100,000 live births
120
80
78.9 100
60 80
60.3
%
40 60
34.6 45 40
20 31.4
20
0 0
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
Contraceptive Prevalence Rate Skilled Birth Attendance Maternal Mortality Ratio
Pre-1980 1980–1995 1996-2012
1937: Official Fatwa
1982: Control of Diarrheal 1996: Law of the child enacted
(declaration) supports use of
Disease (CDD) Program
family planning under specific 1997: IMCI introduced
conditions 1985: Child Survival Project
1997: Health Sector Reforms
initiated, and National
1945: Family planning services
Population Council (NPC) 1998–2005: Healthy
as part of its health activities
established Mother/Healthy Child Project
1956: DPT vaccination made helps reduce regional
1987: Acute respiratory
compulsory disparities
infections (ARI) program
1962: Egypt’s National Charter 1998: Maternal mortality
1991: Social Fund for
establishes support for family surveillance system established
Development established
planning
and helps reduce poverty 2000: National Council for
1968: Poliomyelitis vaccination and supports activities aimed Women established, and
made compulsory at improving family planning maternal mortality study
and maternal health in
1973: BCG vaccination made subsequent years 2008: Law of the Child
compulsory amended based on a rights
1992–93: Maternal Mortality based approach, and female
1973: The first National Study circumcision is criminalized
Population Policy; family
planning program follows 1993: Student health 2012: Free MCH services and
insurance introduced to healthcare for the poor
1977: Compulsory Measles address gaps in coverage guaranteed under the
vaccination introduced. through targeting public Constitution.
school populations.
64
Selected References
Campbell, O., R. Gipson, A. H. Issa, N. Matta, and B. El Deeb. 2005. “National Maternal Mortality
Ratio in Egypt Halved between 1992–93 and 2000.” Bulletin of the World Health Organization
83: 462–471.
Cobb, L. K., F. C. Baer, M. J. P. Debay, M. A. El Feraly, and A. Kashmiry. 1996. Final Assessment of
the Egypt Child Survival Project. POPTECH Report No. 96-073-41. USAID Mission to Egypt,
Washington, DC
Grun, R., J. Ayala. 2006. Impact Evaluation of the Egyptian Health Sector Reform Project: Pilot
Phase. Health, Nutrition and Population (HNP) discussion paper, World Bank, Washington,
DC.
John Snow, Inc., Arabic Software Engineering (ArabSoft), Clark Atlanta University, The Manoff
Group Inc., and TransCentury Associates. 2005. Healthy Mother/Healthy Child Project
Completion Report.
Khallaf, N., A. Pio. 1997. “A National Programme for the Control of Acute Respiratory Infections.”
World Health Forum 18 (3–): 339–44.
Levine, R., M. Kinder. 2004. Millions Saved: Proven Successes in Global Health. What works
Working Group. Center for Global Development: Washington, DC
Nandakumar, A.K., M.R. Reich, M. Chawla, P. Berman, W. Yip. 2000. Health Reform for Children:
The Egyptian Experience with School Health Insurance. Health Policy, Vol. 50, No. 3, pp: 155-
170
Rakha, MA., Abdelmoneim, A-NM. Farhoud, S., Pieche, S., Cousens, S., Daelmans, B., Bahl, R.
2013. "Does Implementation of the IMCI Strategy have an Impact on Child Mortality? A
Retrospective Analysis of Routine Data from Egypt." BMJ Open 3:e001852.
doi:10.1136/bmjopen-2012-001852
UNDP (United Nations Development Programme). “Policy Brief #3: Pro-Poor Healthcare for Egypt.”
UNDP, New York.
USAID (US Agency for International Development). 2011. Egypt Health and Population Legacy
Review Vol. 1 USAID, Washington, DC.
World Bank 2003. Arab Republic of Egypt Gender Assessment. Washington DC: The World Bank.
______. 2006. Egypt Health Policy Note: Public Expenditure Review. January 2006. Washington DC:
The World Bank.
______. 2008. Egypt - Population Project. Washington DC: The World Bank.
______. 2009. Egypt, Arab Republic of - Health Insurance Systems Development Project. Washington
DC: The World Bank.
______. 2012. Interim Strategy Note: Arab Republic of Egypt. Washington DC: The World Bank.
______. 2013. “Egypt’s Progress on MDGs 4 and 5”, The World Bank, Washington DC (mimeo).
World Health Organization. 2010. Country Cooperation Strategy for WHO and Egypt 2010–2014.
Cairo, Egypt.
______. 2012. Female genital mutilation and other harmful practices: Prevalence of FGM. 2012.
http://www.who.int/reproductivehealth/topics/fgm/prevalence/en/index.html
Zohry, A.G. 1997. “Population Policies and Family Planning Program in Egypt: Evolution and
Performance.” In CDC 26th Annual Seminar on Population Issues in the Middle East, Africa
and Asia, pp. 194–111. Cairo Demographic Center, Cairo.
65
ANNEX 4: MALAWI’S PROGRESS ON MDGS 4 AND 5
Key Messages
• Malawi has more than halved its burden maternal and child mortality since 1990: maternal
mortality declined from 1100 to 510 deaths per 100,000 live births between 1990 and 2013,
while child mortality declined from 244 to 71 per 1000 live births between 1990 and 2012.
• Community based service delivery has been integral to reaching rural populations. This
includes use of health surveillance workers for immunizations and community based
distribution agents for providing family planning services.
• Provision of free primary care services at public facilities, and subsidized care through
partnering with the Christian Health Association of Malawi (CHAM) has facilitated an
increase utilization of maternal and child health services, especially in rural areas.
• Addressing HIV/AIDs and malaria has been an important aspect of improving maternal and
child health.
• The Emergency Human Resources Program (EHRP) is helping to build up human resources
and has already been associated with facilitating an increase in maternal and child health
service provision.
• Malawi needs to maintain focus on reducing drug and staff shortages, improving quality of
services and addressing adolescent reproductive health, and unsafe abortions.
1. Introduction
Malawi is a low-income country with a per capita GNI (PPP) of US$ 650 in 2011 and an
average annual GNI growth rate of 3.8 percent over the past ten years. Poverty is high with 62
percent of the population living on less than US$1.25 a day. Eighty percent of the population
lives in rural areas where the incidence of poverty is also higher: 56.6 percent of the rural
population is poor compared to 17.3 percent of the urban population (World Development
Indicators 2013; 2014).
Malawi has a large youth population: of the 15.3 million people, 45.8 percent are under 14
years of age. . The primary education completion rate is 72 percent for females and 70 percent for
males. Gross secondary enrollment, however, drops considerably from the primary completion
rate of 33 percent for females and 36 percent for males. Investment in education and health of this
young population is essential to promote future economic growth and reap the benefits of a
potential demographic dividend.
Malawi has made great progress in improving maternal and child health (MCH). According
to interagency estimates, the under-five mortality rate declined substantially from 244 deaths per
1,000 live births in 1990 to 71 deaths per live births in 2012. The annual rate of reduction from
1990 to 2012 was 5.6 percent. Maternal mortality has also declined, from 1,100 maternal deaths
per 100,000 live births in 1990 to 460 deaths per 100,000 live births in 2010, a 59 percent
decrease in MMR, and an average annual decline of 4.4 percent.
66
Figure 1. Child Mortality (1990-2012) Figure 2. Maternal Mortality Ratio (1990-2013)
Estimated Deaths per 1,000 Live Births Estimated Deaths per 100,000 Live Births
1200
300 1100
244
250 1000
213 870
750
200 174 800
570 540
150 600
120 510
83 76
100 71 400
280
50 200
0
1990 1995 2000 2005 2010 2012 2015 0
(MDG 1990 1995 2000 2005 2010 2013 2015
Target) (MDG
Target)
Source: WHO 2014; UNICEF 2013
2. Maternal and Child Health Policies
Maternal Health Policies: Maternal and child health (MCH) gained considerable importance in
Malawi in 1994 after the first newly elected democratic government came into power bringing
with it a change in the political atmosphere towards population and health issues. The National
Population Policy was approved in March 1994 which included strategies on increasing the
contraceptive prevalence rate, safe motherhood, prevention of sexually transmitted diseases,
HIV/AIDS, education, gender, development, and employment, employing a holistic approach to
population growth and maternal and child health (Chimbweteàà et al. 2005). The Reproductive
Health Strategy (1999-2004) further identified six key priority areas of focus: safe motherhood;
adolescent reproductive health; family planning; prevention, early detection, and management of
cervical, prostate, and breast cancers; prevention and management of STIs and HIV/AIDS;
elimination of harmful practices and reduction of domestic violence; and infertility. The strategy
was further updated for the 2006-2010 period to guide programmatic direction within the context
of health sector priorities and challenges (MoH 2006).
Malawi has also adopted several regional strategies such as the African Union Commission’s
Maputo Plan of Action on Sexual and Reproductive Health and Rights (2006) and the Campaign
to Accelerate the Reduction of Maternal Mortality in Africa (CARMMA) (2009). A key element
of the plan is that it urges compliance with the Abuja 2001 commitment of increasing resource
allocation to the health sector by at least 15% of the national budget. Malawi’s Sexual and
Reproductive Health and Rights Policy (2009) is a rights based policy that domesticates the
Maputo Plan (UNFPA 2011; SAfAIDS 2011).
Child Health Policies: The Integrated Management of Childhood Illness (IMCI) strategy has
been critical in addressing the preventive and curative aspects of child health. It was first
implemented in 1999 at the facility level. In the following years, there was an improvement in
child health indicators: The percentage of children under five with diarrhea who received oral
rehydration therapy or increased fluids increased from 51 percent in 2000 to 54 percent in 2004.
The percentage of children under five with suspected pneumonia who were taken to a provider
also increased, from 27 percent in 2000 to 37 percent in 2004 (WHO and UNICEF 2012). In
2006, the Government of Malawi (GoM) established an IMCI policy to coordinate and guide
implementation of IMCI activities, and was the result of a multisectoral effort among the Ministry
of Health, the Ministry of Women and Child Development, and other GoM ministries (USAID
2011).
The IMCI approach was influential in the development of the five-year strategic plan for
Accelerated Child Survival and Development, which was launched in 2006 to scale-up key
67
interventions in child health. It aims to deliver a package of integrated and high-impact services
including immunizing children and women, providing antiretroviral treatment to HIV-positive
children, delivering life-saving micronutrients, encouraging breastfeeding, supplying oral
rehydration salts for diarrhea and insecticide-treated nets (ITNs) to protect children and women
from malaria, and ensuring that young children have access to early childhood learning. District
and village implementation plans were also developed as part of this strategy, and services are
provided through home visits, village clinic outreach programs, and other key points of contact
with the health system 25 (UNICEF Malawi 2007).
3. Maternal and Child Health Programs
Childhood Immunization: Malawi has focused a great deal of attention on child health since
1979 when it launched the Expanded Program of Immunization (EPI) to improve immunization
coverage and health outcomes at which point only 58 percent of the children had been immunized
for DPT and 49 percent for measles. As of 2010, the immunization rate for both DPT and measles
was 93 percent and the percentage of fully immunized children is 80.9 percent. The high
immunization coverage rate has been attributed in part to the Health Surveillance Assistants, who
have been responsible for the majority of all vaccinations that are given to under-five children in
the rural areas.
Table 1: Childhood Immunizations in Malawi, 2000–2010
Indicator 2000 2004 2010
Percentage of children fully immunized 70.1 64.4 80.9
Immunization, DPT (% of children aged 12–23 months) 75 89 93
Immunization, measles (% of children aged 12–23 months) 73 80 93
Sources: DHS/WDI.
Childhood Illnesses: Malawi implemented the Child Lung Health Program in 2000 to address
severe pneumonia in children. The program used the widely accepted International Union against
Tuberculosis and Lung Disease’s model. The program also strengthened the skills of 312 health
workers in district hospitals, and improved supplies of antibiotics and equipment for oxygen
therapy. By the end of the pilot in 2005, the program had reduced fatalities by more than 55
percent.
Malawi also adopted the Emergency Triage Assessment and Treatment (ETAT) program to
address weaknesses in recognizing and managing the treatment of severely ill children. The
program was simplified and adapted for Malawi’s context and capacity so it can be used by health
workers with basic skills. By January 2011, 89 facilities were implementing ETAT, and mortality
decreased 17 percent between 2009 and 2011.
Family Planning: Family planning efforts began rather late in Malawi. In 1982, family planning
was adopted as part of public health service delivery in the context of child spacing in an effort to
reduce maternal and child mortality. The right of the family to have as many children as they
wanted was left intact, however. The program consisted of counseling and the distribution of
modern contraceptives (World Bank 1987). The 1994 elections and the National Population
Policy allowed more intensive actions to be taken on maternal health.
25
Such as prenatal clinics, mother and child clinics, maternity wards, pediatric wards, and nutrition
rehabilitation units.
68
As with childhood immunization, community based service delivery has been important in the
uptake of family planning in Malawi. Community Based Distribution Agents (CBDAs) are mainly
volunteers who provide and distribute contraception, raise awareness about family planning, and
act as referral agents to facilities. A pilot project carried out in three districts during 1999-2003
showed the efficacy of this approach: contraceptive prevalence rate (CPR) increased 12 percent
(from about 23.5 percent to 36 percent) in pilot districts compared to a 6 percent increase in the
control districts (World Bank 2004; Soto et al. 2005), strengthening the case for further
investment in community based health workers for delivery of family planning services.
Table 2: Maternal Health Indicators in Malawi, 1992–2010
Indicator 1992 2000 2004 2010
Total fertility rate 6.73 6.3 6 5.7
Adolescent fertility rate — 159.8 143.1 111
Contraceptive prevalence rate: Any method 13 31 33 46
Contraceptive prevalence rate: Modern method 7.4 26 28 42
Unmet need for contraception 36.5 29.9 30.3 26.2
Skilled birth attendants 55 56 56 71
Percentage of live births delivered at a health facility 55.3 55.3 69.4 73.2
Prenatal care from a skilled provider 90 91 93 95
Sources: DHS/WDI.
Note: — = not available.
National Safe Motherhood Program: Launched in 1996 to coordinate safe motherhood
strategic activities, the program aimed to reduce maternal mortality ration (MMR) by 50 percent
between 1996 and 2000. The program had four key strategies: (1) to increase public awareness
on maternal mortality issues; (2) to generate political, government, and donor commitment for
resource allocation; (3) to reduce delays by expectant mothers in reaching emergency obstetric
care; and (4) to improve the quality of reproductive health care and reduce the total number of
high-risk pregnancies. While not successful in achieving its goals due to structural weaknesses, it
program did establish a routine monitoring system to evaluate facilities which has helped district
management teams identify problems (Pearson 2010; Hussein 2001)
One of the more recent efforts to improve maternal and child health has been the Community-
Based Maternal and Newborn Care (CBMNC) package, which was adopted by the Ministry of
Health in 2007. This integrative package includes maternal and newborn child health,
HIV/AIDS, and malaria services. The CBMNC package includes three prenatal house visits by
HSAs (who are linked to facility-based health workers), and three postnatal visits. By 2011,
1,700 HSAs were trained and the CBMNC package was being implemented in 17 of 28 districts
(Zimba et al. 2012).
Nutrition: In 2006, Malawi began implementing UNICEF’s biannual Child Health Days, to
deliver free essential health services through mass campaigns. This includes messaging on
breastfeeding, feeding sick children, Vitamin-A rich foods, deworming, handwashing with soap,
and use of insecticide-treated nets (ITNs). In 2010, Child Health Days resulted in nearly 100
percent of children aged 6 to 59 months receiving vitamin A supplements and deworming
(UNICEF; UNICEF 2011).
Malnutrition in children under five declined from 52.5 percent in 2005 to 47.8 percent in 2010
(WHO 2013). Disparities remain, however, and according to the 2010 Demographic and Health
Survey (DHS), under-five mortality is higher in rural areas (130 deaths per 1,000 live births) than
in urban areas (113 deaths per 1,000 live births). Further, under-five mortality is 133 per 1,000
69
live births in the lowest quintile compared to 105 per 1,000 live births in the highest quintile
(NSO 2011).
Malaria: Malaria is endemic in Malawi and is among the leading causes of morbidity and
mortality in children under five and pregnant women, responsible for 40 percent of all
hospitalization for children under the age of five. The National Malaria Control Program was
established in the 1980s to identify and implement more effective ways to fight the disease than
the status quo. Malawi adopted sulfadoxine/pyrimethamine (SP) for intermittent preventive
treatment for pregnant women (IPTp) in 1993, becoming the first country to abandon chloroquine
and the first country to use SP for IPTp. For malaria treatment in children, Malawi moved from
SP to artemisinin-based combination therapy (ACT). Insectide treated nets (ITNs) have also been
important in preventing malaria in Malawi, which are available free of cost as of 2006. The
malaria program (specifically, the distribution of ITNs) has been attributed with decreasing
anemia in women (aged 15 to 49 years) from 47 percent in 2001 to 29 percent in 2010.
Current malaria prevention and management is guided by the 2011–2015 Malaria Strategic
Plan, which aims to provide universal access to prevention, care, and treatment (with an 80
percent utilization rate of interventions) including a focus on pregnant women.
HIV/AIDS: At 11 percent, Malawi has one of the highest prevalence rates of HIV/AIDS in the
world and contributes to nearly a third of maternal deaths in the country. Women generally bear
a higher burden of the disease (13 percent) compared to men (9 percent), and at 25 percent
mother to child transmission is high (DHS 2010; World Bank 2012).
The government has prioritized HIV/AIDS in policy and strategies; the current National HIV
and AIDS Policy was approved in 2003, and the most recent guiding framework is the National
Strategic Plan 2011–2016. In 2003, Malawi also began implementing a comprehensive
Prevention of Mother-to-Child Transmission (PMTCT) program. Under the program, HIV/AIDS
services are available through antenatal clinics (ANCs), maternity wards, and outreach programs.
With investment in scale up of service delivery, the number of ANCs that provide access to a
minimum package of PMTCT services has increased from 60 to 491 clinics between 2006 and
2010.
Additionally, since CD4 testing is limited in the resource strapped country, Malawi pioneered a
hybrid of the WHO recommended Option B approach to PMTCT – “Option B+” provides
lifelong treatment for any pregnant woman with HIV status regardless of CD4 count. Since
implementation began in July 2011, there has been a six-fold increase in the number of pregnant
women starting antiretroviral therapy. Other countries are now following Malawi’s lead in
implementing Option B+. In September 2012, Uganda announced that it was going to adopt the
Option B+ strategy (GoM 2009; Schouten 2011; MSH 2012; IRIN 2012).
4. Responsiveness of Health System
The gains made in recent years toward addressing MDGs 4 and 5 are strongly linked to Malawi’s
efforts to strengthen its health system and provide affordable services. About 60 percent of health
care services are provided through the public system free of charge, and about 37 percent are
provided through the not-for-profit Christian Health Association of Malawi (CHAM) and the
remaining 3 percent are provided by the private, for-profit sector for a fee. Since 1995, Malawi
has seen a sharp increase in the per capita health expenditure and a decline in out of pocket
expenses – although still low, health care expenditures per capita have roughly tripled from US$
26 to US$ 83 between 1995 and 2012 (figure 3), while out-of-pocket health expenditures have
halved from 29 percent to 13 percent during the same period (figure 4).
70
Figure 3. Health expenditure per capita, PPP Figure 4. Out-of-Pocket Health Expenditure
(constant 2005 international $) (% of total expenditure on health)
100 40
83 35
80 30
25 29
60
20
40 15
10 13
20
26 5
0 0
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Source: WDI 2014
The government of Malawi has taken several steps to address the weaknesses in its health system.
These include the following:
Streamlining investment for the Essential Health Package (EHP): In 2002, the Government
of Malawi initiated changes to its health strategy due to persistent weaknesses in the health
system (shortages of drugs and personnel; poor quality of infrastructure; lack of access to health
services). At the national level, free provision of a package of 11 essential interventions was
included in the country’s Poverty Reduction Strategy. This was aligned with resource
mobilization in the health sector - the government adopted a Sector Wide Approach (SWAp) to
streamline investments for the delivery of the EHP. The removal of user fees has helped to
increase the utilization of health services, with outpatient visits increasing from 0.8 to 1.2 per
person between 2004/05 and 2007/08. The use of skilled birth attendants also increased from 38
percent to 45 percent during the same period. As of 2009, 65 percent of facilities were delivering
the EHP and 55 percent offered emergency obstetrics care (World Bank 2002 & 2009,
Vaillancourt, 2009).
Public-Private Partnership for service delivery: Engaging in a public-private partnership with
the CHAM has also been important in reducing coverage gaps, including for maternal and child
health services in rural areas. While CHAM operated health facilities have existed since the
1960s, since 2002, the government has entered into service level agreements (SLAs) with CHAM
health facilities to provide subsidized care to pregnant women and children in catchment areas not
covered by public health services Since then, evidence points to an increase in utilization of
health services, with a 75 percent increase in live births at CHAM facilities and a 13 percent
reduction in maternal and newborn deaths between 2004 and 2008 (DFID 2010; MSH 2010).
Addressing Human Resource Shortages: Human resource shortages have posed a significant
challenge to the delivery of maternal and child health services, especially in rural areas.
Community based health workers, including Health Surveillance Assistants (HSAs), and more
recently Community Based Distribution Agents (CBDAs) have been an important part of
reaching rural women and children with essential services. The HSAs have a long history of
delivering child health services at the community level, beginning from immunizations in the
1960s and 1970s to providing more comprehensive community based package of maternal and
child health services. As of 2011, Malawi had 12,000 HSAs.
Although community based health workers are a critical part of the service delivery system they
do not have a formal medical background. To address the shortage of trained doctors and nurses,
between 2004 and 2010, the Government of Malawi implemented a 6-year Emergency Human
Resources Program (EHRP). The program aimed to increase recruitment, promote retention
(through financial and nonfinancial incentives such as a 52 percent salary top-up), and expand
training. Short term gaps were filled by bringing in international volunteers. It is estimated that
these efforts have contributed to saving 13,000 lives. Maternal and child health service provision
71
has also benefitted with a 15 percent increase in safe deliveries, a 7 percent increase in ANCs, a
10 percent increase in immunization, and an 18 percent increase in PMTCT (MSH 2010).
5. Creating an Enabling Environment
Improvements in women’s status can contribute to longer-term improvements in their health.
Education: Significant strides in improving the quality of and access to education in Malawi
have resulted from key government efforts, such as the establishment of Free Primary Education,
in 1994. To encourage girls to stay in school, Malawian law now allows adolescent girls who
become pregnant to return to school following delivery, and mandates an “assurance of safe
custody of child.” Conditional cash transfers have also been introduced to keep girls in school.
According to a study of the Zomba Cash Transfer Program, the program has not only had an
impact on education, but also on the sexual behavior of girls. For instance, the probability of
getting married for beneficiaries decreased by 40 percent (compared to out of school at baseline),
and the probability of becoming pregnant decreased by 30 percent (Baird et al. 2010).
Empowerment: Malawi has prioritized gender empowerment in its laws. In 1987, Malawi
ratified the Convention on the Elimination of all Forms of Discrimination against Women
(CEDAW) and promulgated the 2000 National Gender Policy, which eventually led to the launch
of the National Gender Programme, which has 8 focus areas: institutional strengthening;
education; health; HIV/AIDS; agriculture, food, and national security; national resources and
environmental management; poverty eradication and economic empowerment; and governance
and human rights.
Gender-based Violence: Malawi also legislated against gender-based violence The Prevention of
Domestic Violence Act in 2006. The 50–50 Campaign in 2008 was launched to increase female
representation in the government. As a result, the share of women represented in parliament
increased from 14 percent in 2004 to 27 percent in 2009. The most recent effort to support gender
empowerment in Malawi is the Gender Equality and Women’s Empowerment Agenda
(GEWEM) program, which was launched in July 2012. The program will be implemented in 13
districts for three years to address a variety of gender issues, including empowerment, gender-
based violence, sexual reproductive health, and HIV/AIDS. One of the outcomes of the program
is the Gender and Youth Sector Wide Approach.
6. Challenges and Future Priorities
To ensure continued progress on maternal and child health in Malawi, there are many
challenges that need ongoing attention. Human resources are still an issue since much of the
workforce is deployed in urban areas. In addition, infrastructure for basic emergency obstetric
care is inadequate, resulting in overcrowding in the available (understaffed) facilities and,
therefore, poor quality of care. Furthermore, the referral system in terms of both communication
and transport is poor.
Maternal mortality is still very high, and little progress has been made in the reduction of
neonatal mortality. Poverty levels also remain high, meaning that out-of-pocket costs such as
transport to a health facility are significant obstacles to care. Although the political will to
improve maternal and child health is generally positive and the target for health sector funding
has been reached, per capita expenditure on health remains below the recommended level.
An area that requires much attention is adolescent reproductive health. Malawi has a huge
youth bulge with 46 percent of the population under age 15. Adolescent fertility is also high at
111 births per women aged 15 to 19. The age of sexual consent in Malawi is 13 and, with
parents’ permission, adolescents as young as 15 can marry. While the incidence of such young
72
marriages appears to be rare, between the ages of 15 and 19, a third of young women have begun
childbearing. Younger girls and their babies are at higher risk of maternal and child mortality and
morbidity. Moreover, it adversely affects their life chances - adolescent pregnancy is one of the
leading reasons for dropping out of school in the country. While the policy has changed to allow
pregnant girls to return to school, in practice, few girls return to school due to the stigma
attached with an unexpected pregnancy, or because they may be unable to meet the school
requirements and take care of their child.
Most adolescents are shy or afraid to seek reproductive health services. For many, peers at
school are the main source of information. Radio advertisements and school-based health
education are other sources of information, mainly about HIV prevention, but do not provide
information on STIs, contraception, or unwanted pregnancies. While steps have been taken to
encourage reproductive health services for youth, often these services are considered by youth to
be inaccessible due to poor location, lack of privacy and confidentiality, and negative attitudes of
staff (Jackson et al. 2011; Munthali, Zulu, and Madise 2006).
Unsafe abortions contribute significantly to maternal mortality. Currently, abortion is only
allowed to save a woman’s life. In practice, this requires spousal consent and endorsement by two
independent obstetricians before the abortion can be performed. The penalty for seeking an
abortion otherwise is 7 to 14 years’ imprisonment. Most women seeking abortions go to
traditional healers or private clinics, or try to self-induce abortion using unsafe methods. Unsafe
abortions are the second leading cause of maternal mortality in Malawi, accounting for 18 percent
of maternal deaths, and the leading cause of obstetric complications. Anecdotal evidence suggests
that the prevalence of unsafe abortion is high among adolescents, with a third of adolescents aged
15 to 19 reporting having a close friend who attempted to end an unwanted pregnancy (GoM
2005; WHO 2011).
At the programmatic level, a main challenge to improving maternal and child health is the
high unmet need for family planning services. Despite the rising contraceptive prevalence rate,
unmet need remains high (26 percent). In particular, low-income women have little access to
family planning services, but have the greatest need – women in the lowest income group had an
unmet need of 30 percent compared to 22 percent for those in the highest income group (DHS
2010).
In addition, traditional birth attendants will be an important issue for future action. In order
to promote institutional deliveries, the Government of Malawi in 2007 banned traditional birth
attendants (TBA) from delivering babies. The rationale was that TBAs were unable to identify
obstetric complications early enough, contributing to maternal mortality (IRIN 2010). This ban
was lifted in 2010, but there are no known incentives to keep TBAs from practicing.
Drug stock-outs are a significant issue in service delivery in Malawi. On average, 75 percent
of facilities are thought to have experienced drug shortages. One study found 60 percent of EHP
facilities to have insufficient stock and 13 percent to be completely out of co-trimoxazole (a drug
that treats acute respiratory and other infections). Only 24 percent of health centers reported
having sufficient amounts of Benzathine-Penicilline in stock, and only 22 percent reported having
enough Erythromycine in stock. Thirteen percent reported being entirely out of Benzathine-
Penicilline and 20 percent reported being entirely out of Erythromycine (Mueller et al. 2011). In
recent years, there have been efforts to improve the Central Medical Store, which procures and
supplies medical goods for the government. In 2008, the Central Medical Store was designated a
public trust, but its performance is still weak (Wild and Cammack 2013).
Other concerns relate to the management of infectious diseases. The HIV pandemic increased
deaths from puerperal sepsis, and also reduced the availability of safe blood. The malaria
pandemic remains a major cause of mortality, as well as a cause of anemia among pregnant
women.70
73
An overarching concern is funding. Despite considerable donor support, it has been inadequate
to implement successful activities nationwide. Interventions are being implemented across the
country very slowly, which limits their impact. Furthermore, other sectors such as agriculture,
education, and water and sanitation need to be strengthened to complement interventions in the
health sector (UNICEF Malawi 2007). Figure 5 provides a timeline of interventions and
indicators related to MDG 4 and 5 in Malawi.26
26
Caution should be taken in inferring any causality since multiple factors contributed to the decline of
U5MR and MMR as the discussion highlights.
74
Figure 5. Malawi: Timeline of MDG 4 and MDG 5 Interventions
MDG 4: Under 5 Mortality
120 300
96
deaths per 1,000 live births
100 250
256
80 90 200
58
% 60 150
40 49
71 100
20 50
0 0
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
DPT Measles U5MR
MDG 5: Maternal Mortality
80 1200
deaths per 100,000 live births
1100 71.4
70 1000
60
54.8 800
50
40 46.1 600
%
30
510 400
20
10 200
6.9
0 0
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
Contraceptive Prevalence Rate Skilled Birth Attendance Maternal Mortality Ratio
1970 – 1990 1991–2000 2000–2012
1993: First country to adopt SP 2002: GoM/CHAM partnership
1973: Maternal and Child
for IPTp (Malaria treatment) to address service gaps
Health (MCH) program
initiated to improve and 1994: National population 2003: National HIV Policy; PMTCT
expand MCH services policy launched; free primary and Emergency Triage and
education introduced Assessment Programs
1979: Expanded Program of
Immunization (EPI) initiated 1995: Health Surveillance 2004: Emergency Human
Assistants (HSAs) become Resources Program (EHRP); Post-
1980s: National Malaria formal part of health system; abortion care strategy
Control Program introduced National Strategic Plan for
2005: National Road Map for
Safe Motherhood
Accelerating the Reduction of
Community-Based Distribution 1996: Safe Motherhood Maternal and Neonatal
Agents (CBDAs) begin Program Mortality and Morbidity; ACT
providing contraception Malaria
1999: Integrated
1982: Family planning is Management of Childhood 2006: Child Health Days; Malawi
adopted nationally for Illness (IMCI) launched Growth and Development
purpose of child spacing and strategy; Maputo Plan
1999–2004: National
better MCH outcomes Reproductive Health Strategy 2006–2010: National RH strategy
enacted.
2009: SRHR Policy; CARMMA
2000: Child Lung Health campaign
Program
2010: “Option B”+ for PMTCT;
Gender equality program
75
Selected References
Baird, S., E. Chirwa, C. McIntosh, and B. Ozler. 2010. “The Short-term Impacts of a Schooling
Conditional Cash Transfer Program on the Sexual Behavior of Young Women.” Health
Econ 19 (Suppl): 55–68. doi: 10.1002/hec.1569.
Chimbweteàà, C., E. Zulu, and S. C. Watkins. The Evolution of Population Policies in Kenya and
Malawi. Population Research and Policy Review January 2005, Volume 24, Issue 1, pp
85-106
Chinyama, V. 2012. “Outreach Programme in Malawi brings Healthcare Closer to Communities.”
UNICEF, September 14.
DFID. 2010. “Malawi - making strides in essential healthcare” 15 Mar
http://reliefweb.int/report/malawi
GAVI. 2005. Financing of Immunization Services in Malawi. Doc. 21. 16th GAVI Board
Meeting, Paris, July 19-20.
International Union Against Tuberculosis and Lung Disease
http://www.theunion.org/index.php/en/what-we-do/child-lung-health-/pneumonia
Kadzandira, J. M., and W. R. Chilowa. 2001. “The Role of Health Surveillance Assistants
(HSAs) in the Delivery of Health Services and Immunisation Malawi.” University of
Malawi, Centre for Social Research, Zomba, Malawi.
Management Sciences for Health. 2012. “Option B+ in Malawi: The Origins and Implementation
of a Global Health Innovation,” August 28. http://www.msh.org
Mueller, D. H., D. Lungu, A. Acharya, and N. Palmer. 2011. “Constraints to Implementing the
Essential Health Package in Malawi.” PLoS ONE 6 (6): e20741. Doi:
10.1371/journal.pone.0020741.
National Malaria Control Programme (NMCP) [Malawi] and ICF International. 2012. Malawi
Malaria Indicator Survey (MIS) 2012. Lilongwe, Malawi, and Calverton, Maryland,
USA: NMCP and ICF International.
National Statistical Office (NSO) and ICF Macro. 2011. Malawi Demographic and Health Survey
2010. Zomba, Malawi, and Calverton, Maryland, USA: NSO and ICF Macro.
Schouten, E. J., A. Jahn, D. Midiani, S.D. Makombe, A. Mnthambala, Z. Chirwa, A. D. Harries,
J. J. van Oosterhout, T. Meguid, A. Ben-Smith, R. Zachariah, L. Lynen, M. Zolfo, W.
Van Damme, C. F. Gilks, R. Atun, M. Shawa, and F. Chimbwandira. 2011. “Prevention
of Mother-to-Child Transmission of HIV and the Health-Related Millennium
Development Goals: Time for a Public Health Approach.” The Lancet 378 (9787) (July
16–22): 282–84.
Soto, J., R. Jacobstein, and D. Malema. Repositioning Family Planning—Malawi Case Study:
Choice, Not Chance. The ACQUIRE Project/EngenderHealth, New York.
UNICEF. 2007. Malawi Annual Report 2006. Lilongwe : UNICEF
———. 2011. Annual Report for Malawi 2010. Lilongwe: UNICEF
USAID/BASICS. 2012. Improving Child Health in Malawi. Arlington, VA: Basic Support for
Institutionalizing Child Survival (BASICS)
World Bank. 2004. “Malawi – Population and Family Planning Project.” World Bank,
Washington, DC.
———. 2012. “Malawi – Country Assistance Strategy for the Period FY13–FY16.” World Bank,
Washington, DC.
______. 2013. “Malawi’s Progress on MDGs 4 and 5” World Bank, Washington, DC (mimeo)
76
ANNEX 5: NEPAL’S PROGRESS ON MDGS 4 AND 5
Key Messages
• Nepal is a low-income country that has made great progress in reducing maternal and child
health outcomes. It is on track to meet both MDGs 4 and 5.
• Adopting a community-based approach to service delivery and bringing critical maternal and
child health services closer to the most marginalized populations has been important to
Nepal’s success.
• Ensuring inclusion of the poor and marginalized through provision of subsidized or free care
for maternal and child health services has been critical in the uptake of services.
• Improvements in socioeconomic status have also contributed to maternal and child health
outcomes in Nepal through better access to education and reduction in poverty.
• Donor support has been key in enabling the country to invest efficiently in the health sector in
general, and in maternal and child health, in particular.
1. Introduction
Nepal is a landlocked, low-income country, with a per capita GNI (PPP) of US$1,289 in
2012, and an average GNI growth rate of 4.4 percent during 2003-12. Poverty has declined
considerably in recent years, with the proportion of population living below the US$1.25 per day
declining from 53.1 percent in 2003 to 24.8 percent in 2010. Using comparable concepts of
consumption and poverty lines, Nepal’s headcount poverty rate has declined from 60 percent in
1995/96 to 25percent in 2010/11 (Nepal Poverty Maps, World Bank 2013). Income inequality
has also declined, with the Gini coefficient dropping from 43.83 in 2003 to 32.82 in 2010 (World
Bank 2013).
Nepal has a population of 26.5 million and an average population growth rate of 1.35
percent per year during the past 10 years. Fifty-nine percent of Nepal’s population is in the 15
to 64 years age group, and average life expectancy is 67 years. Majority of the population lives in
rural areas, with only 17 percent living in urban areas. Literacy is low in Nepal, with only 59.6
percent of the adult population able to read or write; and female literacy is significantly lower
than male literacy - 48.8 percent compared to 71.7 percent (UNFPA 2009; World Bank 2013).
In 1990, constitutional reforms established a multiparty democracy within the framework
of a constitutional monarchy. In 1996, a Maoist insurgency broke out leading to a 10-year civil
war between the insurgents and government forces. An interim constitution was established in
2007 following a peace accord with the Maoists. In 2006, the newly formed Constituent
Assembly abolished the Monarchy and declared Nepal a federal democratic republic. Nepal
continues to experience social unrest and political instability which needs to be addressed to
ensure the gains made in health and other sectors can be sustained in the long run.
As of 2012, Nepal has met its MDG 4 and 5 targets. Maternal mortality declined from 790
deaths per 100,000 live births in 1990 to 190 deaths per 100,000 live births in 2013, — an
impressive 76 percent decline, allowing Nepal to achieve its MDG 5 target two years ahead of
time. Similarly, under-five mortality declined from 142 deaths per 1,000 live births in 1990 to 42
deaths per 1,000 births in 2012, exceeding the MDG 4 target of 45 deaths per 1,000 births by
2015 (figures 1 and 2).
77
Figure 1. Maternal Mortality Ratio (1990- Figure 2. Child Mortality (1990-2012)
2013) Estimated Deaths per 1,000 Live Births
900 Estimated Deaths per 100,000 Live Births 160
790 142
800 140
700 109
580 120
600
100
500 82
430 80
400 61
310 46
60
300 42 45
220 190 190 40
200
100 20
0 0
1990 1995 2000 2005 2010 2013 2015 1990 1995 2000 2005 2010 2012 2015
(MDG (MDG
Target) Target)
Source: UNICEF 2013; WHO 2014
2. Maternal and Child Health Policies
Nepal has prioritized family planning and maternal and child health at the national level
since the mid-1960s in its development agenda. An early focus on population growth and
poverty alleviation prompted the launch of family planning and maternal and child health
projects under Nepal’s Third Five Year Plan (1965–1970). Maternal and child health was
also an integral part of the First Long Term Health Plan (1975–1990), implemented as
part of primary health care delivery though integrated community health development.
The Expanded Program for Immunizations (EPI) was also initiated under this plan
(Agarwal 1998; Baral et al. 2012; HMG/N 2005).
National Health Policy (1991): The policy aimed to expand preventive and curative health
services to the rural population, with priority given to interventions to reduce infant and child
mortality. It represents a turning point in access to health care in Nepal – it is the first policy that
adopted an integrated approach to health service provision. The policy strengthened
decentralization of service delivery, with more planning responsibilities given to District Health
Offices, and encouraged community participation through promoting female community health
volunteers, traditional birth attendants, and inclusion of civil society organizations (Agarwal
1998; MoHP 2009).
National Reproductive Health Strategy (1997): Following ICPD 1994, the Government of
Nepal introduced this strategy to provide integrated reproductive health services to all. It covers
family planning; safe motherhood, including newborn care, child health, prevention and
management of complications of abortion, sexually transmitted infections including HIV/AIDS,
prevention and management of infertility; adolescent reproductive health; and diseases such as
cancers in older women, making it one of the most comprehensive policies. Importantly, it also
called for strengthening maternal care (including family planning) at all levels of service delivery.
Several other more specific policies and plans such as on family planning, safe motherhood, and
adolescents had their origins in this policy, catalyzing policy into action, which had been slow
due to factors that include resource allocation and poor implementation planning. Many of these
developments have occurred within the framework of the Second Long Term Health Plan, which
covers the period from 1997 to 2017 (Agarwal 1998; Hardee et al. 1999; MoH 2009).
78
National Adolescent Health and Development Strategy (2000): The overarching aim of this
strategy is improving the health and socioeconomic status of adolescents. Through improving
access to information and providing adolescents’ access to health services including reproductive
health and counseling services, in a safe and supportive environment, the strategy aims to
empower Nepal’s young population to have better health outcomes. The strategy also focuses on
enhancing their life opportunities through better education and skills development. Importantly,
soon after the adoption of this strategy, the National Reproductive Health Program Steering
Committee (under the National Reproductive Health Policy) also endorsed providing adolescent
population access to family planning services, irrespective of their marital status (Pradhan and
Strachan 2003).
National Safe Motherhood Plan (2002–2017): This plan also stems from the National
Reproductive Health Policy. It aims to reduce maternal mortality through improved access to and
utilization of maternal health services, including postpartum care for pregnant women. This
includes establishing at least one comprehensive essential obstetric care facility in each of the 75
districts of Nepal and basic essential obstetric care facilities in 137 primary health care centers
throughout the country over time. In addition, the plan aims to improve ambulatory services and
transport to better address emergencies and improve community-based care of pregnant women.
National Safe Motherhood and Newborn Health Long Term Plan (2006–2017): In 2004, the
safe motherhood plan was revised to include neonatal health. The revised plan aims to improve
maternal and neonatal health and survival especially among the poor and socially excluded. It has
set specific goals of reducing the maternal mortality ratio to 134 per 100,000 live births and the
neonatal mortality ratio to 15 per 1,000 live births by 2017. To achieve this, the plan emphasizes
community-based care, equity in provision of safe motherhood services including prenatal care,
delivery and newborn care by skilled birth attendants, postnatal care, emergency obstetric care,
comprehensive abortion care, and referral services. The Ministry of Health and Population
(MoHP) is operationalizing this through ensuring that both the Family Health division and Child
Health division include newborn health within their programs for comprehensive coverage
(CBNCP 2010; GoN 2006).
Policy on abortion (2003): Prior to 2003, abortion was illegal in Nepal. Earlier policy on
reproductive health included post-abortion care to ensure women who underwent illegal abortions
had medical care. In 2002, the House of Representatives passed the 11th amendment of the
country’s civil code, which allows women to legally terminate unwanted pregnancies under
certain circumstances, which became law in 2003. This has been a key development for
reproductive health rights in Nepal (Pradhan and Strachan 2003).
More recently, the Government has sought to establish the right of citizens to free basic health
care services. The 2008 Aama Surakshya Karyakram program is a step in this direction.
3. Maternal and Child Health Programs
Family Planning: Fertility has been declining steadily in Nepal (figures 2 and 3). Most gains
have taken place after 1990, when fertility was still at 5.1 births per woman and contraceptive
prevalence was under 25 percent. Early focus on family planning was rooted in concerns about
population growth, but has evolved over time within a framework of human and reproductive
health rights after the 1990s, when most gains have been made. Nepal’s current aim is to achieve
replacement fertility—2.6 births per woman—by 2017, which it is likely to achieve.
79
Figure 3. Fertility Decline in Nepal Figure 4. Contraceptive Prevalence in
(1976-2011) Nepal (1976-2011)
7 60
5.9 5.7 48.0 49.7
6 5.5
Births per woman
5.1 50
4.6 39.3
Percentage
5
3.9 40
4 3.2 28.5
2.7 30 24.1
3
20 15.1
2
6.8
1 10
2.4
0 0
1976 1981 1986 1991 1996 2001 2006 2011 1976 1981 1986 1991 1996 2001 2006 2011
Source: WDI 2013
The family planning program in Nepal focuses on birth spacing, prevention of unwanted
pregnancies, managing adolescent reproductive health, and infertility. In keeping with a rights-
based approach, the health facilities offer a range of methods that clients can choose from. The
government has also focused on ensuring coverage at all levels through health facilities at all
levels, outreach clinics, and mobile voluntary surgical contraception camps. Family planning
camps, also known as sibirs, have been an important mode of service delivery since the 1970s,
especially for longer-term family planning methods (GoN 2011; Thapa and Friedman 1998).
The decline in fertility in Nepal has also contributed to improvements in maternal health
outcomes. Through birth spacing and limiting births, and increasing the age of marriage, access
to abortion, and a focus on improving adolescent reproductive health, the family planning
program has helped to lower fertility and, through it, the lifetime risk of maternal deaths—which
had dropped to 1 in 190 in 2010 (WHO 2012; see also Bhandari et al. 2011; Hussein et al. 2011).
Safe Motherhood Program: Safe motherhood has been an integral part of the government’s
health and development agenda. Initiated in 1997 as the Nepal Safe Motherhood Project, it grew
from a 9-district project to a comprehensive program covering all 75 districts during 2005–10.
The program focuses on improving quality and utilization of services, especially emergency
obstetric care (EmOC). With support from donor partners and in collaboration with NGOs, the
Government of Nepal has invested in a comprehensive approach to addressing maternal and child
health. This includes investment in infrastructure and equipment, training health personnel,
monitoring and behavior change, promoting prenatal and postnatal care, skilled delivery, and
emergency transport (Barker et al. 2007; HMG/N 2004).
Since the launch of the program, there has been an increase in the uptake of prenatal services and
of skilled birth attendance, which are core components of the Safe Motherhood Program. Skilled
attendance at birth has increased from 9 percent in 1996 to 36 percent in 2011, and
prenatal/postnatal visits have gone from 23.6 percent to 58.3 percent (Table 1). While prenatal
visits have been increasing steadily over this period, the uptake in skilled birth attendance has
been especially strong after the introduction of incentives, pointing to the key role these
incentives have played in easing the financial constraints to access to better pregnancy care
(World Bank 2013).
Community-Based Integrated Management of Childhood Illness (CB-IMCI) program
provides government support for management of childhood illnesses, with a particular focus on
diarrhea and acute respiratory infections. The program also supports regular immunization that,
with nearly sustained coverage for years, has enabled immunization rates to reach over 80 percent
(Table 1) and nutrition assistance including micronutrient supplementation (Suvedi 2003). A core
component of CB-IMCI is the treatment of pneumonia. Initiated in 1995, community-based
80
pneumonia management was merged with CB-IMCI in 1999. By 2007, the program had been
scaled up to 42 of Nepal’s 75 districts and covered 69 percent of the under-five population
(Ghimire et al. 2010).
Childhood immunizations in Nepal have been increasing steadily under the National
Immunization Program (NIP). Diphtheria Pertussis Tetanus (DPT) immunization was started in
Nepal in 1965 at maternal and child health clinics and later expanded to most clinics at the district
level. By 1978, Nepal had established the Extended Program for Immunization with 4 antigens
(BCG [Bacille Calmette-Guérin] and DPT) in three districts, which expanded to all districts by
1988 with 6 antigens including BCG, DPT, oral polio vaccine (OPV) and measles. Currently, the
National Immunization Program also provides special vaccines such as for Japanese Encephlitis
in high-risk districts as part of routine immunization (Suvedi 2003).
Childhood immunization is a high priority of the government, and services are provided free of
cost. The program is targeted to children under one-year of age and pregnant women.
Supplementary immunization activities, targeted to children 9 months to 14 years of age, are
conducted regularly to provide additional vaccinations, such as for measles and polio. Nepal has
also initiated school immunizations to provide tetanus vaccination to children in grades 1, 2, and
3, in addition to providing the tetanus vaccine to all pregnant women. The program has helped
reduce the burden of vaccine-preventable diseases and, consequently, child mortality. For
example, between 2001 and 2006, measles cases fell from nearly 11,000 to 2,000 cases, and
neonatal tetanus cases decreased from 327 to 42 (MoH 2007; Suvedi 2003).
Table 1: Nepal – Trend in Key MCH Service Delivery Indicators, 1991–2011
Indicator 1991 1996 2001 2006 2011
Births attended by skilled health staff (% of total) 7.4 9 10.9 18.7 36
Pregnant women receiving prenatal care (%) 15.4 23.6 27.9 43.7 58.3
Children fully immunized (aged 12–23 months) — 43 60 80 87
Immunization, DPT (% of children aged 12–23 months) 46 65 72 89 92
Immunization, measles (% of children 12–23 months) 57 65 71 85 88
Source: WDI; NDHS 1996, 2001, 2006, 2011.
Note: To be fully immunized, a child should receive the following vaccinations: one dose of BCG, three
doses each of DPT and polio, and one dose of measles vaccine.
Using community-based approaches has been an important part of the immunizations and CB-
IMCI strategy in Nepal. Services are provided at static facilities and through mobile clinics.
Community Health Workers are a key link between the health system and the population,
especially in the rural and remote areas for provision of services. For example, in districts using
community-based treatment of pneumonia, the number of cases treated doubled compared to
districts with only facility-based treatments. Over half of these are attributed to contact with
female community health volunteers. Annual drives such as through national immunization days
have also been an important mode reaching remote populations and increasing coverage. The
government now plans to also merge the Community-Based Newborn Care Program with the
CB-IMCI to have a more comprehensive approach to addressing child health (Jha and Niraula
2011; Pradhan et al. 2012).
Safe Delivery Incentives Program (SDIP): Initiated in 2005, the program offers cash incentives
to women who attend four prenatal visits, get skilled delivery care, and attend a postnatal visit. To
relieve the financial burden of transport, which makes up 50 percent of the hidden costs
associated with institutional deliveries, the program covers the cost of travel as well. Cash
transfers are based on the region of residence and range from Nepalese Rupees (NPR) 500
(US$5.67 at current exchange rate) in the Plains/Terai districts (richer regions) to NPR 1,500
81
(US$16.90) in the mountain districts (poorest regions). Among the lower-caste women, especially
in the rural and remote areas of the country, there is still a hesitation in accessing formal sector
facilities for a myriad of reasons, including fear of discrimination. Thus, on the supply side, the
government also provides incentives to skilled birth attendants for attending home deliveries.
Within a year of initiation, deliveries with trained birth attendants increased from 20 to 30
percent. A recent study on the SDIP found that women who knew of the SDIP prior to childbirth
were on average 26 percent more likely to deliver in a public health facility, 17 percent more
likely to deliver with a skilled birth attendant, and 36 percent more likely to have a caesarean
section compared to those who did not receive the incentives (Ensor et al. 2009; Hanson and
Powell-Jackson 2010).
Aama Surakshya Karyakram (“Aama”): The Aama program was established in 2009 by the
Government of Nepal to provide free delivery of health services in all public sector and partner
facilities. The program builds on the SDIP to provide services free of cost to women from the 25
poorest districts in the country. Components included free institutional delivery care, a cash
incentive initiated under the SDIP to mothers who complete 4 prenatal care visits and deliver at
health facilities, and transportation costs. As with the SDIP, cash incentives vary depending on
the region in which the recipient lives. Health facilities also receive a payment to cover their
costs, which can vary from NPR 1,000-1,500 (US$11.27-16.90) for normal deliveries to NPR
3,000 (US$33.80) for deliveries with complications, and NPR 7,000 (US$78.88) for c-sections.
Health workers are also provided a small incentive payment of NPR 300 (US$3.38) as part of this
package (MoHP 2010).
A recent assessment of the Aama program in 6 districts shows that despite improvements in
institutional deliveries, vast disparities in utilization exist at the district level. For example,
despite an overall increase in institutional deliveries from 17 to 33 percent during 2008-2011, in
one mountain district, 75 percent of women were still delivering at home without any assistance.
Further study is needed to better understand and address these variations, and to assess the full
impact of the program (Upreti et al. 2012).
4. Health System Responsiveness
Service Delivery: Nepal has a decentralized service delivery system. The Local Self-
Governance Act (1999) decentralized health care responsibility and implementation to the
districts. The Ministry of Health and Population oversees public sector health care through
Regional Health Directorates and District Health Offices, which are supported by Hospital
Development Committees, District and Village Development Committees, and municipalities.
Health services are delivered in central, regional, sub-regional, zonal and district hospitals,
primary health care centers, health posts, and sub-health posts at lowest levels of delivery.
Nepal has a large network of public sector health facilities, with at least one local health post
under each Village Development Committee. Since more than half the women deliver at home,
birthing centers have been set up in the health posts to bring services, especially delivery care,
closer to women’s homes. The combination of the network of facilities on the ground and
community health volunteers has contributed to a strong public health structure at the village
level and enabled effective dissemination of health interventions. This has supported Nepal’s
early and consistent gains in MCH (World Bank 2011).
Public health care services are provided free of cost at health posts and sub-health post levels in
Nepal, a right provided under the interim constitution. At primary health care centers and district
hospitals, the government of Nepal has introduced targeted free care for the poor and the
vulnerable. Since 2008–09, delivery services, including caesarean section, have been provided
free to women at public and some private/NGO facilities. As a result, utilization of the health
82
care system has increased, but it has also overburdened the system with, for example, supply
shortages in 25 percent of facilities (World Bank 2010a; World Bank 2011).
Healthcare Financing: On average, health expenditures make up 5.6 percent of GDP (2002–
12). Over the last decade, public expenditure on health has averaged around 11.2 percent of total
government expenditure, although in recent years it has declined — public expenditure on health
was 9.6 in 2011 compared to a high of 14.5 in 2006. At the same time, the per capita expenditure
on health (in terms of purchasing power parity) has more than doubled (figure 5), and 90 percent
of private expenditure on health represents out-of-pocket spending. After declining from 70
percent of total health expenditure to a low of 46 percent in 2006, Nepal has experienced a slight
increase in out-of-pocket expenditures (figure 6). These trends are driven by remittance-related
increases in per capita income over the last few years, and expected to continue as people’s
disposable incomes increase (World Bank 2010b).
Figure 5. Health expenditure per capita, Figure 6. Out-of-Pocket Health Expenditure
PPP (constant 2005 international $) (% of total expenditure on health)
90
80 80
70 80 70
60 60
50 70 49
50
40 40
30 37 30
20 20
10 10
0 0
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Source: WDI 2014
A significant proportion of the health sector budget comes through donor support. While earlier
efforts were fragmented, in 2004 Nepal launched its first Sector-Wide Approach (SWAp) with
support from the World Bank, the Department for International Development (United
Kingdom, DFID), and the Australian Agency for International Development (AusAID). The
Nepal Health Sector Program has allowed donors to support the program through their individual
focus on an overall objective. The second SWAp was initiated in 2010 and funds health sector
activities through 2015 (Barker et al. 2010). Most of the gains in the last 10 years in maternal and
child health have been made possible through this coordinated donor support. On the other hand,
this has also raised concerns about the long-term sustainability of Nepal’s health sector
financing, especially since in 2008/09 the government moved toward provision of free basic
health services (see, for example, World Bank 2010c).
Human Resources: Female community health volunteers (FCHVs) have played an important
role in facilitating access to services for maternal and child health in Nepal. They are the first
level of contact in the community. Established in 1988, the FCHV program covers mainly rural
areas and has become key for community-level service provision in Nepal. More than 50,000
female community health volunteers work alongside health workers to provide education and
outreach related to health education, family planning, immunization, and integrated management
of childhood illnesses. FCHVs are selected from within their communities by community
members and the local Mother’s Club. Being from the community helps establish trust and
faclitates the women in fulfilling their role with greater ease since they do not have to commute
long distances or migrate somewhere else to provide services. FCHV involvement has been
linked to the increase in the intake of iron supplements during pregnancy, which has more than
doubled between 2001 and 2006, going from 23 to 59 percent. At the village level, Maternal and
83
Child Health Workers and Auxiliary Nurse Midwives are also important in providing maternal
and delivery care services.(Glenton et al. 2010; Micronutrient Initiative)
Surveillance and Monitoring: Nepal has benefited from the availability of timely and reliable
data on maternal and child health for the last two decades. Data on fertility and maternal and child
health collected regularly through the Demographic and Health Surveys and the Maternal
Mortality and Morbidity Surveillance have supported evidence-based policy making in the
country. Nepal has also leveraged existing information systems to monitor child health. For
instance, the polio surveillance system was adapted to monitor neonatal tetanus, allowing
immediate information gathering. Together, the various sources make up the Health Management
Information System (HMIS). Over the years, with the integration of services, routine monitoring
system has improved. While the HMIS is not a perfect system (for example, vital registration data
are incomplete because people simply do not register births), availability of information has
facilitated policy making and programmatic directions.
5. Creating an Enabling Enviroment
Poverty Reduction: Nepal has seen a significant decline in poverty in the last 10 years. Efforts
on the part of the government, such as the establishment of the Poverty Alleviation Fund (2004),
are helping to address poverty. The fund has supported community-driven development in 40 of
Nepal’s poorest districts focusing on income-generating activities and small-scale infrastructure.
It has also contributed to improving food security and education outcomes among the poorest and
most vulnerable in these districts. Food insecurity decreased by 19 percentage points and school
enrollment of children aged 6 to 15 increased by 14 percentage points. Enrollment for girls
increased by 21 percentage points (Parajuli et al. 2012).
In recent years, remittances from migrant labor have contributed significantly toward economic
growth, with personal remittances accounting for 22.3 percent of GDP in 2011. This has
contributed to an increase in consumption expenditure, which has also helped to reduce poverty.
According to one estimate, 79 percent of remittances are used for consumption of goods and
services, including basic services such as health and education (DHS 2011; Khatri 2010; World
Bank 2013).
Education: Nepal has made great strides in improving the education status of its population and
enhancing girls’ education. The Education Regulation (2002) first mandated free education to the
poor, the disabled, girls, Dalits, and the other students who are below the national poverty line. In
2003, under the Tenth Plan, education policy also emphasized functional and income-generating
literacy and postliteracy programs to improve the situation of women. The policy also contains
special provisions for women’s access to education to achieve the "education for all" (by 2015)
target. Gross primary enrollment is high for both boys and girls (123 percent and 106 percent,
respectively). Government commitment to providing free primary education has been an
important factor in increasing the enrollment rates. However, the enrollment rate drops
significantly at the secondary level (43 percent in 2006) and is low for both boys and girls (World
Bank 2013).
Education is an important factor for improving maternal and child health outcomes. A 2012 study
in Nepal, for example, found that children whose mothers had received at least a secondary
education were nearly six times more likely to be completely immunized compared to children of
mothers with no formal education (Pandey and Nim Lee 2012). This also highlights the need for
continued investment in girls’ education, especially beyond the primary level, where enrollment
still lags behind for both boys and girls.
84
Social Inclusion and Gender Equality: Caste and gender are major social barriers in Nepal,
especially in the rural areas. With its population of 26.5 million including more than 100 ethnic
groups, nearly as many languages, and 60 castes and subcastes, discrimination is a challenge of
everyday life. Nepal’s social and economic life has been closely associated with a caste-based
hierarchy. 27 Although the caste-based system was officially abolished in 1963, in practice, it has
been harder to eradicate. For example, the 1990 Constitution, while emphasizing equality, also
left space for protecting “traditional practices.” It also did not go far enough in enhancing gender
equality, with Nepali women still not being able transfer citizenship to their children (World
Bank 2006).
Further steps to promote social inclusion were taken in the 2007 Interim Constitution.It
emphasizes human rights. Article 14 specifically provides protection against discrimination and
untouchability based on caste, descent, community, or occupation. Article 20 on the “Right of
Woman” states that women are to be free from discrimination in any form because of their
gender. 28 The constitution also guarantees the right to reproductive health. In 2007, health care
was declared a basic human right in Nepal’s interim constitution, making the government
responsible for the health of the public. All policies and programs since have emphasized the
importance of health care for all people including women, ethnic groups, and castes.29,30
Gender has been mainstreamed within the country’s development agenda through the Ninth
Development Plan (1997–2002), the Tenth Plan (2002–2007) and the Poverty Reduction
Strategy. In 1998, Nepal also launched the Decentralized Action for Children and Women
(DACAW) in 15 districts, and later expanded to 23 districts, with support from UNICEF and the
United Nations Development Programme (UNDP). Where operational, the program has helped to
improve women’s status through focusing on education, health, HIV/AIDS prevention, and water
and sanitation. For example, DACAW has supported the Out of School Education Program,
which helps children catch up on their education and enrol in formal schools. By 2006, 45,000
children had completed the program, of which 65 percent were girls (UNICEF 2007).
Women’s empowerment is important for their uptake and utilization of reproductive, maternal,
and child health services. Evidence shows that women’s empowerment increased with education
and employment, especially in the urban areas in Nepal. Thirty-six percent of women with
secondary or higher education reported being involved in decisions regarding their health care
compared to 25 percent with primary or no education (see Furuta and Salway 2006; Pandey,
Lama, and Lee 2011; Suvedi et al. 2009).
Nepal’s rights-based agenda has been important for MCH delivery. Against a backdrop of
political and social struggle, the collective forces aligned in such a way that preservation of rights
of minorities and women took center stage in Nepal’s polity. In 2004, when a new coalition
government was formed in Nepal, maternal, newborn, and child health gained further momentum
as part of a propoor government agenda. Better maternal and child health has been described as
one of the few areas where there was strong political cohesion across parties during this period,
creating an enabling environment for better maternal and child health (Ensor et al. 2009; Smith
and Neupane 2011).
27
Nepal’s caste system consists of the priestly Brahmans at the top of the ritual order; the Kshatriya (kings
and warriors) just beneath them and in command of the political order; the Vaishya (merchants); the Sudra
(peasants and laborers); and at the bottom, other occupational groups considered “impure” and
“untouchable” or acchut (World Bank 2006).
28
http://www.worldstatesmen.org/Nepal_Interim_Constitution2007.pdf
29
http://www.rti.org/pubs/31_nepal_assessingimplementation.pdf
30
http://www.idea.int/resources/analysis/upload/Women-s-Caucus-Book-Final-version-eng.pdf
85
6. Remaining Challenges/Future Directions
Skilled attendance at birth is still low in Nepal due to both supply and demand barriers. On
the supply side, this includes shortage of staff, inadequate facilities, and lack of equipment and
supplies, especially in remote and rural areas, where the need is the greatest. On the demand side,
poor quality of care, financial considerations, social norms and preferences create disincentives
for accessing care, especially among the more poor, vulnerable, and ethnic minorities. Some
demand side issues, such as financial stress, are being relieved through conditional cash transfer
schemes. Harder to change are preferences, perceptions, and mistrust related to the formal health
sector, especially among the lower castes. The government has set a target of 60 percent births by
skilled attendants by 2015 and is investing in training Dalits and Janajits (lowest castes) as ANMs
to meet some of the shortages in the underserved areas and promote social inclusion.
Nutrition interventions also require more support. Eighteen percent of Nepal’s population is
undernourished. Chronic malnutrition, an underlying cause of mortality for women and children,
is pervasive even among higher wealth, and is associated with early teenage pregnancy and poor
maternal nutrition. In recent years, Nepal has been making strides toward improving nutrition.
Vitamin A supplementation is high, with 93 percent of children 6 to 59 months of age receiving
the recommended two doses of vitamin A. Further attention, especially to maternal nutrition will
help to improve outcomes.
A large number of teenage pregnancies are unintended in Nepal, and use of modern
contraceptives is low compared to other age groups, even for married women aged 15 to 19.
Although the contraceptive prevalence rate increased from 2.4 percent in 1976 to nearly 50
percent in 2011, there are concerns that uptake has slowed and may stagnate. Enhancing access to
family planning services, including counselling and education for the youth, is important.
Women’s empowerment is important for their uptake and utilization of reproductive,
maternal, and child health services. Education is an important factor in this regard. A recent
study in Nepal, for example, found that children whose mothers had received at least a secondary
education were nearly 6 times more likely to be completely immunized compared to children of
mothers with no formal education. This highlights the need for continued investment in girls’
education, especially beyond the primary level, where enrollment still lags.
Income is a strong predictor of reproductive health outcomes in Nepal. Women in poor
households are more likely to have lower levels of education, get married at a younger age, and
begin child bearing earlier than women in upper-income groups. Continued poverty reduction
efforts are important. Nepal’s community-driven development approach has proven successful
whether through the Poverty Alleviation Fund or DACAW. Maintaining and expanding these
programs is important to ensure that benefits reach the poorest women and children.
Nepal is still a low-income country whose recent history has included long periods of
political unrest - detrimental to long-term growth and stability. Strong government leadership
and accountability is important for successful planning and implementation of programs and
policies. Continued political tensions in the country however pose a challenge to the continuity of
programs and policies by focusing attention away from the health and other social sectors. The
role of Nepal’s partners will continue to be critical. The Ministry of Health and Population
requires not just financial support, but also critical technical assistance related to capacity
building, training, planning, implementation management, and operations research. How the
political situation develops, may also impact this support.
Figure 7 provides a timeline of interventions and indicators related to MDGs 4 and 5 in Nepal. 31
31
Caution should be taken in inferring any causality since multiple factors contributed to the decline of
U5MR and MMR as the discussion highlights.
86
Figure 7. Nepal: Timeline of MDG 4 and 5 Interventions
MDG 4: Under 5 Mortality
90
deaths per 1,000 live births
100 250
209
80 200
86
60 150
%
40 100
42
8
20 50
2
0 0
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
DPT Measles U5MR
MDG 5: Maternal Mortality
deaths per 100,000 live births
80 1200
1100 71.4
70 1000
60
54.8 800
50
46.1
40 600
%
30 400
510
20
10 200
6.9
0 0
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
Contraceptive Prevalence Rate Skilled Birth Attendance Maternal Mortality Ratio
Pre-1990 1991–2000 2001–2012
1965–1970: Third Five-Year 1991: National Health Policy 2002–17: National Safe
Plan Motherhood Plan
1997: National Reproductive
1965: Immunization with Health Strategy 2002: Education Regulation
DPT begins
1997–2017: Second Long- 2003: Abortion is legalized
1975–90: First Long-Term Term Health Plan
2004: Safe Motherhood Plan
Health Plan
1999: Local Self-Governance revised to include neonatal
1977: Expanded Program Act health
of Immunization (EPI)
1997: National Plan of Action 2005: Safe Motherhood
1979: National Commission (NPA) for Gender Equality Incentives Program
on Population established and Women’s
2006: Skilled birth attendance
Empowerment
1983: National Population policy
Strategy 1998: Decentralized Action
2007: Interim Constitution
for Children and Women
1988: FCHV program
(DACAW) 2009: Aama Surakshya
Karyakram (Aama) program
2000: National Adolescent
Health and Development 2009: Community-Based
Strategy Newborn Care Package
87
Selected References
Agarwal, K. 1998. “Reproductive Health Case Study, Nepal.” The Policy Project, The Futures
Group International, Research Triangle Institute (RTI), Centre for Development and
Population Activities (CEDPA), Washington, DC.
Baral, Y. R., K. Lyons, J. Skinner, and E. R. van Teijlingen. 2012. “Maternal Heath Utilization in
Nepal: Progress in the New Millennium?” Health Science Journal 6 (4): 618–33.
Barker, C., K. Ghimire, N. Pandey, and S. Hepworth. 2010. “Capacity Assessment for Health
Systems Strengthening.” Health Policy and Planning, Nepal Health Sector Programme,
Kathmandu, Nepal.
Barker, C. E., C. E. Bird, A. Pradhan, and G. Shakya. 2007. “Support to the Safe Motherhood
Programme in Nepal: An Integrated Approach.” Reproductive Health Matters 15 (30):
81–90.
Ensor, T., S. Clapham, and D. P. Prasai. 2009. “What Drives Health Policy Formulation: Insights
from the Nepal Maternity Incentive Scheme?” Health Policy 90 (2–3):247–53
Ghimire, .M, Y. V. Pradhan, and M. K. Maskey. 2010. “Community-based Interventions for
Diarrheal Diseases and Acute Respiratory Infections in Nepal.” Bulletin of the World
Health Organization 88 (3): 216–21.
Hussein, J., J. Bell, M. D. Lang, N. Mesko, J. Amery, and W. Graham. 2011. “An Appraisal of
the Maternal Mortality Decline in Nepal.” PLoS ONE 6 (5): e19898.
Jha, N., and S. R. Niraula. 2011. “Vaccinating Children against Diphtheria, Pertussis, Tetanus and
Poliomyelitis in Nepal.” Health Renaissance 9 (2): 112–15.
Pradam, Y. V. et al. 2012. “Newborn Survival in Nepal: A Decade of Change and Future
Implications.” 27 (Suppl 3): iii57–iii71.
Smith, S. L., and S. Neupane. 2011. “Factors in Health Initiative Success: Learning from Nepal’s
Newborn Survival Initiative.” Soc Sci Med 72 (4): 568–75.
Suvedi, B. K. 2003. “Immunisation Programme of Nepal: An Update.” Kathmandu University
Medical Journal 2 (3) (Issue 7): 238–43.
USAID (United State Agency for International Development). 2007. “Nepal Family Health
Program; Community-Based Maternal/Neonatal Care.” Technical Brief No. 10, USAID,
Washington, DC.
World Bank. 2010a. “Nepal Public Expenditure Review.” Report No. 55388-NP, Poverty
Reduction and Economic Management Sector Unit, South Asia Region, World Bank,
Washington, DC.
---------. 2010b. “Nepal: Reproductive Health At-a-Glance.” World Bank, Washington, DC.
---------. 2010c. “Project Appraisal Document: Nepal Second HNP and HIV/AIDS Project.”
Report No. 52895-NP, World Bank, Washington, DC.
---------. 2011. “Implementation Completion and Results Report: Nepal Health Sector Program
Project.” World Bank, Kathmandu, Nepal.
--------- 2013. “Nepal’s Progress on MDGs 4 and 5” World Bank , Washington DC
WHO (World Health Organization). 2007. “Policy Papers on Health.” World Health
Organization, Nepal, December.
88
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