Promoting equity to achieve maternal and child health

Abstract

Maternal and child mortality rates, the targets for two of the eight Millennium Development Goals, remain unacceptably high in many countries. Some countries have made significant advances in reducing deaths in pregnancy, childbirth, and childhood at the national level. However, on a sub-national basis most countries show wide disparities in health indices which are not necessarily reflected in national figures. This is a sign of inequitable access to and provision of health services. Yet there has been little attention to health equity in relation to the Millennium Development Goals. Instead, countries have focused on achieving national targets. This has led to an emphasis on utilitarian, as opposed to universalist, approaches to public health, which we discuss here. We recommend a policy of “proportionate universalism”. In this approach, universal health care and a universal social policy are the ultimate goal, but in the interim actions are carried out with intensities proportionate to disadvantage. We also briefly describe an initiative that aims to promote evidence-based policy and interventions that will reduce inequity in access to maternal and child health care in China, India, Indonesia and Viet Nam.

Résumé

Les taux de mortalité maternelle et infantile, cibles de deux des huit objectifs du Millénaire pour le développement (OMD), demeurent à des niveaux intolérables dans beaucoup de pays. Quelques pays ont accompli de remarquables progrès pour réduire les décès pendant la grossesse, l'accouchement et l'enfance au niveau national. Néanmoins, à l'échelle sous-nationale, les indices sanitaires de la plupart des pays montrent de larges disparités qui n'apparaissent pas forcément dans les chiffres nationaux. C'est le signe d'une inégalité dans l'accès et le recours aux services de santé. Pourtant, l'équité dans la santé a reçu peu d'attention dans le cadre des OMD. Les pays ont préféré viser les objectifs nationaux. Cela les a conduits à mettre l'accent sur des méthodes utilitaires, plutôt qu'universalistes, de la santé publique, que nous examinons ici. Nous recommandons une politique « d'universalisme proportionné ». Dans cette optique, les soins de santé universels et une politique sociale universelle constituent le but ultime, mais entretemps, des mesures sont prises avec une intensité proportionnelle aux désavantages. Nous décrivons aussi brièvement une initiative qui encouragera la politique à base factuelle et les interventions qui réduiront les inégalités d'accès aux soins de santé maternelle et infantile en Chine, en Inde, en Indonésie et au Viet Nam.

Resumen

Las tasas de mortalidad materna e infantil, cuya reducción es la meta de dos de los ocho Objetivos de Desarrollo del Milenio, continúan siendo inaceptablemente altas en muchos países. Algunos países han realizado importantes avances para disminuir las tasas de muertes relacionadas con el embarazo, el parto y la infancia a nivel nacional. Sin embargo, a nivel sub-nacional, la mayoría de los países muestran grandes disparidades en los índices de salud, que no necesariamente se reflejan en las cifras nacionales. Esto es un signo de desigualdad de accesibilidad y prestación de los servicios de salud. No obstante, se ha prestado poca atención a la equidad en salud con relación a los Objetivos de Desarrollo del Milenio. En vez, los países se han concentrado en lograr las metas nacionales, por lo cual se ha hecho hincapié en enfoques utilitarios en salud pública, y no en enfoques universalistas, que son los que se tratan en este artículo. Recomendamos una política de “universalismo proporcional”. En este enfoque, los servicios de salud universal y una política social universal son la meta final, pero en el ínterin, se toman acciones con intensidades proporcionales a las desventajas. Además, resumimos una iniciativa que promoverá una política basada en evidencia e intervenciones que disminuirán la desigualdad de acceso a los servicios de salud materno-infantil en China, India, Indonesia y Vietnam.

Key Words:

• maternal and child health
• maternal mortality
• child mortality
• Millennium Development Goals
• equity and access

A 2007 review of progress in reducing maternal morbidity and mortality reported both successes and failures. Successes included the introduction of effective interventions for prevention of unwanted pregnancies and provision of safe abortion. Failures included widespread, continuing, unacceptably high levels of maternal morbidity and mortality, overwhelmingly due to the failure of health systems to respond to women's needs. Some of the systemic problems identified were failure to act, lack of adequate finances and resources, and the lack of evidence-based maternity care.¹

At this writing, maternal and child mortality rates are still not decreasing to the extent necessary to reach the Millennium Development Goal (MDG) targets by 2015. In fact, only nine of 137 developing countries are projected to meet targets for both child mortality and maternal mortality, China being one of them.²

Still, accelerated rates of decline, particularly in child mortality, less so for maternal mortality, have been reported in more than half of the world's countries, giving cause for cautious optimism for the longer term.² What continues to be worrying is the lack of attention being paid to the large and growing inequities in provision of and access to services within countries. It is evident that, in the absence of widespread population registration, the measurement of targets has defaulted to country-level estimates, which do not reveal in-country variations.³ As countries strive to meet their national targets, the MDGs have become ends in themselves, achievable by gains for some but not for all.⁴

This paper proposes a renewed focus on equity to achieve the MDGs on maternal and child health, and outlines what needs to be done to realise it.

The problem: health inequalities

Health inequalities exist, and will always exist, in every population. Women, by virtue of their reproductive role, will need more health services in their lifetime, on average, than men. Poor people, because of a variety of structural and social factors (i.e. social determinants of health), will need more health care than rich people. Equitable health policies attempt to control for these inequalities by providing the opportunity for everyone in a society to achieve good health. Such opportunities include, but are not limited to, health care. Improvements in the health of all also depend on social factors such as education, employment and working conditions, nutrition, housing and living conditions, and social wages. Given the inevitable health inequalities in a population, one would expect to see greater use of health services among those with more need and more services made available to them, such as for poor women during their childbearing years. When services are actually used more by those in less need (i.e. by more well-off women during childbearing years), it is a sign of an inequitable system. Unfortunately, this is the case in a great many countries in the world.⁵

Despite their numbers and greater need, the poor and other disadvantaged populations are frequently the last to benefit from improved health policies and interventions. Instead, “the availability of good medical care tends to vary inversely with the need for the population served”.⁶ The reasons for this are complicated and rarely limited to barriers in the health system. However, utilitarian public health systems – those that focus on having the greatest impact possible with the least amount of investment – have exacerbated existing inequalities, pushing the poorest into greater poverty through the “medical poverty trap”.⁷

The MDGs targets have served to promote the utilitarian approach to public health. In order to gain consensus and buy-in among the countries of the world, “minimum threshold” targets were established.⁴ When a country reaches this threshold, it is considered to have met its goal. In countries with large numbers of people living in poverty, in underserved remote rural areas, with undocumented or otherwise invisible or marginalized populations, such as migrant workers, ethnic minorities or adolescents (who are assumed in some countries to be sexually abstinent and not need services), the benefit or absence of improvements for these populations are rarely included in data analysis in any meaningful way.

Below we present examples of these persisting inequities in four Asian countries that are in varying states of progress towards meeting maternal and child health targets.

China

Nationally, China has made impressive progress in maternal health. The overall maternal mortality ratio decreased from 64/100 000 in 1996 to 38/100 000 in 2008;⁸ overall hospital births increased to 94.7% of all live births in 2008;⁹ and overall contraceptive use was above 80% in 2006.¹⁰ These achievements can be attributed to China's rapid economic development¹¹¹² and the promotion of maternal health services by the government.¹¹ However, at a sub-national level, there are still large sectors of the population who are disadvantaged in maternal health. Disparities in maternal health outcomes between low- and high-income households still exist,⁸ often mirroring differences in economic development between the Eastern, Central, and Western regions.¹¹ Efforts by the Chinese government to promote maternal health care in rural and poor areas¹² have led to reductions in inequities between urban and rural areas, and between the rich and poor,⁸¹¹¹² particularly in relation to maternal mortality and hospital delivery rates.⁸⁹ However, the status of maternal health in the poorest rural and remote areas remains very weak,⁹ and rural women still receive less antenatal and post-partum care than urban women.¹² Ethnic minorities in China also face economic barriers, geographic marginalisation, and poor quality health facilities in the remote areas where they live. As a result, they continue to have a high rate of home births, placing them at greater risk of maternal morbidity and mortality.¹³

The particular form that China's economic development has taken has resulted in a great number of rural-to-urban migrants. Migrant workers in urban areas without formal, long-term jobs are not registered and cannot benefit from health insurance in the urban areas, yet health insurance is necessary to be reimbursed for maternal and child health care. Consequently, migrant workers have less reproductive health knowledge and use maternal health care and contraception to a lower extent than registered residents of urban areas, and are forced to obtain unsafe abortions.^14–16 Moreover, because of restrictions on the number of births, women with illegal pregnancies may migrate to other places or hide at home, reducing the likelihood of their accessing maternity care.¹⁷

India

India accounts for more than 20% of the global burden of maternal mortality and the largest number of maternal deaths for any country.²¹⁸ Although the rate of decline has been almost 6% in the last decade, the current maternal mortality ratio is still 187 per 100,000.² Wide disparities between different populations exist at the sub-national level, both between and within states. Additionally, in India, socioeconomic status is highly associated with access to and utilization of maternal health care.¹⁹²⁰ Over the last two decades, India has launched several flagship programmes on improved access to maternal health care and family planning, the latest being the National Rural Health Mission. Many initiatives are attempting a paradigm shift from individualised, vertical interventions to a more holistic and integrated life-cycle approach.²¹ However, progress has been slow in many states. Increases in access to antenatal care and skilled attendance at birth are happening mainly in the non-poor populations, while access among poor populations remains low.²² In 2006, 13% of women in the lowest wealth quintile delivered their babies in an institution compared to 84% of women from the highest wealth quintile.²³ Women belonging to a Scheduled Caste or Scheduled Tribes and those living in urban slums also have low access to and utilisation of maternal health care.²⁴²⁵

Indonesia

Reducing maternal mortality is one of the top priorities of the Government of Indonesia, given the current high ratio (228 per 100,000 live births)²⁶ compared to Southeast Asia in general. In addition to the slow reduction of maternal mortality, there are large disparities within the population, based on woman's education, socioeconomic quintile, region or province, and geography (urban vs. rural). Such disparities are related to access to skilled birth attendance and/or health facility deliveries and other maternal health services indicators.

In the last 30 years, there have been many policies and strategies affecting maternal health in Indonesia, including the Safe Motherhood Initiative in the 1980s, Gerakan Sayang Ibu (Mother Friendly Movement) in the 1990s, Making Pregnancy Safer and district decentralization in the 2000s, and Healthy Indonesia in 2010. The dominant strategy throughout these initiatives has been to ensure the presence of professional attendants at every birth.²⁷ However, problems still remain. The quantity, quality and distribution of health personnel are below international standards.²⁸ There is a lack of access to quality health care, particularly for poor populations in remote, border and island areas. The village midwife programme has significantly increased the skilled birth attendance and reduced the gap between the poorest and the richest, but the equity gap in access to emergency obstetric care is still very high,²⁹ The increase in the proportion of births with skilled attendants from 66.7% in 2002 to 82.3% in 2010³⁰ has not been enough to stem the tide of maternal death.³¹ Use of contraception is low and unmet need is still high. Decentralization, which gave extensive authority to the districts, has not improved health system performance. Finally, although the private sector plays an important role in health provision in Indonesia, district health offices lack capacity to create public–private partnerships in critical public health programmes.³²

Viet Nam

Economic development in Viet Nam has consistently gone well and the country is showing good progress towards reaching targets in maternal and child mortality. In the latest population census in 2009, the under-five mortality rate was 24/1000, as compared to the estimated baseline level of 58/1000 in 1990.³³ There was also a reported decline in maternal mortality from 233/100,000 in 1990 to 69/100,000 in 2009.³³ One explanation for the relative success of Viet Nam's health sector is its comprehensive public health system, covering the whole population with more than 10,000 commune health stations and 600 district hospitals.³⁴ There has also been a purposeful targeting in the budget allocation for child health, and since 2005 all children under six are provided with health care free of charge.³⁵ Rapid economic development in the last 20 years has also contributed to improvements in health. At the same time, inequities in health have increased considerably and disadvantaged groups have been left behind.³⁶

In line with its socialist ideology, the Vietnamese authorities have deliberately targeted the poor, both through the National Target Programmes on Health in the 1990s and later with the National Health Care Fund for the Poor that was launched in 2002. Economic status is therefore not the main source of inequity in health in Viet Nam.³⁷ There are instead great divides between rural and urban populations, and ethnic minority groups are marginalized.³⁸ Ethnic minorities are disproportionately poor and usually live in more remote areas.³⁸ However, this is not the only reason for the worse health situation of these groups. Ethnic minorities are less well covered by social benefits aimed at the poor than their majority counterparts.³⁹ Additionally, ethnic minorities have an increased risk of under-five and neonatal mortality independent of economic or educational status.⁴⁰⁴¹ Ethnic minority women say they are mistreated by health staff and there are language as well as cultural barriers that contribute to the inequities.⁴²⁴³

“Proportionate universalism” as a solution

What is to be done? In fact, we already know what has to be done to drastically reduce maternal morbidity and mortality: universal access to good quality antenatal and postpartum care, skilled attendance at birth, comprehensive emergency obstetric care, contraception, and access to safe abortion. A relatively small number of evidence-based perinatal interventions provided within a continuum of maternal and newborn care could prevent a major proportion of neonatal deaths.⁴⁴ Thus, “getting on with what works” has been a rallying call from much of the world in the last few years.⁴⁵

Scaling-up of evidence-based strategies is also necessary. At the same time, as we have shown in these examples, even countries that have reached, or are nearing reaching, their MDG targets will be leaving a large proportion of their populations behind. Thus, “more of the same” is not enough.⁴⁶ There must be increased attention paid to achieving health for all.

An equitable system “treats those with equal need equally and those in greater need ought to be treated in proportion to that greater need”,⁴⁷ the goal being to narrow gaps between the advantaged and the disadvantaged. Universalist systems, comprised of full employment, social transfers and an interventionist state are intended to reduce general inequities in society, including health inequities.⁴⁸ Strategies to address health inequities often lead either to the universalist approach (i.e. welfare state approaches) or to “targeting”. The difference is that while universalism strives to provide the entire population with equal social benefits (through some kind of membership criteria), with targeting “eligibility to social benefits involves some kind of means-testing to determine the ‘truly deserving’”.⁴⁹

Mkandawire provides an excellent rebuttal of targeting for poverty reduction, which can be summarized in three points: it doesn't work, it is not cost-effective, and it is stigmatizing.⁴⁹ Dahlgren and Whitehead provide a fourth argument: it risks creating a “three-tiered system”, whereby the richest pay out of pocket, the very poor receive free services, and the middle group receives nothing.⁵⁰ However, there is a middle ground, which is what has been referred to as “proportionate universalism”.⁵¹ In this approach, universal health care and a universal social policy are the ultimate goal, but in the interim actions are carried out with intensities proportionate to disadvantage.

We believe that efforts to reduce poverty and inequity (the original purpose of the MDGs) will require governments to implement and ensure universalist approaches in the long run (i.e. universal health care). At the same time, we cannot sit back and watch hundreds of thousands of women die every year while waiting to put such a system into place. Ideally, governments would put the majority of resources in pulling the poorest out of poverty through an increasing focus on reducing the equity gap between rich and poor, rural and urban, men and women, old and young, and minority and majority groups.

A new initiative to promote equity

We have launched a new initiative, entitled Evidence for Policy and Implementation, with the goal of contributing to the capacity of countries to make evidence-based decisions on social policies and provision of health care to benefit disadvantaged populations in relation to MDGs 4, 5 and 6 in China, India, Indonesia and Viet Nam. The project is creating networks in each of the four countries that will discuss evidence around what works and does not work and prioritize interventions to recommend to the government to decrease inequities in health. The networks consist of about 10–15 policymakers, representatives of civil society organizations and researchers who have decision-making capacity or other influence at the political level.

To our knowledge, this is the only current effort to promote and achieve equity in the health-related MDGS through a research-to-policy-and-implementation approach. Given that these four countries together represent 40% of the world's population, reducing national health inequities would have major beneficial demographic and economic consequences, and thus represent a critical means of improvement.

Acknowledgements

The project Evidence for Policy and Implementation is funded through a grant from the Swedish International Development Cooperation Agency.