Investment case for improving maternal and child health: results from four countries

The Philippines is a highly decentralised country with a growing urban population increasingly served by private providers, and a rural population relying primarily on the public sector. Progress toward the provision of equitable health services has been slow [14], despite the 1995 national mandate aimed at achieving universal coverage through social insurance [15]. One key factor is that access to social insurance benefits is restricted to services provided by facilities accredited with the Philippine Health Insurance Corporation as part of the quality assurance process. The factors constraining access to these accredited facilities differ between urban and rural sites, and different strategies and investments are required to scale up these services equitably.

The recent priority of the national government towards improving facility-based delivery is reflected in the focus on constraints and strategies for services during pregnancy and birth in all three sites. Prior to the Investment Case analysis, government officials in Pasay City were exploring the option of constructing two new public delivery facilities that would meet requirements for insurance accreditation, to increase the availability of quality services. The Investment Case analysis revealed an alternative that would substantially reduce the expenditure necessary to improve coverage of quality services. While public facilities providing delivery care are limited, there are several private maternity and delivery care providers, and a high proportion of women (86%) deliver in a facility. Construction of public delivery facilities would incur substantial costs, but would not add much value to alternative strategies focused on working more strategically with existing private sector providers (see Table 2). City officials can exert greater influence on private providers by enacting city ordinances that require private delivery facilities within their jurisdiction to secure insurance accreditation as a requirement to hold a business licence, improving both access for the disadvantaged and quality as a whole. Such legislative measures can be complemented by other activities targeting the quality of care provided within the private sector and demand-side information barriers preventing access by the poor.

In Pasay City these strategies focusing on the scaling up coverage of quality delivery care can be expected to achieve reductions in maternal mortality of 13% (11%-15%), newborn mortality of 5% (4%-6%), and child mortality of 5% (4%-7%) by 2015, with annual recurrent costs of USD 0.73 (USD 0.61-0.92) and early capital cost of USD 0.05 per capita. This compares favourably with the alternative scenario involving public facility construction, which would entail a much higher early capital cost (USD 0.74 per capita) without achieving an additional impact on mortality (see Table 2).

By contrast, the limited availability of facility-based services was identified as a major constraint in the mainly rural provinces, with 19% and 34% of deliveries taking place in facilities in Northern Samar and Eastern Samar respectively. Therefore strategies were aimed at getting the basics right, including strengthening procurement, training health workers, and recruiting additional midwives. A key strategy identified was the upgrading of public health facilities to provide quality maternity and delivery care, including emergency obstetric care. These upgrades would enable facilities to become accredited by the national health insurance programme, which would reduce financial barriers for the poor. The establishment of community health teams and member services for the national health insurance programme aim to raise community awareness of the programme and assist existing members in accessing their entitlements.

These combined strategies in Northern Samar aimed at improving uptake of quality delivery care can achieve mortality reductions of 39% (32%-46%), 25% (20%-29%), 17% (14%-19%), and for maternal neonatal, and under-five mortality respectively, at an annual recurrent cost of USD 2.20 (USD 2.01-2.40) per capita (early capital expenditure of USD 2.72). As a result of a more extensive infrastructure strategy in Eastern Samar – which includes building, equipping, and staffing two new health facilities, and the recruitment of a greater number of midwives to accommodate the more widely dispersed population – the per capita costs in this province is substantially greater than in Northern Samar (see Table 2) Note that the lower baseline coverage of interventions and higher levels of mortality in the Provinces mean greater mortality reductions are possible in Eastern and Northern Samar compared to Pasay City.

Similar to the Philippines, Indonesia is a decentralised country pursuing universal coverage through mandatory social insurance, with a highly urbanised population served by a mixture of public and private providers. Inequity is an important concern in Indonesia. An in-depth analysis of equity in maternal, newborn and child health (MNCH) service access and health outcomes has demonstrated large variation in outcomes and intervention coverage between regions and between different population groups. In particular disparities appear to be pronounced between island groups and following the years of the decentralisation reforms in Indonesia [16].

Like the Philippines, the root causes of poor quality health services identified in all four locations differed along rural–urban lines. While in the rural sites geographical access to MNCH interventions was the key concern, in the urban areas a large and unregulated private sector compromised the quality of care. This was particularly evident in the emergency interventions where access to basic and comprehensive emergency obstetric care was found to be between 98-100% in the cities compared to 13%-46% in the districts. However, in the cities only a fraction of those with access were receiving quality care, with overall quality coverage for basic emergency obstetric care only slightly higher (25%-29%) than in the districts (18%-19%).

Many of the strategies employed in the cities to improve quality care involved not only improvement in public facilities but also stronger regulation and incentives for improvement of quality in the private sector. A clearly identified constraint in both cities was that of private midwives not following protocols for antenatal care, monthly reporting, and referral of complicated deliveries. Incentives, training, and monitoring of private midwives by the Midwives Association were therefore included as key strategies. Since emergency obstetric interventions address many of the major causes of maternal and neonatal death, the full reduction in mortality of 15% (6%-22%), 12% (7%-17%) and 5% (3%-10%) in maternal, newborn and under-five mortality respectively, in Pontianak City (with similar results for Tasikmalaya City) will only be realised if these strategies succeed in improving access to full comprehensive emergency obstetric care.

Key strategies to improve coverage of quality services in the Indonesian rural districts focused on strengthening essential components of the health system. In line with those discussed in the Philippines, these included upgrading facilities; recruitment, training, and retention of staff in remote areas; and improving demand for services.

In Indonesia, policymakers at central level also requested the development of alternative scenarios that would provide more guidance on priority setting to local government officials. We modelled a “Full scenario” scaling up the entire programme of health interventions currently delivered, along with a “National Priority scenario” that reflected the national priorities and so focused on strategies to scale up those interventions addressing the key causes of maternal and neonatal death (see Table 3). This National Priority scenario – focusing on antenatal care and emergency maternal and newborn interventions – included strategies essential to the provision of high-quality care and was seen as a better investment in three out of the four sites. For instance in Sikka district, implementation of priority strategies suggest a marginal reduction of 24% (17%-28%), 14% (10%-17%) and 7% (5%-11%) in the MMR, NMR and U5MR respectively. Annual recurrent costs of this scenario would be USD 1.63 (USD 1.53-1.76) per capita. The full scenario provides little additional benefit in terms of mortality impact (additional reduction of around 4%, 3% and 6% in MMR, NMR and U5MR, respectively), but incurs significantly higher annual recurrent costs (USD 3.33 per capita). Similar results can be seen in the case of Pontianak City and Tasikmalya City (Table 3). It should be noted that for Merauke in Papua Province, which has high post-neonatal mortality, there is a greater argument to implement the ‘Full scenario’ since it offers more substantial benefits for this age-group than for the other sites, with around an additional 12% in U5MR for this scenario over that of the ‘National Priority scenario’.

A key difference between the Philippines and the Indonesian analyses is the greater emphasis that local government officials in the former have placed on the funding linkages with mandatory health insurance. Since the health insurance scheme in the Philippines has been in place for longer, this might reflect lessons learnt during the last decade about constraints to accessing health insurance benefits. Notwithstanding differences in the focus of the analyses in both countries, common themes have emerged including the potential of relatively inexpensive strategies such as innovative public-private partnerships. In the Indonesian sites these included conducting regular coordination activities between public and private hospitals to facilitate referral and reporting of obstetric emergencies, establishing and distributing practice guidelines to both private and public providers and partnering with private midwives associations to provide additional monitoring and training opportunities. These types of partnerships require strong supervision and regulation of the private sector in urban areas. In disadvantaged rural areas there is a need to invest in “getting the basics right” to deliver quality maternal, newborn, and child health services.

The need for “getting the basics right” is also evident in the Investment Case analyses in Orissa, a predominantly rural and tribal state in India with very minor private health sector presence [17, 18].

A significant rise in utilisation of key MNCH services – such as antenatal care and facility-based births – reflects the success of innovative demand-side financing schemes introduced by the National Rural Health Mission and supported by the State Government [19]. However this increase in use of health services has not always been accompanied by improved quality of care, which in turn is affected by basic supply constraints and availability of skilled manpower. Inadequate availability of health services across disadvantaged districts in India has been recently stressed as a major challenge for universal health coverage [20]. This challenge is particularly noticeable in Rayagada, a typical rural, tribal, and sparsely populated hilly district. Whilst 49% of births are attended by skilled birth attendants at a facility, only an estimated 20% take place at well-equipped facilities which meet Indian Public Health Standards. Kendrapara, a typical rural coastal district with a higher population density, faces some similar constraints.

Problem analysis indicated that there were underlying issues of low availability of basic infrastructure, supplies, equipment, and staff, particularly at peripheral facilities. Key strategies focused on strengthening outreach services and enabling task shifting to lower levels of the health system. This required the reconstruction or rehabilitation of at least 10-30% of sub-centres, the upgrading of select Primary Health Centres to provide basic emergency obstetric and neonatal care, and the installation of blood storage units at select Community Health Centres. In addition to these capital investments, other important strategies included: increasing travel allowances and additional training for sub-centre health workers; performance incentives for field staff delivering post-natal care; capacity building for management and supervisory activities; and arrangements to reimburse private sector specialists for providing emergency care to public patients. Although these findings were not surprising, and upgrading infrastructure and staffing have been part of previous plans, the IC analysis highlighted particular bottlenecks in implementation. One example is the need to include the cost of land acquisition for sub-centre construction, to ensure that they can be built in the villages where they will be used.

While investments in fundamental resources such as infrastructure and staff are critical, the analysis also revealed the potential for basic low-cost management strategies to supplement these investments by overcoming implementation issues. One example suggested by field workers and district officials, was to divide the geographical area covered by the sub-centre between health workers, rather than have them ”doubling-up” which is current practice. This would maximise the time spent per household during outreach and enable the efficient sharing of work.

Should the conservative coverage targets set in the bottleneck workshop be reached, reductions of 25% (22%-27%) and 23% (21%-26%) in under-five mortality, and 28% (23%-33%) and 34% (30%-38%) in the maternal mortality ratio, can be expected for Rayagada and Kendrapara respectively over a five year period (See Table 4). Importantly, reductions of around 35% may be expected for neonatal mortality in both districts. This is significant for Orissa as neonatal mortality rates have remained high over the last decade despite declining maternal mortality rates [21]. As shown in Table 4, additional per capita costs of USD 1.61 (annual recurrent) and USD 1.70 (early capital) for Kendrapara, and USD 3.92 (annual recurrent) and USD 3.56 (early capital) for Rayagada will be required to implement these strategies. The high marginal per capita costs for Rayagada reflect not only the lower baseline indicators for human resources and infrastructure, but also the challenges of providing health services in a sparsely populated district.

The basic management strategies that arose out of the problem solving analysis for Orissa were identified by peripheral workers in all countries. The case of the Nepal illustrates that national level analyses cannot capture such constraints and practical strategies. This can result in more costly and unrealistic targets.

While Nepal’s health policies and centralised planning support universal coverage, there is a concern that national progress may mask regional inequities – a situation that may worsen unless central plans are informed by realistic sub-national targets, priorities, and costs. The IC analysis in Nepal was performed in the context of the Nepal Health Sector Programme – Implementation Plan with prescribed national targets for both service delivery inputs and intervention coverage.

To analyse the difference between nationally prescribed and locally derived targets, two scenarios were modelled in Nepal. One scenario was informed by the analyses of constraints in disadvantaged locations in the three distinct ecological regions of Nepal (Mountains, Hills, and Terai) from our Investment Case. The other applied the national strategies and targets set by the Nepal Health Sector Programme – Implementation Plan.

There were broad similarities between key strategies in both scenarios, such as the revitalisation of the work of Female Community Health Volunteers and mothers’ groups, and the introduction of population-based health planning. Strategies from our Investment Case placed emphasis on overcoming the context specific constraints, and were more focused on specific logistical challenges such as the provision of accommodation for outreach staff in remote locations.

Many of the national coverage targets are not realistic for disadvantaged areas, with many involving at least a tenfold coverage increase within a five year period. For example the average coverage of skilled birth attendance in the disadvantaged districts of the mountains is 10%, while the national target is 60%. The more realistic targets set by peripheral workers during the problem solving workshops can be achieved at a substantially lower cost while still making an important impact on mortality (see Table 5). For an additional investment of between USD 2.75 and USD 5.82 per person (capital and annual recurrent costs), major progress towards MDGs 4 and 5 can be achieved in disadvantaged districts. For example, reductions in neonatal mortality rates of 39% (35%-43%), 57% (53%-61%), and 40% (30%-49%) can be expected for the Terai, Hills, and Mountains respectively. These costs compare favourably against the estimated USD 6.07-11.77 (capital and annual recurrent costs) required for the implementation of strategies recommended in the national health plan.

Costing differentials between these two scenarios are driven primarily by the more ambitious infrastructure targets set by the national health plan, which impose heavy demands on disadvantaged locations. For example in the populous terai, if the current national ratio of population to Primary Health Care Centre of 50,000: 1 were enforced, it would require a threefold increase in current facilities in our disadvantaged terai districts (from 38 to 114 over the next five years). Our analysis suggests that a ratio of 90,000:1 (an additional 25 facilities) would meet targets for basic emergency obstetric care, particularly if supported by additional services at the community and sub-post level.

Ethical clearance was obtained by the University of Queensland, Medical Research Ethics Committee and the University of Queensland Behavioural & Social Sciences Ethical Review Committee.