Showing posts from category global health.
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Improving Monitoring, Transparency, and Accountability for Maternal, Newborn, and Child Health
›“There is a knowledge gap between global targets and locally owned goals,” said Sallie Craig Huber, global lead for results management at Management Sciences for Health (MSH). The seventh meeting of the “Advancing Policy Dialogue on Maternal Health” series – cosponsored by the Global Health Council, MSH, and PATH – comes at a critical time as world leaders meet next week at the high-level, plenary UN Summit to review progress toward the Millennium Development Goals (MDGs).
Panelists Marge Koblinsky, senior technical advisor, John Snow Inc., Ellen Starbird, deputy director, U.S. Agency for International Development, and Monique Widyono, program officer of PATH, discussed strategies for improving maternal health evaluation methods while balancing the interests of donors and beneficiaries.
Maternal Health Indicators: Contact vs. Context
“Skilled birth attendants [have] become the strategy [for improving maternal mortality rates], but one size does not fit all,” said Koblinsky. The proportion of births attended by skilled birth attendants is a key maternal health indicator; however, it is not sufficient and says little about what the attendants actually did during the birth.Koblinsky demonstrated how other indicators such as near-miss morbidity, rates of cesarean section, and contraceptive prevalence rates (CPR) are better aligned with maternal mortality outcomes. “CPR is much more closely linked with the outcome we desire as [contraception] reduces pregnancies for those at higher risk and reduces unwanted births and unsafe abortions,” said Koblinsky.
“Are the present benchmarks enough?” asked Koblinsky. “The answer is no….Indicators based on contact with skilled birth attendants focuses attention on contact, not on the quality of care or event context.”
Qualitative Data Is Necessary“When we talk about monitoring and evaluation, transparency and accountability, it’s really critical to engage [in a discussion] on how we gauge progress,” said Widyono. In the field, “collection of data varies widely and depends on the capacity of those collecting, aggregating, and analyzing the information,” said Widyono. Such inconsistencies demand increased investment in local research capacity and qualitative analysis.
Such engagement also provides an opportunity for feedback. This “qualitative data helps to reinforce, illuminate, and deepen the understanding of what this quantitative data is showing on the ground,” said Widyono. Moving forward, policymakers, donors, and program managers will need to find a balance between these two sets of data and work together to galvanize action.
“There is a lack of attention paid to developing local, sustainable research capacity,” said Widyono. “We have an obligation to build local research capacity and disseminate findings in collaboration with the people who are going to be affected by this data,” she said.
Innovation and Research
“We really need to think about monitoring and evaluation and research and innovation as a continuum,” said Starbird. “They reinforce each other and play different roles in helping us understand what makes programs work or why they are not working.”“We have a myriad of indicators that we expect people to monitor, collect data for, and report back to headquarters in a way that has not given countries and programs the freedom to be country-specific,” said Starbird. Therefore, “one of the goals is to minimize the reporting burden and better coordinate around indicator definition with other donors,” she said.
In order to strengthen “M&E;” for maternal health, Starbird called for new indicators as well as new ways of thinking about data analysis. “Having a results framework is really important to do good monitoring and evaluation,” she said. Evaluating the relationship between inputs, outputs, outcomes, and impacts requires a wide range of data resources so we can “get under the numbers” and determine what needs to be improved, she said.
“It’s really important to have realistic goals, otherwise it’s difficult to put programs into place and get where we want to go,” said Starbird. She said that MDG 5.B, which calls for universal access to reproductive health, “is great, but there’s never going to be universal access to reproductive health. If we really want to make progress we need to define something that is achievable and is something we can come together around.”
In conclusion, it is necessary to provide “countries with the room to do what needs to be done locally, so we can better understand these concepts rather than imposing indicators on everybody,” said Starbird. -
GMHC 2010: Maternal Health Realities: Accountability and Behavior Change
›Four days ago a young woman died giving birth in a bustling marketplace in New Delhi. Just steps away from Parliament, this woman was left to die and no emergency care was sent to her – no midwives, nurses, or doctors; just people walking around her accepting the situation as normal and an uncontrollable way of life. But this is Delhi…not a remote tribal village where the nearest health clinic is hours away (on foot).
This juxtaposition lingers on in me as I sit in the plenary session of day two at the Global Maternal Health Conference and listen to Syeda Hameed, member of the Indian Parliament Planning Commission, discuss her recent visit to a remote village where every house has 10 children living in filth, flies, and emptiness.
Although I have been working on such development issues for the last five years I do not work in the field, nor do I visit the developing world on a regular basis. Hearing these stories, coupled with my firsthand experience of witnessing poverty here in Delhi reminds me of the daily reality of those 342,900 women who die every year. This is their way of life and I think it’s poignant that today’s sessions emphasize community based care, family planning, accountability, behavior change, and culture.
“Context, context, context,” said Wendy Graham of IMMPACT at yesterday’s plenary session. I agree, the context of social and cultural norms is an underlying factor that must be taken into consideration when implementing maternal and child health (MNCH) programs. With a background in psychology, I appreciated when Dr. Zulfiqar Bhutta, of Aga Khan University, recognized the toll of poverty on the imagination and the mentality of fatalism.
That is why it is so essential to “ask the people how they feel and bring their voices into the forums where policy decisions are made,” said Hameed. It is also important to hold key players accountable and include men in MNCH activities.
During the side session Male Involvement in Reproductive and Maternal and Newborn Health six field experts (in which half the panelists and audience members were men!) discussed effective methods for increasing male participation in family planning, vasectomies, gender equality, and hospital care.
The key findings from this discussion include:- Targeted interventions that educate men about danger signs and pregnancy complications correlates with behavior change and increased facility births.
- Many young married men feel pressured to prove their fertility. A sample of men was evaluated and those who had increased education and income were more likely to delay first pregnancy.
- Vasectomy is not something men want to talk about with family planning fieldworkers; however, official recognition of the vasectomy benefits by the government did increase referrals.
- Puppet and theater shows that demonstrate gender equity behaviors provide an opportunity for dialogue. Women in this study reported increased gender equity in family planning decision-making.
Originally posted at Maternal Health Task Force, by Calyn Ostrowski of the Woodrow Wilson International Center for Scholars, Coordinator of the Maternal Health Dialogue Series in partnership with the Maternal Health Task Force and UNFPA.
Photo Credit: “Parliament Street” courtesy of flickr user ~FreeBirD®~. -
GMHC 2010: Empowering the Next Generation
›“We do not need new legislation… we need affordable, effective, and scalable solutions,” said Shn Gulamnabi Azad, Minister of Health, India, at the opening ceremony of the first-ever Global Maternal Health Conference in New Delhi. Co-hosted by the Maternal Health Task Force and the Public Health Institute of India, this three-day technical meeting builds upon the momentum of Women Deliver and the G8 summit by bringing together 700 researchers, program managers, advocates, media, and young people to exchange ideas, share data, develop strategies, and identify solutions for reducing maternal mortality.
In order to reduce India’s maternal mortality rates, Azad called for the repositioning of family planning programs to include maternal and child health and not limit the scope of services to population control as historically executed. Improving family planning and maternal health services must also address the reproductive health needs of adolescent girls, and India is currently developing a new ministry that will target gender inequality, poverty, early child marriages, as well as other critical health issues important to young girls such as the dissemination of sanitary napkins.
“Although the legal age of marriage is 18, there are districts in India where 35 percent of the population is married between the ages of 15-18,” said Azad. During the side event “Adolescent Girls: Change Agents for Healthy Mother and Child,” technical experts such as Anil Paranjap of the Indian Institute of Health Management presented evidence that girls who marry between 15-18 are five times more likely to die during childbirth than women in their early 20’s.
“We still have deep-rooted subordination that makes it very difficult for young women to realize their sexual and reproductive health rights,” said Sanam Anwar with the Oman Medical College. Interventions such as the UDAAN project – a private-public partnership between the Center for Development and Population Activities (CEDPA) and the Government of India – demonstrate promising solutions for empowering young people through the use of existing infrastructure. In collaboration with teachers, parents, principals, and students, this project successfully increased leadership skills and improved youth knowledge on menstruation, health, friendship, peer pressure, early marriage, and reproductive health, said Sudipta Mukhopadhyay of CEDPA.
Empowering “young people” to improve maternal health also requires that the community support committed new thinkers and future leaders. The Young Champions of Maternal Health Program is a unique and refreshing group of young professionals from 13 countries dedicated to improving maternal health, and I look forward to learning how this new energy will further the maternal health agenda.
Originally posted at Maternal Health Task Force, by Calyn Ostrowski of the Woodrow Wilson International Center for Scholars, Coordinator of the Maternal Health Dialogue Series in partnership with the Maternal Health Task Force and UNFPA.
Photo Credit: “Indian Girl” courtesy of flickr user Jarek Jarosz. -
‘NSB’ Blogs from the 2010 Global Maternal Health Conference in New Delhi
›The 2010 Global Maternal Health Conference kicked off today, perhaps fittingly, in India – one of the world’s fastest growing nations but one that also faces serious reproductive health challenges. The Wilson Center’s Calyn Ostrowski is in New Delhi for the conference and will be providing updates to The New Security Beat throughout the week.
Those interested can also find a schedule of events and list of participants on the conference website as well as live webcasted events on the main page. Stay tuned!
Photo Credit: “Mumbai, India, November 2009” courtesy of flickr user travelmeasia. -
Fire in the Hole: A Look Inside India’s Hidden Resource War
›August 18, 2010 // By Schuyler NullThis month’s Foreign Policy has two features on India’s ongoing internal conflict with Maoist and tribal rebels – perhaps the least known insurgency and resource conflict in the world.
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Misguided Projections for Africa’s Fertility
›By assuming that sub-Saharan Africa’s total fertility rate will decrease to 2.5 children per woman by 2050, the most recent population projections issued by the Population Reference Bureau likely continue to underestimate fertility for Africa. Though northern Africa has significantly lowered fertility, sub-Saharan Africa’s TFR is still 5 children per woman. Achieving the levels projected by PRB or the United Nations will largely depend on whether the conditions that led to past fertility declines for other states can be established in sub-Saharan Africa.
Demographers have identified numerous factors associated with fertility decline, including increased education for females, shifting from a rural agricultural economy to an industrial one, and introduction of contraceptive technology. Sub-Saharan Africa is only making slow progress in each of these areas.
Surveying Obstacles to Development
Primary school enrollment is up, but the pace of improvement is declining. Meanwhile, gender gaps persist: Enrollment for boys remains significantly higher than for girls. Girls’ education is associated with lower fertility, partly because education helps women take charge of their fertility and also because education influences employment opportunities. Increased female labor force participation has been shown to increase the cost of having children, and is therefore associated with initial fertility declines.
Disease is one wildcard for Africa that limits the utility of past models of demographic transition in the African context. HIV/AIDS is decimating sub-Saharan Africa’s adult workforce and creating shortages of teachers that will impede future efforts to boost primary school enrollment. According to the United Nations, the number of teachers in sub-Saharan Africa needs to double in the next five years to reach Millennium Development goals.
Development that would shift the region’s economies from agriculture to industry is also lagging. While several West African countries are seeing some gains, the African continent on the whole faces major structural impediments to development. In The Bottom Billion, Paul Collier points out that many of these countries may have “missed the boat” to attract investment and industry that would pull the region out of poverty, partly because the least developed countries are still not cost-competitive enough when compared with current centers of manufacturing, like China.
Finally, there remains a high unmet need for family planning. One in four women aged 15 to 49 who are married or in union –- and who have expressed an interest in using contraceptives — still do not have access to family planning tools. In general, maternal mortality remains high and adolescents in the poorest households are three times more likely to become pregnant and give birth than those in the richest households, according to the most recent UN Millennium Development Goals report.
Sub-Saharan Africa: Off the Radar?
Sub-Saharan Africa suffers from a lack of attention by the international community and lack of political capacity at home. Many countries in the region are plagued by civil strife and poor governance, and developed countries continue to fall short of development assistance pledges. There is not the same sense of urgency today among developed countries about the global population explosion as there once was. Cold War politics and the environmental and feminist movements motivated much of the study of fertility and funding of population programs during the second half of the 20th century. Attention by governments and NGOs sped the fertility transition among many countries.
Today, the world’s wealthiest countries are not concerned primarily with Africa’s problems, but rather are more concerned with their own population decline and with the national security implications of population trends in areas associated with religious extremism. The recession has further hindered the flow of development funds.
Fertility is the most difficult population component to predict, and demographers must draw on the experiences of other regions to inform assessments of Africa’s population patterns. Demographers seem to be overconfident that Africa’s fertility will follow the pattern of recent declines, particularly in Latin America, which were more rapid than Western Europe’s decline due to the diffusion of technology and knowledge.
Once states begin the demographic transition towards lower fertility and mortality, they have tended to continue, with few exceptions. Therefore, most projections for Africa assume the same linear pattern of decline will hold. Yet, the low priority of Africa’s population issues among the world’s wealthiest states, combined with shortfalls in education, development, and contraception, may mean that the demographic transition in Africa will be slower than predicted.
Projections are useful to give us a picture of what the world could look like if meaningful policy changes are made. In the case of sub-Saharan Africa, prospects for these projections are dim.
Jennifer Dabbs Sciubba is the Mellon Environmental Fellow in the Department of International Studies at Rhodes College in Memphis, Tenn. She is also the author of a forthcoming book, The Future Faces of War: Population and National Security.
Photo Credit: “Waiting,” ECWA Evangel Hospital, Jos, Nigeria, courtesy of flickr user Mike Blyth. -
How Maternal Mortality and Morbidity Impact Economic Development
›“Investing in women and girls is the right thing to do,” says Mayra Buvinic, sector director of the World Bank’s gender and development group. “It is not only fair for gender equality, but it is smart economics.” But while it may be smart economics, many developing countries fail to address the underlying social causes that impact economic growth, such as poverty and gender inequality. Buvinic was joined by Dr. Nomonde Xundu, health attaché at the Embassy of South Africa in Washington, D.C., and Mary Ellen Stanton, senior maternal health advisor at the U.S. Agency for International Development (USAID), at the sixth meeting of the Advancing Policy Dialogue on Maternal Health Series, which addressed the economic impact of maternal mortality and provided evidence for the need for increased investment in maternal health.
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“There Is No Choice:” Climate, Health, Water, Food Security Must Be Integrated, Say Experts
›August 9, 2010 // By Russell SticklorBureaucratic stovepipes plague international development efforts, and aid for pressing environmental and human security concerns—such as climate change, food shortages, fresh water access, and global health threats—rarely matches the reality on the ground in the developing world, where such health and environmental problems are fundamentally interconnected.
Instead, development efforts in the field—whether spearheaded by multilaterals, bilaterals, or NGOs—are commonly devoted to single sectors: e.g., the prevention and treatment of a single disease; the implementation of irrigation infrastructure in a specific area; or the introduction of a new crop in a certain region. The reasons for such a narrow focus can come from multiple sources: finite resources, narrowly constructed funding streams, emphasis on simple and discrete indicators of success, and institutional and professional development penalties for those who conduct integrated work. But some experts argue that integrating problem-solving initiatives across categories would not only improve the efficacy of development efforts, but also better improve lives in target communities.
As part of the USAID Knowledge Management Center‘s 2010 Summer Seminar Series, a recent National Press Club panel on integration featured a frank discussion of both the opportunities and challenges inherent in breaking down barriers within and between development agencies. Panelists from the World Bank’s Environment Department, the White House Council on Environmental Quality, and the Woodrow Wilson Center’s Environment Change and Security Program weighed in on the prospects for cross-sectoral integration.
Addressing the impacts of a global problem like climate change “requires multilevel approaches,” and necessitates that we “think multisectorally along the lines of agriculture, water, transportation, energy, [and] security,” said Loren Labovitch of the White House Council on Environmental Quality. The four topics under discussion—climate change, food security, water, and health—are all Obama administration priorities, as reflected by dedicated programs and special initiatives. Finding ways to practically integrate these interrelated challenges (through efforts like the Feed the Future Initiative or the Global Health Initiative) is getting more attention from policy analysts and policymakers with each passing year.
Integration in Practice: Success Stories
While there may be an emerging willingness to discuss and even experiment with holistic programming, what does it actually look in practice? Panelist Geoff Dabelko, director of the Woodrow Wilson Center’s Environmental Change and Security Program, singled out integrated development programs in the Philippines, the Democratic Republic of Congo, and Asia as examples.
Philippines: The PATH Foundation Philippines’ Integrated Population and Coastal Resource Management (IPOPCORM) initiative uses an integrated approach to address health and environmental concerns in coastal communities. Their “basket of services” includes establishing a locally managed protected marine sanctuary to allow local fish stocks to recover, promoting alternative economic livelihoods outside of the fishing industry, and improving access to local health services and commodities, said Dabelko. To date, IPOPCORM has yielded several notable improvements, among them reduced program costs and improved health and environmental outcomes as compared to side-by-side single sector interventions. A forthcoming peer-reviewed article will appear in Environmental Conservation, and will detail the controlled comparison study of the IPOPCORM project.
Democratic Republic of Congo: Mercy Corps has also successfully pursued cross-sectoral programming as part of a larger effort to be more holistic in its humanitarian and development responses. In war-torn eastern DRC, Mercy Corps brought practitioners with expertise in natural resource management into the fold of what has historically been an emergency relief mission. In particular, the Mercy Corps mission has fused humanitarian assistance with longer-term development efforts such as enhanced environmental stewardship. For example, promoting the use of fuel-efficient cookstoves eases pressure on local forest resources by lowering the need for firewood, and improves respiratory health by lowering air pollution. The project scaled up the effort through resources from further integration, with carbon credits from avoided emissions being sold through a local broker to the European cap and trade market. These resources in turn helped finance more cook stoves, which now total 20,000 for this project.
“The lesson is we have no excuse for not doing this anywhere in the world and saying some place is too unstable,” Dabelko said. “If we can do it [integrated projects] in eastern DRC, we should be able to do it anywhere.”
Asia: Tackling programmatic integration starts with better understanding the interconnections between environmental and health challenges. Dabelko cited a recent effort of the environment and natural resources team within USAID’s Asia Bureau as an example of breaking out of narrow bureaucratic stovepipes.
USAID staff recognized that a wide set of climate, energy, economic, governance, and conflict issues affected their core biodiversity and water portfolios, even if they did not have the time, expertise, or resources to investigate those issues in detail. Trends that appeared to be in the periphery were not viewed as peripheral to planning and designing programs for long-term success.
Working with the Woodrow Wilson Center, the USAID Asia Regional Bureau engaged experts on a diverse set of topics normally considered outside their portfolios. The resulting workshop series and report led to a deeper understanding of the possible impacts of increased Himalayan glacier melt and Chinese hydropower plans on food security and biodiversity programs in the lower reaches of the Mekong River. Bringing analysis from these topically and geographically remote areas into local-level development planning is a process that will require a similar willingness to go outside the typical bounds of one’s brief.
More Integration Ahead?
These case studies provide a glimpse of what integrated programming can look like on the ground. Still, significant hurdles remain standing in the way of regular and effective integration. Cross-sectoral programming demands that old problems be addressed in innovative and perhaps unfamiliar ways, requiring the addition of new capacity in development organizations and better coordination within and between agencies. That can be a complicated process, noted Dabelko, since efforts to pursue greater programming integration can be “hamstrung by earmarks and line items.”
Integration can also prove tricky because it requires a greater willingness to accept multiple indicators of success unfolding over different time frames—health gains may occur quickly, for example, while progress on environmental conservation may unfold less speedily. This means existing programs might need to be reshaped and reoriented to accommodate these divergent time frames, which could prove somewhat difficult. “Integration can be a challenge, both from a programming perspective and from an organizational perspective,” acknowledged moderator Tegan Blaine, climate change advisor for USAID’s Africa Bureau.
Further, the temptation remains strong among appropriators and implementers alike to maintain control over authority and resources in their traditional portfolios. Getting long-time practitioners in particular issue areas to willingly cede some of their turf in the pursuit of greater integration has historically been the “real world” that stands in the way of such integrated work.
But, as shown by the standing-room-only crowd at the seminar, momentum is slowly starting to build in pursuit of breaking down old programming walls and finding new approaches to addressing emerging challenges in human and environmental security.
“There is no choice” but to fuse development agendas with climate change adaptation efforts, asserted Warren Evans, director of the World Bank’s Environment Department. “It can’t be a parallel process anymore.”
Photo Credit: “2010 Summer Seminar Series – July 15th Panel Discussion on Food Security, Climate Change, Water and Health,” used courtesy of USAID and the National Press Club.
