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Improving Transportation and Referral for Maternal Health
›“Referral has been called an orphan cause,” said Patricia Bailey, public health specialist for Family Health International and Columbia University, because it is “everybody’s responsibility and therefore nobody’s responsibility.”
As part of the Maternal Health Dialogue Series the Woodrow Wilson International Center for Scholars’ Global Health Initiative convened a small technical meeting on May 19, 2010, with 25 experts from five countries to discuss their experiences and share lessons, challenges, and recommendations for improving transportation and referral for maternal health. Following the technical meeting, a public dialogue was held on May 20, 2010, to share the knowledge gaps and recommendations identified. The formal report from the technical meeting will be available in the near future.
Mobilizing District Communities in Rural GhanaTo improve maternal health care in Ghana, “we needed to shift [services] to the community level, where 70 percent of our population lives,” said Dr. John Koku Awoonor-Williams, the east regional director of Ghana Health Service. The “Community-based Health Planning and Services” (CHPS) program was created to galvanize local leadership and empower communities to engage in health outreach activities.
Through this approach, “community health officers and nurses are trained and delegated to distant village locations called CH[I]P zones, in which they are responsible for health education, treatment of minor illnesses, maternal and antenatal care, and referral to district hospitals for emergency care,” said Awoonor-Williams. Community health officers use two-way Motorola walkie-talkies to communicate with traditional birth attendants and referral centers. Pregnant women are given the phone numbers so they can call in the event of complications.
1-0-8 Emergency Number for Improving Maternal Health in IndiaMany parts of the developing world do not have a 911-style emergency response service. To address this gap, the GVK Emergency Management & Research Institute in India developed the toll-free 1-0-8 telephone number for all medical, police, and fire emergencies.
“We assure every citizen that wherever you are, [if] you call us we will be there,” said Subodh Satyawadi, chief operating officer of GVK. In order to reach the 433 million people covered by GVK, they have:
“Although we address all kinds of emergencies, we heavily focus on maternal health…31 percent of emergencies are pregnancy-related,” said Satyawadi, who said that GVK’s emergency response system has helped save more than 200,000 mothers. Institutional deliveries have increased in the state of Gujarat by 92 percent. “We have been able to reduce maternal mortality by 20-25 percent in different geographies,” he said.- 19,623 EMTs and 10,000 doctors and other healthcare professionals
- 2,710 ambulances
- 16,300 call-center employees
Pre-Hospital Barriers: Reducing Maternal Morbidity in BoliviaWomen in Bolivia receive free maternal care. In cities like La Paz, emergency obstetric care is often available within a short distance. However, “37 percent of our maternal deaths [occur] at our hospitals,” said Víctor Conde Altamirano, OB/GYN of CARE Bolivia.
To better understand this mortality rate, Altamirano evaluated whether pre-hospital barriers and routine antenatal care are associated with near-miss morbidity. He found that women who are older, have lower levels of education, lack antenatal care, are pregnant for the first time, or live in rural areas are at a greatest risk of illness or death
“We are trying to organize our communities and service facilities, and promote improved health management by the municipalities. If our authorities can be sensitive and invest in health; invest in fuel, drugs, and human resources; we can improve near-miss morbidity rates,” said Altamirano.
Strategies and Recommendations for Improving Transportation & ReferralThe workshop participants agreed on six key topic areas for improving transportation and referral:1. Multi-sectoral collaboration
The group called for improved multi-sectoral engagement and continuous dialogue among key ministries: Health, Finance, Communication, Social Welfare, Security and Defense, Transportation, and Public Works.
2. Mobile phone technology
3. Public-private partnerships
4. Referral for newborns
5. Indicators for referral
6. Sharing evidence
Private-public partnerships, such as those demonstrated by GVK in India and the CH[I]P program in Ghana, create opportunities for collaboration. “Cell-phone technology can reduce delays in transport and treatment by identifying which facilities might be the most appropriate for referral,” said Bailey.
The final recommendation by the group calls for increased pooling and use of existing evidence to move the transportation and referral agenda forward. Updated synthesis papers on existing evidence are needed, said Bailey. “We have a lot of data that is perhaps less than perfect, but this should not be a barrier for further action,” she said. -
VIDEO: Family Planning in Conflict Areas
›“Displaced people are like every other human being, they want, they need the advantage of family planning. They are asking only for services to be available for them, affordable for them, and acceptable for them,” said Dr. Grace Kodindo in a recent interview with ECSP about the challenges of family planning in conflict regions. The OB/GYN from Chad calls for family planning services to be included in the provisions made for displaced and refugee communities.
Kodindo identified five key barriers to family planning for displaced people, including a lack of coherent policies for displaced people in host countries and a lack of awareness and attention by donors to family planning. Other barriers include the lack of access in remote areas, and a lack of knowledge and therefore demand.
However, in many cases family planning services are very much in demand. One refugee mother compared herself to a “hen being followed by many chicks,” said Kodindo, who “ask[s] the government and the donors to give and to make policy that can really facilitate the provision of services and to provide funding so that services can be available to all these people.”
Kodindo, who recently spoke at a Wilson Center panel on “Family Planning in Fragile States,” is also speaking in DC on Thursday, June 3 at a showing of the documentary about her work in the Democratic Republic of the Congo, Grace Under Fire. -
Top 10 Posts for May 2010
›Fragile states and food security top the Beat this month:
1. VIDEO—Harriet Birungi: Challenges Facing HIV-Positive Adolescents in Kenya
2. On the Beat: The Food Security Debate: From Malthus to Seinfeld
3. Guest Contributor Michael Kugelman, Wilson Center: Look Beyond Islamabad To Solve Pakistan’s “Other” Threats
4. As Somalia Sinks, Neighbors Face a Fight to Stay Afloat
5. Copper in Afghanistan: Chinese Investment in Aynak
6. Feed the Future: USAID’s Shah Focuses on Women, Innovation, Integration
7. Eye on Environmental Security: USAID Launches GeoExplorer: Connecting Natural Resource Management Activities, Practitioners, and Communities
8. Guest Contributor: Todd Walters, International Peace Park Expeditions: Imagine There’s No Countries: Conservation Beyond Borders in the Balkans
9. DOD Measures Up On Climate Change, Energy
10. Campus Beat: Finding a Home for Political Demography -
Voices of World Water Day: Water and Health
›“Inadequate access to water supply, sanitation, and hygiene cause the deaths of over 1.5 million children each year,” Secretary of State Hilary Clinton said at the National Geographic Society and Water Advocates’ “World Water Day 2010” event. Her address marked a warmly welcomed recognition by the U.S. government of the strong connections between water and health.
“Voices of World Water Day” is a video capturing highlights of the discussion on water and health. Created by PATH and Water Advocates, it seeks to keep the messages and momentum from World Water Day alive and to share them with others.
Importantly, Clinton was not alone in her recognition, and her sentiments were widely shared among the event participants representing both the public and private sectors. Congressmen, Clarissa Brocklehurst of UNICEF, and William Asiko of the Coca-Cola Africa Foundation – to name a few – all weighed in on the necessity of clean, available water for public health. -
‘Frontlines’ Interviews John Sewell: “Promoting Development Is a Risky Business”
›May 31, 2010 // By Wilson Center StaffQ: Foreign assistance has had major achievements over the past 50 years. What are some examples?
SEWELL: There have been many but off the top of my head I can think of three. First, the Green Revolution where the combined efforts of American aid and private foundations revolutionized agriculture in Asia. As a result, many more people lived a much longer time. Second, the efforts put into improving education, particularly of women and girls. The third is population growth. When I started working on development, the best predictions said that global population would rise to over 20 billion at the end of the 20th century. Now we know it will not go much above 9 billion and perhaps lower. That wouldn’t have happened without American leadership and funding.
Q: What are the major failures of foreign assistance?
SEWELL: Failures have occurred either because countries were not committed to development, or because aid agencies designed ineffective programs. But most major failures came about because aid was provided for political reasons— for Cold War purposes in Southeast Asia or the Middle East, not for economic and social development. And we should remember that promoting development is a risky business. If there were no failures, development agencies were being too cautious.
But the more important failures are at the strategic level. Assistance really is only effective when governments and leaders want to speed economic growth, improve health and education, and address poverty. When the government isn’t committed to development, a lot of aid is wasted.
That’s why the choice of countries is so important. Korea is one example. Korean leaders knew how to use foreign aid effectively to build agriculture and industry. Part of that assistance funded investments in health and education. We all know the result.
Egypt, on the other hand, also has received large amounts of American assistance since 1979. But its growth rates are low and they still have one of the highest rates of adult illiteracy in the world.
Perhaps the largest failure has been in Africa. Except for a small number of countries, Africa lags far behind other regions. The blame lies not just with African leaders but also with aid donors who have continued to provide assistance in ways that hinder development.
Q: In what ways can global poverty be reduced quickly in the next three to four years?
SEWELL: In the short term, it won’t happen. The global financial crisis makes that a certainty.
The best estimates are that up to 90 million people will fall back into poverty because they will have lost jobs and livelihoods. The most important thing the U.S. can do in the near term is to continue to lead the reform of the international financial systems that are essential to restarting global economic growth, particularly in the developing world.
Q: That’s the way to reduce poverty?
SEWELL: In the short term, yes. But the U.S. can target aid to build poor peoples’ capacities and can make a great difference. That means aid for education, especially women, and to enable poor people to improve their health. And jobs are critical.
I think the right goal is to empower people to move into the middle class.
That means helping to provide technical assistance and in making low-cost credits for both farmers and small scale entrepreneurs. They will be the generators of jobs that enable men and women to move out of poverty.
Q: Why do you say in one of your papers that economic growth alone will not eliminate poverty?
SEWELL: Because it’s true. Growth does not automatically diminish poverty; it has to be complemented by government actions to share the gains from growth by investing in better health and education. For this you also need a competent state. That’s how the East Asian countries managed to develop so successfully. On the other hand, many Latin American countries have grown at decent rates but have lousy income distribution. But now countries like Brazil are starting to change. For instance, the Brazilian government now pays mothers to keep their children in school where they can get education and health care.
Q: USAID has restrictions that inhibit advertising. How can the public and Congress be informed about the successes and importance of development assistance?
SEWELL: USAID has been very timid about educating the public and Congress. I am not even sure that the earlier successful programs of development education exist anymore. Some steps are easy.
USAID staff knows a lot about development. Why not send them out to talk to public groups around the country? USAID staff doesn’t even participate actively in the yeasty dialogue on development that goes on in the Washington policy community and they should be encouraged to do so. Other changes may require funding and perhaps legislation and the administration should work with the Congress to get them.
Informing the public is particularly important now when there are two major processes underway to modernize U.S. development programs and Congress is rewriting the development assistance legislation.
Q: Since China and Vietnam have both developed without democracy, how important is it to push for democracy and good governance? Are they really necessary?
SEWELL: We need to separate democracy and governance. Very few of the successful developing countries have started out as democracies; India is the big exception. On the other hand, all of the successful countries have had effective governments to do what governments should do: provide security and public goods like health and education, establish the rule of law, and encourage entrepreneurship.
We need to face the fact that no outsider, including the U.S., can “democratize” a country. But it can play an important role in helping to improve governance in committed poor countries. And one of the important parts of successful development is what a Harvard economist calls “conflict mediating institutions” that allow people to deal with the inevitable conflicts that arise within successful development.
Q: You have said that we need to make markets work. How can we help poor people begin to trade when Europe, Japan, and the United States either block imports or subsidize exports?
SEWELL: If you are serious about development, you have to give high priority to trade policy. Unfortunately, USAID seems to have very little voice in trade decisions.
The U.S. needs to focus its development trade policy on the poorest countries. The highest priority should be dropping the remaining subsidies for U.S. production of highly subsidized agricultural products like cotton that can be produced very competitively in very poor countries.
But many of these countries have difficulty selling goods in the U.S., not only because of subsidies, but also because they are not equipped to export. Transport costs are high as are the costs of meeting U.S. health and quality standards, and knowledge of marketing in America is scarce.
Here’s where USAID can play an important complementary role. U.S. companies are already providing technical assistance, some with USAID support. But USAID can expand its trade capacity building programs and focus them on the poorer countries.
Q: What about microcredit?
SEWELL: Microcredit is a very important innovation, especially for empowering poor people, particularly poor women. It’s part of the solution to ending poverty.
But there are other needs. In most poor countries, there are large groups of poor entrepreneurs who are not poor enough to get microcredit but who can’t get commercial banks to lend to them. These are people who produce products for sale— handbags, for instance—that employ 10 to 20 people, but they need capital and advice in order to grow. In the U.S., small businessmen used to borrow money from local banks.That’s how America grew. But similar institutions don’t exist in many poor countries.
Q: We are involved in so many different programs—20 or 30 different federal agencies do some sort of foreign assistance— why not just invest in education and health and let each country figure out what their own development plan should be?
SEWELL: A very good idea. I have long advocated that the U.S. should focus its programs on a few major development issues but I would go beyond just health and education. I add climate change and dealing with global health threats. We dodged the bullet on SARS [severe acute respiratory syndrome] and avian flu but we may not be so lucky in the future. And strengthening governance and strengthening weak states is essential.
The real need now is for some mechanism that oversees and coordinates the multiplicity of agencies that have programs and expertise on these critical issues. Let’s hope that emerges from the current administration’s reviews of development policy
John Sewell a senior scholar at the Woodrow Wilson International Center for Scholars, was interviewed by FrontLines Editorial Director Ben Barber. Originally published in USAID FrontLines, April 2010.Can Food Security Stop Terrorism?
›May 28, 2010 // By Schuyler NullUSAID’s “Feed the Future” initiative is being touted for its potential to help stabilize failing states and dampen simmering civil conflicts. Speaking at a packed symposium on food security hosted by the Chicago Council last week, USAID Administrator Rajiv Shah called food security “the foundation for peace and opportunity – and therefore a foundation for our own national security.”
USDA v. Taliban
›May 28, 2010 // By Dan AsinAgricultural development is the “top non-security priority” in Afghanistan, said U.S. Secretary of Agriculture Tom Vilsack, in a recent speech. “Unemployment is the best recruiting tool for the Taliban,” he told the Des Moines Register.
Sixty USDA experts are working with their partners in State, USAID, DOD, and other members of U.S. government to increase agricultural opportunities in rural areas of the country. Embedded in small civil-military units of 15-100 people, USDA experts have worked on projects of all scales: installing windmill water pumps, training veterinarians, refurbishing university research laboratories, stabilizing river banks and irrigation canals, and developing storage facilities.
In his keynote speech at the Feed the Future launch, Vilsack emphasized the need to build markets. In Afghanistan, USDA is focusing on improving infrastructure so farmers can receive deliveries and ship produce, and boosting credit vehicles to help farmers purchase the inputs to grow crops. Opium traders provide seeds to the farmers and pick up the crops at the farms, he said, which makes opium easier to produce than legal crops.
Alternative crops could be just as or more valuable, Vilsack told NPR:Table grapes are in some cases perhaps four and five times more valuable than poppy. Saffron, almonds, pomegranates, a number of fruits are significantly more profitable. What we have to do is we have to establish that the reward of putting those crops in the ground is greater and the risk is equal to or less than poppy production.
On the same NPR program, Vilsack’s counterpart agreed: “Agriculture growth means employment and employment means security. They’re so much related to each other. In places where the military operates, if you do not offer people the future, just by military means, security and stability will be a very far-reaching dream,” said Minister of Agriculture, Irrigation, and Livestock Mohammad Asif Rahimi.
But the Afghan government faces an immense challenge: Afghanistan’s unemployment rate is estimated at 35 percent, which ranks it in the bottom 20 countries in the world. With a population growth rate of 3.5 percent and nearly half the population already under the age of 15, the need for job creation is only set to increase.
While agricultural development and food security are essential, Rahimi acknowledged, alone they are not enough. The Afghan government needs a “whole of government approach,” he said. To win the hearts of its people the government must offer “an alternative to what the Talibans were offering to people…more livelihood and security and education and health, and also a better and more secure future.”
Both Vilsack and Rahimi avoid the common trap of equating hunger with conflict, instead emphasizing agricultural employment and economic opportunities as key to solving that intractable conflict.
But it’s not the only piece of the puzzle. I hope the Feed the Future’s “whole of government” approach in Afghanistan will emphasize not only agriculture, but also the environmental policies and health services, such as family planning, that can ensure that agricultural gains are sustainable even after the troops leave.
Sources: Central Intelligence Agency, Des Moines Register, NPR, United Nations Statistics Division, United Nations Population Division, U.S. Agency for International Development, U.S. Department of Agriculture, U.S. Department of State.
Photo Credit: Colonel Stephen Redman and John Van Horn of the USDA discuss crop plans with local residents while surveying the site of the Arkansas Agribusiness Development Team’s (ADT)demonstration farm plot near Shahr-e-Safa, Afghanistan, courtesy Flickr user isafmedia.The Eye in the Sky: Using Remote Sensing for Population-Environment Research
›May 28, 2010 // By Julien KatchinoffA recently concluded web seminar hosted by the Population Environment Research Network (PERN) engaged social scientists and Geographic Information Systems (GIS) and remote sensing experts to appraise the role of remote sensing data collection in population and environment research, and identify effective methods for future collaboration.
As the population-environment relationship attracts more study, scholars should consider how remote sensing data will be integrated within existing research needs, as well as how new programs and sensors will help meet future needs. Invited expert Sean Sloan of the University of Melbourne wrote that the potential societal benefits of this research are “immense, albeit largely unrealized. In my view, the principal benefit is that, for the first time, policymakers may draw upon a rich, national-scale empirical basis to develop social/agricultural/economic policy relevant to large-scale environmental issues.”
Cyberseminar participants considered several questions and topics, from determining the most appropriate sensors and instruments for the measurement of population and environment interactions, to addressing the challenges of interdisciplinary research and data interoperability. The discussion also touched on land use and land-cover change, as well how to apply the technology to specific case studies, geographic regions, PE issues, or scalar resolutions.
Demographer Jack Baker of the University of New Mexico raised a tricky issue in his contribution to the discussion of using night-time missions such as Nightsat to calculate population growth and urban sprawl. For his study of remote hunter-gatherers in rural Paraguay, Baker found that “they don’t have electricity so I don’t think they would be captured in satellite views of the night sky. It would be interesting to see how these population estimates I made perform in comparison to an estimate made using night sky imagery …in reality I would like to see lots of these sorts of comparisons before really feeling like I had a grasp on what the strengths and weaknesses of night sky approaches are,” he wrote.
PRB’s Jason Bremner pointed out that despite the high value of remote sensing to understanding human dimensions of environmental change, “the insights remain largely confined to peer-reviewed journals and the academic community. Conservation and development practitioners and policymakers don’t have access to and don’t read the peer-reviewed journals.” In addition, the increasingly technical nature of these methods will require “finding new ways to communicate what we know to those with no technical knowledge of the field,” he said. He urged the participants “to consider what you are doing to overcome the divide between what we know and what others about understand and can use to make decisions.”
Direct dialogue like this between social scientists and remote sensing experts can help establish stronger, more effective ties between two disciplines that would benefit greatly from each other’s support. Such collaboration will be increasingly necessary to address the increasingly complex challenges of population-environment connections.
Julien Katchinoff is a MA student at American University studying global environmental politics and a former intern with ECSP.
Photo Credit: Nightsat image of Osaka, Japan courtesy the National Oceanic and Atmospheric Administration’s (NOAA) National Geophysical Data Center (NGDC).
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