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“Most Men Pretend to be Busy…” The Struggle for Male-Partner Involvement in Maternal and Child Health in Post-Conflict Northern Uganda

Session: Gender Equity and Transformation for Improving Maternal Newborn Health

Presenter: Primus Che Chi, Peace Research Institute Oslo
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Background: Northern Uganda is recovering from brutal civil war that claimed hundreds of thousands of lives, displaced millions, and severely affected maternal and child health (MCH) outcomes. In a bid to improve the situation, local health authorities are advocating for stronger male-partner involvement in MCH. This initiative has however experienced a lot of challenges. This study seeks to explore the barriers to effective male-partner involvement in MCH in Northern Uganda and the strategies utilized by local health promoters and providers to address the situation.

Methods: This is a qualitative exploratory study utilizing semi-structured in-depth interviews (IDIs) and focus group discussions (FGDs). Participants were recruited from local health providers and staff of non-governmental organizations working in the domain of MCH in the region. Data were analyzed by thematic analysis.

Results: A total of 22 IDIs and 2 FGDs, involving 35 participants were conducted. The main barriers identified are: lack of time; strong cultural norms and beliefs; poor support for policies and programs focused on male involvement; poor engagement with men who accompany their spouses to the facility; and financial barriers. Strategies main being explored to enhance male-partner involvement are: involving local political and cultural leaders to promote the campaign; instituting regulations that oblige men to accompany their spouses for some pregnancy-related services at the facility; and prioritizing the delivery of maternal services to women who are accompanied by their spouses to the facility.

Conclusions: Poor male-partner involvement in MCH remains a major challenge to improving MCH in Northern Uganda. If substantial gains are to be made, local authorities must invest more resources into male involvement-related activities and develop more innovative approaches to effectively engaging men. These initiatives must equally cater for the health needs of the men.

What Determines Trust in Maternity Care?:  Cross-Perspective Findings from Peri-Urban Kenya

Session: Maternal Newborn Health in Urban Settings

Presenter: Pooja Sripad, Johns Hopkins Bloomberg School of Public Health
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Background: Trust in providers and a health facility is important to perceived quality and demand for facility-based maternity care. Barriers to maternity care-seeking include a range of financial, logistical, structural, environmental and experiential factors. Trust is a multidimensional concept that provides a distinctive lens for understanding health system responsiveness during the critical stage of labor and delivery. This study is one of the first to explore determinants of trust in a maternity setting through a range of local perspectives.

Methodology: A theoretically-driven qualitative approach drawing on appreciative inquiry and institutional ethnography was applied. Focus groups (n=8) with recently delivered women (RDW), pregnant women, and male partners; and in-depth-interviews (n=33) with RDW, providers, management, and community health workers (CHWs), were conducted in and around a public sub county-level hospital in a peri-urban area in Central Kenya. Interviews were audio-recorded, transcribed into Kiswahili and translated into English. Data were analyzed through inductive coding and memo-writing.

Results: Distinct maternity care user, provider, and management standpoints converge around a multi-faceted trust determinants framework that clusters around patient/individual, provider, health facility, community, accountability, and structural factors. The complexity of the framework lies in how determinants within factor clusters relate to one another and influence trust simultaneously. For example, a woman’s trust may be influenced by her perceived risk of facility-delivery; provider friendliness; hospital resources; her social network; whether she feels facilities can adjust to the ‘free maternity’ context, and her ability to speak in a normalized user-provider-management hierarchy.

Conclusions: The multi-faceted clustering of determinants in light of Kenya’s new constitution, devolved governance structure, and free maternity policy indicates the critical importance of perspective and socio-political context in understanding trust in the maternity setting. Cross-perspective findings further suggest a key role for communities and community liaisons in building trust and increasing demand for maternity care.

A Scoping of the Status of MNH for the Urban Poor

Session: Maternal Newborn Health in Urban Settings

Presenter: Shanon McNab, Averting Maternal Death and Disability, Columbia University
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Background: By 2050, two-thirds of the world’s population will live in urban areas and nearly 90% of this growth will be in Africa and Asia. In LMICs, over 860 million people are living in slums: 62% of urban residents in sub-Saharan Africa and 35% in south Asia are slum-dwellers. In many cities, MMR and NMR are much higher in slums than the urban average. Despite this massive urbanization, evidence on strategies for effective coverage of MNH interventions for the urban poor is extremely limited. Further analysis of strategic approaches, delivery structures, implementation frameworks, financial mechanisms, and roles of private and public partners is urgently needed. Saving Newborn Lives, in collaboration with Columbia University, conducted a global scoping of the status of MNH in urban settings focusing on south Asia and sub-Saharan Africa.

Methodology: A multi-tiered approach was used to understand the complexity of the ‘urban’ situation. A literature review was conducted to identify existing urban MNH programs, health policies and relevant stakeholders. A critical interpretive synthesis was conducted to better understand the context of the urban slum and its impact on program design and implementation. The findings were analyzed with the goal of identifying potential policy, program and implementation approaches to achieve impact at scale.

Results: Rapidly growing urban poor populations challenge the future of MNH. Innovative strategies around home-based care, care-seeking and access to facility-based services are necessary to address the complex needs of urban populations. Emerging from the MNH evidence-base as well as other sectors working in urban settings, recommendations were formulated for future programming.

Conclusion: Individual aspirations, community structures and health service delivery infrastructure vary widely within cities and across countries. Addressing the urban maternal and newborn health needs will require a shift from the traditional service delivery mode to innovative and comprehensive multipronged approaches.

Maternal and Neonatal Health in the Urban Slums of Bangladesh: Approaches of the Manoshi Program

Session: Maternal Newborn Health in Urban Settings

Presenter: Kaosar Afsana, BRAC
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Background: By 2050, two-thirds of the world’s population will live in urban areas and nearly 90% of this growth will be in Africa and Asia. In LMICs, over 860 million people are living in slums: 62% of urban residents in sub-Saharan Africa and 35% in south Asia are slum-dwellers. In many cities, MMR and NMR are much higher in slums than the urban average. Despite this massive urbanization, evidence on strategies for effective coverage of MNH interventions for the urban poor is extremely limited. Further analysis of strategic approaches, delivery structures, implementation frameworks, financial mechanisms, and roles of private and public partners is urgently needed. Saving Newborn Lives, in collaboration with Columbia University, conducted a global scoping of the status of MNH in urban settings focusing on south Asia and sub-Saharan Africa.

Methodology: A multi-tiered approach was used to understand the complexity of the ‘urban’ situation. A literature review was conducted to identify existing urban MNH programs, health policies and relevant stakeholders. A critical interpretive synthesis was conducted to better understand the context of the urban slum and its impact on program design and implementation. The findings were analyzed with the goal of identifying potential policy, program and implementation approaches to achieve impact at scale.

Results: Rapidly growing urban poor populations challenge the future of MNH. Innovative strategies around home-based care, care-seeking and access to facility-based services are necessary to address the complex needs of urban populations. Emerging from the MNH evidence-base as well as other sectors working in urban settings, recommendations were formulated for future programming.

Conclusion: Individual aspirations, community structures and health service delivery infrastructure vary widely within cities and across countries. Addressing the urban maternal and newborn health needs will require a shift from the traditional service delivery mode to innovative and comprehensive multipronged approaches.

The Role and Effect of Decentralization using Results-based Financing in Honduras

Session: Using Results Based Financing to Scale-up Changes for Maternal and Neonatal Health: What Have We Learned?

Presenter: Sandra Pinel, Ministry of Health, Honduras
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Background: Since 2004, the Ministry of Health of Honduras (SESAL) has been undergoing various phases of health-sector reform. Separating the stewardship role from the provision of services through decentralization has been fundamental in this process. As part of the reform, public funds managed by the SESAL are dispersed using results-based financing (RBF) mechanisms to primary-care decentralized management teams (Gestores). Currently the new model covers 1 million people.

Methodology: Gradually the SESAL began to decentralize primary healthcare services by contracting Gestores to provide a basic packet of services (BPS) in the poorest areas of the country, moving from contracts with individual health centers to “health networks” managed by the Gestores. Contracts are signed with Gestores based on a set of quality and coverage indicators, externally verified quarterly. Payment depends on capitation, in addition to providing an incentive for good performance (10%).

Results: Cost-effective analysis comparing traditional to RBF methods revealed the RBF model was more cost-effective (Measure Evaluation and Prodim, 2008), and Vellez, 2010 and Prado and Leno, 2010, both conclude that units with the BPS demonstrated higher levels of production and increased coverage of the target population. Coverage in hard-to-reach areas increased by 24%. Challenges include linking decentralized primary services with centralized secondary and tertiary services.

Conclusions: Decentralization has been proven effective in hard-to-reach areas; therefore, the SESAL is currently undergoing the process to scale up this model to 4.8 million people, in addition to applying to expanding the results-based focus to secondary levels of care.

Pursuing Universal and Effective Health Coverage through Results-Based Financing (RBF)

Session: Using Results Based Financing to Scale-up Changes for Maternal and Neonatal Health: What Have We Learned?

Presenter: Martín Sabignoso,Ministry of Health, Argentina
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Background: Programa SUMAR is a public health program implemented by the National Ministry of Health of Argentina which provides coverage to uninsured children, adolescents and adult women. The program started in 2004 as Plan Nacer, a maternal-child health program, focused on reducing gaps in access and quality of health services in the most disadvantaged provinces. In 2015 the Program will reach universal coverage by including men, providing explicit coverage to more than 14 million people.

Methodology: Programa SUMAR strengthens public universal coverage embodied in the National Constitution of Argentina. It guarantees a list of health services and provides funding through a Results-based financing model (RBF). The main goal is to improve access and quality of basic health services, while simultaneously strengthening the incentive framework to increase efficiency in the use of public health funds. The Program pursues a cultural change in the management of public health policy and aims to transform existing public coverage into effective universal health coverage.

Results: The Program has achieved high population coverage, reaching 9.4 million of beneficiaries in the whole country, representing 94% of the eligible population. 7,500 public health facilities are successfully engaged across the country with signed management agreements, currently working with high motivation. An external impact evaluation of the program was conducted by the University of Berkeley, revealing positive impacts in terms of early detection (pregnant beneficiaries from Programa SUMAR are identified earlier than non-beneficiaries), prenatal check-ups (pregnant women with Programa SUMAR received 16% more prenatal checks that uninsured pregnant women), as well as a significant reduction of low-birth weight children (23%), whose mothers had coverage from the program.

Conclusion: In the experience of Argentina, RBF programs focusing on the poor and maternal and child health can be successfully scaled-up to the national level and additional areas of health.

Results-based Aid: The Salud Mesoamérica 2015 (SM2015) Experience

Session: Using Results Based Financing to Scale-up Changes for Maternal and Neonatal Health: What Have We Learned?

Presenter: Ferdinando Regalia, Inter-American Development Bank
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Background: The Salud Mesoamérica 2015 Initiative (SM2015) is an innovative public-private partnership between the Bill & Melinda Gates Foundation (BMGF), the Carlos Slim Health Institute (ICSS), the Government of Spain, the Inter-American Development Bank (IDB) and the governments of the Central American countries and the State of Chiapas in Mexico. SM2015 works to reduce health equity gaps faced by extreme poverty populations of the Mesoamerican countries according to priorities established by the governments of the region.

Methodology: The SM2015 results-based financing (RBF) model uses money and independent measurement to change health-system incentives. The RBF model generates a new set of incentives to solve problems and achieve results, as a portion of grants are tied to independently verified results using external surveys conducted by the Institute of Health Metrics and Evaluation (IHME). Publication of results generates reputational incentives that can change current practices, while the financial incentive can be used by program managers for budget support in their programs.

Results: SM2015 donors provided US$114 million, leveraging nearly US$41 million in counter-part resources from country governments, for a total of US$155 million for the poorest populations in Mesoamerica. Countries who reach their goals receive 50 percent of their counterpart investment to use freely within the health sector. Demand-based technical assistance is also offered to countries. At the end of the first operation, which focused on system readiness, 4 of the 7 countries have met their externally verified goals, but all countries showed vast improvements in the permanent availability of critical inputs. Over 10 national policies were adopted or updated in the eight countries.

Conclusions: The model has demonstrated its effectiveness in improving process indictors; however, moving to the next phase of quality and coverage indicators will be more challenging. Lessons learned have been incorporated into SM2015, as well as traditional IDB programs.

Results-Based Financing to Improve Health Quality and Coverage in Hard-to-reach areas: The World Bank’s Experience in Africa

Session: Using Results Based Financing to Scale-up Changes for Maternal and Neonatal Health: What Have We Learned?

Presenter: Dinesh Nair, World Bank
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Background: RBF programs are a core part of World Bank’s efforts to improve maternal and child health, particularly in Africa. There are currently 31 countries implementing RBF programs, including several countries with nationwide programs. A total of US$2.5 Billion in funding from The World Bank Fund for the Poorest Countries (IDA) and Health Results Innovation Fund (HRITF) is supporting the programs jointly with in-country support from bilateral and multilateral partners.

Methodology: The World Bank invests extensively in learning from this RBF portfolio with over 40 impact evaluations and mixed method studies. In addition by attaching a premium to results, RBF projects provide unique opportunities to track verified operational data to draw inferences.

Results: Using data from the ongoing programs, this presentation will highlight evidence that well-designed and supervised RBF programs can achieve results. In Rwanda, the RBF program improved coverage and quality of health services and improved population health outcomes (Christel MJ Vermeersch, 2011). In Burundi, over just one year, births at health facilities rose by 25% and prenatal consultations went up by 20%. The introduction of the RBF program contrib-uted to the dramatic reduction in child mortality from 176 per 1,000 to 96 per 1,000 from 2005 to 2010.   (Robert Soeters, 2013). Additionally, operational data from Nigeria, Zimbabwe and Zambia show that this approach can make health systems more efficient and accountable whilst improving both the quantity and quality of maternal and child health services delivered. (Health Results Innovation Trust Fund, 2013)

Conclusions: Results Based Financing can be one of the options for countries embarking on health systems strengthening activities to improve the utilization and quality of maternal and child health services.

Sub-Saharan Africa’s Progress Towards MDGs 4 & 5: Do Changes in Coverage of Maternal and Child Health Interventions Enlarge or Lessen the Equity Gap?

Session: Equitable Coverage: Supporting Those Most Vulnerable

Presenter: Jean Christophe Fotso, Concern Worldwide
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Background: The Millennium Development Goals (MDGs) did not include any equity focus, yet for many regions of the developing world and sub-Saharan Africa in particular, inequities constitute major barriers to development. This paper examines trends in the coverage of key maternal, newborn and child health (MNCH) interventions, compares trends in coverage of interventions with changes in poor-rich gaps over time, and draws implications and lessons for applying an equity lens to programming.

Methods: All sub-Saharan African (SSA) countries with four Demographic and Health Survey (DHS) data points since the 1990s were included in the analysis. Three indicators are analyzed: modern contraceptive prevalence rate (MCPR), skilled birth attendance (SBA), and full vaccination. The rich-poor ratio, derived from the household wealth index recoded as tertiles, serves as the equity variable. We use population figures to generate weighted averages of aggregate indicators for West & Central Africa, Eastern & Southern Africa, and the region as a whole.

Results: SSA’s MCPR expanded steadily from 10% in the early 1990s to 24% in the 2010s. Encouragingly, the poor-rich gap shrank from nearly 5.1 to 2.3. SBA remained virtually stagnant at 45% until the mid-2000s, and jumped to 53% at the end the study period. The equity gap remained constant throughout the period at 3.1. The rapid increase in childhood vaccination coverage in the last 6-8 years offset the decline recorded in the 1990s. The gap between the rich and the poor remained low at around 1.6.

Conclusion: Improvements in MCPR have been achieved by narrowing the gap between the lowest and highest tertiles. Focused efforts are needed to address the persistent inequity in SBA and immunization by targeting the poor subgroups of the population. In the absence of targeting, progress towards the achievement of the targets of the health MDGs may be limited.

Strengthening Demand and Access to Healthcare with Focus on the Most Vulnerable

Session: Equitable Coverage: Supporting Those Most Vulnerable

Presenter: Adeodata Kekitiinwa, Baylor Children’s Clinical Center of Excellence, Uganda
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Background: SMGL undertook community-based activities in Uganda and Zambia to educate and engage families and community influentials, improve self-care, increase demand for services, and facilitate access to appropriate care. Two interventions focused on the most vulnerable: the provision of travel and service vouchers to poor women (Uganda) and building maternity waiting homes next to EmONC facilities for rural women (Zambia).

Methods: To address the first delay, SMGL focused on mobilizing, training, and deploying community health workers (CHWs) and leaders in both Uganda and Zambia as change agents in their catchment areas. To address the second delay, SMGL strengthened district transportation and communications networks, distributed means-tested travel and service vouchers, and refurbished/built maternity waiting homes.

Results: Over 5,000 CHWs were trained to conduct home visits to educate pregnant women, their families, and community leaders on the importance of facility delivery managed by a skilled birth attendant, and develop birth and savings plans. In Uganda, 15,655 clean birth kits containing a coveted receiving blanket were distributed at facilities to incentivize institutional deliveries. In Zambia, Chiefs were recruited and trained to become ‘Champions’ who would make facility deliveries normative in their chiefdoms. In remote areas, preexisting local transportation options were organized to transport women to facilities. Motorcycle operators—boda boda drivers—were enlisted in Uganda. Other transport innovations were utilized including motorcycle “Zambulances.” Distribution of means-tested travel and delivery-care vouchers contributed to a 62% increase in facility deliveries in Uganda. Maternity waiting homes were upgraded in Zambia to provide access to skilled care for women who live greater than two hours from an EmONC facility; facility deliveries increased by 35%. The met-need for EmONC services increased 25% in Uganda and 23% in Zambia.

Conclusion: SMGL successfully used community-based, equity-focused activities to increase demand and use of services by poor and rural women.