Report: Importance Of Keeping Promises To African Mothers
Report: Importance Of Keeping Promises To African Mothers
Over the past several decades the United Nations General Assembly, the World Health Assembly, the WHO Regional Committee for Africa and other international conferences have adopted a number of resolutions designed to promote the health of African women. National governments, working with their development partners in Africa, have also made global, regional and national commitments. The right to health is enshrined in several core international human rights treaties to which most countries in the African Region are State Parties. As previously stated in a report, specific to women’s health is the United Nations Convention on the elimination of All Forms of Discrimination Against Women (CEDAW), which specifies state obligations in the prevention of maternal morbidity and mortality, and the provision of appropriate health care services for women. All countries of the African Region are signatories to CEDAW. At the Regional level the African Charter on Human and People’s Rights (Banjul Charter), together with the Protocol to the African Charter on Human and People’s Rights on the Rights of Women in Africa, recognize the right to health of women and identify different measures to be taken by State Parties in ensuring full implementation of the instruments. At national level the right to health, which includes the health of women, has been enshrined in over 80% of the constitutions of countries in the African Region.
In 2000 the United Nations adopted the Millennium Declaration which sets eight Millennium Development Goals (MDGs) to be achieved by 2015 including: (a) MDG 5A which is specifically aimed at reducing maternal mortality by three quarters between 1990 and 2015; and (b) MDG 5B which aims to achieve universal access to reproductive health. It is important to note that the other goals also relate, directly or indirectly, to women’s health particularly MDG 3 which seeks to promote gender equality and the empowerment of women, and MDG 4 which targets the reduction of child mortality. More recently, in May 2010, the World Bank announced a five-year Reproductive Health Action Plan to reduce maternal deaths, and fertility rates in 58 low-income countries. Under the plan the Bank pledges to increase its lending to help expand access to contraception, antenatal care and education for women and girls. The lending will also help provide training for health workers on the common causes of maternal death.
African countries have also made numerous regional and sub regional commitments to improving women’s health, the most recent of which is the Campaign for Accelerated Reduction of Maternal Mortality in Africa (CARMMA) launched in May 2009 with the slogan – Africa Cares: No woman should die while giving life. The African Union, in collaboration with UNFPA, UNICEF, and WHO, had launched CARMMA in 34 countries in the Region by the end of 2011.
However, despite the impressive roll call of conventions and initiatives, only a few of which are mentioned here, the good intentions have often failed to result in change. This is true, for example, of The Safe Motherhood Initiative that was launched at a conference in Nairobi, Kenya, in 1987, calling for the halving of maternal mortality by the year 2000 and urging countries to improve the status and education of women. Following the Nairobi meeting, many African countries made commitments to reduce maternal mortality and morbidity, and initiated National Safe Motherhood Programmes, but little concrete progress was achieved.
While many countries review and revise their laws and policies, for example to conform to the MDG declarations, a large gap still exists between stated policy priorities and the financial commitments required for implementation. Progress has been particularly disappointing with regard to maternal mortality reduction. One way of gauging this is to look at progress on MDG 5 requiring an average 5.5% annual reduction of maternal mortality between 2000 and 2015. In the African Region, the actual annual average reduction over the period between 1990 and 2010 was 2.7%. By 2010, only two countries in the African Region were on track to achieve MDG 5.
At a meeting of the African Union in Kampala in July 2010, leaders again made pledges, this time to invest more in community health workers and to re-commit to the Abuja Declaration target on health spending. As noted before, to date, only seven countries are meeting their Abuja Declaration target. Some leaders at the Kampala summit expressed concern about lacking the resources to be able to prioritize health care, and funding is clearly an issue.
African leaders at the Kampala Summit also pledged to reduce OOP health care expenditure stating their intention to do so through strategies such as free provision of obstetric care and care for children under five. One way to ensure that these decisions are fully implemented at the national level would be to introduce monitoring mechanisms. African leaders could also help by publicly setting and announcing time frames with clear deadlines for achieving the targets in the run-up to the 2015 MDG deadline.
Evidently, building and staffing new clinics alone will not be enough. As stated in Chapter 1, there is need for a change in thinking about health system design, with greater emphasis on a primary health care (PHC) approach informed by the principles of social justice, equity, solidarity, effective community participation and multisectoral action.
The prevailing tiered pyramidal health systems in which health facilities typically provide rudimentary care at the base are failing to meet the needs of African women many of whom are actually excluded from the care provided in sophisticated urban hospitals by distance, cost and subtle barriers such as staff attitudes towards the rural poor.
The optimal system design for the delivery of maternal health services in the African Region comprises two levels providing basic and comprehensive obstetric care.35 This is because even basic obstetric care, if delivered effectively at the time of need, can save lives. The failure of district hospitals to provide life-saving treatment for obstetric emergencies – part of the so-called “third delay” in care – has contributed largely to the high maternal mortality ratios in the African Region.
The importance of PHC approaches to the delivery of health care in Africa is now understood as evidenced by the adoption of the Ouagadougou Declaration on Primary Health Care and Health Systems in Africa which was endorsed by the Regional Committee for Africa in 2008 and which re-affirmed the principles of the 1978 Alma Ata declaration. However, much remains to be done in terms of political will and political commitment if the Ouagadougou Declaration is not to become just another declaration on a list of declarations dating back to several decades. There are also signs that maternal health care is now being prioritized in some places. According to the World Health Organization, over the past three years concerted maternal and perinatal death reviews have started in 27 countries in the Region, while 17 countries have started the work of improving the skills of health workers in essential newborn care using WHO course materials. WHO has also published a guide to clinical practice of emergency obstetric and newborn care and “homebased” newborn care training materials for community health workers.
User Fees Penalize Poor Women
Obviously, even physically accessible, properly equipped and adequately staffed clinics and hospitals will do little to serve the health needs of African women unless the women themselves feel they can actually walk in to seek help. Where a woman has to pay out of her own pocket to see a doctor, she may forego medical consultation until it is too late to provide effective treatment. User fees were introduced in most African countries in the aftermath of the global recession in the 1970s, which resulted in structural adjustment policies restricting government expenditures.
An influential World Bank report published in 1987 suggested that charging fees was not only a good way to generate revenue, but would reduce overuse and encourage the provision of services at low charges and costs. The report also argued that user fees would improve equity because the money raised in cities and towns could be used to subsidize the poor in rural areas. However, as already noted before, the African experience with user fees has not been positive.
User fees were introduced in a number of countries in the 1980s and 1990s, in any cases as part of conditions for the granting of loans by the World Bank and International Monetary Fund. In 2007, 90% of global financial catastrophe (defined as the forced disbursement of more than 40% of household income after basic needs have been met) resulting from user fees occurred in the Region where borrowing and the sale of assets to finance health care are common practices. Even when the fees charged are quite low they can discourage the use of health services. In this regard, a recent study in Kenya showed that introducing a US$ 0.75 fee for previously free insecticide-treated bed nets reduced demand by 75%.
The barrier to access created by user fees presents a particular problem for women in the African Region because they are often dependent financially on men. As a result, their access to purchased health services depends on men’s decisions on how financial resources are to be used. The effect of such gender imbalance is greatly amplified in cultural contexts where fear of divorce or abandonment, violence, or stigma prevents women from using reproductive health services.
The alternative to user fees is some form of pooling of financial resources so that the risk of paying for health care is borne by all members of the pool and not only by the individual when she or he falls ill. For pooling to materialize, funds must be prepaid either in the form of taxes or insurance contributions. Some African countries, notably Ghana and Rwanda, have already started to move in this direction, and there are many examples worldwide of low- and middle-income countries that have adopted prepayment and pooling as the basis for financing universal health care.
However, it should be noted that the problem posed by user fees cannot be solved by simply dropping them. When Uganda abandoned user fees in 2001 the incidence of catastrophic health spending among the poor did not fall immediately, the most likely explanation being that frequent unavailability of medicines at government facilities after 2001 forced some patients to go to private pharmacies. Without proper planning the abandonment of user fees can also lead to an increase in the charging of unauthorized user fees by health workers.
Therefore, the transition must be handled with care if policy makers want to prevent unpaid staff abandoning clinics. A recent UNICEF study of six sub-Saharan countries that have discontinued user fee payment revealed that the process is facilitated where there is clear leadership from high up in the political establishment, and where there has been dialogue between political leaders and national technicians. Where politicians have been tempted to abandon fees too quickly, often for political reasons, technicians have sometimes struggled with the formulation and implementation of reform. According to WHO, 17 countries in the Region have removed financial barriers to emergency obstetric and newborn care since 2008.
World Health Report