Sustainable Development Goal 10, to reduce inequality within and among countries, stands out as one of the most pressing and challenging obstacles of our generation. Since the Alma Ata Declaration was signed in 1978, countries have struggled to provide primary health care in an equitable manner. Communities in poverty are consistently excluded from national and global health programming, and we cannot discuss an improvement in maternal and child health without dealing squarely with the problem of inequity.
Dr. Ulla Larsson in Ethiopia saw this problem head-on when she led a mobile maternal and child health clinic in Addis Ababa. The clinic focused on low-income communities and provided vaccinations for children, basic ante-natal consultation and health education programming in the form of lectures on adequate sanitation and nutrition practices. As part of the public health programming, the organization handed out free powdered milk supplies from UNICEF to mothers to supplement their children’s diets. The mobile clinic was well attended, until the powdered milk supplies ran out. Suddenly, mothers stopped coming to the lectures.
Why did women stop attending a health clinic when they no longer received milk supplements? The answer is simple: poverty. Dr. Larsson lamented that the educational mission of her mobile clinic failed, but how were her patients expected to appropriate the lessons of the health curriculum without a change in their means or livelihood? Women could not afford to give their children more nutritious food, especially without the handout of milk. So there was little purpose in attending a lecture on improving child nutrition when they had no means to do so.
The story of Dr. Larsson’s clinic is actually very old: the clinic operated in Addis in the late 1960s, but the impact of poverty on maternal health choices has remained a persistent problem. Too often, RMNCH programming, especially information and sensitization campaigns, neglect the impact of livelihood constraints on women’s health seeking behaviors.
Dr. Asfaw Desta, a 50-year veteran of public health education and policy planning in Ethiopia, has learned this lesson time and again in his decades of experience in public service. He explained to me that as public health educators, while “we tell people to use soap to wash and be cleaner, and nutritional advice to eat better, they used to say: ‘We know that, give us the means and we can provide ourselves with the soap and nutritional foods you’re talking about.’ The means. It was very challenging to hear people say that. When you tell them about what to do – they know what to do, but they don’t have the means.”
Moving forward into the next phase of post-MDG programming, we must learn from the past, and avoid the repeated mistakes of expecting health policies to operate the same across different economic classes. The promotion of equity through poverty reduction (SDG #1) is paramount in the fight for improved maternal health. Further, if we are going to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030 (SDG #3.1), there is a need to target programming to the poorest women who are traditionally excluded from health services. At the upcoming Global Maternal Newborn Health Conference, discussions must focus on the poorest women, and their unique financial and non-financial barriers to accessing maternal health services. We cannot expect mothers to radically improve their health and nutrition status without providing them the means to do so.
Photo: “Ethiopia 3” © 2012 Swathi Sridharan/ICRISAT, used under a Creative Commons Attribution license: http://creativecommons.org/licenses/by/2.0/