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The Lancet Maternal Health Series: External Shocks and Health System Innovations

By: Sarah Hodin, Project Coordinator II, Women and Health Initiative, Harvard T.H. Chan School of Public Health

The Lancet Maternal Health Series published in September 2016 contains six papers highlighting the importance of improving access to high quality maternal health care for all women across the globe. In paper 5, “Next generation maternal health: External shocks and health-system innovations,” Kruk and colleagues discuss how social, political, environmental and demographic changes will influence the future of global maternal health and highlight key health system innovations with potential for large impact.

External shocks

The authors review a number of rapid societal and health system changes or “external shocks” that are anticipated over the next two decades, focusing on those that they believe will have the greatest influence on maternal health.

Rise in domestic health financing

In the coming years, external donor funding and international aid for health financing is projected to decline, and low- and middle-income countries (LMICs) in particular will need to boost domestic financing. Despite evidence that spending on health is a wise investment, many countries lack the political will to allocate sufficient resources. The vast majority of countries in sub-Saharan Africa, for example, designate less than 15% of their national budgets to health. While initiatives such as the Global Financing Facility offer hope for continued financial investment, LMICs will need to prioritize maternal health to improve access, utilization and quality of care.

Shifts in governance for health

Under the Millennium Development Goals, maternal health was a stand-alone goal. Now that the world has transitioned to the Sustainable Development Goals, maternal health is just one focus area within the broader goal to “ensure healthy lives and promote wellbeing for all at all ages.” Continued prioritization of maternal health is crucial given this broader framework. Furthermore, there has been a trend towards fragmentation in governance and financing related to maternal health: For example, the introduction of related initiatives focused on newborns, adolescents, family planning and nutrition, while important, may complicate priority setting and dilute funding for maternal health programs. Ensuring the synergy of reproductive, maternal, newborn, child and adolescent health efforts will amplify collective impact.

Urbanization

According to the United Nations, about 66% of the world’s population will live in urban areas by 2050. Fifteen years ago, 39% of births occurred in urban areas; The authors project that in 2030, that figure will rise to 52%. Urbanization carries a number of benefits for pregnant women including reduced travel time to health facilities and a higher ratio of well-trained providers to patients. However, the rich-poor gap can be even larger in cities compared to rural areas. Additionally, many families move from rural areas to urban slums, where quality of care and people’s overall health status tend to be poor. To respond to the effects of urbanization, countries will need to strengthen their health systems and prepare for higher demand for services in cities.

Emergencies

Infectious disease outbreaks, armed conflict and natural disasters due to climate change create a double burden by increasing the demand for health services and decreasing the capacity of health systems to provide those services. Pregnant women and children are disproportionately affected by such humanitarian crises. One study found that the maternal mortality ratios (MMRs) of countries in Sub-Saharan Africa that recently experienced armed conflict were 45% higher than those that did not. Following the Ebola virus outbreak, maternal mortality has risen dramatically in Guinea, Liberia and Sierra Leone, whose current MMR is approximately 1,360 deaths per 100,000 live births. More recently, the Zika virus has created unique challenges related to women’s sexual and reproductive health and rights. Health systems must become more resilient to ensure that women and children receive the care they need during emergencies.

Health-system innovations

Universal health coverage

The goal of universal health coverage (UHC) is to ensure that everyone, regardless of socioeconomic status, receives essential health services without suffering financial hardship. UHC has the potential to improve maternal health by expanding coverage of maternity services, as well as access to care for chronic illnesses, non-communicable diseases and other conditions affecting women before, during and after pregnancy. Countries including Mexico and Rwanda have improved poor women’s access to health services by instituting national health insurance programs. However, the authors astutely point out that access alone will not improve outcomes: Quality of care is also critical.

Behavioral economics

Evidence from behavioral economics illustrates the power of psychological factors in driving decision-making. People do not always make informed, rational decisions, especially those experiencing the daily stresses associated with poverty. Public health professionals can help address this challenge by implementing programs that encourage people to make better decisions about their health. Strategies include using a default choice, framing information differently and providing economic incentives such as cash transfers. Such programs need to be rigorously evaluated in diverse contexts.

mhealth

Mobile health or “mhealth” is a relatively new field that leverages the growing accessibility of cell phones around the world, even in low-resource settings. Many countries, communities and health facilities have integrated mhealth into patient education interventions, data collection systems and performance-based payments for providers. Additional research evaluating the effectiveness of such programs is needed to better understand how these strategies can help improve maternal health.

Read summaries of other papers in The Lancet Maternal Health Series.

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