Informing maternal and child health policies through research
Dr Queen Dube, chief of health services at Malawi’s Ministry of Health, says that “Africa does not have a shortage of policies. The challenge is how we implement the policies.” And that, she says, requires evidence. As a decision-maker, Dube was co-principal investigator (Co-PI) on an Innovating for Maternal and Child Health in Africa (IMCHA) project that aimed to integrate a package of interventions to reduce neonatal mortality in Malawi.
Like Dube, each of IMCHA’s 28 research projects included a Co-PI decision-maker. Whether they were at the district, regional, or national level depended on the project’s intervention coverage. They all worked closely with the other members of their respective teams to shape the research. They also played an important role in project implementation and in knowledge translation for the uptake of evidence into policy and practice.
Burkina Faso: monitoring policy implementation
In April 2016, Burkina Faso became one of the first African countries to introduce a national policy for universal and free health care for pregnant women, mothers with newborns, and children under five. This was followed in 2018 by the adoption of a universal health-insurance program and a policy to include family planning in the package of the free health-care services. The IMCHA research team set out to provide the Ministry of Health with analyses to help monitor the impact of these policies on equity, quality, and cost. The Ministry’s Technical Secretary for Universal Health Care was a member of the research team.
Over three years, the multidisciplinary team worked in communities in eight health districts, assessing the implementation of the free health-care and family-planning policies and their impact on the population, particularly in rural areas. Issues of gender and inclusion were analyzed in terms of services delivered, quality of care, and women’s decisions on matters such as family planning.
The team found that the free health-care policy had been effectively implemented and that most maternal and child health indicators had improved. For example, more women delivered with a skilled attendant, reaching 85% in 2017, and there were fewer miscarriages and neonatal deaths. Under-five visits to health facilities doubled between 2015 and 2018. The introduction of free contraceptive methods provided women with expanded choices to space their children and plan their family.
But although free health care had increased vulnerable women’s access to care, the team noted that, on its own, this was not enough to overcome entrenched gender barriers: women still needed their male partner’s permission to seek care. The evidence shows that decision-makers need to develop non-health policies that address challenges posed by broader social, cultural, and gender norms to promote women’s empowerment and decision-making power.
Ethiopia and Mozambique: cause-of-death data leads to life-saving programs
In Ethiopia, about 220,000 children and women of reproductive age die every year. For most, the cause of death (CoD) is not documented due to the weak civil registration and vital statistics (CRVS) system. This makes it difficult for the Government of Ethiopia to do effective health planning and allocate appropriately needed resources and services, at both national and sub-national levels of the health system.
To support Ethiopia’s efforts to strengthen the CRVS system and improve maternal and child health, an IMCHA research team conducted a systematic review of CoD data from 1990 to 2016 and generated a national open-source catalogue of maternal, neonatal, infant, and under-five mortality. This review ― Ethiopia’s first-ever representative data on the causes of maternal, neonatal, infant, and under-five deaths ― enabled the team to identify the major causes of death in those population groups.
Summarized in an article and presented to the federal Minister of Health and the National Advisory Council, this data fed into the Ministry’s decision to make reducing maternal post-partum hemorrhage a national priority. The research team also discussed the use of misoprostol ― recommended by the World Health Organization to prevent post-partum hemorrhage ― and other procedures with decision-makers. As a result, the Ministry of Health is pilot-testing misoprostol in selected areas of the country.
The project also piloted a low-cost, high-quality CoD data-collection and monitoring system suitable for low-resource settings, as well as a simple, innovative e-platform to decrease the cost of CoD surveys, while increasing their quality and feasibility. The platform was customized to capture information at health facilities, as well as through verbal autopsies ― accounts of deaths gathered through interviews with members of the household of the deceased. As a result, verbal autopsies are now widely accepted and used as an integral component of Ethiopia’s national CoD database.
In Mozambique, the same team built on its research in Ethiopia to improve facility-based reporting of child, maternal, and adult CoD in health facilities. The first steps were to understand how deaths were registered and certified medically, how the registration forms flowed from facilities to civil registration offices, and what challenges clinicians experienced with those processes.
In collaboration with the Ministries of Health and Justice, the team then developed a simplified national notification, certification, and registration process that provides the information needed by both ministries. The team also elaborated a customized electronic medical death-certification course applying international standards for CoD certification for Ministry of Health staff, health leaders, and physicians. Obtaining buy-in while ensuring that the course is aligned to the needs of the Ministry was critical to the course’s sustainability.
This new, universal national process, together with the availability of trained health professionals to apply international standards to report on CoD, will provide Mozambique’s decision-makers with the robust data they need to determine CoD and decide on health-care priorities and policies to address them.
Research findings help drive change
These and other IMCHA projects show how collaboration between researchers and decision-makers can help drive change. Research does not, by itself, save lives, but it contributes to showing what works and what doesn’t. Addressing deficiencies in knowledge is critical to improving outcomes, whether by providing evidence of a policy’s effectiveness (or lack thereof), as in Burkina Faso, or by identifying gaps in the information that decision-makers need to implement programs that address CoD, as shown in Ethiopia and Mozambique.
These projects are just three examples of how collaboration between researchers and decision-makers in IMCHA’s 19 research teams has led to greater access to health care, improved maternal and child health-care services, and better trained health personnel. The key is generating evidence and bringing that knowledge to bear on services, programs, and policies at community, health facility, health system, and policy levels.
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IMCHA projects show how collaboration between researchers and decision-makers can help drive change
Addressing deficiencies in knowledge is critical to improving health outcomes