chapter seven reconciling maternal, newborn and child health with health system development This last chapter looks at the place of maternal, newborn and child health within a wider context of health system development. Today, maternal, newborn and child health are no longer discussed in purely technical terms, but as part of a broader agenda of universal access. this frames it within a straightforward political project: responding to society s demand for the protection of the health of citizens and access to care a demand that is increasingly seen as legitimate REPOSITIONING MNCH on Population and Development(ICPD). Third, there is Maternal and child health programmes have long lacked a clear stra- now a general consensus that MNCH programmes will tegic focus and a consistent policy articulation (1). Tensions between be effective only if a continuum of care is established programmes that concentrate on the health needs of mothers and within strengthened health systems those developed for their children have proved counterproductive for This forces programmes with different histories, strat oth: sets of distinct, legitimate needs had often turned into com- egies and constituencies to work together and to tackle peting demands for care and attention(2) Programmes for women the dilemma of competition for the attention of decision and children have now been repositioned. First, the specific needs of makers and donors. Funding for maternal, newborn and newborns are now recognized: this has led to the introduction of an child health is difficult to track it tends to be diluted N for newborn into the well-worn acronym of MCH so that it becomes within the overall health system and fragmented in MNCH. Second, it is now generally acknowledged that the interests of juxtaposition of programmes and initiatives. For all the mother and child are closely intertwined, and that the MNCH agenda rhetoric about integration, donors and agencies have cannot be separated from the right of access to reproductive health shown little interest in smoothing out the evident distor care for all which was promoted by the Cairo Intemational Conference tions within the funding envelopes, and in particular the
125 chapter seven reconciling maternal, newborn and child health with health system development This last chapter looks at the place of maternal, newborn and child health within a wider context of health system development. Today, maternal, newborn and child health are no longer discussed in purely technical terms, but as part of a broader agenda of universal access. This frames it within a straightforward political project: responding to society’s demand for the protection of the health of citizens and access to care, a demand that is increasingly seen as legitimate. REPOSITIONING MNCH Maternal and child health programmes have long lacked a clear strategic focus and a consistent policy articulation (1). Tensions between programmes that concentrate on the health needs of mothers and those developed for their children have proved counterproductive for both: sets of distinct, legitimate needs had often turned into competing demands for care and attention (2). Programmes for women and children have now been repositioned. First, the specific needs of newborns are now recognized: this has led to the introduction of an N for newborn into the well-worn acronym of MCH so that it becomes MNCH. Second, it is now generally acknowledged that the interests of mother and child are closely intertwined, and that the MNCH agenda cannot be separated from the right of access to reproductive health care for all which was promoted by the Cairo International Conference on Population and Development (ICPD). Third, there is now a general consensus that MNCH programmes will be effective only if a continuum of care is established within strengthened health systems. This forces programmes with different histories, strategies and constituencies to work together and to tackle the dilemma of competition for the attention of decisionmakers and donors. Funding for maternal, newborn and child health is difficult to track: it tends to be diluted within the overall health system and fragmented in a juxtaposition of programmes and initiatives. For all the rhetoric about integration, donors and agencies have shown little interest in smoothing out the evident distortions within the funding envelopes, and in particular the
126 The World Health Report 2005 Box 7.1 International funds for maternal, newborn and child health External Official Flows(EOF)on health from 2000-2002. The share of EOF going to control. It is not possible to disaggregate rants and loans increased from USS 3. 2 to population and reproductive health, which these funds so as to ascertain the evolution USS 6.3 billion between 1990 and 2002 (in includes support to maternal health, increased of funding intended for child health, but it is constant 2002 USS), which equates to a rise from 30% to 39%. This corresponds to a likely that funding actually increased, albeit from USS 0.62 to USS 0.88 per capita. These doubling of funding, from USS 1 billion to USS 2 in a less visible and traceable way. Private amounts do not include spending on sectors billion per year (in constant 2002 USS)between international funding for child health through such as water and sanitation, or spending on 1990-1992 and 2000-2002. This is mainly a nongovernmental organizations and large health in the context of budget support pro- result of increases for programmes targeting foundations, such as the Bill Melinda Gates tion of global health expenditure(0.4-0.6%, AIDS. Some 4% of EOF for health were directed by smaller private foundations on child excluding the 22 richest OECD countries' total to such programmes in 1990-1992, compared health decreased, but their global impact on nditures), in many countries it is of with 19%(nearly USs 1. 4 billion per year) in child health is relatively small For national strategic importance, for two reasons. First, 2000-2002. Funds allocated to family planning programme managers the dilution of child because the average masks a huge variation nd other reproductive health care areas, which health funds in system or sectoral support in some countries external resources repre clude maternal health, decreased both in channelling through vertical sub-programmes sent a very large percentage (38% in Niger in relative and absolute terms such as the polio eradiation efforts, and 2002, for example). Second, because within The proportion allocated to basic health increased channelling of external aid through the health sector some areas depend almost care has increased from 23% to 37%(Uss international nongovemmental organizations exclusively on donors. This is the case for child 0. 14 to Uss 0.32 per capita)between 1990 health in most poor African countries (5). 1992 and 2000-2002. Most of the increase to and control over resources needed for Allocation of resources by sector changed was committed to basic and primary health the development of integrated child health ignificantly between 1990-1992 and care programmes and infectious disease programmes have actually diminished (5) External official aid flows for health between 1991 and 2001 9%0.171 Population policies/programmes 5%0038 6%02口 STI control including HIV/AIDS Reproductive health care 37%0.278 24%028口 Family planning 当 0347%0294 0.2 37%034口e 23%0.14 1990-1992 1995-1997 2000-2002 Data source: OECD DAC statistical database I Made up mostly of Official Development Assistance, but also including Other Official Flows(loans)as described in the OECD DAC statistical
126 The World Health Report 2005 2000 –2002. The share of EOF going to population and reproductive health, which includes support to maternal health, increased from 30% to 39%. This corresponds to a doubling of funding, from US$ 1 billion to US$ 2 billion per year (in constant 2002 US$) between 1990–1992 and 2000–2002. This is mainly a result of increases for programmes targeting sexually transmitted infections, including HIV/ AIDS. Some 4% of EOF for health were directed to such programmes in 1990-1992, compared with 19% (nearly US$ 1.4 billion per year) in 2000–2002. Funds allocated to family planning and other reproductive health care areas, which include maternal health, decreased both in relative and absolute terms. The proportion allocated to basic health care has increased from 23% to 37% (US$ 0.14 to US$ 0.32 per capita) between 1990– 1992 and 2000–2002. Most of the increase was committed to basic and primary health care programmes and infectious disease External Official Flows (EOF)1 on health from grants and loans increased from US$ 3.2 to US$ 6.3 billion between 1990 and 2002 (in constant 2002 US$), which equates to a rise from US$ 0.62 to US$ 0.88 per capita. These amounts do not include spending on sectors such as water and sanitation, or spending on health in the context of budget support programmes. Although globally this is a small fraction of global health expenditure (0.4–0.6%, excluding the 22 richest OECD countries’ total health expenditures), in many countries it is of strategic importance, for two reasons. First, because the average masks a huge variation: in some countries external resources represent a very large percentage (38% in Niger in 2002, for example). Second, because within the health sector some areas depend almost exclusively on donors. This is the case for child health in most poor African countries (5). Allocation of resources by sector changed significantly between 1990 –1992 and control. It is not possible to disaggregate these funds so as to ascertain the evolution of funding intended for child health, but it is likely that funding actually increased, albeit in a less visible and traceable way. Private international funding for child health through nongovernmental organizations and large foundations, such as the Bill & Melinda Gates Foundation, has also increased (6). Spending by smaller private foundations on child health decreased, but their global impact on child health is relatively small. For national programme managers the dilution of child health funds in system or sectoral support, channelling through vertical sub-programmes such as the polio eradiction efforts, and increased channelling of external aid through international nongovernmental organizations, have led to a perception that their access to and control over resources needed for the development of integrated child health programmes have actually diminished (5). Box 7.1 International funds for maternal, newborn and child health External official aid flows for health between 1991 and 2001 Data source: OECD DAC statistical database. 0.141 STI control including HIV/AIDS 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 1990–1992 0.294 0.076 0.073 0.022 23% 47% 12% 12% 4% 2% US$ per inhabitant per year 0.282 1995–1997 0.278 0.045 0.079 0.038 37% 37% 6% 10% 5% 4% 0.034 0.324 2000–2002 0.208 0.067 0.052 0.171 37% 24% 8% 6% 19% 6% 0.054 Reproductive health care Policies, management, training and research on reproductive health Family planning General health Basic health care Population policies/programmes and reproductive health cation and collaboration among organizations beginning to work in newborn health. The new Child Survival Partnership intends to galvanize global and national commitment and action for accelerated reduction of child mortality worldwide. All three put their work in a context of poverty reduction, equity, and human rights. They collaborate closely to ensure a coordinated approach to the continuum of care and universal coverage with cost-effective interventions at the country level. The first function of these partnerships is to stimulate and sustain the political will to keep the maternal, newborn and child health agenda as a central priority. They do so through dialogue at the highest level of government. As many countries have to step up their efforts in combating exclusion, monitoring inequities in maternal, newborn and child health and uptake of services, as well as tracking resources flows have become matters of prime concern (8, 9). By keeping track of progress made, the partnerships can help to hold countries and their partners accountable (10). Against the backdrop of slow progress towards the Millennium Development Goals concerning maternal and child health, the need for an urgent, global coordinated response has prompted several agencies and international organizations to join forces and create partnerships for maternal, newborn and child health. Over the past few decades, it has become clear that the support required for the development of a resource-constrained country is so multifaceted and complex, that it cannot be successfully taken on by one agency alone (7). Within the field of maternal, newborn, and child health, three partnerships are currently active: the Partnership for Safe Motherhood and Newborn Health, the Healthy Newborn Partnership, and the Child Survival Partnership. The recently established Partnership for Safe Motherhood and Newborn Health aims to strengthen and expand maternal and newborn health efforts. The Healthy Newborn Partnership has been established to promote awareness and attention to newborn health, exchange information, and improve communiThe partnerships can also assist in bridging the gap between knowledge and action (11) by facilitating the interaction between policy-makers, researchers, funders and other stakeholders who can influence the uptake of research findings – and reorient research towards solving the operational and systemic constraints that hold back the scaling up of effective interventions. Finally, the partnerships can help bring together the various parties involved in maternal, newborn and child health (ministries of health, finance and planning, national nongovernmental organizations, health professional groups, donor agencies, United Nations agencies, faith-based groups and others), or provide technical support to existing coordination mechanisms. This creates national partnerships through which funding, planning and implementation of national and subnational maternal, newborn and child health plans can be accelerated (12). Box 7.2 Building pressure: the partnerships for maternal, newborn and child health 1 Made up mostly of Official Development Assistance, but also including Other Official Flows (loans) as described in the OECD DAC statistical database (www.oecd.org/dac/stats)
reconciling maternal, newborn and child health with health system development 127 disappointing contributions for maternal health and family planning within reproduc tive health funding (3, 4)(see Box 7.1) In contrast to the route chosen by the advocates of a number of other major public health priorities, such as malaria, tuberculosis or HIV/AIDS, champions of maternal newborn and child health -including the various global partnerships(see Box 7.2) prefer to tap into the greater funds available for overall health sector development rather than to create new, parallel funding mechanisms. Whether this is for tactical reasons or for more fundamental considerations, it fits well with the growing impor tance of the health sector reform movement (13 ). The emphasis on health sector development as the platform for maternal, newborn and child health coincides with the recognition among key multilateral and bilateral donors that poverty reduction is the primary goal of development assistance(14). It comes at a moment when the wave of health care reforms in the aftermath of primary health care, rooted in a neo- liberal ideology of rolling back the presence of the state, is well under way. These re- forms were promoted in contexts of transition from socialist to market economies-in countries such as Mongolia or Tajikistan-and of rebuilding services in post-conflict areas such as Cambodia, or as part of the structural adjustment programmes of many African and Asian countries that were facing severe resource crunches MNCH conse- quently evolves in a context dominated by discussions on the role and responsibility of the state in tackling underfunding of the health sector, accessibility of services inequities and exclusion, inefficiencies, and lack of accountability he result is that maternal, newborn and child health can no longer be framed in purely technical terms. The appearance of a shared commitment to solving health sector problems that are obviously relevant to maternal, newborn and child health contributes to the assumption that MNCh policy interests are synonymous with those Box 7.2 Building pressure: the partnerships for maternal, newborn and child health Against the backdrop of slow progress towards cation and collaboration among organizations The partnerships can also assist in bridg the Millennium Development Goals concern- beginning to work in newborn health. The new ing the gap between knowledge and action ing maternal and child health, the need for Child Survival Partnership intends to galvanize (11)by facilitating the interaction between an urgent, global coordinated response has global and national commitment and action for policy-makers, researchers, funders and other prompted several agencies and international accelerated reduction of child mortality world- stakeholders who can influence the uptake ganizations to join forces and create partner- wide. All three put their work in a context of of research findings-and reorient research ships for maternal, newborn and child health. poverty reduction, equity, and human rights. towards solving the operational and systemic Over the past few decades, it has become They collaborate closely to ensure a coordi- constraints that hold back the scaling up of clear that the support required for the devel- nated approach to the continuum of care and effective interventions. opment of a resource-constrained country is universal coverage with cost-effective inter Finally, the partnerships can help bring together the various parties involved in mater- ncy alone The first function of these partnerships is to nal, newbom and child health(ministries of (7). Within the field of maternal, newborn, and stimulate and sustain the political will to keep health, finance and planning, national non- child health, three partnerships are currently the maternal, newbom and child health agenda governmental organizations, health profes active: the Partnership for Safe Motherhood as a central priority. They do so through dia- sional groups, donor agencies, United Nati Partnership, and the Child Survival Partner- many countries have to step up their efforts in provide technical support to existing coordina- ship. The recently established Partnership combating exclusion, monitoring inequities in tion mechanisms. This creates national part- for Safe Motherhood and Newborn Health maternal, newborn and chid health and uptake nerships through which funding, planning and ms to strengthen and expand matemal and of services, as well as tracking resources flows implementation of national and subnational newborn health efforts. The Healthy Newborn have become matters of prime concern(8, maternal, newborn and child health plans can Partnership has been established to promote 9). By keeping track of progress made, the be accelerated (12) awareness and attention to newborn health, partnerships can help to hold countries and xchange information, and improve communi- their partners accountable (10)
reconciling maternal, newborn and child health with health system development 127 disappointing contributions for maternal health and family planning within reproductive health funding (3, 4) (see Box 7.1). In contrast to the route chosen by the advocates of a number of other major public health priorities, such as malaria, tuberculosis or HIV/AIDS, champions of maternal, newborn and child health – including the various global partnerships (see Box 7.2) – prefer to tap into the greater funds available for overall health sector development rather than to create new, parallel funding mechanisms. Whether this is for tactical reasons or for more fundamental considerations, it fits well with the growing importance of the health sector reform movement (13). The emphasis on health sector development as the platform for maternal, newborn and child health coincides with the recognition among key multilateral and bilateral donors that poverty reduction is the primary goal of development assistance (14). It comes at a moment when the wave of health care reforms in the aftermath of primary health care, rooted in a neoliberal ideology of rolling back the presence of the state, is well under way. These reforms were promoted in contexts of transition from socialist to market economies – in countries such as Mongolia or Tajikistan – and of rebuilding services in post-conflict areas such as Cambodia, or as part of the structural adjustment programmes of many African and Asian countries that were facing severe resource crunches. MNCH consequently evolves in a context dominated by discussions on the role and responsibility of the state in tackling underfunding of the health sector, accessibility of services, inequities and exclusion, inefficiencies, and lack of accountability. The result is that maternal, newborn and child health can no longer be framed in purely technical terms. The appearance of a shared commitment to solving health sector problems that are obviously relevant to maternal, newborn and child health contributes to the assumption that MNCH policy interests are synonymous with those cation and collaboration among organizations beginning to work in newborn health. The new Child Survival Partnership intends to galvanize global and national commitment and action for accelerated reduction of child mortality worldwide. All three put their work in a context of poverty reduction, equity, and human rights. They collaborate closely to ensure a coordinated approach to the continuum of care and universal coverage with cost-effective interventions at the country level. The first function of these partnerships is to stimulate and sustain the political will to keep the maternal, newborn and child health agenda as a central priority. They do so through dialogue at the highest level of government. As many countries have to step up their efforts in combating exclusion, monitoring inequities in maternal, newborn and child health and uptake of services, as well as tracking resources flows have become matters of prime concern (8, 9). By keeping track of progress made, the partnerships can help to hold countries and their partners accountable (10). Against the backdrop of slow progress towards the Millennium Development Goals concerning maternal and child health, the need for an urgent, global coordinated response has prompted several agencies and international organizations to join forces and create partnerships for maternal, newborn and child health. Over the past few decades, it has become clear that the support required for the development of a resource-constrained country is so multifaceted and complex, that it cannot be successfully taken on by one agency alone (7). Within the field of maternal, newborn, and child health, three partnerships are currently active: the Partnership for Safe Motherhood and Newborn Health, the Healthy Newborn Partnership, and the Child Survival Partnership. The recently established Partnership for Safe Motherhood and Newborn Health aims to strengthen and expand maternal and newborn health efforts. The Healthy Newborn Partnership has been established to promote awareness and attention to newborn health, exchange information, and improve communiThe partnerships can also assist in bridging the gap between knowledge and action (11) by facilitating the interaction between policy-makers, researchers, funders and other stakeholders who can influence the uptake of research findings – and reorient research towards solving the operational and systemic constraints that hold back the scaling up of effective interventions. Finally, the partnerships can help bring together the various parties involved in maternal, newborn and child health (ministries of health, finance and planning, national nongovernmental organizations, health professional groups, donor agencies, United Nations agencies, faith-based groups and others), or provide technical support to existing coordination mechanisms. This creates national partnerships through which funding, planning and implementation of national and subnational maternal, newborn and child health plans can be accelerated (12). Box 7.2 Building pressure: the partnerships for maternal, newborn and child health
128 The World Health Report 2005 of reforms. In countries where external assistance plays an important role, it also gives the impression that the policy interests of maternal, newborn and child health are those of the poverty reduction strategies(PRSPs)and sector-wide approaches (SWAps)through which reforms are steered (13)(see Boxes 7.3 and 7.4). The reality, however, is not so clear-cut. Different constituencies, different languages The constituencies from which champions of reform and those of maternal, newbom and child health draw support are quite different. Safe motherhood and child health programmes have been rather conservatively technical in emphasis(4, 31), with solu tions presented consistently in terms of technical strategies and cost-effectiveness 2-36). For all the logical imperatives driving it, integration of the sub-programmes in the areas of maternal, newborn and child health and reproductive health has long been problematic (37-40) Well-established vertical health programmes are frequent- ly resistant to change, and there is apprehension (often with good cause) that the transition to integrated management and information systems carries the risk of losing corporate and technical skills that previously sustained their activities (28, 40). Where integrated programmes have been established, they frequently bring with them paral- lel human resources, finance, logistics and monitoring systems (28 ) To be fair, thi has often helped to consolidate health systems. There remains, however, a persistent perception of selectivity and verticality in these programmes that inhibits their easy accommodation into comprehensive sectoral approaches. The convergence of the maternal, newborn and child health agenda with that of the Cairo ICPD has added a second dimension policy discussions have become more inclusive, politicized and rights-driven in orientation. Firmly rooted in a vision where Box 7.3 MNCH, poverty and the need for strategic information The requirement for countries to poverty reduction policies is being recognized. in many developing countries. While in some Poverty Reduction Strategy Papers a precursor to debt relief and th strategic advantage. Ministries of health often sible to disaggregate key health information by commitment to the Millennium Development find it difficult to conceive that poverty reduc- age, gender, economic quintile and geographi Goals have cemented the links between pro- tion is their core business; they are often late cal division, few health information systems por policy and maternal, newbom and child in their participation in the PRSP drafting pro- have that flexibility or specificity (18-20). Infor- ss, at a relatively low level of representation. mation on MNCH, and particularly on maternal PRSPs systematically include maternal But the potential exists, because by their very health, remains problematic, as is shown by the and child health(often not including a focus nature MNCH programmes fit naturally within difficulties in documenting maternal mortal on newborn health) among their priorities, a poverty reduction framework: they share ity and establishing effective vital registration but the strategies to access the poor and the similar values of entitlement and elimination systems(21). An even bigger obstacle, from excluded are often a mere continuance of cur- of exclusion a planning perspective, is the sketchiness of rent (and not demonstrably successful) prac- The first cycle of PRSPs has been criticized crucial information on resource availability tice (15). The significant shift, though, is that for their"striking sameness"and superfici- within health care systems: estimates of the the PRsp relocates MNCH priorities, ality, with global strategies dominating over total number of skilled attendants for Burkina poverty and exclusion securely on the national locally developed and more productive options Faso, for example, range between 78 and 476, enda, giving the health sector a seat at the (15, 17). In decentralized Uganda, for exam- according to the data source Information on table when the government discusses budget ple, the introduction of PRSPs brought with it the public network is often sketchy, while that allocation to pro-poor policies(16). No longer generic, rather than specific, solutions, eroding on the private, not-for-profit and commercial are MNCH programmes developed in isolation advances achieved through the local initiatives sectors is often non-existent. WHO is now help n the basis of vertical interventions: they are that had been taken under the decentralized ing countries to fill these gaps, for exam ow being considered in the broader context of District Development Programme. through Service Availability Mapping exercises pro-poor health policy, and, more importan The analysis required for PRSPs has exposed or, more broadly by helping establish health eir significance for the overall governmental the scarcity of relevant strategic information metrics networks
128 The World Health Report 2005 of reforms. In countries where external assistance plays an important role, it also gives the impression that the policy interests of maternal, newborn and child health are those of the poverty reduction strategies (PRSPs) and sector-wide approaches (SWAps) through which reforms are steered (13) (see Boxes 7.3 and 7.4). The reality, however, is not so clear-cut. Different constituencies, different languages The constituencies from which champions of reform and those of maternal, newborn and child health draw support are quite different. Safe motherhood and child health programmes have been rather conservatively technical in emphasis (4, 31), with solutions presented consistently in terms of technical strategies and cost-effectiveness (32–36). For all the logical imperatives driving it, integration of the sub-programmes in the areas of maternal, newborn and child health and reproductive health has long been problematic (37–40). Well-established vertical health programmes are frequently resistant to change, and there is apprehension (often with good cause) that the transition to integrated management and information systems carries the risk of losing corporate and technical skills that previously sustained their activities (28, 40). Where integrated programmes have been established, they frequently bring with them parallel human resources, finance, logistics and monitoring systems (28). To be fair, this has often helped to consolidate health systems. There remains, however, a persistent perception of selectivity and verticality in these programmes that inhibits their easy accommodation into comprehensive sectoral approaches. The convergence of the maternal, newborn and child health agenda with that of the Cairo ICPD has added a second dimension. Policy discussions have become more inclusive, politicized and rights-driven in orientation. Firmly rooted in a vision where poverty reduction policies is being recognized. Little gain has as yet been drawn from this new strategic advantage. Ministries of health often find it difficult to conceive that poverty reduction is their core business; they are often late in their participation in the PRSP drafting process, at a relatively low level of representation. But the potential exists, because by their very nature MNCH programmes fit naturally within a poverty reduction framework: they share similar values of entitlement and elimination of exclusion. The first cycle of PRSPs has been criticized for their “striking sameness” and superficiality, with global strategies dominating over locally developed and more productive options (15, 17). In decentralized Uganda, for example, the introduction of PRSPs brought with it generic, rather than specific, solutions, eroding advances achieved through the local initiatives that had been taken under the decentralized District Development Programme. The analysis required for PRSPs has exposed the scarcity of relevant strategic information The requirement for countries to formulate Poverty Reduction Strategy Papers (PRSPs) as a precursor to debt relief and the shared commitment to the Millennium Development Goals have cemented the links between propoor policy and maternal, newborn and child health (MNCH) priorities. PRSPs systematically include maternal and child health (often not including a focus on newborn health) among their priorities, but the strategies to access the poor and the excluded are often a mere continuance of current (and not demonstrably successful) practice (15). The significant shift, though, is that the PRSP process relocates MNCH priorities, poverty and exclusion securely on the national agenda, giving the health sector a seat at the table when the government discusses budget allocation to pro-poor policies (16). No longer are MNCH programmes developed in isolation on the basis of vertical interventions: they are now being considered in the broader context of pro-poor health policy, and, more importantly, their significance for the overall governmental in many developing countries. While in some cases – such as Gambia’s – it has been possible to disaggregate key health information by age, gender, economic quintile and geographical division, few health information systems have that flexibility or specificity (18–20). Information on MNCH, and particularly on maternal health, remains problematic, as is shown by the difficulties in documenting maternal mortality and establishing effective vital registration systems (21). An even bigger obstacle, from a planning perspective, is the sketchiness of crucial information on resource availability within health care systems: estimates of the total number of skilled attendants for Burkina Faso, for example, range between 78 and 476, according to the data source. Information on the public network is often sketchy, while that on the private, not-for-profit and commercial sectors is often non-existent. WHO is now helping countries to fill these gaps, for example through Service Availability Mapping exercises or, more broadly, by helping establish health metrics networks. Box 7.3 MNCH, poverty and the need for strategic information