reconciling maternal, newborn and child health with health system development 129 public or quasi-public services would play a major role, they make increasingly explicit reference to entitlements to access care and health systems. As a result, the language used by champions of maternal, newborn and child health has become a combination of technical arguments and advocacy. The specificity and focus of maternal, newbom and child health thus reinforce an appearance of vertical special interest programmes, despite attempts to locate them more broadly within health systems. This generates resistance in the comprehensive ethos of sectoral approache In contrast to the technical focus of maternal, newborn and child health programmes, health care reforms are driven by cross-cutting economic and managerial imperatives The focus of operations for reform is the entire health sector, and its primary advo- cates are used to working at the systems level, both within national health systems and from outside. They naturally concentrate on a number of the systemic problems that constrain the health systems on which maternal, newborn and child health care relies, but the technical and service delivery considerations that are at the centre of the MNCH agenda are a secondary preoccupation (13 ) Most importantly, the opera- tional articulation between community-level intervention, primary care and hospital referral services-the essence of district health systems and the organization of a continuum of care- is often inadequately dealt witl The gap between the system-level focus and managerial language of reform, the on-the-ground service delivery preoccupations of district-level managers and the BoX 7.4 Sector-wide approaches Poverty Reduction Strategy Papers(PRSPs) coordinated) development assistance, in return SWAps came into being partly as a result appeared when"sector-wide approach" for greater policy leverage and the opportunity of broad discontent with the efficiencies of (SWAp)mechanisms were emerging as the to influence sectoral reform. Local ministries project-based development assistance, an ordination and financing mechanisms to of health gained at least nominal leadership of with the fragmentation and lack of coordination harmonize and align development assistance the collaboration and access to an expanded among donors, which was tackled in the around a coherent sectoral reform (20, 22, resource pool, though they have lost the coordination offered by their sectoral approach tactical advantage that previously accrued (23 ) The second element in their development, SWAp partners in a country-government, through negotiations with individual agencies however, was the Worid Banks experience with civil society and donor agencies-commit their (26, 27). This simultaneous recognition of resources to a collaborative programme of work. local "ownership" of sectoral reforms and the processes (19, 22). The combination of thes his includes policy development, capacity commitment of both donors and government strategies gave SWAps the potential to ste building and institutional reform: usually a mix to finance necessary reforms is significant: reform across the whole sector, with sufficient of decentralization, restructuring of the civil it marks a shift in development practice, collective influence and financial leverage to ervice and ministries of health, broadening of moving from the coordination of resources to drive long-term policy change with ministries health financing options, and the recognition their active management by a government-led of health that health systems are pluralistic(24). SWAps coalition of stakeholders (20 The SWAp structure also does not always fit are underpinned by the preparation of mid-term Even if results are by no means always comfortably with the development assistance penditure plans and corresponding financial, satisfactory, indications are that the trend to procurement, disbursal and accounting use such cooperation mechanisms and shift agencies committed to maternal, new mechanisms. Implicit in the collaboration is the to budget support is going to continue in the born and child health and supportive of the evelopment of processes to negotiate strategic countries that make up the bulk of those in values that underlie SWAps. They may find and management issues, and monitoring and which progress is stagnating or in reverse themselves limited by domestic legislation evaluation of progress against agreed criteria ( 29). The PRSPs have the potential to give or administrative regulation in the extent to 23,25 SWAps a unifying policy focus against which which they are able to commit to pooled he shared recognition by both donors the outcomes of reform might be measured funding mechanisms or shared monitorin and recipient governments of the need for (18), while the processes required for the and evaluation processes (30). Crucially, in coordination of resources was a critical achievement of the Millennium Development many countries nongovernmental organizations factor in the ears meory- prepared to sacrifice the overall outcomes of the health systems but usually have only limited access to SWAp cceptance of SWAps(26). Goal targets are sufficiently complex to reflect actively engage in maternal and child health. profile by investing in pooled (or otherwise reforms coordinated under the SWAps. governance mechanisms
reconciling maternal, newborn and child health with health system development 129 public or quasi-public services would play a major role, they make increasingly explicit reference to entitlements to access care and health systems. As a result, the language used by champions of maternal, newborn and child health has become a combination of technical arguments and advocacy. The specificity and focus of maternal, newborn and child health thus reinforce an appearance of vertical special interest programmes, despite attempts to locate them more broadly within health systems. This generates resistance in the comprehensive ethos of sectoral approaches. In contrast to the technical focus of maternal, newborn and child health programmes, health care reforms are driven by cross-cutting economic and managerial imperatives. The focus of operations for reform is the entire health sector, and its primary advocates are used to working at the systems level, both within national health systems and from outside. They naturally concentrate on a number of the systemic problems that constrain the health systems on which maternal, newborn and child health care relies, but the technical and service delivery considerations that are at the centre of the MNCH agenda are a secondary preoccupation (13). Most importantly, the operational articulation between community-level intervention, primary care and hospital referral services – the essence of district health systems and the organization of a continuum of care – is often inadequately dealt with. The gap between the system-level focus and managerial language of reform, the on-the-ground service delivery preoccupations of district-level managers and the coordinated) development assistance, in return for greater policy leverage and the opportunity to influence sectoral reform. Local ministries of health gained at least nominal leadership of the collaboration and access to an expanded resource pool, though they have lost the tactical advantage that previously accrued through negotiations with individual agencies (26, 27). This simultaneous recognition of local “ownership” of sectoral reforms and the commitment of both donors and government to finance necessary reforms is significant: it marks a shift in development practice, moving from the coordination of resources to their active management by a government-led coalition of stakeholders (28). Even if results are by no means always satisfactory, indications are that the trend to use such cooperation mechanisms and shift to budget support is going to continue in the countries that make up the bulk of those in which progress is stagnating or in reverse (29). The PRSPs have the potential to give SWAps a unifying policy focus against which the outcomes of reform might be measured (18), while the processes required for the achievement of the Millennium Development Goal targets are sufficiently complex to reflect the overall outcomes of the health systems reforms coordinated under the SWAps. Poverty Reduction Strategy Papers (PRSPs) appeared when “sector-wide approach” (SWAp) mechanisms were emerging as the coordination and financing mechanisms to harmonize and align development assistance around a coherent sectoral reform (20, 22, 23). SWAp partners in a country – government, civil society and donor agencies – commit their resources to a collaborative programme of work. This includes policy development, capacity building and institutional reform: usually a mix of decentralization, restructuring of the civil service and ministries of health, broadening of health financing options, and the recognition that health systems are pluralistic (24). SWAps are underpinned by the preparation of mid-term expenditure plans and corresponding financial, procurement, disbursal and accounting mechanisms. Implicit in the collaboration is the development of processes to negotiate strategic and management issues, and monitoring and evaluation of progress against agreed criteria (23, 25). The shared recognition by both donors and recipient governments of the need for coordination of resources was a critical factor in the early acceptance of SWAps (26). Donors were – in theory – prepared to sacrifice profile by investing in pooled (or otherwise SWAps came into being partly as a result of broad discontent with the efficiencies of project-based development assistance, and with the fragmentation and lack of coordination among donors, which was tackled in the coordination offered by their sectoral approach (23). The second element in their development, however, was the World Bank’s experience with its structural adjustment and macroeconomic processes (19, 22). The combination of these strategies gave SWAps the potential to steer reform across the whole sector, with sufficient collective influence and financial leverage to drive long-term policy change with ministries of health. The SWAp structure also does not always fit comfortably with the development assistance profile of other bilateral or nongovernmental agencies committed to maternal, newborn and child health and supportive of the values that underlie SWAps. They may find themselves limited by domestic legislation or administrative regulation in the extent to which they are able to commit to pooled funding mechanisms or shared monitoring and evaluation processes (30). Crucially, in many countries nongovernmental organizations actively engage in maternal and child health, but usually have only limited access to SWAp governance mechanisms. Box 7.4 Sector-wide approaches
130 The World Health Report 2005 advocacy language in maternal, newborn and child health, puts champions of MNCH in an uncomfortable position ( 31, 41). The strategic discussions take place in a highly politicized arena, where ministries of health compete with other ministries that have an interest in health, planning or financing; programmes are in tension with integrated services, hospitals with community-based services; central planning and budgeting contrasts with peripheral autonomy; and governments and nongovernmental orga nizations compete for the same donor funds (42 ) Real pooling of resources through government financial systems is exceptional, even in countries where SWAp mecha nisms attempt to apply this principle (43). Despite the rhetoric of collaboration and consensus in shared priority setting, matemal, newborn and child health programmes often try to safeguard support through continued vertical donor funding (44). Institu tional agendas being what they are, this is probably inevitable to some degree( The net effect, however, is often that maternal, newborn and child health programmes remain sceptical about their capacity to draw on sectoral resources, while sector managers may be tempted to locate such activities outside their core preoccupations. To keep maternal, newborn and child health at the centre of a policy agenda of health system development is particularly difficult for governments that have gone through decades of working on shoestring budgets and whose health systems are carved up in a patchwork of projects. These are precisely the countries that now face the biggest problems and the slowest progress, and are the most dependent on donors and their shifting agendas SUSTAINING POLITICAL MOMENTUM Long-term sustained improvements in maternal, newborn and child health require long-term commitments that go well beyond the political lifespan of many decision makers. Countries such as Cuba, Malaysia and Sri Lanka have rooted their impressive results in a stepwise extension of health systems coverage, over many years. They went through different phases-laying a foundation by building up a cadre of profes- sional health workers, developing an accessible network of primary and referral-level services, and consolidating advances by improving the quality of care (46 )-all in conjunction with improvements in living conditions and the status of women (47) They prioritized broad social safety nets that ensured equitable access to health and education, making health services widely available, reducing barriers to key services, and providing primary and secondary schooling to all children(48 ). Even in some of the poorest countries in Latin America, where monetary crises, weak institutions social inequalities and poverty continue to hinder progress, there have been notable successes in countries that move towards generalized access to care These countries share a long-term commitment to build up health systems over many years, with sustained"political will " and"ownership"(49-56). Most analysts would agree that a reasonable degree of macroeconomic and political stability and budget predictability is a precondition for mobilizing the institutional, human and financial resources that strengthening the health system requires. In many of the countries that experience problems in accelerating progress towards the MDGs, this precondition does not exist. Without sustained political momentum, however, effec- tive leadership is unlikely to be present, be it at the centre where the broad sectoral decisions are made, or at the operational level, in the districts where the interaction ith the population takes place What does it take to encourage national leaders to act to ensure the health rights of mothers and children -rights to which they are committed? There is extensive
130 The World Health Report 2005 advocacy language in maternal, newborn and child health, puts champions of MNCH in an uncomfortable position (31, 41). The strategic discussions take place in a highly politicized arena, where ministries of health compete with other ministries that have an interest in health, planning or financing; programmes are in tension with integrated services, hospitals with community-based services; central planning and budgeting contrasts with peripheral autonomy; and governments and nongovernmental organizations compete for the same donor funds (42). Real pooling of resources through government financial systems is exceptional, even in countries where SWAp mechanisms attempt to apply this principle (43). Despite the rhetoric of collaboration and consensus in shared priority setting, maternal, newborn and child health programmes often try to safeguard support through continued vertical donor funding (44). Institutional agendas being what they are, this is probably inevitable to some degree (45). The net effect, however, is often that maternal, newborn and child health programmes remain sceptical about their capacity to draw on sectoral resources, while sector managers may be tempted to locate such activities outside their core preoccupations. To keep maternal, newborn and child health at the centre of a policy agenda of health system development is particularly difficult for governments that have gone through decades of working on shoestring budgets and whose health systems are carved up in a patchwork of projects. These are precisely the countries that now face the biggest problems and the slowest progress, and are the most dependent on donors and their shifting agendas. SUSTAINING POLITICAL MOMENTUM Long-term sustained improvements in maternal, newborn and child health require long-term commitments that go well beyond the political lifespan of many decisionmakers. Countries such as Cuba, Malaysia and Sri Lanka have rooted their impressive results in a stepwise extension of health systems coverage, over many years. They went through different phases – laying a foundation by building up a cadre of professional health workers, developing an accessible network of primary and referral-level services, and consolidating advances by improving the quality of care (46) – all in conjunction with improvements in living conditions and the status of women (47). They prioritized broad social safety nets that ensured equitable access to health and education, making health services widely available, reducing barriers to key services, and providing primary and secondary schooling to all children (48). Even in some of the poorest countries in Latin America, where monetary crises, weak institutions, social inequalities and poverty continue to hinder progress, there have been notable successes in countries that move towards generalized access to care. These countries share a long-term commitment to build up health systems over many years, with sustained “political will” and “ownership” (49–56). Most analysts would agree that a reasonable degree of macroeconomic and political stability and budget predictability is a precondition for mobilizing the institutional, human and financial resources that strengthening the health system requires. In many of the countries that experience problems in accelerating progress towards the MDGs, this precondition does not exist. Without sustained political momentum, however, effective leadership is unlikely to be present, be it at the centre where the broad sectoral decisions are made, or at the operational level, in the districts where the interaction with the population takes place. What does it take to encourage national leaders to act to ensure the health rights of mothers and children – rights to which they are committed? There is extensive
reconciling maternal, newborn and child health with health system development 131 In order to improve maternal newborn and child health there is a clear need for continuity of care from pregnancy through childbirth the neonatal period and early childhood
reconciling maternal, newborn and child health with health system development 131 WHO/PAHO P. Wiggers/WHO R. Kameyama/WHO In order to improve maternal, newborn and child health, there is a clear need for continuity of care from pregnancy through childbirth, the neonatal period and early childhood. A. Waak/WHO/PAHO