“We have the knowledge to improve maternal health outcomes and in general, we know what interventions and strategies are needed to achieve this goal. In order to scale up efforts and accelerate progress towards achieving the Millennium Development Goal to improve maternal health, however, we must be able to implement effective maternal health programs given a country’s particular setting, policies and resource constraints” [1]

Despite the renewed global effort since 1990, insufficient progress is being made towards improving maternal health in many African countries. Effective, cost-efficient interventions exist that if more widely implemented would significantly decrease maternal mortality. The key challenge for maternal health programmes is how to increase the uptake and coverage of these interventions and strategies. Unfortunately, there is very little evidence about how universal coverage can best be achieved. Recent analyses have argued that broader health system strengthening needs to become more central to current maternal health strategies, and have correctly identified human resource issues and problems in health care financing as critical health system priorities that need to be addressed. Though an important advance, these insights do not translate into quick simple solutions. For one thing, they tend to under-estimate the institutional resources and capacities required to implement system change. Those weak health systems that have been least effective in scaling-up maternal health programmes are also likely to struggle with the management of the complex interventions required to address the current human resource crisis or health financing failures in health systems in Africa.

Current national and international strategies adopted for the implementation of health system strengthening in support of maternal health in Africa may actually undermine the development of such local system capacity. For example:

• Maternal health programme reforms have often been determined by outside agencies and donors, and then driven by international technical experts;
• Programmes have prioritised the search for proven, generalisable interventions rather than identifying local, context-specific, solutions;
• There has been a continuous succession of health system reform ‘fads and fashions’ which has meant that new reforms are adopted before the previous initiatives have been properly implemented or evaluated;
• Reformers have been preoccupied with health system reform rather than health system development – trying to identify the once-off, large-scale structural change that will fix the health system rather than supporting more long-term, incremental improvements; and
• Programme managers have been more concerned with trying to find the correct technical solution rather than understanding the processes required to get people to change. Such strategies do not support sustainable development; they discourage local problem-solving, inhibit organisational learning, and create a culture of dependency.

Certainly, there will be little improvement in health systems in Africa without significant additional financial and human resources, but ongoing effective organisational change and adaptation also require new institutional resources. Health system strengthening is important but a key health system priority that is frequently overlooked is the development of the institutional capacity required to manage ongoing change and support continuous system improvements in the long term.

The scaling-up of effective maternal health interventions poses specific demands – for example, understanding how interventions will be interpreted by local policymakers, health workers and communities; learning how to adapt interventions for local settings so that they are accepted and remain effective; generating innovative approaches when international evidence doesn’t exist or isn’t relevant; managing complex local task networks and multiple partners; and modifying strategies in reaction to experience, changing conditions or technological advances. These demands require specific institutions and capacities for information generation, knowledge management, option appraisal, planning, policy reform and change management.

We need to ensure that current maternal health programme and health system strengthening initiatives support the development of such institutions and capacities within our national health systems because long term, sustained improvements in maternal health will not be possible without them.

References

Nanda G, Switlick K, Lule E. (2005). Accelerating progress towards achieving the MDG to improve maternal deaths. A collection of promising approaches. Washington: World Bank.