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
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
132 The World Health Report 2005 knowledge of the technical and contextual interventions required to improve maternal, newborn and child health. In contrast, little is known about what can be done to make national political leaders give it their sustained support. The international community knows how to put things on the global policy agenda-the MDGs are proof of that but there is a lot more to learn about how to bridge the gap between global attention and national action, and on how to maintain attention spans long enough to make a difference Political will first requires information on the magnitude, distribution and root causes of the problems that mothers and children face, and on the consequences, in terms of human capital and economic development, of failing to confront them effectively. Maternal, newbom and child health can boast a large network of advocates at the international level that has done much to produce and disseminate such information Considerable progress has also been made in developing a battery of interventions, to demonstrate their cost-effectiveness, and to share that knowledge(10, 36). Finally, much has been done to emphasize the need for a wide range of interventions to be implemented simultaneously at household level, in communities, and through health centres and hospitals This work is important and must continue. Framing discussions on maternal, new- born and child health in terms of a wide range of technical interventions, however, has given the impression of a complex and expensive undertaking. To attract the sustained attention of policy-makers, it needs to be articulated in a different language The programmes have to be perceived by national decision-makers as effective and affordable ways of tackling well-recognized problems, but also as an agenda that commands a wide constituency and provides political mileage The common project that can bring together the interests and preoccupations of the MNCH programmes, as well as those of sector managers and health care providers, is that of universal access to care for mothers and children . embedded within an overall strategy of universal access for the whole population. Presenting MNCH in terms of progress towards universal access to care is not only a question of language. It frames the health of mothers, newborn babies and children within a broader, straightforward political project that is increasingly seen as a legitimate concern and is the subject of a wide social debate: responding to society's demand for the protection of the health of all its citizens HABILITATING THE WORKFORCE Not just a question of numbers Providing universal access requires a viable and effective health workforce. Yet, as demand has increased and as more ways of delivering effective treatment and preven- tion have become available to respond to increasing needs and demand, the size, skills and infrastructure of the workforce have not kept pace. Indeed, in many countries eco nomic and financial crises have destabilized and undermined the workforce during the past two decades. The resulting human resources crisis affects the whole spectrum of health care activities and MNCH programmes in particular. it has long been a major concern for health workers in the field as well as for officials in ministries of health, but the problem has proved so intractable that the international community started to recognize it explicitly only in the late 1990s The most visible features are the staggering shortages and imbalances in the dis tribution of health workers. with insufficient production, downsizing and caps on
132 The World Health Report 2005 knowledge of the technical and contextual interventions required to improve maternal, newborn and child health. In contrast, little is known about what can be done to make national political leaders give it their sustained support. The international community knows how to put things on the global policy agenda – the MDGs are proof of that – but there is a lot more to learn about how to bridge the gap between global attention and national action, and on how to maintain attention spans long enough to make a difference. Political will first requires information on the magnitude, distribution and root causes of the problems that mothers and children face, and on the consequences, in terms of human capital and economic development, of failing to confront them effectively. Maternal, newborn and child health can boast a large network of advocates at the international level that has done much to produce and disseminate such information. Considerable progress has also been made in developing a battery of interventions, to demonstrate their cost-effectiveness, and to share that knowledge (10, 36). Finally, much has been done to emphasize the need for a wide range of interventions to be implemented simultaneously at household level, in communities, and through health centres and hospitals. This work is important and must continue. Framing discussions on maternal, newborn and child health in terms of a wide range of technical interventions, however, has given the impression of a complex and expensive undertaking. To attract the sustained attention of policy-makers, it needs to be articulated in a different language. The programmes have to be perceived by national decision-makers as effective and affordable ways of tackling well-recognized problems, but also as an agenda that commands a wide constituency and provides political mileage. The common project that can bring together the interests and preoccupations of the MNCH programmes, as well as those of sector managers and health care providers, is that of universal access to care for mothers and children, embedded within an overall strategy of universal access for the whole population. Presenting MNCH in terms of progress towards universal access to care is not only a question of language. It frames the health of mothers, newborn babies and children within a broader, straightforward political project that is increasingly seen as a legitimate concern and is the subject of a wide social debate: responding to society’s demand for the protection of the health of all its citizens. REHABILITATING THE WORKFORCE Not just a question of numbers Providing universal access requires a viable and effective health workforce. Yet, as demand has increased and as more ways of delivering effective treatment and prevention have become available to respond to increasing needs and demand, the size, skills and infrastructure of the workforce have not kept pace. Indeed, in many countries economic and financial crises have destabilized and undermined the workforce during the past two decades. The resulting human resources crisis affects the whole spectrum of health care activities and MNCH programmes in particular. It has long been a major concern for health workers in the field, as well as for officials in ministries of health, but the problem has proved so intractable that the international community started to recognize it explicitly only in the late 1990s. The most visible features are the staggering shortages and imbalances in the distribution of health workers. With insufficient production, downsizing and caps on
reconciling maternal, newborn and child health with health system development 133 recruitment under structural adjustment and fiscal stabilization policies, and with frozen salaries and losses to the private sector, migration and HIV/AIDS, filling the supply gap will remain a major challenge for years to come (57-61). The scaling up of projected requirements for matemal, newborn and child health described in Chap- ters 5 and 6, for example, assumes the production, in the next 10 years, of at least 334000 additional midwives(or professionals with midwifery skills), and the upgrading of 40 000 others. some 27 000 doctors and technicians have to learn the skills to provide back-up maternal and newborn care, and the 100 000 full-time equivalent multipurpose professionals(many more under scenarios that rely less on community health workers), have to learn to follow up maternal and newborn care with integrated child care Along with the shortages, it appears that many countries have also witnessed a dete rioration in the effectiveness of their workforce. The public expects skills, knowledge and competencies in maternal, newbom and child health care that health workers often lack, putting lives at risk. Upgrading can improve the effectiveness of the present workforce but the current levels of skills are so poor and the mix so inappropriate that the potential of upgrading is limited. In-service training and supervision are generally considered key elements in improving outcomes, but there is a dire lack of evidence on cost-effed Box 7.5 Rebuilding health systems in post-crisis situations Building the district health systems required be maintained or reinstated. All this works that make it possible to channel funds into the for maternal, newborn and child health, better with short-term planning horizons such health sector. let alone their equivalent in more pluralistic as the 90-day cycle used in Liberia or Darfur, Cambodia, recovering after the decimation ettings, supposes a reasonable degree of Sudan, involving nongovemmental organiza- of its health workforce as a consequence of macroeconomic and political stability and a tions and humanitarian agencies, and engaging the actions of the Khmer Rouge, introduced reasonable degree of budget predictability. directly with peripheral service networks. accelerated training to build capacity in the In many of the countries where progress is In the phase of post-crisis recovery the early 1980s. By the time sectoral reforms tagnating, various forms of instability rule situation changes and a difficult transition were introduced, its health workforce wa out systematic long-term approaches to rolling has to be made from relief to development, in bloated, poorly trained and maldistributed. The out health systems coverage and coordinating a context of competing priorities and scarce upgrading of nurses to doctors eroded com efforts through sector-wide approaches. resources Offering minimum health services Complex emergencies require the initial focus in rural areas requires immediate strengthen- changes in the nursing curriculum resulted in to be on repair, on getting things working, not ing of the health care network and, crucially, the closure of one-year primary midwife train- reform of the workforce ing, and the introduction of a postgraduate Even k tirelessly at field level, often without shows that support of recurrent expenditure, the curent concentration of midwives in urban ountries in crisis, many profession- Mozambique's recovery from years of war midwifery diploma that will serve to reinforce salaries. To achieve progress, the first require- decentralized planning and strengthening of the areas, where private practice provides wel ment is for cash to get institutions working, information base, even at the peak of a crisis, come additional income (62, 63 ). While aware to enable those who work in them to feed can pay off. These measures can be the start- of the critical dilemma it faces, the Cambodian themselves and to avoid their having to resort ing point for rationalizing aid flows, and can Mi r of Health has been unable to mount a to levying user charges or pilfering supplies. pave the way for integrated planning and incre- strategic response that will effectively redress Paying decent wages to staff in place is then mental sector-wide approaches. Disbursement this shortage. etter than bringing in volunteers: sustainabil- of aid for post-confiict reconstruction is often The responsibility for quickly restoring ty is less an issue in these situations than pre- slow, and disproportionate to what the public acceptable standards of health services falls on venting the disappearance of the basic public health sector in these countries can mobilize by under-resourced ministries of health. In such health system itself. Aid flows are particularly important for circumstances the expansion of the network The first priority often is to establish institu- sustaining primary health care and maternal, to cover remote areas is far slower and more tional islands of dependable critical services: newborn and child health care services. Inter xpensive than would usually be expect medical supply depots and hospitals, even if national actors have disproportionate power in If recurrent this sometimes conflicts with the urge to launch these circumstances. But the transition from investment decisions are made, this under- population-wide immunization programmes. relief to development aid is particularly difficult: mines the sectors long-term sustainability Efforts should not be diluted but concentrated public administrative structures are very weak, where the threshold for basic functioning can so it takes time to re-establish the relations
reconciling maternal, newborn and child health with health system development 133 recruitment under structural adjustment and fiscal stabilization policies, and with frozen salaries and losses to the private sector, migration and HIV/AIDS, filling the supply gap will remain a major challenge for years to come (57–61). The scaling up of projected requirements for maternal, newborn and child health described in Chapters 5 and 6, for example, assumes the production, in the next 10 years, of at least 334 000 additional midwives (or professionals with midwifery skills), and the upgrading of 140 000 others. Some 27 000 doctors and technicians have to learn the skills to provide back-up maternal and newborn care, and the 100 000 full-time equivalent multipurpose professionals (many more under scenarios that rely less on community health workers), have to learn to follow up maternal and newborn care with integrated child care. Along with the shortages, it appears that many countries have also witnessed a deterioration in the effectiveness of their workforce. The public expects skills, knowledge and competencies in maternal, newborn and child health care that health workers often lack, putting lives at risk. Upgrading can improve the effectiveness of the present workforce, but the current levels of skills are so poor and the mix so inappropriate that the potential of upgrading is limited. In-service training and supervision are generally considered key elements in improving outcomes, but there is a dire lack of evidence on cost-effecbe maintained or reinstated. All this works better with short-term planning horizons such as the 90-day cycle used in Liberia or Darfur, Sudan, involving nongovernmental organizations and humanitarian agencies, and engaging directly with peripheral service networks. In the phase of post-crisis recovery the situation changes and a difficult transition has to be made from relief to development, in a context of competing priorities and scarce resources. Offering minimum health services in rural areas requires immediate strengthening of the health care network and, crucially, of the workforce. Mozambique’s recovery from years of war shows that support of recurrent expenditure, decentralized planning and strengthening of the information base, even at the peak of a crisis, can pay off. These measures can be the starting point for rationalizing aid flows, and can pave the way for integrated planning and incremental sector-wide approaches. Disbursement of aid for post-conflict reconstruction is often slow, and disproportionate to what the public health sector in these countries can mobilize by itself. Aid flows are particularly important for sustaining primary health care and maternal, newborn and child health care services. International actors have disproportionate power in these circumstances. But the transition from relief to development aid is particularly difficult: public administrative structures are very weak, so it takes time to re-establish the relations Building the district health systems required for maternal, newborn and child health, let alone their equivalent in more pluralistic settings, supposes a reasonable degree of macroeconomic and political stability and a reasonable degree of budget predictability. In many of the countries where progress is stagnating, various forms of instability rule out systematic long-term approaches to rolling out health systems coverage and coordinating efforts through sector-wide approaches. Complex emergencies require the initial focus to be on repair, on getting things working, not on reform. Even in countries in crisis, many professionals work tirelessly at field level, often without salaries. To achieve progress, the first requirement is for cash to get institutions working, to enable those who work in them to feed themselves and to avoid their having to resort to levying user charges or pilfering supplies. Paying decent wages to staff in place is then better than bringing in volunteers: sustainability is less an issue in these situations than preventing the disappearance of the basic public health system. The first priority often is to establish institutional islands of dependable critical services: medical supply depots and hospitals, even if this sometimes conflicts with the urge to launch population-wide immunization programmes. Efforts should not be diluted but concentrated where the threshold for basic functioning can that make it possible to channel funds into the health sector. Cambodia, recovering after the decimation of its health workforce as a consequence of the actions of the Khmer Rouge, introduced accelerated training to build capacity in the early 1980s. By the time sectoral reforms were introduced, its health workforce was bloated, poorly trained and maldistributed. The upgrading of nurses to doctors eroded competent leadership in nursing. Donor-supported changes in the nursing curriculum resulted in the closure of one-year primary midwife training, and the introduction of a postgraduate midwifery diploma that will serve to reinforce the current concentration of midwives in urban areas, where private practice provides welcome additional income (62, 63). While aware of the critical dilemma it faces, the Cambodian Ministry of Health has been unable to mount a strategic response that will effectively redress this shortage. The responsibility for quickly restoring acceptable standards of health services falls on under-resourced ministries of health. In such circumstances the expansion of the network to cover remote areas is far slower and more expensive than would usually be expected. If recurrent costs are underestimated when investment decisions are made, this undermines the sector’s long-term sustainability. Box 7.5 Rebuilding health systems in post-crisis situations