This document analyzes policies in 8 countries aimed at reducing maternal mortality rates to achieve MDG 5. It begins with definitions of key terms like maternal death, mortality rate, and direct and indirect causes. Countries are categorized as developed, emerging, or developing based on their UN HDI score. The document will examine determinants of maternal mortality, policies implemented in different countries and time periods, and make recommendations to help countries achieve MDG 5 goals.
2. Introduction
Eight hundred women die every day worldwide while giving birth to the future generation. This
means that almost 300,000 mothers or motherstobe die each year. This statistic is terrible in
itself, but what is more striking is that most of those deaths are avoidable and occur in similar
parts of the world: in emerging and developing countries.
Governments, nongovernmental organizations, and governmental organizations have mobilized
for the last few decades in effort to reduce maternal mortality, a plague that has lasted for
centuries and will likely persist, but what is important is the fact that those deaths are not all
inevitable. It is possible to change this as we have seen throughout the last few centuries in many
northern European countries where pregnant women do not die due to pregnancy complications
but rather from other factors not attributable to their pregnancy. For example, in Sweden, a
pregnant woman is more likely to die in a car accident than while giving birth. 1
Maternal death is important for many reasons. Firstly, even if women and men are not
biologically the same, that does not mean that women have to sacrifice themselves in giving birth
the next generation. Women have the right to be able to give birth without being afraid of dying
during the process. Maternal death is also a significant matter for countries because it means that
thousands of children each year grow up without their mothers and this is important because in
general, the health of a child is tangentially related to the health of the mother, as maternal health
is linked closely with newborn survival rates. Maternal mortality is also indicative of health 2
systems and the quality of care in that system because the health care system failed to keep those
women alive. Furthermore, is an important indicator of a country, because it gives information
on many factors not only related to health, but also on general attitudes on women and gender
equality.
1
"1 Million Babies Die the Day They’re Born, Save the Children Says." Save the Children, Dec 2013. Web.
2
“Maternal, Newborn, and Child Health.” Bill and Melinda Gates Foundation, 2014. Web.
2
3. But which factors influence maternal mortality? What are the main causes of women’s death
during pregnancy and childbirth? Only once those factors have been determined can we ascertain
the most effective methods of reducing maternal mortality. The main strategy to combat maternal
mortality is through the implementation of public policy because it can do everything from
influencing individual behavior to changing the healthcare organization of a country. Now we
need to ask: what have been the policies implemented to reduce maternal mortality around the
world? Which ones have been the most efficient and why? These questions are essential because
as Professor Mahmoud Fatalla said, “Women are not dying because of diseases we cannot treat.
They are dying because societies have yet to make the decision that their lives are worth
saving.” It is absolutely necessary that societies and governments realize that these women must
have access to quality health care during and after their pregnancies, not only for their personal
sake, but also for their families’ and their countries’.
The World Health Organization has already recognized the need to reduce maternal mortality,
including the need to address care deficiencies in the maternal health sector in its Millenium
Development Goals. Many countries have taken steps towards reducing their maternal mortality
rates through the implementation of public policies. However, the WHO only provided broad,
overarching recommendations on the worldwide level, which are often ineffective due to the lack
of tailoring towards each country’s specific needs. Consequently, progress towards this goal has
been slow and has fallen short of hopes and expectations.
In this paper, we will examine the main determinants of maternal mortality, study different
policies implemented in different countries during different time periods, and propose policies
that should be implemented in countries most severely affected by maternal mortality. The
ultimate goal of these recommendations is for these countries to try and achieve the Millenium
Development Goal 5, which is aimed at reducing maternal mortality in each country and
worldwide by 75 percent throughout the 19902015 period as soon as possible.
3
4.
1. Maternal mortality: worldwide observations and introduction to policy
analysis
a. Definitions
This section of the paper will define the many terms that are necessary for readers to better
understand the topic of maternal mortality. Because this paper uses maternal mortality rates
(MMR) as the main indicator for the effectiveness of improvements in maternal health, it is first
important to define what can be defined as a maternal death and how that contributes to the
calculation of the MMR.
Maternal death is the death of a woman while pregnant or within 42 days of the termination of
pregnancy irrespective of the duration and site of the pregnancy from any cause related to or
aggravated by the pregnancy or its management, but not from accidental or incidental causes. 3
The terms maternal mortality and maternal death are identical, while maternal morbidity
defines any health condition attributed to and/or aggravated by pregnancy and childbirth that has
a negative impact on the woman’s wellbeing. More specifically, late maternal death can be 4
defined as deaths caused by either direct or indirect obstetric causes that occur after 42 days but
less than one year after termination of pregnancy. 5
The following are terms linked with women’s mortality, particularly in explaining causes of
maternal death. It is important to note that there are many different indirect and direct causes of
maternal death, which can make combatting the issue even more difficult. Understanding the
3
"Maternal Mortality Ratio (per 100 000 Live Births)." WHO. Web.
4
"PREEMPT." WHO Maternal Morbidity Working Group. Web.
5
"Family Planning and Reproductive Health Indicators Database." Maternal Mortality Ratio (MMR) — MEASURE Evaluation. Web.
4
5. mechanisms affecting maternal death are essential to determining what can be done to decrease
such deaths.
Cause of death is the disease or injury initiating a train of morbid events that lead
directly to death or the circumstances of an accident that produced the injury. These 6
following terms can directly cause or complicate maternal health status, thus contributing
to maternal death.
Hemorrhage is the internal or external bleeding or abnormal flow of blood 7
Anemia is a medical condition where the red blood count or hemoglobin is less
than normal (10g/dl) 8
Sepsis is the presence of bacteria, other infectious organisms, or toxins created by
infectious organisms in the bloodstream that can spread throughout the body 9
Obstructed labor is when the presenting part of the fetus cannot progress into the
birth canal despite strong uterine contractions; this is usually due to the mother
having an abnormally small pelvis as a result of malnutrition 10
Obstetric causes of death are obstetric complications during pregnancy, labor,
and postpartum; complications are usually due to postpartum hemorrhage, sepsis,
eclampsia, obstructed labor, and complications from unsafe abortions, as well as
interventions, omissions, and incorrect medical treatment 11
Nonobstetric causes of death result from preexisting conditions or from
diseases arising during pregnancy (but without direct obstetric causes), that were
aggravated by pregnancy (i.e. HIV, malaria, and cardiovascular disease) 12
Abortion is the induced termination of pregnancy with the destruction of a fetus
or embryo, usually within the first 28 weeks of pregnancy 13
6
"Glossary of Statistical Terms." OECD. Web.
7
"Hemorrhage." MedicineNet. Web.
8
Levy, Amalia, Drora Fraser, Miriam Katz, Moshe Mazor, and Eyal Sheiner. "Maternal Anemia during Pregnancy Is an Independent Risk Factor
for Low Birthweight and Preterm Delivery." European Journal of Obstetrics & Gynecology and Reproductive Biology 122.2 (2005): 18286.
Web.
9
"Sepsis." MedicineNet. Web.
10
Dolea, Carmen, and Carla AbouZahr. Global Burden of Obstructed Labour in the Year 2000: 117. World Health Organization. Web.
11
"Untitled1." Untitled1. Web. <http://www.icm.tn.gov.in/intersession/Matnal.htm>
12
"Untitled1." Untitled1.Web. <http://www.icm.tn.gov.in/intersession/Matnal.htm>
13
Saunders. "Abortion." TheFreeDictionary.com. 2007. Web.
5
6. Unsafe abortion is the procedure of terminating a pregnancy either by persons
lacking the necessary medical skills or in an environment lacking minimal
medical standards, or both 14
Eclampsia is a condition characterized by high blood pressure and protein in the
urine that can eventually leads to seizures in the mother 15
Hypertensive disorder is a pregnancyinduced increase of systolic blood
pressure of 140 mm Hg or greater, and/or a diastolic blood pressure of 90 mm Hg
or greater which develops after 20 weeks of gestation, and can lead to thrombosis
(blood clots), stroke (disruption of blood flow to the brain), or separation of the
placenta 16
Embolism is the obstruction of a blood vessel by a foreign substance or a blood
clot that is traveling through the bloodstream and plugs the vessel 17
Concurrent disease is the suffering from both a medical disorder and a substance
abuse problem at the same time 18
Neoplasm is an abnormal new growth of tissue cells that grows more rapidly than
normal and forms a distinct mass of tissue that can either be benign
(noncancerous) or malignant (cancerous) 19
Suicide is the act of intentionally killing oneself or taking one’s own life 20
Later in this essay we will categorize the countries studied into three categories in order to better
compare policies and their subsequent effects on maternal mortality. We will define countries as
developed, emerging, and developing based upon the UN Human Development Index, which 21
considers different criteria for development within the economic (GNI/capita), health (life
expectancy) and education (mean years of schooling and expected years of schooling) sectors of
a country to produce an index statistic. We used an index that takes into account various factors
14
"Preventing Unsafe Abortion." WHO. Web.
15
"Preeclampsia and Eclampsia: Get the Facts on Symptoms." MedicineNet. Web.
16
"Hypertension in Pregnancy." Patient.co.uk. Web.
17
"Embolism." MedicineNet. Web.
18
"About Concurrent Disorders." Central West Concurrent Disorder Network. Web..
19
"Neoplasm." TheFreeDictionary.com. Web.
20
"Suicide." The Free Dictionary. Farlex. Web.
21
"Human Development Reports." Human Development Index (HDI). UNDP. Web..
6
7. to determine our groupings rather than an index focusing only on one dimension, such as that of
the World Bank, which looks only at economic mattersand then categorizes countries into low,
middle, or high income countriesbecause other factors besides wealth can play important roles
in how the development in a country is progressing.
Based on the UN Human Development Index, we have defined developed countries as those
with a development score index labeled as either “high” or “very high”, which are indicated by a
value between 0.7 and 1. Emerging countries are those with a “medium” development index
score, between 0.5 and 0.699, and developing countries have the lowest development index
score, from 0.337 (the lowest score on the index) to 0.549. 22
The next portion of the paper will discuss policy efficiency and country results. There are
multiple factors that can play a role as indicators of maternal health status. The following are
definitions of important indicators of maternal health status, which will be used to assess the
efficiency of implemented policies and the progress towards or achievement of MDG 5.
Maternal Mortality Rate (MMR) is the ratio of recorded or estimated number of
maternal deaths per 100,000 live births 23
Fertility rate is the number of children who would be born to a woman if she was
to live to the end of her childbearing years and bear children in accordance with
current agespecific fertility rates 24
Unmet need for family planning is when a fertile woman not using any method
of contraception expresses the desire to delay her next child or stop having
children 25
Contraception is the use various devices, drugs, agents, sexual practices, or
surgical procedures to prevent conception or impregnation (pregnancy) 26
Prevalence of contraception used is the percentage of women who are currently
using, or whose sexual partner is currently using, at least one method of
22
Ibid.
23
"Maternal Mortality Rate (MMR)." Family Planning and Reproductive Health Indicators Database. Web.
24
"Fertility Rate, Total (births per Woman)." The World Bank. Web.
25
"Unmet Need for Family Planning." WHO. Web.
26
"What Is Contraception? What Is Birth Control?" Medical News Today. MediLexicon International. Web.
7
8. contraception, regardless of the method used. It is usually reported for married or
inunion women aged 15 to 49 27
Prenatal (Antenatal) care is when women receive 80% or more of the four
recommended visits given the timing of prenatal care entry and gestational age at
delivery 28
“Level of education” is the progression from very elementary to more
complicated learning experience, embracing all fields and programme groups that
may occur at that particular stage of the progression 29
Midwives are traditional care providers for mothers and infants. Midwives are
trained professionals with expertise and skills in supporting women to maintain
healthy pregnancies and have optimal births and recoveries during the postpartum
period. 30
Skilled birth attendants are analogous to skilled birth professionals who are
known as accredited health professionals – such as a midwives, doctors or nurses
– who have been educated and trained to proficiency in the skills needed to
manage routine pregnancies, childbirth and the immediate postnatal period, and
also in the identification, management and referral of complications in women
and newborns. 31
Health expenditure per capita is the sum of public and private health
expenditures as a ratio of total population. It covers the provision of preventive
and curative health services, family planning activities, nutrition activities, and
emergency aid designated for health but does not include the provision of water
and sanitation. 32
Political climate is a term describing the emotional environment generated by the
public’s feelings on various political issues. It is generally measured and analyzed
by public opinion pollsters who ask certain questions to get a sense of people’s
27
"Metadata: Contraceptive Prevalence." UN News Center. UN, 2011. Web.
28
Vincetto, Ornella, Seipat I MothebesoaneAnoh, Patricia Gomez, and Stephen Munjanja. "Antenatale Care.": WHO. WHO on Behalf of The
Partnership for Maternal Newborn and Child Health, 2006. Web.
29
"Glossary of Statistical Terms." OECD. Web.
30
"What Is a Midwife?" Midwives Alliance of North America. Web.
31
"Skilled Birth Attendants." WHO. Web.
32
"Health expenditure per capita." The World Bank.
8
9. viewpoints and how much passion people feel towards different subjects,
typically referring to recent social clashes and elected officials 33
Maternal health, and more specifically, maternal mortality, is being increasingly recognized as a
serious problem worldwide. Evidence of the subject’s growing importance is the United Nations’
decision to include the improvement of maternal health as the 5th Millennium Development
Goal (MDG 5). In 2000, eight goals were established by the United Nations after the Millenium 34
Summit of the United Nations with the goal of achieving them by 2015. These eight goals cover
a broad range of topics, from poverty reduction to incidences of HIV. The aim of MDG 5 is to
reduce the maternal mortality ratio by three quarters in between the years of 1990 and 2015 and
to achieve universal access to reproductive health. Reproductive health is defined as people
having the ability to reproduce when and how often they want to, and also the the ability to have
and maintain a responsible, satisfying and safe sex life. 35
As of 2013, MDG5 has not yet been achieved; global maternal mortality ratio has only been
reduced by 45 percent since 1990 and only half of the women in developing countries have
access to reproductive health. Out of the eight, MDG 5 is considered to be the one showing the 36
least amount of progress worldwide. 13 developing countries out of 66 are considered to be “on
track” by the WHO, while 25 are considered to have made little or no progress. 37
b. Worldwide Overview: Background and Statistics
As long as women continue to give birth, maternal mortality is a worldwide phenomenon that
cannot be completely eradicated, and the subject has increasingly become a concern in many
countries over the last few decades. In 2013 more than 289,000 women died while giving birthm
and although this statistic is significantly lower than that of 1990, during which more than 38
33
Queen, Jacob, and Lauren Fritsky. "What Is a Political Climate?" WiseGeek. Conjecture. Web.
34
"United Nations Millennium Development Goals." UN News Center. UN, Web.
35
"Reproductive Health." WHO. 2014. Web. 02
36
"United Nations Millennium Development Goals." UN News Center. UN, Web.
37
“Most Countries Will Not Meet MDG 4 and 5.” Maternal Health Task Force, 20 September 2011. Web.
38
"United Nations Agencies Report Steady Progress in Saving Mothers' Lives." WHO. 6 May 2014. Web.
9
10. 523,000 women died during pregnancy or childbirth, maternal mortality is still a major 39
concern. It is not only because most of these deaths are preventable, but also because there is an
unequal distribution of these preventable maternal deaths worldwide: 99 percent of preventable
maternal deaths occur in developing and emerging countries. This disparity is clearly visible 40
when comparing the lifetime risk of dying during pregnancy or childbirth: 1 in 3,300 in Europe
as compared to 1 in 40 in Africa. 60 percent of all maternal deaths are concentrated in just 10 41
countries, but such countries are not necessarily those with the highest maternal mortality rates; 42
Sierra Leone currently has the highest lifetime risk of dying from maternal complications, 43
followed by Somalia and Chad. 44
It is important to note that the biggest risk of death during pregnancy around the world is no
longer related to obstetric factors but rather due to the presence of other, preexisting diseases
such as diabetes, HIV, or malaria, which represented 28 percent of maternal deaths in 2013.
Meanwhile, hemorrhaging or other bleeding complications, while still important and causing 27
percent of maternal deaths, has decreased in importance as risk factors. The fact that the causes 45
of maternal death are not the same around the world proves that efficient policies can be
implemented to reduce preventable maternal deaths. It is important to note that nonobstetric
causes of death such as preeclampsia and hypertensive disorders make up a higher proportion of
deaths in developed and emerging countries as compared to in developing countries, where the
main proportion of deaths are due to obstetric reasons like bleeding complications. MDG 5 raises
worldwide concern for this topic, as it is not only a matter of health but also the right of all
women worldwide to be able to give birth without risking their own lives.
c. Countries Chosen and Why
39
"Saving Mother's Life." WHO. 2014. Web.
40
"Maternal Mortality." WHO. May 2014. Web.
41
"Saving Mother's Life." WHO. 2014. Web.
42
"United Nations Agencies Report Steady Progress in Saving Mothers' Lives." WHO. 6 May 2014. Web.
43
"WHO | Maternal Mortality Interactive Charts." WHO. Web.
44
"United Nations Agencies Report Steady Progress in Saving Mothers' Lives." WHO. 6 May 2014. Web.
45
"Saving Mother's Life." WHO. 2014. Web.
10
11. In this part, we are going to explain why we chose to analyze the following eight countries:
Sierra Leone, Nigeria, Rwanda, Equatorial Guinea, India, Chile, France and Sweden. We hope
that the differences between these countries will illustrate the scope of maternal mortality
policies while also representing the general worldwide trends in this subject in order to better
make policy recommendations for these general groups of countries.
Sierra Leone is the country with the highest maternal mortality rate in the world. Because its
MMR was already one of the highest globally in 1990, its slight decrease since then is less
significantin terms of overall improvements in maternal healththan those of other countries
with previously high maternal mortality rates. Sierra Leone is one of the only countries with a
previously high MMR to make almost no progress. As Sierra Leone is not on track to achieve
MDG 5 by 2015, it might be the country most concerned by our policy recommendations.
Rwanda is considered one of the models for MMR reduction, and it is often cited as an ideal
example of effective MMR reduction by the WHO. A country with one of the highest MMRs in
the 1990’s, it implemented effective policies to reduce this mortality during the past few years,
far surpassing the results of its neighbors, such as Sierra Leone. Despite the devastating genocide
that shattered the country less than 20 years ago, Rwanda’s quick and effective stabilization
provides an outstanding example of the ways in which a stabilizing country can address maternal
health despite political issues.
Although Nigeria has been moderately successful at reducing its MMR since 1990, it has not
been as successful as its neighboring countries. Therefore, analyzing Nigeria’s effective
implemented policies (and some of their failures) illustrates what has truly been efficient in
reducing MMR. Nigeria is the most densely populated African country, so a reduction in this
country’s MMR would have a large impact on the total number of maternal deaths per year.
Equatorial Guinea is one of the few African countries to achieve the MDG 5, having effectively
reduced its maternal mortality rate by more than 80 percent. Although Equatorial Guinea is a
11
12. model in this respect, not much research has been published on the actual policies implemented
to aid in this reduction, making it difficult to use it as a standard.
India was chosen to study because it is one of the few nonAfrican countries with a very high
maternal mortality rate. Because it is a country with an extremely high birth rate and recent, it is
very much affected by maternal deaths, despite the recent economic boom. It was also interesting
to compare the causes of maternal mortality from one geographical area to another.
Chile is an interesting case for many reasons: first, the availability of data detailing policy
changes over a long period of time (starting in 1957) allowed for an analysis of the country’s
maternal health policies over time. This is important because some policy changes, like
increasing compulsory education, can have benefits that can take more than a generation to come
to fruition. The country’s steady decrease in MMR from 1957 to 2010 indicates that the policies
put in place were effective in the fight against maternal mortality. Fifty years ago, Chile had
what was considered an “average” MMR and now has obtained better results than the United
States without a large increase in economic status, which could help us determine how much
impact public policy alone can have on maternal mortality.
France is a country with a very low maternal mortality rate compared to all the other countries of
our study; however, its MMR is only considered to be average in regards to western Europe, and
France’s MMR is three times higher than that of Sweden. Because of this, it could be interesting
to see what the factors that could explain France’s lower success rate are, especially after that
INSERM, a French Agency, declared that a proportion of French maternal deaths are still
avoidable.
Finally, Sweden was studied for many reasons. First, we could obtain data about Sweden’s
maternal mortality dating back to 1750, which is interesting because Sweden at that time could
be compared to some African countries today in terms of fertility rate, access to care, and
urbanization rate. This gave us an interesting case to study, as they rapidly decreased their
12
13. maternal mortality during the 19th century in order to be the country with the lowest MMR in the
early 1900’s. The country is also an interesting case for today because it still has one of the
lowest maternal mortality rates in the world. What’s also interesting is that currently the main
causes of maternal death are not linked with obstetric causes, but instead due to external factors.
d. Paper Target
This paper has many different target audiences: first, it is intended as a resource for
governmental departments of health of developing and emerging countries to allow them to
evaluate the situation in their own country and then be able to implement the policies that are
needed in their own countries. This is necessary because all countries, due to their own
characteristics and organizations, do not face the same kinds of problems in the fight against
maternal mortality. It is also not feasible to make policy recommendations for countries with
completely different governmental landscapes and organization of health care. For example,
policies that could be implemented and efficient in Sierra Leone might not be as effective in
Nigeria due to its decentralization of health care. Because of this, it is important that every
country completes its own evaluation in order to determine which policies they need to
implement.
Our paper is also aimed at the World Health Organization because broad, global
recommendations are not enough to be effective in all countries. For each country, different
inadequacies need to be targeted, in both the health and economic sectors. Actions that are most
effective when implemented by global health authorities like the WHO. The WHO will be able
to suggest and create the most tailored and effective policy recommendations.
Finally, our paper is intended to draw the attention of healthcare workers, healthcare policy
makers, and other healthrelated organizations to the immediacy and severity of maternal
mortality problem. Not only must these entities realize that maternal mortality is a preventable
problem that is unnecessarily killing thousands of women each year, but they also must
13
14. understand the various mechanisms behind maternal mortality and which policies have been
most effective in reducing MMR in varying situations.
II. Eight Countries: Eight Ways to Tackle Maternal Mortality and an
Analysis of Their Respective Policies
a. Country Profile: Developing Countries
i. Sierra Leone
Background of Sierra Leone
General Economic and Demographic Overview of Sierra Leone
Sierra Leone, a country located in west Africa, boasts an estimated population of 6 million. In
2012 it had an estimated GDP of $3.77 billion with a per capita GDP of $613. The gross national
income per capita increased rapidly in the country during the last few years, as it was only
$324.6 in 2005. Out of the countries chosen for this study, Sierra Leone suffers from the lowest 46
human development index in 2013 with a ranking of 183 out of the 187 ranked countries, for a
value of 0.374. Sierra Leone has the highest MMR in the world, with 860 maternal deaths for 47
100,000 live births reported in 2012. The average life expectancy for men and women is 46.0 48
years and 47.0 years, respectively. Sierra Leone is one of the poorest countries in the world, with
70.2 percent of the population resting at or below the poverty line, with unemployment and
illiteracy running high, especially among the younger generations. A country with many 49
mineral resources such as diamonds, Sierra Leone is now allowed to sell again at the
international level after the dissolution of a trade embargo put in place during its civil war.
Despite its relative poverty, the economy has experienced over 10 percent growth since 2012. 50
The country is still quite rural, with an urbanization rate under 25 percent. 51
46
“Country Profiles: Sierra Leone.” United Nations, 2013. Web.
47
“Sustaining Human progress: reducing vulnerabilities and building resilience”, Human Development Report 2014, United Nations
Development program, 227p. [p. 162]. Web.
48
“Sierra Leone Statistics.” UNICEF, 2014. Web.
49
“Country Info: Sierra Leone.” United Nations Development Profile, 2013. Web.
50
World Bank Data, 2013. Web.
51
Léonidas and al. “West African Urbanization Trends.” West African Future, 2011, n°1. 8p. [p.4]. Web.
14
15.
Political Situation in Sierra Leone
Sierra Leone, situated between Guinea and Liberia, suffered from a terrible, tenyearlong civil
war between 1992 and 2002 that had dramatic consequences for both the economy and the
political situation. Intervention from the United Nations was necessary to put an end to the armed
conflict. The war was provoked by the 1991 invasion by the Revolutionary United Front of
territories which contained large diamond mines. This later led to tension within the Sierra Leone
army and resulted in a coup lead by Valentin Strasser. In 1996 Strasser was usurped by a military
coup from the Revolutionary United Front, who financed its missions through the sale of
socalled “blood diamonds”, a name given to diamonds mined in a war zone and sold to other
countries in order to finance an insurgency or a warlord’s activity. This war led to 52
condemnation of some individual war leaders for crimes of war and human rights violations by
the International Court of The Hague. 70,000 people died during this conflict and an additional
2.6 million were displaced or forced to flee the country. Since the official end of the civil war 53
in 2002 the UN has kept some “blue helmet troops”including soldiers, police officers, and
civiliansto maintain peace in the territory but has reduced surveillance within the country in
order to promote growth and allow the formation of a democracy. In 2012, the first democratic
election without UN control took place with the election of Ernest Bai Koroma. 54
Education in Sierra Leone
Sierra Leone ranks relatively poorly in terms of literacy and secondary education, especially
among the younger generations who were most affected by the civil war in their formative years.
Female (1524 years) literacy rate rests at 50.2 percent, which is significantly lower than the
male literacy rate of 70.5 percent. The Sierra Leone Civil War destroyed 1,270 primary schools.
In 2001, 67 percent of all schoolaged children were out of school, but the situation has improved
52
“Blood diamonds.” Shine on Sierra Leone. Web.
53
“Evaluation of UNDP Intervention.” UNDP, 2006, 40p. [p.4]. Web.
54
“Country profile: Sierra leone.” BBC, 2013. Web.
15
16. to only one out of three schoolaged children being out of school in 2012. Education in Sierra
Leone is legally required for all children starting at six yearsold at both the elementary level and
three years in secondary school, but the sheer shortage of schools, teachers, and poverty has
made its enforcement extremely difficult. However, the situation improved dramatically 55
between 2001 and 2005 with the construction of additional schools and the doubling of primary
school enrollment. On average, men have four years of formal education while women have
slightly more than two. 56
Health Care organization in Sierra Leone
Sierra Leone currently does not have an organized health care system in place. Currently health
care resources are provided publicly, privately, and by NGOs, even though health expenditure 57
in Sierra Leone represents 15.1 percent of its GDP, with a health care expenditure per capita of
$205. The average family in Sierra Leone pays 91.36 percent outofpocket for health expenses 58
per year, compared to the average of 73.7 percent in other similar African countries. 59
Maternal Mortality in Sierra Leone
In 1990, Sierra Leone already had a significantly high MMR, with 1,300 maternal deaths
reported per 100,000 live births. As other African and Asian countries had similarly high 60
MMRs at that time (between 1100 and 1300), Sierra Leone’s rate of maternal mortality had been
considered about average for that region. Over the years, however, while almost every other
country made significant progress in lowering their MMR, Sierra Leone has made virtually no
progress with a current MMR of 1200. The main causes of maternal death are obstetric ones, 61
including hemorrhage, unsafe abortion, and sepsis. The percentage of births attended by skilled 62
health personnel was 62.5 percent in 2010. Sierra Leone had a fertility rate of 4.86 births per
55
“Education in Sierra Leone.” Shine on Sierra Leone. Web.
56
Ibid.
57
. "Health in Sierra Leone." Wikipedia. Wikimedia Foundation,Web
58
"Sierra Leone." WHO. Web.
59
"Health System Report: Sierra Leone." US Aid., 2013. Web.
60
Trends in maternal mortality: 1990 to 2010, WHO, UNICEF, UNFPA and World Bank estimates.
61
“Maternal Mortality 19902013: Sierra Leone” WHO. Web.
62
"Sierra Leone: Slashing the Maternal Mortality Rate in Bo." IRIN News, 2012. Web.
16
17. woman in 2011 and a contraceptive rate of 11 percent, as compared to 21.36 percent amongst
similar African countries. 63
Policies Related to Maternal Health in Sierra Leone
Free Healthcare Initiative
Sierra Leone experiences one of the highest maternal mortality rates in the world. Given the fact
that most cases can be prevented with adequate medical surveillance and care, the government in
2010 implemented the Free Healthcare Initiative in order to make medical care more accessible
to expectant and new mothers and to take a more preventative approach to pregnancy
complications with the goal of reducing the maternal mortality rate in Sierra Leone. This policy
was also implemented to ensure that Sierra Leone would be on track to meet the Millennium
Development Goals on time by 2015. The Free Healthcare Initiative specifically abolishes the 64
health care costs for pregnant women, new mothers, and children under five. The elimination of 65
these costs meant that cost of medical care would theoretically no longer be a barrier to receiving
care and as a result, more women would seek prenatal care and elect to give birth in medical
settings as opposed to giving birth at home. The initiative aimed to change the approach towards
prenatal care and push for the adoption of modern medical care.
Maternal Death Review
The Ministry of Health and Sanitation, in collaboration with the WHO, UNFPA, and UNICEF,
began in 2003 to implement maternal death reviews (MDR) programs. MDRs are case studies, 66
including qualitative information, looking at what may have caused the death, examining
medical as well as personal and social factors that may have contributed to the death. MDRs help
identify gaps in service delivery and also give insight in health system failures and weaknesses,
63
"Health System Report: Sierra Leone." US Aid., 2013. Web.
64
"Free Healthcare Services for Pregnant and Lactating Women and Young Children in Sierra Leone." . Government of Sierra Leone, Nov. 2009.
Web.
65
"Free Healthcare Services for Pregnant and Lactating Women and Young Children in Sierra Leone." . Government of Sierra Leone, Nov. 2009.
Web.
66
"Legislation for Maternal Death Review Policy Brief." MamaYe Web.
17
18. which in turn allow for the prioritization, implementation, and evaluation of maternal mortality
policies. Specific benefits include improving training and professional practice and better 67
understanding of community barriers and challenges. The goal of the MDR project thus is to 68
assess and to obtain specific information that will allow for Sierra Leone to better tackle the issue
of maternal mortality and prevent unnecessary deaths.
Addition of TBA and MCH Aides
The government of Sierra Leone also implemented a program to train women to be Traditional
Birth Assistants (TBA) or Maternal and Child Health aides (MCH) that provide health care,
support, and advice during pregnancy and childbirth. The certification process involves a two
year program sponsored by the Sierra Leone Ministry of Health; however, some women bypass
this process and become unofficial community aides through apprenticeships. By mobilizing
these aides and making them available throughout the countryespecially in rural regions where
access to care can be difficultmaternal mortality should decrease due to the presence of a
trained professional. 69
Implications of Policies Affecting Maternal Mortality in Sierra Leone
Though the government of Sierra Leone currently provides free health care to pregnant and
lactating women as well as children under five years of age, still today one out of every eight
women dies during pregnancy or childbirth. It is obvious from these statistics that there are still 70
issues regarding maternal mortality.
Increased Access to Health Care Services
A year after the Free Healthcare Initiative (FHCI) was implemented, the Sierra Leone health
system saw an improvement in maternal complications managed at health facilities by 150
percent, with a decrease in maternal case fatality rate by 61 percent when compared to the period
67
"Implementing CommunityBased Maternal Death Reviews in Sierra Leone." Care. 2011. Web.
68
"Legislation for Maternal Death Review Policy Brief." MamaYe Web
69
“Save the Children of Sierra Leone.” Sierra Leone Herald, 2013. Web.
70
"Maternal Mortality in Sierra Leone." Amnesty International USA. Web.
18
19. before the implementation. Because previous research conducted by the health system had 71
shown that user fees were the biggest barrier women faced in accessing maternal health services,
the FHCI had expected demand for services to increase dramatically. During the first year of
implementation alone, the number of women accepting modern family planning services rose by
140 percent, and the percentage of women making at least one antenatal care consultation
increased by 35. Although the FHCI program saw significant results, it may not be sustainable 72
as it receives over 87 percent of its funding from foreign donors. Furthermore, Sierra Leone’s
weak health infrastructure, with poorly equipped health facilities and illtrained health workers,
may not be able to continue the program without further aid and/or a restructuring of its health
system. 73
Delays in Seeking Care
One major issue is that even though health care is free for pregnant women, many have problems
in being transported to the hospital in the case of an emergency. 62 percent of the population live
in rural areas not within walking distance of a hospital, and the fear of having to pay for
transportation can delay some medical decisions after it is too late. Few ambulances are 74
available for emergencies, forcing families to pay for costly taxi services. Much of the country’s
health care infrastructure was destroyed during its decadelong civil war, which forces patients to
travel long distances to reach the appropriate medical centers and even upon arrival, the doctor
may refuse to operate on a patient who may not be able to pay for her own medical supplies. 75
Transfer Delays
For women who chose to give birth in the presence of either an MCH or a TBA aide,
complications during delivery which require hospitalization can create more delays and further
worsen the situation. Many hospitals do not have ambulances, requiring the patient to pay for a
taxi. Furthermore, many hospitals only have one or two doctors who specialize in obstetrics, so
71
Unicef/nyhq20110727/asseli. "Case Study on Narrowing the Gaps for Equity." Case Study on Narrowing the Gaps for Equity Sierra
Leone(2011): 2. Nov. 2011. Web.
72
Ibid, p. 3
73
Ibid, p. 5
74
"'Healthy Women, Better World' – Tracking Maternal, Newborn and Child Survival." At A Glance: Sierra Leone. UNICEF. Web.
75
Ibid.
19
20. patients may arrive at the hospital in dire condition and be forced to wait until a doctor is free or
a surgical room is made available. Patients in need have been turned away when the only doctor
oncall is too fatigued and overworked from performing other surgeries to take on more
patients. Many hospitals also lack the necessary medical equipment, some even requiring
patients’ families to supply blood for blood transfusions or pay for basic medical supplies such
as needles. This scarcity of resources can also lead doctors to pick and choose patients based on 76
their ability to pay. 77
Poor Quality of Care
Additionally, though there has been the addition of Traditional Birthing Assistants (TBA) and
Maternal and Child Health aids (MCH) across the nation, the quality of care remains relatively
poor. MCH and TBA aides receive two years of education provided by the Sierra Leone 78
Ministry of Health and are then considered to be certified to carry out normal deliveries, usually
at the village level where there is no direct access to a hospital. Some critics consider only two
years of education to be too little to deal with possible complications during childbirth, and it has
been suggested that the government increase the required years of education. However, it would
be costly for the government to train its staff, which could hinder its implementation. Since the
implementation of these birthing aides, there has been massive demand for MCH and TBA aides,
leaving them struggling to meet the needs of these women. Also, even though health care is 79
free, many of these birthing assistants are not paid or are paid very poorly through small amounts
of rice or chicken. Consequently, many are forced to charge their patients for their services. 80
Being poorly paid also gives little incentive to staff to provide the upmost quality of care for
their patients, while the fear of being charged can hinder women from seeking help during
delivery. For example, 25 out of 27 birthing assistants interviewed said the lack of incentive is
what kept them from referring women to health centers to deliver. In the hopes of decreasing 81
76
“Country Profile: Sierra Leone.” HFG Project, UNAID, 2013. Web.
77
Anderson, Jill. “Sierra Leone Slashing Maternal Mortality Rate.” CNN News, 2014. Web.
78
"Sierra Leone's Free Health Care Initiative." Health Poverty Action (2010): 17. Web.
79
“Country Profile: Sierra Leone.” HFG Project, UNAID, 2013. Web.
80
“Trends in maternal mortality: 1990 to 2010.” WHO, UNICEF, UNFPA and World Bank estimates. Web.
81
Anderson, Jill. “Sierra Leone Slashing Maternal Mortality Rate.” CNN News, 2014. Web.
20
21. the number of people who give birth in a TBA aide’s home in the hopes of forcing women to
give birth in a healthcare facility, the Sierra Leone government has started to redefine the role of
the TBA by transforming them into Maternal Health Promoters (MHP’s), or women who
accompany pregnant women to appointments and assist them after the birth with nutrition and
breastfeeding information. However, 45 percent of women still report giving birth in the
presence of a TBA, with the percentage being as high as 77 percent in rural areas. 82
All of these issues (delays in seeking care, transfer delays, and low quality of care) contribute to
the continually high rate of maternal mortality amongst women in Sierra Leone despite the
implementation of free healthcare for pregnant women and children. Though health services are
technically free, many doctors and other health professionals are forced to charge their patients
for care and medical supplies, which hinders women out of fear of her inability to pay. Hospitals
and health centers still lack the appropriate supply of medical necessities that can further hinder
access and quality of care even after a patient arrives.
ii. Rwanda
Background of Rwanda
General Economic and Demographic Overview of Rwanda
Rwanda, a densely populated central African country, has been marked with political tumult in
the past. With a GDP of $7.452 billion in 2013, a GDP per capita of $633, and a population of 83
11.78 million, it is considered to be a lowincome country. 44.9 percent of its population was at
the national poverty line in 2011, a slight decrease from previous years. Life expectancy at birth
in 2012 was 57.7 years for men and 60.8 years for women. The country has a Human 84
Development Index of 0.434, a slight increase from previous years but still below the average of
other countries in the low human development group, as well as its neighboring countries in
subSaharan Africa. 85
82
"Sierra Leone: Slashing the Maternal Mortality Rate in Bo." IRIN News. Nov. 2012. Web.
83
"GDP per Capita (current US$)." Data. World Bank. Web.
84
"Rwanda." Data. World Bank. Web.
85
"Rwanda." Africa Bibliography 2003 (2004): 107110. Web.
21
22.
Rwanda has been striving to rebuild its economy, aiming to transform from a lowincome,
agriculturebased economy to a middleincome, knowledgebased, serviceoriented economy by
2020; average economic growth between 2001 and 2012 was 8 percent a year, driven primarily 86
through coffee and tea exports and increased tourism. Rwanda is highly dependent on foreign 87
aid, with 30 to 40 percent of its budget coming from aid organizations. Rwanda experienced a
sharp decline in the amount of foreign aid in mid2012, which did not seem to affect the
economy until 2013, when economic growth declined significantly. 88
Political Situation in Rwanda
Rwanda’s political history has been marked by severe ethnic tensions, most notably culminating
in the unforgettable and devastating 1994 genocide that rocked the country, killing between
500,000 and 1 million Tutsis and moderate Hutus. The government claims that the country is 89
now stable. The Rwandan government is organized as a semipresidential constitutional 90
republic, in which the president elected by popular vote is the head of the state and appoints the
prime minister and other cabinet members. The current constitution, which was adopted in 2003
to replace the transitional constitution that had been in place since 1994, mandates a multiparty
government system and explicitly condemns genocidal ideology. 91
Education in Rwanda
Education is provided at no cost by the Rwandan government for nine years, which include six
years in primary school and three in secondary. President Paul Kagame announced in his 2010
reelection campaign that he would extend the free education to cover the final three years of
secondary school. Although the education is provided for free, many students are still unable to
attend because of commitments at home or the financial burdens of purchasing uniforms and
86
"Rwanda." Overview. World Bank. Web.
87
"Rwanda Country Profile Overview." BBC News. Web.
88
"Rwanda." Overview. World Bank. Web.
89
"Politics and Government in Rwanda." Wikipedia. Wikimedia Foundation. Web.
90
"Rwanda Country Profile Overview." BBC News. Web.
91
"Rwanda Politics and Government." UNICEF. UNICEF Foundation. Web.
22
23. books. The female literacy rate in Rwanda was 65 percent as compared to the men’s literacy 92
rate of 72 percent, a significant increase from previous years. Secondary school net enrollment 93
is currently at 28 percent, and 30 percent of females attend secondary school. 94
Health Care Organization in Rwanda
Progress had started towards decentralizing Rwanda’s health management system, first to the
province and then to the district level, but was interrupted by the 1994 genocide which crippled
the entire country, including the health system that had already been in place. The current 95
system is a multitiered, decentralized system comprised of dispensaries for primary care; health
posts for outreach activities like immunizations, antenatal care, or family planning; health centers
for inpatient care; 39 district hospitals; and 4 national referral hospitals.
Health insurance is provided mainly through the CommunityBased Health Insurance Scheme
introduced in 2004 that is comprised of a social health insurance program known as “Mutuelles
de Santé.” The insurance covers care at all public and nonprofit centers in the country but not at
private health centers. By 2010, 91 percent of the Rwandan population was insured through this
scheme. Members pay annual premiums ($6 per family member), with a 10 percent service fee
paid at each hospital or health center visit. The Rwandan health system is financed by both state
funds and individuals’ contributions through health insurance and direct payment for services. 96
The average family in Rwanda pays for 49.4 percent of their health care expenditure
outofpocket per year. 97
Maternal Mortality in Rwanda
Rwanda has seen the greatest success in reducing the rate of maternal mortality (MMR) amongst
its African neighbors, decreasing from 1400 deaths per 100,000 live births down to 320 in the
past twenty years. The main causes of maternal mortality in Rwanda are currently hemorrhage, 98
92
"Rwanda Education." International Rwanda. Rwanda Free Press. Web.
93
"Rwanda Statistics." UNICEF. Web.
94
"Education in Rwanda." UNICEF Rwanda. Web.
95
“Health Care in Rwanda.” UNICEF Rwanda. Web.
96
"Health System." Department of Health. Government of Rwanda. Web.
97
"Rwanda." HFG Statistics. USAID. Web.
98
“Maternal Health in Rwanda.” World Health Organization, 2013. Web.
23
24. followed by sepsis and eclampsia. Many attribute this development to the increase in births 99
occurring with a skilled medical attendant, with now 71 percent of deliveries being in the
presence of a skilled professional. Other changes in the care of expectant mothers include 100
increase in the accessibility of care and the training of more healthcare professionals to take care
of the population. The fertility rate in 2012 was 4.6 women per children, and the average
contraceptive prevalence was 51.6 percent, compared to the average of 21.4 percent amongst
similar African countries. 101
Policies Affecting Maternal Mortality in Rwanda
Though Rwanda is similar to other African countries in terms of scarce access to resources and
heavy reliance on external resources to fund public health, Rwanda has been steadily making
improvements in its effort towards MDG 5 with its new policy changes.The WHO decided that
there are three common obstacles to the effective delivery of care in most African countries:
delays in seeking care, transfer delays, and shortcomings in the quality of care. The Rwandan 102
government, through the Ministry of Health, has been taking steps to implement effective policy
changes in order to systematically combat these issues. 103
Delay in Seeking Care
In Rwanda, the fast uptake of modern medical assistance, including family planning as well as
health centers, is a part of a health education campaign on the importance of these activities for
maternal and child health. This has helped to combat the delays of some women to seek health
care when it is necessary, which can delay or inhibit timely diagnosis and treatment. The delays
could be due to suspicion or ignorance of modern health services, prohibitive costs, and weak
incentives to use public health facilities. This has been supported by a series of fines imposed on
women who fail to attend antenatal care and deliver in health care centers. 104
99
“Family Planning Policy”: 1017. Ministry of Health. Government of Rwanda. Web.
100
“Maternal Health in Rwanda.” World Health Organization, 2013. Web.
101
“Health Indicators.” World Bank. Web.
102
"Country Accountability Framework: Rwanda." World Health Organization (2013). Web.
103
"Delivering Maternal Health: Why Is Rwanda Doing Better than Malawi, Niger and Uganda?": 12. Overseas Development Institute, May.
Web.
104
Ibid, pps. 34.
24
25.
Increased Family Planning Services
The family planning program implemented in Rwanda has been spearheaded by strong
government commitment and the support of developmental partners in order to drastically
increase the percent of women with access to contraceptives. The National Reproductive Health
Policy passed in 2003 identifies FP as a key priority area and set a rather modest target of
achieving 15 percent modern CPR among women of childbearing age by 2010, up from 4
percent at that time. The policy outlines key strategies to achieve the set target including
improving awareness of and access to FP services for the population via social communication
programs; integrating FP in Safe Motherhood and Child Health services; strengthening men’s
participation through communitybased structures; increasing availability and revival of FP
services in all health facilities; establishing a system to monitor FP activities in all health centers
at all levels; and involving political and administrative authorities and community leaders in FP
mobilization.
The CommunityBased Provision of this program, aimed at tackling the issue of
105
access for women in rural regions, has been mobilizing the country’s villagebased Community
Health Workers to increase the use of modern contraceptive devices, support effective
contraceptive supply, stimulate demand, and create an environment of support. The Ministry of
Health has created a program in order to promote efficiency and results. These defining elements
include training, integration of newer methods of FP into the communitybased provision health
care package, service delivery, monitoring and supervision, quality assurance through
performance reviews and promotions, logistics management to eliminate overstock, and
performancebased financing. 106
Transfer Delays
The feasibility of timely transfers to higherlevel health facilities for medical interventions was
also a problem in Rwanda, where the physical distances for patients are smaller than most other
countries, but transport challenges are not insignificant. These barriers have been reduced
105
"Family Planning Policy." (2012): 17. Republic of Rwanda Ministry of Health. Web.
106
Chambers, Victoria. "Improving Maternal Health When Resources Are Limited: Safe Motherhood in Rural Rwanda." Africa Power and
Politics (2012): 14. Africa Power and Politics Programme. Web.
25
26. significantly thanks to the adherence of a community insurance scheme that covers 90 percent of
the cost of ambulance transfers. Rwanda’s Mutuelle insurance program, where participants pay 107
a yearly fee and 10 percent of their medical costs, has greatly increased medical care access to
both women and children. Now more than 90 percent of the population is enrolled.104
In addition,
voluntary community health workers have been issued mobile phones in order to call health
facilities for referrals about care. There has also been an increase in socalled “waiting wards”
for expectant mothers in order to decrease the risk of accidental home birth. The health
expenditure per person in Rwanda has increased from roughly $20 in 1995 to slightly over $100
in 2009. Similarly, the percentage of government budget allocated to health care increased from
8.2 percent in 2005 to 10.2 percent in 2010. 108
Improving Quality of Care
Finally, service quality has been an issue in the country for years. In order to keep health care
facilities up to standards, superior authorities from hospitals pay visits to regional health centers
in order to make sure that opening hours are respected, the levels of hygiene are adequate, and
staff are respectful towards patients. These visits are random and unannounced and are part of
the P4P scheme and therefore tied to the income of health care facilities. Overall, consistent
incentives through rewards and sanctions have played a large role in the improvement of health
care in Rwanda by ensuring that different health care workers are working towards the same
goals. Though the health care system is decentralized, local actors remain accountable to the
national health care apparatus. Therefore, improvements in service delivery have been driven by
topdown performance pressures. The rewards are usually cash incentives for health care service
workers for satisfactory performance and sanctions such as audits after a maternal death or losing
employment for poor performance. More details are provided in Table 1. 109
107
"Delivering Maternal Health: Why Is Rwanda Doing Better than Malawi, Niger and Uganda?" Overseas Development Institute, May 2012.
Web.
108
"Country Accountability Framework: Rwanda." World Health Organization (2013). Web.
109
“Delivering Maternal Health: Why is Rwanda doing better than Malawi, Niger, and Uganda?” p. 3. Overseas Development Institute, May
2012. Web.
26
27.
Table 1: Examples of Incentives
Job/Position Rewards Sanctions
Users Free gifts for neonatal care
attendance
Fines imposed for home birth
Community Health Workers Cash incentives for strong
performance reviews
Can be removed from post
Health Service Providers Monetary incentives for good
hospital performance reviews
Health center audit in the case of a
maternal death
Local Authority Staff Local authority rankings confer
high status on good performers
Can lose job for poor performance
Source: Observational fieldwork in Nyamagabe and Musanze districts, 20092011
Rwanda’s P4P Scheme
The Rwandan government also instituted a Pay for Performance (P4P) scheme in 2005 to
supplement primary health care’s inputbased budgets after encouraging results by
nongovernmental organizations who have had success with similar programs. In this scheme,
payments are made directly to facilities and funds are used at that facility’s discretion. There are
fourteen key maternal and child healthcare output indicators for which P4P indicators are given.
Some indicators are reason for a visit, such as delivery, and some are services provided during a
visit, such as vaccinations. The Rwandan government set these output indicators on the basis of
national health priorities and budget. Facilities must submit monthly activity reports and
110
quarterly requests to a district payment committee, which is responsible for the verification of
data and the process of payment. The verification process includes random auditing of health
110
“Delivering Maternal Health: Why is Rwanda doing better than Malawi, Niger, and Uganda?” p. 3. Overseas Development Institute, May
2012. Web.
27
28. centers on random, unannounced days to verify that the data reported is the same as those in the
facility's records. The Ministry of Health has completed a oneoff tracking survey of roughly
1000 patients to verify the accuracy of the records and found a falsereporting rate of less than 5
percent.
111
Results of Policies Affecting Maternal Health in Rwanda
Although Rwanda had had similar conditions of resource scarcity and similar approaches to
health financing as Malawi, Niger, and Uganda, it implemented specific policies to overcome the
three main obstacles to service provision common to all four countries (delays in seeking care,
transfer delays, and shortcomings in the quality of care) to see significantly better outcomes in its
MMR by comparison. Since 2000, Rwanda’s maternal mortality rate has declined steeply, 112
from about 1,050 deaths per 100,000 live births in 2000 to fewer than 500 deaths per 100,000
live births in 2010, and was estimated to have an MMR of 320 in 2013. Between 2005 and 113 114
2010, the percentage of women giving births in health facilities increased from 28 to 69 percent,
respectively. The unmet need for family planning also decreased from 38 to 19 percent, in 115
large part due to the increased uptake of family planning in the country.
Improving Quality
According to a large study by the Rwanda School of Public Health, the P4P program has had a
significant positive impact on the percentage of institutional deliveries and the quality of prenatal
care, with no impact on the number of prenatal care visits. In the sample of 80 treatment facilities
in the study, the P4P payments increased average overall expenditures by 22 percent. On
average, facilities allocated 77 percent of the P4P funds to increase personnel compensation,
111
Ibid, p. 4.
112
Ibid, p. 4.
113
Ibid, p. 2..
114
“Trends in maternal mortality: 1990 to 2013” pps. 2, 26. World Health Organization, 2014. Web.
115
“Delivering Maternal Health: Why is Rwanda doing better than Malawi, Niger, and Uganda?” p. 2. Overseas Development Institute, May
2012. Web.
28
29. amounting to a 38 percent increase in staff salaries. Facilities with the P4P scheme experienced a
23 percent increase in the number of institutional deliveries and increases in the number of
preventive care visits by children aged 23 months or younger (56 percent) and aged between 24
months and 59 months (132 percent). 116
These differences found are probably related to the structure of the incentives. In general, there
was a larger impact on services with higher incentives and for services that are more in the
control of the provider and depend less on patients’ decisions, like prenatal care quality and
tetanus vaccination. Deliveries have the highest unit payment rate at $4.59. Providers reported
they found deliveries to be so lucrative they not only encouraged women to deliver in the facility
during prenatal care, but some also commissioned community health workers to conduct
outreach in the community to find pregnant women to deliver in the facility. Similarly, the large
increase in preventive child visits is also explained by the higher payment rate. One of the
strongest monetary payoffs is for prenatal care quality. Specifically, every administration of
tetanus vaccine yields $0.92, as well as increases the prenatal care quality index score. Health
care providers can also use prenatal care visits to lobby women to deliver in the facility, a service
for which they receive a relatively high payout rate. Finally, improved compliance with prenatal
care clinical practice guidelines raises the facility’s overall quality score and thereby the share of
the P4P payments actually received. Similarly, the lack of improvement in the utilization of
prenatal care can be explained by its low payment rate of $0.09 per visit. 117
One of the more important results of the P4P scheme is the impact on the quality of care
provided. Although health workers may be competent to perform a medical procedure or
consultation, they may not always be willing or motivated to expend the effort to perform all the
required components of that procedure. In order to combat this, the Rwanda P4P payment is
based on a quality index score determined through patient interviews and checklists of questions
that should be asked during the visit (e.g. medical and sexual history). The evidence suggests that
116
"Rwanda's P4P Programme." Paying Primary Health Care Centers for Performance in Rwanda:12. 2010. Web.
117
Ibid, p. 5.
29
30. the incentive gives providers the motivation to translate their knowledge about prenatal care into
better practice.
The Rwandan government has been using this knowledge to increase the payment incentives for
services which have the largest impact on health and trying to increase the dependency of
incentives on the quality score. Similarly, they are moving to compensate the patient instead of
the provider for health care services that depend more on patient behavior, such as the decision
to seek prenatal care. This is important because better care yields better primary health
outcomes; however, while access to care is important, it also matters that the care received is of
high quality. 118
Effects of Increased Family Planning
Although contraceptive prevalence in 2010 had been projected by researchers to reach 26.3
percent in 2010, it increased significantly from 17 percent in 2005 to 52 percent in 2010. Of 119
the increased prevalence rate of contraceptives, the most effective characteristic of the increase
(responsible for about 77 percent of the effects) can be attributed to the contribution of effects
such as women’s education, the experience of child mortality, and the woman’s place of
residence. 120
The Rwandan government recognized early on that high fertility rates (and subsequent
population growth) were one of the main hurdles to their efforts towards MDG 5 and committed
to a high level of family planning as a result, increasing the budget allotted towards family
planning activities sixfold, from $91,231 in 2004 to $5,742,112 in 2007. 121
One of the main challenges in regards to family planning for the Rwandan health system was that
of finding a way to provide contraceptives to citizens. Because a significant proportion of the
health facilities in Rwanda are faithbased (40 percent in 2001), they do not usually offer modern
118
"Rwanda's P4P Programme." Paying Primary Health Care Centers for Performance in Rwanda: 110. 2010. Web.
119
“Measuring the Success of Family Planning Initiatives in Rwanda: A Multivariate Decomposition Analysis” p. 3. Muhoza, 2013. Web.
120
Ibid, p. 1.
121
Ibid, p. 4
30
31. contraceptives. In order to overcome this barrier, the Rwandan government constructed 122
‘secondary posts’ nearby the religiouslyaffiliated health clinics to meet the needs of women
from those areas. 123
The specific policies the Rwandan government implemented were successful because they
addressed both the way the communities learned to use the services available and widened the
availability of services provided. The increase in contraceptive use in Rwanda between 2005 and
2010, which helped to lower the fertility rate from 6.1 to 4.6 births , can be explained not only 124
by the increased availability of contraceptives but also changes in women’s socioeconomic
factorssuch as education about sexual and reproductive healthand exposure to family
planning messages. 125
Rwanda is considered to be “on track” by the WHO to achieve the MDG 5 target 5A by 2015, a
classification given to countries whose MMR has declined by at least 75 percent between 1990
and 2013. 126
iii. Nigeria
Background of Nigeria
General Economic and Demographic Overview of Nigeria
Nigeria, Africa’s most populous country with a total population of 173.6 million, has a low
human development index rating of 0.504 given by the United Nations and is ranked 152 out of
187 countries. In 2013, its total GDP was $528.1 billion with a per capita GDP of $3,416. 46.0 127
122
Ibid, p. 3
123
Ibid, p. 5
124
Ibid, p. 1
125
Ibid, pps. 89
126
“Trends in maternal mortality: 1990 to 2013” pps. 2, 26. World Health Organization, 2013. Web.
127
“Sustaining Human progress: reducing vulnerabilities and building resilience”, Human Development Report 2014, United Nations
Development Program, 227p. [p. 162]. Web.
31
32. percent of its population rests at or below the poverty line. Currently 49 percent of Nigeria’s 128
population lives in rural areas, which is a marked decrease from 56 percent recorded in 2002. 129
Political Situation in Nigeria
Wrecked with the havoc of multiple military coups and violence between religious and ethnic
groups, the recentlyelected Nigerian leadership faces the challenge of preventing the country
from breaking apart. Thousands of people have been killed in recent years by the terrorist group
Boko Haram, and although the government has been trying to improve the economy through an
oil boom, the country experiences significant amounts of corruption. Nigeria is a federal 130
republic formed after that a brutal period of civil strife between 19701997, and is modeled after
the United States, with executive, judicial, and legislative branches and four different systems of
law, which include English law, Common law, Customary law, and Sharia law. All major 131
parties have practiced vote rigging and other means of coercion in order to remain competitive.
In 1983, the policy institute at Kuru concluded that only the 1959 and 1979 elections to that time
were conducted with minimal vote rigging. 132
Education in Nigeria
The Nigerian education system, which is divided into kindergarten, primary education,
secondary education, and tertiary education, is controlled by local authorities in each state. The
Universal Basic Education Commission in the country mandates nine years of formal schooling
that is free, compulsory, and “the right of every child”. The literacy rate for women was only 133
49 percent in 2011, significantly lower than the average men’s literacy rate of 78.2 percent. 54
percent of the total female population has either obtained or is in the process of obtaining
secondary education. 134
128
“Nigeria.” WorldBank, 2013. Web.
129
“Rural Population as Percentage of Whole Population.” Trading Eceonomics, 2013. Web.
130
“Country Profile: Nigeria.” BBC, 2013. Web.
131
Ibid.
132
Igitseme, Joseph. “Nigeria at Cross Roads.” Third Term, May 2012. Web.
133
“Education in Nigeria.” Info by Country. UNICEF, 2013. Web.
134
“Nigeria Statistics.” Info by Country. UNICEF, 2013. Web.
32
