Public action for gender equality
issues, change behavior, and boost demand. In Cambodia, Indonesia, and Vietnam, appeals to people’s sense of collective community responsibility contribute to sustainable sanitary behaviors. Some rural communities in Vietnam agreed on targets for better sanitary practices (building facilities, disposing waste), with local governments monitoring compliance and publicizing the results over community radio. Some communities in Indonesia initiated competitions by schools and found that the subsequent pressure from children to adopt “winning” behaviors were the main drivers of changes in hygiene practices. Reducing maternal mortality While significant progress has been made in reducing maternal mortality in the past twenty years, global progress is happening at a pace far short of that needed to reach the Millennium Development Goal of reducing maternal mortality by three-quarters. Certain regions lag behind. In Sub-Saharan Africa, a woman faces a 1 in 31 chance of dying from complications from pregnancy or childbirth; in rich countries, this risk is 1 in 4,300.7 Significant disparities exist within countries as well. In Afghanistan, the overall maternal mortality rate of 1,400 per 100,000 live births masks large variations—the rate is around 400 in Kabul but over 6,500 per 100,000 live births in some remote rural areas.8 The key to lowering maternal mortality is to provide prompt and adequate attention to expectant mothers. As chapter 3 noted, that is easier said than done because of the number of links in the chain—for mortality to come down, the whole system needs to work. Women need attention before, during, and after childbirth so that the risk of potentially life-threatening conditions can be mitigated or addressed in a functioning hospital if necessary. Better institutions are critical because they mean that pregnant women and their families do not need to make a series of difficult decisions about what medical attention to seek, when, and where. Improving the institutions charged with providing maternal health care means acting on many fronts. First, more resources are required to expand access to the chain of services—especially to front-line service providers—that can reduce maternal mortality. Recognizing that need, the global community in 2009 committed an additional $5.3 billion to improve health care for
mothers and young children. And early in 2011, a group of bilateral and multilateral aid agencies and private foundations launched a grant facility—the Grand Challenge for Development—to reduce maternal and neonatal mortality. But as Malaysia and Sri Lanka illustrate, more money is not always the critical factor—both countries dramatically reduced maternal mortality with fairly modest increases in spending. In both countries, spending on maternal and child health since the 1950s has never exceeded 0.4 percent of GDP annually. Instead, they upgraded the quality of the people delivering the chain of services. While there will be a continuing need for additional health workers, especially skilled birth attendants, coverage can also be increased especially in underserved areas by drawing in community-level providers and the private sector. One way of doing this is to delegate many clinical tasks from higher-level health providers to mid- or lower-level providers. In rural India, the management of sepsis, typically done by physicians, is instead done by trained communitybased health workers using preassembled antibiotic packages.9 Locating skilled health workers closer to those who lack access also helps. An example is Indonesia’s Bidam Di Desa (village midwife) program, which trained more than 50,000 midwives and placed them in rural areas throughout the country. The proportion of attended births increased significantly, especially among the poorest rural residents.10 Technology can help provide these front-line service providers with assistance when they need it. Uganda’s Rural Extended Services and Care for Ultimate Emergency Relief program uses radios and walkie-talkies to connect health facilities, ambulances, and midwives and to provide birth attendants with a way to receive immediate advice from more senior medical staff.11 Purchasing services from private providers can also be a cost-effective alternative to the public provision of maternal health services. In Cambodia, districts in which nongovernment organizations received government funding to
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We need a clinic nearby and it should be open every day. Rural woman, South Africa
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