The DFID-funded Reducing Maternal and Neonatal Death in Kenya programme aims to reduce mortality through increased access to and utilisation of quality maternal and newborn health (MNH) services. The original programme design focused on improving the knowledge and skills of health workers to provide emergency obstetric and neonatal care (EmONC), strengthening health systems and interventions to increase demand for MNH services in six of Kenya’s 47 counties (Homa Bay, Turkana, Garissa, Kakamega, Nairobi and Bungoma).

This Assignment Report reviews the performance of the programme. The programme has made good progress since the 2017 DFID Annual Review and has scored an overall ‘A’ (outputs exceeded expectations). At the current rate of progress, it is on track to meet its original outcome and output targets for 2019.

Originally designed for the cadre of Health Advisers at DFID, it has been adapted to suit a broad range of actors involved in strengthening policy and programming interventions.

This resource has been collaboratively produced by members of the HEART PEAKS consortium in collaboration with colleagues in the UK Department for International Development (DfID), and beyond.

The package is divided into two components:

Inform: What are the issues, concepts and frameworks that I need to get to grips with? What does the latest evidence indicate?

Engage: What can we learn from experience with and beyond DFID’s portfolio of work, about making progress towards quality outcomes in MNH?

It should be no secret that approximately 830 women die every day of pregnancy- or delivery-related complications. A significant proportion of these deaths, and the deaths of 7000 newborns every day, is due to infection. Without clean water and basic sanitation, a safe delivery, without risk of infection, is severely compromised.  Instead of viewing WASH as a separate issue from maternal and newborn health, we must include WASH when recognising and tackling the factors that cause infection and threaten safe, clean birth.

At The Soapbox Collaborative, we are committed to ensuring mothers and babies avoid preventable infections at the time of delivery. Working in low- and middle-income countries (LMICs) with overseas and UK partners, we aim to improve hygiene practices with low-cost simple interventions through both research and action.

Since our previous HEART blog, our work has developed a strong focus on the importance of cleaners and domestic staff in health facilities, a group which is often marginalised and forgotten in the bigger WASH picture. This key group is often neglected when it comes to proper training in cleaning practice and IPC measures. A barrier to this is low-literacy, meaning a traditional lecture-style approach based on reading and writing is not sufficient for training. Soapbox has developed a participatory training package for cleaners that we have piloted in The Gambia and can be adapted for local contexts. This package includes practical teaching modules and visual, accessible guidelines for IPC and cleaning. Training in this area makes health facilities cleaner, safer places for mothers and newborns, and indeed all patients, who may be at risk of life-threatening infections.

WASH is linked in many ways to maternal and newborn health. Imagine giving birth in a facility where there was no clean water to prevent infections during delivery and aid the healing process. In LMICs however, 35% of health facilities lack access to water and soap for handwashing. These basic resources are critical to hand hygiene, which has been hailed as the single most important intervention to prevent infection. Our work on the HANDS Project with partners from the Ministry of Health, Jhpiego, WaterAid Tanzania and others, looked at resource availability and other barriers to hand hygiene in maternity units in Zanzibar, Tanzania. The resulting interventions included the restructuring of the maternity units to improve workflow and make practising effective hand hygiene easier. Simple solutions such as this can make all the difference to improving IPC and hygiene.

Finding and implementing solutions to WASH and IPC within maternity units requires commitment from partners at every level; from national and global, right down to local health facility staff. The solutions to improving WASH and IPC, and reducing deaths and illness from maternal and newborn infections can often be the simplest ones. With maternal and newborn health, WASH, and IPC undeniably linked, they must be addressed together to ensure no more lives are lost to preventable infection.

By Joanna MacQueen (Junior Communications Officer, The Soapbox Collaborative), June 2018.

The More Mobilising Access to Maternal Health Services in Zambia programme (MORE MAMaZ), funded by the UK charity Comic Relief (2014-2016), achieved transformational change for women and girls, particularly those who are under-supported at household and community level by successfully scaling up an evidence-based demand-side intervention in support of the Ministry of Health’s safe motherhood policy response.

MORE MAMaZ punched above its weight in so many ways. The health-related results achieved can be seen in this infographic, including institutional delivery rates up at 89% in intervention districts, compared to the national average for rural areas of 56%. There has also been a significant improvement in the proportion of women opting for early antenatal care, which is a key priority of the MOH.

Behind these results lie other gains which are just as important: considerable empowerment-related gains, which will help to position women and girls so that they benefit from other development-related opportunities in the future; a very significant reduction in gender-based violence; and evidence that the most difficult to reach women and girls are being targeted and supported by their communities.

It is also worth noting that the training approach used by the programme helped produce volunteer retention rates of 82% among volunteers trained 4-5 years ago and 95% among volunteers trained two years ago. These rates are much higher than those achieved by many other similar programmes globally.

MORE MAMaZ showcases to a large extent what Health Partners International does best: developing and supporting implementation of practical and sustainable systems-oriented solutions to global health challenges; achieving value for money – MORE MAMaZ achieved more than MAMaZ while working on a considerably larger scale; and forming honest and lasting partnerships with government and consortium partners, while building sustainable local capacity.

We invite you to read the programme’s seven evidence briefs, which showcase the results achieved, and different components of the approach, and other programme materials, including the 8 key messages for policy makers in the health sector, and to share them within your networks. Many of the strategies and approaches developed by the programme and its local partners lend themselves to adaptation for implementation in different contexts.

By Cathy Green, Technical Lead- Community Health Systems, Health Partners International

For more information on how Health Partners International is transforming health systems and the lives of women and girls please visit www.healthpartners-int.co.uk or contact info@healthpartners-int.co.uk.

Depression is a mental disorder characterised by low mood, loss of interest or enjoyment, and reduced energy, leading to increased fatigue, reduced activity, and marked functional impairment (WHO, 1990). Other common symptoms are reduced concentration, reduced self-esteem, ideas of guilt or unworthiness, pessimistic views of the future, ideas or acts of self-harm or suicide, disturbed sleep, disturbed appetite and irritability. Depression is more severe than everyday fluctuations in mood, and leads to significant personal suffering and impairment in normal functioning.

Maternal depression is defined as depression experienced by a mother during pregnancy or the postnatal period (first 12 months of her baby’s life). The experience of maternal depression may vary substantially across cultures, with a variety of culture-specific idioms of distress. Examples include kufungisisa “thinking too much” in Zimbabwe (Patel et al, 1997), ukudakumba “being sad or unhappy” and ucingakakhulu “thinking too much” in South Africa (Davies et al, 2016), and yandimukuba “being struck by pressure” in Uganda (Nakku et al, forthcoming). These experiences are often accompanied by social isolation, withdrawal and stigma. Prevalence estimates for maternal depression vary. A recent systematic review reported that 16 per cent of pregnant women and 20 per cent of postnatal women experience depression in low- and middle-income countries (LMIC) (Fisher et al, 2012). This is higher than high-income countries, where 10 per cent of pregnant women and 13 per cent of postnatal women experience depression (O’hara and Swain, 1996).

Risk factors for maternal depression include poverty, unintended pregnancy, younger age, being unmarried, lacking intimate partner empathy and support, trauma (especially intimate partner violence), insufficient emotional and practical support, and HIV status (Fisher et al, 2012; Hartley et al, 2011). Conversely, protective factors include, social support, family involvement, planned pregnancy, partner involvement, and individual resilience factors such as optimism (Grote and Bledsoe, 2007).

Impact on the woman and her children

Maternal depression has a number of negative consequences for the woman herself. These include loss of functioning (inability to perform everyday tasks or social roles), loss of interest in self-care and child care, behaviour that affects other health conditions (for example, poor adherence to antiretroviral treatment for HIV), and risk of suicide or self-harm. A global systematic review reports that between 5 per cent and 14 per cent of women report suicide ideation during pregnancy or the postnatal period (Lindahl, Pearson and Colpe, 2005). Most suicides happen in the postnatal period (Gentile, 2011) and the presence of perinatal depression predicts suicide (Lindahl, Pearson and Colpe, 2005). Suicide now surpasses maternal mortality as the leading cause of death in girls aged 15-19 years, globally (Petroni, Patel and Patton, 2015).

Recent research from LMIC has revealed a number of negative consequences of maternal depression for the child. These include effects on children’s general health, development and behaviour (Wachs, Black and Engle, 2009; Hayes and Sharif, 2009), diarrhoeal episodes (Ross et al, 2011), malnutrition (Anoop et al, 2004; Patel, De Souza and Rodrígues, 2002), impaired physical development including significantly reduced height and weight and impaired mental development (Patel, De Souza and Rodrígues, 2002; Hadley et al, 2008), as well as poor mother-infant attachment and impaired mother-child relationships (Tomlinson, Cooper and Murray, 2005; Cooper et al, 1999).

Given the effect of maternal depression on infant and child developmental trajectories, maternal depression may play a key role in maintaining inter-generational cycles of poverty. However, the longitudinal data to support this hypothesis is not yet available in LMIC. Atif Rahman and colleagues in Pakistan are conducting long-term follow-up of children of maternally depressed women and are investigating this area in an ongoing way (Maselko et al, 2015).

Screening and diagnostic tools for maternal depression in low-income settings

A variety of screening tools have been used in low-income settings, including the Edinburgh Postnatal Depression Scale (EPDS) (Cox, Holden and Sagovsky, 1987), which has been validated in many settings (De Bruin et al, 2004) and other general depression screening tools such as the Patient Health Questionnaire (PHQ) (Kroenke and Spitzer, 2002), the Centre for Epidemiological Studies Depression Scale (CESD) (Radloff, 1977) and the Self Reporting Questionnaire (SRQ20) (Beusenberg and Orley, 1994). The benefits of screening tools are that they can facilitate a relatively quick and cheap assessment of potential depression and facilitate access to community-based care. General health practitioners such as nurses or community health workers can be trained to administer screening tools. The risks are that such tools may lack local cultural validity: with inadequate sensitivity they may miss real cases of depression and with inadequate specificity they may overburden services with ‘false positive’ cases (Kagee et al, 2013). A further risk is that if adequate resources are not in place in the health system, the system may be flooded by new referrals whose needs cannot be met. Careful consideration of the broader health system requirements of introducing routine screening is therefore essential.

A more rigorous but also more costly alternative is a diagnostic assessment by a mental health professional (for example using the WHO ICD10) (WHO, 1990), or the use of diagnostic assessment instruments such as the Mini International Neuropsychiatric Interview (Sheehan et al, 1998) or the Composite International Diagnostic Interview (CIDI) (Kessler and Ustun, 2004). The latter instruments take longer to administer than screening tools, require more skilled personnel and are therefore more costly. They may also suffer from similar problems of inadequate local cultural validity if they have not been properly adapted and translated into the local language.

A third alternative (and relatively recent innovation) is the use of idioms of distress to generate vignette based detection tools such as the Community Informant Detection Tool in Nepal (Jordans et al, 2015). This approach marks a step forward in identifying culturally valid experiences of depression, although substantial adaptation may be required for local cultural settings.

When should one screen? Some researchers have argued that the perinatal period is a time of high risk for women and their infants, and that routine antenatal screening for mental health, particularly in communities where high prevalence has been reported, should be mandatory (Honikman et al, 2012). Recently, the US Prevention Task Force published findings in the Journal of the American Medical Association (JAMA) recommending routine screening for depression, especially for pregnant and postpartum women (Siu et al, 2016). The final decision on whether to introduce routine antenatal or postnatal depression screening should depend on a number of considerations, including the prevalence of maternal depression in the local setting, the local validity of screening tools, and the availability of resources for detection and treatment.

What is good practice? Interventions in low resource settings

There is good emerging evidence for the cost-effectiveness of adapted psychological interventions, such as cognitive behaviour therapy (CBT), delivered by community health workers or lay counsellors, using a task shifting or task sharing approach (Chowdhary et al, 2014). For example, a large randomised controlled trial using Lady Health Workers to deliver a Thinking Healthy intervention in Pakistan demonstrated a significant improvement in depression outcomes (Rahman et al, 2008). As a result, the WHO has endorsed this approach and published a Thinking Healthy manual for maternal depression (WHO, 2015). Other trials are underway currently, for example, using peer counsellors in India and Pakistan (Sikander et al, 2015), and community health workers in South Africa (Lund et al, 2014).

How can maternal depression interventions be integrated into general maternal health programmes?

Integration is possible and there are several best practice examples, for example, the Perinatal Mental Health Project in Cape Town, South Africa (Honikman et al, 2012). Steps for integrating maternal depression interventions into wider maternal health programmes include the following:

• Select a suitable locally relevant screening or detection tool. Examples of screening tools include the EPDS or PHQ9 (see above) and clinical algorithms include the WHO mhGAP Intervention Guide (WHO 2010).
• Adapt and translate the screening tool if necessary.
• Conduct a needs assessment: administer the screening tool to all antenatal and postnatal mothers over a specified period of time to determine prevalence.
• Based on the identified need, design a stepped care approach, appropriate to the local setting:
  • Step 1: routine or selected antenatal and postnatal screening
  • Step 2: screen positives referred for evidence-based counselling
  • Step 3: referral of mothers who are not responsive to counselling for assessment by a medical doctor or a suitably qualified prescribing practitioner for potential anti-depressant medication
• Note:
  • Five-day training (for example, using the WHO Thinking Healthy manual) (WHO, 2015), plus ongoing supervision of counsellors is essential. Appropriately selected lay counsellors or community health workers within the existing health system may be able to take on this role, although careful attention should be paid to potential counsellors’ personal capacity, motivation and skills (Honikman et al, 2012). Counsellors can include psychological counsellors and community health workers such as the Lady Health Workers in Pakistan (Rahman et al, 2008). Currently trials are under way in Pakistan and India to assess the effectiveness and cost-effectiveness of peer counsellors for perinatal depression (Sikander et al, 2015). The time required for counsellors to provide counseling will depend on the caseload, whether group or individual sessions are conducted and the number of sessions attended by each woman detected with depression.
  • It is also important that the broader health system is strengthened to cope with the possible additional demand. This should include appropriately trained medical personnel and the supply of appropriate anti-depressant medication for mothers who do not respond to psychological interventions. See other models, such as the Perinatal Mental Health Project (PMHP) for an indication of possible demand for medical personnel and medication – in the case of the PMHP only 2 per cent of women who received counseling were referred and seen by a psychiatrist (Honikman et al, 2012), but needs are likely to vary substantially based on a variety of contextual factors.
  • Costs to the health system are likely to vary substantially depending on demand, coverage and local health system costs (including personnel, medication and facilities). Estimates of the costs of integrating maternal mental healthcare into general primary care systems in LMIC are the subject of ongoing studies, such as the PRogramme for Improving Mental health carE (PRIME) study, which generated estimates of between US$5.05 in Ethiopia and US$14.48 in India per perinatally depressed woman treated with psychosocial care (Chisholm et al, 2016).

Some research and innovation groups working in maternal mental health in LMIC are:

• Atif Rahman, Vikram Patel and colleagues at the University of Liverpool, working in Pakistan and India
• Simone Honikman and colleagues at the Perinatal Mental Health Project in Cape Town, South Africa
• Jane Fisher and colleagues at Monash University, Australia
• Ricardo Araya and colleagues at the Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, United Kingdom, with projects in Brazil and Chile
• Juliet Nakku and colleagues at Makerere University, Kampala, Uganda
• Charlotte Hanlon and colleagues at Addis Ababa University, Ethiopia

Funders who have supported research in this area include the Wellcome Trust, Grand Challenges Canada, the National Institute of Mental Health and the Department for International Development (DFID).

For more on global mental health innovations, see the Mental Health Innovation Network: http://mhinnovation.net

Key readings

Reading 1: Fisher J, Mello MCd, Patel V, et al. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. Bull World Health Organ 2012; 90(2): 139-49. /doc_lib/prevalence-determinants-common-perinatal-mental-disorders-women-low-lower-middle-income-countries-systematic-review/

Reading 2: Patel V, De Souza N, Rodrígues M. Postnatal depression and infant growth and development in low income countries: a cohort study from Goa, India. Arch Dis Child 2002; 87: 1-4. /doc_lib/postnatal-depression-infant-growth-development-low-income-countries-cohort-study-goa-india/

Reading 3: Rahman A, Malik A, Sikander S, Roberts C, Creed F. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised control trial. Lancet 2008; 372: 902-9. /doc_lib/cognitive-behaviour-therapy-based-intervention-community-health-workers-mothers-depression-infants-rural-pakistan-cluster-randomised-controlled-trial/

Reading 4: Honikman S, van Heyningen T, Field S, Baron E, Tomlinson M. Stepped care for maternal mental health: a case study of the perinatal mental health project in South Africa. PLoS Med 2012; 9(5): e1001222. /doc_lib/stepped-care-maternal-mental-health-case-study-perinatal-mental-health-project-south-africa/

Reading 5: WHO (2015). Thinking Healthy: A manual for psychological management of perinatal depression. Geneva: WHO. /doc_lib/thinking-healthy-manual-psychosocial-management-perinatal-depression/

Reading 6: Kagee A, Tsai AC, Lund C, Tomlinson M. Screening for common mental disorders in low resource settings: reasons for caution and a way forward. International Health 2013; 5(1): 11-4. /doc_lib/screening-common-mental-disorders-low-resource-settings-reasons-caution-way-forward/

References

• Anoop S, Saravanan B, Joseph A, Cherian A, Jacob K. Maternal depression and low maternal intelligence as risk factors for malnutrition in children: a community based case-control study from South India. Arch Dis Child 2004; 89(4): 325-9.
• Beusenberg M, Orley J. A user’s guide to the Self-Reporting Questionnaire (SRQ). Geneva: World Health Organization; 1994.
• Chisholm D, Burman-Roy S, Fekadu A, et al. Estimating the cost of implementing district mental healthcare plans in five low- and middle-income countries: the PRIME study. The British Journal of Psychiatry: The Journal of Mental Science 2016; 208 Suppl 56: s71-8.
• Chowdhary N, Sikander S, Atif N, et al. The content and delivery of psychological interventions for perinatal depression by non-specialist health workers in low and middle income countries: a systematic review. Best Practice & Research Clinical Obstetrics & Gynaecology 2014; 28(1): 113-33.
• Cooper PJ, Tomlinson M, Swartz L, Woolgar M, Murray L, Molteno C. Post-partum depression and the mother-infant relationship in a South African peri-urban settlement. The British Journal of Psychiatry 1999; 175(6): 554-8.
• Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. The British Journal of Psychiatry 1987; 150(6): 782-6.
• Davies T, Schneider M, Nyatsanza M, Lund C. “The sun has set even though it is morning”: Experiences and explanations of perinatal depression in an urban township, Cape Town. Transcultural Psychiatry
• De Bruin G, Swartz L, Tomlinson M, Cooper P, Molteno C. The factor structure of the Edinburgh Postnatal Depression scale in a South African peri-urban settlement. South African Journal of Psychology 2004; 34: 113-21.
• Fisher J, Mello MCd, Patel V, et al. Prevalence and determinants of common perinatal mental disorders in women in low-and lower-middle-income countries: a systematic review. Bull World Health Organ 2012; 90(2): 139-49.
• Gentile S. Suicidal mothers. Journal of Injury and Violence Research 2011; 3(2): 90.
• Grote NK, Bledsoe SE. Predicting postpartum depressive symptoms in new mothers: the role of optimism and stress frequency during pregnancy. Health & Social Work 2007; 32(2): 107-18.
• Hadley C, Tegegn A, Tessema F, Asefa M, Galea S. Parental symptoms of common mental disorders and children’s social, motor, and language development in sub-Saharan Africa. Ann Hum Biol 2008; 35(3): 259-75.
• Hartley M, Tomlinson M, Greco E, et al. Depressed mood in pregnancy: prevalence and correlates in two Cape Town peri-urban settlements. Reprod Health 2011; 8: 9.
• Hayes B, Sharif F. Behavioural and emotional outcome of very low birth weight infants–literature review. The Journal of Maternal-fetal & Neonatal Medicine 2009; 22(10): 849-56.
• Honikman S, van Heyningen T, Field S, Baron E, Tomlinson M. Stepped care for maternal mental health: a case study of the perinatal mental health project in South Africa. PLoS Med 2012; 9(5): e1001222.
• Kagee A, Tsai AC, Lund C, Tomlinson M. Screening for common mental disorders in low resource settings: reasons for caution and a way forward. International Health 2013; 5(1): 11-4.
• Kessler RC, Ustun TB. The World Mental Health (WMH) survey initiative version of the WHO-CIDI. International Journal of Methods in Psychiatric Research 2004; 13: 95-121.
• Kroenke K, Spitzer RL. The PHQ-9: A new depression diagnostic and severity measure. Psychiat Ann 2002; 32(9): 509-15.
• Jordans MJ, Kohrt BA, Luitel NP, Komproe IH, Lund C. Accuracy of proactive case finding for mental disorders by community informants in Nepal. The British Journal of Psychiatry: The Journal of Mental Science 2015; 207(6): 501-6.
• Lindahl V, Pearson JL, Colpe L. Prevalence of suicidality during pregnancy and the postpartum. Archives of Women’s Mental Health 2005; 8(2): 77-87.
• Lund C, Schneider M, Davies T, et al. Task sharing of a psychological intervention for maternal depression in Khayelitsha, South Africa: study protocol for a randomized controlled trial. Trials 2014; 15: 457.
• Maselko J, Sikander S, Bhalotra S, et al. Effect of an early perinatal depression intervention on long-term child development outcomes: follow-up of the Thinking Healthy Programme randomised controlled trial. The Lancet Psychiatry 2015; 2(7): 609-17.
• Nakku J, Elialilia O, Kizza D, et al. Maternal mental health care in a rural district, Uganda: A qualitative study of barriers, facilitators and needs. BMC Health Services Research Under review.
• O’hara MW, Swain AM. Rates and risk of postpartum depression-a meta-analysis. Int Rev Psychiatry 1996; 8(1): 37-54.
• Radloff LS. The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement 1977; 1(3): 385-401.
• Ross J, Hanlon C, Medhin G, et al. Perinatal mental distress and infant morbidity in Ethiopia: a cohort study. Archives of Disease in Childhood-fetal and Neonatal Edition 2011; 96(1): F59-F64.
• Patel V, Todd C, Winston M, et al. Common mental disorders in primary care in Harare, Zimbabwe: associations and risk factors. The British Journal of Psychiatry 1997; 171: 60-4
• Patel V, De Souza N, Rodrígues M. Postnatal depression and infant growth and development in low income countries: a cohort study from Goa, India. Arch Dis Child 2002; 87: 1-4.
• Petroni S, Patel V, Patton G. Why is suicide the leading killer of older adolescent girls? Lancet 2015; 386(10008): 2031-2.
• Rahman A, Malik A, Sikander S, Roberts C, Creed F. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised control trial. Lancet 2008; 372: 902-9.
• Sheehan DV, Lecrubier Y, Sheehan KH, et al. The Mini-International Neuropsychiatric Interview (MINI): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998; 59: 22-33.
• Sikander S, Lazarus A, Bangash O, et al. The effectiveness and cost-effectiveness of the peer-delivered Thinking Healthy Programme for perinatal depression in Pakistan and India: the SHARE study protocol for randomised controlled trials. Trials 2015; 16: 534.
• Siu AL, Force USPST, Bibbins-Domingo K, et al. Screening for Depression in Adults: US Preventive Services Task Force Recommendation Statement. Jama 2016; 315(4): 380-7.
• Tomlinson M, Cooper P, Murray L. The mother–infant relationship and infant attachment in a South African peri‐urban settlement. Child Dev 2005; 76(5): 1044-54.
• Wachs TD, Black MM, Engle PL. Maternal depression: a global threat to children’s health, development, and behavior and to human rights. Child Development Perspectives 2009; 3(1): 51-9.
• ICD-10 Classification of Mental and Behavioural Disorders. Geneva: WHO; 1990.
• mhGAP Intervention Guide for Mental, Neurological and Substance Use Disorders in non-specialized health settings: Mental health Gap Action Programme (mmhGAP). Geneva: WHO; 2010.
• Thinking Healthy: A manual for psychological management of perinatal depression. Geneva: WHO; 2015.

At national level, women parliamentarians had played a pivotal role in keeping maternal health care on the policy agenda. Understanding the role of women in health system governance at the sub-national level was key to understanding how they could contribute to maternal health care utilisation, and ultimately to Uganda’s attainment of the new Sustainable Development Goals. One theme that kept popping up during my interviews and discussions with community leaders, health workers and officials in the district governments was the role women in leadership played in shaping health service delivery for the better. Two distinct patterns emerged: women’s leadership within their communities; and within decentralised government.

Leadership in the community

In Northern Uganda’s patrilineal-based society, women still belonged to the “outer court”– so to speak – they were not recognised as important actors in the community. There were indeed some volunteering roles increasingly taken up by women in the post-conflict communities that had an element of leadership. These included: volunteering as budget monitors (like community level ombudsmen monitoring the quality of health service delivery); community health workers; and, prefects supporting the distribution of humanitarian aid to resettling households. These activities certainly had a positive impact on health care but had a major drawback: they were not culturally rooted and this would not portend their survival once NGOs funding these activities shut down.

However, an incident took place in Northern Uganda that gained some media attention. It was not directly related to health but still spoke to this issue. In Amuru District, a more remote area of the region hundreds of villagers sat across a road in a desperate bid to block a team of government surveyors flanked by senior politicians and armed enforcement that had come to redraw the boundaries of their ancestral land. The government team were just as unflinching, determined to get this vacillating dispute out of the way. The confrontation was about to turn violent were it not for some elderly women that suddenly stepped out of the now emotionally charged crowd, they stripped themselves bare and marched towards the armed foe. The standoff came to an abrupt end as the government’s team withdrew in embarrassment. So far, the exercise has been shelved following the national outrage that the incident generated. Granted, this may have merely been an act of desperation, rather than an orchestrated strategy but it was a pointer to the sense of responsibility that women felt.

Leadership in local government

Conversely, further afield in the corridors of decentralised power, a very different scenario was playing out. Women politicians were being portrayed as totally cowed individuals, unable to effectively represent their constituents in Council. They were said to be actively avoiding engagement with the electorate and their impact was impalpable. Women respondents that I interacted with felt that male politicians were more proactive and had done a lot more for maternal health care. Many argued that the women politicians were still acting in obeisance to tradition norms that expected women to maintain silence as men deliberated. It was also considered that the lowly education of women councillors limited them in debate with their better-educated, more exposed male counterparts.

What does this mean for health systems?

In his book, “Displacing Human Rights: War and Intervention in Northern Uganda”, Branch spoke of this. The war in Northern Uganda diminished the absolute authority of the traditional leader and propagated the leadership role of women. Before the war, older men were often seen as community leaders and protectors of the region’s age-old patrilineal tradition. According to Branch, the authority of these male elders was further buttressed by the direct links that communities in the region had to state power. The war eroded these links and disrupted community ties as people were dispersed into internally displaced camps or out of the region. In the camps, men’s role as a breadwinner was superfluous; women became the household contact for the distribution of food rations and were more engaged in livelihood support activities. Redundancy, it is stated, drove many men into drunken debauchery. This pattern was seen to continue even after people returned to their homes at the end of war.

On the other hand, echoing my findings in decentralised government, a recent UNDP report recognises that women are limited to playing a “seconding, signing and supporting” role in the District Councils. The report explicitly attributes this to adherence to cultural norms that “thrive on the subordination of women”.

Just like the MDGs, the SDGs will be difficult to attain if women do not play a role in supporting the prioritisation of maternal health care. The government’s gender mainstreaming agenda has provided an enabling environment for post-conflict tradition societies to harness the women’s leadership roles at community level. However, the formal governance establishment remains insulated from such positive trends. Health systems strengthening efforts require more concerted efforts to promote and engage women’s governance roles in all echelons of society if they are to be successful.

By Andrew Alyao Ocero, Commonwealth Scholar pursuing a PhD in Policy and Health Systems Research at the Liverpool School of Tropical Medicine, where he is affiliated with the ReBUILD and RinGs DFID-funded projects. He has a medical background having worked as a specialist physician for 18 years in clinical and public health settings in conflict-affected Northern Uganda.

Photo credit: Singers performing at an International Women’s Day event in 2011. Photo by Jake Lyell.

This blog was originally posted on Health Systems Global on 7 March 2016. Reposted with permission.

The presentation focused on standards based audit as CMNH’s key methodology, the linkages with maternal death audits and also the importance of effective measurement, including the outcomes of improved quality.  Dr Ameh presented a case study from Kenya which reinforced many of the key points made by Prof van den Broek.

Throughout the presentation Prof van den Broek advocated for different ways of thinking about QoC, based on the assumption that women understand what is available to them and make decisions on this basis.

Traditional approaches have focused on increasing access; however is it now time to think about what should be done at health facility level to make sure women come to the facility? There is limited research but it is clear that if the QoC is poor, women and their families are less likely to visit a facility.

Three key methodologies/tools for quality of care were highlighted: Maternal audit/review, perinatal death audits; and standards based audits. There is currently insufficient robust evidence on the effectiveness of audits.

Key learning from the case study: setting up confidential enquiry into maternal deaths in Kenya include:

• Setting up the system is a long process, the advocacy requires time.
• Surveillance systems needs a more innovative approach.
• There can be a catalytic effect.
• Essential ingredients for an effective/successful maternal death and surveillance response:
  • Strong structures put in place
  • National committee supported by competent and motivated assessors
  • National ownership
  • Political will and funding
  • Ownership at level of MoH and professional associations

The challenge of good quality EmOC is that good quality care is underfunded and understaffed. Ayesha de Costa looks into bringing in the private sector to improve provision. She presents a case study: The Public Private Chiranjeevi Yojana (CY) to support institutional delivery in Gujarat, India. The programme was largely designed to provide access for vulnerable women but also to ensure the care is of good quality. India is dominated by private health care and most qualified obstetrician/gynaecologists (OB/GYNs) practice in the private sector. Public sector EmOC is largely inadequate and this was recognised by the State. In CY the State pays private obstetricians to care for vulnerable women. The aim of the project is to harness the private sector resource for vulnerable women rather than move towards privatisation.

CY have performed one million deliveries for women below the poverty line and tribal women since its inception in 2007. Ayesha further describes the rationale for the programme, the programme contribution to institutional delivery, uptake, and quality of care. Quality of care is assessed by looking at outputs: EmOC services, skilled staff, facilities, drugs equipment, transport and outcomes; facility deliveries, skilled birth attendants, critical clinical interventions. Criteria to ensure quality of care were for facilities to have: at least ten beds, full-time OB/GYN, operating theatres for CS’s, and access to an anaesthetist. CY facilities were found to be significantly better staffed and equipped than government facilities.

Some CY obstetricians have left the scheme, due to difficulties in interfacing with the State. There is often mistrust regarding payments. Private obstetricians were finding payments not remunerative enough, the State have now raised payments.

To deter induced demand (unnecessary CS’s) CY facilities were paid per 100 deliveries irrespective of whether they were CS or not. Accountability to the user is also important in maintaining quality. Quality in the processes of care is difficult to assess in the CY programme because they are private facilities. Inability to monitor is a drawback. Impact indicators, particularly maternal mortality, are not used as they are so few and they are not disaggregated by programme and non-programme.

The programme has not been found to weaken the public sector.