News Release

Health system policy gaps and conflicts hindering the route to MDGS for many priority countries

Peer-Reviewed Publication

The Lancet_DELETED

Many priority Countdown countries have policy gaps hindering their progress towards MDGs for maternal and child mortality. Coupled with formidable challenges in health financing and human resources, lack of policy measures poses a serious threat to rapid scaling-up of effective maternal, newborn, and child health interventions. These are the conclusions of Dr Elizabeth Mason, WHO, Geneva, Switzerland and colleagues from the Countdown Working Group, who discuss the issues in a Health Policy paper in this week’s Countdown Special Issue of The Lancet.

The authors say: “To have a broader understanding of the environment in which health services are delivered and health outcomes are produced is essential to increase intervention coverage. Programmes to address maternal, newborn, and child health rely on health systems to generate information needed for effective decisions and to achieve the expected outcomes. Governance and leadership are needed throughout the process not only to create policies and implement them but also to assure quality and efficiency of care, to finance health services sufficiently and in an equitable way, and to manage the health workforce.”

They looked at 13 separate indicators of health policy and systems under five categories – evidence and information; leadership and governance; service delivery; financing; and health workforce. There was a huge variation in the status of these indicators both between and within countries. In terms of the health workforce, 54 of the 68 priority Countdown countries have fewer than 2.5 physicians, nurses and midwives per 1000 population, a benchmark that has been assessed internationally as a critical threshold for countries to achieve adequate coverage rates – notably those crucial to MNCH.. For service delivery, one intervention – use of community health workers to treat childhood pneumonia – was only authorised in 18 of the 68 countries. However another intervention under the same category - use of oral hydration salts and zinc to prevent diarrhoea – has seen substantial progress in many of these countries. Under the financing category, the authors looked at, among other issues, out-of-pocket expenditure for health services at point of use – and propose that where this expenditure is more than 15% of the total health expenditure, this can cause households big problems and lead to them not seeking the care they need. Unfortunately, this payment burden is above 15% for 60 of the 68 priority countries.

The authors also identify three potential conflicts that prevent policy uptake – commercial interests, professional interests, and product availability. For commercial interests, they found that policies which require intersectoral action and involve employment, trade, and financial interests can be the hardest to adopt. For professional interests, they found that, for example, policies that promote task delegation and support task shifting to less qualified (eg, nurses) of health workers can be resisted by those who are more highly qualified (eg, doctors). And for product availability, the effectiveness of a new policy can obviously be hindered by lack of product availability – for example the zinc supplementation policy mentioned above has been troubled by lack of a suitable product.

The authors conclude: “If governments are to exert leadership to promote the maternal, newborn, and child health agenda, policies need to be in place to create a facilitating environment and direct the use of scare resources….The Countdown initiative will continue to monitor the status of indicators of health policy and health and health systems as a complement to coverage indicators, will seek to work with partners to improve the measurement methods,, and will facilitate the integration of policy and health system considerations into the efforts to rapidly scale-up maternal, newborn and child health interventions.”


Dr Elizabeth Mason, WHO, Geneva, Switzerland, Tel +41227913281, mobile +41793089873.

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