Getting to the Last Mile – diagonal approach and pathways for improving maternal and child health outcomes in South Africa

South Africa is committed to reaching the Millennium Development Goals (MDGs) for maternal and child health. Over the last few years, the country has made tremendous progress in improving the health outcomes for women and children across the country. However, the country still faces various challenges in reaching the targets as outlined in the Government plans as well as the MDGs.

Maternal mortality still high

According to the independent Expert Review Group (iERG) 2013 report titled "Every women, every child: Strengthening equity and dignity through health", South Africa's maternal mortality ratio (MMR) for 2010 was 300 per 100 000 live births" (1). As per Statistics South Africa (StatsSA), nearly 1.3 million births were registered in the country in 2010. If this is used as a basis to extrapolate from the 300 per 100 000 then well over 3 800 South African women died in that year, either as a result of their pregnancy or during or after childbirth. According to the report South Africa is not among those countries "on track" to meet the MDG target of reducing its MMR by three-quarters between 1990 and 2015, which translates to 38 deaths per 100 000 births by 2015.

The latest District Health Barometer (2) shows a national decrease in the numbers of maternal deaths. The use of maternal and child health services, such as prenatal care and professionally assisted delivery, are significantly related to quality of care and the MMR. Data from the DHIS based on the information from public health facilities, suggests that the percentage of expected deliveries that occur in health facilities in the country is high, showing an increase from 67% in 2003 to 91% in 2011 (3).

Access and use of contraceptive and antenatal care services are components of reproductive health. However, poor transport facilities, lack of proper health care facilities and lack of appropriately trained staff, the latter being responsible for an inability to follow standard procedures and poor initial assessment and diagnosis, are some of the factors that hinder progress in reducing maternal mortality in South Africa (3). The interplay of socio-economic factors and gender inequalities exert a negative outcome on maternal health, affecting not only the extent to which health care services are accessed and utilised, but access to family planning services as well, making empowerment of women and girls essential in lowering maternal mortality.

A key challenge in maternal mortality in South Africa is the absence of multi-sectoral planning for addressing socio-economic inequities necessary for the primary healthcare approach to be successful.  In the long term, the empowerment of women is important as the interplay of socio- economic factors and gender inequalities exert a negative outcome on maternal health. This affects not only the extent to which health-care services are accessed and utilised, but access to family planning services as well.

Child deaths

South Africa is committed to reducing the deaths of children under the age of 5 years to 20 deaths per 1 000 births as part of the MDGs. But in 2011, the country had triple this target with almost six percent of all children born dying before their fifth birthday – mainly from AIDS-related illnesses, diarrhoea, pneumonia, malnutrition and within a week of being born.

Worldwide, the leading causes of death among children under five include pneumonia (18%), preterm birth complications (14%), diarrhoea (11%), intra-partum-related complications (9%), malaria (7%), and meningitis and tetanus (6%). Infectious diseases are typical of those who are poor and vulnerable and who lack access to basic prevention and treatment interventions (1).

Under-five mortality is generally considered as an indicator of the general health status of a population as well as the level of socio-economic development in a country. As per the MDG report submitted by South Africa (3) it seems likely to achieve the set target of 20 under-five child deaths per 1 000 live births, with the current level estimated at 53 child deaths per 1 000 live births. Similarly, the targeted IMR of 18 is likely to be achieved, with the 2010 level estimated at 38 infant deaths per 1 000 live births. This is in part due to the successful implementation of the prevention of mother-to-child transmission (PMTCT) program and the improvement in access and coverage to paediatric HIV programs, as well as the immunization programs. It is also linked to the decrease in trends of diarrhoea and pneumonia amongst children (3).

However, the challenge is to understand the influence of contributory socio-economic factors on child mortality levels: challenges regarding poverty levels, type of dwelling, access to basic services such as piped water, clean drinking water, basic sanitation services and the availability of safe energy sources remain. Furthermore, there is wide disparity at district levels. The extent to which these differentials may be responsible for pushing up national estimates of child mortality needs further examination.  The lack of integrated planning on issues of child health also contributes to the vertical and silo-ed approach to improving child health outcomes.

While provision of adequate health facilities may be the responsibility of the Department of Health, the provision of an efficient transportation system, provision of safe water and sanitation is not its responsibility. There is therefore a need for integrated sectoral planning so that developmental issues including health can be approached in a holistic manner.

Diagonal approach to improving maternal and child health programs

With all the above commitments, and South Africa’s thrust towards achieving results for women and children, there is a sense of urgency at all levels to change the statistics (for the better) and to meet the said targets. Three areas can be considered: coverage, quality and equity. Underlying these three areas should be the principle of ‘science and evidence’ and ‘innovation’. This is graphically represented in the Figure below.


This may seem simplistic at a glance, however, the systematic scientific approach embedded in strong evidence using innovative ways of doing things can just tip the scale towards meeting the goals for women and children. We have a lot of information on what works, and we know the challenges in the country. So how do we fast track action through all layers – policy makers, to program managers, to health care providers and community systems?

South Africa has witnessed major gains in the HIV treatment program, in the PMTCT program over the last decade. One can consider a diagonal approach to improving maternal and child health programs. Frenk and Sepúlveda describe the diagonal approach as a "strategy in which we use explicit intervention priorities to drive the required improvements into the health system, dealing with such generic issues as human resource development, financing, facility planning, drug supply, rational prescription, and quality assurance." (4).

While using the diagonal approach it is also important to identify pathways to make quality care for all women a reality. These pathways must reflect the lifecycle approach for all women – starting from adolescent girls, to women of the reproductive age group, pregnancy, child birth and post-natally. The pathways must also intersect and define the linkage between communities and health facilities as well as referral linkages.

Way forward – looking at the bigger picture

One principle of the post-2015 development framework is that actions that reinforce other development goals should receive particular emphasis. Maternal mortality and morbidity are not only health issues, they are core to a host of other aspects of development.  Women at higher risk of dying or experiencing pregnancy-related complications often also face the pressures of poverty, poor infrastructure, and restrictive gender norms that undermine their ability to care for their health (1).

Equity in health highlights, for example, access to maternal care across social groups and geographic regions within a country. Accelerating progress in maternal health requires that we disaggregate maternal outcomes in ways that provide the data for better, more targeted resource allocation. It is critical to implement targeted actions to make maternal information and services available to the most-in-need, underserved communities (5). We should channel resources in accordance with needs on the basis of data disaggregated by age, geography, wealth quintile.

Some of the critical questions and areas for South Africa in the coming years should be strengthening the systems of accountability with some concrete steps. How does one allocate budgets? How are these monitored and what is the accountability system in place? Who should be monitoring maternal health programmes and held accountable at all levels?

We must select highly cost effective high impact interventions that bridge the link between communities and households with facilities. We must invest in pathways that we know are effective with levels of consistency and accountability of that investment measured and monitored towards improved outcomes for our women and children.

Note that the views expressed in this article are those of the author and do not necessarily represent the views of UNICEF or PHASA.

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