Quality healthcare for all children – where are we in achieving the MDGs for maternal and child health?

At the United Nations General Assembly in 2000 more than 150 global leaders, including the President of South Africa, signed the Millennium Declaration. In doing so they committed their countries to achieving a set of goals known as the Millennium Development Goals (MDGs). Child health is represented by MDG 4 that states that all countries will reduce the under 5 mortality rate (U5MR) by two thirds by 2015 from the base year of 1990. For South Africa this would mean bringing it down to a rate of 20/1,000 live births by 2015. For maternal health MDG 5 states that all countries will reduce by three quarter the maternal mortality ratio (MMR). For South Africa this means reaching a MMR of 38/100,000 live births by 2015.

So 2015 is an important year. A year to take stock of where we are with regards to the MDGs as well as prioritize actions based on lessons learned for the next phase, namely to meet the Sustainable Development Goals (SDGs) (2016-2030).

How have we performed on MDG 4 and MDG 5?

At face value South Africa is falling well short of achieving either of the maternal and child health MDGs. The most recent estimates are that the U5MR was 44 in 2013 and the MMR was 140 (1). It is very unlikely that the MDGs will be met by 2015.

However, dig beneath these headline numbers and the picture is more encouraging. According to the latest UNICEF "A Promise Renewed" report (2), South Africa has one of fastest declining mortality rates in the world. This has been achieved thanks to substantial progress in critical programmes such as the prevention of malnutrition, prevention of mother to child transmission of HIV (PMTCT), immunisation and access to free health care facilities.

Further acceleration, however, will be inhibited on the one hand by environmental factors such as epidemics, persistent socio-economic inequalities and access to other services affecting sexual and reproductive health; and on the other hand by issues of management of the centres of delivery such as hospitals and clinics reflected in sub-optimal quality of care.

Can we sustain progress?

Over the last decade, there have been several programme reviews, operational research studies and surveys giving both quantitative and qualitative insights to behaviours and practices and outcomes related to maternal and child health indicators in South Africa.

The recommendations from the MDG report from the Government (3) included:

1. The influence of contributory socio-economic factors on child mortality levels: 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 differ widely at district level. The extent to which these differentials may be responsible for pushing up national estimates of child mortality needs further examination.
2. Empowering women: the challenge arises of how maternal education can be made an integral part of poverty reduction strategies.
3. Lack of integrated planning: issues of child health are often left to the Department of Health (DoH), but certain developmental factors that may impact on child survival are not the responsibility of the DoH. While provision of adequate health facilities may be the responsibility of the DoH, 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, as the DoH uses the primary healthcare approach to provide child care services.
4. Monitoring: it is clear from the estimates that accurate data for monitoring childhood mortality levels is still a challenge. A Demographic Heath Survey should be conducted in 2014. There is also a need to strengthen the registration of deaths and associated causes of deaths.

The key Maternal, neonatal, child and women's health and nutrition review 2014 (4) recommendations include:

1. Know your issues, track your response, we are accountable: target setting and data management, accountability and involvement.
2. Getting the basics right: infrastructure, drugs, equipment, balance supply and demand, supervision and mentoring systems, consistency and quality of care.
3. Connecting the dots: Cascades and pathways and transport and referrals.

Furthermore, the review prioritized the following key population groups, namely, women, with a focus on adolescent girls and the first 1,000 days of life (mother and child).

The MDG Countdown report for South Africa 2014 (5), lists 33 interventions that if implemented at scale could potentially save 25,000 child lives annually. Eleven of these interventions account for 70% of these potential child lives saved, amounting to about 16,500 child lives.

Transition from MDGs to Sustainable Development Goals (SDGs)

The MDGs’ focus on national and global averages and progress can mask much slower progress or even growing disparities at the sub-national level and among specific populations. Accelerating progress towards some targets is easier when resources are concentrated among the better off which may result in channelling of resources away from the poorest population groups or from those that are already at a disadvantage because of the effects of discrimination based on their gender, ethnicity, disability or residence.

MDGs marked a historic effort for global mobilization. While the SDGs favour a new concept of health that moves away from the notions of absence of disease and survival towards wellbeing, resilience, and capability.

The Sustainable Development Goal for health is proposed as:  Ensure healthy lives and universal health coverage at all ages. The sub goals include:

1. Achieve and exceed the health-related Millennium Development Goals (MDGs)
2. Address the burden of non-communicable diseases, injuries, and mental disorders
3. Achieve Universal Health Coverage including financial risk protection
4. Address the social and environmental determinants of health

The SDG framework also proposed a cycle of well being: The life-course approach takes into account the multisectoral nature of advances in women’s and children’s health. Universal health coverage has special importance. That means ensuring women and children have access to care, that services are designed with women and children in mind, and that women and children are assured of financial risk protection.

Key recommendations

The way forward for SA should be ruthless prioritization of quality delivery at scale for a small number of interventions that address the major causes of child deaths in their specific context is urgently needed. It is critical that health for women and children is seen as a right and not a privilege.