Investment case for improving maternal and child health: results from four countries
1 School of Population Health, 4th Floor, Public Health Building, University of Queensland, Herston Road, Herston, QLD 4006, Australia
2 Centre for International Child Health, Murdoch Childrens Research Institute, Level 4, Front Entry Building, Royal Children's Hospital, University of Melbourne, Flemington Road, Parkville, VIC 3052, Australia
3 Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
4 Nossal Institute for Global Health, Level 4, Alan Gilbert Building, University of Melbourne, 161 Barry Street, Carlton, VIC, 3010, Australia
5 UPecon Foundation, Inc. Room 322, UP School of Economics, University of the Philippines, Diliman, Quezon City 1101, Philippines
6 Center for Health Systems and Policy Research & Development, National Institute of Health Research & Development, Jalan Percetakan Negara 23A, Jakarta 10560, Indonesia
7 Public Health Foundation of India (PHFI) 4, Institutional Area, Vasant Kunj, New Delhi 110 070, India
8 New ERA, Rudramati Marg, Kalo Pul, Kathmandu, Nepal
9 Centre for Health Service Management, Faculty of Medicine, Gadjah Mada University, Jl. Farmako Sekip Utara, Jogjakarta 55281, Indonesia
BMC Public Health 2013, 13:601 doi:10.1186/1471-2458-13-601Published: 21 June 2013
Without addressing the constraints specific to disadvantaged populations, national health policies such as universal health coverage risk increasing equity gaps. Health system constraints often have the greatest impact on disadvantaged populations, resulting in poor access to quality health services among vulnerable groups.
The Investment Cases in Indonesia, Nepal, Philippines, and the state of Orissa in India were implemented to support evidence-based sub-national planning and budgeting for equitable scale-up of quality MNCH services. The Investment Case framework combines the basic setup of strategic problem solving with a decision-support model. The analysis and identification of strategies to scale-up priority MNCH interventions is conducted by in-country planners and policymakers with facilitation from local and international research partners.
Significant variation in scaling-up constraints, strategies, and associated costs were identified between countries and across urban and rural typologies. Community-based strategies have been considered for rural populations served predominantly by public providers, but this analysis suggests that the scaling-up of maternal, newborn, and child health services requires health system interventions focused on 'getting the basics right'. These include upgrading or building facilities, training and redistribution of staff, better supervision, and strengthening the procurement of essential commodities. Some of these strategies involve substantial early capital expenditure in remote and sparsely populated districts. These supply-side strategies are not only the 'best buys', but also the 'required buys' to ensure the quality of health services as coverage increases. By contrast, such public supply strategies may not be the 'best buys' in densely populated urbanised settings, served by a mix of public and private providers. Instead, robust regulatory and supervisory mechanisms are required to improve the accessibility and quality of services delivered by the private sector. They can lead to important maternal mortality reductions at relatively low costs.
National strategies that do not take into consideration the special circumstances of disadvantaged areas risk disempowering local managers and may lead to a “business-as-usual” acceptance of unreachable goals. To effectively guide health service delivery at a local level, national plans should adopt typologies that reflect the different problems and strategies to scale up key MNCH interventions.