Health & Development n. 75 June 2017

HEALTH AND DEVELOPMENT

June 2017/ No. 75

Magazine on International Development and Health Policy June 2017 — No. 75

health and development 75 â „ june 2017

â „ doctors with africa cuamm

NEWS Funding sources for health spending Health spending consists of and is covered by different sources, including: a) public health spending (through taxes, as in the Beveridge model, or social health contributions, as in the Bismarck model); b) prepaid private spending (through insurance); c) direct spending by individuals at the time of health care delivery (out-of-pocket - OOP); d) development assistance.

The figure below shows health spending by funding source in various countries.

FIGURE / PROPORTIONAL DISTRIBUTION OF FUNDING SOURCES FOR HEALTH SPENDING IN VARIOUS COUNTRIES (2014)

100% 90% 80% 70% 60% 50% Development assistance 40% 30%

Private out-of-pocket (OOP) spending

20% Prepaid private spending 10% Public spending

So m al ia M $3 oz am 3 bi qu e Ba $9 ng 2 la de sh $9 Ta 2 nz an ia $1 66 Ke ny a $3 3 Ch in a $6 97 Br az il $1 ,3 57 It al y $3 Sw ,3 11 ed en $5 ,4 46 US A $9 ,2 37

0%

Source: Institute for Health Metrics and Evaluation, Financing Global Health 2016: Development Assistance, Public and Private Health Spending for the Pursuit of Universal Health Coverage. Seattle, 2017.

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health and development 75 ⁄ june 2017 ⁄ 1

CONTENTS EDITOR

DIALOGUE

Gavino Maciocco EDITORIAL STAFF

Andrea Atzori, Andrea Berti, Dante Carraro, Adriano Cattaneo, Donata Dalla Riva, Silvio Donà, Fabio Manenti, Martha Nyagaya, Ana Pilar Betran Lazaga, Giovanni Putoto, Angelo Stefanini, Anna Talami, Ademe Tsegaye, Calistus Wilunda EDITOR-IN-CHIEF

Anna Talami

P. 2

FIVE YEARS OF CHALLENGES IN SUB-SAHARAN AFRICA Text by / don Dante Carraro P. 3

INEQUALITIES IN HEALTH SPENDING Text by / Adriano Cattaneo

A PUBLICATION OF

Medici con l’Africa Cuamm

OVERVIEW

ADMINISTRATION

Via S. Francesco, 126 - 35121 Padova t 049 8751279-8751649 f 049 8754738 e-mail cuamm@cuamm.org

P. 5

“MOTHERS AND CHILDREN FIRST” PROGRAM Text by / Fabio Manenti

EXPERIENCES FROM THE FIELD

EDITORIAL COORDINATION

Chiara Di Benedetto and Valentina Isidoris COVER ILLUSTRATION

Lorenzo Gritti LAYOUT AND PRINTING

Publistampa, Via Dolomiti, 36 - 38057 Pergine Valsugana (Trento) COPYRIGHT

Doctors with Africa CUAMM, Via S. Francesco, 126 - 35121 Padova.

Articles and materials contained in this publication can be reproduced in whole or in part provided that the source is cited

P. 9

AT THE FURTHEST OUTPOSTS: THE ROLE OF COMMUNITYAGENTS Interviews with / Edoardo Occa, Federico Calia, Marco Pratesi, Barbara Andreuzzi, Laura Villosio and Maria Nannini By / Valentina Isidoris and Chiara Di Benedetto P. 14

PERIPHERAL HEALTH CENTERS: “MINI” HOSPITALS Text by / Manuela Straneo

REGISTRATION AND AUTHORIZATION

P. 18

Law Courts of Padua no. 1129 on 5 June 1989 and on 11 September 1999.

Health and Development is a triannual magazine on international development and health policy

HOSPITALS: THE HEART OF THE HEALTH SYSTEM Text by / Fabio Manenti and Mario Zangrando

DISPATCH

Poste italiane s.p.a. - Spedizione in Abbonamento Postale - D.L. 353/2003 (convertito in Legge 27/02/2004 n° 46) art. 1, comma 1, NE/PD TRANSLATION

Sara Copeland Benjamin, Miriam Hurley

TAKING A CLOSER LOOK P. 21

FROM PRACTICE TO POLICY: LESSONS LEARNED Text by / Giovanni Putoto P. 22

With the support of

RESEARCH FOR BETTER MATERNAL AND CHILD HEALTH Text by / Valentina Isidoris and Chiara Di Benedetto

From villages to peripheral health centers to hospitals: Doctors with Africa CUAMM works at every level of the healthcare system, side by side with mothers and their children, to ensure equity of access to healthcare in places where it is still a mirage.

NEXT STEP P. 26

NEW GOALS FOR MATERNAL AND CHILD HEALTH Text by / Ana Pilar Betran Lazaga P. 27

CUAMM’S ONGOING COMMITMENT TO MOTHERS AND CHILDREN Text by / Giovanni Putoto

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DIALOGUE FIVE YEARS OF CHALLENGES IN SUB-SAHARAN AFRICA In the five years since Doctors with Africa CUAMM first took up the challenge of expanding safe assisted deliveries and infant care, we have actually surpassed the goals laid out in 2012 for our “Mothers and Children First” program. We will now continue to work alongside the world’s most vulnerable peoples, implementing a new program that will include all 7 of the countries in which CUAMM operates. text by ⁄ don dante carraro ⁄ director of doctors with africa cuamm

“Mothers and Children First”: when we launched our program in 2012, this was both our chief objective and the name we decided to give to the enormous challenge we’d taken on. It’s been five years since we launched our “battle” in some of SubSaharan Africa’s poorest areas to ensure that pregnant women can have access to safe assisted deliveries, and their babies to infant healthcare. We’ve carried out activities in 4 countries, 4 hospitals, and 22 peripheral health facilities, and seen assisted deliveries increase by 27% in hospitals and almost 80% in peripheral health facilities in the period from 2012 to 2016. In areas where so many rights seem to be denied, we’ve worked hard to fulfill our commitment to make women and their families aware that they can deliver their babies safely, with the help of skilled attendants.

It hasn’t been easy. We’ve often found ourselves in difficult situations, such as last year’s unprecedented food crisis in Ethiopia, where the severe drought caused by the El Niño climate event and subsequent flooding forced more than ten million people to try to survive without food or water security. To tackle the emergency situation in the country’s South Omo and South West Shoa Zones, we provided care to mothers and their children, especially malnourished ones, and worked to improve linkages between the three levels of healthcare. Then there’s the precarious situation in Angola, which was severely tested following the recent oil crisis that left those living in the most remote rural areas without access to basic healthcare. There, too, we worked tirelessly to provide care to mothers and children, including building a waiting home for women about to give birth and attempting to set up a well-functioning referral system. At times, though, we failed to achieve the outcomes we’d been able to reach in other settings.

Yet despite the emergencies, unpredictable circumstances, and critical settings in which we worked, which often proved even more difficult than expected, we managed not only to achieve but actually to surpass the goals we’d set for ourselves: at the end of this initial phase of the program, we’re pleased to report that overall it has brought positive results that point up some of the good practices implemented to achieve them. The “Mothers and Children First” program is the focus of this special edition of Health and Development, a sort of “interim report” that reviews the work done during its first five years: the challenges tackled, the good practices followed, and some of the lessons learned. The articles it contains provide a look not only at the work we do at the hospital level, but also with local health centers and communities; in fact, CUAMM believes in a systemic approach that enables us, to the greatest extent possible, to reach those living in the most remote corners south of the Sahara. When we first launched the program in 2012, we set ourselves the goal of ensuring at least 125,000 free assisted deliveries in 5 years’ time. By the end of 2016, however, our health facilities had ensured 134,910 such deliveries, as well as 308,102 antenatal visits and 5,929 free or reimbursable ambulance trips for obstetric emergencies. What made it possible to achieve these results and to ensure the system’s future – albeit relative – sustainability was our partnership with local authorities, as well as the training of nearly 600 new health workers.

But the challenges we met weren’t only those encountered in health facilities; we were determined to move beyond those “safe boundaries” to support populations living in the most isolated areas. “Doing good”, in fact, isn’t just about gathering data and figures. It means getting out there to find and meet people, and developing trusting relationships with them – something that would be impossible without the precious support of local volunteers, the community health workers who took CUAMM’s mission to heart, sharing our commitment to bring support to the most vulnerable living in the most isolated areas.

That commitment to mothers and children will continue over the next five years. Indeed, the scope of the “Mothers and Children First” program will now be broadened both in terms of the services provided and the areas in which we provide them, which will now include all seven of the countries in which CUAMM operates: activities will be expanded beyond the delicate moment of childbirth to provide support and care from conception through the first 2 years of a baby’s life. These first 1,000 days – a period in which nutrition plays a key role – are critical for children’s healthy development.

It’s a major new challenge, and we are excited to present and discuss the progress made in the first year of the “Mothers and Children First: The First 1,000 Days” program at CUAMM’s annual meeting on 11 November 2017.

While there is little we can do to prevent what seem like never-ending wars and conflicts – the devastating famine and humanitarian crisis that has brought South Sudan to its knees in recent months is just one example – or the increasingly severe environmental disasters taking place worldwide, we can and will continue to ensure that the most vulnerable people – mothers and children first! – have access to the healthcare they need.

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DIALOGUE INEQUALITIES IN HEALTH SPENDING In many countries with limited resources – particularly in Sub-Saharan Africa – annual per capita health spending is less than $100, while in the wealthiest countries it exceeds $5,000, even climbing past $9,000 in the United States. How much of this expenditure falls on families?

text by ⁄ adriano cattaneo ⁄ epidemiologist, trieste

Those who work in global health are very familiar with the Institute for Health Metrics and Evaluation (IHME) at the University of Washington in Seattle, U.S., thanks to its Global Burden of Disease publication series. 1 The Bill and Melinda Gates Foundation (BMGF) funds many of IHME’s activities, including Financing Global Health 2016, the eighth edition of IHME’s annual series on global health spending and health financing, whose authors analyzed both public and private health spending and development assistance for health (DAH) in 184 countries around the world, and the implications for future goals related to the pursuit of universal health coverage (UHC) 2. The document provides an enormous amount of information, but we will narrow the focus here to particular aspects of health spending.

Let’s start out with inequalities. As those working on the topic know far too well, in many countries with limited resources – particularly in Sub-Saharan Africa – annual per capita health spending is less than $100, while in the wealthiest countries it exceeds $5,000, even climbing past $9,000 in the United States. Between 1995 and 2014, the countries that increased per capita health spending the fastest were upper-middle- and lower-middle-income ones, with annualized average growth rates of 5.9% and 5.0% respectively. This meant a near tripling of health spending in upper-middle-income countries over the course of those two decades, from $309 to $914 per capita. Spending growth in low-income countries was slower, at 4.6% a year, while annualized growth was slowest in high-income countries, at around 3.0% a year. However, in absolute terms this percentage corresponded to an additional $2,244 per capita in spending between 1995 and 2014, well above the $605 and $162 per capita added by upper-middle- and lower-middle-income countries respectively. Low-income countries increased health spending by just $69 per capita in the same period. Thus rather than shrinking, the gap in per capita health spending has grown considerably.

In addition to looking at how much different countries spend on health per capita, it’s also important to understand how they finance this expenditure. Figure (see inside front cover) shows health spending in various countries, from Somalia, the country with the lowest per capita health spending in 2014 ($33), to the United States, with the highest ($9,237). The figure shows 8 other countries between these two extremes, including Italy. The figures are given in purchasing power parity (PPP) dollars, i.e. adjusted for purchasing power and inflation to make the data comparable both between countries and over time.

As can be seen, the percentage of public health spending per capita tends to increase with an increase in overall health spending. It is higher in Scandinavian countries (as with the case of Sweden) and lower in countries that rely more on the free market, such as the U.S. and Brazil. In Mozambique, where development assistance covers almost all health spending, public expenditure is just slightly over 10%.

The percentage of prepaid private spending through various types of insurance is notoriously high in the U.S. – about 39% – but is also becoming more common in some low-income countries such as Tanzania.

Private out-of-pocket (OOP) spending – i.e., direct spending by families at the time of health care delivery – is the greatest cause for worry. It accounts for 29% of the financing of health spending in Somalia and soars to 66% in Bangladesh.

OOP spending tends to increase as health spending per capita decreases, and is therefore relatively higher in the poorest countries: in lower-income ones the average figure is 29%, while in lower-middle-income ones it is 58%. This gap is a major barrier to ensuring equity in the use of health services and one which unfortunately, in addition to not having shrunk until now, is also not expected to shrink significantly over the next two decades. It is clear that we are a long way away from achieving Goal 3 of the U.N.’s 2030 Agenda for Sustainable Development, i.e. to ensure healthy lives and promote wellbeing for all at all ages 3.

NOTES 1 Institute for Health Metrics and Evaluation, Global Burden of Disease, available at http://www.healthdata.org/gbd 2 Institute for Health Metrics and Evaluation, Financing Global Health 2016: Development Assistance, Public and Private Health Spending for the

Pursuit of Universal Health Coverage, Seattle, 2017 United Nations, Goal 3: Ensure healthy lives and promote well-being for all at all ages, available at http://www.un.org/sustainabledevelopment/health/

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MOTHERS AND CHILDREN FIRST: FREE ACCESS TO SAFE ASSISTED DELIVERIES AND INFANT CARE Doctors with Africa CUAMM’s “Mothers and Children First” program focused on four countries in Sub-Saharan Africa, a region that the World Health Organization (WHO) defines as one of the poorest in the world, with some of the highest levels of maternal and infant mortality. The map below shows where Doctors with Africa CUAMM worked during the five years of the program, with a spotlight on the hospitals and districts involved.

ETHIOPIA Population: 99.4 million Number of physicians: 0.25 per 10,000 residents Neonatal mortality: 41.1 per 1,000 live births Maternal mortality: 353 per 100,000 live births Wolisso Hospital Wolisso (urban/rural), Goro and Wonchi Districts

UGANDA Population: 39 million Number of physicians: 1.7 per 10,000 residents Neonatal mortality: 37.7 per 1,000 live births Maternal mortality: 343 per 100,000 live births Aber Hospital Oyam District

TANZANIA

ANGOLA Population: 25 million Number of physicians: 1.7 per 10,000 residents Neonatal mortality: 96 per 1,000 live births Maternal mortality: 477 per 100,000 live births Chiulo Hospital Ombadja District

Population: 53.3 million Number of physicians: 0.3 per 10,000 residents Neonatal mortality: 35.2 per 1,000 live births Maternal mortality: 398 per 100,000 live births Tosamaganga Hospital District of Iringa D.C.

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OVERIEW “MOTHERS AND CHILDREN FIRST” PROGRAM The “Mothers and Children First” program focused on 4 hospitals and their districts in 4 African countries, covering a population of approximately 1,300,000. The initial goal, which was to reach 125,000 attended births, was attained and surpassed, and good results were also achieved with respect to correlated activities, such as prenatal visits, transportation for obstetric emergencies and personnel training. text by ⁄ fabio manenti ⁄ doctors with africa cuamm

PROGRAM ORIGINS

In September 2000, the United Nations convened in New York to launch a joint effort projected to last eight years and aimed at fighting poverty, hunger, and disease on the basis of the eight Millennium Development Goals. Although a number of countries succeeded in reducing their poverty level, there are still considerable inequalities that hamper the achievement of these goals; the 4th and 5th Millennium Goals are specifically aimed at reducing child and maternal mortality, which are still critical issues for many parts of Africa. This is why Doctors with Africa CUAMM decided to focus its programs and projects, giving priority (though not exclusively) to maternal and child health.

Building on CUAMM’s experience supporting hospitals owned by the Catholic Church in Sub-Saharan Africa, the idea of establishing a new program in line with CUAMM’s 2008-2015 strategic plan began to take shape between 2010 and 2011. The program's aims would be to strengthen the local health system at three levels of intervention (community, peripheral centers, and hospitals) and to reduce three types of delay affecting attended births: delays in identifying problems during childbirth and making appropriate decisions, delays in reaching health facilities, and delays in receiving quality health care.

This was the inspiration for the idea to strengthen the partnership between the public and private nonprofit sectors by launching a five-year program in four African districts where the main hospital belongs to the Catholic Church and virtually all other parts of the system are managed by public authorities.

GOALS

The choice of four countries — Angola, Ethiopia, Uganda, and Tanzania — was based on the fact that maternal mortality in these countries is among the highest in the world (>500/100,000 live births), access to births attended by qualified personnel is largely insufficient, and CUAMM had an already established presence and solid relationships in the areas.

The indicator chosen as maternal health improvement was the coverage of attended births; i.e., how many pregnant women made use of health facilities and were attended by qualified per-

sonnel during childbirth out of the total number of pregnant women in the local population.

Access to attended births is a proxy of how a health system as a whole is functioning, since it entails the availability of basic obstetric services in accordance with a continuum of care approach.

Increasing access to attended births remains one of the most difficult goals to achieve within the health systems of countries with limited resources, since it requires around-the clock availability of basic and advanced obstetric services as well as skilled human resources, drugs, and equipment (including for possible blood transfusions). Yet, the constant availability of services is not in itself a guarantee of access, for access requires that other obstacles be overcome, such as financial difficulties due to the cost of services and transportation to health facilities, cultural barriers, and issues such as whether the mother can leave the family for a period and whether someone else can manage the household during her absence.

We decided to adopt a strategy that could fit the specific context of intervention and that would be based on two fundamental principles: Strengthening the district health system and consolidating the management skills required to address the community’s reproductive health needs; Increasing access to free attended births for all women, improving the quality of services offered in health centers and hospitals, and starting a free ambulance service for obstetric emergencies.

Doctors with Africa CUAMM launched the “Mothers and Children First” program in 2012 with the objective of doubling the number of attended births in five years, achieving 125,000 attended births, of which 39,000 would take place in district hospitals and 86,000 in peripheral government-run health centers.

THE FOUR COUNTRIES

The “Mothers and Children First” program focused on four hospitals and their districts in four African countries, covering a population of approximately 1,300,000. In Angola, we chose the Chiulo hospital in the Ombaja district, where we have been active since 2002. In Ethiopia, we chose the Wolisso hospital with its four sur-

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FIGURE 1 / THE PROGRAM’S FINAL RESULTS

Antenatal visits

308,102

Total births

134,910

5,929

Ambulance transfers

590

People trained

rounding districts (Wolisso urban/rural, Wonchi and Goro), where we have been active since the hospital was built in 1997. In Tanzania, we chose the Tosamaganga hospital, where we have been present for over 30 years, and the hospital’s Iringa D.C. district.

In Uganda, we chose the Aber hospital, where we have been active for 30 years, and the Oyam district.

FIGURE 2 / TRENDS IN ATTENDED BIRTHS IN PERIPHERAL FACILITIES AND HOSPITALS No. births in hospitals

Total attended births

No. births in peripheral centers

35,000

32,763 31,063

30,000

28,725

25,000 22,122 22,784

20,237

20,000

23,558

20,577

15,000 14,486 13,165 9,205

10,000

8,148

8,279

7,072

7,636

2012

2013

2014

2015

5,000 2016

A combination of good relations and support for public health activities made a positive collaboration possible aiming to reach the program’s goals in line with the specific needs of the different countries and with the Millennium Development Goals for the reduction of maternal and child mortality.

The country that had the most problems during the implementation stage was Angola, where excellent prospects for economic growth and healthcare resources were dashed by the oil crisis that started in 2014, leading to the virtual stagnation of public health programs and making it impossible to reach the expected increase in attended births anywhere outside of the hospital.

The other countries experienced either substantial stability or continuous economic growth, albeit with some tensions regarding wages for healthcare workers, especially in Tanzania and Ethiopia, due to the global economic crisis and a rapid loss of purchasing power due to inflation. The lack of qualified personnel and the ongoing increase in production costs for health services are clearly still the main challenges that must be faced in order to ensure the sustainability of facilities and safe access to attended births.

OVERALL RESULTS

The final results achieved in the four countries after five years went well beyond the target of 125,000 attended births (Figure 1). The other related activities also showed improvements, such as the number of comprehensive prenatal check-ups (from the first to the fourth check-up and beyond), the number of guaranteed transportation services provided for obstetric emergencies, and the number of health workers trained with courses on pregnancy care and birth assistance.

In addition to improving the trend in attended births and prenatal visits, we also aimed to increase the proportion of births that actually take place in healthcare facilities out of the total number of expected births in the districts. This goal was thoroughly achieved in Ethiopia, where the proportion increased from 20% to 56.4%, and in Uganda, where it increased from 42.2% to 66.9%. The proportion remained stable in Tanzania, where the initial figure was already very high, while it did not substantially change and remained rather low in Angola, growing from 18.2% to 20.8%, for reasons already mentioned.

We achieved good overall results, and this was possible in part because we were able to focus attention on the program’s critical points through continuous monitoring and outcome analysis and to adjust our activities accordingly, even while remaining aware of the limitations of our chosen indicators, often based on uncertain data.

Also regarding comprehensive data, we analyzed the trends in attended births in health centers and in hospitals during the duration of the intervention. Figure 2 shows that the bulk of the increase occurred in peripheral health facilities, with an increase of approximately 80%, from 13,163 to 23,558 attended births. This is an extremely important point because peripheral facilities are the

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assistance centers closest to pregnant women and their use reduces the second type of delay behind obstetric emergencies, i.e. an excessive distance between villages and local hospitals.

For this reason, the number of normal or complicated but nonCesarean attended births in hospitals increased by “only” 27%, while Caesarean sections increased by 40% (Figure 3). This last figure is very significant, since it seems to be directly correlated with an increase in the number of complicated pregnancies attended by hospital health workers. The increase in attended births with obstetric emergencies is due both to the higher quality of services offered and to the implementation in all four countries of a system for the transportation of women with obstetric emergencies from the community and peripheral health centers to the nearest hospital. The transportation system — using mainly regular ambulances and motorcycle ambulances — and the use of vouchers to ensure service coverage enabled us to reduce as much as possible the third type of delay in health assistance caused by complications and emergencies. Although Cesarean sections are a very valuable tool to reduce maternal and infant mortality in the countries were CUAMM operates, the use of this technique needs to be better analyzed on a country-bycountry basis and in terms of the proportion between the minimum number of necessary C-sections and the actual number of C-sections carried out. According to the parameters of the World Health Organization (WHO), the number of Caesarean sections within a population should be around 5% of total expected births.

On the basis of these parameters, in Angola we remained well below the maximum limit, with an estimated incidence of C-sections of approximately 1%, without variation for the duration of the program. On the other hand, the incidence of C-sections increased from 2.5.% to 2.7% in Ethiopia, from 2.4% to 3.2% in Uganda, and from 7.6% to 11% in Tanzania. In Tanzania, we should

NOTES 1 United Nations, The Millennium Development Goals Report 2010, New York – United Nations Department of Economic and Social Affairs, 2010.

FIGURE 3 / TRENDS IN NORMAL BIRTHS AND CESAREAN SECTIONS IN HOSPITALS

Normal hospital births

Cesarean births

8,000 7,000

7,033 6,330

6,000

6,524

6,000 5,530

5,000 4,000 3,000 2,172

2,000

1,550

1,640

2012

2013

1,820

1,755

2014

2015

1,000 2016

monitor the use of Cesarean sections, trying to remain within standard international parameters.

We achieved satisfactory overall results and got positive feedback from our public and private partners, as well as from the community and the health system. We reached and exceeded the goals set six years ago, but we remain aware that much more remains to be done in order to guarantee safe access to health services and adequate care for mothers and children.

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DOCTORS WITH AFRICA CUAMM: WORKING AT EVERY LEVEL OF THE HEALTHCARE SYSTEM Most of the beneficiaries of our “Mothers and Children First” program live in very remote areas. Their distance from urban centers means that pregnant women must travel hours – and sometimes even days – to get to the nearest hospital, putting their own health as well as that of their future child at risk. This is why Doctors with Africa CUAMM continues to work at all three levels of the health systems in the countries in which we are active, to help those in need of health care get more quickly to a facility that can assist them.

Specialized health services Transport to a health facility Basic health services Hospital

Transport to a health facility Emergency transport

Risk perception and care-seeking Peripheral health centers Emergency transport Community

1,300,000

22

4

individuals

peripheral health centers

hospital facilities involved

Activities: - Educating villagers about maternal and infant health - Raising awareness about the availability of checkups and assisted deliveries at health centers - Building up relationships between local communities and community health workers

Activities: - Treating the least complicated cases - Providing vaccinations and essential medicines - Providing prenatal care and visits - Handling normal deliveries without obstetric complications - Presence of skilled personnel - Referring patients to higher-level facilities

Activities: - Treating more serious/complex cases - Handling deliveries with obstetric complications - Presence of units for neonatal intensive care, resuscitation and support - Presence of personnel skilled in obstetric emergency care

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EXPERIENCES FROM THE FIELD AT THE FURTHEST OUTPOSTS: THE ROLE OF COMMUNITY AGENTS Working in a system to bring health services to people, reaching even the most remote villages - this is one of the goals of Doctors with Africa CUAMM’s “Mothers and Children First” program, where community health agents were an invaluable help. These local volunteers serve as “bridges” between the community and health centers and bring help and health information where no one else manages to reach. interviews with ⁄ edoardo occa, federico calia, marco pratesi, barbara andreuZZi, laura villosio ⁄ doctors with africa cuamm and maria nannini ⁄ department of economics – university of florence by ⁄ valentina isidoris and chiara di benedetto / doctors with africa cuamm

HEALTH ON THE BORDER

Africa’s health systems are extremely diverse, and they reflect the degree of fragility of their local areas. In the sub-Saharan African countries where Doctors with Africa CUAMM works, most of the population has no access to essential health services.

Among the many obstacles to equal access to treatment are the scarcity of human and financial resources, long distances to reach the closest hospitals and difficulty in crossing rough geographical terrains far from city centers. These are joined by the many cultural barriers that hinder the use of health centers, especially by women who prefer to give birth in their homes following local traditions.

To meet the needs of this population, especially mothers and children, Doctors with Africa CUAMM has sought to strengthen the health systems in the four countries where we are active,

working simultaneously on the three levels of intervention: hospitals, peripheral health centers, and communities. The communities are the most challenging level of intervention because it involves getting to these places — including very isolated ones — to offer help and identify emergencies that require transfer to adequate health facilities.

COMMUNITY AGENTS

Doctors with Africa CUAMM relies on the help of community health agents to bring health services to the village. They are also known as Health Extension Workers (HEWs) in Ethiopia, Village Health Workers (VHWs) in Uganda, and Community Health Workers (CHWs) in Tanzania. Community agents are men and women, members of the community, who volunteer in connec-

COMMUNICATING IN THE FARTHEST CORNERS OF THE WORLD text by ⁄ samuele Zamuner / doctors with africa cuamm

«Good evening to everyone. It’s 7:30 PM and you’re listening to Radio VCC FM». The radio presenter, transmitted live from one of Uganda’s top radio stations, wastes no time in introducing his guest, Dr. Emanuela De Vivo of Doctors with Africa CUAMM. «Thank you, Moses, and good evening to all of you. I’m here tonight to announce that we’ve signed an agreement to ensure free ambulance transportation from the Dima health center to the Aber Hospital for pregnant women with obstetric emergencies».

CUAMM uses a wide range of tools, including radio microphones, to conduct its educational and awareness-raising activities and achieve its goal of getting important messages out to the largest possible number of potential beneficiaries. That’s what we did in Sierra Leone, for example, during its recent horrific Ebola outbreak, using radio to let people know how to protect themselves from infection and recognize suspected cases, and to launch campaigns to persuade them to donate blood.

Face-to-face meetings and dialogue with local communities are equally important, and technology can be a great help to community health workers as they go about their work. In Tanzania, for example, CUAMM invites those using its services to voice their impressions, suggestions and critiques by way of text messages – a cheap and popular means – and free calls.

More traditional forms of communication such as theater have also proven effective. In Mozambique, for example, the Kuplumussana Association puts together short performances to talk to audiences about important issues, especially HIV/AIDS. They’re both enjoyable and educational, and the idea behind them is not only to encourage people to use good practices but also to help combat the social stigma around certain diseases.

Even though the actors’ only “stage” is a field outside a village or a hospital waiting room, people throng to see the performances, paying close attention to them, laughing, and – almost without realizing it – learning healthier behaviors in everyday life.

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tion with health centers and live in the villages where they work.

In Ethiopia, most are young women who have studied up to grade 10 (equivalent the second year of high school in Italy) and who take a year-old training course to learn how to work in the community. During our “Mothers and Children First” program, CUAMM formed a strong relationship with these volunteers, supporting them with a small financial incentive to perform the daily tasks and we gave them their training sessions. Edoardo Occa, an anthropologist with CUAMM, explains, “In Tanzania, about 900 agents were trained to monitor pregnant women and children under five, screen for malnutrition, and educate about nutrition issues.”

EDUCATION AND SUPPORT

One of the major tasks of community agents is to educate and inform the population, especially women, about health issues, addressing maternal and child health, chronic illnesses, and malnutrition, and working to prevent major infectious diseases.

Their help was essential for gathering information about the health of mothers and children and identifying cases of women with at-risk pregnancies as well as cases of malnutrition. Federico

Calia, a public health expert with CUAMM, gives us an example from Ethiopia: “Community agents play a key role in linking basic health facilities and communities by providing basic health services, including vaccinations, pre- and post-natal visits, and checking child growth.”

Over the years, many projects have involved community agents, who have become invaluable assets for Doctors with Africa CUAMM. Marco Pratesi, a doctor with CUAMM, tells us, “When a project ends, many CHWs try to become part of a new program and we are eager to have them because they already have basic training.” Plus, there is the advantage of being able to put trust in people who live in the villages where they work and have the trust of the local people. Maria Nannini, a CUAMM researcher and volunteer in Uganda, explains, “It’s important that the health system approaches people through Village Health Workers; while providing health information and education, they also listen to the needs and we get new ideas that come out of the community itself. “The VHWs help local people and health workers to know and understand each other.”

CHALLENGES AND PROBLEMS

Community agents usually work no more than five kilometers

INCENTIVIZING THE USE OF HEALTH SERVICES IN UGANDA text by ⁄ maria nannini / department of economics, university of florence

Development in the rural district of Oyam in northern Uganda, which is home to approximately 400,000 people, has been held back by the country’s recent civil war. Given Uganda’s poor overall health conditions, Doctors with Africa CUAMM’s “Mothers and Children First” program has used a mix of strategies to help ensure free access to maternal and neonatal health services there. The starting point for our targeted intervention was the local population’s demand for health care: once we had identified the main geographic and financial barriers preventing the most vulnerable groups from using maternal and neonatal services, we sought to devise innovative schemes to overcome those barriers and make said services more accessible, thereby moving one step further toward health equity. Specifically, we evaluated two different types of incentives: Transport vouchers: Provided to pregnant women who travel to one of CUAMM’s healthcare facility for an antenatal visit, these vouchers enable them to use whatever type of local transport is available (generally motorcycles or bicycles), free of cost, to return to the facility when they are ready to give birth, thus minimizing their transport-related costs, which are covered by CUAMM;

Baby kits: These kits include various items useful for caring for babies, including a plastic basin, a bar of soap, a sheet, a piece of fabric in which to wrap newborns, and half a kilogram of sugar. Every woman who gives birth in the health facility is given such a kit, helping to cut down significantly on the cost to her household of caring for her infant.

We undertook a pilot study to analyze the impact of such incentives on the demand for maternal health services, assessing the effectiveness and efficiency of each, and saw significant increases in the number of both assisted deliveries and antenatal visits in the healthcare facilities in which they were introduced. Indeed, the percentage of women who went to a health center to give birth rose from 31% to 53% in the facilities where baby kits had been introduced, and jumped from 13% to 53% in those that offered transport vouchers; in addition, the percentage of women taking advantage of all four antenatal visits leaped from 8% to 47% in the latter.

Thus both types of incentive proved effective in increasing the community’s access to maternal and neonatal health services, cutting down considerably on existing barriers to demand for them.

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from their homes because they usually go by foot for home visits.

But in Tanzania and Uganda, the homes are spread out in the area and it takes hours to walk from the closest village, often over rough, hard-to-access terrain. Doctors with Africa CUAMM provides the agents with bikes in these cases so they can reach the families and give free transportation to pregnant women to the closest health center.

In most cases, the community agents are also given raincoats, boots, flashlights, t-shirts and caps to make them recognizable; these items all help their work in communities and give a small incentive to the volunteers, who feel appreciated in their roles as assistants and educators in the village.

The community agents’ job is not easy. Raising awareness in the village about caring for the health of women and children and building a trusting relationship with locals are challenges met daily and often come up against difficult situations and settings.

Barbara Andreuzzi, a nurse for CUAMM, notes that community agents encounter many difficulties in Angola, from having to get around on foot to dealing with desperate family situations without being able to help, and not being listened to. In some cases, cultural barriers are a leading cause of agents becoming demotivated and giving up the role. In Ethiopia, for example, women have difficulty getting the respect and attention of all members of the community, because of their young age and because of the very fact of being women.

DAILY VICTORIES

Despite the many obstacles, there are many examples of good practices enacted by community agents spreading through a growing part of the local population: such as by improving general hygiene practices, like boiling river water if there is no running water, going to early antenatal visits, involving men in childcare and respect for motherhood. In Ethiopia, the HEWs provide basic health services and have been leaders in building community women’s associations, founded to raise money so women can give birth in health centers or hospitals if they have at-risk pregnancies, covering the cost of transportation and food.

There is still a great deal to do to ensure quality access to care and safe births, but there are evident positive results of the fiveyear program “Mothers and Children First”, thanks to the invaluable work of community agents at the furthest outposts of the health system.

health and development 75 ⁄ june 2017 ⁄ 11

OVERCOMING BARRIERS TO ASSISTED DELIVERY text by ⁄ chiara di benedetto and elisa bonino ⁄ doctors with africa cuamm

Ethiopia has one of the highest maternal mortality rates in the world – 676 maternal deaths per 100,000 live births – and is one of the ten countries in the world accounting for 58% of global maternal deaths.

Doctors with Africa CUAMM has carried out two operational studies to examine the factors determining whether or not Ethiopian women make use of assisted delivery services.

Understanding the cultural, social and economic reasons behind this decision is the first step toward becoming more familiar with cultures different from our own, and finding ways to tackle such gaps with effective interventions in the field.

One of the two studies involved 500 women between the ages of 15 and 49 1, while the other involved 999 women divided into three separate groups: prior to, during and after CUAMM’s intervention 2. Various barriers to the use of these services were found, including cultural ones, such as having a positive or negative attitude toward motherhood or becoming pregnant at a young age or outside of marriage; cognitive ones, including women’s awareness (or lack thereof) of the benefits of different healthcare services, and what those services actually consisted of (for example, the recommended number of visits, basic services, obstetric postpartum visits); economic ones related to the women’s socioeconomic status (the poorest cannot afford transportation to the place of delivery); and physical ones (some 45% of the women interviewed lived more than an hour by foot from the nearest health center).

It is therefore essential to identify and implement strategies aimed at alleviating these inequities, improving infrastructure, and raising people’s awareness about maternal healthcare.

The latter is especially key, and it is important to sensitize not just women but also – particularly in a patriarchal culture such as Ethiopia’s – their husbands and other family members, who often hold the decision-making power. Making women aware of the services available to them is perhaps the most significant determinant in increasing the number that make use of them, and reducing the maternal mortality rate.

NOTES 1 Wilunda C. et al., Determinants of utilisation of antenatal care and skilled birth attendant at delivery in South West Shoa Zone, Ethiopia: a cross sectional study, in Reproductive Health Journal, 2015.

2 Wilunda C. et al., Evaluation of a maternal health care project in South West Shoa Zone, Ethiopia: before-and-after comparison, in Reproductive Health Journal, 2016.

REFERRAL SYSTEMS FOR OBSTETRIC EMERGENCIES

To strengthen delivery services in Angola, Ethiopia, Uganda and Tanzania, Doctors with Africa CUAMM has activated referral systems to transport pregnant women with obstetric complications to hospitals where they can be given timely and appropriate emergency care.

Thus far, 5,929 such trips have been provided from villages and peripheral health centers to hospitals, with the number of ambulance trips climbing from 385 in 2012 to 1,332 in 2016.

Different trends have emerged in the four countries: while 3,305 free ambulance trips were provided in Ethiopia over the past five years, matters proved more difficult in Angola, where only 108 such trips could be provided.

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EXPERIENCES FROM THE FIELD PERIPHERAL HEALTH CENTERS: “MINI” HOSPITALS African countries’ health systems are shaped like a pyramid, and its base is the facilities that provide primary health care to the people. These facilities include peripheral health centers, which can provide assistance for normal births and offer essential preventive services, such as vaccinations, prenatal visits, and treatment for HIV and common diseases. text by ⁄ manuela straneo / doctors with africa cuamm

PRIMARY HEALTH CARE STRUCTURE

Hospitals are not the only facilities where women can give birth.

African countries ‘ health systems are shaped like a pyramid, and its base is the facilities that provide primary health care to the people. District hospitals, such as the Tosamaganga Hospital in Tanzania, are the second level up with regional, and university hospitals are above them. Primary health care facilities include health centers. Health centers are essentially “mini” hospitals, equipped to provide preventive services, such as vaccinations, prenatal visits, and treatment services, such as for HIV and common diseases. There are usually about 25 hospital beds, plus outpatient services. Birth assistance is an essential component of these services. They generally do not provide surgeries, so Cesarean sections are not available and birth complications must be transferred to higher level facilities. Local health centers are essential for providing basic care to the rural population.

TABLE 1 / FUNCTIONS OF BASIC AND COMPREHENSIVE OBSTETRIC AND NEONATAL CARE

FUNCTION*

BASIC EMERGENCY OBSTETRIC/ NEONATAL CARE (B-EmONC)

COMPREHENSIVE EMERGENCY OBSTETRIC AND NEONATAL CARE (C-EmONC) ✔

INTRAVENOUS / INTRAMUSCULAR ANTIBIOTIC ADMINISTRATION

✔

ADMINISTRATION OF DRUGS TO INCREASE UTERINE TONE (SUCH AS, OXYTOCIN)

✔

✔

INTRAVENOUS / INTRAMUSCULAR ANTICONVULSANT ADMINISTRATION

✔

✔

MANUAL REMOVAL OF PLACENTA

✔

✔ ✔

REMOVAL OF RETAINED PRODUCTS OF CONCEPTION (SUCH AS FROM INCOMPLETE MISCARRIAGES)

✔

PERFORM ASSISTED DELIVERY (FOR EXAMPLE, WITH A VENTOUSE)

✔

✔

✘

✔

BASIC NEONATAL RESUSCITATION (E.G., WITH AN AMBU MASK) CESAREAN SECTION BLOOD TRANSFUSION

✔ ✘

* Functions must have been performed in the previous three months

✔ ✔

Tanzania was a pioneering country in primary health care as it built a widespread network of dispensaries and health centers right after decolonization. About three times the size of Italy, with a population of only 53 million, Tanzania ‘s widespread distribution of its basic health facility network means that almost 9 out of 10 people in the population are within an hour walk from a health facility.

FUNCTIONS OF HEALTH CENTERS

The numbers show the importance of peripheral health facilities for births in Tanzania. Recent national data shows that more than half of births attended in health facilities are in primary health care facilities 1. Furthermore, the first rung of the health system is where the poorest parts of the population in the country ‘s rural areas go for birth assistance. Health centers and dispensaries are dispersed throughout the area and can easily be reached by villages by those who only have their feet for transportation and cannot afford to use public or private vehicles.

The “Mothers and Children First” program, with the goal of reaching the least advantaged women, supported six primary health centers in Iringa, Tanzania, providing assistance the remote areas too.

According to Tanzania ‘s health policy, health centers must be able to provide all Basic Emergency Obstetric and Neonatal Care, B-EmONC). There are seven essential functions (Table 1). The second level of the health system is the district hospitals that can provide Comprehensive Emergency Obstetric and Neonatal Care, C-EmONC), which can provide Cesarean sections and blood transfusion.

ENSURING QUALITY CARE

The “Mothers and Children First” program applied a variety of approaches to the peripheral health centers. One was the continuous training of health staff, coupled with the regular supervision of the health centers. Another was the supply of medicine and other supplies, to ensure uninterrupted availability of all material needed to handle obstetric and neonatal emergencies. We also supported a system to support referrals from health centers to the hospital through shared supervision and protocols and the

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health and development 75 ⁄ june 2017 ⁄ 15

CHILDBIRTH IN HEALTH CENTERS text by ⁄ fabio manenti and mario Zangrando / doctors with africa cuamm

Decentralizing normal deliveries without complications to peripheral health facilities has been one of the main goals and anticipated outcomes of the “Mothers and Children First” program in all 4 countries in which we implemented it. This “centrifugal” strategy has disencumbered hospitals of the need to handle simpler obstetric cases, instead delegating them to peripheral health facilities with the capacity to perform effectively as Basic Emergency Obstetric and Newborn Care (BEmONC) centers, thus helping to improve the quality of services provided at Comprehensive Emergency Obstetric and Newborn Care (CEmONC) facilities in cases of obstetric emergencies and complications.

In 2012, out of a total 20,237 assisted deliveries in the four countries, slightly over 65% (13,165) were carried out at peripheral facilities. As the latter continue to improve, the trend has continued to rise, with 72% of all assisted deliveries taking place in health centers in 2016.

The same trend has been found with regard to antenatal care (ANC) visits: in 2012, out of a total 40,343 such visits, 79% took place in peripheral health centers, while in 2016, out of the total 71,441 ANCs carried out, the figure rose to 86%.

Antenatal and postnatal activities in health centers have clearly been positively impacted by the number of qualified midwives working in them, which has more than doubled since 2012, growing from 123 in that year to 255 in 2016 – a sign of the commitment of public authorities to help improve the availability and quality of healthcare services (see Figure 1).

use of ambulances. Building maternity waiting homes in two strategic health centers (Kiponzero and Kimande) was the program ‘s last pillar. These are hostels where women in the final weeks of pregnancy can live, awaiting the birth. When labor begins, the women are already close to the hospital; these hostels help to reduce the distance from villages to birth facilities. These accommodations, which provide beds and clean bathrooms, are greatly appreciated by women from rural areas.

EVALUATING THE WORK DONE

Over the years, Doctors with Africa CUAMM has assessed the work performed in the country ‘s health centers; through a survey with the authorities of the District of Iringa, we analyzed how its obstetric and neonatal services changed after the start of the "Mothers and Children First" program in six health centers.

Evaluating B-EmONC functions revealed greater availability of health services following the introduction of CUAMM ‘s program in some of these facilities: assisted vaginal delivery, not available before the program ‘s introduction, was seen in over a third of the health facilities, as well as parenteral anticonvulsant administration, found in 67% of the facilities, compared to 37% before the

FIGURE 1 / ACTIVITY TRENDS IN HEALTH CENTERS No. ANCs (antenatal care visits)

No. PNCs (postnatal care visits)

No. of midwives active in peripheral health facilities

80,000

500 73,238

450

70,000

400

60,849

60,000 350

54,090

50,000

300 255

38,498

40,000 31,796

164 20,000

200

199

164

30,000 123

21,899 16,576

14,176

250

150 100

11,363

10,000

50

5,369

0

0 2012

2013

2014

2015

2016

The only exception was Angola, which continues to have an inadequate number of qualified childbirth staff.

It is important to note that last year the number of ANC visits fell in all four countries; the reason for this is not yet clear.

program. One conclusion of the survey was that the regular training of staff and the continuous availability of drugs and supplies mean that B-EmONC functions are potentially available in all health centers involved. Among other positive results of the survey regarding birth assistance, it showed the regular use of fetal monitoring, essential for following the birth ’s progress, and the regular availability of uterotonic drugs, both of which had been lacking before the project. However, the fairly limited number of births (births per year ranging from 101–306) prevents the facilities from performing the B-EmONC functions in the three-month period set in the guidelines.

NOTES 1 Demographic and Health Survey, 2015-2016.

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AMBULANCE SERVICE FOR ASSISTED CHILDBIRTH text by ⁄ edgardo somigliana / ospedale maggiore policlinico mangiagalli, milan

In the final stage of pregnancy and during childbirth, women often face unexpected and sometimes extremely serious risks. To address this problem, Doctors with Africa CUAMM has put in place in the areas in which we work around-the-clock ambulance services specifically dedicated to women in need of obstetric care.

While at first glance it might seem exaggerated to provide such a specific service in rural areas, this is not actually the case. Indeed, the obstetric care is meant for otherwise healthy women who, after receiving appropriate treatment, can return to their communities and continue to play their usual role there, most importantly caring for their children. Live-saving interventions in obstetrics therefore have high cost-effectiveness ratios. To corroborate its decision, CUAMM has carried out two cost-effectiveness analyses, one in Uganda and one in Ethiopia; in both cases the ambulance service was found to be very cost-effective, costing $14 and $25 respectively for each extra year of healthy life, thus well below the World Health Organization (WHO)’s optimal upper limit of $30. The way in which the referral system is managed is also critical. In this regard, rather than relying on a single rigid model, we adapted the service to individual local settings, using three different ones, i.e.: Calls for ambulance service made by health centers alone (Oyam, Uganda): this model makes it possible to carefully screen each call, but can only be used where there are relatively well-functioning health centers;

Calls made directly by patients (Yirol, South Sudan): this model entails higher risks of misuse of the service, but is necessary in areas without reliable health centers; A mixed model: this enables both patients and health centers to call for an ambulance; also, patients are not always brought directly to a hospital, but initially to a peripheral health center (Wolisso, Ethiopia). This is the most advanced model, but it requires optimal organization in the area.

Comparing data from different countries continues to be difficult, but the service seems to generate positive outcomes.

CUAMM 1-4 has published four related studies in international journals in order to share our experience with our international peers and make it possible for others to put similar services into place.

NOTES 1 Somigliana et al., Ambulance service within a comprehensive intervention for reproductive health in remote settings: a cost-effective intervention, in Tropical Medicine & International Health, 2011.

2 Groppi et al., A hospital-centered approach to improve emergency obstetric care in South Sudan, in International Journal of Gynaecology and Obstetrics, 2015.

3 Tsegaye et al., Ambulance referral for emergency obstetric care in remote settings, in International Journal of Gynecology and Obstetrics, 2016.

4 Accorsi S. et al., Gender Inequalities in Remote Settings: Analysis of 105,025 Medical Records of a Rural Hospital in Ethiopia (2005-2015), in Journal of Community Health, 2017.

RATIONALIZING DELIVERY SITES IN TANZANIA text by ⁄ manuela straneo, piera fogliati ⁄ doctors with africa cuamm pierlorenZo fantoZZi ⁄ university of siena

Primary health care facilities play a key role in ensuring access to safe deliveries for women. Indeed, more than half of all institutional deliveries – 52% in Tanzania – take place in such facilities.

This is why ensuring quality standards is vital to improving equity: the women who give birth in these facilities are the poorest of the poor, thus it is they who bear the greatest burden when health services are of poor quality. In Tanzania one finds a sort of paradox: an “excess” of rural delivery sites. Indeed, the country’s extensive network of primary health care facilities means that 85% of Tanzanian women can get to one from their homes by foot within an hour, in a country with a low population density. Yet this excellent coverage, where deliveries are carried out across a large number of such facilities, ends up becoming a problem in terms of the quality of the services provided, since the low annual delivery volumes [in individual facilities] make it difficult for staff to gain sufficient childbirth experience. And Tanzania continues to rank in the top ten countries globally with the greatest number of deaths of mothers and children. The extensiveness of the healthcare network is good for the population for a variety of reasons: they provide access to vaccinations, antenatal consultations and care for under-‐5 children. But childbirth services are more complex: since the timing of deliveries cannot be planned, it is essential to provide around-‐the-‐clock service.

Two CUAMM surveys carried out in Tanzania’s Iringa and

Njombe Regions 1,2 have found that more than half of the country’s delivery sites analyzed do not have enough staff to ensure regular service, and most carry out less than two deliveries per week. With such low delivery volumes, how can midwives keep their skills sharp enough to know how to resuscitate a newborn who has stopped breathing, or stop a mother’s bleeding during childbirth? There are no easy solutions, but it seems clear that the health system could be centralized, reducing the number of delivery sites without reducing access to critical health services by women living in the most remote areas. Our research has shown that if these facilities were cut by 40%, the increase in the number of people needing to walk more than 2 hours to get to a delivery site would be quite small – just 7%. This important finding could point the way to the rationalization of delivery sites and improvement in the quality of the services they provide 3.

NOTES 1 Straneo M. et al., Where do the rural poor deliver when high coverage of health facility delivery is achieved? Findings from a community and hospital survey in Tanzania, in PLoS One, 2014.

2 Fogliati P. et al., How can childbirth care for the rural poor be improved?

A contribution from spatial modelling in rural Tanzania, in PLoS One, 2015.

3 Straneo M. et al., Minimum obstetric volume in low-income countries, in The Lancet, 2017.

EXPECTANT – AND READY FOR A NEW BEGINNING

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CUAMM managed eight maternity waiting homes during the first phase of its “Mothers and Children First” program. Some of these facilities already existed and were adapted for the purpose, while others were built from scratch. For example, in Sierra Leone – even as memories of the Ebola outbreak remained vivid – a new waiting home was inaugurated last May in Gbondapi, in the southern part of the country. It took the place of the former Ebola isolation unit, now no longer in use, and hosts pregnant women from the Pujehun and Bonthe Districts, whose residents live in areas accessible only by boat, and where the governmental hospital is located on an island that takes three hours of sailing to get to.

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EXPERIENCES FROM THE FIELD HOSPITALS: THE HEART OF THE HEALTH SYSTEM Hospitals are the top rung of the health system in Africa. Doctors with Africa CUAMM’s efforts to strengthen hospitals have focused on two issues: increasing demand by lowering barriers to accessing health services and improving the quality of services provided.

rext by ⁄ fabio manenti and mario Zangrando ⁄ doctors with africa cuamm

LOWERING BARRIERS, IMPROVING SERVICES

Hospitals are the heart of the health systems and offer the most complex level of service. Not everyone can reach them, which is why the “Mothers and Children First” program invested in supporting them with the end strategy in mind, which is to provide access to safe deliveries and ensure broad coverage, quality, and equity of services, particularly for obstetric and neonatal emergencies.

The four hospitals chosen for the program are the only referral facilities for these districts. All are private, owned by the Catholic Church, but well-integrated into the district health system. Though their being private can be a guarantee of efficiency and quality, it also means the patients must pay direct fees, which is a major obstacle to accessing the services. Our efforts to strengthen hospitals have focused on two issues: increasing demand by lowering barriers to accessing health services and improving the quality of services provided.

In order to increase demand, we worked to: end fees for Cesarean sections by helping cover the hospital's direct costs to ensure it has the necessary staff and drugs; activate or improve referral systems for obstetric emergencies from communities to peripheral facilities, and from there to the hospitals, at no cost to the pregnant women; Distribute mosquito nets and baby kits (a basin, a soap and a blanket for the newborn) to women who have come to the hospital to give birth; Distribute special vouchers to cover transport costs for women to reach the health facility during antenatal visits; Supporting or starting maternity houses to accommodate pregnant mothers with health risks or who are far from the health center/hospital.

To increase the quality of services, we provide for: qualified personnel, such as gynecologists or surgeons for obstetric emergencies, pediatricians/neonatologists, and healthcare directors or technical support to the hospital management;

A COMPUTERIZED INFORMATION SYSTEM AT THE WOLISSO HOSPITAL text by ⁄ alessandro domanico / project manager & software analyst developer / InformatIcI senza frontIere

In 2012 Ethiopia’s Wolisso Hospital began to use a computerized data collection system in order to improve the management of information through a precise match-up between epidemiological and financial data. Based on a software called “OpenHospital” that was developed by Informatici Senza Frontiere Onlus (IT Experts Without Borders), a non-profit organization with which Doctors with Africa CUAMM has formed a working partnership, the system was first tested in Italy using forecasts and simulations and later adapted to meet concrete local needs.

Work was organized to enable hospital personnel to enter data in real time to the greatest extent possible, with special stations in key “nerve centers” and the introduction of small variations to existing protocols, such as the writing and annotation of new codes. The various buildings of the hospital communicate wirelessly, while wire technology is used inside each individual building, with special attention given to the need for access by multiple users, and the use of special terminals to

facilitate maintenance and maintain the proper division of roles. The most significant difficulties arose during our analysis of patient flow and of specific software-usage scenarios and while training personnel on data entry in a setting in which people are accustomed to recording such information manually.

Since most of the local population speaks Amharic and Oromo, language was an additional difficulty.

Five years on, key information from patient records including personal data, visits, admissions and receipts, has been digitized, and much of the paperwork related to day-to-day activities and manual computations has been eliminated. Given these positive results, the same OpenHospital software-based system will be used starting in late 2017 to collect data on patients with acute and chronic malnutrition or chronic diseases (e.g., diabetes, tuberculosis, HIV and hypertension) whose use of health services is periodic and whose conditions therefore need to be continuously monitored.

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FIGURE 1 / MAJOR OBSTETRIC FATALITY RATE

4,5% 4,0% 3,5%

CHIULO HOSPITAL’S MATERNITY WAITING HOME

Aber Tosamaganga Wolisso Chiulo mean

text by ⁄ mario Zangrando ⁄ doctors with africa cuamm

3,0% 2,5% 2,0% 1,5% 1,0% 0,5% 0,0% 2011

2012

2013

2014

2015

2016

FIGURE 2 / FATALITY RATE OF STILLBIRTHS PER 1,000 LIVE BIRTHS

30 Aber Tosamaganga Wolisso Chiulo mean

25 20 15 10 5 0 2011

2012

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2013

2014

2015

2016

training of the delivery room staff and maternity wards, particularly to support normal and complicated births and the resuscitation and care of newborns; evaluating the quality of obstetric and neonatal care through an external team of experts using the Monitoring Obstetric and Neonatal Care tool, created by WHO – World Health Organization, as the basis for precise indicators of the situation and steps to improve the quality of services; starting neonatal intensive care units.

Located in the province of Cunene in southern Angola in a semi-desert area near the border with Namibia, the diocesan hospital of Chiulo is the only second-level health facility in the entire region. Long distances and difficult connections between communities, health centers and the hospital, together with people’s inability to afford transportation from one to the other, mean that as women from the area near their delivery dates, they often get to health care facilities well beyond the ideal time, or instead decide to give birth at home.

In order to solve this problem, in 2012 a maternity waiting home was set up close to the hospital to accommodate pregnant women with complications as well as those living a long way away. Equipped for meal preparation, the facility provides its guests with food packages. Because of its proximity to the hospital, it is much easier for its guests to go for antenatal visits and to be constantly monitored, so that they can be referred to the hospital as soon as labor begins or a complication appears. An analysis of the waiting home’s guest register shows that in 2015 and the first six months of 2016, an average of 50 pregnant women were admitted there each month. In the second half of 2016, this number rose to 90, at times climbing past 100. Some 60% of the women who gave birth at the hospital in 2016 had first been guests at the waiting home. The 2016 data show that 70% of the women who stayed at the home lived over 10 kilometers from the hospital, while another 10% lived from 20 to 30 kilometers away.

While this is good news for the women who were assisted in a timely manner both before and during labor, it also indirectly points up the weakness of the peripheral healthcare system. Indeed, because of its inability to provide qualified assistance and timely transportation (in five years’ time just 108 ambulance trips were provided in our area of intervention, compared to 3,335 in Ethiopia), women nearing the end of their terms prefer to move closer to the hospital in order to avoid risks. In Angola, therefore, the waiting home is currently the only low-cost method of reducing maternal and neonatal morbidity and mortality.

POSITIVE GROWTH TREND

Out of the total attended births within the program, 30% took place within one of the four hospitals, with a constant growth trend (+27%).

The trend was not exponential as it was in the health centers, an intentional side effect of freeing hospitals from normal births to concentrate on obstetric emergencies that need more skilled assistance and where there is the greatest concentration of risks for mothers and fetuses. This explains the larger growth of Cesarean sections in hospitals, rising from 1,544 in 2012 to 2,172 in 2016 (40%).

While this increase in Cesarean sections was necessary, in theory, to adhere to WHO guidelines to avoid possibly fatal complications, its

use should be strictly monitored to avoid increasing this practice too much, as it is not without immediate and future risks for the women.

For this purpose, we introduced the Robson Classification as a tool for continuously monitoring the proper use of Cesarean sections.

REDUCING MATERNAL AND CHILD MORTALITY

Two indicators were measured regarding overall quality of care: the mortality rate for major obstetric complications as a mater-

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nal indicator (Figure 1) and the rate of stillbirths as a fetal indicator (Figure 2). The obstetric mortality rate decreased in all hospitals with an average of around 1%, a rate set by WHO as an indicator of good quality. The only hospital where the rate stayed around 2% is Chiulo Hospital, for the reasons already explained, including poor access and delayed arrival to the hospital. The rate of stillbirths for causes directly tied to the assistance during de-

livery has declined in all hospitals with numbers below ten per every 1,000 live births, which is a reasonable statistic given the settings where Doctors with Africa CUAMM works.

NOTES 1 Tognon and Putoto, The rise in the use of cesarean sections, in Health and Development, June 2015, No. 71.

ORGANIZING TOSAMAGANGA HOSPITAL: A COMPLEX CHALLENGE text by ⁄ gaetano aZZimonti ⁄ doctors with africa cuamm

As soon as I took on the job of Project Manager for the “Mothers and Children First” program to be implemented in Tanzania’s District of Iringa D.C., it became clear how difficult it would be to achieve acceptable qualitative standards without having an adequate hospital governance system in place. A further obstacle had to do with a widespread mentality according to which problems were to be tackled only when they arose, with all the shortcomings in terms of the planning and monitoring of activities entailed by such an approach.

Even so, by sharing ideas and identifying medium- to long-term priority needs we were able to develop the hospital’s first-ever Working Plan (2012-2017), which incorporated goals that were both realistic and verifiable over time.

The next step involved reorganizing the hospital’s governance, which we did by bringing onto the hospital’s Board of Directors individuals capable of controlling the facility in a systematic manner, especially in terms of its system for the collection and analysis of data, in order to improve both the quality and the reliability

of the latter. We then moved on to restructure the Tosamaganga Hospital’s administrative and accounting system, an ongoing project first launched in 2015 in partnership with Informatici senza Frontiere (IT Experts Without Borders): the administrative office now has software for entering, analyzing and managing accounting data. This system made it possible to prepare the firstever financial statement in 2016.

From a clinical standpoint, the creation of a continuous quality improvement team and a monthly perinatal death auditing meeting helped us devise interventions to improve the quality of maternal and neonatal services. Indeed, perinatal mortality fell from 59 deaths per 1,000 live births in 2012 to 29 in 2016, and neonatal mortality in the first 24 hours of life fell from 13 deaths per 1,000 live births in 2012 to 5 in 2016.

While these indicators are encouraging and CUAMM’s suggestions have always been well received by the hospital, there are still some doubts with regard to the ability of its management to ensure the continuity of the project.

THE NEONATOLOGY DIVISION IN ABER text by ⁄ emanuela de vivo / doctors with africa cuamm

In Uganda CUAMM’s five-year “Mothers and Children First” program focused on the Aber Hospital and the Oyam District, located in the northern part of the country. Its primary goal was to improve maternal and neonatal mortality indicators by strengthening solid partnerships between governmental health facilities and private not-for-profit ones. Activities were carried out in the Lira Diocese’s Aber Hospital in Anyeke, the second largest governmental health center, which has an operating room for obstetric emergencies, and in the other 28 healthcare facilities providing maternity services in the area. In Aber the most important work was done with regard to neonatal care, with a monthly visit by a pediatrician and an annual one by two neonatologists. Ongoing training of the district’s health workers on essential newborn care significantly improved their infant care skills. Thanks to the help of local staff, protocols for managing hypothermia, hypoglycemia, asphyxia and appropriate infant nutrition were also developed, as were graphics on proper breastfeeding and the vital parameters of healthy and unhealthy infants. As a result, neonatal mortality in Aber fell from 51 deaths per 1,000 live births (2014 data) to 36.6 deaths per 1,000 live births (in 2016). To improve pregnant women’s access to health

services, special attention was given to the issue of transportation for those with obstetric emergencies or in need of antenatal visits or care for sick infants. In addition to a pair of ambulances, four motocycle ambulances and two three-wheeled motorcycle ambulances were also introduced, with priority being given to patients living in the most remote areas. In addition, vouchers were distributed to cover the cost of transportation to health centers. As a result of these interventions, delivery coverage in the district rose from 42% in 2012 to 71% in 2016, while Caesarean-section coverage rose from 2.4% of total estimated births in 2012 to 3.2% in 2016 (according to the World Health Organization, in a given population at least 5% of total deliveries are expected to be Caesarean sections). To help achieve the program’s goals, 150 health promoters were trained on maternal and neonatal health in the district to enable them to act as a bridge between the community and health centers. In addition, monthly meetings were held with community leaders to raise awareness in villages on maternal and child health. We at CUAMM are pleased with the results thus far, and determined not only to maintain them but hopefully to improve upon them over the next few years of the program.

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TAKING A CLOSER LOOK FROM PRACTICE TO POLICY: LESSONS LEARNED The “Mothers and Children First” program has been an extraordinary experience for Doctors with Africa CUAMM. We’ve learned many lessons while implementing it, from understanding the importance of the individual settings in which we operate, to supporting operational research and effective monitoring systems for our work with local and international partners. text by ⁄ giovanni putoto ⁄ doctors with africa cuamm

The “Mothers and Children First” program to ensure free access to safe deliveries and newborn care has been an extraordinary experience – a sort of lab for innovation – for Doctors with Africa CUAMM. Throughout the duration of the program we learned numerous and wide-ranging lessons in the field which can be encapsulated as follows: Understanding the importance of specific settings/actors 4 countries, 4 major hospitals, 22 peripheral health centers, 1,300,000 individuals, and 5 years of work in the field. This was CUAMM’s first such multi-country program aimed at reducing maternal and neonatal mortality, and the biggest challenge was the need to keep uppermost in our minds the differences between the settings and actors with which we were involved. The same approaches cannot be used always and everywhere; for example, it is essential to vary the kinds of incentives used to encourage women’s use of safe deliveries or make improvements in the quality of neonatal care. In carrying out such large-scale programs it is also vital to be intimately familiar with the health system where one is working, as well as with local actors and their concerns.

Including innovative elements in monitoring and assessment Our monitoring and assessment system was based on a series of indicators. Since it was not possible to measure the program’s impact on maternal mortality, we used the process indicators recommended by the World Health Organization (WHO) for obstetric emergencies. Data was collected using local information systems and enriched in some cases with specific surveys on coverage, quality and equity. One important lesson learned was that monitoring and assessing complex programs requires the use of innovative tools for data collection and analysis, work standardization, the involvement of external professionals, the use of modern epidemiological methodologies and adequate financial coverage.

Promoting operational research as an added value Operational research made a significant contribution to the program, in terms of both demand and supply. With regard to the former, we delved into topics related to social determinants, incentives and the referral system; with regard to the latter, we carried out analyses on topics including the effectiveness of maternity waiting homes, the quality of the services provided by health facilities and other clinical topics such as infant hypothermia and hypoglycemia. In some cases, such as our analysis of delivery site density in Tanzania, questions arose vis-à-vis the effectiveness of national policies. Thus operational research plays a key role in terms of helping understand not only programs but also the functioning of health systems. The “before”, “during” and “after” all need to be carefully thought through.

Disseminating program results: transparency and accountability Disseminating our program results locally, in Italy and abroad entailed a continuous process of feedback among ourselves, our partners and the international institutions with which we work. Activities and outcomes, constraints and good practices, costs and expenditures were all put on the table and discussed, generating an ongoing, participatory dialogue among all the parties involved. This is the kind of approach that we intend to develop and fine-tune over time, as we believe strongly in the importance of transparency and accountability.

Developing authentic and solid partnerships This program involved a range of actors, including single individuals, groups, professional organizations and public institutions. Various kinds of partnerships ensued: financial, scientific and communications-related ones, but also – most importantly – new relationships and collaborations focused on the issue of health in Africa, especially with regard to the protection and improvement of the health of mothers and their children.

Every one of the lessons we learned while carrying out the “Mothers and Children First” program will be valuable as we continue our work to reduce maternal and infant mortality and to achieve more equitable health for all. These are areas where there should be no barriers of any kind, so that everyone has the opportunity to contribute to “the cause”.

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TAKING A CLOSER LOOK RESEARCH FOR BETTER MATERNAL AND CHILD HEALTH More than twenty publications on maternal and infant health care and valuable partnerships formed with universities and international research groups in the first five years of the “Mothers and Children First” program: Doctors with Africa CUAMM continues to conduct operational research in the field to fulfill its commitment to improve the quality of health services in low-resource countries. text by ⁄ valentina isidoris and chiara di benedetto ⁄ doctors with africa cuamm

Despite the signing in 2000 of the Millennium Declaration, in which United Nations member states committed to help achieve the Millennium Development Goals (MDGs) by 2015 1, maternal and infant mortality in Sub-Saharan Africa remains unacceptably high due to the lack of basic health services and deaths from curable diseases. This is why Doctors with Africa CUAMM has made helping mothers and children a top priority in its work in the region.

In the first five years of our “Mothers and Children First” program we undertook activities to support local facilities and staff in ensuring women’s access to safe deliveries and health care for newborns. This meant both concrete work in delivery rooms and hospital hallways as well as years of research to support local health services and monitor the activities carried out by the facilities involved in the program. Following the World Health Organization (WHO)’s emphasis on the importance of conducting research in developing countries to achieve the post-2015 Sustainable Development Goals (SDGs) 2, Doctors with Africa CUAMM, too, believes that doing such work in the countries in which we are active serves as a precious resource, enabling us to better meet the needs of local health services and to identify the most effective solutions to problems in complex settings.

Building up solid partnerships with universities and international research groups has been key to our research efforts in the world’s poorest countries (including in terms of studies and analyzes), enabling us to share experiences and to identify new work and research foci. We are pleased to have such partnerships with the Karolinska Institute in Stockholm, Sweden, the University of Bergen in Norway, the University of Padua (with which we have partnered for many years), the University of Bari and the Fondazione Bruno Kessler in Trento.

Between 2012 and 2016 Doctors with Africa CUAMM published some 22 articles on maternal and infant health in international medical journals including The Lancet, PLOS ONE, Reproductive Health and the International Journal of Gynecology & Obstetrics. In addition, we gave numerous presentations and presented posters at international conferences and other events, including the Pediatric Academic Societies (PAS) Meeting.

The methodologies and foci of the research we conducted as we implemented the “Mothers and Children First” program varied. Some studies were purely clinical, others qualitative, having to do with social determinants; others yet provided an overall picture of the current situation in the countries where we work, or involved evaluative operational research. The latter has been especially valuable: knowing how to assess one’s work and verify processes and outcomes is key to being able to develop effective interventions and improve strategies. Indeed, as the “Mothers and Children First” program was wrapping up, a team of outside experts assessed the work done to improve maternal and infant health: 7 evaluations were carried out to measure the quality, coverage and equity of the health services provided in the 4 countries that were the focus of the program. While its overall impact was clearly positive, the assessments also cast light on some critical areas that will require extra focus over the next several years.

In 2016 CUAMM intensified its commitment to operational research, working in partnership with the University of Padua on our first-ever randomized controlled trial (RCT), which aimed to assess the effectiveness of using woolen caps and booties together with the Kangaroo Mother Care (KMC) method to maintain a stable body temperature in preterm infants 3.

Our research efforts will not come to an end with the conclusion of the first five years of the “Mothers and Children First” program; we will continue to do studies in the area of maternal and infant health, with a special focus on the first 1,000 days of children’s lives, from conception until the age of two. We will also conduct research on chronic diseases and infectious diseases, particularly tuberculosis and HIV/AIDS, and in the field of nutrition in the second phase (2017-2021) of the program.

NOTES 1 For official documents see: General Assembly, United Nations Millennium Declaration, 2000 and United Nations, The Millennium Development Goals, available at www.un.org/millenniumgoals 2 United Nations, The Report of the High-Level Panel of Eminent Persons on the Post-2015 Development Agenda. A new global partnership:

eradicate poverty and transform economies through sustainable development, 2013.

3 Trevisanuto D. et al., Is a woolen cap effective in maintaining normothermia in low-birth-weight infants during kangaroo mother care?

Study protocol for a randomized controlled trial, in Trials Journal, 2016.

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CUAMM RESEARCH 2012-2016 2012  Uganda Somigliana E. et al., Endometriosis in a rural remote setting: a cross-sectional study, in Gynecological Endocrinology

2013  Tanzania Wilunda C. et al., Determinants of moderate to severe anaemia among women of reproductive age in Tanzania: analysis of data from the 2010 Tanzania Demographic and Health Survey, in Tropical Medicine & International Health

2014  Multicountries Stenberg K. et al., Advancing social and economic development by investing in women’s and children’s health: a new GlobalInvestment Framework, in Lancet  Uganda Wilunda C. et al., A qualitative study on barriers to utilisation of institutional delivery services in Moroto and Napak districts, Uganda: implications for programming, in BMC Pregnancy Childbirth Mucunguzi S. et al., Effects of improved access to transportation on emergency obstetric care outcomes in Uganda, in African Journal of Reproductive Health

 Tanzania Straneo M. et al., Where do the rural poor deliver when high coverage of health facility delivery is achieved? Findings from a community and hospital survey in Tanzania, in PLoS One

2015  South Sudan Groppi L. et al., A hospital-centered approach to improve emergency obstetric care in South Sudan, in International Journal of Gynaecology and Obstetrics  Uganda Wilunda C. et al., Availability, utilisation and quality of maternal and neonatal health care services in Karamoja region, Uganda: a health facility-based survey, in Reproductive Health Journal  Multicountries Wilunda C. et al., Assessing Coverage, Equity and Quality Gaps in Maternal and Neonatal Care in SubSaharan Africa: An Integrated Approach, in PLoS One  Ethiopia Wilunda C. et al., Determinants of utilization of antenatal care and skilled birth attendant at delivery in South West Shoa Zone, Ethiopia: a cross sectional study, in Reproductive Health Journal

health and development 75 ⁄ june 2017 ⁄ 23

Area: maternal and child health  Tanzania Fogliati P. et al., How Can Childbirth Care for the Rural Poor Be Improved? A Contribution from Spatial Modelling in Rural Tanzania, in PLoS One

 Multicountries Trevisanuto D. et al., Effect of a Neonatal Resuscitation Course on Healthcare Providers’ Performances Assessed

by Video Recording in a Low-Resource Setting, in PLoS One

2016  Tanzania Bizzocchi A., Metz D., Treating Pyloric Stenosis Medically in a Resource Poor Setting, in Annals of Pediatrics and Child Health  Mozambique, Ethiopia, Uganda Trevisanuto D. et al., Is a woolen cap effective in maintaining normothermia in low-birth-weight infants during kangaroo mother care? Study protocol for a randomized controlled trial, in Trials  Mozambique Schiavone M. et al., Prune Belly Syndrome: care report of a failed management in a low-income country, in EuroMediterranean Biomedical Journal

 Sierra Leone Quaglio Q. et al., Maintaining Maternal and Child Health Services During the Ebola Outbreak: Experience from Pujehun, Sierra Leone, in Plos  Tanzania Straneo M. et al., On the way to universal coverage of maternal services in Iringa rural district in Tanzania.

Who is yet to be reached?, in African Health Sciences

 Ethiopia Tsegaye A. et al., Ambulance referral for emergency obstetric care in remote settings, in International Journal of Gynecology Obstetrics

Wilunda C. et al., Evaluation of a maternal health care project in South West Shoa Zone, Ethiopia: before-andafter comparison, in Reproductive Health  Mozambique Cavicchiolo M.E. et al., Reduced neonatal mortality in a regional hospital in Mozambique linked to a Quality Improvement intervention, in BMC Pregnancy and Childbirth Cavicchiolo M.E. et al., Participants’ opinions of the limited impact of an adapted neonatal resuscitation course in a low-resource setting, in Acta Paediatrica  South Sudan Wilunda C. et al., Barriers to Institutional Childbirth in Rumbek North County, South Sudan: A Qualitative Study, in Plos One

NUTRITION, GROWTH AND DEVELOPMENT

In Tanzania 34.7% of children under the age of 5 are affected by symptoms attributable to chronic malnutrition, while 3.8% suffer from acute malnutrition – exceptionally high levels according to the classification parameters of the World Health Organization (WHO).

To tackle this critical problem, in December 2015 Doctors with Africa CUAMM launched an innovative fouryear program in two areas of the country that takes an integrated approach to preventing and treating chronic and acute malnutrition in women and children up to the age of two, i.e. during the crucial “window of opportunity” of the first 1,000 days.

matteo de mayda

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NEXT STEP NEW GOALS FOR MATERNAL AND CHILD HEALTH Much has been done in recent decades to reduce Africa’s high maternal and child mortality rates. But despite the progress that has been made, there is still much work to be done in terms of breaking down the barriers and socioeconomic inequalities that prevent regular access to basic healthcare from being available to all. text by ⁄ ana pilar betran laZaga ⁄ who – maternal and child health

Maternal deaths in Africa fell from 532,000 in 1990 to an estimated 303,000 in 2015 1, yet there are still 30 times more such deaths in Africa than in Europe.

The reason for this striking difference is directly related to the fact that African women, especially those living in Sub-Saharan Africa, do not have regular access to basic healthcare during their pregnancies as women in more developed parts of the world have had for decades. Thus while there has been progress, the global inequalities that continue to persist among countries, in the field of health as in other areas, have blunted it.

Even while we have the expertise to prevent and treat many of the conditions that complicate pregnancy and delivery, we’re often unable to implement good practices when caring for mothers-tobe in the field. Indeed, it is one thing to know what needs to be done, but quite another to take that know-how and put it into actual, day-to-day practice in a given clinical, cultural and social setting where we have but limited resources. Thus a first essential step towards developing successful health programs is to become deeply familiar with the local settings in which we work.

Another key factor in upcoming years will involve improving the monitoring and ongoing assessment done of work already implemented. We often push ahead with activities in order to save lives quickly, rather than waiting for the findings of assessments to understand outcomes; but doing so does not always bring about the hoped-for results. We need to learn how to monitor our activities step by step, appraising outcomes and acting based on that knowledge. This is the only way to improve our work and to come up with effective guidelines for the future.

It is also crucial that we continue to scale up efforts to promote contact between women and local healthcare systems. In low-re-

NOTES 1 Alkema L. et al., Global, regional and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group, in Lancet, 2016.

source countries pregnancy is often one of the few occasions where women can establish such contacts, thus it offers a unique opportunity to provide them and their children with care and to keep them healthy. And health systems must work to develop trusting relationships not just with women, but the entire community, providing care of an adequate quality in order to overcome one of the barriers related to women’s use of health services, i.e. their perception of being neglected or forsaken due to the weak performance of health facilities.

Health inequalities exist not just among but also within countries, and health systems often highlight the gap between those who are able to access adequate health services and those who are not. One such case involves the use of Caesarean sections. Cultural and socioeconomic status plays a significant role in determining whether or not pregnant women use this procedure: in Ethiopia, just 0.4% of uneducated women do so, as compared with 16.2% of women with a secondary school education or higher. In Namibia, 35.5% of wealthy women undergo the procedure, as compared with 6.3% of poor women. Many cases of maternal and perinatal morbidity and mortality could be prevented if this cultural gap were overcome; at the same time, the procedure ought to be undertaken with due precaution. Indeed, often – especially in low- to middle-income countries – the reasons underlying a woman’s decision to have the procedure are debatable, and it is not always beneficial to her health. Thus it is important to be able to intervene in health care provision while always making sure to implement the necessary controls. Opportunities for continuing to improve maternal and child health can be created through knowledge and awareness. This is all of our responsibility, each of us doing what we can to the best of our ability.

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CUAMM’S ONGOING COMMITMENT TO MOTHERS AND CHILDREN Doctors with Africa CUAMM’s “Mothers and Children First” program has wrapped up successfully.

A new five-year program will now be launched in all seven of the countries in which we work, with a special focus on nutrition during the first 1,000 days of children’s lives from pregnancy to their second birthdays. text by ⁄ giovanni putoto ⁄ doctors with africa cuamm

Doctors with Africa CUAMM’s five-year program, “Mothers and Children First” drew to an end a few months ago, but our commitment to improving maternal and infant healthcare certainly has not. We will now integrate the work we’ve done thus far with a new, expanded health program that focuses on the so-called “window of opportunity”, i.e. the first 1,000 days of a child’s life.

Over the next five years this new challenge will involve all seven of the countries in which CUAMM works – Angola, Ethiopia, Mozambique, Sierra Leone, South Sudan, Tanzania and Uganda – and aim to ensure healthcare and support to mothers and their babies from pregnancy to the child’s second birthday, until she or he has been weaned. These first 1,000 days are in fact a critical phase for a child’s health and development, when inadequate care can jeopardize her or his future growth and health.

Nutrition will play a key role in the new phase of the intervention.

Even though the trend for the global fight against malnutrition over the last 15 years has been a positive one 1, in Africa one out of every three under-five children still has symptoms of chronic malnutrition (irregular growth and development) or acute malnutrition (weakened immune systems and a greater risk of contracting infections). More than 40% of under-five child mortality is associated with malnutrition, and those who survive often have both physical and motor deficits and cognitive and social ones.

The data on mothers is also alarming: one out of every three pregnant women is malnourished, with serious consequences both for her health and pregnancy. Indeed, undernourished mothers-to-be are highly likely to become anemic, negatively impacting not only their own health but also that of their future babies, who are at risk of being born underweight.

Today, however, there are innovative and valid actions that can be taken to reduce malnutrition, for example, preventing and

NOTES 1 International Food Policy Research Institute, Global Nutrition Report 2016: From Promise to Impact: Ending Malnutrition by 2030, Washington DC, 2016.

treating anemia in pregnant women and treating those affected by acute or chronic malnutrition. These actions bring about clear benefits not only in terms of the health of mothers and their babies, but also of the latter to work and help generate economic growth in their countries once they become adults.

This is the backdrop against which Doctors with Africa CUAMM’s new five-year (2017-2021) commitment will take place. The second phase of the “Mothers and Children First” program will continue to ensure that pregnant women have access to safe assisted deliveries, and newborns to the care they need, as well as providing both groups with adequate nutrition and nutritional education. The program will involve ten hospitals and ten districts in the countries in which we work, and will cover some 3 million people; our goal is to treat at least 10,000 children with severe acute malnutrition and follow another 50,000 during their first few years of life in an effort to tackle chronic malnutrition.

A further aim of the program is to strengthen local healthcare systems by integrating new activities into communities, peripheral health centers and hospitals, and providing training to local human resources to create health groups that include staff specialized in nutrition as well as other areas. CUAMM will also continue to conduct operational research in support of our work at each of these three levels, with more studies on the various phases of maternal and infant health, from pre-pregnancy to breastfeeding to weaning, and a special focus on nutrition and early child development, including social, cognitive and psychological growth.

Improving people’s lives and above all preventing deaths that we believe have no place in today’s world: this is the new challenge facing Doctors with Africa CUAMM as we accompany mothers and children in those crucial first 1,000 days, step by step, towards a safer future.

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DOCTORS WITH AFRICA CUAMM Founded in 1950, Doctors with Africa CUAMM was the first non-governmental organization focused on healthcare to be recognized by the Italian government. It is now the country’s leading organization working to protect and improve the health of vulnerable communities in Sub-Saharan Africa.

CUAMM implements long-term development projects, working to ensure access to quality health care even in emergency situations.

HISTORY In our 65-year history: 1,615 individuals have worked on our projects abroad; 434 of them have gone on to repeat the experience at least once 1,053 students have lodged at CUAMM’s university college 165 major programs have been carried out by CUAMM in cooperation with the Italian Foreign Ministry and various international agencies 221 hospitals have been served 41 countries have been the beneficiaries of CUAMM’s work 5,096 years of service have been provided, with each CUAMM worker serving for an average of three years.

IN AFRICA Today, Doctors with Africa CUAMM works with local communities in Angola, Ethiopia, Mozambique, Sierra Leone, South Sudan, Tanzania and Uganda, implementing 72 major development projects and around one hundred smaller related ones. Through this work we provide support to: • 15 hospitals; • 45 local districts (with activities focused on public health, maternal and child health care, the fight against AIDS, tuberculosis and malaria, and training); • 3 nursing schools; • 1 university (in Mozambique).

1,628 staff members including 218 individuals from around the world.

IN EUROPE Doctors with Africa CUAMM has long been active in Europe as well, carrying out projects to raise awareness and educate people on issues of international health cooperation and equity. In particular, CUAMM works with universities, institutions and other NGOs to bring about a society – both in Italy and in Europe – that understands the value of health as both a fundamental human right and an essential component for human development.

PLEASE SUPPORT OUR WORK Be part of our commitment to Africa in one of the following ways: • Post office current account no. 17101353 under the name of Doctors with Africa CUAMM • Bank transfer IBAN IT 91 H 05018 12101 000000107890 at Banca Popolare Etica, Padua • Credit card call +39-049-8751279 • Online www.mediciconlafrica.org Doctors with Africa CUAMM is a not-for-profit NGO; donations made to our organization are tax-deductible. You may indicate your own in your annual tax return statement, attaching the receipt.

In Health and Development you will find studies, research and other articles which are unique to the Italian editorial world. Our publication needs the support of every reader and friend of Doctors with Africa CUAMM.

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health and development 74 ⁄ december 2016

AFRICA IN NEED EVERY YEAR IN SUB-SAHARAN AFRICA: 4.5 million children under the age of 5 die from preventable diseases that could be treated inexpensively; 1.2 million infants die in their first month of life due to lack of treatment; 265 thousand women die from pregnancy- or childbirth-related complications.

Doctors with Africa CUAMM works in

SIERRA LEONE SOUTH SUDAN ETHIOPIA UGANDA TANZANIA ANGOLA MOZAMBIQUE where we offer healthcare services and support to such women and children.

Please help us wage the battle against these silent yet deadly scourges.

With just €6 a month for 33 months – 1,000 days – you can ensure care for a mother and a child, including: € 50 to provide four checkups for a mother-to-be; € 40 to provide an assisted delivery; € 30 to support a mother and her baby during the breastfeeding phase; € 80 to provide vaccinations and growth checkups during the weaning process.

Magazine on International Development and Health Policy June 2017 — No. 75 www.doctorswithafrica.org