Lessons from the Effective Promotion of Maternal Health Care in Zambia

Rationale Gender mainstreaming often appears ineffective, yet the alternative is unclear. But maybe we could learn from what works in getting gender issues onto development agendas. What ideas, interests and institutions are key? Methodology Identify a gender issue that has been prioritised by government DISTRICT LEVEL: Started by exploring the reasons underlying variation in performance over time in 3 rural Copperbelt districts. Interviewed health workers & managers at district & provincial levels. Observed their routine activities (outreach & planning), as well as their participation in donor-financed workshops. This revealed the importance of top-down attention to maternal health indicators. CENTRAL GOVERNMENT: So next studied why MoH was putting pressure on provinces and districts to promote safe motherhood. Observed high-level meetings and interviewed senior civil servants. Lived at the National Assembly Motel, interviewed parliamentarians. Bottom-up Accountability Capacity Building Supportive Supervision LIMITED EVIDENCE OF IMPACT. HEALTH EDUCATION has been the assigned role of rural, voluntary NHCs & SMAGs; their participation in planning and accountability appears limited. QUIET INDIVIDUALS, PERIPHERAL CSOS 'In some [rural] areas, even if outreach is not done for a year they will just keep quiet until the health worker decides to resume' (a District Maternal and Child Health [MCH] Coordinator). Also in urban areas, mothers explained that they did not complain about poor treatment because they were anxious to secure treatment from nurses. OCCASIONAL COMPLAINTS THROUGH PRIVATE MEDIA DISSATISFACTION WAS EXPRESSED IN THE NATIONAL ELECTIONS (2011). This technocratic expectation ignores the financial meaning of workshops: 'It will be difficult to implement. There will be resistance. They will resent the money I got' (nurse at rural hospital). 'They will say he's gone on an 'IGA' trip, Income Generating Activity! Whatever you say they won't listen. [They will think] 'We didn't get that money, so why should we listen?'. Those who have attended must have very good persuasive powers. At my office we spread it out [workshop attendance], so the frictions are reducing' (DMO). TWO QUESTIONABLE ASSUMPTIONS: Limited knowledge, rather than motivation Information will be disseminated and collectively implemented Many health workers and managers stressed the importance of supportive supervision. Participatory interactions, plus thorough, unannounced visits seem to enhance motivation, fostering the perception that work on maternal health is not only valued but also scrutinised. Some managers inspire and motivate staff through their own prioritisation of safe motherhood. Providing concrete instances of practical support, and Fostering the perception that maternal health matters. But supportive supervision was often said to be inadequate. Extended periods of absence from line-managers often leads nurses to feel that no one cares about what they are doing. Performance -based Management INCREASING TOP-DOWN PRESSURE TO IMPROVE MATERNAL HEALTH INDICATORS To varying degrees, provincial health teams pay attention to these results and provide more support to under-performing districts. Many DMOs have become focused on maternal health in order to satisfy managers at provincial level. DMOs who feel pressured to improve their indicators seem more open to criticisms about their own behaviour. Top-down targets can thus foster the kind of supportive supervision and passion for which more intrinsically-motivated managers are praised. Results-based financing (RBF) pilot programme Funded by DfID and NORAD, through the World Bank. Piloted in 11 districts in Zambia, following a pre-pilot. Health facility staff are financially rewarded according to their institution's quantity and quality scores, as well as their own individual assessments, adjusted for their cadre level. The quantity score incorporates a number of MCH indicators, each of which has a unit fee, multiplied by coverage. Control districts are allocated resources to the same value of RBF. Participating staff suggest that this combination of incentives has amplified behaviour elsewhere associated with high maternal health indicators: more motivation and supportive supervision. Rebecca (midwife): It has changed our attitude, we are working hard because of the money. Way back we were so relaxed... Our attitude has really changed, people used to come late for work, now everyone is on time. We were doing shortcuts, but now we are doing full procedures. When a patient comes to the labour ward, you do the partograph [a tool to monitor the progress of labour], but before it was an 'I don't care attitude': you forget, you just want to finish so you can sit and relax... People have changed now. If the results are poor you're not going to get anything. [Previously] the Performance Assessement was done after six months, maybe they don't even come, they just get the registers [i.e. it was not always a thorough investigation]. Now, RBF, it's daily, there's quantity and quality [monitoring]. The more deliveries you have, the more money in your pocket!... They can increase the salary but RBF is the only way of motivating us because we're paid according to the number of deliveries... Sarah (nurse): RBF, it encourages people to work hard and to do things correctly, not shortcuts like it used to be... If it was not RBF we were not going to pressure them [pregnant women] to come here. Can you pressure yourself when the government is not doing anything? I would like to do only a few things then I go home and rest. The money we are given by the government is very little, the time we spend here is much, so are you going to be doing a lot of things? They'd rather be sitting. But now they've started encouraging people to come here. Susan (nurse): It is inclusive. It doesn't leave out anyone at the facility (in terms of financial rewards), but a workshop like this only targets a few. Some MoH senior management expressed concerns about the financial sustainability of RBF. It will be interesting to explore how Government concerns are shaped by ongoing comparative evidence of cost-effectiveness. Perceptions of limited government ownership may underlie such qualms. Another worry is that performance-related pay may lead workers to focus exclusively on financial benefits. As one senior manager explained, 'It was an initiative in the World Bank, they wanted to push it to show evidence... There was resistance to World Bank handling of the programme [in terms of choosing locations and recruitment of programme managers]'. Donors privately protested, maintaining that 'there is alignment and coordination with the use of government systems', such as in terms of procurement and auditing. This kind 'ownership' does not appear to have been perceived as sufficient. Many pointed to evident human resource-based constraints. But these impediments may be lessened by making existing workers more efficient Also, existing expenditure could be rerouted. But is it unrealistic to think that all workers might be intrinsically motivated to improve service-delivery? Such commitment is not universal, hence relevance of PBM. Note also, pecuniary concerns are not particular to RBF alone. Staff already undertake a range of activities in order to augment their incomes (e.g. 'IGAs' & additional work). Also, does nurses' enthusiasm for RBF merely reflect mercenary motivations? - rather than the symbolic value of the reward: recognition of good performance. Recall, health workers often feel that their efforts are not appreciated. DISTRICT LEVEL NATIONAL PRIORITIES GLOBAL DEVELOPMENT AGENDAS Safe motherhood may have been historically overshadowed by divergent global health agendas. A preponderance of clinical trainings previously focused on HIV, rather than maternal health. Not matched by increased recruitment, this compounded staff workload. This donor emphasis on HIV/AIDS meant that even if the Zambian government sought to promote maternal health, external support has been limited. Lately there has been an international redirection of attention towards safe motherhood and health systems strengthening more generally. In Zambia, aggregate official development assistance to maternal, newborn, and child health per live birth increased from US$24.7 in 2003 to US$46.1 in 2008. DfID, SIDA & EU set to provide extra funding for MDG5. HIV THE EFFECTIVE PROMOTION OF MATERNAL HEALTH CARE 'Donors would lobby through technical planning meetings, to indicate one health issue to be prioritised... The donors were not so much focused on safe motherhood. Now there has been a change' (a former Minister of Health). 'In SAG [Health Sector Advisory Group] meetings [prior to 2006], we would discuss it [maternal health] very superficially, not being focused and giving attention to it. It would be a routine part of what is presented... It was a quick run through. It was like any other programme, what was drawing the attention was the programmes with a lot of money: HIV, TB and malaria'. Dr Mwale: The ministers can have the passion, but the donors set the agenda. All the funding was Global Fund, this time Global Fund is interested in maternal health. That time they were not. Lombe: With health systems strengthening to cut across all sectors you can then get a lot of resources to strengthen maternal health... [Previously] donors wanted to focus on HIV, so the Government couldn't obtain funding for safe motherhood. For example, my former director had to fight to oppose the building of a new theatre for male circumcision, which would mean that a mother would give birth on the floor and the baby would be transferred to a new building! The amplification of efforts to reduce maternal mortality did not start with the MDGs but with the recent realisation that the country was lagging behind, unlikely to meet agreed international targets. Many senior managers in the Ministry of Health expressed their keenness to avoid the embarrassment of trailing behind other countries making rapid progress: 'MDGs - we have to be part of the world... We found that we are not on track. The commitment has been there but it was enhanced by the MDGs'. 'We are a stable country; to be put in that place [sharing rankings with conflict-afflicted states] is a shame' . 'If you look at our performance towards the MDGs, the only indicators that are quite a challenge are MDGs 4&5, so it prompted us to say, 'What can we do?'. To meet the targets we need to do some extraordinary things [i.e. RBF]'. International benchmarking and consequent awareness of comparatively poor national performance appears to have increased attention to maternal health indicators within MoH – an institution already working towards this objective. MDGs Sensitisation workshops presumes some unaware of the MMR, or think this is 'normal'. Effectiveness varies. COMPARATIVE EVIDENCE shows the avoidability of MM & invokes a sense of competition. 'SMART ECONOMICS'. HORIZONTAL LEARNING & NETWORKING Developing an 'African' agenda Perceptions depend on standpoint: Advocacy This technocratic expectation ignores the financial meaning of workshops: 'It will be difficult to implement. There will be resistance. They will resent the money I got' (nurse at rural hospital). 'They will say he's gone on an 'IGA' trip, Income Generating Activity! Whatever you say they won't listen. [They will think] 'We didn't get that money, so why should we listen?'. Those who have attended must have very good persuasive powers. At my office we spread it out [workshop attendance], so the frictions are reducing' (DMO). Outsiders, like a former Minister of Finance, colleagues in the Ministry of Health, and other targets of such lobbying, had little or no recollection of these events, when asked. The vast majority of policy-makers downplayed the significance of such advocacy. As one senior manager explained, 'we have so many awareness campaigns', attention is not sustained on a particular issue. Are non-executive parliamentarians as powerful as lobbyists assume? Can policy-makers be persuaded by information-dissemination alone? A number of individuals with experience in the health sector have recently gained power: critical mass of support. Doubling of spending on reproductive health, announced at London Family Planning Summit Increased budget allocation for health. 'He was previously Minister of Health, so he understands the problems and is easily convinced they need more money' (senior party leader commenting on the President). 'It was all done by the Government. It caught us by surprise. We hadn't imagined they would increase it by that much' (donor staff). Political space and critical mass of health champions While collective discussions on reproductive health were sometimes cited as inspirational and informative by those already interested in this topic, disinterested others largely remain so, even when a range of innovative discursive frames are used. Advocates often attribute their commitment to safe motherhood to long-term, first-hand experience, which enabled them to see the need for more resources but moreover be personally affected by trauma of maternal deaths: 'For me it's personal conviction, rather than international conferences. I bought into that [the policy about health posts] because I had personal experience, I was brought up in rural areas... I know access to health is severely limited by distance. We are aware of the problems. These are the things we see ourselves. Workshops were started by donors then public service got hooked. It's massive wastage. They need to be reduced' (former Minister of Finance). People also interpret their experiences according to their background ideologies. 'This is just to give me the statistics to use... Once in a while we must converge, but workshops will not make us champions of these issues' (MP commenting on workshops). 'I think it's about if they perceive the information as relevant to them' (donor). Neither empathy nor outlook seem to be easily shifted by sensitisation alone. MDG 5 has become institutionalised as a Performance Assessment Indicator of MoH. TBAs were excluded from the indicator on institutional deliveries, on in line with international consensus about their ineffectiveness, as reflected in MDG 5. This shifted attention to human resource constraints. 'You see this indicator was really low. That's how we began to really address issues of HR [human resources]. The indicator reinforced the policy direction'. Strategic actors collectively developed a shared commitment to this global goal. Regular interactions Sector based support was conditional on performance indicators. However, despite increased concern to prevent maternal mortality, some relevant programmes (like abortion access) remain unsupported.