Promoting safer motherhood for all:

The role of innovative social

protection

Dr. Nicola Jones Research Fellow

Social Development Programme ODI

March 9 2012

Presentation overview

1. Safe motherhood challenges

2. CTs with Safe

Motherhood components 3. CTs with Safe

Motherhood focus 4. Policy and programming

implications

1. Safe motherhood challenges

Quality Maternal Health Care...

• is an essential human right for women

• is tightly linked to child survival and development

• is required for health care strengthening

• is linked to environmental sustainability

• is vital to meeting broader development goals

UNICEF (1994)

The “Three Delays”: Time that costs women’s lives

Women face a variety of obstacles to obtaining quality reproductive health care: Recognising the need for care • Early signs of complications may go unrecognized • Cultural practices may preclude spending scarce

resources on women. Women’s ability to access care • Poor infrastructure, lack of transport and long

travel times slow even determined women and their families.

Obtaining quality care: funding is key • Poor funding levels result in shortages of staff and

supplies, undermining quality of care at health facilities

‘

‘A woman in labour came to the health post … I saw that she had a foot showing [a baby in breach position]. I advised her family to quickly take her to the health centre. The woman did not go right away. The family had to raise money for transportation and other costs. When she went to the health centre they told her to go to the hospital 100 km away. Finally she went to the hospital. She survived but lost her baby.’

Bizunesh Megersa, Heath Extension worker, Chiri Kebele, Ethiopia.

Promising Programming

Cash Transfers, used since the mid-1990s in Latin America, and increasingly internationally, provide regular cash payments to improve children’s basic service access, and in some cases maternal health. Fee exemption policies remove user fees for maternal health services in order to promote ante- / post-natal service uptake, and institutional deliveries. Cost-sharing schemes, including subsidies and community health insurance, aim to spread financial risk. Voucher schemes, which provide women with vouchers in exchange for a service, aim to make care more affordable for the poorest. Social marketing approaches promote behaviour change vis-à-vis reproductive/ sexual health issues through information, education, mobilisation through women’s groups. Community-based initiatives include programmes to train community-based health personnel, develop community transport systems, distribute clean delivery kits, etc.

Cash Transfers and Safe Motherhood

Cash transfers: provide regular social transfers for vulnerable

households, help mitigate immediate disadvantage, contribute to longer-term human capital development.

Many first generation CTs offer: benefits to pregnant and lactating women as part

of a larger package focused on child wellbeing usually conditional on service uptake and

attendance at educational programmes

A small number of newer CTs are specifically focused on Safe Motherhood.

2. CTs with Safe Motherhood Components

How do CTs impact Safe Motherhood?

CTs impact maternal health through five main channels: 1. Some programmes offer free care to incentivise service use, all raise family income, and

open financial space for maternal care.

2. Programmes that condition service uptake engage women in a social contract to ensure they and their families regularly use those services

3. CTs often include education about sanitation, health and nutrition—which promotes behavioural change and stimulates demand for those services.

4. CTs may raise women’s status in the family, as mothers are typically the main programme beneficiaries.

5. CTs often address supply-side constraints, encouraging investment in health infrastructure, providing training and/or incentives for community health workers, and incentivising local governments with additional funding.

The jury remains out on the pros and cons of conditional vs unconditional approaches, and in the case of safe motherhood, evidence base is esp. weak

Mexico’s Oportunidades: A world pioneer

• Initiated in mid-1990s, Oportunidades includes health service uptake as part of a broader set of behavioural conditions to programme participation.

• Reached 5.8 million hhs as of 2010

• Pregnant women are required to complete a prenatal care plan, obtain nutritional supplements, and attend health educational programmes

• Lactating women and children under 4 are also eligible for health benefits.

• The monthly health benefit is fixed at $15/ per hh, which represents approximately 20% of HH income.

Gertler (2000); Gobierno Federal (2010)

Burgeoning array of CCTs promoting access to maternal healthcare

Guatemala Indonesia Philippines

Programme name

Mi Familia Progresa

Program Keluarga Harapan

Pantawid Pamilyang Pilipino Programme

Aims To promote uptake of a basic package of nutritional and preventative maternal-child health care services

To improve HH socioeconomic conditions by addressing a wide variety of disparities, including access to maternal health care.

To provide income assistance to the poor and to break inter-generational transfer of poverty

Transfer details

Pays pregnant and lactating women up to $18/mo

Pregnant women receive $67 per quarter; more if they also have older children.

Offers women $10/mo provided they obtain prenatal care, deliver with skilled personnel and attend parenting education classes

Coverage Reaching almost half a million beneficiaries/ 47% of extreme poor

In 2009 720,000 hhs in 14 provinces received the transfer; aiming to reach 6.5 million by 2015.

Aimed to reach 2.3 million hhs by end of 2011

Barrientos et al. (2010); Gaia (2009); Pablo (2009)

In Mexico’s Progresa/ Oportunidades • Both the quantity and quality of prenatal care has increased, with women

having more exams and procedures.

• Women are more active in consuming health care—they are more educated and make more decisions.

• Rates of skilled delivery, maternal vaccination and post-natal care have increased.

• Supplements have pushed anaemia rates down.

Freedman et al. (2007); Barber and Gertler (2009); Rivera-Dommarco (2006)

In El Salvador • Even without conditioning, Comunidades Solidarias Rurales has increased

rates of ANC and skilled delivery.

De Brauw and Peterman (2011)

Impacts: Evaluations are rare, but positive

3. CTs Focused on Safe Motherhood Aims

India’s Janani Suraksha Yojana: incentivising safe motherhood

Launched in 2005, India’s Janani Suraksha Yojana (Safe Motherhood Scheme) CCT programme incentivises antenatal care and facility delivery.

Its core aims are to:

– Ensure pregnant women complete 3 ante-natal and 1 post-natal visits.

– Deliver in a public healthcare facility.

– Incentivise delayed childbearing and smaller families.

Programme benefits include:

• Free care and travel expenses

• Cash payment of $13 to $31 for eligible beneficiaries

• Sliding payment scale in relation to need

• Support from community health workers, who are in turn

financially incentivised

Nepal’s Safe Delivery Incentive Programme: Providing coverage for all

• Nepal’s SDIP initially covered all births to women with no more than two living children—as long as delivery took place in a government facility.

• Subsequent focus on institutional delivery but not-for-profit facilities are now covered due to acknowledged supply-side constraints.

• Recognizing transport difficulties, the delivery benefit varies by location.

• Removal of user fees for delivery care at

public facilities.

• Providers also receive incentives.

Powell-Jackson (2009, 2008)

Ghana-Luxembourg Social Trust Pilot

• The GLST is a pilot CCT programme in four area councils in Dangme West District. • Provides poor pregnant women and mothers with under 5s with:

– monthly cash transfer of Ghc. 15, paid bi-monthly

– on condition of health insurance registration, attendance at ante- / post-natal check-ups, skilled delivery and immunisation.

• Recipients and community members are provided with education on maternal and child health.

• Financed through a ‘Global Social Trust’ mechanism:

– funded by Luxembourg gov’t (two-thirds)

– a workers union NGO (one-third)

– with support of ILO and national partners

(National Health Insurance Scheme, Ghana Health Services, District Assembly, LEAP CT).

European Report on Development, 2010.

Interact-ODI SM pilot

• DFID-funded CCT and UCT pilot to promote SM in Ethiopia, Malawi, Uganda in 2011

• Implemented by Interact local health NGO partners; with involvement of community women’s groups

• Designed with potential to link to mainstream social protection programmes, e.g. Ethiopia’s PSNP

• CCT was conditional on:

– women attending four antenatal visits from second trimester – institutional delivery, or at least attended by skilled birth attendant – attending two postnatal appointments – bonus for attending all visits

• UCT made 4 bi-monthly payments starting from 4th month of pregnancy

• Complementary emergency fund for complicated deliveries

Impacts: Growing awareness, encouraging results

In Nepal • Women exposed to the SDIP were 24% more likely to deliver at

government facilities. • The poorest women were 64% more likely to use a skilled delivery

attendant. • By the third year of implementation, over half of delivering mothers

received the benefit. Powell-Jackson (2008, 2009)

In India • Antenatal care and facility delivery are both showing positive impacts. • Ethnic minorities are showing good uptake. • Rates of postnatal care and breastfeeding advice are increasing.

Lim et al. (2010)

Challenges facing CTs

• Care must be taken not to incentivise pregnancy.

• Family planning must be included to encourage healthier birth spacing. • Important to recognise that women do not make

decisions regarding reproductive health in isolation.

• Not only cost but also transport infrastructure is a barrier to service access

• Without preparation, health systems can be overwhelmed—or simply non-existent.

• CCTs may add to women’s time burden, and can be complex and resource intensive to monitor.

• Women who face complicated deliveries need additional support

Elamon, 2010; Lim et al., 2010

4. Policy & programming implications

Policy & programming implications

1. A robust, context-sensitive vulnerability and needs assessment is

needed upon which to build interventions and assess potential for scale up; including an understanding of political economy dynamics

2. Appropriate infrastructure—including personnel, processes and systems—

is critical.

3. Adequate and stable funding is required:

– donor funds for piloting and rapid scale up +

– domestic funding to ensure long-term stability.

Policy & programming implications (cont.)

4. Conditionalities, if adopted, need to be carefully tailored and care

taken to avoid penalising the most disadvantaged—and to avoid incentivising pregnancy.

5. Complimentary programmes are important – including programmes

that address broader health issues, as well as poverty reduction, education and women’s social status

6. Government ownership and political commitment is key in order to develop high quality services:

national-level structures need to be involved from the outset

and supported through capacity-strengthening initiatives

7. Monitoring and evaluation is crucial and

needs to be well-resourced with an emphasis on lesson learning.

Further reading

ODI Briefing Papers and Working Papers • Jones, N and Samuels, F. (2011) Rethinking cash transfers to protect maternal health: good practice

from developing countries. ODI Background Notes, London, UK • Samuels, F. and Jones, N. (2011) Cash transfers for maternal health: design opportunities and

challenges in low-resource settings. ODI Briefing Paper 68, London, UK • Holmes, R. and Jones, N. (2010) Social protection programming: the need for a gender lens. ODI

Briefing Paper 63, London, UK • Jones, N. and Holmes, R. (2010) Gender, politics and social protection. ODI Briefing Paper, London

62, UK • Holmes, R. and Jones, N. (2010)Gender-sensitive social protection and the MDGs. ODI Briefing

Paper 61. ODI: London. • Holmes, R. And Jones, N. (2010) Rethinking social protection using a gender lens. ODI Working

Paper 320, London, UK • Holmes, R. and Jones, N. (2009) Putting the social back into social protection: a framework for

understanding the linkages between economic and social risks for poverty reduction. ODI Background Note, ODI London

Toolkit • Holmes, R. and Jones, N. (2010) How to design and implement gender-sensitive social protection

programmes. A toolkit. ODI, London UK