As public-health experts from around the world gather this week in Berlin for the World Health Summit to discuss progress in improving healthcare and health systems, the slow progress on improving maternal health will likely be at the top of the agenda. According to the World Bank's 2012 World Development Report, for women in many countries, pregnancy and childbirth remain the main causes of death for women of child-bearing age, and in fragile states, such as Afghanistan, Chad, Mali, Sierra Leone and Somalia, at least 1 in every 25 women will die as a result of complications from childbirth or pregnancy.
Millennium Development Goal 5 (MDG 5) has been one of the most ‘off-track’ goals, with fewer than 25 countries expected to reduce maternal mortality by the required 75% between 1990 and 2015. Within this context, the decline seen in maternal mortality in Nepal, one of the poorest countries in South Asia, during the 1990s and 2000s is striking. Despite having some of the most difficult terrain for the delivery of health services (hundreds of villages are only accessible by foot for example), a 10-year insurgency and persistent political upheaval, Nepal was able to lower its maternal mortality ratio (MMR) by 47% between 1996 and 2006. More recent survey data support this trend, and the country is on track to meet MDG 5.
Nepal’s story of progress, illustrated in the first of a new phase of Development Progress case studies, can provide important lessons for other countries struggling to address high levels of maternal mortality and morbidity, especially within a context of difficult terrain and high poverty rates.
What enabled this remarkable achievement? As pointed out in a recent article in the Economist informed by our research,reductions in maternal mortality have benefited from a consistent policy focus and sustained financial commitment by the government and donors (who cover approximately 40% of the health budget) throughout the past two decades. Policy-making in maternal (and child) health has been formulated by a highly capable cadre of top-level officials in the Ministry of Health, backed by evidence and data, and supported by a vocal advocacy community with the former prime minister’s wife at its helm. The centrality of maternal health in the MDG (and in turn donor) agenda has led to a further targeting of resources to this issue: one policymaker interviewed for the case study told us that his colleagues had been instructed to achieve the target ‘at all costs’.
Policies have focused on improving access to health services, particularly in remote areas, while reducing the costs entailed in accessing these services, including through the abolition of fees and innovative cash-transfer schemes that reward women for giving birth in clinics. This has been facilitated by almost 50,000 female community-health volunteers, who spread awareness on issues of preventative health, including safer birthing practices, family planning and hygiene, and are able to reach some of the most remote villages in the country.
Perhaps even more significant have been profound changes at the household level. Women are now more likely to have paid work, and increased access to micro-finance means many more now run their own business than they were even 10 years ago. Access to education has improved substantially: the percentages of women and men with at least some secondary or higher education have increased by 48% and 26% respectively in the past five years. Poverty (according to the national poverty line) has dropped from 42% of the population to 25% in the past 15 years. And longstanding efforts to facilitate family planning have led to a massive reduction in the fertility rate: Nepali women went from having six children in the early 1980s to an average of 2.6 in the most recent 2011 household survey pointing to the centrality of family planning and the reduction of unplanned pregnancies in improving the health of young women.
These trends can be explained in part by the massive rise in outward-migration of Nepali men and, increasingly, women. Remittances now account for over 20% of GDP and a total of 56% of Nepali households receive them, up from 23% in the mid-1990s according to the most recent 2011 Nepal Demographic and Health Survey. However, the scale of migration is also a symptom of the persistently poor state of the Nepali economy and many Nepali migrants endure severe hardships abroad.
Sustaining current rates of progress will depend on addressing numerous systemic challenges. The country suffers from high levels of inequality of access: according to the 2008/09 Maternal Mortality and Morbidity Study, the MMR of the Muslim minority is three times that of the high-caste Newaris. And there are indications, particularly since the collapse of the first Maoist government in 2009, that governance and management of the health system are becoming increasingly volatile in the absence of a stable government, consistent leadership and policy coherence.
Finally, sustaining high levels of finance remains questionable: donors like to support a success story and the pace of improvements is likely to slow down, while more complex institutional reforms to improve the system’s efficiency and accountability are still in their nascent stages. Thus there is a risk that appetite to continue increasing aid to health may wane.
What can other countries with high levels of maternal mortality learn from Nepal’s experience? Many of Nepal’s circumstances –high-level advocacy support, a cross-party political consensus on prioritising maternal health, consistent donor engagement – are specific to the country. However, these and others can be transferable. For instance, Nepal's extensive and informed use of data and evidence could play a big role in informing policy elsewhere. Nepal’s health officials drew on a relatively standardised set of interventions to address maternal mortality, but generally did so in an evidence-based, targeted and sequenced manner. While there is scope to improve the quality the data collection and particularly death registration systems, the country has made great strides in being able to target the most frequent causes of maternal deaths.
Nepal’s progress in maternal health shows the importance of thinking ‘multi-sectorally’in addressing preventable maternal deaths. Success required the cooperation of a broad set of actors at all levels of society, and the synergistic interaction of numerous policies and interventions that added up to more than the sum of their parts.