1. Creating an Enabling Environment for PE/E Interventions 23 February 2011 Addis Ababa, Ethiopia Lindsay Morgan 1 Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21-25 February 2011

2. Outcomes Depend on Context Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21-25 February 2011

3. Health Systems 101 3 Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21-25 February 2011

4. Other Aspects of the Health System  Fill in with pics – terrain, and something showing social interactions..culture Physical environment Climate Terrain Population Density Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21-25 February 2011

5. And others… 5 Social Environment Culture Household characteristics Individuals Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21-25 February 2011

6. For Effective PE/E Care-- What Needs to Happen? 6 Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21-25 February 2011

7. STEP 1: A Woman Learns She Is Pregnant 7 Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21-25 February 2011

8. Between Point A and Point B – What Needs to Happen? Discovery Decision to seek care depends on: Knowledge Social pressures and norms Cost Transport ANC 8 AB Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21-25 February 2011

9. How Can We Help Women Seek Care? Insurance to overcome financial barriers to accessing services  Social Insurance: national programs financed by combination payroll and other taxes and premiums, with exemptions for the poorest  Community-Based Insurance: smaller, voluntary, community-based initiatives to reach rural dwellers and informal sector 9 Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21-25 February 2011

10. Results and Challenges  Care-seeking more likely  Reaching the poorest isn’t easy  Coverage of CBI tends to be small and increases slowly  Insurance schemes challenging to implement and fund  They depend on the benefit package 10 Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21-25 February 2011

11. Another Approach for Overcoming Financial and Social/Geo Barriers: Targeted Subsidies Vouchers: A purchaser contracts accredited health facilities and vouchers are distributed to patients entitling them to services at contracted facilities. Voucher is either heavily subsidized or free, and provider is reimbursed for the cost of provision, plus a reasonable profit, after delivery is verified. Conditional Cash (or in-kind) Transfers: transfer cash to ease constraints on household investment in human capital development by reducing out-of-pocket expenditures and opportunity costs; induce health and nutrition behavior changes by conditioning the transfers on the use of preventive health services and attendance to health education talks. 11 Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21-25 February 2011

12. Results and Challenges  High demand for vouchers for delivery- related services; increased revenue for facilities  Managing claims is time consuming and difficult to verify whether services have been delivered  CCTs are powerful motivator 12 Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21-25 February 2011

13. Overcoming Geographic Barriers: Bring Services to Communities Community Health Workers Mobile clinics Health camps 13 Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21-25 February 2011

14. Results and Challenges  Strengthened links between communities and health facilities/health system  Challenges of overburdened workers, regulation, trouble establishing clear lines of supervision and support 14 Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21-25 February 2011

15. STEP 2: Woman Arrives at Facility For Care 15 Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21-25 February 2011

16. Between Point B and Point C – What Needs to Happen? 16 Arrival at Facility Provision of care depends on: Presence of skilled providers Drug availability Clinical guidelines Provider motivation to deliver quality care Birth BC Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21-25 February 2011

17. How Can We Help Providers Deliver Quality Care? Quality Tools Provide guidelines Introduce continuous quality improvement processes (such as Standards-based Management and Recognition) 17 Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21-25 February 2011

18. Rewarding Quality Care  Accreditation of facilities in voucher schemes  Accreditation of hospitals in Brazil  Payment linked to quality score in Burundi and Rwanda 18 Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21-25 February 2011

19. Success of PE/E interventions can be helped or hindered by strengths and weaknesses in the health system 19 In Summary… Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21-25 February 2011

20. Thank you! wwww.mchip.net Follow us on: Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21-25 February 2011