Tracking progress towards safe motherhood: Meeting the benchmark yet missing the goal? An appeal for better use of health-system output indicators with evidence from Zambia and Sri Lanka

  • Tropical Medicine and International Health, Volume 16, No. 5, Year 2011

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Study Justification:
– The study aims to promote the use of health-system output indicators, specifically Emergency Obstetric Care (EmOC) density, for monitoring progress in reducing maternal mortality.
– Currently, these indicators are underused, and this study seeks to demonstrate their effectiveness at the subnational level.
– By evaluating the differentiation between a high-maternal-mortality country (Zambia) and a low-maternal-mortality country (Sri Lanka), the study provides evidence for the need to improve the use of these indicators.
Highlights:
– Both Zambia and Sri Lanka performed similarly in terms of EmOC facility density, indicating that the current indicator fails to differentiate between high- and low-maternal-mortality settings.
– In Zambia, while the WHO benchmarks for doctors/midwives were met overall, there was a highly unequal distribution between provinces.
– Sri Lanka exceeded the suggested benchmarks for midwives and doctors by a significant margin.
– Geographical access to EmOC facilities in Zambia was poor, with less than half of the population living within 15km of a facility.
Recommendations:
– The current health-system output indicators and benchmarks for EmOC need revision to enhance their discriminatory power.
– The indicators should be adapted for different population densities.
– Subnational disaggregation and assessment of geographical access should be routinely considered to identify gaps in EmOC provision.
– Increased use of an improved set of output indicators is crucial for guiding international efforts to reduce maternal mortality.
Key Role Players:
– Ministry of Health (Zambia and Sri Lanka)
– World Health Organization (WHO)
– International organizations working on maternal health
– Local health authorities and professionals
– Researchers and academics specializing in maternal health
Cost Items for Planning Recommendations:
– Research and data collection costs
– Training and capacity-building for health professionals
– Development and implementation of revised indicators and benchmarks
– Improving geographical access to EmOC facilities (infrastructure, transportation, etc.)
– Monitoring and evaluation of progress in implementing the recommendations

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study compares national and subnational density of health facilities, EmOC facilities, and health professionals in Zambia and Sri Lanka. It identifies shortcomings in the current use of health-system output indicators and benchmarks for monitoring progress towards reducing maternal mortality. The study suggests that the indicators fail to discriminate between high- and low-maternal-mortality settings and highlights the need for revision and adaptation. The study also emphasizes the importance of subnational disaggregation and assessing geographical access. To improve the evidence, the study could provide more detailed data and analysis on the specific benchmarks, their relevance, and potential alternative indicators. Additionally, including a larger sample size and considering other countries with varying maternal mortality rates would strengthen the findings.

Objectives Indicators of health-system outputs, such as Emergency Obstetric Care (EmOC) density, have been proposed for monitoring progress towards reducing maternal mortality, but are currently underused. We seek to promote them by demonstrating their use at subnational level, evaluating whether they differentiate between a high-maternal-mortality country (Zambia) and a low-maternal-mortality country (Sri Lanka) and assessing whether benchmarks are set at the right level. Methods We compared national and subnational density of health facilities, EmOC facilities and health professionals against current benchmarks for Zambia and Sri Lanka. For Zambia, we also examined geographical accessibility by linking health facility data to population data. Results Both countries performed similarly in terms of EmOC facility density, implying this indicator, as currently used, fails to discriminate between high- and low-maternal-mortality settings. In Zambia, the WHO benchmarks for doctors/midwives were met overall, but distribution between provinces was highly unequal. Sri Lanka overshot the suggested benchmarks by three times for midwives and over 30 times for doctors. Geographical access in Zambia – which is much less densely populated than Sri Lanka – was poor, less than half the population lived within 15km of an EmOC facility. Conclusions Current health-system output indicators and benchmarks on EmOC need revision to enhance discriminatory power and should be adapted for different population densities. Subnational disaggregation and assessing geographical access can identify gaps in EmOC provision and should be routinely considered. Increased use of an improved set of output indicators is crucial for guiding international efforts towards reducing maternal mortality. © 2011 Blackwell Publishing Ltd.

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The recommendation to improve access to maternal health is to revise and enhance the current health-system output indicators and benchmarks for Emergency Obstetric Care (EmOC). This can be achieved by:

1. Enhancing discriminatory power: The current EmOC facility density indicator fails to differentiate between high- and low-maternal-mortality settings. The indicators should be revised to better reflect the variations in maternal health outcomes.

2. Adapting for different population densities: The benchmarks for health professionals, such as doctors and midwives, should be adjusted based on the population density of the region. This will ensure that the distribution of healthcare providers is equitable and meets the needs of the population.

3. Subnational disaggregation: It is important to analyze the data at a subnational level to identify gaps in EmOC provision. This will help in targeting resources and interventions to areas with the greatest need.

4. Assessing geographical access: Geographical accessibility to EmOC facilities should be routinely considered. Linking health facility data to population data can help identify areas with poor access and guide efforts to improve access in those regions.

By implementing these recommendations, international efforts to reduce maternal mortality can be better guided, and access to maternal health services can be improved.
AI Innovations Description
The recommendation to improve access to maternal health is to revise and enhance the current health-system output indicators and benchmarks for Emergency Obstetric Care (EmOC). This can be achieved by:

1. Enhancing discriminatory power: The current EmOC facility density indicator fails to differentiate between high- and low-maternal-mortality settings. The indicators should be revised to better reflect the variations in maternal health outcomes.

2. Adapting for different population densities: The benchmarks for health professionals, such as doctors and midwives, should be adjusted based on the population density of the region. This will ensure that the distribution of healthcare providers is equitable and meets the needs of the population.

3. Subnational disaggregation: It is important to analyze the data at a subnational level to identify gaps in EmOC provision. This will help in targeting resources and interventions to areas with the greatest need.

4. Assessing geographical access: Geographical accessibility to EmOC facilities should be routinely considered. Linking health facility data to population data can help identify areas with poor access and guide efforts to improve access in those regions.

By implementing these recommendations, international efforts to reduce maternal mortality can be better guided, and access to maternal health services can be improved.
AI Innovations Methodology
The methodology used in this study aimed to simulate the impact of the main recommendations on improving access to maternal health. The study focused on comparing the current health-system output indicators and benchmarks for Emergency Obstetric Care (EmOC) in two countries, Zambia and Sri Lanka.

1. Data collection: The study collected data on the density of health facilities, EmOC facilities, and health professionals in both countries at the national and subnational levels. This data was used to assess the current situation and identify gaps in EmOC provision.

2. Benchmark evaluation: The study compared the collected data against the current benchmarks for EmOC facility density and health professionals. This evaluation aimed to determine whether the benchmarks accurately reflect the variations in maternal health outcomes and if they are set at the right level.

3. Subnational analysis: The study analyzed the data at a subnational level to identify disparities in EmOC provision within each country. This analysis helped to identify areas with the greatest need for improvement and resource allocation.

4. Geographical accessibility assessment: In Zambia, the study linked health facility data to population data to assess geographical accessibility to EmOC facilities. This assessment aimed to identify areas with poor access and guide efforts to improve access in those regions.

5. Comparison and conclusions: The study compared the findings from Zambia and Sri Lanka to evaluate the effectiveness of the current indicators and benchmarks. The results showed that the current indicators fail to differentiate between high- and low-maternal-mortality settings and that adjustments are needed to better reflect variations in maternal health outcomes.

Overall, this methodology allowed for a comprehensive assessment of the current health-system output indicators and benchmarks for EmOC. It provided evidence to support the recommendations for revising and enhancing these indicators to improve access to maternal health services.

Statistics:
Citations: 31
Authors: 5
Identifiers:
DOI: 10.1111/j.1365-3156.2011.02741.x
ISSN: 13602276
Research Areas:
Health System and Policy, Maternal and Child Health, Quality of Care, Social Determinants, Workforce
Study Countries:
Zambia
Study Design:
Cross Sectional Study
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