Governance
Governance deals with how decision-making is organised and shared across health system-levels (national, sub-national, hospital, health centre and community), management and leadership capacities for MNCH policies and programme development, and implementation and existing accountability mechanisms in country for health systems and MNCH. The desk review as well as the KI interviews highlighted a wide range of limiting factors related to governance. These included priority setting, vision and leadership capacity. Conversely, improved leadership and other capacities were found to be conducive [43].
“Misplaced priority by the governance: sometimes there are more serious issues to be done but then actually the governance is doing something else, when the communities are looking for something else and so on, so there is a misplaced priority.” (Local NGO staff, Nigeria)
“… some don’t have any vision, it’s just because they have been appointed to be there … [they have] inadequate knowledge and skills to be in a leadership position. People have not been trained to be in a leadership position and they are there, so they are unable to perform.” (National health director, Ghana)
Institutional power hierarchies were reported to be strong in several countries and affected decision-making and implementation in various ways. For example, one of the conclusions of work in Senegal to identify barriers to, and facilitators of implementation of facility-based maternal death reviews was that institutional leadership and hierarchy affected the implementation and outcomes of the intervention. Specifically, non-participation of the head of department in the audit meetings and lack of feedback to staff who did not attend the audit meetings were identified as barriers. Strong traditional hierarchies in the relationship between doctors and other categories of personnel acted as a barrier to the establishment of multi-disciplinary teams. Conversely, the main facilitators were involvement of the head of the maternity unit, acting as a moderator during the audit meetings, and participation of managers in the audit session to plan appropriate and realistic actions to prevent other maternal deaths [44].
The nature and depth of implementation of decentralisation and insufficient decentralised decision-making authority acted as a limiting factor through its effect on the ability of mid and floor level managers to respond flexibly and appropriately in context to effectively implementing policies and programmes. Work in Ghana on district manager decision space showed that hierarchical authority and resource uncertainty constrained district manager decision space. These constraints gave rise to a leadership type oriented toward serving the bureaucratic functions of the health system. As a result, district-level management and leadership were sometimes constrained in their ability to respond to MNCH service delivery challenges [45].
In a study of the impact of decentralisation on sexual and reproductive health services in Ghana, Mayhew [46] found that, while some decision-making about resource allocation was meant to take place at district and regional level, in practice, it remained centrally controlled. Though this might have been a necessary safeguard for sexual and reproductive health services, it also hindered aspects of implementation at the local level.
However, decentralisation did not always have a positive effect on outcomes. Abimbola et al. [47] found that decentralisation in Nigeria negatively influenced the retention of rural health workers in two ways. Firstly, the salary of primary healthcare (PHC) workers was often delayed and irregular because of delays in transfer of funds from the national to sub-national governments. Secondly, the primary responsibility for PHC was often left to the weakest tier of government, namely local governments. The result was that rural PHC workers were attracted to working at secondary levels of care run by the state government and tertiary levels run by the federal government. These were often in urban areas where salaries were higher and more regular.
There could also be complex challenges with uniformity in national policy and programme acceptance and implementation depending on the model of decentralisation.
“… Another bottleneck is the complex governance system … in Nigeria it is not unitary, so it’s not mandatory for a State to keep into the national health policies, we have to do a lot of advocacy to ensure buy-in.” (National health director, Nigeria)
Floor or facility level governance issues such as leadership, interpersonal and interprofessional relations, conflicts among staff, higher level officials’ failure to adequately recognise, acknowledge and deal with the frontline worker resource availability, motivation and conflict also affected implementation of interventions and programmes [42].
“… the important ingredient for strengthening health system development will be harmony across the cadres. There is largely a lot of disharmony in that sector and it impacts negatively on health systems development so we need to have a way of ensuring industrial harmony, we need to also ensure accountability in service delivery.” (Head of department, Nigeria)
Public accountability of those who decide and act also emerged as a conducive or limiting factor depending on the circumstances. Lodenstien and Dao [48] found in rural Mali that, if decentralisation policies do not address public accountability, they will not fundamentally change human resource management, quality and equity of staffing. KIs also commented on accountability and the related issue of corruption.
“Regarding accountability, I’ll sincerely admit that the absence of the requisite tools and relevant accountability mechanisms within the health system makes it difficult for people to be answerable even if they are willing to do so.” (Representative of an NGO, Burkina Faso)
“… then the issue of corruption which whether we like it or not is a canker among our people.” (Local NGO, Nigeria)
“Corruption and nepotism is bedevilling the health system in Mali. You know, a Director needs people and competent people for that matter to get things done but you just can’t appoint or recruit people, no matter their competence. As a director, I know what I want in a head of department but all efforts to have certain people to occupy certain positions have not yielded much fruit for political reasons. Most people occupying positions within the health system are there for political reasons, not because of their competence.” (National level director, Ministry of Health, Mali)
Regulation and accreditation of healthcare providers, including providers of MNCH, also appeared to be an area of some weakness in governance.
“Because we do not have any accreditation system, service providers do not really see the need to update their knowledge, some have never undergone any additional training since they graduated.” (Head of an academic department, Burkina Faso)
Conducive governance factors included softened institutional power hierarchies, egalitarian team functioning such as shared decision-making and responsibility for results, facilitation of local innovation and continuous improvement, and multi-stakeholder, multi-level participation in governance to improve decision-making and strong and functional accountability arrangements.
Medicines and technologies
Conducive and limiting factors influencing the availability and use of medicines and technologies included supply chain, quality of medicines and the related issues of storage conditions for essential medicines.
There were some success stories in the sub-region.
“The UN life-saving commodities programme is a very good conducive factor, if countries in the region can now adopt it, Nigeria has adopted it making sure that these commodities are available … Government, working with partners, have made a commitment to make family planning commodities which are some of the life-saving commodities free and are available to all. … there is local production of Chlorhexidine so that’s also one of the life-saving commodities in Nigeria.” (Head of department, Nigeria)
Unfortunately, as with many of the health system factors, the more common stories this study unearthed were challenges related to shortages, inadequacies, non-availability of essential medicines, tools and supplies (including blood), lack of technologies, and problems with infrastructure.
Information, communication and technology-related interventions are of increasing importance in the West African sub-region in small and large scale pilot projects. A systematic review of the role of mobile health interventions targeting healthcare workers in improving pregnancy outcomes in low- and middle-income countries found nine studies from Africa that met the inclusion criteria, of which three were from West Africa (Ghana, Nigeria and Liberia). Mobile health is defined as “a medical and public health practice supported by mobile devices such as mobile phones, tablets and other wireless devices” [49]. The studies showed that despite the potential of mobile health interventions there were gaps in the knowledge base as to how they affect maternal and neonatal health outcomes [50].
Human resources
Human resources affected the quality of care, accessibility, availability, affordability, acceptability and appropriateness of MNCH services. Conducive factors included successful implementation of strategies and interventions such as task shifting, ensuring organisational environments, climate and cultures that encourage and support performance, and availability of qualified staff and local training institutions. Limiting factors included inadequate staff numbers, inequitable distribution, migration and inadequate resources for training as well as logistics and tools to work with. Closely related to problems with inadequate staff numbers were problems with competence and skills of available staff and the appropriateness or otherwise of capacity-building interventions. This manifested in diverse ways such as in knowledge gaps on obstetric danger signs and when and how to refer clients to the next level [39].
“There is a proliferation of training institutes but the products from these institutions are no longer graduating with the skills required to make them deliver adequately on the field.” (Regional level director, Burkina Faso)
Motivation, namely the degree of willingness of health workers [50] to maintain efforts and continous quality improvement [51] towards achieving organisational goals [52–54], was an important conducive or limiting factor. Factors negatively affecting motivation included poor conditions of service, perceived inequity in distribution of incentives, lack of workplace protection, lack of respect and respectful treatment, poor remuneration, non-availability of essential equipment, tools and supplies, and poor work environments. One study reported burnout, expressed as emotional exhaustion and depersonalisation among staff. The same study noted that, despite the challenges, staff still retained a strong sense of accomplishment and confidence in their work [55].
Poor remuneration apart from affecting motivation also led to behaviours that were counter progressive.
“Due to poor remuneration, most Doctors holding administrative position have become what I call ‘des reunionites’ [regular meeting attenders] just to get enough perdiem to supplement their meagre salaries, thus delegating their responsibilities to anybody including the less competent personnel.” (Head of an academic department, Burkina Faso)
On the positive side, and therefore conducive, an opportunity to gain additional education was reported as the most important factor motivating midwifery students in deciding where they would eventually work.
Contextual factors, such as insecurity, conflict and insurgency, affected staff willingness to accept postings and therefore availability, distribution and retention. Migration was fuelled by contextual and health system factors that pushed staff out as well as external factors that pulled staff out.
“Migration of experts to greener pastures or to where security is more guaranteed or future is better secured.” (National health director, Nigeria)
Financing
“Funds flow is not really regular so at the district and sub-district level they are a bit constrained in implementation and mostly dependent on donor funding. So when there is no donor funds available then service provision is at a standstill.” (Bilateral development partner, Ghana)
The inadequacy of financing resources to develop and maintain the health system and support service delivery was a problem across all the sub-region. User fees in the form of out-of-pocket payments at point of service use were a common mechanism to try and mobilise the needed money. However, these fees were a limiting factor documented by several studies. They acted as a deterrent to service use, and exposed women and their families to catastrophic expenditures. Several interventions, such as targeted user fee exemptions, community-based health insurance and national health insurance, had been put in place or were being piloted in the sub-region to completely remove or significantly reduce the exposure of mothers and children to these fees.
Several of these interventions had documented positive effects, with evidence of reductions in inequities in access once out-of-pocket user fees were removed. For example, El-Khoury et al. [56] observed that a free delivery and caesarean section policy in Mali had resulted in increased institutional deliveries and needed caesarean sections. In addition, post-caesarean maternal and neonatal deaths declined in most regions from 2006 to 2009, most likely as a result of shorter delays in seeking emergency care and shorter wait times experienced at facilities.
A study in three West African countries (Mali, Senegal and Ghana) found that membership in a community-based health insurance scheme was positively associated with the use of maternal health services. This was particularly so in areas where utilisation rates were very low and for more expensive delivery-related care [57].
Unfortunately, the effect of interventions to remove out-of-pocket fees was often modified by other health system factors such as ability to finance the policy, service availability, perceived quality of service and human resource constraints. The exemption policy for children less than 5 years old in Ghana did not work as designed in part because of failure to reimburse providers in a timely and complete manner [58]. In reaction to reimbursement delays and failures, frontline providers stopped giving exemptions and reinstituted user fees. The NHIS was facing similar problems.
“People may have the NHIS: I’m sure recently you’ve heard of some facilities that have pulled out of the NHIS because they were not reimbursed, and so they may be registered with the National Health Insurance Scheme but since these facilities will not be offering services, they will not be able to use their insurance for health care. … The scheme actually owes most facilities; they are in arrears. That means that most of these facilities may not be able to purchase most of the things that you probably need for MNCH, so limits their capacity and their ability to deliver very good service to these clients.” (Health practitioner, Ghana)
The free caesarean section policy in Mali referred to earlier was observed to have inequities in access and utilisation related to service availability with wealthier women making up a disproportionate share of those having free caesareans [56, 59–61]. Women in the richest two quintiles accounted for 58% of all caesareans, while women in the poorest two quintiles accounted for 27%. In rural Mali, some households continued to incur catastrophic health expenditures in accessing maternal health services despite the policy [62]. Living in remote rural areas was associated with the risk of catastrophic spending. Women who underwent caesarean sections continued to incur catastrophic expenses, especially where prescribed drugs were not included in the government-provided caesarean kits.
Fournier et al. [59] observed that, for women living in cities with district hospitals that provided caesarean sections, rates increased from 1.7% before the policy was enforced to 5.7% after 83 months. No significant change in trends was observed among women living in villages with a health centre or no health facility. Abolishing fees for emergency obstetric and newborn care reduced maternal deaths through increased caesarean sections. However, this was not equitable and accessible for those in the rural areas [60].
A KI commented on similar problems with the programme in Burkina Faso.
“Despite the subsidy system in Burkina Faso, some people are still not able to access caesarean sections in certain regions due their inability to pay for the remaining 20%.” (Representative of a national professional association, Burkina Faso)
Information systems
Information and documentation gaps in medical files and records affected the quality of data for decision-making and priority setting. Among the barriers identified to sustaining near-miss audits in Benin were poor or unavailable documentation [63, 64]. The main barriers to the implementation of maternal death reviews in Senegal included poor quality of information in medical files [44].
Timely dissemination and access to and use of information from research and other sources to inform decision-making and implementation were reported as limiting factors.
“Emerging MNCH related services don’t get introduced until later because national protocols and policy frameworks are not regularly updated to reflect current research finding and WHO standards.” (Bilateral development partner, Senegal)
Positively, a significant potential to improve access to and use of data for decision-making was reported, and deployment of credible evidence to show policymakers that a problem existed could influence decision-making. A study on agenda-setting in Ghana showed that, where data was available, decision-makers drew on the data to help them frame maternal health problems in a way that got them into and kept them on the agenda [65].
Vital registration systems, despite their importance for monitoring, evaluation and decision-making for MNCH, were under-resourced and poorly implemented.
Health systems mortar (software)
“Trust based relationships enhancing community involvement in decision-making is conducive to improving MNCH outcomes. A district medical officer and his collaborators put in place an innovative system for motivating community health workers and have seen a drastic improvement in their MNCH indicators in 2 years. This trust based relationship existing at the community yielded impressive results so we are trying to scale it up to other local health areas.” (National level director, Ministry of Health, Benin)
Despite the importance of actors, process and power in the functioning of health systems, most of the papers we found were focused on health systems building blocks and/or interventions. The critical role of the mortar often only emerged as a sub-theme. For example, a paper whose primary focus was the evaluation of a task-shifting intervention in Senegal to resolve a long-term shortage of obstetricians (by training district teams consisting of an anaesthetist, general practitioner and surgical assistant in emergency obstetric surgery) encountered several limiting factors related to ‘mortar’. Of the 11 surgical teams trained between 2001 and 2006, only six were functioning in 2006, and the rate of training was not rapid enough to cover all districts by 2015. Reasons included varying and conflicting stakeholder perspectives on the programme, relationships, trust, power and motivation. Central decision-makers considered the policy more viable than training gynaecologists for district hospitals. Senior academic clinicians, on the other hand, resisted the programme. A perceived lack of career progression among the doctors trained and lack of programme coordination were seen as obstacles by these groups. Practitioners felt the work was valuable, but complained of low additional pay and not being replaced during training. Communities appreciated that the services saved lives and money, but called for improved information and greater continuity of care [66].
Information and information asymmetries can be major sources of power or lack of power. Several papers observed that client access to information and use of information acted as part of the conducive or enabling software of health systems. For example, Mills et al. [33] observed, from a study in Northern Ghana, that awareness among women of the policy on free delivery of care at the health facility and of antenatal care services was conducive to utilisation.
Key global actors in health systems development and MNCH in West Africa mentioned by KIs were development partners such as WHO, USAID and UNFPA. These actors and their agents were active at global as well as country level. At the West African sub-regional level, the key actors were seen to be WAHO and the committee or council of ministers. The role of WAHO was described as both political and technical. KIs also mentioned that politicians, especially higher level office holders such as presidents and ministers of health, interface with the sub-regional level in the context of ECOWAS through their interactions with colleague politicians from other countries in the sub-region.
Within countries, the political leadership was described as wielding a lot of power, including the control of resources for health systems and MNCH.
“… the political leadership, … they wield a lot of power and they control a lot of money and they have a lot of influence when it comes to policy direction.” (Obstetrician gynaecologist, Ghana)
At the country level, apart from the political leadership, national civil and public service bureaucracy heads such as Chief Directors, Director and Deputy directors were seen as the main holders of power. Non-state actors, such as the Christian Health Association of Ghana, were also mentioned as important at national level. At the sub-national level, frontline provider staff such as doctors, nurses and administrators could wield considerable power often derived from their technical knowledge and control of services and expertise.
“… health care givers, be it doctors, be it nurses, you know, all the people, pharmacists etc. who work in a health care setting, are also very important when it comes to MNCH.” (Obstetrician Gynaecologist, Ghana)
Local government, communities and clients were also mentioned by several respondents as key actors with power to affect MNCH outcomes at the sub-national level.
Context
Multi-level contextual factors emerged from the study as important in health systems and MNCH; these can be clustered as sociocultural, economic, political, ideological, historical, international or global, and challenges with other systems, such as roads and transport, that can directly impact health. These contextual factors acted as conducive and limiting factors to MNCH by their effects on health systems, and on the social determinants of health.
Context inter-related with the health system and its components and caused some of the variability in outcomes. Thus, for example, there were variations in mortality not only by geographic area, but also by socioeconomic and contextual variations such as rural-urban, income quintile, and mother’s education and ethnicity. In one study, socioeconomic status, and religion (Muslim) highly influenced the use of skilled birth attendants [33]. The effects of quality of the road on referral and especially poor road security at night has already been mentioned [48]. Other systems, such as water and sanitation and food and nutrition, also affected MNCH outcomes.
Sociocultural factors included the status of women, and influence of other household and community members on care seeking and decision-making in contexts in which decisions can be the responsibility of members of the extended family rather than the individual. Other factors included low status of women, translated into a lack of control over decision-making, and a low value on girls’ education, which further reinforced domestic power imbalances, and the low status and dependence of women. Literacy (mothers’ education) predicted use of safe motherhood care. Some papers noted that, sometimes, women were expected to justify less obvious needs in an unequal bargaining process with ambivalent recourse opportunities, and might suffer delays in or exclusion from healthcare, low self-esteem and domestic power imbalances. All these translated into effects on service access and utilisation.
Macroeconomic factors affected household access to income as well as the ability to access needed healthcare through their effects on national and household incomes. Political transitions, ideologies, priorities and the availability of champions also affected how MNCH fared.
“In Ghana there is a lot of political will and commitment [to the NHIS]…. There has been a lot of political will, there have been domestic resources that have been mobilized.” (Bilateral development partner, Ghana)