By Lara Brearley
2014 must be the year of the newborn. As Smith’s recent article states, despite huge strides in child survival, progress during the neonatal period has been disproportionately slow. Inaction is no longer an option – in many countries, persistently high rates of newborn mortality will hold countries back from attaining their Millennium Development Goal (MDG) 4 targets. Looking forward, beyond 2015, as we raise ambition to end all preventable maternal and child deaths, the newborn burden is ever more pertinent. Achieving such gains will require greater political resolve and investment to increase coverage of interventions for those who need them most, while tackling the social determinants of health that shape health inequities. But as the article critically demonstrates, efforts to scale up and sustain coverage must promote complementary and integrated solutions for the sector through strengthening the health system. As such, our focus on newborns must be a catalyst for progress towards universal health coverage (UHC).
A proxy for health system strength
The time of birth and the weeks that follow are when a child is most vulnerable and in need of responsive, quality care. Patterns in newborn survival are a powerful proxy for the strength of the health system, with wide inequities revealing our failure to build robust health systems that ensure all expectant mothers are in reach of a health worker who is appropriately trained, skilled, equipped, supported, remunerated and motivated to meet her needs and those of her newborn baby. Inadequate, ineffective and inequitable health financing, leave the system weak and underfunded and place the burden of ill-health on those most vulnerable and in need, causing an estimated 100 million people to face impoverishment each year.
As countries endeavour to improve newborn survival they will need to address the systemic bottlenecks that impede access to quality care. Progress for mothers and newborns will require comprehensive primary health care systems with referrals that provide integrated care across the two continuums (house to hospital, and reproductive through childbirth to childhood). This will bring value for money with benefits felt during the first month of life and beyond.
A catalyst for UHC
UHC is a concept that links the objectives of scaling up coverage of quality needed interventions and preventing financial hardship whilst doing so. It critically involves the removal of user fees for essential services and increased cross-subsidisation through mandatory and progressive prepayment. It also helps us to move away from thinking and acting in silos within the sector – a danger the article clearly highlights. Comprehensive primary care – that is sufficiently and equitably resourced, and free at the point of use – may be a first step towards UHC.
If our objective is to improve equity in health outcomes of the newborn and its mother, improved nutrition and a focus on the most vulnerable are no doubt imperative. But the current modus operandi in health fosters competition and silos, as expressed by Smith, when discussing the case of newborn survival in Bolivia: “Morales’ presidency came with an agenda promoting the social welfare of the very populations most affected by newborn health problems (poor, rural, indigenous). How could political priority for newborn survival decline in this context?” We must learn to leverage such opportunities to realise our ambition for the newborn baby and his or her family. The basis of UHC in the human right to health has great appeal and we must find ways to seize the potential of sub-sectoral priorities to galvanise progress towards UHC. The Every Newborn Action Plan, which will go through the World Health Assembly in May next year, presents an opportunity to shift gear and accelerate progress towards MDG 4 and beyond.
Time to strengthen accountability
We need increased political will backed with sufficient resources to achieve this. As the article documents, political champions and priorities present both a contribution and challenge to our plight. As fast as they raise the profile of an agenda, attention can turn. This volatility underscores the importance of strengthening accountability. Here the role of communities and civil society organisations is crucial. We’ve seen the potential of health budget advocacy to empower civil society to hold governments accountable for promises, policies and plans. The article cites the pivotal role of evidence to force attention to an otherwise silent scandal – whether it’s survey data or a budget analysis.
When a mother or her baby dies in the act of giving life, the world must hear. Ending this injustice requires political will, strong systems and accountability.
Lara Brearley is Senior Health Policy and Research Advisor at Save the Children UK