Political Priority for Public Health Causes in Developing Countries:

Implications From a Study on Maternal Mortality

Jeremy Shiffman - Center for Global Development. June 2007

PDF: http://www.cddev.org/files/13281_file_Maternal_Mortality.pdf

“….. Why do some serious health issues--such as HIV/AIDS--get considerable attention and others--such as malaria and collapsing health systems--very little? Why and under what conditions do political leaders consider an issue worthy of sustained attention, and back up that attention with money and other resources? In this CGD Brief, visiting fellow Jeremy Shiffman discusses nine factors that influenced the degree to which national leaders in five countries made one public health issue--maternal mortality--a political priority.

Pregnancy-related complications are the leading cause of mortality globally among adult women of reproductive age, with more than half a million deaths annually. But in some countries maternal health has become a priority and maternal deaths have fallen, while in other countries this has not yet occurred. Drawing on his comparison of these countries, Shiffman offers recommendations for public health priority-setting in developing countries.

His bottom line: attaining public health goals is as much a political as it is a medical or technical challenge; success requires not only appropriate technical interventions but also effective political strategies……”

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This message from the Pan American Health Organization, PAHO/WHO, is part of an effort to disseminate
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Social Inequalities in Perinatal Mortality in Belo Horizonte, Brazil: The Role of Hospital Care

Sônia Lansky,  Elisabeth França and Ichiro Kawachi
At the time of the study, Sônia Lansky was with the Department of Society, Human Development and Health, Harvard School of Public Health,
Boston, Mass; the Federal University of Minas Gerais, Brazil; and the City Health Department, Belo Horizonte, Brazil. Elisabeth França is with the
Department of Social and Preventive Medicine, Federal University of Minas Gerais, Brazil. Ichiro Kawachi is with the Department of Society,
Human Development and Health, Harvard School of Public Health, Boston.
May 2007, Vol 97, No. 5 | American Journal of Public Health 867-873

Abstract: http://www.ajph.org/cgi/content/abstract/97/5/867

Objectives. We examined the contribution of hospital type and quality of care to perinatal mortality rates in the city
of Belo Horizonte, Brazil.

Methods. We used a cohort study of all births (40953) and perinatal deaths (826) in Belo Horizonte in1999.
 After adjusting for maternal education and birthweight, we compared mortality rates according to hospital category
—defined by a hospital’s relation to the national Universal Public Health System (SUS)—and quality of care.

We used the Wigglesworth Classification to examine perinatal deaths.

Results. After we controlled for birthweight and maternal education, the highest perinatal death rates were observed
in private and philanthropic SUS-contracted hospitals (relative to private, non-SUS-contracted hospitals).
Hospital quality was also directly associated with perinatal death rates. Mortality rates were especially high for

normal-birthweight babies born in private SUS-contracted hospitals. Intrapartum asphyxia was the leading cause
of preventable death.

Conclusions. In a class-segregated health care system, such as Brazil’s, disparities in quality of care between
SUS-contracted and non-SUS-contracted hospitals contribute to the unacceptably high rates of perinatal mortality.

 Impact of packaged interventions on neonatal health: a review of the evidence

Rachel A Haws¹, Abigail L Thomas¹, Zulfiqar A Bhutta² and Gary L Darmstadt^1,*

¹Department of International Health, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD, USA.
²Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan.
Health Policy and Planning Advance Access published online on May 25, 2007
Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine

Abstract: http://heapol.oxfordjournals.org/cgi/content/abstract/czm009v1

“……..A disproportionate burden of infant and under-five childhood mortality occurs during the neonatal period, usually within a few days of birth and against a backdrop of socio-economic deprivation in developing countries. To guide programmes aimed at averting these 4 million annual deaths, recent reviews have evaluated the efficacy and cost-effectiveness of individual interventions during the antenatal, intrapartum and postnatal periods in reducing neonatal mortality, and packages of interventions have been proposed for wide-scale implementation. However, no systematic review of the empirical data on packages of interventions, including consideration of community-based intervention packages, has yet been performed.

To address this gap, we reviewed peer-reviewed journals and grey literature to evaluate the content, impact, efficacy (implementation under ideal circumstances), effectiveness (implementation within health systems), type of provider, and cost of packages of interventions reporting neonatal health outcomes. Studies employing more than one biologically plausible neonatal health intervention (i.e. package) and reporting neonatal morbidity or mortality outcomes were included. Studies were ordered by study design and mortality stratum, and their component interventions classified by time period of delivery and service delivery mode.

We found 41 studies that implemented packages of interventions and reported neonatal health outcomes, including 19 randomized controlled trials. True effectiveness trials conducted at scale in health systems were completely lacking. No study targeted women prior to conception, antenatal interventions were largely micronutrient supplementation studies, and intrapartum interventions were limited principally to clean delivery.

Few studies approximated complete packages recommended in The Lancet's Neonatal Survival Series. Interventions appeared largely bundled out of convenience or funding requirements, rather than based on anticipated synergistic effects, like service delivery mode or cost-effectiveness. Only two studies reported cost-effectiveness data. The evidence base for the impact of neonatal health intervention packages is a weak foundation for guiding effective implementation of public health programmes addressing neonatal health. Significant investment in effectiveness trials carefully tailored to local health needs and conducted at scale in developing countries is required. ^{………………”}

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This message from the Pan American Health Organization, PAHO/WHO, is part of an effort to disseminate
information Related to: Equity; Health inequality; Socioeconomic inequality in health; Socioeconomic
health differentials; Gender; Violence; Poverty; Health Economics; Health Legislation; Ethnicity; Ethics;
Information Technology - Virtual libraries; Research & Science issues.  [DD/ IKM Area] 

“Materials provided in this electronic list are provided "as is".Unless expressly stated otherwise, the findings
and interpretations included in the Materials are those of the authors and not necessarily of The Pan American
Health Organization PAHO/WHO or its country members”.
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