Sub-Saharan Africa and the health MDGs: the need to move beyond the “quick impact” model
Serious global discussions have begun in the lead-up to the Millennium Development Goal (MDGs) deadline of 2015. Governments and international agencies are asking what has been achieved, what still needs to be done and how best to proceed after the deadline. Fabienne Richard, researcher at the Institute of Tropical Medicine in Antwerp thinks that good intentions and quick win strategies may have hampered progress.
Initially, it was thought that the way to achieve the MDGs was mainly through resource mobilization to scale up the delivery of the 18 priority targets, and that the indicators would be used to measure the extent to which the targets were being reached. To achieve the health-related goals, it was assumed that an increased share in national health budgets, as well as a larger share of bilateral and multilateral aid dedicated to health, would suffice. New global funding instruments, currently called Global Health Initiatives (GHIs), were launched, mainly to support disease control programmes focused on prevention and treatment of the priority diseases.
The quick win approach
At a practical level, the agencies involved were in favour of short-term, “quick wins”, that is, interventions with “very high potential short-term impact that can be immediately implemented”. The UN Millennium Project presented these interventions as “simple and proven strategies” in contrast to “other interventions which are more complicated and will take a decade of effort or have delayed benefits”. It was thought that donors would be less interested in complex interventions which would take ten or more years to produce measurable changes (e.g. in the status of women), and that quick wins were more likely to convince donors to invest. The term “quick wins” was later replaced by the term “quick impact” interventions but the basic concept was unchanged. This concept became a buzzword in MDG discourse.
These selective quick win/quick impact approaches to health development have allowed the picking of several ‘low-hanging fruits’ in many settings.
Quick impact interventions are usually based on the availability of a cost-effective technology, often medicines, and the ability of their promoters to attract the attention of public and private donors to support their scaling-up at global level. Quick wins (and simple packages) have successfully attracted a significant proportion of international and philanthropic funding for global health and seem to have successfully expanded the overall pool of development assistance for health over the past decade. But many of these initiatives have been developed parallel to, not integrated into, the health care system in countries. Parallel approaches have been shown to lead to duplication (e.g. running parallel systems for delivering medicines), distortion (e.g. creating a separate cadre of better paid health workers for a specific programme), and disruptions (e.g. uncoordinated training programmes taking staff away from their jobs).
For example, in Burkina Faso, almost ten immunization campaigns per year were organized in 2009 and 2010, each of them taking roughly ten days of work and largely drawing resources (human resources, vehicles) from general health services – with detrimental consequences for ongoing care. Similarly, in Mali, mass drug distribution to control and eliminate trachoma, schistosomiasis and soil-transmitted helminthiasis, as well as vitamin A distribution campaigns are carried out several times a year. Yet a study in 2006, in the rural district of Douentza in Mali, showed that each nurse in charge of a health centre had been absent from their health centre for 45–47 working days to participate in campaign-related activities.
Progress do not benefit the poorest
The MDGs indicators are expressed only as national averages, and the data are not disaggregated for different parts of a country or by socioeconomic status, they fail to catch any inequities because they represent only the national average. However, progress towards achieving the health MDGs may not necessarily benefit the poorest, whose access to health and health care may actually worsen. Evidence shows that most countries are making progress, but that few are managing to achieve inclusive and equitable progress. Instead, most of the gains are taking place among the top socioeconomic quintiles, while the lower quintiles are seeing little or no progress.
For Kenya, for example, using access to caesarean section as a proxy for access to emergency obstetric care, a comparison of disaggregated data from the 1993 and 2008-09 Kenya Demographic Health Surveys shows overall improvement at national level, but reduced access among the two lowest quintiles. In 1993, the caesarean section rate was four times higher for the highest quintile compared to the lowest quintile, but it was seven times higher in 2008-09.
Similarly, as regards the coverage of family planning by level of education, women with no education had less access to a modern method in 2008-09 than in 1993. In addition, the rural-urban gap remains wide in most countries, with progress being considerably faster in cities than in villages.
Development and solidarity are more than a process of money changing hands
Looking to the future, further progress will depend largely on developing medium-term and long-term strategies that pay more attention to the development of health systems.
Fast-track interventions promoted by donors and Global Health Initiatives need to be complemented by mid- and long-term strategies, cutting across specific health problems.
Some African countries show that change is possible: that it is possible to move from a selected, free services policy to a national health insurance system, as in Ghana; to combine community-based and facility-based approaches, as in Ethiopia, and increase the number of community health workers while training more qualified health centre staff; and to coordinate donors to support a national health plan, as in Rwanda. These three countries have in common the strong leadership of their presidents and ministries and the political will to move beyond “quick wins”.
Implementing the MDGs is more than a process of “money changing hands”. Combating poverty needs a radical overhaul of the partnership between rich and poor countries and between rich and poor people within countries.
More can be found in the full article published in the November issue of Reproductive Health Matters
Richard F, Hercot D, Ouédraogo C, Delvaux T, Samaké S, van Olmen J, Conombo G, Hammond R , Vandemoortele J. Sub-Saharan Africa and the health MDGs: the need to move beyond the “quick impact” model. Reproductive Health Matters 2011, 19(38):42–55
Fabienne Richard (43), is a registered midwife who specialised in tropical medicine and public health (MSc). She has 10 years experience as clinical midwife, a field experience of 5 years in developing countries (Afghanistan, Burkina Faso, Kenya, Liberia, Somalia, Sri Lanka). She joined the Department of Public Health of the Institute of Tropical Medicine in Antwerp in 1999. Her field of research is maternal health, access to health care and quality of care.