The global maternal health agenda has been largely defined by the Millennium Development Goals (MDGs) for the last decade and half, but what will happen after they expire in 2015? What kind of framework is needed to continue the momentum towards eliminating preventable maternal deaths and morbidities? 

For a panel of experts gathered at the Wilson Center on February 20, universal health coverage is a powerful mechanism that may be crucial to finishing the job.

Inequality Remains a Killer

There has been significant progress towards MDG 5 – reduce the global maternal mortality ratio by 75 percent between 1990 and 2015 and achieve universal access to reproductive health. But “we still have challenges and the agenda is not finished,” said Jacqueline Mahon of the United Nations Population Fund.

There is persistent inequality in access to maternal health services and discrimination too, she said. The global maternal mortality rate has declined by 47 percent since 1990, far below the MDG 5 goal, and an estimated 800 women still die every day from preventable causes linked to pregnancy and childbirth, with 99 percent of those deaths occur in developing countries. Only 58 percent of women in developing countries give birth with a skilled attendant.

The most vulnerable are “women living in conflict situations, or women who are part of an ethnic minority, women living with disabilities,” said Dr. Ana Langer, director of the Maternal Health Task Force. Poor women are more vulnerable in general. According to a recent report from the International Conference on Population and Development (ICPD), 150 million people each year suffer financial catastrophe and another 100 million fall under the poverty line as a result of out-of-pocket spending on health care. At least a billion people, caught in “development traps of bad governance, wasted natural resource wealth, lack of trading partners, or conflict,” have been largely passed over by gains in health care.

These problems suggest a critical need to develop a new framework to take the place of the MDGs after 2015. There is some debate about how effective the MDGs were in different development sectors, but Langer suggested the model has been very helpful for maternal health. “The fact that we had that very, very measurable, concrete goal, that it was embraced by the global community and also by governments, and that it also included concrete mechanisms to track progress and measure progress, it definitely helped to focus the global attention on maternal mortality,” she said.

But for those pockets of poor service and underserved women that remain, what needs to change?

Can Universal Health Coverage Bridge the Gap?

A new PLOS Medicine essay, written by Langer alongside Dr. Jonathan Quick, president and CEO of Management Sciences for Health, and Jonathan Jay, senior writer at Management Sciences for Health, makes the case for universal health coverage as a means to prevent vulnerable and marginalized populations from slipping through the cracks. “In terms of women’s health, it’s the only approach that addresses all of women’s health needs,” said Quick.

Universal health coverage makes it easier for families that otherwise couldn’t afford it to get essential primary care. It also promotes service integration, creating more pathways to the vital pre- and post-natal visits needed to ensure healthy pregnancy, delivery, and childhood.

“The key thing is to have a vision for universal health coverage and build your system around that vision,” Quick said:

It’s about mobilizing resources and focusing them from all sources, domestic and international. It’s about using those financial resources to leverage health system improvements; it’s about providing protection against poverty. A mother shouldn’t go bankrupt because her child needs surgery but 100 million households – families – go bankrupt a year because of health expenses. And finally, it adapts to changing health needs.

According to Langer and Quick, universal health coverage programs address five critical factors: they provide an essential services package; give reliable, easy access to services; eliminate financial barriers; diminish social barriers; and provide performance indicators. “Whenever you’re starting a major global movement on something, monitoring and the measuring is important,” said Quick. “What gets measured is what gets done.”

Universal health coverage programs have already shown positive impacts in several low-resource countries.

Mexico’s Seguro Popular (“Popular Health Insurance”) was conceptualized after a study in the 1990s revealed that more than 50 percent of health-related expenditures in the country were paid for out of pocket, said Langer. The health package included 250 interventions covering expensive treatments for breast cancer, cervical cancer, and HIV/AIDS, and was funded by a budget designed to increase by one percent of the GDP a year. In addition, the government introduced a national center for gender equity for reproductive health to address and monitor pressing gender and access issues. Seguro Popular undergoes evaluations every year, to assure accuracy in health coverage, access, and health outcomes through extensive tracking mechanisms.

In Afghanistan, Quick said a package of essential primary care services implemented in 2003 by Dr. Suhaila Seddiqi, the minister of public health at the time, embodies the principles of universal health coverage. The package made a considerable difference in one of the worst places to be a mother (at the time, 9 out of 10 women delivered without a skilled birth attendant), providing training opportunities for hundreds of midwives and thousands of community health workers. In less than 10 years, access to primary health care increased from less than 10 percent to over 60 percent, Quick said, with 100,000 fewer infant deaths, double the prevalence of family planning, and a 50 percent reduction in maternal mortality.

An Unfinished Agenda

As the development community considers the post-2015 framework, universal health coverage programs could be an important way to reach marginalized women around the world, but it shouldn’t be the only health goal, said Langer. “We as a community, have to be very smart to make sure that we don’t lose focus or traction on what we’ve achieved in the last 15 years,” she said, pointing out non-communicable diseases as an important emerging health issue that isn’t necessarily addressed by universal coverage.

Quick advocated for an integrated approach that uses universal health coverage to help focus on healthy life expectancy. He proposed combining MDG 5 (maternal health), MDG 4 (child health), and MDG 6 (HIV/AIDS and malaria) and introducing better measures of accountability. “You can’t achieve the unfinished agendas and deal with the chronic disease epidemic without an integrating platform that maximizes the financial resources and uses them to improve the health system,” he said.

As world leaders finalize the next global development framework, the maternal health agenda should maintain a top priority. Although maternal mortality rates have declined over the past two decades, the overwhelming need to create a framework that reduces persistent inequalities and improves life expectancy remains.

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