metadata: authors: 0: author: Howard, L. M.
docna: 0: docna: Supporting safe motherhood : a review of
            financial trends : summary
docty: Policy Research Working Paper
subtopic: Health Care Services Industry,Demographics,Reproductive Health,Nutrition,Family Planning Research
teratopic: Gender
abstracts: cdata!: An estimated 500,000 women, 99 percent
            of them from the developing world, die each year from
            pregnancy-related causes. About three quarters of these
            deaths are the direct result of obstetrical complications --
            hemorrhage, infection, toxemia, obstructed labor, and
            abortion (under primitive and illegal conditions). An
            estimated equivalent number of infants do not survive their
            mother's death. For surviving mothers, the consequences
            of pregnancy have a severe impact on health and family
            economics. The strategy for safe motherhood is based on two
            approaches. First, the encouragement of activities that
            indirectly improve maternal health. These include education,
            policies to improve women's rights and working
            conditions, health care and nutrition, transportation and
            communication systems, water and sanitation facilities, and
            increases in family income and food production. The second
            approach targets activities to reduce maternal deaths. These
            activities include reducing unwanted pregnancies through the
            provision of family planning services, and through national
            policies that recognize the importance of this issue. A
            second objective is to reduce the risks of pregnancy through
            providing community-based family planning and prenatal
            services to identify high-risk cases' adequate referral
            services for the complications of pregnancy, and
            communication and transport systems to support patient
            referral procedures.
repnme: repnme: Supporting safe motherhood : a review of
            financial trends : summary
display_title: Supporting safe motherhood : a
            review of financial trends : summary
listing_relative_url: /research/1990/05/700267/supporting-safe-motherhood-review-financial-trends-summary
topicv3: Maternal Mortality and Morbidity m1326338 1456,Nutrition m1326779 644,Sexual Reproductive, Maternal and Child
            Health m1327262 639,Family Planning m1327501 1452,Health m1504661 3480
publishtoextweb_dt: 2010-07-01T00:00:00Z
historic_topic: Gender
origu: Policy, Research & Ect Affairs
no_of_pages: 23
model_extractions: **Policy, Research, and External Affairs**

# **Population, Health, and Nutrition**

This paper - a product of the Population, icalth, and Nutrition Division, Population **and** IHUI;11;rn Resources Department - is part of a larger clffort in PRE to promote policy and rcsource commiiticnlt to **IhC** Safe Motherhood Initiative. Copics are availabic frec from the World Bank, 1818 11 Strect N\V, Washington DC 20433. Plcasc contalct Sonia Ainsworth, room S6-065, extension 31091 ( 16 pages . 1 figurcs).

_Financial trends for safe_ **_motherhood_** _initiatives._ Problems of definition and accounting methiods preclude an accuratc analysis of Financial trends among donors. Global support for specific safe motherhood activities is limitcd. For the 17 major bilateral sources, funding for selccted activities which contributc to safe motherhood is estimatcd to have increased (in currenlt dollars) from $691.5 million in 1986 to $818.8 million in 1988. About half this amount was lor so-called core* activities, including family planniilg scrvices. The magnitude of support lor preventionr of the complicatioris of pregnancy is less certain. Gcneral health, population, and nilIr-iion sector flows increased substantially over thc same period. These treneds wcre positivc fbr 13 sourccs, unchanged for **itrece,** and **ncat ivc** for year's total. This is due primarily to substantial increases in general loaIs for **health,** population. and nutrition. New specific safl motlherhood activities **are** beginning to emergc in **the** fornn ol care for thc complications of pregnancy, better secondary and tertiary facilities, training, and promotionail workshops.

The magnitude **and** elfectivencss ol donor firlancing will require nmore attention to two special problems:

* Strengthening recipicnt counLtrics' ability to articulate project demnd -- providing specific training, technicazl advisorv assistancce and operational guidelines for mobiliz.ing financial resources.

Of the six major multi lateral soUirces, totaIls for selected safc moithcrhood activities \Acre estimated to be $477.7 millioni in 1988. ai 41.7 percerit increase over 1987 and **a** 17 pcrcent increase over 1986, rclcctingt dilffercnces in thlc annual volume of' World Bank loan approvals. I lalf of this went for core scrvices. primaril **_\_ Ifaily** il planning.

Improving the data otn safe' motherhood financial tend(is -- establishing a conSCnsus on1 de finitions: seek ino a consenisus on fi nanc,all measurable programr or project catoornies ol s;f. mothlierhood; dcininig methods for tlhe s\stematic collection of donor and recipicent countrv data ont financial trncids.

**For tihC** full sectionI **onl** Interview **Noics \ ili** dilfI'crent financing sources, see WPS 413.

E.stirn ated World Bank saflc motherhood expenditurcs in 1989 are triplec the prcvious At the I ) X7 ConerenSceonic* SafeNl M'Ihc rho< si nl **Nair** hi **.1** I e rz andJ Mea sh en recoi ni emrr dd a coeTr program i'r safe n oitherhr sd th t 1rit I h **reduLinIg the nurinherof pregnancics** through **iadnI I\** p niang educ ation, pronotion, arld CoTilntunity -hased scr\ ices; reduc inIg the rAik **s to prct** an tchildhirih; pro\iding prcnatial care, lupcr\ ed deliscrit s, **screcinig,** and referral for highr-sk mothers; arid pros idirg coiITrLiricir **i :ti!Jii,** transjwuiation for complicated dcliscrie.

> The **P RE** Working Paper Series disset Iti.Ite the findIinis Of **'Aork** undcrr **\Xa\** in **tIie** Bank's Po ic ResearchI. inid Extcti.i

> Affairs Corimple An ohjecti% e of the series is tn get these findings out quicCkh. even if restentations _are_ **less** thlan full polished. The findiings, interpretations. aid uotlcusions in these palpwrs dlo not necessarily represent official Bank potlic>

i'ro<.:,!ei< it !thc _ItRE_ I sseiri, t,n **_('nlIelr_**
The author is an M.D., Dr. P.H consultant to<sup>the World Bank, and Senior Adviser, The Pragma</sup> Corporation. He wishes to express appreciation<sup>and thanks for the generous time and cordial</sup> cooperation extended b-y those interviewed.<sup>The informality of these meetings and the ability to</sup> exchange views were of immense value in<sup>gaining a perspective on the outlook for the Safe Motherhood</sup> Initiative. **The** author regrets that an internal<sup>reorganization of NORAD precluaed a visit to Oslo. All</sup> conversations are considered unofficia' xchanges<sup>and the author accepts full responsibility for estimates</sup> and interpretation.

The World Bank initiated this study with the endorsement<sup>of the Safe Motherhood cosponsors.</sup> Special thanks all extended to Bank staff for guidance<sup>and support, in particular to Dr. Anthony</sup> Measham, Chief of Population, Health, Nutrition<sup>Division; Dr. Barbara Herz, Chief of the Women in</sup> Development Division; Dr. Frederick Sai, Senior<sup>Population Adviser; Mrs. Eleanor Folta (PHN</sup> Division) and Ms. Anne Gr.misrud (Women in Development<sup>Division).</sup> The Director General of WHO, Dr. Hiroshi Nakajima,<sup>and his Director for Planning,</sup> Coordination and Cooperation, Dr. Yuji Kawaguchi,<sup>shared their perspectives on the problems and</sup> outlook for financial resource mobilization. Dr. Mark<sup>Belsey, chief of the Maternal and Child Health</sup> Unit at WHO, Geneva, was most helpful in collaborating<sup>on the initial design of the study, and his</sup> cooperation in arranging for a field questionnaire<sup>is greatly appreciated.</sup>
# **T AUBL-Et O F C ONNalrTFIlS**

|**I**|**.**<br>**DNrRODUCTION**<br>**.....................**|2|
|---|---|---|
|II.|**TERMS OFRKyERENCE .....................**|2|
||A.<br>Purpose ...........|1,|
||B.<br>Assumptions.|3|
||C.<br>Methodology.|4|
||D.<br>Definitions and Criteria for||
||Safe Motherhood Activities .......<br>...............|..........<br>5|
||E.<br>Official Multilateral and Bilateral Development Data ...|..... 8|
||F.<br>Developing Country Data .........<br>...................|.........<br>8|
|III.|**ENTERVIEW NOTES: SUMMARY........**<br>**..................**|**.........**<br>10|
||A.<br>Summary of Donor Financial Trends .10||
||B.<br>Safe Motherhood Financing By Developing Countries<br>.<br>.Countr|ie<br>11|
|**IV.**|**CONCLUSIONS............................**|13|
||A.<br>Statistical Methods ............................|13|
||B.<br>Financial Trends ................... ...................|.....13|
||C.<br>Policies .....................|14|
||D.<br>Endnotes .....................|15|
|**V.**|**REFERENCES.16**||
-2-

# **1.** INTRODUCTION

At the February 1987 Conference on Safe Motherhood in Nairobi', Herz and Measham (1987) presented a paper on 'The Safe Motherhood Initiative,* in which they proposed a new approach to reduce maternal mortality and morbiditv in developing countries. Herz and Measham noted that in spite of progress toward child survival and improvements in life expectancy, an estimated 500,000 women, 99 percent of them from the developing world, die each year from pregnancy-related causes-.

**About** three quarters of these deaths are the direct result of obstetrical complications -- hemorrhage, infection, toxemia, obstructed labor, and abortion (under primitive and illegal conditions). An estimated equivalent number of infants do not survive their mother's death. For surviving mothers, the consequences of pregnancy have a severe impact on health and family economics.

The proposed strategy for safe motherhood is based on two approaches. First, the encouragement of activities that indirectlv improve maternal health. These include education, policies to improve women's rights and working conditions, health care and nutrition, transportation and communication systems, water and sanitation facilities, and increases in family income and food production.

The second approach, which serves as the core strategy for the Safe Motherhood (SM) Initiative targets activities to reduce maternal deaths. These activities include reducing unwanted pregnancies through the provision of family planning services, and through national policies that recognize the importance of this issue (although Maine (1985) estimates that even if all unwanted pregnancies were avoided, only a fourth to two fifths of maternal mortality would be avoided).

A second objective is to reduce the risks of pr.gnancy through providing community-based family planning and prenatal services to identify high-risk cases' adequate referral services for the womplications of pregnancy, and communication and transport systems to support patient referral procedures.

Given the long history of support for maternal health by international bilateral, multilateral, and nongovernmental organizations (NGOs), the conference recognized that the limited progress in reducing maternal mortality and morbidity required moving to a svstems approach utilizing selected, targeted, core activities.

# II. TERMS OF REFERENCE

## A. _Purpose_

In response to a request from the Meeting of Interested Parties, which serves as the international forum for monitoring the Safe Motherhood Initiative, the World Bank has undertaken this study to measure aid flows for this program since the 1987 conference. The study is designed to measure financial trends and new initiatives in support of the program's objectives; identify issues of statistical methodology that may constrain the analysis, and establish a baseline fir 1988 against which to measure future financial trends.

A second objective of the study is to identify SM policies and programs among the major official sources of external financing. In view of the four-month timetable to cor.mplete this study, it concentrates on Official Development Assistance (ODA) and does not include nongovernmental and private contributions except for official contributions to nongovernmental organizations (NGOs)<sup>3</sup> .
**The** expectations of this review are modest in view of four factors:

1. The wide variations in statistical methods for recording maternal health data make it difficult to compare data sets.

2. New projects started immediately after the conference are unlikely to have recorded expenditures in time to be included in this review.

3. The absence of international uniformity on the criteria for the initiative and the wide range of activities with direct and indirect maternal health effects means that much of the data were based on interpretations.

4. The relatively brief duration of the study.

# B. **_Amwtpton_**

1. The study looks at financial flows rather than cost-effectiveness, and does not assume that magnitude of investment is directly correlated to improvements tn maternal health.

2. Because there is no coniprehensive global system to monitor health expenditures by developing countries or exter'; .l sources, the data would have to be obtained from each financial source.

3. Because of variations in statistical recording systems and in definitions of health, full comparability would be difficult to assure.

4. It would be premature to expect identifiable new financing specifically addressing the initiative. Official statistical systems have not been adjusted to identify SM components. As a result, the data reflect unofficial estimates derived from multiple sources. The author, not the sources, is responsible for the- composite estimate.

_5._ To accomplish the study in the foul-mr.onth period prior to the June 1989 Meeting of Interested Parties, direct interviews with the major bilateral and multilateral financial sources were considered preferable to risking a low response rate to a mailed questionnaire. For developing countries. however, the sources of information were resident WHO and UNDP representatives.

## C. **_Methodology_**

1. The study drew on data sets for 1985 to 1989 in order to permit a comparison of trends before and after the Nairobi conference.

2. The data were examined for characteristics that would identify components.

3. Where there were no specific components within a health loan or primary health care program, the respondent was asked to estimate the amount of financing for SM. Information from interviews was supplemented by the official annual reports of bilateral and multilateral agencies.

4. For purposes of comparisorn, each financial source was asked to use common definitions and to include all major categories of ODA for the health sector as follows: