Improving Maternal and Child Health in Difficult Environments: The Case For “Cross-Border” Health Care
Authors: Gijs Walraven, Semira Manaseki-Holland, Abid Hussain, John B Tomaro
Journal: PLoS Medicine (2009)

The evidence base on organising, delivering, and paying for effective and equitable health services in any resource-constrained setting is very weak [1]. To make health service delivery work in difficult environments, such as Badakhshan province in Afghanistan, the Northern Areas of Pakistan, and Gorno-Badakhshan province in Tajikistan, substantial challenges must be addressed because each has to overcome one or more “traps” of bad governance, emerging from civil war, and/or being landlocked [2]. To improve maternal and child health (MCH), emphasis must be given to strengthening health systems, increasing access to information and care, and addressing the related community and development issues [3].

In the high mountainous areas of Central Asia, the successor states of the Russian and British empires govern communities that are often forgotten and frequently unserved [4]. In some measure, the health status of these communities, especially that of the women and children living in the contiguous border areas of three states (Afghanistan, Pakistan, and Tajikistan) reflects the challenges, successes, and failures of these states. Although the communities in these adjacent geographical areas share a common ethnicity, religion, and culture, MCH indicators vary widely along with the capacities and efforts of governmental and non-governmental actors to reduce the disparities.

In the rural province of Afghan Badakhshan, a remote region with minimal infrastructure and few modern health services, Linda Bartlett and others recently carried out a reproductive age mortality survey [5]. Reported in 2005, this survey found the highest maternal mortality ratio ever documented (6,507 per 100,000 live births) for a three-year time period (April 1999 through March 2002), and a very high infant mortality rate (217 per 1,000 live births) [5]. Gorno-Badakhshan Autonomous Oblast sits on the other side of the Oxus (Amu Darya, Panji) River in the newly independent Republic of Tajikistan. Here, the Soviet health system contributed to a relatively low maternal mortality ratio (54 per 100,000 live births) and infant mortality rate (28 per 1,000 live births), even as late as 1994. Recent surveys in the Oblast suggest that the new republic's health system has not been able to maintain or improve the indicators achieved during the Soviet period. In the Northern Areas of Pakistan, a disputed territory but contiguous with the other regions, local government institutions have traditionally been very weak. However, important improvements in maternal and child health indicators, including a substantial reduction in the maternal mortality ratio (from 550 to 68 per 100,000 live births) and infant mortality rate (from 158 to 31 per 1,000 live births) have been observed over the last 20 years. While under-reporting of maternal, infant, and especially neonatal deaths is a global problem, and variations in data collection methods challenge the comparability of the measures across the three regions, the substantial differences strongly suggest true distinctions that should be examined to determine why women and infants in the Northern Areas and Gorno-Badakhshan have markedly lower risk of death.

Summary Points

Health indicators, including levels of maternal and infant mortality, are very different in adjacent geographical border areas of Afghanistan, Pakistan, and Tajikistan.


These differences reflect the combined and complex interplay of elements within the different health systems, as well as political, economic, social, and cultural factors.


Reducing maternal and child mortality requires focus and balance in all of these dimensions and can best be achieved through service interventions underpinned by general development.


A policy promoting “cross-border” health programmes could immediately make available existing resources that could contribute to reducing maternal and child mortality in all three geographical locations.