|19. What Are Maternal Health Policies in Developing Countries and Who Drives Them? A Review of the Last Half-century|
Annex 1. Ideologies that Have Influenced Maternal Health Policies11
Developments in maternal health have been guided by particular ideological paradigms which have been adopted to varying degrees. Beyond the obvious role played by economic rationales, the most prominent of these have been, first, the need to prioritise interventions that are appropriate for delivery at basic PHC facilities and, second, the desire to address health problems through improving the status of women. To some extent this has been based on political expediency and presentation rather than technical or scientific evidence, a process that has led to problems with implementing effective health programmes at national level.
Family planning policy from the 1950s to the late 1980s was driven by a macro-economic agenda of concern over the impact of rapid population growth on developing economies. This concern led to the development of vertically funded and managed family planning programmes, heavily prioritised by international donors, in particular, the United States Agency of International Development (USAID) (Finkle & McIntosh 1996), UNFPA, a number of international family planning NGOs, including the Population Council. The Human Reproduction programme within WHO was also started in the mid 1960s. Large US-based foundations, such as Rockefeller and Ford also took a significant interest in population issues (Finkle & McIntosh 1996).
Primary Health Care
PHC, since its origins in the 1960s and 1970s was guided by five principles: equitable distribution; community involvement; focus on prevention; appropriate technology; and a multi-sectoral approach (Walt & Vaughan 1982). It was grounded in a broad theory of development that rejected economic modernisation as the only means to human well being and placed good health firmly at the centre of an economic growth-equity-productivity nexus. Furthermore, in the Alma Ata declaration of 1978, the international public health community committed to comprehensive PHC as part of a broader political and economic development agenda (WHO 1978).
During the 1980s, PHC ideals ceded to selective care based on what were perceived to be cheap service packages (Walt 1998) (see below). The failures of PHC therefore came under intense scrutiny, especially the unrealistic nature of the original objectives, given levels of public sector expenditure, and the difficulties of ensuring equitable resource allocation (Chen 1986, Rifkin & Walt 1986, McPake et al. 1993, Collins & Green 1994, Kalumba 1997). Ironically, many of the PHC concepts were absorbed by those drafting the ICPD Programme of Action (Chapter eight starts with a discussion of PHC (para. 8.1)), apparently ignoring 20 years of PHC experience, which suggested that a comprehensive approach was difficult to implement in practice, given low levels of funding (Walt & Vaughan 1982).
Neo-liberal Economic Policies
The global trend towards neo-liberal economic policies also influenced policy-making at Ministries of Health of developing countries. In the 1980s, cost-effectiveness of health interventions became a priority, necessary for the structural adjustment programmes that the IMF and World Bank recommended to the indebted developing countries. Limiting the costs of healthcare spending was considered essential in globalised competition (Zapata & Godue 1997) and comprehensive PHC pared back. This shift also reflected the growth in influence and financial commitment of richer and more economically-motivated international actors, such as the World Bank (Walt 1998).
More recently, major reforms were initiated in many low income countries to try to increase efficiency in health service financing, expand access to primary level services and improve quality of care (Berman 1995, Janovsky 1996). As part of this effort, international donors emphasised basic packages of care that were considered to be cheap and cost-effective and should therefore be available to all. Two of the top five most heavily promoted cost-effective address preventing unwanted pregnancy and preventing maternal mortality (World Bank 1993).
Womens status in low-income countries and its relationship with poor health outcomes has long been a cause for concern among Western womens groups and increasingly among low-income country womens groups themselves (Kabeer 1994). There is also a well-documented inter-action between poverty and gender, whereby poor women often live in extremely vulnerable situations (Folbre 1983, Boserup 1989, Oppenheim Mason 1993).
There is considerable debate remains over what the goal with respect to womens status is and what should be the means of achieving it (van Staveren 1994, Basu 1997, Oppenheim Mason 1993, Agarwal 1994). Nevertheless, during the 1980s, improving gender equality and womens rights became a central tenet of womens health activists arguments (Lane 1994), some going as far as saying that meaningful improvements in reproductive health could only be achieved by improving womens status.