Learning from health systems strengthening in maternal and newborn health (MNH) in China to inform accelerated progress for saving lives in Africa

Globally, 289,000 women die each year due to complications of pregnancy and childbirth, and 2.9 million babies do not survive the first month of life. Sub-Saharan Africa - with only one tenth of the world's population - carries the greatest burden and there is little evidence of progress. Several strategies have been identified to accelerate progress in reducing maternal and newborn mortality, including increasing the number of health workers and upgrade specific skills for care at birth and exploring ways to attract health workers to rural areas, but how to implement these measures at large scale in sub-Saharan Africa remains uncertain.

Sub-Saharan Africa can learn important lessons from China's progress in maternal and newborn health (MNH), in particular in terms of the process and the "how". Over the last twenty years, China's newborn and maternal mortality rate fell dramatically. The reasons for this success are multiple, but China's strategic investments in health systems strengthening have no doubt contributed, particularly in terms of building a strong midwifery workforce, encouraging women to give birth in hospital and making delivery care mostly free. Regional disparities in access to MNH care persist, but even the poorest regions, - which face geographical barriers not dissimilar to sub-Saharan Africa - have made substantial progress. The mortality difference between China and sub-Saharan Africa at national level is about 3-fold for newborn mortality and ten-fold for maternal mortality; and the current urban-rural maternal and newborn survival gap in China is about 3-fold. So evaluation of China's learning could serve to both accelerate progress for closing China's urban-rural gap and to the increasing momentum for change in Africa.

The aim of this project is to use China's experience in MNH to answer a number of questions that are critical to understanding how similar progress can be achieved in sub-Saharan Africa, including:
1. Do existing health systems indicators discriminate among areas with high and low maternal and newborn mortality? Can thresholds be set (e.g. density of providers per 1000 population) below which mortality cannot decline?
2. What is the appropriate midwifery workforce, and how is it best deployed, to equitably deliver essential MNH interventions at scale and quality, and what resources and systems (financial, training, governance, supervision, etc.) need to be in place to achieve universal access to these interventions?
3. How do existing structures and processes enable successful referral from the community to facilities offering obstetric care?
4. What changes in the health financing system, including introduction of new insurance schemes, pooling arrangements, and provider payment mechanisms, have reduced financial barriers, thereby supporting the expansion of coverage of essential MNH services?
5. What lessons from China can be transferred to Tanzania?

We will answer the above questions through a number of studies. First, we will use China's unique and extensive routine data systems to examine the relationship between health systems inputs and maternal and newborn mortality across all counties. Second, we will collect data in eight counties in China's poorest Western provinces to provide an in depth understanding of the relationship between MNH inputs that are more difficult to capture through routine data sources, including the mix and levels of the midwifery workforce, referrals and levels and allocation of health care financing, and selected service coverage and outcome indicators. Third, we will examine whether the successful MNH strategies deployed in China can be implemented in Tanzania and whether the effectiveness would remain the same given Tanzania's different health and socio-economic context.

The aim of this project is to examine China's progress in reducing maternal and neonatal mortality to draw lessons applicable to the MNH context in sub-Saharan Africa. The focus will be on understanding the health systems inputs and outputs that have enabled progress towards comprehensive obstetric care in health facilities, particularly for the rural poor and those living in remote areas, and the financing mechanisms that facilitated reimbursement of hospital delivery charges. We will contribute knowledge in three areas:
1. We will assess implementation strength, an emerging approach to programme evaluation which aims to characterise the intensity of programme effort required to achieving programme goals. This will be done through a quantitative analysis of the relationship between health system inputs/outputs, contextual factors and maternal and neonatal mortality across all 3255 counties in China between 1996 and 2013, using routinely available data. Multilevel statistical models will identify thresholds for MNH health systems indicators, incorporating time varying covariates where possible.
2. A case study in eight counties in Western China will provide an in depth understanding of the relationship between MNH inputs that are more difficult to capture through routine data, including the mix and levels of the midwifery workforce, referrals, levels and allocation of health care financing, and selected service coverage and outcome indicators. Eight counties will be selected purposively to reflect various levels of maternal and neonatal mortality, matching counties as far as possible within provinces on contextual factors. Data will be collected at province, county and facility levels and methods will include document review, in-depth interviews with key stakeholders and facility and patient surveys.
3. We will adapt lessons from China's experience in MNH to low income countries, by analysing the transferability of policy lessons from China to Tanzania

This research will accelerate progress in MNH in Tanzania and other countries in sub-Saharan Africa through stakeholder engagement, capacity strengthening and communication in China and Tanzania.

Recently, the Chinese Government has recognised that lessons learned from China's health development could be useful in supporting progress towards health systems development in low and middle income countries. This has led to the launch by the Ministry of Commerce, in collaboration with DFID, of the Global Health Support Programme (GHSP), which will help China improve its contribution to global health. Peking University, in collaboration with LSHTM, has been successful in securing funding to analyse China's experience in health systems strengthening and examine how these lessons can help other countries improve their effectiveness in scaling up their health systems. The GHSP project, which includes capacity strengthening of researchers in generating and synthesizing evidence on health systems in China and Tanzania and increasing the capacity of Chinese academics and officials in distilling and disseminating China's success story in low income countries, will enable this study to incorporate the findings specific to MNH within a broader health systems framework.

Our research partners in China lead Health Systems Research Centres which work in close partnership with the Ministry of Health: The China Centre for Health Development studies (Peking University) and the West China Centre for Rural Health Development Research (Sichuan University). The Centres respond to direct requests from Government, and their members serve as advisers on various national committees in the Ministry of Health. Given the Centres' geographically distinct locations, we will be able to directly involve central Government (via Peking University) while also engaging with local policy development in poorer Western counties (via Sichuan University).

The Tanzanian Government, in its efforts to accelerate progress in MNH, is supported by a number of national and sub-national initiatives, two of which offer a unique opportunity for our consortium to engage with: Evidence for Action (E4A) and The Countdown to 2015. E4A, established in Tanzania in 2012, consolidates and synthesises existing MNH evidence, fills critical evidence gaps, and packages the findings such that they are accessible to and can be acted upon by a wide range of audiences. E4A seeks to ensure that evidence underpins decisions and accountability regarding MNH at all levels of the health system and builds capacity of health sector stakeholders at national, regional and district levels to analyse and understand results, and to budget and plan based on evidence. The Countdown to 2015, which tracks progress in major health indicators to hold governments to account, is actively involved in evaluating progress in Reproductive, Maternal, Neonatal and Child Health outcomes in Tanzania in order to inform accelerated progress particularly for MNH. The President of Tanzania co chaired the Commission for Information and Accountability in 2011 and the Countdown process is part of the follow up.

Both these initiatives are in close collaboration with the Tanzanian Ministry of Health, WHO Tanzania and other national stakeholders, ensuring ownership of the findings. Working alongside these initiatives will enable our consortium to integrate the Chinese evidence directly into the Tanzanian experience, and to engage with the channels of communication and accountability already established. This will involve a range of interactions including two way learning visits. Countdown also provides extensive opportunities for dissemination beyond Tanzania and indeed beyond sub-Saharan Africa. In addition, E4A is working in five other sub-Saharan African countries (Ethiopia, Ghana, Malawi, Nigeria, Sierra Leone) and has close linkages with the African Union, providing a wider platform for dissemination