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

Lead Research Organisation: London Sch of Hygiene and Trop Medicine
Department Name: Epidemiology and Population Health

Abstract

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.

Technical Summary

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

Planned Impact

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
 
Description Training in health systems research, qualitative methods and paper writing
Geographic Reach National 
Policy Influence Type Influenced training of practitioners or researchers
Impact We organised three short courses for PhD students and faculty at the Schools of Public Health in Peking University and Sichuan University. These courses were organised by Senior Faculty from the London School of Hygiene and Tropical Medicine and covered the following topics: (1) Research methods for heahlth systems research; (2) Qualitative research methods and (3) Scientific paper writing. Each course had about 20 participants.
 
Description China Medical Board Scholarships
Amount £447,261 (GBP)
Organisation China Medical Board 
Sector Charity/Non Profit
Country United States
Start 09/2015 
End 08/2019
 
Description Evaluation of Save the Children's programme in Xide and Mianning County in Liangshan Prefecture, Sichuan Province
Amount ¥273,273 (CNY)
Organisation Save the Children 
Department Save the Children - China
Sector Charity/Non Profit
Country China
Start 03/2016 
End 12/2016
 
Description Evaluation of Save the Children's programme in Xide and Mianning County in Liangshan Prefecture, Sichuan Province
Amount £15,342 (GBP)
Organisation Save the Children 
Department Save the Children - China
Sector Charity/Non Profit
Country China
Start 03/2016 
End 12/2016
 
Description Spatial Access to Maternal and Child Health Care: An Empirical Study in China
Amount $80,000 (USD)
Organisation China Medical Board 
Sector Charity/Non Profit
Country United States
Start 01/2018 
End 12/2020
 
Title Case study qualitative tool for maternal health service providers 
Description This is a qualitative tool that will allow for the generation of data to assess how the different health system components have contributed to maternal health outcomes in rural China at the province, county and township levels. The health system components assessed include financing, human resources, drugs and medical supplies, referral mechanisms, clinical guidelines and information management systems. 
Type Of Material Physiological assessment or outcome measure 
Provided To Others? No  
Impact This research tool will not only allow us to conduct our fieldwork but will also be useful for future researchers exploring health systems issues in China 
 
Title Community maternal health qualitative tool 
Description This resource provides both a protocol and a tool for collecting community-level data on attitudes towards and use of maternal health services among women of reproductive age in rural China and their families. It includes guides for interviews as well as focus groups with the relevant population groups. 
Type Of Material Physiological assessment or outcome measure 
Provided To Others? No  
Impact This tool will provide our team (and any other future researchers) with a protocol for conducting community level interviews with women. 
 
Title Province level data base on health systems inputs and outputs in China 1997-2014 
Description Province based data on health systems inputs (human resources, financing, health institutions), processes of care (health facility births, antenatal care, caesarean sections) and health outcomes (matrenal mortality) for 18 years (1997-2014) 
Type Of Material Database/Collection of data 
Provided To Others? No  
Impact No impact yet, this is work in progress 
 
Description Health Systems Strengthening in China and Africa 
Organisation Ifakara Health Institute
Country Tanzania, United Republic of 
Sector Charity/Non Profit 
PI Contribution Conceptualisation of the research, Study design, Development of data collection, Training, Project management and leadership
Collaborator Contribution Facilitation and hosting of workshops, Collaborative involvement in study design and co-ordination of fieldwork, Contribution of routine data
Impact No outputs yet; work is on-going epidemiology, statistics, economics, public health, social policy, health systems, social sciences
Start Year 2015
 
Description Health Systems Strengthening in China and Africa 
Organisation Peking University
Department Peking University Academic Health Science Centre
Country China 
Sector Academic/University 
PI Contribution Conceptualisation of the research, Study design, Development of data collection, Training, Project management and leadership
Collaborator Contribution Facilitation and hosting of workshops, Collaborative involvement in study design and co-ordination of fieldwork, Contribution of routine data
Impact No outputs yet; work is on-going epidemiology, statistics, economics, public health, social policy, health systems, social sciences
Start Year 2015
 
Description Health Systems Strengthening in China and Africa 
Organisation Sichuan University
Country China 
Sector Academic/University 
PI Contribution Conceptualisation of the research, Study design, Development of data collection, Training, Project management and leadership
Collaborator Contribution Facilitation and hosting of workshops, Collaborative involvement in study design and co-ordination of fieldwork, Contribution of routine data
Impact No outputs yet; work is on-going epidemiology, statistics, economics, public health, social policy, health systems, social sciences
Start Year 2015
 
Description Participation in Conference, and contribution to the content of the Conference 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact The ongoing research on this grant has informed a presentation made by Carine Ronsmans at a meeting held in Beijing on March 22-24, 2016. The meeting was a joint effort between UNICEF, Beijing, the Chinese Ministry of Commerce, the National Health and Family Planning Commission (NHFPC) of China, and the China Countdown Case Study team (Peking University, Sichuan University and the London School of Hygiene and Tropical Medicine). The overall aim of the meeting was to explore ways to strengthen the collaboration between China and countries in Sub Saharan Africa to improve maternal, newborn and child health. The main focus of the meeting was to draw lessons from China's success in maternal, neonatal and child health, especially the development of a robust national immunization programme, achieving near-universal hospital delivery with consequent and significant reductions in newborn and maternal mortality from the 1990s onwards, and the expansion of primary health care and health insurance services across this large country. Many of these experiences provided valuable lessons to guide progress in many countries, especially those in Sub Saharan Africa.
Year(s) Of Engagement Activity 2015,2016
 
Description Presentation at the Countdown meeting in Beijing in December 2018 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact I presented the findings of our study at a Countdown meeting in Beijing in December 2018. This meeting was organised and attended by senior policy makers in maternal and child health in China (including the Health Minister), and an international group of experts. This meeting partly aimed at celebrating China's success as well as drawing lessons for China's work in sub-Sharan Africa
Year(s) Of Engagement Activity 2018
 
Description Workshop on transferability of lessons from China to Tanzania 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact In a one-week workshop bringing together senior Tanzanian and Chinese policy makers and academics, which took place in Chengdu, China, we discussed the transferability of lessons from China's success in Maternal and Neonatal Health to Tanzania. Three senior Tanzanian policy makers, including the head of Reproductive Health at the Ministry of Health, visited Chengdu for one week. We presented our preliminary research findings on the factors underpinning China's success, we visited health facilities in remote rural areas in Sichuan province and we brainstormed on which elements of China's health system can be transferred to Tanzania. Our Tanzania's colleagues have planned a workshop in Dar es Salaam on March 28th 2018 to discuss the findings.
Year(s) Of Engagement Activity 2017