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Engaging communities to achieve equity in maternal and child health


In recent decades, equity has continued to gain importance in public health policy and practice. Equity is a core principle of the 2030 Agenda for Sustainable Development and its rallying cry is to leave no one behind.

The World Health Organization defines equity as the fair opportunity for everyone to attain their full health potential regardless of geography or of demographic, social, or economic status. Despite being a self-evident goal, achieving health equity ― ensuring that everyone has access to what they need to be as healthy as they can ― is not easy.

This goal has always been at the heart of the Innovating for Maternal and Child Health in Africa (IMCHA) initiative. Lessons from two IMCHA research teams working in Mali and Nigeria are showing how communities can actively identify and address the causes of inequity that prevent people from accessing and using healthcare services.

Identifying those in need in Mali

Research in Mali sought to understand whether government programs were ensuring equitable access to healthcare and helping to meet the country’s goal of universal health coverage. A research team that included the Association de Recherche et de Formation en Anthropologie des Dynamiques Locales in Mali and researchers from the Université de Montréal in Canada focused on the Régime d’assistance médicale, a free, governmental medical assistance policy launched in 2011 to provide health services to indigents, defined as “any person deprived of resources and recognized as such by the local authority covering them.” The program targets 5% of Mali’s population, nearly 1 million people, although extreme poverty is estimated to affect more than 20% of the population. 

Enrolment under this policy is voluntary, but its complex process is often a deterrent. A person must apply to the office of the mayor or another similar authority, local authorities must investigate to prove the applicant’s eligibility, and a plethora of documents must be sent to the program’s administering organization.

Because the number of people registered for this free medical assistance has been lower than expected, the government carried out three large campaigns to identify and register indigents in 2016 and 2017. Still, the number of registrants remained lower than expected. To determine why, the research team held 42 focus groups with various governmental and community actors involved in the campaigns in two communities of the capital city of Bamako and in the rural health districts of Bougouni and Dioila. The researchers found that some of the poorest people excluded themselves at various stages of the campaign because they felt the process would stigmatize them or reveal confidential information about them. Others were unable to meet complex access requirements. 

As the research team discovered, the vague official definition of “indigent” and the challenges of translating it into local languages contributed to the difficulties. Indeed, the community representatives who need to decide who is considered “indigent” do not have clear criteria to make their decision, which leads to people who should qualify being left out. Further, many players were involved in the process without a clear understanding of their roles.

Based on their findings, the research team is testing a revised approach to identify and enroll indigents more accurately. It has mobilized existing groups representing a greater diversity of community members to participate meaningfully in identifying indigents. Their inclusion allows for a more democratic process. The research team also worked with public authorities to redefine and adapt the criteria for inclusion to reach those who really need access to free health services.  Moreover, based on the team’s recommendations, structures and procedures have been put in place to make sure all actors involved in implementing the Régime d’assistance médicale are kept informed and understand their roles. 

Watch a video about this IMCHA-supported research in Mali

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Overcoming hurdles to equity in Nigeria

Nigeria has also implemented various programs to promote health equity and reduce high rates of maternal illness and death. The country’s policies emphasize the provision of quality care for women from conception through pregnancy and the postnatal period, but it has yet to achieve its goals among the most vulnerable women.

The Women's Health and Action Research Centre in Nigeria and the University of Ottawa in Canada launched a project in 20 communities in Edo, a state in the Niger Delta region, to identify why many women didn’t use primary healthcare services for maternal and child health. Working with the federal and state ministries of health, they also set out to design and test innovative, community-led interventions to overcome the barriers they identified.

Through household surveys, focus group discussions with women and men, conversations with community leaders, and interviews with health providers and government officials, the research team determined that fewer than 47% of pregnant women used available primary healthcare services. The inability to pay was a major barrier to accessing care, as were long distances to facilities on bad roads and the poor quality of services. 

The research team worked with community stakeholders to understand and address these bottlenecks more fully. Developed with and led by community members, interventions included creating a revolving fund for drugs and a community health insurance fund. By reducing the amount that individuals must pay for care, these funds contribute to equitable access. In addition, a text messaging service, Text4Life, was launched for pregnant women who lacked the means of transportation to facilities. The system links these women to registered taxi drivers who can quickly bring them to health centres when they are in labour.  

The result? The demand for skilled maternal and child healthcare services increased threefold and even fourfold in some areas. Among the many factors that contributed to this success were the interventions that responded to issues identified by the communities themselves and community participation in their design and implementation. The resulting sense of ownership contributes to sustainable change.

Watch a video about this IMCHA-supported research in Nigeria

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The importance of communities 

These projects showed that making healthcare available is not enough to foster equity: governments and implementing agencies must also work with communities to ensure that everyone, including the most marginalized, can access services. 

Acknowledging inequities and being willing to tackle them are critical to meeting the goals of the 2030 Agenda for Sustainable Development. As IMCHA research shows, clearly identifying those most in need of services and their barriers to access, by and with communities, is crucial to achieving greater equity. 

Watch a video about the IMCHA-supported research that improved equity to save lives

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Research highlights

  • Lessons from the Innovating for Maternal and Child Health in Africa initiative show how communities can help to identify and address barriers to health equity.
  • In Mali, broader community participation with defined roles and guidelines is helping the government offer free health services to the neediest.
  • In Nigeria, communities are identifying and helping to address barriers preventing women from accessing and using health services.