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Recep Akdag

RecepAkdagSquareRecep Akdag

Minister of Health of Turkey 2002 - 2013

Recep Akdag was born in Erzurum, Turkey in 1960. As a pediatrician, he has been holding a professor title from the Ataturk University School of Medicine since 1999. During his career as a medical specialist and academician, he had been involved in a number of administrative tasks. Between 1994 and 1998, he worked as the Deputy Chief Medical Director, Chairman of the Procurement Commission and Deputy Editor of the Medical Bulletin in the Research Hospital of the Medical Faculty of Ataturk University. He also co-founded the Biotechnology Research Center of the University and served as the Deputy Head of the Center from 1997 to 2000.

After being elected as a Member of Parliament from the Province of Erzurum, he had served as the Minister of Health of Turkey between 2002 and 2013. During his tenure, he has been the key figure for the implementation of the influential Health Transformation Program (HTP) in Turkey. This comprehensive program brought a people-oriented approach to healthcare service delivery and strengthened the health system with successful implementation of universal health coverage. Major aspects of this health system reform included integration of public hospitals, increased patient access to medical services and prescription drugs, invigorated primary healthcare delivery with the implementation of family medicine, improved maternal and childhood healthcare services, better quality and reach of emergency services, and establishment of a national medical rescue team.

HTP generated high access rate for essential services thru the adequate healthcare supply and universal health insurance covering the poorest. Infant mortality rate, maternal mortality ratio and catastrophic health expenditures decreased dramatically. Public satisfaction with health services increased from 39% in 2002 to 75% in 2012. Apart from leading this influential program, Prof. Akdag has edited a number of reports and contributed/co-authored academic articles about HTP. He has addressed, directed and moderated in many international conferences including of those the WHO and UNICEF. He has received the WHO’s “World No Tobacco Day” Award as a recognition of his efforts in the fight against the global tobacco epidemic and in the promotion of tobacco control initiatives and policies. He has been an advisory board member of the Ministerial Leadership in Health (MLIH) Program at Harvard University since 2012.

Prof. Akdag still serves as an MP in the Grand National Assembly of Turkey for his third consecutive term. He also is a Richard L. and Ronay A. Menschel Senior Leadership Fellow, Harvard School of Public Health.


Variation in Dietary Intake and Pre-eclampsia and Eclampsia in Indian women: Findings from the National Family Health Survey.

Author(s) Sutapa Agrawal1, Jasmine Fledderjohann2, David Stuckler3, Sukumar Vellakkal 4, Shah Ebrahim 5
Affiliation(s) 1South Asia Network for Chronic Disease, Public Health Foundation of India, New Delhi, India, 2Deaprtment of Sociology, University of Oxford, Oxford, United Kingdom, 3Department of Sociology, Oxford University, Oxford, United Kingdom, 4SANCD, PHFI, New Delhi, India, 5Non communicable Disease Epidemiology, LSHTM, London, United Kingdom.
Country - ies of focus India
Relevant to the conference tracks Women and Children
Summary Pre-eclampsia/eclampsia is responsible for upwards of 20% of maternal morbidity and mortality in developing countries. We examine the relationship between food intake and symptoms of pre-eclampsia and eclampsia among Indian women aged 15-49 (n=39,657) for the most recent live birth in the five years preceding the National Family Health Survey-3 (2005-06). Daily consumption of milk, vegetables, chicken/meat and weekly pulses/beans consumption are associated with substantially lower risk of pre-eclampsia. Eclampsia risk is higher among those who consumed fruit and chicken/meat occasionally, and lower among those consuming vegetables daily.
Background Pre-eclampsia and eclampsia pose significant threats to maternal health, particularly in developing countries. In low-and middle-income settings, these two conditions affect approximately 8% of all pregnancies, causing an estimated 15%-20% of maternal morbidity and mortality. Pre­eclampsia is a life threatening complication of pregnancy that typically starts after the 20th week of gestation. Women with pre-eclampsia may present with symptoms such as headache, upper abdominal pain, or visual disturbances and have raised blood pressure, ankle oedema and proteinuria. When pre-eclampsia is left untreated or is severe, giving rise to seizures/convulsions which cannot be attributed to other causes (such as epilepsy), the condition is known as eclampsia. Although several studies have found that micronutrient deficiencies, such as iron, vitamin A, vitamin C, and calcium, contribute to pre-eclampsia risks, few studies have evaluated the potential role of different food types.
Objectives Existing nutritional evidence is highly variable. Dietary patterns may influence maternal antioxidant levels, mediating the link between pre-eclampsia and oxidative stress, an established risk factor. However, consumption of high-energy diets may increase risk of pre-eclampsia by inducing abnormal lipid metabolism, while consumption of dietary fibre may regulate these metabolic processes, thereby reducing risk. However, studies which have attempted to test these links empirically have not been conducted in high burden countries, nor have they employed appropriate multivariate models. To our knowledge, there has not been any previous large-scale report concerning the dietary risk factors for pre-eclampsia and eclampsia in Indian women. Here, we evaluate potential dietary risk factors of pre-eclampsia and eclampsia, using a large representative sample of Indian mothers in the third National Family Health Survey conducted during 2005-06.
Methodology Data were taken from the most recent wave of the National Family Health Survey (NFHS-3, 2005–2006), India’s Demographic and Health Surveys. NFHS-3 collected demographic, socioeconomic and health information from a nationally representative probability sample of 124,385 women aged 15–49. The sample is a multistage cluster sample with an overall response rate of 98%. All states of India are represented in the sample (except the small Union Territories), covering more than 99% of the country’s population. The analysis presented here focuses on 39,657 women in the sample who report being married and who have had a live birth in the five years preceding the survey. The survey was conducted using an interviewer-administered questionnaire in the native language of the respondent. To assess the occurrence of pre-eclampsia, mothers were asked if at any time during their last pregnancy they experienced relevant symptoms, including difficulty with vision during daylight, night blindness, convulsions (not from fever), swelling of the legs, body or face, excessive fatigue, or vaginal bleeding. Women who reported difficulty with vision during daylight, swelling of the legs, body, or face, or excessive fatigue were coded as having symptoms of pre-eclampsia, whereas those who reported experiencing convulsions (not from fever) were coded as symptomatic of eclampsia. Data on blood pressure and proteinuria during pregnancy were not available in the NFHS. Dietary intake variables were based on the self-reported frequency of consumption of milk or curd, green leafy vegetables, fruits, pulses and beans, eggs, fish, chicken or meat, categorised into daily, weekly, occasionally, or never. Potential confounders and covariates were selected on the basis of previous knowledge of their association with pre-eclampsia/eclampsia. We used multiple logistic regression to estimate the association between variation in dietary intake and pre-eclampsia and eclampsia risk after adjusting for maternal factors, biological and lifestyle factors and socio-demographic characteristics of the mothers. Models were adjusted for sampling weights (IIPS & Macro International 2007). All analyses were conducted using the SPSS statistical software package Version 19.
Results Overall 55.6% of mothers reported pre-eclampsia symptoms, and 10.3% reported eclampsia. Table 1 reports the results of our statistical models. After adjusting for maternal, biological, and chronic disease risk factors, as well as socio-demographic characteristics, we found that the risk of pre-eclampsia was significantly lower among women who consumed milk daily (OR:0.88;95%CI:0.81-0.96), green leafy vegetables daily/weekly (OR: 0.69 to 0.76), pulses or beans at least weekly/occasionally (ORs ranges from 0.84 to 0.92), fruits daily (OR:0.92), eggs weekly/occasionally, consumes fish (OR:0.90) or chicken/meat daily or occasionally, with added reference to those who never consumed them. However, a greater risk of pre-eclampsia was found among women consuming fruits weekly/occasionally (OR:1.11), eggs daily (OR:1.23) and fish weekly (OR:1.22). The risk of eclampsia was lower among those consuming green leafy vegetables (ORs ranges from 0.74 to 0.79), consuming fish weekly or occasionally (ORs ranges from 0.44 to 0.62), eggs weekly or occasionally (Ors ranges from 0.61 to 0.76), but was higher among those who consumed fruits (ORs ranges from 1.18 to 1.44), chicken/meat occasionally (OR:1.28;95%CI:1.11-1.48) with reference to those who never consumed them.
Conclusion Our study provides empirical evidence of an association between the frequency of intake of specific food items and prevalence of pre-eclampsia/eclampsia in a large nationally representative sample of Indian women. Findings suggest that variation in the frequency of consumption of specific foods has a substantial effect on the occurrence of symptoms suggestive of pre-eclampsia/eclampsia in this population. The strengths of our study include the large nationally representative study sample and the population-level focus on the predictors of pre-eclampsia and eclampsia. However, due to the general challenges of measuring hypertensive disorders in population-based studies, the information of the symptoms of pre-eclampsia and eclampsia presented here is based on self-reports and should therefore be interpreted with care. Although we adjusted for several confounding variables, we cannot exclude the possibility of residual confounding. In these analyses, the cross-sectional design precludes causal inferences and we were limited to the questions used to elicit lifestyle and dietary information. Few population level studies exist which assess the dietary determinants of pre-eclampsia and eclampsia. This study is important because few others have reported pre-eclampsia/eclampsia prevalence rates based on population-level data. Our study implicates that modifiable risk factors for pre-eclampsia/eclampsia exists and thus there is a need for replication of findings given that the dietary patterns are modifiable. Our study findings may serve as an important call for health care providers to heighten their awareness of the increased population-level risk for pre-eclampsia and eclampsia disease originating in pregnancy. With the target of the Millennium Development Goals in sight, pre-eclampsia/eclampsia should be identified as one of the priority areas in reducing maternal mortality in India. However, further research involving the use of a more comprehensive dietary measure, pre-pregnancy assessment of all the risk factors and ascertainment of dietary intake prior to the development of pre-eclampsia and eclampsia and accuracy of reporting of the symptoms of pre-eclampsia and eclampsia are needed in a developing country setting.

Causes, determinants, andtrends in maternal mortality among Palestine refugees during 2000-2010

Author(s) Ali Khader1, Majed Hababeh2, Wafaa Zeidan3, Irshad Shaikh 4, Yousef Shahin 5, Akihiro Seita6, 7, 8
Affiliation(s) 1Health, UNRWA, Amman, Jordan, 2Health, UNRWA, Amman, Jordan, 3Health, UNRWA, Amman, Jordan, 4Health, UNRWA, Amman, Jordan, 5Health, UNRWA, Amman, Jordan, 6health, UNRWA, Amman, Jordan, 7, , , , 8, , ,
Country - ies of focus Palestine
Relevant to the conference tracks Women and Children
Summary Despite the hardship socioeconomic status, the patern of Maternal mortality among palestine refugee population is similar to that among stable midle income countries, A shift was observed during the last decade from causes related to poor obstetric care such as hemorrage and infection to thromboemblic diseases.
Background The United Nations Relief and Works Agency for Palestine Refugees in the Near East has for over 60 yearsprovided comprehensive primary health care to 5.2 million Palestine refugees in five fields of operation: Gaza, Jordan, Lebanon, Syria and the West Bank. Despite the contextual challenges of chronic instability and poverty, the agency maintains high standards of antenatal care supported with subsidy of delivery in local hospitals, with comprehensive follow up of all registered pregnant women.
During the period 2000-2010 a total of 978,446 pregnant women were registered and followed up through UNRWA antenatal care services. A system to trace the outcome of each pregnancy was established. During the first year (2000) of implementation, 2145 (2.8%) pregnancies were with unknown outcome that was reduced to only 199 (0.2%) cases in 2010 and during this period a total of 230 maternal deaths were reported.
Objectives The aim of this analysis is identify the main causes and determinents of maternal mortality among Palestine refugees women served by UNRWA PHC system
Methodology UNRWA uses the Confidential Maternal Mortality Enquiry method for in-depth investigation of the direct and indirect causes of each maternal death. This retrospective study examines 230 confidential enquiry reports on maternal deaths of Palestine refugee women in five fields of operation during one decade. The confidential enquiry is completed immediately after a maternal mortality. A thorough investigation is conducted by a special committee established to investigate and reoprt on each maternal mortality
Results Analysis of the confidential enquiry reports revealed a maternal mortality ratio of 24/100000 with significant variations among fields (Lebanon and Syria the highest at 34, followed by Gaza and West Bank at 25 and Jordan at 19). 1.8% delivered at home while 14.8% of deaths occurred at home. 53% of them died in hospitals during the intra-post-partum period. 88% received 4 or more antenatal visits. Maternal deaths increased with higher parity. There was a shift in the leading documented causes of maternal deaths from pre-eclampsia and hemorrhage to pulmonary embolism. Thromboembolism was the first cause of death with 41% followed by toxemia and hypertensive disorders at 12, heart diseases at 11.8%, hemorrhage at 10.5% and infection and sepsis at 7.4%
Conclusion Maternal Mortality has plateaued over the last 10 years among Palestine Refugees. We have managed to reduce the deaths from infections, hemorrhage and pregnancy induced hypertension but the deaths from obstetric embolism and medical disorders in pregnancy have either stayed the same or have increased over the years. This can be partially attributed the lack of embolism prophylaxis in high risk cases as well as poor care of high risk women with medical disorders prior to pregnancy

mAmbulance: An innovative intervention to reduce maternal deaths in rural Uganda

Author(s) Alakananda Mohanty
Affiliation(s) 1Healthcare, Kissito Healthcare, Inc., Roanoke, United States.
Country - ies of focus Uganda
Relevant to the conference tracks Health Systems
Summary Achieving the fifth Millennium Development Goal (MDG5) by reducing maternal deaths remains a significant challenge in Uganda. Uganda has a high Maternal Mortality Ratio (MMR) of 438/100,000 live births with the life-risk of 1 in 27 women dying in pregnancy. One of the many underlying factors that contribute to high MMR in the country is delay in reaching an emergency obstetric care (EmOC) facility. Evidence indicates that access to appropriate health care, including timely referrals to EmOC services, can significantly reduce maternal deaths.
Background Ensuring timely access to quality EmOC for women with obstetric complications are increasingly recognized as priority interventions needed to reduce maternal deaths. To reach EmOC services, one of the vital factors is the availability and accessibility of suitable and affordable transport. Delay in accessing and receiving EmOC is a major predisposing factor for maternal deaths in rural Manafwa and Mbale districts in Uganda. The high prevalence of maternal illnesses, and other emergency obstetric complications suffered by women in these two districts have been linked to their poor access to emergency obstetric services. Earlier studies indicate that motorcycle ambulances reduce the delay in referring women with obstetric complications where health centers have no access to other transport or means of communication. In order to reduce the referral delays in Manafwa and Mbale districts, Kissito Healthcare International partnered with PONT (UK based charity) to implement a pilot project where five specially designed eRanger motorcycle ambulances were stationed at 5 remote health centers for transporting obstetric emergencies to the health facilities.
Objectives The objective of the project was to assess referral time, acceptability, and feasibility of motorcycle ambulances (mAmbulances) for referral of obstetric emergencies to the nearest Health Facility and to compare the referral delays and costs with those of a 4WD vehicle ambulance.
Methodology Five mAmbulances were placed at 3 remote rural health centers in Manafwa (Bubutu, Bugobero and Bushika) and 2 health centers in Mbale (Busiu and Wanale) districts for transporting obstetric emergencies and other emergency cases to the health centers free of cost.
At each health center drivers were recruited and trained over 2 weeks to drive the mAmbulance, to be responsible for its maintenance , and on data recording in logbooks.
Community volunteers were identified, trained , and provided with pre-paid mobile phones to call the mAmbulance in case of an emergency for transport to suitably equipped health centers.
Data was collected over a 17 month period, from January 2011 to May 2012 using logbooks, referral forms, and maternity registers.
Specially designed referral forms were used to record data on all emergency referrals, irrespective of means of transport.
Specially designed logbooks were filled in by the drivers of the motorcycle ambulances recording data concerning all trips, including departure and arrival times for the patients referred.
The maternity registers at the health centers were used to identify all referred obstetric cases and the reason for referral.
Semi-structured interviews were conducted with health workers, ambulance drivers about transport issues, referral procedures, and referral delays
Results The mean duration of referral to reach a health facility for all emergency obstetric cases varied between 1:01-1:09 hrs.
Conclusion In resource-poor Uganda, mAmbulances are a useful means of referral for emergency obstetric care, particularly under circumstances where health centers have no access to other transport or means of communication to call for a vehicle ambulance and they are a relatively cost-effective option for the health sector. By providing on-site, designated EmOC referral transport at rural health facilities, the mAmbulances can fill a critical gap in maternal services. If implemented widely in the country, mAmbulances may also potentially help reduce cost for women and their families to access EmOC.

Integrating health promotion to improve maternal and newborn health in El Salvador

Author(s) Janet Perkins1, Nicole Répond2, Cecilia Capello3, Ana Ligia Molina Araniva4, Carlo Santarelli 5.
Affiliation(s) 1Health Department, Enfants du Monde, Geneva, Switzerland, 2Health Department, Enfants du Monde, Lausanne, Switzerland, 3Health Department, Enfants du Monde, Geneva, Switzerland, 4Health Deparment, Concertación de Educación of El Salvador , San Salvador,El Salvador, 5Enfants du Monde, Enfants du Monde, Geneva, Switzerland.
Country - ies of focus El Salvador
Relevant to the conference tracks Women and Children
Summary Women and newborns in El Salvador continue to face elevated risks related to pregnancy and birth. Historically, the Ministry of Health (MoH) has focused primarily on strengthening the health services while neglecting the critical role that women, men, families and communities play in improving maternal and newborn health (MNH). Our project integrates a Health Promotion component (Ottawa Charter) in the broader MNH strategy in order to empower women and communities to improve MNH, increase access to quality MNH services and incorporate community participation in the health system. As a result of our project, we have seen important changes at both the national and local level towards improving MNH.
What challenges does your project address and why is it of importance? Women and newborns living in El Salvador face among the greatest risks related to pregnancy and childbirth in Central America and the Caribbean. With a maternal mortality rate of 81/100,000, a woman living in El Salvador faces a 1 in 490 lifetime risk of death due to maternal causes, compared to the 1 in 3,900 risk of a woman living in a developed country. In addition, 15 out of every 1,000 infants fail to survive the first year of life, with a high proportion of these deaths occurring before the end of the first month. Risks related to pregnancy and birth are magnified in rural areas where the utilization of health services, and institutional birth in particular, remains low.
Achieving real improvement in MNH requires not only improving and expanding health services but also action with the community to improve care in the home of women and newborns as well as increase demand and utilization of health services. However, historically action aiming to improve MNH in El Salvador has been directed primarily at the health services, with only marginal emphasis accorded to the role of individuals, families and communities within the health system. Our efforts aim to address this gap by empowering women, men, families and communities to improve MNH.
How have you addressed these challenges? Do you see a solution? The World Health Organization’s framework for Working with Individuals, Families and Communities (IFC) to improve MNH is designed to facilitate the inclusion of Health Promotion in national MNH strategies. Its primary aims are to empower women, men, families and communities to improve MNH and increase access to MNH services. The IFC framework was integrated into the Pan-American Health Organization’s (PAHO) regional MNH strategy in 2004 and El Salvador was selected as one of four countries for pilot implementation.
Since 2005, Enfants du Monde (EdM), a Geneva-based NGO, in collaboration with the Concertación de Educación of El Salvador (CEES), a consortium of local NGOs, has been supporting Ministry of Health (MoH) to implement the IFC framework. Initially, a national IFC coordinating body was established to oversee IFC implementation in the country and assure that the framework is integrated in broader health initiatives. This IFC committee includes representatives from MoH and CEES, with technical support by EdM and the PAHO country office. This committee collaborates with and supervises IFC coordinating bodies at sub-national and local levels.
The national committee selected eight municipalities, covering approximately 100,000 women of reproductive age, for initial implementation of the framework at the local level for validation. Participatory community assessments (PCAs) were conducted in each municipality at the outset in order to guide planning. These PCAs consist of a series of roundtable discussions with community members and leaders where they discuss priority MNH needs and participate in designing interventions to tackle identified challenges. Results of these discussions were used to develop IFC action plans which were integrated into broader district action plans and implemented. Interventions vary by municipality, but include in general: birth preparedness; strengthening interpersonal skills of health providers; community oversight of health services; sensitizing men to MNH needs and their roles; and promoting rights to health.
At the national level, efforts have focused on institutionalizing health promotion and community participation in the national health strategy. Notably, due to the success of the program, the IFC committee has been invited to participate in elaborating a number of policies related to reproductive health. In addition, actors at the municipal level were consulted by MoH in the revision of the national birth preparedness strategy.
How do you know whether you have made a difference? The actions undertaken at both national and local levels have been successful at reaching their objectives. At the national level, the IFC committee participated in drafting the Strategic Plan for Reducing Maternal and Neonatal Mortality 2011-2015, the Sexual and Reproductive Health Policy, and the Technical Operational Guidelines for the Birth Preparedness Strategy. Largely as a result of their participation, each of these documents contains lessons from the implementation of the IFC framework, thereby highlighting Health Promotion and community participation in each one. These documents have now been finalized and endorsed by MoH. Furthermore, the IFC committee is now participating in drafting the Technical Guidelines for Promoting the Right to Health.
The PCA has elicited a great deal of enthusiasm by MoH at national and local level. Stakeholders have witnessed the benefit of working with communities using this tool and as a result MoH has adopted it for use beyond MNH for analyzing and planning health action more broadly. A range of actors at national, sub-national and local level are being trained to use it, contributing its institutionalization.
At the local level, IFC action plans have been implemented in the eight selected municipalities. Trust has been built between women and families and healthcare providers. Women have been empowered to demand quality health services which have been defined as their right. For example, women mobilized to obtain the right to be accompanied by a companion of choice when receiving MNH services at health facilities, notably during birth, and were successful in this goal. In addition, MoH responded to the community when they demanded that certain positions which had been vacant (i.e., gynecologist, pediatricians) be filled in rural health facilities.
Women and families report seeking health services to a greater extent and high satisfaction with services received. Women take action to prepare for birth and potential obstetrical and neonatal complications. However, challenges still exist in terms of women following through on their plan. Utilization of both routine and emergency MNH services is increasing. Men are increasingly participating in MNH by accompanying women to health facilities, though not to the extent anticipated. Promisingly, in each of the implementation municipalities maternal, perinatal and neonatal death has decreased and no maternal death has been reported in 7 of 8 municipalities for 3 years.
Have you or the project mobilized others and if so, who, why and how? We recognized from the outset of our project that long term success and real integration of the project in national policies and programs can only occur when a variety of actors across different sectors are mobilized. Notably, each year a team of 10 actors from national and local MoH, NGO’s and members of the IFC committee participate in the PAHO/EdM diploma awarding course on the IFC framework at the University of Antioquia in Colombia. This course helps actors from Latin-American understand the critical nature of working with and empowering individuals, families and communities and how to institutionalize mechanisms allowing them to participate to reach the goals laid out in the national MNH strategy. Following the training, these actors support implementation of the framework at national, sub-national and local level.
The national IFC committee’s participation in the Alliance for Sexual and Reproductive health has also served to mobilize others. This intersectoral alliance operates under MoH and includes a number of organizations such as PAHO, UNFPA, Save the Children, Plan International, and World Vision. This alliance has helped to increase visibility of the IFC component and encourage the interest of other members. For example, as a result of this alliance, Save the Children has become financially engaged to support the implementation of certain interventions of the IFC program.
Moreover, efforts have been undertaken to strengthen the system of community health teams at the national and local levels. At the local level these teams include community health workers as well as trained doctors and nurses. They visit under-served communities providing services. Within our program we are training them to integrate health promotion and community participation into their work and conduct PCAs. As a result, their capacities are reinforced to work with and empower communities.
In addition, community members, leaders and groups have been mobilized to participate in MNH action. Links have been created between communities and health facilities allowing for meaningful community participation to be institutionalized in the health system. Mayors and religious groups have become involved in funding the implementation of local interventions. Perhaps most importantly, the community, notably women, their partners and mothers-in-law, have mobilized to improve the care of women and newborns and increase access to health services, for example in facilitating transport.
When your donor funding runs out how will your idea continue to live? Sustainability of the program has been a priority since its inception and has therefore been implemented with a long term vision and the constant search for alliances. To begin with, a central priority of implementation process has been to institutionalize the IFC framework and community participatory processes into the national MNH strategy as well as in other policies at various levels. As highlighted earlier, we have made a great deal of progress in this domain, as components of the IFC framework have been integrated into some of the most important sexual and reproductive health documents and policies recently elaborated.
In addition, the IFC framework is being implemented by MoH, with the support of outside actors, including NGOs and PAHO. As a result MoH is directly responsible and accountable for its implementation. It has been institutionalized within the MNH program at all levels, ensuring that participatory processes themselves are integrated as well. MoH is now planning a strategy for scaling up to new municipalities.
In addition, at its core, our project focuses on building the capacities of in-country actors. Notably EdM has no expatriate staff on the ground. Rather, locals are staffed as coordinators in existing offices (of PAHO and MOH). Likewise, CEES is composed of a consortium of local NGOs, based and operating in El Salvador. Moreover, at every phase of IFC implementation, the focus remains on building the capacities of State and other local actors to implement the framework and assume primary responsibility for interventions. This focus on capacity building of in-country stakeholders prevents an over reliance on outsiders and ensures local ownership of initiatives, thereby promoting sustainability.
Finally, the program has also launched processes of empowering women, men, families and communities. This empowerment is considered not only a means to an end, but also an end in and of itself. These exercises of working together have built the capacities of community members to collaborate to identify their needs and design methods of addressing these needs. The capacities of the health services have simultaneously been reinforced to include the participation of community members in health planning and services action. This bodes well for the sustainability of the idea as local actors have the capacity to participate and the health sector is better equipped with the capacity to integrate and promote community participation.

Integrating Community Participation in Maternal and Newborn Health Services: Burkina Faso

Author(s) Janet Perkins1, Cecilia Capello2, Aminata Bargo3
Affiliation(s) 1Health Department, Enfants du Monde, Geneva, Switzerland, 2Health Department, Enfants du Monde, Geneva, Switzerland, 3Health Department, Fondation pour le Développement Communautaire/Burkina Faso , Ouagadougou, Burkina Faso.4
Country - ies of focus Burkina Faso
Relevant to the conference tracks Social Determinants and Human Rights
Summary Improving maternal and newborn health (MNH) in regions where women and newborns suffer most requires a rights-based approach which identifies and addresses the broader social determinants of health. In Burkina Faso, we are implementing a health promotion component within the national MNH strategy. A central feature is the institutionalization of community participation in the identification of priority MNH needs as well as the design of interventions. The result is a system in which data related to social determinants of health are collected and used within the health sector. This allows the health sector to participate in addressing these determinants and promotes the rights of community members.
What challenges does your project address and why is it of importance? Despite progress over the past two decades, women and newborns in Burkina Faso continue to face elevated risks related to pregnancy and childbirth. With a maternal mortality ratio of 300/100,000, a woman in Burkina Faso faces a 1 in 55 lifetime risk of death due to maternal causes. Thirty-eight of every 1,000 newborns fail to survive the first month of life. Effectively addressing MNH demands a rights-based approach to health programming that focuses on rooting out inequities and addressing social determinants of health.
Central to a rights-based approach is the promotion of meaningful participation of individuals and communities in the development and implementation of actions designed for their benefit. Participation is both an ends in and of itself, as participation is defined as a right, as well as a means of contributing to a process of empowerment. One of the aims of our program is to integrate participatory processes into health programming. This contributes to assisting the health services in becoming aware of and designing appropriate and tailored interventions to address challenges in MNH, including social determinants, as well as to give a voice to community members and ensure that they are able to participate and are empowered in the process.
How have you addressed these challenges? Do you see a solution? Since 2006, Enfants du Monde, a Swiss NGO, in collaboration with the local NGO Fondation pour le Développement Communautaire/Burkina Faso (FDC/BF), has been supporting Ministry of Health (MoH) in implementing a programme based on the World Health Organization’s framework for Working with Individuals, Families and Communities (IFC) to improve MNH. The IFC framework is designed to form a health promotion component of a broader MNH strategy, as it does in the Burkina Faso national strategy. One of the principal aims is to empower women, men, families and communities to improve MNH. A central component of the empowerment process is institutionalizing participatory processes in health planning.Notably, participatory community assessments (PCA) are conducted at the outset of district-level implementation. These assessments provide a platform for community members, with an emphasis on marginalized groups, to discuss MNH needs in the community and develop tailored interventions. During the PCAs, participants explore the broad array of factors, including social determinants that contribute to poor MNH. The ensuing results of these assessments are planned interventions which are appropriate and specific to the context as well as the initiation of the empowerment of community members as they assume influence in improving the health of their community.While participatory planning processes are not new in health programming, the IFC framework institutionalizes these processes within the broader health system to make community voices systematically represented and to allow for the systematic collection of information related to social determinants of MNH. With the endorsement of the national MoH, actors from within the sub-national MoH have been trained to conduct PCAs in collaboration with other actors working within MNH at the regional and district level. In this position, they have been able to assume the responsibility of listening to the voices of community members and of taking direct action in response to their participation. This process has created a mechanism by which community participation has been integrated within the health sector. This contributes to promoting participation, and thereby rights, of community members, and increases accountability and transparency in the health services. It allows for health inequities and socioeconomic determinants of health to be identified and addressed within the public health sector.
How do you know whether you have made a difference? To date, PCAs have been conducted in seven districts (Tenkodogo, Zabré, Kongoussi, Ouragaye, Barsalogho, and Sindou) over three regions. These assessments have effectively identified challenges related to MNH, many related to rights and socioeconomic determinants, that did not surface through more traditional, non-participatory situation analyses. These include: lack of knowledge of health behaviors during and following pregnancy; lack of awareness of danger signs during and following pregnancy; lack of planning for birth or potential complications; women’s inability to make the decision to seek health services autonomously or use family resources to pay for services due to low socioeconomic status; financial and transportation barriers to reaching health facilities; and lack of satisfaction in interactions with health care providers.
To address these priority concerns, community members, leaders and the health sector worked together to develop interventions. These interventions vary by district, but include health education activities (theatrical performances, culinary demonstrations, radio game shows, etc.), birth preparedness and complication readiness, mobilization of men and the broader community to increase their awareness of MNH rights and needs and enlist their participation in MNH actions, building maternity waiting homes and training health workers to build their capacities to interact with women.Preliminary results to date suggest the success of the processes and interventions. Notably, the IFC interventions have been directly integrated into the MNH action plans of each district. This mechanism has assured the institutionalization of community members’ participation in the planning of activities designed to benefit them. This has not only contributed to the promotion of their rights, but has also provided a way for the health sector to gather data and become involved in addressing the broader determinants of health, including social determinants. Where interventions have been implemented, health care providers have created links for exchanging information with communities. Male partners are accompanying women when receiving MNH services in greater numbers and health information system data has revealed an increase in utilization of MNH services. A current evaluation is assessing the degree to which the activities have contributed to change in MNH knowledge, attitudes and practices in these initial sites of implementation.
Have you or the project mobilized others and if so, who, why and how? We initiated the project based on the assumption that improving MNH cannot effectively be accomplished in a vacuum and requires the mobilization and action of a myriad of actors. As such we have mobilized a variety of agencies and sectors acting at the national, sub-national and district level. This process began with the introduction of the IFC framework at national level. Workshops were held with MoH, Ministry of Education, international organizations and others working on MNH at this level. These workshops were designed to help these actors understand the critical nature of working with and empowering individuals, families and communities and institutionalising mechanisms that allowed them to participate in reaching the goals laid out in the national MNH strategy and ultimately fulfill women’s maternal health rights. Actors from within MoH to be responsible for the IFC component at the national level were identified and their capacities built to lead these efforts.
At the same time, IFC committees, operating under MNH bodies, at sub-national and district level were formed. This structure of IFC committees has created a mechanism allowing for both horizontal and vertical communication. This has reinforced the institutionalization of community participation in MNH as actors at both the national and sub-national levels become aware of the specific needs expressed by community members as well as the social determinants of maternal and newborn health in play at the local level. They are then able to respond with centralized action when necessary and appropriate.
In addition, community members, leaders and groups have been mobilized to participate in MNH action. Notably, health care providers have created linkages for working with communities and for the exchange of information. They have contacted and begun working with community leaders, male partners, community health workers and village birth attendants. Through these links, actors in the community have become engaged in encouraging women to attend MNH services. They also transmit information from the health services to the community and gather information on an on-going basis in the community and relaying it back to the health services. This contributes to the realization of rights, including promoting community members’ rights to information and education and through ensuring accountability and transparency. It also provides a mechanism for continued community participation within the health sector.
When your donor funding runs out how will your idea continue to live? Sustainability of the program has been a priority since its inception and has therefore been implemented with a long term vision. To begin with, the IFC framework and its related interventions have been directly integrated into the national MNH strategy, as the health promotion component and fifth pillar of the national Plan for Reducing Maternal and Newborn Mortality: A Road Map. This has assured that it has never been implemented as a standalone, vertical program. In addition, the component is being implemented directly by MoH, with the support of outside actors, including NGOs and UNFPA. As a result MoH is directly responsible and accountable for its implementation. It has been institutionalized within the MNH program at all levels, ensuring that participatory processes themselves are integrated as well. Moreover, while the program is still financially supported primarily by exogenous actors (i.e. UNFPA, EdM), MoH understands that this funding will ultimately expire and has identified and begun implementing strategies for resource mobilization internally.
In addition, at its core, our project focuses on building the capacities of in-country actors. Notably EdM has no expatriate staff on the ground. Rather, locals are staffed as coordinators in regional offices. Likewise, FDC/BF is a local NGO, based and operating in Burkina Faso. Moreover, at every phase of IFC implementation, the focus remains on building the capacities of State and other actors to implement the framework and assume primary responsibility for interventions. This focus on capacity building of in-country actors prevents an over-reliance on outside actors and ensures local ownership of initiatives, thereby promoting sustainability.
Finally, the program has also launched processes of empowering women, men, families and communities. This empowerment is considered not only a means to an end, but also an end in and of itself. These exercises of working together have built the capacities of community members to collaborate in identifying their needs and designing methods to address these needs. The capacities of the health services have simultaneously been reinforced to include the participation of community members in health planning and services action. This bodes well for the sustainability of the idea as local actors have the capacity to participate and the health sector is equipped with the capacity to integrate and promote community participation.

Primafamed: An Institutional Network for the Development of Family Medicine in Africa

Author(s): M. M. Flinkenflögel*1, J. De Maeseneer1
Affiliation(s): 1Department of General Practice and Primary Health Care, Ghent University, Ghent, Belgium
Keywords: Family medicine; African universities; primary healthcare; institutional network

Facing the challenges of high rates of infant and maternal mortality, HIV/AIDS, TB infection, endemic malaria and pervasive poverty, countries in Africa, need to develop an accessible, high quality comprehensive primary healthcare system. Nowadays, specific community based training of future family physicians is lacking in most of the African countries. WHO - World Health Report 2006 ‘Working together for health’ emphasises the need for primary healthcare-training in the local community in order to tackle actual ‘brain-drain’.


Primafamed is a 2 year project, coordinated from Ghent University, funded by Edulink, a programme from the European Union. 10 African Universities in 8 different Sub-Saharan countries are participating in this project. Primafamed is establishing an institutional network between departments and units of family medicine and primary healthcare in African universities, focussing on South-South cooperation, in order to:
1 – strengthen development of departments of family medicine/primary healthcare in African countries;
2 – create a forum for international cooperation to enhance the quality of programme content, educational methods and training in family medicine;
3 – encourage research collaboration in family medicine and primary healthcare education;
4 – insert motivated and locally well-trained generalists or ‘African family doctors’ into the primary healthcare systems;
5 – contribute to improvement of access to quality primary healthcare, especially for the most vulnerable communities in Africa.


The Primafamed-network, Ghent University and the 10 African partner institutions, has started and is working on the implementation of its mission to set up family medicine education in Africa to create a sustainable quality primary healthcare system in Africa, accessible and affordable for all.

Lessons learned:

Primafamed embraces the principle of South-South cooperation, encouraging the sharing of unique knowledge and wisdom between African institutions. By motivating, stimulating and supporting these institutions in the set up of family medicine training, primary healthcare systems in Africa can improve.

Cultural Competences Help to Improve Healthcare among Indigenous Populations

Author(s): F. G. Arevalo1
Affiliation(s): 1Sociology, Universidad de San Carlos de Guatemala, Guatemala
Keywords: Maternal and neonatal health, indigenous health

Every three minutes, a neonatal death occurs in Latin America. The poorer urban and rural populations are the most affected and within them, in Guatemala, the indigenous population has also the lowest levels of access to basic infrastructure and insufficient coverage to essential maternal and neonatal health services. For instance, in Guatemala, the national neonatal mortality rate is 23 per 1,000 live births but in indigenous communities, the rate can reach up to 39, almost 60% higher. This paper will present a Case Study and Analysis of a new approach for health services provision, focused on Maternal and Newborn Care, developed for rural and indigenous areas of Guatemala. The approach is based in the incorporation, within a Basic Health Team, of an auxiliary nurse, called Mayan Obstetrical Nurse (MON), as a specialized health worker, in charge of neonatal health, within the maternal, newborn and child health (MNCH) continuum of care.


The purpose of this paper is to describe the process followed to design, implement and evaluate the incorporation, of the MON within a Basic Health Team, in rural and indigenous populations of Guatemala, where health service provision is provided by a programme called Extension of Coverage Programme (ECP) through a team, composed by 1 physician, 1 educator and at least one community health worker. Guatemalan Ministry of Health (MOH) provides services to approximately 4.2 million of inhabitants with this modality, sub contracting local NGOs, selected in an open and competitive process, with participation of local authorities and civil society representatives. However, even though, ECP has been working in the country for almost ten years, some indicators as Neonatal and Post Partum care, as well as Maternal Mortality have not been improved substantially.
Given this situation, two years ago the Ministry of Health, with the support of the International Cooperation, developed a curriculum of a new cadre, which was going to be focused to specifically address maternal and neonatal service provision. Beside of detect and refer complications, train and supervise traditional birth attendants, among other activities, some specific characteristics were defined: All participants should be Mayan, must have previous training, of at least 1 year as auxiliary nurse, some experience in maternal and neonatal care, be proficient in the language spoken in communities to serve, and reside in the area of work. MON was in charge of the National School of Nurses, and supported with scholarships granted by USAID.


MON experience is an innovative project in Latin American region, in particular for those countries with predominance of indigenous populations. After almost two years of the incorporation of the MON in health teams, there is solid evidence of improvements in some key maternal-child indicators, but also, there is solid evidence of improvement in the quality of services. In this point is necessary to stress that the majority of health personnel in Guatemala do not speak other languages but Spanish. Among the most remarkable results, there was an important increment for family planning information and use of methods for birth spacing. Post partum and neonatal early detection and care were substantially incremented and by the end of 2,007, more than 100 references were made, for mothers and newborns detected in danger of death.

Lessons learned:

The experience or MON produced several lessons, in relation with health workers and training centres. Cultural competences have showed to be extremely important in order to improve access and quality of health services. It is possible to develop acceptable levels of competence for community health workers to address critical public health issues, as maternal and neonatal death. With relatively small resources, Ministries of Health can be able to train, hire or certify qualified personnel to address key maternal and child health issues.

Utilization and Equity of Health Services in Developing Countries

Author(s): B. Joshi*1, B. Sharma2
Affiliation(s): 1Sociology and Rural Development, Tribhuwan University, Ktm, Nepal, 2C.M, All India Institute of Medical Sciences, New Delhi, India
Keywords: Inequity, healthcare,developing country, access

Nepal is one of the world poorest countries. Life expectancy is 46 years, HIV prevalence 1.5%, infant mortality rate 64/1000 born alive, maternal mortality 340/100.000.Access of the poor population to healthcare services is a fundamental issue.


Specific objectives: (1) measure basic health data in the two districts: (i) children vaccination coverage, (ii) delivery care coverage, (iii) formal health services utilization in case of baby sickness. (2) Measure inequities stratifying the results by (i) distance from the nearest health unit, (ii) mothers years of school, (iii) socioeconomic status of the family. Methodology: Basic health survey performed through households interviews. Sampling selection performed through the ‘stratified cluster sampling method’ proposed by WHO to measure vaccination coverage. To achieve statistically significant results (p<0.01) 693 households in the urban area and 600 in the rural were interviewed.


Coverage of all measured services showed to be much higher in urban district than in the rural one. The stratification of the results in the rural district gave these results: Vaccination coverage: 68% if distance > 30 minutes walking versus 86% if distance < 30 minutes (p<0.001); 73% if very poor family versus 87% if less poor family (p<0.01); 75% if not educated mothers versus 76% if basic educated mothers (not stat. sig.). Delivery coverage: 46% if distance > 30 minutes walking versus 59% if distance < 30 minutes (p<0.01); 47% if very poor family versus 77% if less poor family (p<0.001); 44% if not educated mothers versus 55% if basic educated mothers (p<0.05). Formal health services utilization in case of baby sickness: 57% if distance > 30 minutes walking versus 76% if distance < 30 minutes (p<0.01); 61% if very poor family versus 88% if less poor family (p<0.001); 63% if not educated mothers versus 65% if basic educated mothers (not stat. sig.).

Lessons learned:

Health coverage data of the urban district are, higher than rural one. Walking distance from the health unit and poverty level of the family seem to play a major role in vaccination coverage, delivery coverage and formal health services utilization in case of baby sickness. Mother education level appears to influence only delivery coverage. Equity and accessibility to basic healthcare services represent still a main concern. Possible solutions are: building of new infrastructures in remote areas and facilitating of the very poor people to sustain the financial burden of healthcare (mostly transport and loss of income due to missing work).

MDG on Infant Mortality Achieved: GK’s Experience in Bangladesh

Author(s): E. Manikandan*1, M. Ahmed2, R. Huq3, Z. Chowdhury4
Affiliation(s): 1Associate Professor Physiotherapy, 2Director, Health Programmes, 3Director, Rural Health, 4Project Coordinator, Gonoshasthaya Kendra, Dhaka, Bangladesh Keyword
Keywords: Millennium Developmental Goals, infant mortality rate, traditional birth attendants

Developing countries attention has not yet been properly focused on how to achieve Millennium Development Goals (MDGs) and managing Non-Communicable Diseases (NCD) which are on the rise. Enough money is not invested in the health sector and even if it is done, because of the inefficient policy and lack of political commitment it doesn’t benefit the needed rural population. Bangladesh has made remarkable progress on both infant and child mortality measures over the past three decades and expected to achieve MDG on Infant Mortality Rate (IMR), even a year ahead of 2015.


Gonoshasthaya Kendra (GK), a pioneer health NGO in Bangladesh adopted Primary Health Care (PHC) strategy since 1972. Presently GK provides PHC among 1.2 million rural populations in 616 villages. The paper will highlight the process of utilization of local resources to reduce infant mortality by training Traditional Birth Attendants (TBAs) as members of the PHC team and introduction of public audit of all infant deaths in respective village. Gonoshasthaya Kendra (GK) provides health service including reproductive health and family planning services at the village and community level through a cadre of village based trained health workers called “paramedics”. The general responsibilities of a paramedic cover pregnancy care, vaccination and immunization, maintaining birth and death records in their communities, family planning, treatment of common diseases, performance of minor operations and sharing information on public health, hygiene, nutrition as well as creating social awareness amongst the villagers, especially women. GK health workers keep detailed records on all patients, which over time will encompass essentially all villagers. Community-based participatory research methodology was followed. Health workers collect data of infant deaths through in-depth interview with family members, teachers, Imam (Priest) and local elected representatives.


In its areas of activity GK has already achieved the MDG for infant mortality a decade ahead of time, while the rest of the country remains at a level two-thirds higher. During 1994-1995, the IMR in GK area was 62.1, and in 2003-2004 it came down to 30.29, which means GK had already exceeded the MDG target of 32 deaths per thousand live births in its area. Current IMR for the year 2006-2007 is 25.72.The reason for this success is that GK’s coverage targets mainly the poor, including the very poor and destitute. In GK programme villages, Maternal Mortality Rate has declined from 300 per 100,000 live births during 1993-1997 to 145 per 100,000 live births in 2005-2006.

Lessons learned:

Bangladesh has done very well in achieving some of the health MDGs with the help of the NGOs who play a unique role in the healthcare system of Bangladesh. GK has been actively applying its model since 1972 and the model is time-tested which can be expanded nationwide in a cost-effective manner which will help to achieve Infant Mortality Rate way ahead of time. GK is not a competitor for the government. It is only to supplement to public health system of the government. GK’s primary focus is to work with the government, so that it’s innovative schemes, if found result-yielding, can easily be adopted by the government.