Global Postpartum Care

“Big Push” Global Health Model for Reducing Maternal Mortality Has Broad Healthcare Systems Benefits

Researchers at Columbia University’s Mailman School of Public Health evaluated the first year of the Saving Mothers, Giving Life program, a global public-private partnership founded by the U.S. and Norway, Merck for Mothers, Every Mother Counts, and the American College of Obstetricians and Gynecologists. The program focuses on improving women’s access to high-quality obstetric care during the 24 hours around delivery—the time period when more than half of maternal and neonatal deaths occur. It aims to reduce maternal mortality rates at a dramatic pace by capitalizing on existing U.S. and international health-assistance platforms—called a big push model. Study findings are published in the June issue of the journal, Health Affairs.

Launched in 2011, Saving Mothers, Giving Life began implementing activities in eight districts in Uganda and Zambia in 2012. The evaluation led by Margaret Kruk, MD, MPH, Mailman School associate professor of health policy and management, and Sandro Galea, MD, DrPH, chair and the Anna Cheskis Gelman and Murray Charles Gelman Professor of Epidemiology, included examining data for the program launch, its early achievements, and its effects on the health system, governance, and sustainability in the two countries. The most prominent intervention using a big push approach is the President’s Emergency Plan for AIDS Relief (PEPFAR), whose goal is to treat six million people living with HIV/AIDS with antiretroviral medication over ten years.

“Our evaluation of the first phase of Saving Mothers, Giving Life in Uganda and Zambia found that the big push model—which features high visibility, large expenditure, and demand for rapid results—succeeded in delivering a large volume of interventions in target districts,” said Dr. Kruk, ­­­­­­­­­­­­who is also director of the Mailman School’s Better Health Systems Initiative.

The program was innovative in several ways: It tackled both supply and demand barriers to maternal survival; it used donor-assistance platforms to strengthen existing health systems; in Uganda it contracted private providers to expand services. Here, hiring new doctors and nurses to staff hospitals and health centers in the intervention districts reportedly improved capacity of the facilities as a whole.

According to Dr. Kruk and colleagues, the results also gave a renewed political urgency around the issue of maternal and newborn mortality in two countries that were not on track to reach the UN Millennium Development Goal to improve maternal health by 2015. However, the program was less successful in promoting national ownership, and at the outset there was no plan for sustaining the program after the first year or expanding beyond the initial eight districts. The program now has plans to add more countries in the next four years.

“Early benefits to the broader health system included greater policy attention to maternal and child health, new health-care infrastructure, and new models for collaborating with the private sector and communities. However, the rapid pace, external design, and lack of a long-term financing plan hindered integration into the health system and local ownership,” said Dr. Kruk. “Sustaining and scaling up early gains of such a big push initiative for health assistance requires longer-term commitments and a clear plan for transition to national control.

Saving Mothers, Giving Life also facilitated important health-financing reforms in Uganda. Respondents in both countries agreed that the big push approach further motivated their respective health ministries to accelerate efforts on maternal health. However, their experiences also suggest that a longer program timeline would allow more rational sequencing of interventions, more meaningful participation of national governments, and more time to refine the model to permit scale-up.

“In particular, our results suggest the imperative for a health-system legacy plan that details how the program will sustain service delivery in the long term and bring programs to nationwide scale. We strongly recommended a three-to-five-year commitment, rather than a year-by-year approach to program planning and financing; and successful transition planning should begin at the start of the program.”

This article originally appeared on the Mailman School of Public Health website.