Time to Deliver: Evaluating the Successes and Challenges in Improving Maternal Health and Achieving the 5th Millennium Development Goal

Abstract

The 5th Millennium Development Goal (MDG 5) represents an international commitment to improving maternal health by the target date of 2015. However, of the eight MDGs, the least amount of progress has been made towards MDG 5. With less than two years remaining until the target date, we are at a critical juncture at which to evaluate the efforts undertaken towards MDG 5 and assess possible steps forward. South Africa serves as the primary case study for this research. The country is an emerging economy with adequate health funding, political commitment to reaching the MDGs, and comprehensive maternal health policies, yet South Africa has a high maternal mortality ratio of 310 deaths per 100,000 live births and is far from reaching its MDG 5 target of 38 deaths per 100,000 births by 2015. In order to fully investigate this situation, qualitative field research was undertaken in Cape Town and guided by two main objectives. The first was to verify the research hypothesis—that a primary contributor to lack of progress towards MDG 5 is the subpar implementation of health policies—and to determine the factors that lead to this poor implementation. The second was to identify the successes achieved and challenges faced by South Africa in the years since the foundation of the MDGs. Brazil was also utilized as a secondary case study because South Africa remodeled its primary health care structure on the Brazilian system. As such, Brazil’s experiences with MDG 5 and primary health care can serve as a basis of comparison for suggesting improvements in South Africa. Overall, 33 interviews were conducted with public health officials, academics, and NGO staff involved in women’s and maternal health in Cape Town, South Africa, and 9 with public health officials and NGO staff in Rio de Janeiro, Brazil. The results of field research highlighted clear gaps between maternal health policies and their implementation. These gaps are primarily the result of a substandard, weakly managed health system in which provincial and district health facilities are poorly linked and thus unable to provide comprehensive care to women. Another factor contributing to subpar implementation is the negative work attitudes and poor quality of care provided by many staff members, especially nurses, at public health facilities. As a result, many health policies are not implemented properly and many women are discouraged from seeking out services in the public health sector. These research findings illustrate that a well-functioning health system is vital to ensure the proper implementation of maternal health policies in South Africa. As such, steps to accelerate progress towards MDG 5 should address two main problems within the health system. The first issue—the divide between the provincial and district departments—can be reconciled by increasing transparency between district health officials and appointing national supervisors to help bridge the two levels of the health system. The second problem—the quality of care provided by health care workers—can be addressed through hands-on management, regular training programs, and other opportunities for career development. These measures, informed by the research findings, could improve the implementation of health policies and thus maternal health outcomes in South Africa.