EDITORIAL: Integrated Maternal, Newborn and Child Health (IMNCH) Strategy: How has it advanced in Africa?

Abstract

Although accelerated declines in rates of maternal
and child mortality have recently been reported
from several regions of the world, Africa is still
cited as the continent with the slowest rate of
progress1. Increasingly, apprehension is being
expressed in many research and policy arenas
regarding the likelihood that several African
countries may not achieve the MDG targets in
child and maternal health by 2015 unless an
accelerated action plan is developed and
implemented. While the MDG itself provided
targets, goals and aspirations to guide countries,
one major limitation has been that it fell short in
making specific recommendations on
implementation and plans of action for achieving
the desired results. The introduction of the
Integrated Maternal, New-born and Child Health
(IMNCH) strategy2has provided a uniquely
understandable approach for targeting
interventions and leveraging resources for
addressing the inter-related problems of maternal,
newborn and child mortality, especially within the
context of developing countries. This approach
provides a simplified continuum of care
framework for integrated service delivery,
leveraging and coordinating the use of resources,
involving a broad range of stakeholders and
engaging families and communities in providing
care for women and children. It was hoped that the
integrated approach would improve the delivery of
maternal, newborn and child health services better
than previous approaches based on separate
implementation of these programs. In September
2010, the UN MDG summit generated global and
high level support for the coordinated
improvement of maternal, newborn and child
health culminating in pledges of US$40 billion
over the next five years to address women’s and
children’s health3.
About five years into the implementation of
this framework and only two years away from
2015, it is important to reflect on how it has
worked or is working for attaining optimal
maternal, newborn and child health outcomes in
Africa. To date, there is little documentation of
the number of countries in Africa that have
accepted or are using this framework to address
maternal, newborn and child health. While
membership of the global Partnership on Maternal,
Newborn and Child Health currently hosted by the
WHO, could be used as an indication of
acceptance by countries of the strategy, it speaks
little about official commitments especially
because memberships are often facilitated by
individuals rather than by official sources within
those countries.
Among African countries accepting the
IMNCH framework, several issues pertaining to
implementation remain unknown. These include:
the extent to which policies and action-plans have
been domesticated for implementing the
framework, the amount of resources allocated by
countries on an on-going basis, multistakeholders’
understanding and involvement
(including at family and community levels), and
the readiness of implementing countries to scale
up and sustain the momentum even after 2015.
Beyond these considerations, extensive debate
regarding the impact and potential impact of the
strategy on various indicators of maternal and
child health is beginning to emerge. The most
important of the issues currently generating
discussion in different global forums is whether or
not an integrated approach could diminish the focus on maternal health4, thereby benefiting child
health more than maternal health and therefore
reducing the pace of reduction in rates of maternal
mortality.
This concern is borne out by previous
experiences whereby Maternal and Child Health
approach that was implemented in the 1970s up to
the early and mid-1980s focused more on child
health delivery services with the results that
maternal health services became almost invincible
in local, regional and international implementation
plans. It took the groundbreaking paper by Allan
Rosen field and Deborah Maine in the Lancet in
19855titled: “Where is the M in MCH”, for the
global community to re-focus emphasis on
maternal health. The documentation by Professor
Kelsey Harrison of the high state of maternal
mortality in northern Nigeria at the same time6, as
well as the emphasis placed on women’s overall
social and economic empowerment by the
International Conference on Population and
Development in Cairo, Egypt in 1994 and the 4th
World Conference on Women in Beijing, China in
1995 helped the process of consolidation of this
paradigm shift. Now that the world is poised to
adopt the integrated service delivery approach, the
vital question is whether we would be going back
to yester-years when maternal health was downplayed
in comparison to child health.
There is yet no clear answer to this question at
least within the context of sub-Saharan Africa,
especially because many countries are yet to
completely supplant the separate delivery of these
services with integrated services. As an example,
Nigeria launched its IMNCH strategy in 2007 with
eight strategic objectives and a list of planned
activities7. However, the approach is yet to
completely replace the previous separate delivery
of services due to poor funding, inadequate
training and sensitization of health workers, as
well as escalating poverty with citizens still unable
to access evidence-based care while relying on
traditional forms of health care. It was therefore
not surprising when a recent study that
investigated reasons for non-use of primary health
care centres in six states of Nigeria8reported the
perception by youth and adults alike that these
centres are meant for delivery of child health care
(immunization, treatment of childhood illnesses,
childhood nutrition, etc.) rather than for adult care.
Thus, a complete re-organization of service
delivery is needed for this approach to fully take
root before its impact on maternal and child health
indicators can be fully assessed in many African
countries.
Clearly, integrated maternal, newborn and child
health strategy is an important approach for
accelerating the tempo of service delivery for the
reduction in rates of maternal and child mortality
in African countries. However, at the present time
its true impact and relevance are not well known in
the continent. It might not be possible to conduct a
quasi-experimental study or even a randomized
controlled trial to compare the effects of separate
versus integrated implementation of maternal and
child health services in the region. However,
considerable formative, descriptive,
implementation and interventional research is
needed to enable countries and the international
community understand what is working and what
may not work, and to develop an evidence-based
framework for deepening its implementation. No
doubt, IMNCH strategy might eventually prove to
be one of the greatest innovations in maternal,
new-born and child health that addresses barriers
to service delivery in African countries. But the
successes, challenges, results and benefits
experienced by countries in using the framework
need to be better investigated and documented.