For women such as Charity Chansa the completion of the Millennium Development Goals and the dawn of the Sustainable Development Goals has made little, if any, difference. Charity has given birth to three children, twin girls and a new born son, at home in her community of Mpata Hill, in Zambia. the nearest hospital being an 18 kilometre walk away. The journey is almost impossible for a heavily pregnant woman to make and she, and her community, make do with traditional herbs without clean water or modern sanitation.
2015 is over. The celebrations have been held, hearty pats on backs given and many, many evaluations conducted. Significant progress was supposed to have been made towards achieving the Millennium Development Goals and yet, no matter how positive the results are painted, suffice it to say, progress has fallen far short of the targets the world set for itself a decade and a half ago.
In particular, Millennium Development Goal number five was aimed at improving maternal health, reducing the maternal mortality rate by three-quarters, while increasing the number of births attended by a skilled professional in the developing world. Zambia, Charity’s home and a signatory to the Millennium Convention – the agreement that set these goals into action, fell short of achieving this goal.
Despite falling short of these targets, Zambia made significant improvements – at least in reducing maternal mortality. In 2014, there were 398 maternal deaths per 100,000 live births, compared to 729 at the beginning of the millennium. In comparison, Finland has a maternal mortality rate of five deaths per 100,000 live births. According to a 2014 report by UNFPA, the percentage of births attended by a professional, however, was 47% in 2007, the same as ten years previous.
Why hasn’t the country been able to make progress towards this goal? The answer may lie less in Zambia’s reproductive health policies and more in the implementation of these policies.
As a ratifying party to the International Conference on Population and Development in 1994, Zambia has incorporated policies promoting reproductive and sexual health. Zambia’s healthcare policy claims to ensure universal access to family planning, skilled birth attendants, and basic and comprehensive emergency obstetric care. In addition, the government’s policy on abortion is liberal compared to its African peers, with legal abortions being permitted for economic or social reasons; foetal impairment; to preserve mental health; to preserve physical health; or to save a women’s life.
Zambia’s policy framework looks good in terms of women’s reproductive rights, family planning and reduction of maternal mortality. However, a large rural population, poor road networks and lack of health care infrastructure means that story of the women of Mpata Hill remains much too common. The failure of the country to meet the MDG targets, prove that even a policy-friendly environment cannot undo the stark realities of life where policies and strategies regarding women’s reproductive rights have not been prioritised, funded and implemented.
To have any hope of fulfilling its obligations towards its mothers, Zambia needs a pragmatic, focused approach to improving women’s access to reproductive health services which targets specific problem areas and creates strategies to deal with those areas.
For instance, the major causes of maternal mortality in Zambia arise from complications during pregnancy, such as haemorrhaging, sepsis, and hypertensive conditions. Thus, reducing delays in seeking and accessing emergency assistance should be a key component of any policy directed at improving women’s outcomes.
Training community based first responders, such as midwives, could be a stop-gap measure in lieu of building more healthcare infrastructure. Rwanda’s programme to reduce maternal mortality, which has been quite successful, used this method. Since 1997, Rwanda has trained over 1,000 midwives, while also investing in its health workforce, increasing the amount of deliveries attended by a skilled provider to 69 percent.
While Zambia has attempted at a national level to provide universal access to comprehensive care and family planning, it is still centralised. Decentralising the health sector has proved to be one of Rwanda’s keys to success. Community health workers are elected at the village level and then are trained by the Ministry of Health. Community committees are also responsible for the country’s comprehensive insurance plan including mobilising and registering members; collecting fees; and clearing bills at local health facilities. The country also funds its health sector through a performance-based financing system, which rewards communities that do well in particular indicators.
The 2013 report on Zambia’s progress suggests that the country continues to focus on family planning and reducing unwanted pregnancies. The decentralised community based health approach could also be beneficial to improving these statistics. Since village leaders elect health workers, they will have more legitimacy to spread lessons about family planning and abortion options. Sensitising pregnant women on proper care can also help them to make the decision to seek care in the case of an emergency. Having community health workers who are trusted could also incentivise pregnant women to seek care.
While there is always the policy option of improving infrastructure in order to increase access to care, it is also currently unrealistic. The cost of building, maintaining and staffing healthcare facilities in a time where aid budgets are decreasing and the country’s currency is falling; it is unlikely that there would be enough financial support for this option to be viable – without Zambia’s government prioritising this sector and ring-fencing financing for the long term.
Mothers such as Charity Chansa are evidence of how Zambia still not only falls short of achieving its policy targets, but how it is failing its women. Zambia must increase access to reproductive and sexual healthcare, in order to have any hope for achieving SDG targets. Increasing community involvement in the health sector would be a positive step forward for the country; one which may take less financial investment than many of the other options. However, the real solution to the enduring state of sexual and reproductive healthcare provision lies in increasing the government’s political and financial commitment to the health sector and finally implementing the numerous international, regional and national commitments it had made.
Photo by Namfumu Conservation Trust: endeavours to promote strong environmental conservation partnerships to effectively contribute to the mitigation of climate change, global warming through holistic sustainable rural development and poverty alleviation in Zambia and Southern Africa.