Recent Lancet Series on maternal, newborn, and child health1, 2, 3 have showed that evidence-based, cost-effective interventions can improve health outcomes in mothers, newborn babies, and children in low-income and middle-income countries. The experiences of several countries confirm that the health of women and children can be improved through carefully designed and incrementally implemented strategies.4 These need to address barriers and constraints in many sectors, including health, education, infrastructure, water and sanitation, and social protection.1, 2, 3, 5, 6, 7 One important step towards such progress is gradual strengthening of health-care systems, to enable delivery of effective primary health care with maternal, newborn, and child health at its core. Community-based action will also be needed, to enhance sustainability and ensure accountability.8
Key messages
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Maternal, newborn, and child health is at the centre of primary health care and cannot be effectively improved and sustained by vertical approaches
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District health teams need to plan for incremental additions to maternal, newborn, and child health, within primary health care and linked to referral units
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Private efforts should be integrated where possible
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Vulnerable groups should be prioritised at the district level
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Actions in health-related sectors (eg, social and legal protection, water and sanitation, and transport and communications) should be promoted
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Development of human resources needs to adhere to a comprehensive approach from training to practice, including shifting of tasks to ensure efficiency
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Care for mothers, newborn babies, and children should, in principle, be free for poor clients at the point of provision
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District health-management teams need support to strengthen their capacities to plan, cost, budget, implement, monitor, and evaluate interventions for maternal, newborn, and child health
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National governments should support district-level health care, through strategy, policies, training, and supervision
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Global initiatives need to identify a feasible agenda based on priorities that will support countries to improve outcomes in maternal, newborn, and child health
A review of the maternal and child health agenda from a health-systems perspective9, 10 has identified key packages of interventions that provide for a continuum of care for mothers, newborns babies, and children.11 However, strategies for implementation of an integrated agenda for maternal, newborn, and child health at the district and community level has not been synthesised in the same way.9 We review evidence on maternal, newborn, and child health, and assess the experiences of countries that have successfully integrated interventions to improve maternal and child health.
Integration of interventions can encompass addition of interventions at one point of service delivery (eg, integrated management of childhood illness, or use of an immunisation visit to promote and provide family-planning services); creation of links between different levels of service (such as community, primary, and referral levels), and coordination between the necessary activities that make up the delivery system, such as service delivery, logistics and supplies, and monitoring and assessment.12 Therefore, such integration applies not only to district-level health care but also to national strategies and global support (figure 1).
Despite advances in defining cost-effective interventions for maternal, newborn, and child health, a coherent agenda for the integration of maternal, newborn, and child health is recognised to be lacking. Reasons for the lack of progress include both historic factors and more recent global policy concerns (panel 1). Several of these factors operate at national and international levels. Therefore, although much of the actual work of planning and implementing an integrated agenda for maternal, newborn, and child health must take place at the district level, specific efforts to introduce change at the national and global levels will be pertinent. Therefore, we aim to address key policies, strategies, and financing issues for integrated interventions for maternal, newborn, and child health at the district and national levels, and to briefly comment on global issues. Earlier contributions have discussed the extent of the problem,13 the existence of effective interventions,2, 14 and particular parts of the nexus for maternal, newborn, and child health.1, 3, 7
Substantial reforms and behavioural changes are needed both within the health sector and outside it.5, 6 For effective mobilisation of resources, rich countries need to move from rhetoric to action.15, 16 The current aid relationship is characterised by high transaction costs, inefficiencies, and a general lack of accountability.17, 18 One way to enhance commitments could be to allocate a defined share of development assistance in health to primary health care in general, and to maternal, newborn, and child health in particular. National governments have a role in allocation of public funds in an equitable manner, and in management and regulation of the health sector.19 District health planners will need to adopt a systematic approach to the implementation of programmes that includes monitoring and evaluation, implementation research, and dissemination of results. Moreover, local communities should be involved in the design, implementation, and assessments of interventions to empower socially excluded people, including those from ethnic and other minorities.8, 20, 21, 22
Experiences of success in some countries suggest the need to use incremental approaches to implement integrated packages for maternal, newborn, and child health, taking into account existing strengths and potentials at local levels, giving priority to disadvantaged groups, and exploiting potential synergies.5, 6, 9, 23 We provide an implementation framework intended as a guiding tool for assessment and systematic improvement of local health systems, and for intersectoral action. For target population groups to reap the potential benefits of integrated maternal, newborn, and child health, managers, decision makers, health-care providers, and stakeholders at district and national levels need to enact policies, act strategically, and implement financing mechanisms to support implementation of evidence-based interventions. The framework centres on: (i) availability of an integrated package of essential services for maternal, newborn, and child health (including outpatient services and associated socioeconomic interventions), and of referral mechanisms and institutional childbirth facilities; (ii) access for all pregnant women, newborns, and children, especially poor families; and (iii) affordability of these packages for poor households and resource strapped governments.
