I think that establishing a fund for maternal health and then focusing it on health systems would be a waste of effort and we'd lose a percentage off the top to the fund adminsitration. We already have structures in place for health systems support.

A global fund for health systems is an interesting idea.

Alanna, I have to agree with Robert on this and say that you are contradicting yourself. 

In your comment you say that a fund for maternal health focused on health systems would be wasted effort and "lose a percentage off the top to the fund administration." ...but then in the VERY next sentence say that a fund for health systems is interesting.  You can't have it both ways.  Either "global funds" are effective and efficient ways of raising and administering donor funds, or they aren't. 

I also don't see how a maternal health fund with a narrow approach could be both "efficient" and "lack overall impact."  If it doesn't have a large impact, then it isn't very efficient at solving maternal health issues.

To be honest, (I'm sure you'll disagree with me here) I don't think anyone has really been able to define concretely what a health system is and how to strengthen it.  In fact, I would  welcome a post on the topic.  In my mind, a "health sytem" is an amorphous idea - the sum of anything effecting health in a country.  And an amorphous idea can hardly be strengthened.

Shouldn't the issue of the funding pie staying the same vs. the funding pie growing bigger be factored into this discussion? I think most would agree that the majority of funding raised by the GFATM wouldn't have been brought into the system if the Fund hadn't been created. If a Global Fund for Maternal Health identified a series of specific interventions that appealed to donors and raised an extra 3 billion dollars a year for maternal health, a small percentage of that going towards admin seems like a good tradeoff. I absolutely agree with your point about where money should go in your last paragraph - if another global fund is the best way to get money into those things, then I'm all for it.

I agree with Alanna. Maternal and child health can only improve with focus on imroving primary health care in resource deprived settings. Global health interventions must be inclusive and take into consideration different causes of poor maternal health and try to focus on capacity building to tackle those issues.

Interesting discussion. Somewhat along the lines of "if we have efficient health systems in place appalling maternal mortality rates will go away."

I agree with Alanna re not creating another fund whose management will eat up about 20% of the money available. There should be strenghtening of the existing health system to make maternal health part and parcel of existing healthcare. The mother has to continue her medical care when she is done with ante and post maternal care. Isolating maternal health will be disastrous to continued healthcare after delivery.

But we have think of: what if preganant women just don't go to the existing health facilities for ante-natal care, deliveries and post-natal care. What if they are comforatble with the trusted midwife in their community? 

Building health facilities, roads to the health facilities and where possible instituting emergency maternal transportation within communities all come second place to the woman making the choice to go to the health institution.

Managing Maternal Choices. That is the key.

Although there clearly have been cases where programs with a single-issue focus have weakened health systems, I don't think that necessarily HAS to be the case. The Global Fund/PEPFAR were established to catalyze an emergency response and at the start, perhaps too little thought was put into how to set up HIV programmes without throwing already fragile health systems off-balance. But we know better now; and these institutions are evolving to adopt a health systems strengthening lens when planning and implementing programmes and interventions. To fulfil their mandate, this has to happen anyway, because HIV care and treatment programmes will only be sustainable, equitable and universal when they are decentralised to the primary care level. It simply can't be done without strengthening the health system.

RE a Global Fund for maternal-child health: True, MCH also requires health systems strengthening & there is a very long laundry list of essential MCH activities. But many of the complexities you mention are just part of delivering any healthcare intervention in resource-limited settings (specialised human resources, often equipment (at least re diagnostics/lab), accessibility, financial/social barriers to care, transportation -- though rarely emergency). Addressing gender inequity, reproductive rights and sexual autonomy are also critical for the HIV prevention programmes being implemented by PEPFAR/Global Fund. These programs aren't just distributing pills.

However, I think setting up a Global Fund for maternal-child health could inadvertently transfer to the new multilateral much of the national government's responsibility for providing essential MCH services (just as some 'focus' countries leave HIV to PEPFAR). And if you can't convince countries to allocate adequate resources for the health and survival of mothers and children, there is little hope of getting them to invest in 'health systems.' Of course, because of the sorry state of health systems, these countries do need help — starting with debt forgiveness and other policies to get countries to invest sufficient resources in their own health systems. This should lead to programmes that are home-grown and not dependant upon the whims of international donors.

No one can dispute the fact that women need specialisd care during prgnancy, labour, delivery, post -partum care etc. However leaving them at the mercy of traditional birth attendants is not a healthy option. Unfortunately that hapens in resource deprived settings, resulting in disasters such as fistula, fetal death and maternal death. How can this be prevented? Improving access to health care by building infrastructure, training professional staff and improving transportation. All that needs a comprehensive approach and not a narrow focus.

The issue here is about making a choice between developing a comprehensive primary healthcare programme of specific intervention programme. A GF for maternal health falls into the second category. Such decisions have been at the centre of an ongoing debate about development in general. The problem is that no primary health care system has never been established properly because of limited funding and attempt at developing one usually results in specific intervention.

The difference between efficient and impact is better understood when looking at a specific intervention programme, like vaccination. A vaccination programme may be very efficient in a developing country and end up protecting a population against a disease, but when there is no clean water, malnutrition and other disease, protecting children against let's say measles is great but has no little impact when most chid will die of diarrhoea.

Most importantly the intervention must lead be sustainable.

Maternal and child health care are part of a comprehensive primary health care and we should better invest in developing proper health care than only maternal health. This will just disrupt further a system already fragile.

This has been a fascinating discussion. I run an NGO dedicated to making pregnancy and childbirth safer; in May, I co-wrote (with some colleagues from the AIDS and child health communities) a Comment published in the Lancet calling for the Global Fund (and/or GAVI) to expand their mandate to include MDGs 4 & 5 as well as MDG 6. We actually discussed calling for it to be a global fund for health systems strengthening, since that was really what we thought is needed, but decided to stick to the "health MDGs" because that's what gets political attention these days.

Basically, I agree that a global fund specifically for maternal health doesn't make sense and isn't feasible at this point -- the transaction costs of setting it up are too high, and in the current economic climate it's a non-starter.  But it is still true that the major obstacle to making progress on maternal mortality is lack of investment in KEY ELEMENTS of health systems strengthening. So while I would support a broader focus on strengthening health systems capacity, there needs to be an explicit focus on maternal health services and maternal health outcomes in order to ensure that the elements of the health system that are strengthened include those that are key to preventing and managing obstetric copmlications -- so that it's not just training more health workers or purchasing more supplies/equipment generically, but specifically includes midwifery and obstetric skills, and drugs like misoprostol and magnesium sulfate.

Ann Starrs, President, Family Care International (www.familycareintl.org)

Very interetsing discussion about Maternal and child health. In my experience as a Maternal and child health nurse the fundamental issues are lodged in the following issues:

Who is responsible for the child and mother? In most cases the family take the most interest especially the partner. Health care is a family decision therefore the more the family knows about good health the more likely they will reach out for such health care. Having the best health care syatem on the ground becomes useless if he families do not access it for a whole variety of reasons including fear and traditions. Even in the most indutrialised nations men are less likely to seek medical assistance unless absolutely necessary. The notion of preventative health is rare.

Alanna's comments particularly the last paragraph stricks true because the community has to have good access to health information enabling them to make decisions. Information and education as well as empathetic health workers can make a world of difference. Practical demonstartions of what is possible and what works gains respectability in the community.

Having worked in developing countries and developed countries my observations remain as above. The more empowered the community the more educated their decisions about health. The other element is respect for their traditions and ways of combining modern health strategies with the old.

The startegy of focussed interventions in general tend to be short term programs. In addition such programs are made with finances as a focus as opposed to people as a focus, which is a long term program that will earn the respect of the community. Empowering a community is the best approach to improve health in any community as it involves a person/family's dignity, respectability and abilty to continue when the professionals leave. They ned to be able to make those important decisons. Of course the health services have to be made available and made available without placing obstacles in their path. In my experience in the 2 developing nations that I have worked in I found the health professionals to be lacking in respect and considerations towards clients/patients. A person who is feeling vulnerable and is treated in such way will not return to that health facility if he/she is belittled.

The approach proposed by Alann is a multi pronged approach where the health workers and the community are trained and empowered to get on with dealing with their health issues in cooperation ( I assume). I have never found a patronising/paternalistic approach worrk.

For all this to work there has to be a political commitment nationally and internationally. If health funding is tied to a multitude of other factors the focus on health disappears or diminishes. The commitment has to empower the nation and there has to be long term ongoing startegies that over a generation could alter approach to health. In the main preventative health as a strategy which includes health education and provision of services, I feel is the answer to reducing the morbidity and mortality seen especially in poor nations. Short term single focus projects produce short term short term results and usually single focus is made difficult as maternal health is not a single focus issue. Mothers in just about all the countries remain the main organisers, supporters and main stay of families. The first connection a child has is with the mother and its importance lasts a life time. This alone opens up the issue of a community being able to support a mother through the deands on her. A community approach, the old fashioned way may, but is the most effective broad approach to obtaining the reuslts that will stay with the community.