Learning from health systems strengthening in maternal and newborn health (MNH) in China to inform accelerated progress for saving lives in Africa

在全球范围内，每年有289 000名妇女死于妊娠和分娩并发症，290万名婴儿活不过第一个月。撒哈拉以南非洲-人口仅占世界十分之一-负担最重，几乎没有取得进展的迹象。已经确定了若干战略，以加快降低孕产妇和新生儿死亡率方面的进展，包括增加保健工作者人数，提高分娩护理的具体技能，并探讨如何吸引保健工作者前往农村地区，但如何在撒哈拉以南非洲大规模实施这些措施仍不确定。撒哈拉以南非洲可以从中国在孕产妇和新生儿健康方面的进步中吸取重要教训，特别是在过程和“如何”方面。在过去的二十年里，中国的新生儿和孕产妇死亡率大幅下降。这一成功的原因是多方面的，但中国在加强卫生系统方面的战略投资无疑起到了作用，特别是在建立一支强大的助产士队伍、鼓励妇女在医院分娩和使分娩护理基本免费方面。在获得产妇和新生儿保健方面的地区差距仍然存在，但即使是最贫穷的地区-它们面临的地理障碍与撒哈拉以南非洲没有什么不同-也取得了实质性进展。中国与撒哈拉以南非洲国家的新生儿死亡率差距约为3倍，孕产妇死亡率差距约为10倍;中国目前城乡孕产妇和新生儿存活率差距约为3倍。因此，对中国学习的评估既有助于加快中国缩小城乡差距的进程，也有助于非洲不断增长的变革动力。该项目的目的是利用中国在MNH方面的经验来回答一些问题，这些问题对于了解撒哈拉以南非洲如何取得类似进展至关重要，包括：1。现有的卫生系统指标是否区分孕产妇和新生儿死亡率高和低的地区？是否可以设定死亡率不能下降的阈值（例如每1 000人提供服务者的密度）？2.什么是合适的助产士队伍，以及如何最好地部署，以公平地提供规模和质量的基本MNH干预措施，以及什么资源和系统（财务，培训，治理，监督等）。为实现这些干预措施的普遍可及性，需要采取哪些措施？3.现有的结构和程序如何使社区能够成功地转诊到提供产科护理的设施？4.卫生筹资系统的哪些变化，包括引入新的保险计划、统筹安排和提供者支付机制，减少了财政障碍，从而支持扩大基本MNH服务的覆盖面？5.中国的哪些经验可以借鉴给坦桑尼亚？我们将通过多项研究来回答上述问题。首先，我们将利用中国独特而广泛的常规数据系统来研究所有县的卫生系统投入与孕产妇和新生儿死亡率之间的关系。其次，我们将在中国西部最贫困省份的八个县收集数据，以深入了解MNH投入之间的关系，这些投入更难以通过常规数据来源获得，包括助产士队伍的组合和水平，转诊和医疗保健融资的水平和分配，以及选定的服务覆盖率和结果指标。第三，我们将研究在中国成功实施的MNH战略是否可以在坦桑尼亚实施，以及考虑到坦桑尼亚不同的健康和社会经济背景，其有效性是否保持不变。

Globally, 289,000 women die each year due to complications of pregnancy and childbirth, and 2.9 million babies do not survive the first month of life. Sub-Saharan Africa - with only one tenth of the world's population - carries the greatest burden and there is little evidence of progress. Several strategies have been identified to accelerate progress in reducing maternal and newborn mortality, including increasing the number of health workers and upgrade specific skills for care at birth and exploring ways to attract health workers to rural areas, but how to implement these measures at large scale in sub-Saharan Africa remains uncertain.Sub-Saharan Africa can learn important lessons from China's progress in maternal and newborn health (MNH), in particular in terms of the process and the "how". Over the last twenty years, China's newborn and maternal mortality rate fell dramatically. The reasons for this success are multiple, but China's strategic investments in health systems strengthening have no doubt contributed, particularly in terms of building a strong midwifery workforce, encouraging women to give birth in hospital and making delivery care mostly free. Regional disparities in access to MNH care persist, but even the poorest regions, - which face geographical barriers not dissimilar to sub-Saharan Africa - have made substantial progress. The mortality difference between China and sub-Saharan Africa at national level is about 3-fold for newborn mortality and ten-fold for maternal mortality; and the current urban-rural maternal and newborn survival gap in China is about 3-fold. So evaluation of China's learning could serve to both accelerate progress for closing China's urban-rural gap and to the increasing momentum for change in Africa. The aim of this project is to use China's experience in MNH to answer a number of questions that are critical to understanding how similar progress can be achieved in sub-Saharan Africa, including:1. Do existing health systems indicators discriminate among areas with high and low maternal and newborn mortality? Can thresholds be set (e.g. density of providers per 1000 population) below which mortality cannot decline?2. What is the appropriate midwifery workforce, and how is it best deployed, to equitably deliver essential MNH interventions at scale and quality, and what resources and systems (financial, training, governance, supervision, etc.) need to be in place to achieve universal access to these interventions?3. How do existing structures and processes enable successful referral from the community to facilities offering obstetric care?4. What changes in the health financing system, including introduction of new insurance schemes, pooling arrangements, and provider payment mechanisms, have reduced financial barriers, thereby supporting the expansion of coverage of essential MNH services?5. What lessons from China can be transferred to Tanzania?We will answer the above questions through a number of studies. First, we will use China's unique and extensive routine data systems to examine the relationship between health systems inputs and maternal and newborn mortality across all counties. Second, we will collect data in eight counties in China's poorest Western provinces to provide an in depth understanding of the relationship between MNH inputs that are more difficult to capture through routine data sources, including the mix and levels of the midwifery workforce, referrals and levels and allocation of health care financing, and selected service coverage and outcome indicators. Third, we will examine whether the successful MNH strategies deployed in China can be implemented in Tanzania and whether the effectiveness would remain the same given Tanzania's different health and socio-economic context.