Building the good CARMMA
Akinyele Dairo (MPH) is the technical advisor to the United Nations Population Fund (UNFPA) East and Southern Africa program.
Currently UNFPA is closely supporting an Africa Union (AU) initiative to promote and advocate renewed and intensified implementation of the Maputo Plan of Action for Reduction of Maternal Mortality in Africa and the attainment of the fifth target of the Millennium Development Goal. The new program dubbed Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA) was launched by AU in 2009 together with UNFPA in Addis Ababa. On CARMMA media advocacy workshop held from 20-22 March in Kampala, Uganda, Mihret Aschalew of The Reporter caught up with Akinyele Dairo and discussed the overall progress of the program.
What were some of the initiatives taken to improve maternal health in Africa under the program thus far?
First of all, we are the partners of the African Union on this program. AU, however, has taken so many initiatives to improve maternal health conditions in the continent. The core of this initiative in my opinion is the adoption of continental policy on sexual and reproductive health in 2005. The policy was agreed up in Gaborone by African ministers of health and then the agreement was taken to another level with the Maputo Plan of Action in 2006. The focus on the matter came to be following the discussion of the Millennium Development Goals (MDGs) in 2000, where maternal health was identified as one of the targets. By 2005, it had already become clear that the progress in maternal health was too slow. The heads of state and ministers of the continent then decided to pick up the pace and hence this is how this policy came to be. Again in 2006, they felt that there were too many policies in Africa that are not put into proper implementation except warming up the shelves. This led to the Maputo Plan, an action plan to implement the policy. The Maputo Plan of Action looks at all sorts of things that are affecting women’s health in the continent. In spite of the Maputo Plan of Action, however, policy dialogue, advocacy and capacity building were completely stopped. And they felt that the agenda was not progressing as it was supposed to progress, so the ministers of health met again in Addis Ababa in 2009 to revisit the issue. And that was when they decided to launch the campaign on accelerated reduction of maternal mortality in Africa. Generally, there were three things concerning maternal health agenda in the continent. For one thing, we were not making progress as we were supposed to. We were supposed to be reducing maternal mortality by 75% by then. However, the reduction was 2% in 2005. So, what do we do? The second point was the economic crisis. As the crisis was fast approaching, everyone was concerned how it would affect donor money supporting us. Hence, we were looking for ways on how to get attention. And the third reason was that there were countries doing well, so how do we learn from them and build on the good experiences. That was when the campaign was launched. At the beginning people expected we move fast and launch the campaign in seven and eight countries. But today we have 37 countries that have fully launched CARMMA. If you look at the progress of the campaign across the continent, you can see that in 2009 we had eight countries launching CARMMA, and in 2010 we added one additional country to the list. In 2011, we had a total of eighteen countries launching the campaign. By 2012, the move was a bit slow as we only had one additional country joining the list of CARMMA countries; that is why the AU and UNFPA, as a development partners, agreed to re-energize everybody and have a high level event on CARMMA at the AU summit at the end of 2012. As a continental initiative, we have a continental policy, the Maputo Plan of Action, CARMMA and we are also working on establishing a children’s and women’s health policy secretariat at the moment.
What makes CARMMA different from previous initiatives?
CARMMA is not like winning a trophy. It was initiated by AU and was able to mobilize high-level policymakers including heads of states. In 2010, when African heads of state met in Kampala, it was supposed that the heads and high level policymakers would discuss issues, of which maternal and infant health was the one .What is different was that all high-level policymakers supported the agenda and many development partners and NGOs were also present at the discussion. So, this is an initiative for bringing everybody together. Second its unique character is that as some of the countries were launching the campaign, some were also committing themselves to one or two things. For instance, as seven countries launched the program, 24 others increased maternal health monitoring or allocated more resources in their budget for health. Still, other 22 countries strengthened their health service systems and mobilized community members behind the target. It’s like a national movement on health issues. Hence, these and many others can be taken as distinct characters of CARMMA.
But, July 2010's AU summit had maternal, infant and children's health as its main thematic focus. Nevertheless, the main agenda of the meeting was ICC’s arrest warrant on Sudan's President al-Bashir. The main topic on of discussion for the media was also this issue. How did you see this?
In my own view, you can have your plan, but at any point in time things can change; this can happen any time. The manner one responds to sudden changes is entirely another issue. The issue of ICC dominated the AU floors on the July meeting because of the crisis that was building up at the time. And of course, it affected the coverage given to infant and maternal health; but the effect was felt more on the media side. The heads of state did give attention to infant and material health topic. In fact, they were supposed to discuss the matter for two hours but ended up spending close to a day and a half on the issue. So, it was the media coverage that didn’t get attention. What really happened at the meeting was that the seven countries which launched CARMMA have been extended to 18 countries after the meeting. We can see that the result is outstanding: 24 out of 37 gave more money to health sectors at the end of the meeting. It might not have been visible on media outlets, but the result is there to see. Now, CARMMA is getting more coverage even in the media. So, for me, that was more of an isolated incident that happened.
CARMMA was launched in 2009 with the presence of heads of state and presidents at the AU summit. But why did it take countries like south Africa around three years to launch the campaign?
When we talk about support of individual governments. There could be a variety of factors that we need to consider. In South Africa's case, it was a period of presidential change for the country, where Thabo Membeki was leaving office being replaced by Jakob Zuma. After that, the new government had to take time, to reaffirm its focus on what it really want to focus on. Prior to the change, South Africa was not giving attention to HIV/AIDS and related health matters. But now time has changed and the country is giving attention to the health sub-sector. Incidentally, the minister of health of SA, when the county was not giving enough attention to HIV, was the one who launched the program. So, at times, it is the politics that makes the difference. Secondly, a support from an international media or the international community would help to draw attention to the campaign. I can say that it was what was observed widely in that country following the change; after the new government came into power, the leaders have come to the understanding of the whole situation and of course the need to launch the campaign. But finally, when it was launched in 2012, it was quite a good campaign as it was well planned and also ranked as one of the best in terms of follow up.
What about the rest of the countries which didn’t launch CRMMA until now?
There are about 17 countries which are yet to launch CARMMA. The AU, UNFPA and other model development partners are trying to look into ways to support those countries to launch the campaign. For example, between now and the next two years, we want at least another two countries to launch it and we are working on that. In this meeting, Comoros and Madagascar are here to learn from other countries that have launched the campaign. We have four East and Southern African countries yet to launch out of the 17 across the continent. We have Comoros, Madagascar, Mauritius, South Sudan and Somalia. Actually, Somalia is not yet on the road to launch.
How do you see Ethiopia’s commitment to CARMMA?
I think Ethiopia is one of the countries where CARMMA has been well implemented. Ethiopia is central because the launch of CARMMA in May 2009 took place at the regional levels. The minister of health at that time, Tedros Adhanom (Ph.D.), is someone who I do not know how to describe really; he was a minister who is really on the ground unlike someone at his position who simply floats in space. He goes down to the villages and the communities; and he had already started his work with the village health workers by that time. He also brought the partners to work together as a team and he has done very well in terms of maternal health in Ethiopia. The results might not be there to be seen today, but in two, three years, people would begin to see the benefits. So, Ethiopia is not only committed but also one of the countries sharing their good experience, specially regarding the village health workers.
Did you observe any significant maternal mortality reduction since the launch of CARMMA?
I think yes. As I mentioned before, one of the reasons why we want to launch CARMMA was that we had 2% maternal mortality reduction in 2005. But I am happy to say that, today, from 1990 figure to that of 2010, maternal mortality rate was reduced by 41%; this is significant. It shows that this thing is doable and that we can work and be able to go forward. The other thing is having increased commitment to maternal health conditions. Government budgetary support is also another added advantage, and I see we have more intervention as we train more midwives. So, I can say that things are moving forward.
Does CARMMA have any plans to address issues like child marriage and female genital mutilation?
I think what is happening with regard to addressing maternal mortality issues is that the focus depends on the objective problem that a given country is facing. For example, in Congo Brazzaville the focus is on family planning because that is a major problem that they want to address. In Eritrea, the focus was to address maternity at home and for Ethiopia, the focus is on fistula. In Togo as well, the focus is on obstructive fistula. In Sierra Leone, the government felt that in rural areas people are not going to health facilities hence we anchored this problem. So, every country looks at problems aggravating maternal health conditions.
How do you expect to work with the media?
I see cordiality between UNFPA and the media due to common agendas both advance. I heard from the media people that they want to inform the community about maternal mortality so that they can prevent maternal death. UNFPA too is working to support initiatives for maternal health improvements. But there is a disparity in working together. So, what we need now is partnership between the media and UNFPA. In the past governments and UNFPA were generally afraid of the media institutions, but if we had common agendas why do not we work together? What has been achieved in this workshop is better understanding between the media and UNFPA.
What are the challenges so far for CARMMA?
Issues of funding is for sure one. But we also have a challenge with regard to human resources, especially in rural areas. Of course, we still have the challenges in terms of meeting family planning needs of the society. Countries that did not launch it because of different reasons and the strive to help them do it is also another big challenge. (The Reporter)