Skip to 0 minutes and 12 seconds DR LYNN FREEDMAN: The Lancet Maternal Health Series does a great job of mapping out the mismatch between the burden of poor maternal health and the coverage of maternal health services. They call this a quality and access gap. But I would argue that underlying those big gaps that this series exposes is actually a dangerous disconnect between the way that the global health community frames problems, devises solutions, and pushes those solutions on the one hand, and the actual lived experience of people and providers at the front line of the health system.
Skip to 1 minute and 2 seconds And so in addition to using traditional public health methods to describe and expose a quality and access gap, I would argue that we can also think about this as an implementation and aspiration gap and use different kinds of methods that are available to us in public health to really understand something about the nature of those gaps.
Skip to 1 minute and 31 seconds But to really understand, not just to identify that gap and describe the gap, but to actually understand the gap, we have to try to understand why organisations like health systems have now begun to turn their face, in a sense, to the global level and away from the people in the communities and at the front lines of the health system whose needs they are supposed to be serving. And one concept that can be useful in trying to understand that is this idea of isomorphic mimicry.
Skip to 2 minutes and 12 seconds The term “isomorphic mimicry” refers to the way in which an animal, like a chameleon, actually changes their form, the way they look, their outward appearance so that it meets the requirements of the environment so they can survive. A chameleon changes its colour to disguise it. When it’s in green grass, it will turn green. When it’s on a brown tree, it will turn brown. So that changing your outward appearance enables you to survive, to succeed. But it’s by mimicry. Right? You’re just changing your form. You’re not actually changing that you’re a chameleon. You’re not changing the way in which you function.
Skip to 2 minutes and 58 seconds So similarly, health systems, when pressed from the outside, for example, by donors or ministers, or when others external to communities are demanding that certain indicators be met, that certain protocols be followed, when the system actually doesn’t have the capacity to do it, the state doesn’t have the capability, perhaps, to do it, or there may be other reasons. But the point is, unless we look, unless we learn how to look behind the form and actually begin to investigate the function, then we’re just kidding ourselves. Here we are as a global community. We talk about evidence-based policies, evidence-based practices.
Skip to 3 minutes and 55 seconds Often, the global community comes up with some blueprint based on what it considers good quality evidence about a maternal health service, something like skilled birth attendants. And, it pushes this policy as a best practice and comes up with indicators to assess it and count it. Skilled birth attendants or institutional delivery is a good example. The global community presses this practice as a good practice, based on the evidence, and counts, what is the proportion of births that are done in health facilities, and gets an institutional delivery rate. And they press countries to show a higher and higher institutional delivery rate in the hope that it will mean better health services, better childbirth services.
Skip to 4 minutes and 55 seconds And the concept of isomorphic mimicry would imply that health systems responding to this pressure from outside– in this case, global donors, the global community, the global technical community– would start trying to change the system so that it meets these externally imposed criteria, or externally imposed indicators, or benchmarks for progress. But very often, what happens is that the services don’t actually change.
Skip to 5 minutes and 36 seconds So what we see is essentially that the form of the services are changing. Countries are doing what donors ask of them. The numbers are going up; they’re getting better and better. But as other papers in the series show, the services are not actually changing, even as the numbers change. And so there is this quality and access gap. For us particularly, coming from the human rights field, where a big part of the problem is that the policymakers and programme managers, ministry officials in many countries feel themselves accountable to donors, to outside actors in global health, and not accountable to the people in their health systems.
Skip to 6 minutes and 27 seconds So if we change that direction of accountability, actually, if health policymakers and programme designers, and indeed, global actors were actually attuned to the reality that people experience on the ground, they would recognise that the services are not actually living up to what they are supposed to be on paper. I think it’s very important for us to acknowledge that the choices that women make in childbirth– where to deliver, how to deliver, with whom to deliver, who they should have with them, if they’re allowed, when they deliver– all of these things are not just about getting a health outcome, but they also signal who women are, who they want to be.
Skip to 7 minutes and 18 seconds It says something about their aspirations, in some cases, their aspirations to be modern, their aspirations to be part of a certain community, to be in a certain socioeconomic class. And so childbirth is never just about technical health services. It’s always about all of these other aspects of women’s emotional and social lives. And so we have to acknowledge that a big part of making health services good quality and of drawing women in, of providing good access for women, is ensuring that services meet their aspirations as well as their technical health needs. Three emerging areas have very promising practices for shifting the way the global community begins to respond to maternal health and other major health issues as well.
Skip to 8 minutes and 24 seconds These include in the research domain, the field that’s coming to be called health policy and systems research, gives special attention to actually documenting empirically the lived reality at the front line and understanding the reality in a health system to be deeply embedded in a social, economic, and political system, and acknowledging that if you want to understand how the health system works, you need to always see it as playing a role as a social institution as well as a health system.
Skip to 9 minutes and 3 seconds At the programme level, the whole field of implementation science is beginning to pay new attention not just to ‘do we have the right policy?’, with a sort of black box notion of how it will be implemented, but to the actual study and practice of how you support front-line workers to exercise the judgement that’s needed over and over again for every single birth, wherever it is, to ensure that good quality, respectful care is delivered. Finally, in the advocacy field, I think the growing field of social accountability is critically important.
Skip to 9 minutes and 51 seconds Instead of the health system and health providers having only upward accountability to their bosses in the health system, or to donors, or to global actors, social accountability is about the mobilisation of citizens, of civil society groups, to assert their rights and to take actions to ensure that health services actually respond to their needs, to their aspirations. I think it’s also really important for us in maternal health to be calling for investment, not just in people’s voices. It’s not enough to say, we need to hear people’s voices. We need to listen to people’s voices.
Skip to 10 minutes and 42 seconds We need to invest in the channels, in the organisational channels in the civil society organisations that provide venues for making people’s voices heard and asserting it into the system at all levels of the system. Because only then will the system be able to be responsive to the needs at the front line. One overriding lesson of all of this for us as global actors is the need to show some humility. We have to recognise that, as important as the work we do might be, the engine of change in maternal health is not going to be new clinical guidelines, or great new training curricula, or patient rights charters, or model laws, or anything like that that comes from outside.
Skip to 11 minutes and 46 seconds Those things are all tools. But ultimately, the engine of change is when people take the power to transform their own reality. And so our job in global health is really first to listen to them, and then to work with people to co-create the conditions that make locally-driven transformation possible.
Are we giving the illusion of quality maternal health care provision?
When is a health care facility appearing to deliver quality maternal health care, but not functioning to deliver it?
Using the evolutionary biology concept of “isomorphic mimicry”, when animals change their appearance to survive but do not change their function (such as chameleons), Lynn Freedman (Columbia; AMDD) explains the need to understand the function of health systems beyond their appearance. In addition to the quality and access gaps highlighted by The Lancet Maternal Health Series, important implementation and aspiration gaps are highlighted barriers to improving maternal health. Three promising practices are described: 1) health policy and systems research; 2) implementation science; and 3) social accountability.
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