Chapter 8: Maternal, Child and Women's Health
White Paper for the Transformation of the Health System in South Africa

1. Background and Introduction

Maternal, Child and Women's Health (MCWH) services have historically been fragmented, unco-ordinated, and under-resourced. Additionally, there is unequal access to these services, especially in the rural areas. One of the five main aims of the restructuring of the health sector is to give priority to Maternal, Child and Women’s Health (MCWH). The Department of Health states its commitment to achieving universal access to, and improving the quality of, health services. MCWH services will be an integral part of the primary health care package. These improvements should contribute to the reduction of infant, child and maternal morbidity and mortality, which is one of the goals of the RDP.

2. Guiding principles

The following principles will guide future efforts for MCWH services:

• MCWH services should be accessible to mothers, children, adolescents and women of all ages. A major focus will be on providing services to the rural and urban poor and farm workers.
• MCWH services should be comprehensive and integrated.
• Clear objectives and targets should be set at the national, provincial, district and community levels. These objectives should be developed in accordance with the goals of the RDP, the health sector and the United Nations Convention on the Rights of the Child.
• Individuals, households, and communities should have adequate knowledge and skills to promote positive behaviour related to maternal, child and reproductive health.
• MCWH services should be efficient, cost effective and of a good quality.
• Women and men will be provided with services which will enable them to achieve optimal reproductive and sexual health.

3. Implementation strategies

3.1. Reorganisation and integration of MCWH services

The Department of Health and the provincial health departments will ensure the allocation of adequate resources to provide comprehensive and integrated MCWH services. Further, MCWH services will be reorganised at all levels to ensure the effective coverage of the majority of children and women. A minimum package of MCWH services which needs to be provided at each level of care will be developed and implemented. In addition, health facilities need to be organised so that MCWH services are located closer to one another. MCWH services should also be co-ordinated with other health services, including environmental health, nutrition and disability services. The Department also encourages collaboration with other sectors and NGOs.

At the national level: A Maternal, Child and Women’s Health Directorate will be established. It will formulate policy, and facilitate the reorganisation of MCWH services. In addition, it will develop standardised case management protocols for the care of children and women.

At the provincial level: MCWH units will be established to oversee the planning, implementation, supervision, monitoring and evaluation of MCWH services delivered at the district level. Cost-effectiveness studies will be carried out at the provincial level.

At the district level: The planning and implementation of child and reproductive health programmes will be district-focused and community-based. District health teams will be trained to enhance their capacity in relation to MCWH services. Integrated primary health care advisory committees, whose responsibilities will include MCWH, will be established.

At the community level: Households and communities will be targeted with relevant information. Community health promoters will also be trained to facilitate community action. Collaboration with CBOs and NGOs working in the area of MCWH is recognised to be important. This is seen as important for promoting community participation.

Advisory committees: MCWH advisory committees will be established. Members will include community and NGO representatives and technical advisors.

3.2. Clear objectives and targets

Clear objectives and targets need to be set at all levels, in order to facilitate monitoring and evaluation of MCWH services. In this regard, the Department of Health will formulate health sector goals to be achieved by the year 2000 (see #4 below). The goals will be based on those of the RDP, the World Summit for Children, and the Convention on the Rights of the Child. In addition, annual plans will be drawn up by the provinces and districts. These should include specific and achievable MCWH objectives. Communities will also be enabled to set their own objectives.

3.3. Monitoring and evaluation

The monitoring and evaluation of MCWH services is seen as a priority. A set of tools will be developed to facilitate this. In addition, provinces will be monitored at the national level, and district performance will be monitored at the provincial level. The use of the health information system should be utilised in this regard.

3.4. Improving knowledge and skills

The Department recognises that currently there is a lack of capacity for effective communication, and that education materials are poorly developed. For this reason, a communication strategy which emphasises the promotion of MCWH will be developed in collaboration with the Health Promotion and Communication Directorate. This strategy will focus on developing the communication skills of health workers, developing health materials based on research, and using the media. In addition, at the household level, individuals should be actively involved in the promotion of child health.

3.5. Human resource development

Relevant training will be provided to equip health workers to provide quality, integrated, MCWH services, within the primary health care approach. Communication skills will be improved and workers will be encouraged to develop a caring ethos and to become involved in community-based health care activities. District health teams will also receive training around the monitoring and evaluation of MCWH services. Health managers will be trained in micro-planning.

3.6. Reproductive and sexual health services will be made available to women and men

These services will include HIV/AIDS and STD services, family planning services, pap smears and breast exams.

4. Indicators of success

The following will be indicators of a successful implementation of the MCWH programme:

• Community health centre and clinic coverage rate of 1:20 000 by the year 2000
• 75% of all maternity facilities are "mother and baby-friendly".
• Maternal mortality rate reduced by 50%
• Proportion of pregnant women who receive antenatal care increased to 90%
• 90% of deliveries in institutions attended by trained birth attendants
• Increased clinic attendance for contraceptive services
• Implementation of a plan for cervical cancer education, screening and treatment
• 80% of pregnant women immunised against tetanus
• Reduction of infant and under-five mortality rate by 30%, and reduced disparities in mortality between population groups
• Reduction of prevalence of low birth weight to 10% of all live births
• Reduction in mortality due to diarrhoea, measles and acute respiratory infections in children by 50%, 70%, and 30% respectively.
• Increased immunisation coverage, among children up to one year of age, to at least 80% in all districts and 90 % nationally
• Reduction of neonatal tetanus to fewer than once case per 1 000 live births in all districts by 1997.

5. Some Issues Raised by the Chapter

• The structure and function of the Advisory Committees (see 3.1) are unclear.
• No mention is made of termination of pregnancy services. Will the MCWH Directorate be responsible for the implementation, monitoring and evaluation of these services?
• The Chapter does not talk about the future of free health care for children under the age of 6 and pregnant women.

For more information, please contact Jane Mathieson or Bea Abrahams by telephone @ 021 - 6964954 or by fax @ 021 - 6969308 or by e-mail at philaw@wn.apc.org . The PHILA programme is funded by a grant from the Henry J. Kaiser Family Foundation.

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