Successes, Challenges and Opportunities towards Universal Health Coverage for Maternal and Child Health in South East Asian Region Countries: A Systematic Review

DOI: https://doi.org/10.21203/rs.3.rs-78717/v2

Abstract

Background: Sustainable Development Goal 3 (SDG-3) aims to ensure healthy lives and promote wellbeing for all. Universal Health Coverage (UHC) assures delivering health services to all who need without suffering from financial hardships. This paper aims to identify the successes, challenges and opportunities towards achieving UHC for maternal and childcare in countries in the World Health Organization, South East Asian Region (SEAR).

Methods: We conducted a systematic review of the literature. We searched PubMed, Embase, Scopus, CINAHL, PsycINFO, WHO research portal and Google scholar for studies published in English from 2010 to 2020. We included studies conducted in maternal and childcare focusing on challenges, opportunities or successes towards UHC in countries in SEAR. Data was synthesized and presented as a narrative description, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results: We identified 62 studies with different study designs from eight SEAR countries , majority were from India. We observed successes or opportunities in access and quality in maternal and child health (MCH) with government cash transfer schemes and private sector contribution in India, Bangladesh and Indonesia. Politically prioritized MCH care was identified as an opportunity in a state of India.

Inadequate healthcare infrastructure including trained human resources, medical products and other supplies were identified as the main challenges in the region. Facilities are overcrowded in Bangladesh and Indonesia. From provider perspective, health care workers’ knowledge and skills as well as attitudes and behaviors were also identified as issues in the region. Lack of health literacy, misconceptions and cultural barriers are identified as challenges from clients’ side. Difficulties in geographical distribution and transport were contributing to poor healthcare access in four countries. Deficiencies in government policies and administration were identified in some fields. Poverty was detected as an overarching barrier.

Conclusions: SEAR countries have demonstrated improvements in access, quality and equity on MCH towards UHC. There are, however, challenges related to human and other resources, health care facilities and socio-economic determinants of health. Regional bodies as well as authorities in individual countries should work on these issues to address challenges to achieve UHC.

Registration: PROSPERO: CRD42020166404

Introduction

The Sustainable Development Goals (SDGs) were adopted by all United Nations Member countries in 2015 as a universal action to end poverty, protect the planet and ensure that all people enjoy peace and prosperity by 2030. SDGs contain 17 interrelated goals that their action in one area will affect other’s outcomes 1. The third Sustainable Development Goal (SDG-3) aims to ensure healthy lives and promote well-being for all at all ages1. It has a target to reduce neonatal mortality to at least 12 per 1000 live births, under-5 mortality to 25 per 1000 live births and maternal mortality ratio to 70 per 100 000 live births by 20302. Target 3.8 focuses on achieving universal health coverage (UHC), including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all 1.

Universal health coverage is a broad concept in which all individuals and communities receive the health services they need without suffering financial hardship3. It includes the full spectrum of essential, quality health services, from health promotion to prevention, treatment, rehabilitation, and palliative care4. The definition of UHC expressed three related objectives namely equity in access to health services, good quality of health services and protection against financial risk 5.

There is an index to monitor the status of implementation of UHC, developed by the World Health Organization. The UHC services coverage index (UHCI) is calculated as the geometric mean of the coverage of essential services based on 17 tracer indicators from the following categories: (i) reproductive, maternal, newborn and child health, (ii) infectious diseases, (iii) non-communicable diseases and (iv) service capacity and access and health security. The UHCI is described clearly on a scale of 0 to 100 without a unit 6.

All the countries are progressing towards UHC with different strengths. In middle- and low-income countries, the progress is slow4. Improvements in the index were seen in all WHO regions with European, Western Pacific and the America Regions have reached to almost 80% coverage in 2017. WHO Western Pacific Region had the largest improvement over the specified period. With minor variations between member countries, SEAR coverage has reached near 60% in 2017 7.

More than a quarter of the world population lives in WHO South-East Asia Region, one of the six regions consisting 11 countries. The region has number of priority programmes aligned to SDGs, including UHC2,8. The region shows tremendous achievements in under-five, neonatal mortality and maternal mortality 2. According to WHO progress reviews, at the current rate of progress, the SEAR is likely to achieve the SDG target of under-five mortality reduction. However, for achieving the targets of neonatal mortality and maternal mortality, countries need significant acceleration of actions2. The region also faces many challenges in providing high quality medical services without financial burden to the population. Around 800 million people in this region lack the access to essential health services; over 65 million disadvantage due to out-of-pocket expenditure2,9. Region specific challenges and opportunities may exist towards achieving UHC and other health-related SDG targets. Capacity of the building blocks of the health system plays a major role in achieving UHC. It is thus essential that countries strengthen their health systems, including healthcare financing, health workforce, governance, health information system, procurement and supply of medicines and health technologies, health information system and service delivery4.

As far as our knowledge is concerned, there is no systematically synthesised evidence on the successes and challenges, related to health systems, towards achieving UHC for maternal and child health (MCH) services in the region. The objective of this review is to identify successes, challenges and opportunities towards achieving UHC for MCH care in SEAR countries. Our review will potentially contribute in the regional effort to achieve UHC in relation to MCH.

Methodology

A systematic review was conducted and reported in accordance with the preferred reporting items for Systematic reviews and Meta-Analyses criteria (PRISMA) 10. (See checklist in Additional file 01). In accordance with PRISMA guidelines, the systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 10th of July 2020. (Registration number: CRD42020166404).

Search Strategy

The search strategy was developed to fulfill objectives and characterized them in terms of the four elements [Population, Intervention, Comparison, and Outcomes (PICO)]. Search terms included the terms for all components of UHC, SEAR countries, similar terms for MCH care and parallel terms for challenges, opportunities and successes (Additional file 2). The selected key words were searched in following databases; PubMed, Embase, Scopus, CINAHL, PsycINFO, WHO research portal, and Google scholar. The PROSPERO registry was also searched for the confirmation of none existence of ongoing or recently completed similar systematic reviews.

Selection process

Original studies conducted in SEAR countries on any component of UHC in relation to MCH and which identified challenges, opportunities and successes towards UHC were included in the review. Systematic reviews, scoping reviews and document reviews were excluded. Only studies published in English language and published in or after 2010 up to 31st January 2020 were included. The search was restricted to after 2010 as there has been more improvement in research on UHC with the shifting from millennium development goals to Sustainable development goals 2015. Inclusion and exclusion criteria are clearly described in Table 1.

Table 1

Inclusion and exclusion criteria

 

Inclusion criteria

Exclusion criteria

Study design

Regardless of methodology all original research papers on Universal health coverage in relation to maternal and child health done in SEAR countries, which identified challenges or opportunities or successes were included.

Letters, editorials, reviews, narrative reviews and systematic reviews were excluded. Studies conducted in countries not in SEAR were excluded

Studies which not identified challenges or opportunities or successes were excluded

Language

Studies published in English were included

Studies published in languages other than English were excluded

Publication date

Only studies published after 1st of January 2010 up to 31st January 2020 were included.

Studies published before 2010 were excluded

Initial search was conducted on 3rd of February 2020. All identified papers were imported into EndNote referencing software. After removal of the duplications, the titles and abstracts were screened for relevance and eligibility criteria. Then the remaining full text papers were read and re-evaluated for data extraction. Inappropriate papers were excluded from the study. The selection of the study was done by two independent reviewers. The identified successes/ opportunities and challenges were extracted separately in accordance with access, coverage, equity and quality of the services. The extracted data were presented as a narrative synthesis according to WHO six building blocks of health systems; Service delivery, Healthcare Financing, Human resources, Healthcare information management system, Medical products, and Leadership and governance. FFindings of the review were organized and presented in accordance with objectives of the study.

Risk of bias (quality) assessment

Quality appraisal of the selected full text studies was concomitantly carried out by two independent reviewers. A All included articles were assessed for reporting quality by using appropriate checklists according to the study design. Assessment tools designed by Joanna Briggs Institute (JBI) were used11. The JBI qualitative checklist included 10 questions and each question included four options “Yes,” “No,” “unsure” or “not applicable”. Likewise, the JBI checklist for quantitative studies and intervention studies has 8 and 9 items respectively. Marks were given accordingly as, yes = 1, no = 0 and unsure = 0. At the end of the evaluation of each of the included studies, we gave a score above 80% as high quality, 60–80% as medium quality and below 60% as low quality. In mixed method studies, two parts were assessed separately with both qualitative and quantitative checklists. A field trial was assessed with non-randomized control trial checklist (Additional file 3). No studies were excluded as a result of the quality assessment. However, the methodological rigor of each study added the confidence assessments of each review finding.

Results

The literature search initially identified 3747 papers published between January 2010 and January 2020. One thousand one hundred and eighty nine of these papers were found to be duplicates while 1192 papers were excluded by reading their titles only. One thousand two hundred and fifty four papers were excluded by reading their abstracts, as they were not related to the objectives of the study. Another 19 articles were excluded, as they were only abstract or poster presentations in conferences. Then the full texts were reviewed with 92 papers, which excluded 30, as they have not identified challenges and opportunities (Fig. 1-PRISMA flow chart).

Among studies included in the review, a majority was from India (n = 30, 48%) (12–41). There were 11 studies from Nepal (42–52), 10 from Bangladesh (53–62), six from Indonesia (63–68) and two from Timor-Leste 69, 70. From Bhutan71, Thailand 72, and Myanmar 73 one from each was identified. Unfortunately, no study could be included from Sri Lanka, Maldives and Democratic Republic of Korea. When considering the publication year of the article, majority of selected articles were published in 2018 (n = 16, 26%). In total, 21 quantitative, 33 qualitative, 07 mixed-methods and one field trial were found. Nine quantitative studies, 20 qualitative studies and five mix method studies found to be of high quality studies. The rest were found to be medium quality studies. A data table constructed for selected studies including important characteristics such as author, year of publication, country, study design, sample size, study objectives and quality assessment is attached as Additional file 4.

We found 62 articles related to the successes, challenges and opportunities for UHC with relation to MCH in WHO SEAR countries. We were able to categorize our findings in relation to access, coverage, equity and quality of maternal and childcare services. Summarized tables of extracted data are presented in Table 2. A narrative description of the successes and opportunities and the challenges are presented in the next section.

 
 
 
Table 2

A: Successes/ opportunities and challenges in access to the maternal and child health services

   

Reference no.

Service delivery

Successes/ Opportunities

 

-Changes in the cultural acceptability of institutional delivery are facilitating factors for use of maternal health services by Scheduled Caste women in Bihar, India.

27

-Rural south Indian communities regularly use health care services during pregnancy and for delivery. Uptake of maternity care services are attributed to new government programmes and increased availability of maternity services.

39

-Facilitators for institutional deliveries are identified in rural areas of Chitwan district, Nepal. They are supportive husbands and mothers-in-law, the availability of an ambulance and having birthing centers nearby

52

-All private and public hospitals provide full coverage of Comprehensive Emergency Obstetric and New- born Care in Aceh province in Indonesia

64

-Support from peers, family and co-workers and male participation in accessing ANC are seen as enablers for early ANC booking in Bhutan.

-Antenatal clinics conducted in Primary healthcare level are an important means of reaching the ANC services to women in rural areas where difficult geographical accessibility

71

Challenges

 

-Difficulty in geographical access is an important barrier to accessing institutional delivery services in Northern districts of Karnataka, India

-Lack of financial access is an important barrier to accessing institutional delivery services in Northern districts of Karnataka, India. They includes inconsistent receipt of government incentives, high costs at private institutions, continuing fees at public hospitals.

13

-Cultural barriers include cultural norms such as male infant preference, traditional clinical practices. Poverty is an overarching structural barrier.

38

-Underestimation of the severity of complications by family members, gender inequity and perceptions of low-quality delivery services are barriers for decision to seek maternal care from institution in rural central India.

-Transportation problems and care seeking at multiple facilities are barriers to reach appropriate health facilities timely.

20

-Receiving postpartum care is rare except for neonatal care. Barriers to receive timely maternity and postpartum care include transport problems, perceived quality of facilities, the cost of care, and the lack of recognition that a large proportion of maternal morbidity and mortality occurs in the postpartum period

39

-Low-income pregnant women in rural India get wrong information and misconceptions about pregnancy from elder women, friends, and mothers-in-law and husbands. Lack of access to health care and pregnancy-related health information leads them to rely on that information. Doctors and para-medical staff are consulted during complications only.

All women face personal, societal, and structural level barriers, including feelings of shame and embarrassment, fear of repercussion for discussing their pregnancies with their doctors, and inadequate time with their doctors

15

-Migrant women working in brick kilns are a vulnerable population subgroup in terms of maternal health utilization of district Faridabad, Haryana, India. Identified access barriers are, gaps in knowledge regarding local health system; sub-standard private health care delivered at brick kilns, misconceptions and mistrust about public health system, difficult location of brick kilns, lack of time for attending clinics.

33

-Poor roads and lack of transportation, low quality services, restricted hours of opening, the lack of availability of medical resources and the lack of privacy are identified as barriers to women’s access to maternity services in Timor-Leste.

-Male controlled family structures, intergenerational decision-making and cultural attitudes towards reproductive health information and services potentially reduce women’s access to reproductive health services in Timor-Leste

69

-Sociocultural factors such as husbands’ attitudes, previous antenatal history, minimal birth preparedness, and ethno-physiological beliefs; infrastructure limitations, difficult geographical location, hospital policies and poor staff attitudes are identified access barriers for maternal care in Timor Leste.

70

-Following perceived barriers are identified for maternal health service utilization in Indonesia. : the preference of pregnant women to deliver in their parents’ village; the use of traditional birth attendants; distance to health facilities;

63

-Postnatal care at village level in Klaten district, central Java Province, Indonesia lacks patient-centered care practices.

Low health literacy of mother and family members’ on postnatal care, inappropriate sociocultural beliefs and practices, and poor health service responses are the barriers to postnatal care utilization in villages

68

-Late antenatal care (ANC) bookings are common in Bhutan.

Specific barriers to early ANC are gender insensitivity in providing care through male health workers, cost/time in ANC visits, and the inability to produce the documents of the father for booking ANC.

71

-Following barriers are identified for institutional deliveries in Nepal.

Lack of transportation facility, lack of awareness in about provision of transport incentive from government, difficult geography and preference of Auxiliary Health Workers to conduct delivery in home settings instead of referring mothers to health facilities for safe delivery.

42

-Only one third of women in Mugu District, Nepal deliver in a health facility. The main reasons for mothers not delivering in a health facility are distance to the nearest birthing centre, lack of transportation services, high transportation costs, perceived poor quality care and unfriendly health-care providers, and a personal preference for home delivery.

44

-Access barriers to skilled birth care utilization in mid- and far-western Nepal are identified.

They are inadequate knowledge of the importance of services offered by skilled birth attendants, distance to health facilities, unavailability of transport services, poor infrastructure, inadequate services, inadequate information about services/facilities, cultural practices and beliefs and low prioritization of birth care

49

-Decision to seek skilled care for maternal and neonatal health is delayed in common in a rural setting of Nepal. Delays in receiving appropriate care when at a facility are also seen for maternal care.

Transport problems, lack of money, night-time illness events, low perceived severity and distance to facility are the identified barriers to seeking care at any type of health facility. Facility care is often sought only after referral or following treatment failure from an informal provider.

46

-Difficult geography, poor birth preparedness practices, harmful culture practices and traditions and low level of trust are also found to contribute to underutilization of the birthing center.

45

-Barriers to institutional deliveries are identified in rural areas of Chitwan district, Nepal.

- Socio-cultural, such as beliefs about childbirth being a normal life event, the wish to be cared for by family members, greater freedom of movement at home, a warm environment, the possibility to obtain appropriate “hot” foods, and shyness of young women and their position in the family hierarchy are identified.

-Accessibility such as lack of road and transportation, insufficient financial incentives

52

Healthcare Financing

Successes/Opportunities

 

-Under the National Health Mission of India, Janani Suraksha Yojana offers conditional cash transfer and support services to pregnant women to use institutional delivery care facilities. It provides improvements on the Indian maternal and child health.

18

-Introduction of accredited social health activists, free maternal health services and the Janani Shishu Suraksha Karyakram are main facilitating factors for use of maternal health services by Scheduled Caste women in Bihar, India.

27

-Janani Suraksha Yojana and Indian Public Health standards provide for contracting in EmOC specialists in private sector as a measure to reduce maternal mortality. Contracting in specialists is useful for non-emergency conditions in obstetrics.

29

-The government of India has initiated the Janani Suraksha Yojana cash transfer programme to promote facility births. Even-though quality of intra-partum care provided in facilities under the Janani Suraksha Yojana cash transfer programme is poor in Madya Pradesh, some positive practices are also observed. Companionship during childbirth and women mobilizing in the early stages of labour are among them.

14

-The Indian Government introduces the Janani Suraksha Yojana scheme - a conditional cash transfer program that incentivizes women to deliver in a health facility – in order to reduce maternal and neonatal mortality

37

-Sufficient financial incentives and/or material incentives provided by government is a facilitator for institutional delivery in rural areas of Chitwan district, Nepal

52

-Ministry of Health in Nepal has introduced Safe Delivery Incentive Programme, branded as Aama Surakshya Karyakram (ASK) to facilitate institutional delivery. ASK is effective and efficient in order to address barriers occurring inside the health facility and financial barrier in accessing maternal health services in Nepal.

Healthcare providers have a very good understanding about ASK applied in health facilities

42

-An increase in utilization of maternal health services in Nepal is associated with three innovative financing initiatives, the maternity incentive scheme, reimbursing women for accessing a facility, activity payments in poor districts and universal free-delivery.

43

-Implementation of various health insurance schemes for maternal and child healthcare targeted towards the poor and near-poor, including the Jamkesmas program in Indonesia.

63

-To achieve Universal Health Coverage, Indonesia implements National Health Insurance which integrates four types of health insurance, namely Askes/ASABRI, Jamsostek, Jamkesmas and Jamkesda. Health insurance addresses financial barriers on delivery in health facility.

Health insurance increases delivery at health facilities due to increasing access to maternal delivery service.

67

-Introduction of national health insurance improves timely reference of patients for maternal healthcare in Aceh province in Indonesia. It further reduces financial barriers for patients to search care timely.

64

-Conditional cash transfers are used as a strategy to fight health inequality due to poverty in Indonesia. Household conditional cash transfer programmes and community conditional cash transfers programme improve the utilization of facilities in maternal care.

66

-A voucher scheme initiated in 2007 to reduce financial, geographical and institutional barriers to access for the poorest in Bangladesh, enhanced uptake of the complete continuum of maternal care and the benefits extended to the most vulnerable women

59

-Micro Health Insurance scheme administered by Gonoshasthaya Kendra, one of the largest health-related NGOs in Bangladesh, improves the utilization of ANC in rural, poor women.

57

Challenges

 

-Several barriers exist for the uptake of facilities offered under government led insurance programmes in India. They are shortages in emergency obstetric-care facilities, specialists and staff, essential drugs, diagnostics, and necessary equipment at facilities, weaker linkages between various vertical elements of maternal and primary healthcare programs, misdistribution of resource allocation,. Less transport facilities, socio cultural issues are also identified as barriers

18

-Partial health insurance cover for migrant women working in brick kilns in district Faridabad, Haryana, India, is an access barrier for them to maternal health utilization.

33

-The contracting in of EmOC specialists under Janani Suraksha Yojna programme does not greatly increase EmOC service outputs at facilities in three districts in Maharashtra state of India. Inadequate infrastructure, longer distance to private specialists, insufficient financial provision for contracting in, and poor management capacities are barriers to effective implementation of contracting in.

29

-The major factors serving as barriers to participation of private practitioners in government-led schemes for maternity services in India are low reimbursement amounts, delayed reimbursements, process of interaction with the government and administrative issues, previous experiences and trust deficit, lack of clarity on the accreditation process and patient-level barriers.

41

-Lack of proper documentation for health insurance registration is a perceived barrier for Jamkesmas health insurance membership in Indonesia

63

-High out of pocket expenditure is a major barrier to access to appropriate medicine in children in rural Bangladesh.

62

-Despite the government’s efforts at increasing access to delivery services, for poor women in the private sector with CJ programme, uptake was low.

34

 

Challenges

 

Human

resource

The lack of availability of skilled birth care assistance is identified as a barrier to women’s access to maternity services in three districts of Timor-Leste.

69

Leadership and Governance

-Government of India has provided accreditation of private sector health providers in government-led schemes for maternity services. The private sector plays an important complementary role to the public sector for maternity services.

Both government representatives and private practitioners have expressed enthusiasm in partnering with each other.

41

-The Chiranjeevi Yojana (CY) is a public-private partnership program in India. The government pays private sector obstetricians to provide childbirth services to poor and tribal women. CY beneficiaries experienced a subsidized childbirth compared to women who delivered in non-accredited private facilities.

34

-Availability of EmOC services has greatly improved in Gujarat, India as a result of Chiranjeevi Yojana

40

 
 
 
Table 2

B: Successes / opportunities and challenges in coverage and equity to the maternal and child health services

   

Reference no.

Service delivery

Successes/Opportunities

 

-National Rural Health Mission (NRHM), a community intervention, was implemented in India from 2005 to 2012 to reduce maternal and child health inequalities in India. Improvement in overall health infrastructure through an increased availability of accredited social health activists, free ambulance services, and free treatment facilities in rural areas detected.

NRHM had increased the demand and utilization of MCH services, especially for those related to institutional delivery, even by the poor families. It had Improved MCH outcomes in the poor in rural areas with reduction of geographical and socioeconomic inequalities.

17

-The gap in use of ANC provided by medically trained personnel narrowed in urban and rural areas between 2001 and 2010 in Bangladesh. Over the last decade, equity in utilization of health facilities for deliveries has improved at a faster rate in urban areas in Bangladesh

58

Challenges

 

-Main factors associated with low coverage of immunization in Bangladesh included lack of quantity and quality of supervision, lack of basic immunization supplies and some technical issues such as issues on doses, registration, and poor communication with communities.

54

-Migrant women working in brick kilns are a vulnerable population subgroup in terms of maternal health utilization (India)

33

-Scheduled Caste women are unevenly served and discriminated by maternal health services (India)

27

-There are considerable socio-economic and geographic inequities in newborn care in Indonesia

65

-A marked and maintained inequity in care seeking for fever/ cough and diarrhea, with less educated mothers and those from poor households in Nepal over 15 years Approximately half of them as likely to seek care for their children.

48

Healthcare Financing

Challenges

 

-Receipt of Janani Suraksha Yojana (JSY) benefits is comparatively low among Odisha and Jharkhand area, India. Receipt of the benefits is highly variable by district. JSY benefits are not equally distributed, favoring wealthier groups. The JSY scheme is currently not sufficient to close the poor-rich gap in institutional delivery rate.

37

Human Resources

Challenges

 

-The main factors associated with coverage declines in immunization in Bangladesh included gaps and turnover in human resources.

54

-Shortage of human resources was a major health system barrier for implementation of National Rural Health Mission which implemented in India from 2005 to 2012 to reduce maternal and child health inequalities

17

 
 
 

Table 2C: Successes / opportunities and challenges in quality to the maternal and child health services

 

 

Reference no.

Service delivery

Success/Opportunity

 

-There are quality enablers in health care institutions in India such as appreciation of public-private partnerships, availability of clinical guidelines in the form of wall posters in health facilities, efforts to translate knowledge and evidence through practice and enthusiasm towards value of guidelines

22

-Improved skills and confidence among providers, inclusion of doctors in training, increased training frequency, administrative support, and nursing supervision and feedback are identified factors for facilitating the care provision of obstetric and neonatal emergency care in primary care facilities in Bihar, India

26

-The government of Bangladesh has developed inpatient and outpatient guidelines for the management of SAM in children. There are cadres of community health workers who can be adequately trained to conduct community based management of acute malnutrition. Inpatient management of SAM is available in 288 facilities across the country.

55

Challenges

 

-In two rural districts of Uttar Pradesh, India, process gaps are observed during delivery and post-delivery stages. Key areas of concern includes compromised patient safety like poor hand hygiene, usage of unsterilized instruments; inadequate clinical care like lack of routine monitoring of labour progression, inadequate postpartum care; partially compromised privacy in the labour room and postnatal ward; and few incidents of abuse and demand for informal payments.

30

-Common challenges for provision of quality maternity care in secondary level public health facilities in Uttar Pradesh, India are follows.

Inadequate physical infrastructure, difficult in physical access, less cleanliness, irregular supply of water and electricity, Difficulty in maintaining privacy and interpersonal behavior and less information sharing are also challenges. Poor management of referral cases, non-functioning of blood bank and lack of incentives for work are identified as challenges by providers.

12

-Cultural beliefs and traditional birth attendants influence the mother’s newborn care safe practices at homes in Haryana, India. The lack of supervision by auxiliary nurse midwives, delayed referral and transportation are the other challenges-.

36

-Primary barriers to implementation of quality standards in maternal care in India are provider unwillingness to apply new techniques, inadequate infrastructure, inadequate staffing capacity and lack of required materials and equipment

25

-Factors that reduce the progress of maternal nutrition programme in India are systematic weaknesses, logistical gaps, resource scarcity, and poor utilization

28

-There are gaps in providing quality maternal and neonatal care at primary health centres and district hospitals across districts in Bihar, India. They are inadequate basic infrastructure and less availability of equipment and supplies.

24

-Identified logistical barriers for immediate neonatal care in Bihar are poor facility layout and problems with the local referral system.

38

-Negligence by health staff and unavailability of blood and emergency obstetric care services are barriers for receiving adequate care after reaching a health facility.

20

-Antenatal care is typically delivered at the periphery by non-specialized providers in rural Karnataka State  

39

-Inadequate infrastructure facilities, lack of equipment, low training capacity and health information systems are health system challenges on maternal health in two states of India—Bihar and Jharkhand.

22

-Nurse-nurse hierarchy, doctor-nurse hierarchy, cultural norms, physical resource shortages, corruption, and violence against providers are barriers to care provision of obstetric and neonatal emergency care in primary care facilities in Bihar, India.

26

-Facility readiness for emergency obstetric care is poor  in public and private health facilities of northern Karnataka, India

21

-Primary care facilities in India, both rural and urban areas are not well prepared to provide high-quality obstetric and newborn care. Facility capacity is worst in states with the worst health outcomes

32

-Government training to auxiliary nurse midwives in family planning is inadequate in Jharkhand, India.-Family planning service provision is interrupted by inadequate infrastructure.

23

-Quality of   intra-partum care provided in facilities under the Janani Suraksha Yojana cash transfer programme is poor in Madya Pradesh, India. Poor quality reflects with unsatisfactory delivery environment, unskilled care provided by staff and dominant staff members with passive recipients.

14

-Facility readiness to provide maternal and immediate newborn care is low at facilities in rural Nepal

47

-Poor acceptance of clients due to feeling unsafe and uncomfortable in health facilities as low quality of care was identified as a barriers for reducing perinatal mortality rates in the mountains of Nepal

50

-There are several barriers to provide high quality post-partum family planning services in Nepal, such as lack of  IEC materials and lack of private space for counseling

51

-For newborn care, private facilities are sought due to low quality and reported staff rudeness and drug type and/or supply stock shortages in government facilities.

46

-The rural birthing centers in Nepal are not providing quality services when women are in need. Identified reasons which prevent good service delivery in rural birthing centers are unavailability of 24-hour services and inadequate equipment and capital resources.

45

-Barriers to institutional deliveries are identified in rural areas of Chitwan district, Nepal .Less quality of health services, poor infrastructure and equipment at birthing centers

52

-Postnatal care at village level in Klaten district, central Java Province, Indonesia lacks patient-centered care practices

68

-Health service responses for postpartum care are identified as poor and non-patient-centered. Proper referral system in maternal health care is hindered by lack of family consent   

64

-Quality of newborn care provided at primary healthcare and referral level is generally substandard in Indonesia.

65

-Following perceived barriers are identified for maternal health service utilization in Indonesia. Overcrowded health facilities and lack of health facility accreditation

63

-The quality of healthcare including emergency obstetric care is poor in facilities in rural Bangladesh. Lack or inadequate laboratory support; under use of patient-management protocols; lack of training; insufficient supervision and high volume of patients are several key factors affecting quality services.

56

-Inadequate laboratory capacity is a barrier for the provision of Emergency Obstetric care in public facilities in rural Northwest Bangladesh.

61

-Community poverty and poor quality of care for community health worker referrals are the barriers for management of acute respiratory infection, diarrhea and severe acute malnutrition in southern Bangladesh

60

-Following   barriers exist for quality maternal and perinatal health care in Myanmar.

 shortage of resources, inadequate education and training,  inadequate relationships between health cadres, community/patient perceptions of Midwives  and Auxiliary Midwives, cultural practices and health seeking behaviors of community

73

Healthcare Financing

-High out of pocket expenditure is a major barrier to quality health care services in children in rural Bangladesh.

62

-High out-of-pocket expenditure is a challenge for provision of quality maternity care in secondary level public health facilities in Uttar Pradesh, India

12

Human resources

Successes/opportunities

 

Human resources are available across most public health facilities for delivery care in two rural districts of Uttar Pradesh, India

30

Accredited Social Health Activists (ASHAs) under the National Rural Health Mission was initiated in 2011 to reduce neonatal mortality rates in India. ASHAs play a key role in facilitating the adoption of safe practices in postnatal care in India

36

The 24-h availability of midwives and friendly health service providers facilitates institutional delivery in rural areas of Chitwan district, Nepal

52

Immunization staff and other health staff are aware of the evidence-based planning approach in immunization in Bangladesh

54

Service providers are motivated to deliver quality post-partum family planning services and transfer their knowledge to colleagues that lead to provision of high quality post-partum family planning services in Nepal

51

Challenges

 

Human resource shortages exist in obstetric and neonatal emergency care facilities and primary care facilities in India. Specially, qualified staff including gynecologists and anesthetist to manage complications is lacking.

12,22,24,26,38

The positions of EmOC specialists are vacant in 83% of all facilities in three districts in Maharashtra state of India

29

Provider competencies for emergency obstetric care is poor  in public and private health facilities of northern Karnataka, India

21

Lack of skill for post-delivery counseling is a challenge for provision of quality maternity care in secondary level public health facilities in Uttar Pradesh, India

12

Suboptimal knowledge on complications and high risk conditions in pregnancy, low of confidence and lack of adequate resources exists among healthcare workers in different parts of India. Nurses have limited roles in decision-making.

35

The Auxiliary nurse midwives lack knowledge and skills in family planning

23

Staff nurses involving in maternal, newborn, and child healthcare in government public health facilities in Uttar Pradesh, India, are working in stressful environment. . It influences their perceptions of risk for themselves and for their patients, as well as self-efficacy beliefs, which could lead to avoidance of responsibility, or incorrect care.

16

Human resources are inadequate for service delivery in rural birthing centers and district hospitals in Nepal

45,47,49

Inadequate Human resources and high workload are barriers for postpartum family planning services in Nepal.

51

Young and incompetent midwives make a barrier for institutional delivery in Nepal

52

Skilled birth attendants in private sector have significantly lower knowledge in management of maternal and newborn care.

47

Shortage of staff and specialized staff act as a main barrier for quality services in emergency obstetric care and hospital care in Bangladesh.

56, 61

Social, professional and economic barriers exist with midwifery personnel in Bangladesh which preventing quality maternity care.

53

Less staff is trained on facility-based management of SAM in children in Bangladesh.

55

Shortage of qualified health providers exist as a barrier for maternal health service utilization in Indonesia

63

Limited knowledge and skills, less capacity and high workload among healthcare providers act as barriers for quality care in postnatal mothers and newborn babies.

68, 65

Inadequate relationships between health cadres and shortage of Midwives and Auxiliary Midwives and their roles and capacity are  recognized as barriers to implement WHO Maternal and perinatal health recommendations  Myanmar

73

The lack of availability of skilled birth care assistance professionals is identified as a barrier to women’s access to maternity services in three districts of Timor-Leste.

 

69

Governance and leadership

Success and Opportunities

 

Maternal health has become a political priority at sub-national level in the state of Madhya Pradesh in India, with supportive policy environment in the state for maternal health backed by greater political will and increased resources. There are several opportunities in terms of policies, guidelines and programmes for improving maternal health

19

India has a rich portfolio of programs and policies that address maternal health and nutrition, which can play a major role in improving maternal and child health outcomes

28

Staff motivation, supportive leadership and co-training of nurses and doctors are identified as facilitators to implementing standards aimed at reducing common causes of maternal death in government hospitals in India

25

Challenges

 

Poor governance prevents good service delivery in rural birthing centers in Nepal

45

Lack of support from hospital management is a barrier to provide high quality post-partum family planning services in Nepal

51

Less priority given to primary health care is a barrier for reducing perinatal mortality rates in the mountains of Nepal. Failures are identified in delivering health services during pregnancy and childbirth as poor Health governance

50

Complex administration process is a main barrier in the referral system as perceived by maternal healthcare providers in Aceh province in Indonesia

64

The implementation of comprehensive newborn policies that in line with international standards remains poor in Indonesia. Decentralization of the health sector is an important factor that prevents implementation. It created confusion regarding roles and responsibilities. Management capacity and skills at decentralized level are often found to be limited.

65

Following are the barriers to implement WHO Maternal and perinatal health recommendations in Myanmar ; deficiencies with accountability and monitoring, deficiencies in Policies and political context

73

Understanding that the policy as not focusing on adolescent pregnancy is a barrier to provide effective care for pregnant adolescent women in Thailand.

72

 

There is resistance and disagreement among nutrition stakeholders regarding management of SAM. Nutrition coordination is fragile and there is no functional supra-ministerial coordination platform for multi-sectorial and multi-stakeholder nutrition in Bangladesh

55

 

Successes/Opportunities

 

HIMS

-HMIS records for MCH services at sub-centre level in Haryana state were satisfactory in terms of completeness

31

 

Challenges

 

Medical products

-Regular supply of medicines and therapeutic diet are not available in facilities for management of SAM in Bangladesh.

55

Shortage of medicines and supplies is a challenge for provision of quality maternity care in secondary level public health facilities in Uttar Pradesh, India.

12

- Supply issues are among identified logistical barriers for immediate neonatal care in Bihar.   

38

-Lack of materials and drugs is among health system challenges on maternal health in two states of India—Bihar and Jharkhand. 

22

-Lack of supplies is a barrier to provide high quality post-partum family planning services in Nepal.

51

- Shortage of logistics is a key factor affecting quality services in   emergency obstetric care in rural Bangladesh.

56

-Irregular supplies of medicine is a barriers for management of acute respiratory infection, diarrhea and severe acute malnutrition in southern Bangladesh

60

 

 

Successes and opportunities for UHC to MCH according to health system building blocks

a. Service delivery

Successes and opportunities in access to MCH services were identified in the region. In Bhutan, antenatal clinics conducted in primary healthcare level are an important means of reaching the ANC services to women in rural areas with difficult geographical accessibility71. In a study conducted among Scheduled-Caste (SC) women in Bihar, India, revealed that the changes in the cultural acceptability of institutional delivery are facilitating the use of maternal health services by them27. Another study revealed that rural south Indian communities regularly use health care services during pregnancy and for delivery. New government programmes that increase availability of maternity services are supportive factors for the usage39. A study conducted among Nepal women has identified family support, transport availability and nearby birthing center as facilitators for institutional deliveries52. In Indonesia, a research revealed that all private and public hospitals in a province provide full coverage of Comprehensive Emergency Obstetric and New- born Care64. Support from friends, family and co-workers and male participation in accessing antenatal clinics are identified as enablers for early antenatal clinic (ANC) booking in Bhutan 71.

As a success in equity, National Rural Health Mission, a community intervention in India, had Improved MCH outcomes for the poor in rural areas with reduction of geographical and socioeconomic inequalities17. There detected a marked reduction of inequity among rural and urban antenatal care in Bangladesh between 2001 and 201058.

Few opportunities have been identified in quality of MCH care service delivery in India. One study detected that there are quality enablers in health care institutions such as appreciation of public-private partnerships, availability of clinical guidelines in the form of wall posters in health facilities, efforts to translate knowledge and evidence through practice and enthusiasm towards value of guidelines22. Another study has spotted that improved skills and confidence among providers, inclusion of doctors in training, increased training frequency, administrative support, and nursing supervision and feedback as factors for facilitating obstetric and neonatal emergency care26. In Bangladesh, for the management of severe acute malnutrition (SAM) in children, there are proper guidelines, cadres and inpatient management facilities as identified by a study carried out to assess preparedness 55.

b. Healthcare Financing

To achieve UHC in MCH, under the national health mission of India, several cash schemes such as Janani Suraksha Yojana Janani Shishu Suraksha Karyakram and Chiranjeevanie Yojana have been introduced. These programmes provide improvements in maternal health care in India 14,18, 27,34,37,40. They further provide contracting in emergency obstetric care specialists in private sector as a measure to reduce maternal mortality29. In Nepal, Bangladesh and Indonesia, there are similar programmes to facilitate maternal care including institutional delivery42, 43, 52, 57, 59, 63, 64, 66, 67.

c. Human resources

A success / opportunity with availability of adequate human resources for delivery care across most public health facilities has been identified only in one study in India 30. Accredited Social Health Activists (ASHAs) play a key role in facilitating the adoption of safe practices in postnatal care in India 36. Another study identified having 24 hour availability of midwives and friendly service providers in rural areas of Nepal52. Service providers are identified as motivated to deliver quality post-partum family planning services and transfer their knowledge to colleagues that lead to provision of high quality post-partum family planning services in Nepal51.Immunization staff and other health staff are aware of the evidence-based planning approach in immunization in Bangladesh 54.

d. Health information management system (HIMS)

As a success with HIMS, records for MCH services at a state in India were detected as satisfactory31.

e. Leadership and governance

Jat et. al. has noted that maternal health has become a political priority in India. There is a supportive policy environment with greater political will and better resources. This leads to several opportunities in terms of policies, guidelines and programmes for improving maternal health19. Regarding maternal nutrition, India has a better collection of programs and policies which can play a major role in improving MCH outcomes28. According to Maloney et al, supportive leadership and staff motivation facilitates the implementation of standards aimed at reducing common causes of maternal death in government hospitals in India 25. For the improvement of access to needy mothers and children, government of India has provided accreditation of private sector health providers in government-led schemes for maternity services. Under those schemes, the private sector can potentially play an important complementary role to the public sector for maternity services34, 40, 41. As a positive factor that both government representatives and private practitioners have expressed enthusiasm in collaborating with each other with those programmes 41.

Challenges for UHC to MCH according to health system building blocks

a. Service delivery

Several common challenges were identified in the region in relation to access in MCH care services, which included clients’ factors as well as providers’. Lack of knowledge on local health system, misconceptions and mistrust about public health system and lack of time for attending clinics were among clients’ factors within vulnerable populations in India33. Feelings of shame and embarrassment, fear of repercussion for discussing their pregnancies with their doctors, and inadequate time with their doctors were identified as barriers for access in India15. Underestimation of the severity of the condition, especially in post-partum by family was a main challenge for looking timely postpartum care20. In a study conducted in India, it revealed that receiving postpartum care is rare for maternal problems. The main reason was the lack of recognition that a large proportion of maternal morbidity and mortality occurs in the postpartum period39. Another study revealed that cultural barriers include cultural norms such as preference over male infant and traditional clinical practices delays maternal care seeking among Indian women38.

In addition to that, lack of access to health care related information was detected as a challenge for decision to seek proper care in MCH15. The preference of pregnant women to deliver in their parents’ village and the use of traditional birth attendants were some obstacles in access in Indonesia63. Delayed first antenatal visit was common in Bhutan due to lack of gender insensitivity in providing care through male health workers and cost and time in clinic visits71. Several harmful cultural practices and beliefs are identified as barriers for institutional delivery in Nepal42, 45,46, 49,52. Untrained birth care providers’ practices, improper management of labour / retained placenta, high and law cast discrimination practices are among them 45. Cultural practice of untouchability prevented some pregnant mothers from visiting healthcare facilities49. Perceived low-quality services are barriers for delivery and postpartum care access for rural Indian and Nepal women20, 39, 44, 45. Financial constrains due to poverty was detected as an overarching structural barrier for access38, 39, 46.

Male controlled family structures, intergenerational decision-making and cultural attitudes towards reproductive health information and service has reduced women’s access to reproductive health services in Timor-Leste69. Distance to health facilities, difficulty in geographical access, high transport costs, poor roads and lack of transportation facilities were identified as challenges for access to MCH care institutions throughout the region13,20, 33, 39, 42, 4446,49,52,63,69,70.

Several studies reported that the low quality of delivery and postpartum care provided by the institutions is a major challenge for health care access in the region44,49,69,70. The low quality is reflected with poor infrastructure, unfriendly health care providers, hospital policies and poor staff attitude. The restricted hours of opening, the lack of availability of medical resources and the lack of privacy are identified in maternity services in Timor-Leste69.

Regarding the service coverage, study done in child immunization revealed the challenges for low coverage of immunization in Bangladesh included lack of quantity and quality of supervision, lack of basic immunization supplies and some technical issues such as issues on doses, registration, and poor communication with communities 54. With regard to equity on access of maternal services, inequity was detected in service delivery to migrant women working in brick kilns33and SC women in India27. There are considerable socio-economic and geographic inequities in newborn care in Indonesia65. In Nepal, inequity persists in care seeking for childhood diarrhea and respiratory symptoms among poor, less educated mothers over 15 years 48.

When considering the quality of MCH care, facility readiness was detected as poor for emergency obstetric care and newborn care in public and private health facilities including primary care facilities both rural and urban areas in India, Nepal and Bangladesh21,31,47,56. Several studies detected inadequate infrastructure leads to poor quality in maternal and child care including family planning services in the region 12,22– 24,26,28,38,45,51,52,56,60,65,73. In addition to those problems, irregular supply of water and electricity, less-functioning of blood bank12, inadequate laboratory facilities12,56,61 were detected as challenges. Difficulty in maintaining privacy is another structural barrier12. Overcrowded health facilities and lack of health facility accreditation were detected as challenges for quality in maternal healthcare in Indonesia63. High volume of patients leads to suboptimal quality care in emergency obstetric care in rural Bangladesh56. The rural birthing centers in Nepal are not providing quality services due to unavailability of 24-hour services as identified by Khatri45.

In two rural districts of Uttar Pradesh, India, process gaps are observed during delivery and post-delivery stages compromising mothers’ safety and quality care 30. Few other studies pointed out the problems with referral system for the contribution of poor quality12, 36, 38, 65. According to Puett et al, referrals by community health worker of childhood conditions are treated with low quality in Southern Bangladesh institutions60. It acts as a challenge for community management of them. Health service responses for postpartum care are identified as poor and non-patient-centered in a study done in Indonesia 64. Postnatal care at village level is identified as non-patient-centered care practices in Klaten district, central Java Province, Indonesia 68.

Few other challenges were identified in quality service delivery with regard to providers’. Unwillingness of provider to apply new techniques also acts as barriers for quality care 65. In Myanmar, poor quality of maternal and perinatal health care detected due to inadequate relationships between health cadres73. Interpersonal behavior among staff as well as patient’s relatives which leads to less information sharing is another barrier for quality care12. Hierarchy in healthcare workers is a challenge to care provision of obstetric and neonatal emergency care in primary care facilities in Bihar, India26. Inadequate or lack of training of health staff is another problem in quality services23, 56, 73. Antenatal care is typically delivered at the periphery by non-specialized providers in rural Karnataka State 39. Following providers’ behaviors were identified as challenges for quality maternal and childcare in few institutions; Negligence by health staff 20, rudeness of staff against clients 25, abuse and demand for informal payments 30. Cultural norms and practices also play a role in quality care as identified by few studies in the region26, 36, 73. Few studies have identified that high out of pocket expenditure is a challenge for quality maternal and child care12, 62.

b. Healthcare financing

Even though there are government funded health beneficiary programmes in India, challenges for the proper implementation exist. The health facilities are in poor quality and provide suboptimal benefits due to lack of resources and various interactions, which lead to poor utilization of facilities18. Identified challenges for low participation of private practitioners in government-funded programmes are low and delayed reimbursements, poor infrastructure and administrative issues29,41. Despite the government’s efforts at increasing access to delivery services for poor women in the private sector with programmes, uptake was low34. Partial health insurance cover for migrant women working in brick kilns in district Faridabad, Haryana, India, is an access barrier for them to maternal health utilization33. Lack of proper documentation for health insurance registration is a perceived barrier for Jamkesmas health insurance membership in Indonesia63. High out of pocket expenditure is a major barrier to access to appropriate medicine in children in rural Bangladesh62.

Challenge in equity was detected with low receipt of JSY benefits among mothers in Odisha and Jharkhand area, India37. Receipt of the benefits is highly variable, not equally distributed, favoring wealthier groups. The JSY scheme is currently not sufficient to close the poor-rich gap in institutional delivery rate37. Shortage of human resources was a major health system barrier for implementation of National Rural Health Mission which implemented in India from 2005 to 2012 to reduce MCH inequalities 17.

c. Human resources

Inadequate healthcare workers including specialists was identified as a challenge for provision of better maternal and neonatal care in India, Nepal, Bangladesh, Indonesia, Timor-Leste and Myanmar 12,22,24,26,29,8,45,47,49,51,56,61,63,69,73. Shortage of staff is widespread in rural areas. Provider incompetence in emergency obstetric care and neonatal care are another problem detected by many researchers over the region21, 52. Lack of skills for post-delivery counseling is a challenge for provision of quality maternity care12. Suboptimal knowledge and skills among workers in the field leads to poor quality MCH 22,35,47,65, 68. Few social, professional and economic barriers are identified with midwifery personnel in Bangladesh which preventing quality maternity care53. Staff nurses involving maternal, newborn, and child healthcare in government public health facilities in Uttar Pradesh, India, are working in stressful environment which may lead to low quality of services 16.

d. Medical products

Several studies detected that lack of adequate supplies and drugs affects the quality in maternal and child care including family planning services in the region 12,22,38,51,56,60. Unavailability of medicines and therapeutic diet in facilities was detected as a challenge for management of SAM in Bangladesh 55.

e. Governance and leadership

Poor governance in birthing centers 45, lack of support from hospital administration 51 and less priority given on primary health care50 are the barriers identified in Nepal for good quality delivery and postpartum care. In Indonesia, decentralization of the health sector which created confusion regarding roles and responsibilities as well as complex administration process were identified as important factors which impede the quality care 64, 65. Vogel et al has identified that the deficiencies in policies and political context and deficiencies with accountability and monitoring as the barriers to implement WHO Maternal and perinatal health recommendations in Myanmar73. Health policy on maternal care are not focusing on adolescent pregnancy in Thailand. It is recognized as a challenge in provision of quality care for pregnant adolescent women 72. Pertaining to management of SAM in children in Bangladesh, there detected a conflict situation among nutrition stakeholders and problems in nutrition coordination 55.

Risk of bias assessment

The quality appraisal checklists developed by JBI cover the appropriateness of the research design and standard conceptions for assessing risk of bias and overall quality. The quality assessment helped to collect the strengths and weakness of the evidence summarized by the whole review. All quantitative studies included here are medium in quality due only to failure to identify and mention how they dealing with confounding factors. Twenty one out of 33 qualitative studies are medium due to lack of a statement on locating and influence of the researcher. However, research objectives, data collection and analysis and ethical aspects are presented nicely. Only one qualitative study failed to mention specifically in ethical approval even though other ethical aspects were mentioned 27. Nine quantitative studies out of 21(43%), 20 qualitative studies out of 33 (61%) and five mix method studies out of seven (71%) found to be of high quality studies. Altogether 34 (55%) studies had high quality. The rest of them were found to be medium quality studies. No study was excluded nor weighted due to quality assessment, but the quality is used to inform data interpretation.

Discussion

In this study we explored the successes and opportunities and the challenges encountered by SEAR countries towards UHC in MCH care. Results are presented according to WHO six building blocks; service delivery, health care financing, human resources, healthcare information, medical products and leadership, and governance, with regard to access, coverage, equity and quality of MCH care.

We have detected opportunities to increase access to MCH services throughout the SEAR: public and private partnership, availability of facilities, cultural changes and family support. Government led cash transfer programmes improve MCH. Inequity has reduced in MCH services. Quality of the MCH has improved with motivated human resources and with political priority.

Then we have detected a number of common challenges, which are preventing countries to achieving UHC in MCH services. Low health literacy, less ability to recognize post-partum issues, misconceptions and cultural barriers prevents mothers and children in SEAR from appropriate healthcare access. Difficult geography and transport problems, including high transport cost, worsens the condition. Poverty is detected as an overarching challenge throughout the region leading to health inequity. Poor infrastructure facilities and some administrative issues reduce the benefits from government led cash transfer programmes. Inequity in MCH care persists for vulnerable populations in the region even in state beneficiary programmes.

Healthcare facilities which are providing low quality services with fewer resources are the other major challenge. Poor infrastructure including buildings, laboratory and blood bank facilities, medical products and other supplies with high volume of patients vastly contribute to reduced quality. Unavailability of 24-hour services and inability to maintain privacy are the problems related to public facilities. Inadequate HCW has a major contribution to poor quality. Healthcare personnel’s inappropriate behaviors like negligence, abuse, corruption, poor relationships and unwillingness for change are attributing to poor quality. Poor knowledge and skills due to inadequate training and workplace stress of HCW has a contribution to poor quality. Lack of supervision is another challenge in quality. Deficiencies in government policies and administration were identified in some fields which hindering the quality services in MCH.

In order to address these challenges, regional countries have implemented several initiatives. Numerous cash transfer schemes in SEAR countries facilitate the maternal and childcare including institutional deliveries as detected in our review. It is tally with Hunter et al in their consolidated systematic review 74. Contracting non-government health providers is an important step in reducing maternal mortality in India. The finding is in line with data obtained from LMIC by Rao et al. 75.

Our review identified client perspectives such as lack of awareness and education as well as various cultural barriers as challenges for access to MCH care. These findings are consistent with results from reviews done in African countries76– 78, and LMIC79. This review also highlights the difficult geography and transport problems as a main barrier for access which comparable with number of reviews from LMIC including Africa 76,77,80,81.

We identified that the shortage of human resources was a major barrier for better quality MCH care. Our result is in line with findings from LMIC81, Sub-Saharan Africa 76 and a global situation analysis 82. Even in developed countries, lack of trained staff is a key challenge in maternal care in underserved areas 83. A systematic review published in 2019 on the effect of UHC on equitable access to care in African countries shows that shortages in human resources act as a main barrier in access to health services 77. Human resources are critical to the expansion of health service coverage as described by Campbell et al. 84. HCWs’ inappropriate behaviors such as rudeness, abuse, negligence, poor coordination etc. act as a challenge for quality as shown here. The findings are compatible with other reviews on MCH quality care throughout the world 76, 81,85. This review finds that infrastructure in healthcare facilities including buildings and different medical supplies affect the quality of care. This agrees with findings from few other studies in sub-Saharan Africa countries 76, 86 as well as from LMIC 81 and a global situation analysis 82.

The current review has the following strengths. To our knowledge, this is the first systematic review done on UHC in relation to MCH care in SEAR. The review accessed several databases and used recent publications less than 10 years old. It involved a large number of studies that covered different geographical areas in many SEAR countries. Methodologically, we included articles conducted with quantitative, qualitative, and mixed-methods study designs. Therefore, broader findings were represented rather than a homogeneous source. The studies included in this review have given remarkable findings on the present topic. More than half (55%, n = 34) of the studies were assessed as high quality while no poor quality studies. Quality of included articles was appraised using a standard quality appraisal tools developed by accredited institute and used in systematic reviews widely. Even though nearly half of the included studies were conducted in India, the generalizability will not affect once considering the population distribution. We strictly adhered to the inclusion and exclusion criteria in selection process, which improved the quality of our findings.

This review has some limitations. We could include only articles published in English and indexed in PubMed, CINAHL, Embase, Psych Info, and Scopus. Gray literature, including government reports, was not included in the review. Therefore a possibility that some relevant studies published in other language or indexed elsewhere been missed cannot be excluded. We were unable to include even a single papers from three countries in SEAR, as there were none detected in our search strategy. Further, we could not perform meta-analysis of the findings due to the heterogeneity of the outcome measures and methods employed.

Conclusion And Recommendations:

Overall, despite the above limitations, the study findings have important implications reaching UHC in MCH in the SEAR. As the shortage of HCWs is critical towards UHC, training and recruiting more staff is a priority in the region. However, a mere increase in the number will not improve the quality and accessibility of services as poor attitude and lack of skills have a major contribution. Therefore, persistent competencies, skills, and attitude development programs should be continuing throughout the service ages of HCW. For the countries in the region that have sufficient private sector health staff, contracting them in public maternal and child care will have a benefit to ultimately reaching UHC. However, these programmes should be supervised thoroughly.

Government led insurance schemes report increased utilization of MCH care in countries, even though there may be other interrelated factors which responsible for the improvement. Healthcare financing requires sustained investments on capital and recurrent budget for infrastructure facilities as well as government led insurance programmes. Cash transfer programmes involve handling of large amount of money. Hence administrators must be vigilant to minimize corruption in these programmes. It is recommended to regularly review health expenditure by the governments in MCH care and related spending to commitments. Investments on healthcare infrastructure including buildings, medical products and other equipment as well as capacity building programmes in staff and communities will lead to improve access, quality, equity and coverage in long run. Health insurance facilities should be made available for MCH care whenever possible as the poverty is an overarching barrier there. Special focus should be given in policy making on the under-privileged communities as they are more vulnerable to not getting due MCH care which eventually obstructing UHC.

The review has identified a large number of challenges, which impede health of mothers and children in the region. Effective implementation of strategies after controlling these challenges would lead to significant improvement in MCH care. We identified cultural and societal practices, which prevent provision of proper care to mothers and children. Therefore, it is recommended to incorporate culturally sound modifications in health system reforms wherever possible. Women should be empowered to take decisions of their healthcare as the other family members may support her. The findings suggest that the post-natal care has affected more than antenatal and natal care. The current and future efforts towards UHC in the region should be focused on post-natal care.

Solutions for some of the identified challenges are beyond the health system capacity, which need multi-sectorial approach. Low health literacy should be addressed even through early ages of life with education system. Due to the fact that more than quarter of the world population inhabit in the region, the high volume of patients are inevitable. Poverty elimination will be the most difficult goal to be achieved. As it persists due to geography of the country, difficult terrain issues are hard to solve with limited resources. They should be solved with long term strategies with the help of other authorities outside health. Transport problems including poor road structure, lack of vehicles and high cost of transport should be dealing with many other organizations in the government and non-governmental sectors. All the above mentioned non health solutions as well as health sector solutions are bound tightly with political decisions. Therefore, politics in the region should be supported with WHO and other global organizations.

Policy-makers and policy implementers should work together to strengthen the health system, and mitigate challenges. Inter-sectoral collaboration should be strengthened, and all stakeholders should cooperate and work together to overcome challenges that are observed at multiple levels. Political commitment by national as well as regional leaders is needed to build sustainable programmes that eventually lead to achievements of UHC in MCH care. Although the implications here are for whole SEAR countries, country specific interventions which are able to tackle specific challenges will be needed.

This review found that there is limited availability of quantitative evidence regarding UHC. Further no research could be found in three countries in the region. It is important to encourage SEAR countries to build capacity for research on UHC. Future researches on the exploration of new opportunities and challenges will be helpful to improve MCH not only in the SEAR, but the globally.

In conclusion, countries in SEAR have achievements in UHC with improvements of access, quality and equity on MCH. However, all have further way to go with the challenges on human and other resources, health care facilities and non-health related issues. Health care worker recruitments with continuous trainings and investments on health care programmes with due priority are a need of the time. Proper attention should be given to under privileged groups to minimize inequity. Regional bodies as well as authorities in individual countries should work together to address common major challenges. Ministries of Health in relevant countries, in collaboration with other stakeholders should take immediate actions to strengthen the access and quality of MCH in order to achieve UHC.

Abbreviations

ANC

Antenatal care

ASHA

Accredited Social Health Activists

CJY

Chiranjeevanie Yojana

HCW

Health care worker

HIMS

Health information management system

JBI

Joanna Briggs Institute

JSY

Janani Suraksha Yojana

LMIC

Low - and middle -income countries

MCH

Maternal and child health

NRHM

National Rural Health Mission

PRISMA

Preferred reporting items for Systematic reviews and Meta-Analyses

PROSPERO

Prospective Register of Systematic Reviews

RH

Reproductive health

SAM

Severe acute malnutrition

SC

Scheduled- caste

SDG-3

Third Sustainable Development Goal

SDG

Sustainable Development Goal

SEAR

South East Asian Region

UHC

Universal health coverage

UHCI

UHC services coverage index

WHO

World Health Organization

Declarations

Ethics approval and consent to participate     : Not applicable

Consent for publication                                  : Not applicable

Availability of data and materials                   : Data sharing is not applicable 

Competing interests                : None

Funding                                   : No funding was received for this work.

Authors' contributions             : UAPP and YA designed the study, selected articles, appraised the articles, and synthesized the data. UAPP wrote the first draft of the manuscript. UAPP, CG and YA interpreted the data and contributed the final writing of the manuscript. All authors read and approved the final manuscript.

Acknowledgements                : Staff of School of Public Health, the University of Queensland  

Authors' information               : UAPP is a visiting research fellow attached to the School of Public Health: YA is a senior lecturer in Global Health in the School of Public Health and CG is the Head of the school, the School of Public Health, The university of Queensland.

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