Closing the Gaps: From Science to Action in Maternal, Newborn, and Child Health in Africa

The previous papers in the PLoS Medicine series [1,2] demonstrate that the technical basis for improving maternal, newborn, and child health (MNCH) in sub-Saharan Africa is largely known, but too often policy and practice are not well informed by science. There are two distinct aspects to this ‘‘gap.’’ First there is a ‘‘science to policy and practice’’ gap. Accumulated scientific research on the severity of MNCH problems and strategies to promote MNCH has, at least in part, failed to ensure that MNCH reaches the domestic policy agendas of African countries, and stays there. Furthermore, local, context-specific evidence frequently is not applied in planning and programming interventions to address MNCH. Second there is a ‘‘policy to practice’’ gap: even where clear policy commitments to MNCH are made, there may be substantial challenges to getting such policies implemented. These include challenges related to stakeholder management through the implementation process and challenges associated with the negotiation of health system constraints. Many African countries face weakened health systems characterized by human resource shortages, dysfunctional drug supply systems, decaying health infrastructure, and weak supervisory and governance mechanisms. Consequently, the global community is currently strongly focused on strengthening health systems [3] so that they can provide adequate platforms for the delivery of a range of services, including MNCH. Our discussion focuses on the ‘‘science to policy and practice’’ gap, in the belief that action to address the second gap is already mobilized, although clearly not yet fully effective. In contrast, the first gap remains neglected. This article first addresses what is already known about how scientific evidence has influenced MNCH policy and practice, then it considers some of the key challenges in closing the science to policy and practice gap, and concludes by identifying promising paths for future action. Global and country-specific evidence on maternal and child mortality, service coverage, and effective interventions to improve MNCH has been key to stimulating greater global attention to these issues through monitoring efforts such as those of the Countdown group, which tracks progress towards the Millennium Development Goals (MDGs) that address MNCH. However, much more needs to be done to ensure that MNCH issues reach national policy agendas and that they remain a high priority given the importance of policy consistency in promoting the MNCH agenda [1]. The Countdown project assessed national policy for MNCH through select policy indicators (for example, the adoption and enactment of the International code on Marketing of Breast Milk Substitutes and the presence of a costed implementation plan for MNCH) [4]. It concluded that, while policies had improved in the 68 priority countries, policy environments were not yet fully supportive and a major gap remains between policy and action. Such indicators, however, are probably relatively insensitive measures of the true political priority given by African leaders to MNCH. Shiffman [5] analyzed the political priority given to maternal mortality. Through national-level interviews and document review he assessed the extent to which: (1) national political leaders expressed sustained concern for the issue; (2) the government enacted policies that embraced strategies to address the problem; and (3) the government allocated and released public budgets commensurate with the problem’s gravity. He rated the political priority accorded to maternal mortality as low in the one African country included in the study. Despite intensive global advocacy efforts, MNCH may not be a high policy priority for many African governments. Where there is commitment to MNCH and an intention to support action to address MNCH issues, African countries need to tailor strategies to match health system capacity. Local data need to be compiled and analyzed to guide how MNCH service packages can be integrated and delivered within the given resource constraints. Evidence as to the use of MNCH data in health planning is limited, but we know from multiple sources that, in general, data quality is poor and the use of data for planning and decision making is weak [6].