September 2006, Istanbul Helena Hofbauer Fundar, Centro de Análisis e Investigación

1. Using budget analysis to monitor the reduction of maternal mortality: Fundar’s experience in Mexico September 2006, Istanbul Helena Hofbauer Fundar, Centro de Análisis e Investigación www.fundar.org.mx

2. Most governments have made policy commitments regarding the reduction of maternal mortality, recognizing important elements such as skilled care, emergency transportation and emergency obstetric care (EmOC). • Despite the fact that the policy implications of these elements can be traced and monitored through the budget, little attention has been devoted to the allocation of resources. • Budgets are key instruments to assess how governments comply with their commitments to improve maternal health and reduce maternal mortality in practice, and how adopted policies translate into concrete actions. www.fundar.org.mx

3. The relationship between reducing MM and the budget: • Policy level: • Ensure that safe motherhood policies find adequate reflection in the budget. • Implementation level: • Monitoring and assessment of the delivery of services. • Systemic level: • Increase transparency and accountability. • Advocacy level: • The budget puts priorities into perspective. www.fundar.org.mx

4. The Mexican context • In 2001, 5 women died every day in Mexico due to complications with pregnancy, birth or post-partum. • 65% of the women that died lacked access to social security (unemployed or informally employed). • 49 % of all cases happened in communities with less than 15,000 inhabitants. • 21 % of maternal deaths took place at home, due to hypertension and hemorrhage. • 67.3% of the pregnant women registered were located in the southern and southeastern states of the country, where a significant number of inhabitants are indigenous and reside in conditions of extreme poverty in rural areas. The estimated MM rate for 2003 was 6.2 per 10,000 estimated births, which is the same as the rate observed in 1990. www.fundar.org.mx

5. Focus on programs that could offer maternal health care to unemployed population living in small communities in the southern states of Mexico. Ministry of Health implemented several “Basic Health Packages” (PAC—Program to Expand Health Coverage) that have reproductive and infant health components, and specific efforts to reduce maternal mortality (Arranque Parejo—Fair Start in Life) Finding the policy in the budget… www.fundar.org.mx

6. How does the budget look at the implementation level? • Skilled care indicator: are the capacities that are needed to reduce maternal mortality in place? (Analysis of the resources distributed and decentralized by the federal government) • Investment in health infrastructure is poor and uneven among states • Sometimes there is no capital expenditure at all • Qualified health personnel is scarce in states with higher rates of MM: one doctor per 14,555 persons in Chiapas, in contrats with one doctor per 2,430 persosns in Durango. www.fundar.org.mx

7. www.fundar.org.mx

8. Program to Expand Health Coverage • Prevention and health promotion is prioritized over curative interventions. • Low Cost and High Impact (cost-effectiveness). • Operated in Mexico from 1996 – 2002. • Objective: expand health coverage to marginalized areas with no previous access to health services. • Prenatal, childbirth, postpartum and infant care (one of 13 interventions).

9. Cost estimate - Oaxaca Objective: to estimate the cost of childbirth for poor pregnant women in Oaxaca (one of the 3 highest MMR) Direct versus indirect costs • Direct costs: service fees for medical consultations, medicine, lab exams, use of installations, etc. • Indirect costs: Time spent seeking medical care; transportation, lodging and food, etc. Direct costs are covered by the program (tetanus toxoid, iron, folic acid, and skilled attendance at birth), while indirect costs are covered by women and their families.

10. Cost estimate – Oaxaca – results • Women have to pay for basic health services needed for healthy, normal pregnancies, such as lab exams. • The cost of hospital childbirth ranges from 4,600 and 6,145 pesos, for families whose income is between 100 and 2,000 pesos. • The State saves, but women and their families must pay the difference in order to access basichealth services • In 2001, fees paid by poor women equalled more than 20% of the total PAC budget for Oaxaca. • Poor women and their families spent the equivalent of 61% of the entire PAC budget on transportation and lodging.

11. Advocacy level • In terms of advocacy, being able to illustrate the shortcomings of the health budget concretely, and put them in comparison with other areas of expenditure has been crucial. • It has fostered alliances with a variety of sectors, including health officials themselves. • In 2001, the Navy and the Defense Department increased their spending in infrastructure by 24.9% and 17.2%, respectively, compared to their original budget. • The Ministry of Health, in contrast, failed to use 51.4% of its money for the development of needed infrastructure. www.fundar.org.mx

12. Budget spent on infrastructure, in relation to approved budget (2001) www.fundar.org.mx

13. General findings of the Mexican initiative: • By analyzing the budget in relation to the elements that are needed to implement safe motherhood policies we can identify why some of the efforts are failing. • In many cases, shortcomings are directly related to a non-functional health system, in which the distribution of human, monetary and infrastructure resources is very unequal. • Under this perspective, preventing the death of women due to pregnancy, birth and its afterwards can be achieved by targeted efforts only to a limited extent. • Even though general health conditions can be improved by targeted programs, events that require the immediate availability of health services and emergency solving capacities will continue to be a challenge, unless access to first and second levels of attention is improved. www.fundar.org.mx

14. The Mexican initiative that monitors the public budget and its impact on maternal health has been resting on the following researchers: • Daniela Díaz, coordinator, Fundar • Graciela Freyermuth and Cecilia de la Torre, CIESAS-Sureste, Chiapas • Martha Castañeda, Nääxiwiin, Oaxaca • David Meléndez, Hilda Reyes and Carlos Reyes, Instituto Nacional de Perinatología