Sabine Margarete Damerow

What question did you wish to answer with your thesis?

What did you find out?

First, we found impressive increases in the coverage of essential maternal and child health services during the health system strengthening initiative – which aimed at improving service accessibility and quality of care. However, coverage remained suboptimal, and homebirths remained common in rural Guinea-Bissau: Despite the initiative’s implementation, around half of all births continued to occur at home without skilled birth attendance.

This stands in contrast to our findings revealing that most health workers and women regarded health facilities as the ideal place of birth. In addition, we found that the coverage developments were not associated with the initiative’s implementation. Instead, the coverage increases may have been linked to general socioeconomic trends such as increases in maternal education and household wealth over time.

Meanwhile, perinatal mortality (stillbirths and child deaths during the first week of life) remained unchanged at an alarming level of approximately 80 deaths per 1,000 births despite the initiative’s implementation. We found several likely explanations for these findings: First, geographical and financial access barriers persisted during the initiative’s implementation and made maternal and child health services hard to attain, especially for poor women in rural areas.

Second, the same access barriers led to crucial delays to emergency care, which likely contributed to persisting high perinatal mortality. Third, quality of care was severely compromised due to material and human-resource constraints at health facilities, which likely further contributed to persisting high perinatal mortality.

How did you do it (your methods)?

How can your research be used (in the clinic/society etc.)?

First, our findings strengthen the call for real-life evaluations of health systems strengthening interventions: Despite health systems strengthening gaining increasing popularity as an approach to reduce maternal and child mortality in high-burden settings, such initiatives are frequently implemented on the grounds of “assumed effectiveness” – without much prioritisation of rigorous monitoring and evaluation.

However, health systems strengthening initiatives are often complex interventions which are implemented into typically equally complex contexts. This makes their effects hard to predict. In the case of the initiative we evaluated, effectiveness assumptions did not turn into real-life effects.

Instead, the findings from our assessments fall considerably short from the expectations of implementers and funders. Therefore, we show that rigorous monitoring and evaluation of health systems strengthening initiatives is “a must” to ensure the early detection of adverse developments, a purposive deployment of scarce global health resources, and learning from successes and failures.

Moreover, our findings reveal specific action points that need to be addressed to promote the accessibility of quality and potentially life-saving health services in rural Guinea-Bissau: the reduction of persisting geographical and financial barriers to care.