Maternal health gains limited by budget crunches and deadlines

On a scale of calm to chaotic, Kivunge hospital in Zanzibar, an island off the coast of Tanzania, clocks in around mild disorder.

On top of the dozens of people waiting at the clinic to see a doctor, there are men with power tools and women with paintbrushes working to renovate the crumbling building. It's a slow day in terms of patients, though, so each has a bed to themselves which wasn't the case just the week before.

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That some patients, including women in labour, have to share beds in Tanzanian hospitals isjust one of the reasons some choose not to use the health system and stick withtraditional healing or nothing at all.

For countries wishing to help, providing equipment might seem like a good place to start.

Through a UN fund to which several countries contributed, Canadian money helped UNICEF provide the Kivunge clinic an infant resuscitation unit and the training to use it. The fund also contributed to a new buildingto be used for outpatient care, not yet opened when CBC News visited, though ready for equipmentto move in.

But three years after the equipment and training were provided on the resuscitation unit, Kivunge's staff didn't know how to use it.

"The issue is with the training, because you train the midwives and then they are moved, even to other departments, not only to maternities [maternity wards] in other hospitals,"explained Francesca Morandini, the UNICEF field office chief in Zanzibar, who nevertheless pointed out the equipment has stillsaved the lives of many children.

The CBC's Laura Payton is this year's R.JamesTravers Fellow.The Travers Fellowshipprovided $25,000 in funding for her pitch to look at whether Canada's maternal, newborn and child health program was working. Read more about the series.

• Yesterday: Canadian aid sees results
• Thursday:Canada's family planning problem
• Friday:The trouble with Haiti
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"It's frustrating here, obviously, with the lack of stuff that I'm used to having,"she said.

Undeterred, UNICEF's Morandini discusses with Cusack whether there's anything she needs to make it work. Cusack says she's found an instructional video in Swahili and a doll on which the medical staff could practice using the equipment.

Measuring success on different levels

The problems at Kivunge hospital are not unusual in a developing country. Donors like Canada can contribute either directly or through a multilateral agency such as UNICEF but they can't be sure whether the equipment and infrastructure will be maintained or that staff will be kept up-to-date once the project ends.

In 2010, Canada pledged $2.85 billion for maternal, newborn and child health in the developing world, and it followed through on that commitment, which it called the Muskoka Initiative. It delivered the money, as tracked by the now-defunct North-South Institute, and the NGOs that received the funds can show the results: Small improvements, for the most part, over the two or three years for which the data was collected.

But a problem with trying to measure results is that the funded projects are so short: a five-year span in theory ended up running only two to three years by the time the money was awarded. And just as the projects start seeing results, it's time to call it quits.

After Prime Minister Stephen Harper announced the MuskokaInitiative in June, 2010, there was a 15-month lag beforehe announced which organizations had won fundingfor their projects.

At most three years after the projects got underway, the staff were closing down their offices, selling NGO vehicles and looking for new jobs. That's not a lot of time when they're trying to change a culture that eschews medical care.

While Canada has pledged another $3.5 billion for 2015 to 2020, the $370 million going to CanadianNGOshas yet to be awarded. The projects, even if they were to get a second phase of funding, will have already wrapped up.

Another concern is that Canada has cut its overall overseas development assistance to 0.24 per cent of gross national income, far short of the widely accepted global target of 0.7 per cent a goal the UK hit this year. And, Canada is on a downward trend: Canadian foreign aid in 2014 stood at $4.9 billion, down from $5.4 billion in 2013 and $5.7 billion in 2011.

'We need you. We are growing'

Some of the challenges that remain aren't for Canada to fix.

One problem is simply a lack of money.Tanzania doesn't have enough trained health-care workers to properly staff every rural and remote clinic in the country. It can't pay for equipment or new buildings. Many facilities lack running water, a major challenge for professionals who are trying not to spread germs.

Frustrated health-care workers, overworked and under-equipped, have been known to abuse patients, slapping women who are in labour or otherwise mistreating them. That deters some of the main targets of the world's maternal health efforts from seeking care when it is time to deliver their babies.

In oneregion, for example, the Tanzanian government had provided only 27 per cent of its budget with just two months left in the fiscal year.

"We have received money from the government, but it comes slowly, and not in time,"said Dr.GodfreyIgongo, acting district medical officer ofTabora'sIgungadistrict.

Every Tanzanian health professional or volunteer interviewed by CBC News said they aren't ready to stand on their own. Many pointed to the need for continued training.

"It's a challenge to maintain the success that has been obtained. We need you. We are growing. We are not able to walk [by] ourselves,"said Dr. Ernest Mugetta, an acting district medical officer in Tanzania's Singida region.

'We'll make it work somehow'

Tackling the staffingproblem could help resolve a lingering challenge, which is that maternal mortality hasn't dropped as quickly as infant or child mortality. In the developing world, 289,000 mothers died during labour or childbirth in 2013.

"Most of the newborn and maternal deaths happen around the time of delivery,"said Dr. Sudha Sharma, UNICEF's chief of health in Tanzania.

Sharma said that fact highlights the need for birthing centres that are open 24 hours a day and facilities that can provide emergency obstetric care a tall order in countries that have a hard time just paying health-care workers' salaries.

Kivunge, like many facilities in Tanzania, has its share of problems. There's a well-equipped lab, mostly unused by the Swedish NGO that built it, but which Kivunge staff aren't allowed to use. UNICEF's Morandini isn't happy with that. She has a friendwho knows somebody connected to the lab, andplans to lobby that person to let the hospital use it.

Surveying the challenges,Kivunge administratorPam Allard is calmly stoic.

"As we always do, we'll make it work somehow," she said.

It'sthat optimism and the energy of the people in the field who will make that happen.

• Tomorrow: Canada's family planning problem

The CBC's Laura Payton is this year's R.JamesTravers Fellow. The Travers Fellowship provided $25,000 in funding for her pitch to look at whether Canada's maternal, newborn and child health program was working. Read more about the project here.