Time and again, it has been shown that when governments take the lead and are committed to expanding successful pilot and small-scale projects, these initiatives can rapidly gain nationwide coverage. Brazil’s community health worker programme and the Bolsa Familia initiative; Mexico’s health, nutrition and education programme, PROGRESA, and its Seguro Popular de Salud health insurance scheme; Indonesia’s community health workers and Egypt’s oral rehydration initiatives are just some examples that show the potential for scale-up when governments are willing to commit even scarce funding to health and social welfare programmes.

Given the level of resources required to ensure access to quality primary health-care services and financial protection, scaling up is as much a political challenge as it is a technical one. Sustained improvements in maternal, newborn and child health will necessitate long-term commitments that go well beyond the political lifespan of many decision makers. Countries including Brazil, Sri Lanka and Thailand have rooted their impressive results in a step-by-step extension of health-system coverage and nutrition services over many years. Most of these countries went through several distinct phases:

  • Building up a cadre of professional health workers as the foundation.
  • Developing an accessible network of community-based, primary and referral-level services.
  • Improving the quality of care, along with improvements in living conditions and the status of women.
  • Providing broad social safety nets that ensured equitable access to health, nutrition and education, making health and nutrition services widely available.
  • Reducing barriers to key services and providing primary and secondary schooling to all children.

Even in some of the poorest countries in Latin America, where economic crises, institutional deficiencies and wide socio-economic disparities continue to hinder advances, there has been marked progress towards generalized access to quality health care. Country ownership and public sector leadership can vastly increase the prospects for successful scaling up.

Ownership is more than just funding

Governments must also be committed to supporting health programs at each level of health-system administration – federal, provincial and district. The issue of the sustainability of health programme commitments must also be addressed. Enshrining national commitments in a legal framework can provide the necessary continuity in support of scaling up the continuum of care beyond the political lifespan of its initial champions. This longer-term political agenda requires partnerships between government, civil society organizations and development agencies to maintain the political momentum, overcome resistance to change and mobilize resources. A well functioning health system also requires accountability mechanisms and checks and balances. Finally, sustained investment in both time and resources is required over many years to steadily take programmes to scale. Key examples of such commitment include Sri Lanka’s 50-year project to create a rural health network and Nepal’s long-standing campaigns on micronutrient supplementation.

Leadership in different forms

Many of the countries struggling to meet the MDGs, particularly in sub-Saharan Africa, do not enjoy political or economic stability. Under such circumstances, it is important to mobilize all forms of effective leadership in society. Leadership can come in many different forms: from an individual, such as Fazle Hasan Abed, the founder of BRAC, a successful community health programme that provides essential health-care services to millions in Bangladesh; from the highest levels of national government, as was the case in Mexico, whose PROGRESA programme was championed by President Ernesto Zedillo de Leon and maintained and expanded by his successors, Vicente Fox and Felipe Calderón; from international quarters, such as the Expanded Programme on Immunization, the child survival revolution and GOBI (growth monitoring, oral rehydration therapy, breastfeeding and immunization), and from the multiplicity of global partnerships and programmes for various diseases over the past six decades.

The international community knows how to set the agenda – witness how the MDGs were derived from the Millennium Declaration and have become the benchmark for human development in the early years of the 21st century. But, at the midpoint of the goals, there is still a gap between intention and action and a need to unite in support of strategies, policies and progress that will help rapidly scale up access to a continuum of quality health care.

Learn about national salt iodization in Turkmenistan