*4.2.2 Maternal and child health in sub-Saharan Africa: country-level commitments and progress*

The last section focused on the highest level of commitment, the AU agenda. The most functional level, the country level, is pivotal in implementing sound programs and policies to expect progress in MCH indicators. The section expands on the previous one and borrows main ideas from **Figure 5**. The enabling environment is critical for a country to achieve optimal maternal and child health, while significantly reducing the poor-rich inequality and eliminating urban advantage. But in this search of the "quality of MCH," what is the best enabling mechanism? Of course, education, health, economics, and governance are all important. However, to optimize the achievement of universal health coverage within the lens of MCH, national governments should decide where or what to focus on first and foremost. What need to be done to efficiently utilize resources to create good quality of MCH services? How long did it take to reach SDG-3?

These questions are complementary but even more complex. For instance, what will be the added value in terms of MCH outcomes when healthcare workforce is well trained but not well paid? Just take a minute and think about the Arab spring and all consequences of the long-term frustration in the region, which have devastated the fragile economies. There is an urgent need to critically think of the best way to articulate education and motivation in the health sector in SSA countries. Relatedly, what will happen if human resources are well trained but are employed in small jobs that do not fit their skills? It is a human being instinct to survive. If a well-trained health professional cannot find a job that really fits his/her skills, he/she will take whichever given job to survive. This impeding situation will lead to demotivation and less productivity as the individual will always be thinking of another work and will not be

#### *The Role of Leadership in Sub-Saharan Africa in Promoting Maternal and Child Health DOI: http://dx.doi.org/10.5772/intechopen.105773*

creative as he/she would have been in a job-matching context. In this case, education has a less added value than in a conducive environment.

The paper posits that what happened in "Asian Tigers" to put their economies in right paths and implement sound policies that improved population wellbeing and health is a "manifestation of enlightened and strong leadership," which was able to guide public opinions and behaviors. In 2015, African Union for Population Studies (UAPS) organized its 7th Population Conference in Pretoria (South Africa) under the theme "Demographic dividend in Africa: Prospects, opportunities, and challenges" which registered a high number of papers and presentations, and interesting debate about how sub-Saharan Africa can reap demographic dividend. Dr. Prata presented a paper entitled "Access to family planning and women's health." Using a graph from a previous study to illustrate the relationship between fertility, contraception, and abortion in Korea between 1960 and 2000 [71], Dr. Prata pointed out a striking fact in her presentation to highlight the major differences between SSA countries and the Asian Tigers. The Korean experience showed that the initial stage of fertility decline was accompanied by both increases in contraception and abortion for more than 15 years. However, the difference between SSA and Korea was that Korean women had access to safe abortion, while SSA still experience unsafe and high abortion rates. This illustration symbolizes how policy decisions may have greater impact than simple vows.

Back to our question about the gradient among the enablers and put differently, while the world is vibrating at the rhythm of SDGs and demographic dividend, the paper assumes that "Governance" should be the most important pillar to drive the necessary and sufficient decisions for SSA countries to reach SDG-3. Let us use malaria as a simple case for illustration. It is well known that malaria still is one of the major causes of death in SSA account for 94% of deaths [72], and it is also well known that SSA countries have poorest MCH indicators worldwide. This endemic illness costs to Africa, the poorest continent of the planet, an amount of \$US 12 billion in lost productivity and health expenditures per year [71]. It means that if SSA countries have worked together to find sustainable ways to fight malaria, they could have been able to save up to \$US 12 billion to invest in other productive sectors to boost their economies and improve MCH outcomes. Likewise, better housing and investments in clean environments can mitigate the reproduction of mosquitoes in rural and urban areas and could have saved lives and money.

Both scientists and policymakers however are hiding behind the broad theme of "enabling environment" and unable to decode the black box "Enabling Environment." The terms "governance" seems vague and confusing in some sense, and it has become a condition for international aid. As seen rhetorically, it means "democracy" or "change of regime." Many SSA countries have witnessed changes of regime in the last decade; however, does it really mean "governance" or "good governance"? Admittedly, democracy and change of regime are ingredient to governance, but a transformational leadership capable to guide the countries in the right direction and responsibly address the bottlenecks impeding economic growth to improve population wellbeing is blatantly lacking in the region. SSA has experienced an average growth rate on gross domestic product (GDP); yet most of SSA countries have the lowest Human Development Index (HDI). That is what makes the difference between the Asian Tigers and SSA countries. Strong and transformational leadership in Asian Tigers had a vision and took the necessary policies to change their business models and boost economic growth. In SSA, it is intriguing that countries do not learn from

past experiences: slavery, structural adjustment programs, democratization, political instability, and so on. All those factors are key to understand SSA's history and should guide our vision for the future. The same recipes will always produce to some extent the same results. SSA countries experienced very bad results worldwide on MDGs; they will likely experience the worst results for SDGs. Therefore, SDG-3 will be a futile slogan if there is no radical political shift of leadership in SSA countries. The problem is well known: SSA is suffering from a very poor leadership without a vision of what the governments want for their countries to stand for in the next few decades. SSA countries are comparable to machines without captains. Are we going to expect miracles without a clear roadmap? Absolutely not! Therefore, it is important for SSA governments to stop and see what they are doing well, and mostly what does not help their nations. SSA countries have the potential to reap demographic dividend; however, that should be accompanied by a shift in political will leading to a strong leadership and decisions benefiting the countries.
