Over the past two decades, Portugal has become one of the world leaders in organ donation and transplantation despite significant financial constraints. This study highlights how Portugal achieved success in organ donation and transplantation and discusses how this information might be used by other countries that are seeking to reform their national programs. To accomplish this goal, we performed a narrative review of relevant academic and grey literature and revised our results after consultation with two national experts. Our findings were then synthesized according to a conceptual framework for organ donation and transplantation programs. Our results revealed several key strategies used by the Portuguese organ donation and transplantation program, including collaboration with Spain and other European nations, a focus on tertiary prevention, and sustained financial commitment. This report also explores how cooperative efforts were facilitated by geographical, governmental, and cultural proximity to Spain, a world leader in organ donation and transplantation. In conclusion, our review of the Portuguese experience provides insight into the development of organ donation and transplantation systems. However, other countries seeking to reform their national transplant systems will need to adapt these policies and practices to align with their unique cultures and contexts.  Efforts to develop a high-functioning organ donation and transplantation program require specific investments, including those focused on reimbursement of staff and facilities, infrastructure, robust governing structures, research and development, and digital information technology (IT) . HoweverThe paper aims to provide an updated review of the critical features of the Portuguese program that have led to its status as a world leader in organ donation and transplantation The goal is to describe and discuss insights that might be of use to other countries, notably those that share similar demographics and financial constraints.Our report on the Portuguese transplant program is based on an in-depth study that was initially designed to provide a comprehensive review of the organ donation and transplantation program in Greece . As partvia a Google search. An additional database search was then performed using Medline, Web of Science, and Google Scholar to identify relevant academic literature.We began by conducting a narrative literature review of relevant academic and grey literature, including published reviews that discussed the Portuguese organ donor and transplant system. We performed a search of relevant websites including those maintained by the Portuguese government, the Ministry of Health, and the Instituto Portugues do Sangue e da Transplantação; policy reports that focused on donation reform in Portugal were retrieved We then reviewed our findings with two experts on the Portuguese organ donation and transplantation program (coauthors Dr Jorge Paulino and Dr Ana Franca). These experts were each invited to present key features of the Portuguese transplant system in an online interview. They also answered questions and provided feedback and additional materials such as national statistics or legislative documents.In the following sections, we first outline the main advances and achievements of the Portuguese transplant system. We then describe key elements and insights provided by the Portuguese organ donation and transplantation program. These insights are presented according to the domains of a conceptual framework for transplant systems described by Johnston-Webber et al. as shown in According to Johnston-Webber et al. , the maiAs has been described for other successful programs, the current Portuguese system is the result of many years of planning, development, and review. An overview of the main advances over the past few decades will be helpful to build an understanding of the structure of the program as it stands today. The following sections provide an overview of the key features of the Portuguese program identified in this study as playing important roles in promoting its success .The Portuguese program was initiated in 1993 and is broadly based on the Spanish model which has been the source of many of its key features .via a dedicated registry for non-donors which is maintained by the Ministry of health . Citizens who do not want to be organ donors can declare their will f health . HoweverIn 1993, Portugal implemented the national transplant body which included five regional offices . Followivia national and international schemes that build on existing resources such as the Donation and Transplantation Institute - Transplantation Procurement Management (DTI-TPM) program, Barcelona  and training organ donation coordinators in conducting family consultations , 14, 15.Second, The Portuguese authorities have consistently endeavored to include the public and stakeholders from civil society such as religious groups or patient organizations to dispel misconceptions regarding organ donation and win the trust of the public , 27. The“The quality and safety of organ transplantation depends on the time required for transport, a factor that is crucial in this mission. Therefore, it is the responsibility of the GNR, and in respect of security conditions, to reach the destination in the shortest time possible, thus contributing to saving yet another life. In this noble mission, this year 2021 alone, the GNR has already carried out 135 transportations of organs, involving 271 soldiers, having covered approximately 37 342 kilometres. In 2020, the GNR transported 240 organs, engaged 478 soldiers and covered 64,133 kilometres” .Together, these measures have helped to gain the trust of the general public in Portugal.Portugal has maintained several fruitful international collaborations in the field of organ donation and transplantation. Portugal has participated in multiple EU-funded programs that were included as part of the “EU Action Plan on Organ Donation and Transplantation” (18). Specifically, Portugal has improved its quality assurance system based on a European analysis of end-of-life care practices and an EU-funded indicator-driven quality improvement initiative -32. MoreIn the 2000s, donation rates in Portugal increased steadily along with a set of structural reforms that included general investment in the donation and the transplantation sector, and the introduction of reimbursement for relevant donation activity . UnfortuThe Portuguese transplant authorities have successfully implemented a multi-functional IT platform that supports clinical pathways associated with organ donation and transplantation . The IT platform provides access to a consent registry, patient records , and a real-time clinical workflow system that can be used to document, illustrate, and provide timing for all relevant clinical processes from organ procurement to transplantation. Thus, this IT platform provides critical support for healthcare professionals as it facilitates rapid and safe communication between all clinicians involved in this process. The platform also helps the transplant authorities to track and document critical processes and serves as a tool to support quality improvement and biovigilance. The data collected can also be used for research purposes .Taken together, the Portuguese system illustrates the advantages of implementing robust IT systems to support organ donation and transplantation. The Portuguese experience suggests that the investment needed to establish a functional digital infrastructure will be worth the costs as it will ultimately facilitate the management of complex clinical protocols.Despite its success in providing kidney transplants, Portugal is currently home to the highest percentage of patients maintained on renal replacement therapy in all of Europe . In respOur results suggest that countries seeking to reform their national programs might take demand-side measures into account and focus concerted efforts toward improving the care of patients who might otherwise eventually require an organ transplant. As illustrated by the Portuguese example, these efforts not only help to improve patient care but will also result in reduced costs for the healthcare system.In recent years, Portugal has aimed to increase the rates of living donation and donation after circulatory death (DCD) as a way to complement its successful deceased donation after brain death program.All living donation programs will need to prioritize the implementation of measures that safeguard donor rights and psychosocial wellbeing. In Portugal, a protocol was established in 2015 that included a psychiatric evaluation both before and after live donation . This crSimilarly, DCD only plays a limited role in the Portuguese transplant system. In 2013, the Ministry of Health implemented DCD in cooperation with the professional societies of intensive care medicine, nursing, and emergency services. However, due to ethical considerations brought forward by the National Council of Ethics in Life Sciences and a strong role of the National Institute for Medical Emergency, it was decided to restrict DCD to uncontrolled DCD . Hence, Taken together, both living donation and DCD only play a minor role in the Portuguese transplant system. However, both areas have been identified as areas of reform and will potentially become more important in the near future.The responses of the Portuguese health system to the COVID-19 pandemic included far-reaching containment measures involving two full lockdowns, a mobilization of resources to support the health system, a hierarchical vaccination program, and digital measures to improve contact tracing and telemedicine . While tAs might be expected, transplantation rates fell sharply following both the first as well as second waves of the pandemic  . This reCollectively, these developments document the notable impact of the COVID-19 pandemic on transplantation rates in Portugal. This was accompanied by a rapid recovery of transplant capacity once peak virus transmission had passed.Consistent with findings presented in previous analyses of the Portuguese organ donation and transplantation program, the results of our study demonstrate the importance of a set of core reforms that were successfully adapted from the Spanish model. In general, an integrated national health system that provides broad coverage, sufficient funding, technical infrastructure, comparatively low labor costs, the potential to provide financial incentives to participating clinical staff, and similar baseline demographics have been suggested to facilitate adoption of the Spanish model . These fvia negotiation  beds given the size of its population. When donation rates in Portugal peaked in 2010, the number of available ICU beds in Spain . Howeverin Spain , 58. Thiin Spain . TherefoAge and health status of the general population and the number of fatal accidents are relevant parameters in organ donation and transplantation . In PortAt the same time, there has been a significant reduction in the number of fatal traffic accidents in the country over the past 20 years . AccordiIn summary, an aging demographic in Portugal may serve to maintain a sufficient pool of potential donors, compensating for a decrease in trauma-related deaths. However, donations from elderly, comorbid donors may lead to challenges regarding the quality of organs in the future.Finally, largely due to their geographic proximity, Spain and Portugal share numerous cultural features, including a similar history of governmental and economic development in the 19th through the 21st centuries  as well Taken together, Portugal fulfills many criteria that have been suggested to facilitate the adoption of the Spanish model. This may provide at least a partial explanation of Portugal’s success compared to that experienced by European countries of similar size and with similar financial resources.The findings presented in this study are based on a comprehensive contemporary review of the Portuguese organ donation and transplantation program. Our results reflect a broad range of evidence, including a thorough search of both the academic and grey literature followed by expert review and synthesis using a multi-dimensional framework approach. The study summarizes key features of the program, including some findings that were described in previous analyses. Our study also highlights several complementary aspects and recent developments in Portugal. However, among the limitations of this study, we were unable to explore the post-transplant follow-up or research and development and focused on the time period prior to the disruption of COVID-19. Future studies of the Portuguese organ donor and transplant system might focus on post-transplant follow-up, and the role of professional societies in Portugal and might cover more recent developments in more detail.In conclusion, Portugal has become a world leader in organ donation and transplantation largely because of its successful adaptation and adoption of the main components of the highly effective Spanish system. Thus, the Portuguese experience provides a valuable example to other countries with modest resources seeking to achieve higher rates of donation and transplantation. As outlined above, the Portuguese case provides evidence to support the implementation of a specific set of reforms that may also be used in other settings and contexts. However, Portugal has benefitted from several conditions that have facilitated its strong partnership with Spain and the successful implementation of the Spanish model. These advantages include its close cultural and geographical proximity in the Iberian peninsula as well as a similar economy and health system structure. We recognize that this situation is unique and that other countries may not necessarily have the capacity to build on these specific factors. Thus, while countries seeking to reform their national transplant systems should certainly be inspired by the Portuguese example, they also need to accommodate for local context and build on their individual strengths.


The Philippines has enacted maternity protection policies, such as the 105-Day Expanded Maternity Leave Law and the Expanded Breastfeeding Promotion Act of 2009, to protect, promote, and support breastfeeding. This study aimed to review the content and implementation of maternity protection policies in the Philippines and assess their role in enabling recommended breastfeeding practices. It also identified bottlenecks to successful implementation from the perspectives of mothers and their partners, employers, and authorities from the government and non-government organizations involved in developing, implementing, monitoring, and enforcing maternity protection policies.This study employed a desk review of policies, guidelines, and related documents on maternity protection, and in-depth interviews. Of the 87 in-depth interviews, there were 12 employed pregnant women, 29 mothers of infants, 15 partners of the mothers, 12 employers and 19 key informants from the government and non-government organizations. Respondents for the in-depth interviews were from the Greater Manila Area and were recruited using purposive snowball sampling. Data were collected from December 2020 to April 2021.The study shows that maternity protection policies in the Philippines are mostly aligned with the maternity protection standards set by the International Labour Organization. However, their role in improving breastfeeding practices is limited because: (1) not all working women have access to maternity protection entitlements; (2) the duration of maternity leave entitlements is inconsistent with the World Health Organization’s recommended duration of exclusive breastfeeding; (3) there are gaps in policy implementation including: a lack of monitoring systems to measure the availability, functionality, and usage of lactation spaces; limited workplace support for breastfeeding; poor communication of maternity and paternity entitlements; and limited breastfeeding advocacy and promotion; and (4) there is limited integration between maternity protection and breastfeeding promotion interventions.There is a need to (1) strengthen communication about and promotion of maternity and paternity entitlements for mothers, fathers and employers, (2) improve monitoring and enforcement mechanisms to ensure utilization of entitlements among mothers, (3) develop modalities to extend the coverage of maternity entitlements to the informal sector, (4) fully cover paid leave entitlements from social insurance or public funding sources in line with International Labour Organization recommendations, and (5) revisit the limitations on the coverage of paternity entitlement.The online version contains supplementary material available at 10.1186/s13006-023-00594-w. Despite established evidence of the protections that breastfeeding provides to the mother and child , the gloAccording to a report published by the International Labour Organization (ILO) , 120 couLonger duration of paid maternity leave is associated with reduced infant mortality, improved physical and mental health among mothers, and improved breastfeeding practices –13. In lMaternity leave, along with paternity and other parental leave, is also a form of care leave that allows parents to take care of their children without having to relinquish employment . CurrentThe provision of time, space, and support for breastfeeding for working mothers when they return to work is associated with improved breastfeeding practices –19. The Legislation on maternity protection and workplace lactation support in the country exists, but there has been no study conducted on the effects of these policies on breastfeeding practices of working mothers. This study was conducted to review the content and implementation of maternity protection policies in the Philippines and assess their role in enabling recommended breastfeeding practices, including their potential impact on improving breastfeeding support for working women. The study also aimed to identify bottlenecks to successful implementation from the perspectives of mothers and their partners, and employers, as well as government and non-government organization authorities involved in the development, implementation, monitoring, and enforcement of maternity protection policies.The data collection, analysis and interpretation were guided by a conceptual model for this study published in a research protocol by Nguyen et al. . The conThe Philippines is an archipelagic country located in Southeast Asia with an estimated population of 115.6 million . ClassifDue to restrictions placed to prevent the spread of COVID-19 during the data gathering period, the coverage of the study was limited to study sites within the Greater Manila Area . These regions were among those with the lowest exclusive breastfeeding rates . The GreData were gathered for the desk review from December 2020 - April 2021. Copies of policies, laws, survey reports, and program documents relevant to maternity protection were retrieved from national and local government offices. The effectivity date, legal status, coverage, implementation strategies, and monitoring guidelines were sourced from these documents. The extracted information was compared with the standards set in Convention No. 183 and Recommendation No. 191. Data on the number and proportion of working mothers receiving maternity entitlements and details related to monitoring and reporting were retrieved from agencies or their official websites. In addition, we reviewed information on the implementation, coverage, monitoring, and enforcement of those policies.Purposive snowball sampling was used to select respondents for IDIs. We conducted IDIs with 87 respondents. Eighty-two of the interviews were audio recorded, and 48 were face-to-face interviews Table . The resThe mode and criteria for selection per type of respondents are enumerated below:This included pregnant women who were at least 18 years of age at the time of the interview; and mothers of infants less than 12 months old who were at least 18 years of age at the time of interview and their partners. They were approached by the staff of the Nutrition Center of the Philippines (NCP) through spot mapping, referral by local health centers, or personal contacts within the communities in the study area (Greater Manila Area). Participant selection considered diversity in employment status (full-time/part-time), work set-up (work from home/online/in person), and current breastfeeding practices (breastfeeding/not breastfeeding/mixed feeding). Working mothers were interviewed away from their workplaces  to reduce bias in responses.The interviewed employers were identified through referral by regional program managers of health, national employers’ associations, and personal contacts of NCP staff and were interviewed outside their workplaces to reduce bias in responses. The employers were either leaders, general managers, or human resources personnel of workplaces with at least 50 female employees located within Greater Manila Area.This group of respondents included authorities from the government, representatives of non-government organizations participating in the development, implementation, monitoring, and enforcement of maternity protection policies in the country. The NCP, in consultation with Alive & Thrive, prepared the list of key informants which included representatives from the Philippine Senate, Department of Health (DOH), DOLE, Civil Service Commission (CSC), UNICEF, World Health Organization (WHO), ILO, Social Security System (SSS), and other relevant organizations.Respondents were contacted either through email, telephone, or face-to-face. All refusals were replaced with other candidates until the minimum number of respondents per type of respondent was met. The language used in the majority of the interviews was Filipino.Before the interview was scheduled, each participant was oriented on the purpose and procedure for the IDI, including the confidentiality of the collected information and the use of anonymized information for the study. Respondents were provided with an informed consent form either in-person or via email. The signed informed consent forms were collected prior to the conduct of the interviews. Six interviewers hired by the research team, who happened to be all female, conducted the IDIs. They were all experienced in data collection including in the conduct of IDIs and have undergone specific training before the conduct of the IDIs for this research. All interviews were one-on-one interviews. Each interview took around an hour to finish and was done either online or onsite, according to the respondents’ preference. Verbal consent for the interview and audio recording was audio-recorded at the time of the interview. Participants who consented to the interview were assigned a personal identification number (PIN), which was linked to the personal data collected from each participant. These data are password protected and are only accessible to the research team. Interviews were conducted between 3 December 2020 and 17 March 2021. IDI respondents were given cash tokens worth 3.7 USD for their participation. Table Audio recordings were uploaded to an internet-based storage drive accessible only by authorized team members and transcribed in the language used during the interview. Full transcripts were also translated into English, as needed. Nvivo software  was used to analyze the transcriptions. Line-by-line initial coding of each transcript was done until theoretical saturation was monitored, and the emerging themes were identified. Each transcript was coded independently by two coders. The identified themes from the two coders were compared and discussed by the team and reviewed against data collected from initial key findings of the team and available documents to produce more selective conceptual codes to explain larger segments of data. The results of the IDIs were then compared with the findings from the desk review to identify common themes and related findings.Out of 87 in-depth interviews, 66 respondents were female Table . The motStudy results are presented by theme, based on the combined analysis of the findings of the desk review and the IDIs.Maternity protection policies in the Philippines are aligned with most of the standards set in ILO Convention 183  , the govA timeline of the enacted maternity protection provisions is presented in Fig. Despite recent policy improvements, the ILO’s recommendation that maternity entitlements must cover the majority of working women has not been met. Maternity leave cash entitlements for private and informal sector workers were only granted to mothers enrolled in SSS with at least three-monthly contributions paid in the 12-month period preceding the semester of childbirth . MembersMothers under contract employment, such as independent contractors or freelance employees whose SSS contributions were not updated, were not eligible to receive maternity entitlements. Some respondents reported negotiating maternity leave duration that is less than the mandated 105 days and not receiving any cash payments during leave.I am just new here, under Job Order, so I don’t have these. They only provided me 3 months [of maternity leave], but it does not have maternity pay. So, I didn’t have a salary [while on maternity leave]. Interviews with female employees also revealed that some employers used short-term contracts to avoid provision of maternity entitlements to employees.From what I heard in the factory, they don’t pay contributions for the benefits. Because I know in the factory, contracts end every 5–6 months, after which they will have to be renewed again. Most respondents were not aware of how self-employed workers, such as street vendors and farmers, could access maternity entitlements. There was limited awareness of the SSS mechanism among interviewed self-employed parents. Those who had self-enrolled in SSS faced difficulty maintaining the monthly contributions.I think it will only interfere to our daily needs if we will have to pay [SSS contributions]. Most IDI respondents from the informal sector were more aware of and utilized PhilHealth medical entitlements for childbirth compared to maternity leave entitlements from social security programs.Most fathers were not aware of their right to paternity leave and related entitlements. Among those who were aware, respondents mentioned barriers to accessing entitlements, including not being legally married, as required by the Paternity Leave Act; or working in the informal sector. One respondent also mentioned the type of employment of the mother as the reason for his ineligibility to receive paternity leave entitlements, a violation of the law since there is no such requirement.In our delivery service company, we don’t have something like that [paternity leave entitlement], we were just like business partners with them, but we were not employed under them. I asked the HR (human resources) before, she said I can only avail paternity leave when my wife receives maternity leave. Employers, mothers, and fathers mentioned the following advantages of maternity entitlements: longer bonding time with their infants; increased time for mother to recuperate; and financial support. Only a few specifically mentioned increased time for breastfeeding as one of the benefits. Employers also mentioned benefits of maternity protection policies including increased employee morale; improved maternal and child health; good publicity to recruit and keep talented workers; and removal of the burden of choice between career or family.It positively impacts the bonding between the mother and child. . we have what we called milestones that any mother would not want to miss with their child. It will also help psychologically, since you have a sense of security. Mothers usually experience postpartum [depression] at this time. And it will help if they have period to rest. By receiving these kind of [maternity] benefits, the employee would feel valued and cared by their company. I think they will give it back and do their work better as an appreciation to their company. Some employers felt that having female employees go on maternity leave disrupts workplace operations and acknowledged the possibility of discrimination against women during hiring. Employers also perceived that non-parent workers who may receive additional workload while mothers are on maternity leave may feel upset, as they are unable to avail of such entitlements.In my opinion, I think the non-parents will be upset since they are not entitled [to receive] these benefits. Also, there will be an added cost, aside from their paid leave. For the production operations, we still have to allot time for retraining and transition to work. This also includes planning and designing the work arrangement. Actually, in a profit-oriented atmosphere, like in my workplace before, they request their temporary workers who were pregnant women to resign, since they will have to pay them for three months, and it is a liability. The Expanded Breastfeeding Promotion Act of 2009, which mandates the establishment of lactation rooms and implementation of lactation breaks in workplaces, is aligned with ILO recommendations. This policy requires that workplaces create a breastfeeding policy and prohibits marketing of breastmilk substitutes. Compliance with the Act is required to issue or renew business permits. Private and public workplaces may apply for a renewable exemption from establishing lactation rooms to DOLE and CSC, respectively , 40. TheWorkplaces may apply for Mother-Baby Friendly Workplaces Certification, which are valid for two years, by complying with the requirements of the Expanded Breastfeeding Promotion Act of 2009 and fulfilling additional requirements set by the DOH; requirements include the provision of a manually operated breast pump, paper towels, and a covered trash can in the lactation rooms . Review Some employers mentioned the presence of lactation rooms and refrigerators in their workplaces, while others referred breastfeeding mothers to clinics or unused or vacant rooms for breastfeeding and breastmilk expression.Even if we don’t have a lactation room, we always make sure that they have a private room to do this. Usually, we have “lactation” signage. From our previous lactating mother, sometimes she doesn’t have time to lactate. So usually, she brings this signage and looks for a vacant room, and she will just post this signage. Based on enacted policies, local government units were encouraged to set up lactation spaces and programs for informal workplaces in partnership with the private sector. However, this is not widely implemented across all LGUs.It will depend on the ordinance and the cooperation of the local government. Because these informal sector workers have no formal employers to talk to when they do not have these facilities [lactation spaces] for workers. Employers have policies in place to complement national regulations. Some provide flexible working arrangements, free transportation services, additional cash assistance, free medical check-ups under the workplace’s health insurance package, and free childcare benefits.Aside from maternity leave benefits, the company also gives childbirth assistance. I think it is PHP 1,000 to 2,000 (USD 20 to 40). Some workplace settings made breastmilk expression difficult due to workload and work schedule, with either nonexistent or inadequate break time. Output-based jobs with flexible working hours in the formal and informal sector also forces mothers to choose between earning more income and breastfeeding.I think in this situation, cashiers have no break time unless their duty is finished. In that kind of work [production area], I think it is difficult to let down milk, because the mother does not have ample time to rest. Since the wages depend on product outputs, there is a possibility that the mother will opt for formula milk because of the hassle of extracting milk. Respondents also mentioned that maternity leave is not applicable for workers in the informal sector, making informal workers’ financial needs a contributing factor in their decisions to return to work early. Several informal work settings also had no suitable place for breastmilk expression and storage or were inappropriate environments for children.Additional costs incurred by employers to establish and maintain lactation rooms, and to provide the cost differential from SSS claims was cited as a disadvantage, especially for small and medium enterprises. The mandatory establishment of lactation spaces was considered impractical by some key informants from the government and non-government organizations and employers due to the required investment and space limitations within some types of businesses. The small number of mothers who utilize the facility was also perceived as minimizing the impact of the investment.Most of the employees here are already past their reproductive age, you will just waste that room which could be used for other purposes…. For example, the clinic is located on the first floor, but the lactating mother is located on the fourth floor. Of course, she will put the expressed milk in the refrigerator on the fourth floor. Let’s say in that quarter, she was the only lactating mother in the workplace. It is not wise to establish a lactation station on the fourth floor just for her .Some employers expressed unsupportive views toward breastfeeding and breastmilk expression at work. Employers and mothers recognized the difficulty in continuing breastfeeding once a mother returns to work, implying a lack of awareness of legal entitlements among mothers and a lack of knowledge and support for breastfeeding on the part of employers.When a mother returns to work, they already perceive that breastfeeding is difficult in their work in the production area. They have to bring necessary materials such as containers and breast pumps which is inconvenient. They lack awareness on what would be the best for the baby. Some employers relied on the working mothers’ initiative and the accessibility of information from the internet rather than actively promoting and disseminating information related to maternity protection and workplace lactation support. One respondent equated maternity entitlements with merely compensation or receiving monetary support and did not seem to recognize that mothers need other workplace support during the maternity period.There is no need for a very laborious information campaign, because as I’ve said this information is already available on the internet. So, we just tell them to sign the maternity benefits form. This is what is going to happen, this is the process, the date that you will be able to get it and all of that. Because what they expect really is when will they get the maternity benefits. There was a sense of acceptance among mothers that breastfeeding will stop once they return to work. Mothers working in a variety of different occupations mentioned the difficulty and inconvenience of expressing and storing breastmilk during work. Among women who took maternity leave, some breastfed only until the end of their leave.Since I am working, I have no choice but to switch to infant formula. I am already practicing my child for infant formula, thus I already opted for mixed feeding. Because, after 3 months, I will return to my work. For mothers who need to work, it is usually difficult to pump and pump, then you will have to carry it, also there are uncontrolled times when you can express breastmilk. Both SSS and PhilHealth record the number of maternity entitlement claims paid per year. DOLE has integrated the monitoring of maternity protection policy implementation, including monitoring of workplace lactation support, within its annual inspection for monitoring of workplaces in the private sector. DOLE recorded a high percentage (85 to 99%) of compliance among workplaces inspected from 2014 to 2020 . HoweverThe Department of the Interior and Local Government (DILG) issued a memorandum to guide the establishment of workplace lactation programs in local government offices, inclusion of workplace lactation programs for business registration, and private-public partnership in setting up and sustaining lactation management programs for the informal sector . HoweverThere are no guidelines to monitor the implementation of and compliance with maternity protection policies. The roles and responsibilities of different government agencies have not been clarified. These indicate that there are gaps in understanding on how these agencies should contribute to monitoring and enforcement.I am not aware of any monitoring guidelines developed for all levels as contemplated under Sect. 30, Rule VIII of the IRR. While existing policies include provisions for the establishment of mechanisms for monitoring service utilization, the monitoring systems currently in place are limited in their capability to measure functionality and uptake of maternity protection entitlements.Regional DOH-CHDs conducted stringent inspections but only among workplaces that applied for the Mother-Baby Friendly Workplaces Certification, which is voluntary. The setting up of inter-agency monitoring teams for all levels as mandated by law had not been done. There were recommendations for the integration of monitoring and enforcement activities in the mechanisms for monitoring other current programs of the DOLE and DOH.Policy makers mentioned the need for increased breastfeeding promotion activities among employers, fathers, and mothers to encourage breastfeeding and create more supportive work environments that encourage mothers to utilize their maternity entitlements. At present, employers comply with the mandate because it was included in the DOLE checklist but may not fully recognize the purpose and benefits of the policy. They also had insufficient knowledge to provide proper assistance to breastfeeding employees. One employer provided a care package that included diapers and breastmilk substitutes.On top of their maternity benefits, we have a care package that was given for the babies first 6 months. So, there was a budget for milk and diapers that we provide for them. We conducted a survey, they have provided space for the breastfeeding station, but no advocacy activities are being conducted on the benefits of breastfeeding and how it will be done. The HR [human resource] personnel do not know how long the storage is and how the milk will be transported if they are far from work. We need to invest in teaching mothers how to do it [breastmilk expression and storage]. Do they need a cooler when transporting it? They want to breastfeed, but they do not know how to do it. We can contribute by ensuring that there are facilities in the workplace, but it is the personal decision of the mother, whether or not she will breastfeed because it is such a long process. I believe that people should be re-educated on the benefits of breastfeeding. We need to have a supportive environment, not just the facility. They must view it in a positive way, as a way of life. We need to have that perspective and an accepting organization, wherein you can freely take a break because of your lactation duty. Findings from our study indicate that maternity protection policies in the Philippines are aligned with most of the standards set in ILO Convention No. 183. These policies should be expected to mitigate the impact of return to work as a major structural barrier to breastfeeding , 46.Our findings illustrate how gaps in implementation and unsupportive social norms limit the impact of maternity protection policies on breastfeeding practices. These include a lack of monitoring systems to measure the availability, functionality, and usage of lactation spaces; barriers to the uptake of maternity protection entitlements among workers in the informal sector and short-term/contract workers in the formal sector; lack of workplace support for breastfeeding; poor communication of maternity rights; and limited breastfeeding advocacy and promotion. The lack of integration with breastfeeding promotion interventions likewise limits the role of current maternity protection policies in improving breastfeeding practices.Paternity leave enables fathers to be with their partners during the period after childbirth, and their presence and support during this period considerably impacts the mother’s decision to breastfeed . Our finMothers in our study seemed to have accepted that they need to use breastmilk substitutes or even stop breastfeeding their infants when they return to work. Workplace settings with high workloads, inflexible break times, lack of dedicated time for breastfeeding breaks, and absence of lactation spaces discouraged breastfeeding and breastmilk expression . MothersGenerally, employers were compliant with maternity protection policies, as these were required for their business permits and licenses. However, beyond compliance, there were employers who were not cognizant of their role in providing other forms of breastfeeding support in their workplaces, and their female employees’ right to this support. Lactation facilities were merely seen as spaces for breastmilk expression, and not as spaces for mothers to be safe and comfortable and as investments for children’s health. Our findings are consistent with an earlier study showing that insufficient knowledge of employers on breastfeeding prevented the translation of maternity entitlements to improved breastfeeding practices .The need for technical assistance to support lactation in the workplace and breastfeeding advocacy among employers to improve the uptake of breastfeeding breaks and spaces was recognized by study participants. There is a need to create organizational policies to (1) improve communication and dissemination of information on available interventions, (2) facilitate delivery of practical breastfeeding education among mothers, including the risks of formula feeding and guidance on breastmilk expression and storage; (3) orient and sensitize managers and leaders on the importance of workplace lactation support; and (4) create a supportive environment that enables women to continue breastfeeding when they return to work , 19, 49.Partnerships among DOH, related organizations, and workplaces should be required to ensure continuity of advocacy for breastfeeding programs. Mandating workplaces to set up lactation rooms without providing technical assistance on operationalization, education, and tools to promote breastfeeding in the workplaces is a missed opportunity.The provision of tax incentives in the Expanded Breastfeeding Promotion Act of 2009 could have been a good strategy to encourage early compliance of workplaces to the provisions of the law, but based on the results of the desk review, there were no records on the number of workplaces which made use of the incentive. This may indicate that not many workplaces applied for the incentive. An extension of this tax incentive or development of new incentive program may be explored to promote and sustain functionality of services or provisions on breastfeeding support, protection, and promotion in workplaces. The program should be promoted and communicated with well-defined guidelines on how to avail of the incentives to encourage workplaces to continue and improve workplace breastfeeding support.Policymakers, employers, and mothers recognized that the lack of breastfeeding advocacy and promotion results in negative attitudes towards policies and insufficient support to both employers and workers. There was a high recognition of the benefits of maternity policies among employers. However, the burden of financing part of the paid maternity leave ascribed to employers may inadvertently lead to discrimination against female workers, despite the policy on non-discrimination. This emphasizes the importance of utilizing social insurance or public funds to fully finance maternity leave entitlements, which is currently not the case for the private sector. Hiring and training of workers who will temporarily take on the work assignments of the mothers on leave also entail additional cost. An employer may resort to assigning the duties and responsibilities of the mother to existing employees instead of hiring a temporary worker to save cost, creating negative perceptions about employees using maternity leave entitlements.Our findings also revealed mothers’ perceptions that breastfeeding is difficult and inconvenient. This resulted in underutilization of lactation facilities which the workplaces have invested in. Even paid maternity leave was not associated as an opportunity to practice breastfeeding, but as another form of compensation.There was limited communication on breastfeeding support among employees despite the presence of breastfeeding policies. According to Anderson et al., mothers were unsure how the support would be enacted in individual situations and the interpersonal communication about breastfeeding support was difficult to initiate and maintain . AwareneAllowing individuals to enroll in SSS and PhilHealth as voluntary members widened the population who can avail of health protection from social security programs, regardless of employment status. However, the premium contributions required for SSS and PhilHealth coverage make them inaccessible to most women working in the informal economy. Respondents reported limited awareness of social security programs and financial difficulties as primary reasons for not enrolling or maintaining membership in social security schemes. The financial costs, the scheme-related awareness, understanding and trust, and the need and benefit from the insurance system were factors that influence enrollment and retention in social security and health insurance schemes among informal workers , 54. TheThere was also limited accountability and support on the establishment of lactation spaces for the informal sector as it is strongly reliant on local government’s priorities. There might be a need to revisit the policies to address this gap and develop a different operational modality for provision of maternity entitlements specific to the informal sector. A cost estimate study for the Philippines showed an investment on non-contributory 26-week maternity cash transfer for the informal sector will only cost less than 0.1% of the country’s gross domestic product, considerably lower than the share of cost of not breastfeeding which is 0.7% . In May We acknowledge several limitations to our study, including the purposive sampling design and limited area coverage which may affect the generalizability of the data. The study sites in the Greater Manila Area are not representative of the Philippines as a whole, which remains predominantly agricultural outside of major urban areas. However, given that national program managers in government and non-government agencies were included in the study, they might have provided context on the general situation in the Philippines.Although maternity protection policies were in place and have improved, there is a need to (1) improve communication and promotion of maternity protection rights of mothers, paternity leave entitlements of fathers, and duties of employers, (2) strengthen monitoring and enforcement mechanisms to ensure utilization of entitlements, (3) develop modalities to extend coverage of maternity entitlements to the informal sector, (4) fully cover paid leave entitlements from social insurance or public fund sources, and (5) revisit limitations of paternity leave entitlements to those legally married. The Philippine policies on maternity protection operate separately from breastfeeding promotion programs, resulting in poor recognition of how maternity entitlements are intended to enable breastfeeding. Breastfeeding advocacy should be strengthened in workplaces through partnering with local government and health agencies for educational materials, advocacies with the employers and employees, and other modes of technical assistance. Strengthening and expanding the implementation of Mother-Baby Friendly Workplaces Certification will also improve the utilization of maternity entitlements in the workplaces on practicing breastfeeding.Below is the link to the electronic supplementary material.Additional file 1: Data collection tools. Data collection tools used for the in-depth interviews of pregnant women, mothers of infants and their partners, employers, and key informants from the government and non-government organizations.Additional file 2: Adoption of International Labour Organization’s Maternity Protection Convention and Recommendation in Philippine Policies. Provides a list of Philippine laws where ILO recommendations on maternity protection are reflected.Additional file 3: Summary of provisions of Philippine policies related to maternity protection. Provides a description of policy provisions relating to maternity protection as reflected in Philippine laws.Additional file 4: Key maternity protection provisions in the Philippines over time. Provides a timeline of the adoption of maternity protection policies in the Philippines.


The Indigenous village of Bykovskiy is located 40 km from Tiksi, the administrative center of Bulunskiy District (Ulus), in the northern part of the Republic of Sakha (Yakutiya), Russia. Founded as a Soviet fishing cooperative, it became home to Indigenous Sakha, Evenkis, Evens, as well as to Russian settlers and political prisoners from the Baltic states. Post-Soviet transformations, coupled with escalating environmental change processes, has been altering the local economy and subsistence activities since the 1990s. Although our interlocutors directly observed and experienced such changes, they seemed to ignore the visible problem of severe coastal erosion that was destroying a local cemetery. This article is based on ethnographic fieldwork conducted in the study region in 2019, and combines approaches from the anthropology of climate change with reception and communication studies. It examines “ignorance” as a strategy of adaptation to multiple stressors under historically reproduced colonial structures of governance. When we approached the village of Bykovskiy on the Russian Arctic coast in a small motorboat in August 2019, we were greeted by sights of eroding coastlines, most spectacularly by a graveyard being washed away into the sea. Over the following days, we had the chance to explore these visual witnesses of environmental change in more detail from the land, accompanied by local residents who made sure that we could see and document these signs of permafrost thaw. As social scientists, our attention, however, was focused less on the physical changes in the environment and more on how people perceived and talked about them. To our surprise, the people of Bykovskiy we talked to paid very little attention to collapsing coastlines and other effects of permafrost thaw and/or environmental change in their narratives. Instead, their focus was on the socio-economic challenges of post-Soviet life, on fishing regulations, and other forms of interactions with the state.Nunataryuk, which is devoted to “permafrost thaw and the changing Arctic coast”.The aim of this article is to understand this seeming contradiction: while in many parts of the Arctic, as well as in other regions of the world, the discourse about environmental change—and even about change more generally—is dominated by the trope of climate change, the residents of Bykovskiy seemed to devote little attention to these rather dramatic transformations of the natural environment. Notwithstanding the provocative first line of the title of this article, we are not implying that local residents are ignorant or do not understand what is going on. On the contrary, they specifically pointed out to us sites with visible impacts of permafrost thaw. We were obviously not the first and only ones “hunting” for them. Over the years, members of international groups working at the nearby German research station in the Lena Delta region had stopped by in Bykovskiy and had made clear that these scientists were interested in climate change. We were no exception to the rule, despite being social scientists, as we visited Bykovskiy in the context of the H2020 project When researching the local dimensions of climate change, anthropologists and other social scientists have often focused on the impacts of environmental change triggered by anthropogenic climate change. So-called reception studies have been relatively rare and typically constituted a late addition to the range of research focus areas geared toward climate change  in July and August 2019. As a result, a body of qualitative data, including observations, twenty-two interviews and three focus groups, as well as regional and district socio-economic development reports and plans were gathered in Yakutsk, Tiksi and Bykovskiy. Expert interviews conducted at the Melnikov Permafrost Institute, at the Ministry of Agriculture, and at the Ministry of Arctic Development and Indigenous Affairs of the Republic of Sakha (Yakutiya), and at the regional office of the Russian Association of Indigenous Peoples of the North (RAIPON) in Yakutsk, as well as conversations with experts from local organizations  were important for gaining a deeper understanding of the environmental and social-economic impacts of permafrost degradation on the Arctic coastal communities, their local population, natural resource use and infrastructure. Ten biographical interviews with IndigenousFigure While many of our interviews and other research activities were conducted in Yakutsk and Tiksi, this article will focus primarily on Bykovskiy. The next section will introduce the collective farm “Arktika”, which has a dark past but provides the economic backbone of Bykovskiy untill the present day. This will be followed by a section on the post-Soviet realities of the village, which are characterized by collapsing coasts and diminishing fishing quotas. Another section will be devoted to portraying and analyzing how local residents live with and perceive changing environment. The conclusions will attempt to provide an explanation of the contradiction described above. We will analyze the uses and effects of modernization ideologies, environmental policies, and local knowledge along the Arctic coast to address the main question that prompted this article.The rural community Bykovskiy is located on the Bykovskiy Peninsula in Bulunskiy District of the Republic of Sakha (Yakutiya), 40 km from Tiksi, the administrative center of the district. Its northern part stretches along the Laptev Sea coast, while its southern part faces Neelov Bay. It is the largest Indigenous fishing community in the area populated predominantly by Indigenous Evenkis, as well as by Evens, Sakha and Russians. This coastal territory has been for centuries occupied primarily by two closely related Tungusic-speaking groups—Evenkis and Evens who belong to the so-called numerically small peoples of the North. These two groups were originally leading nomadic lifestyles based on reindeer herding, fishing and partially on hunting. Semi-sedentary fishing groups of Sakha started migrating into the area since the late nineteenth century that is before the start of the large-scale Russian colonization of the Arctic cost, which began in the twentieth century.stroyki veka)  or suspected in participation in anti-Soviet protests. By 1931, collectivization covered 630 or 47% of households in the district. In total 908 people joined collective farms (kolkhozes) including 67 Russians, 439 Sakha, 304 Evenkis and Evens, 85 Yukaghirs and 13 Chukchis  drastically reconfigured the connectivity between the Arctic coast and the country’s mainland. These changes have also affected the Republic of Sakha (Yakutiya) and its remote coastal communities which were suddenly left to survive on their own on the margins of the state. While Tiksi and neighboring communities of the Lena River delta were proud of their direct connectivity with Moscow during Soviet times, Yakutsk has been growing into the dominant economic and political center for this coastal area since the 1990s   prevails. The agricultural sector is represented primarily by fishing, as well as by hunting, reindeer herding, horse breeding, and fur farming. Municipal enterprises (MUP), agricultural farming enterprises (KFKh), and other private collective and individual forms of enterprises and Indigenous The population dynamics of Bulunskiy District reflect the cycles of socio-economic development of the area. In 1989, the total population of the district constituted 17 630 residents, while by 2016 it dropped to 8366 people Gukov , p. 4. Aperestroika, relatives of the buried exiles came to visit these places; cases of exhumation and reburials are known; and a monument to the victims of the Stalinist repressions was erected in the center of Bykovskiy by a Lithuanian NGO. However, in the village itself, there is no one left to take care of the graves.The existing cultural diversity of the region and the village is a subject of pride of local residents who associate it with “northern hospitality” to newcomers, both voluntary and forced ones. Despite a long history of interethnic marriages and cooperation and Russification of the area, interlocutors still draw the lines between locals and Sakha, as well as between locals and “the Balts”. Sakha, the titular ethnic group in the republic, are portrayed by other groups as colonizers and warriors that have been prospering off the lands and resources taken away from “genuinely” Indigenous peoples. Memory of “the Balts” as a past community remains, today embodied in a few descendants left, but, first and foremost, in the cemeteries of exiled Lithuanians, Estonians and Finns in Bykovskiy and on the neighboring Tit-Ary Island in the Lena Delta. During kolkhoz allocated to us sacks full of fish, flour or sugar ... we did not have those hardships [that others experienced]. The kolkhoz was always there , five to six fishing brigades catch fish in the sea waters as far as 40 to 220 km away from the village in the same fisheries that had been allocated to the cooperative in Soviet times. With the disintegration of the local fish-processing workshop, most of this business was lost to outside enterprises. Presently, most of the catch is sent to a large processing enterprise in Yakutsk that produces salted and smoked fish  has been exposed for a long time to anthropogenic environmental changes, including pollution, landscape destruction in the process of resource extraction and, most prominently, thawing permafrost. Transdisciplinary research conducted in consultation with local and Indigenous communities in several districts of the republic distinguishes several types of changes driven by rising seasonal temperatures. They include thawing permafrost; changing hydrological regimes of rivers and lakes; unpredictability of weather patterns; changing habitats and migrations routes of wild animals; shifting seasons, etc.  in central regions of the republic has shown, an unprecedented rate of permafrost thaw challenges the adaptive capacity of traditional animal husbandry in these keystone cultural areas . As a multidisciplinary study of The coastline of the Bykovskiy Peninsula where the community is located, is characterized by the presence of ice-rich sediment. Between 1951 and 2006, the coast retreated at an average rate of 59 cm per year due to erosion caused primarily by thermokarst activity as well as by storms and other factors  are aware of climate change impacts, have directly experienced them or have been living with them for a long time. However, their perceptions and framings of the observed climate and environmental changes appeared to vary between ignorance, indifference, and skepticism  communities of Siberia and the Russian Far East, the last 10–15 years—and especially the years since 2014, when Russia annexed Crimea—saw a progressive tightening of central control, which made local initiatives economically unfeasible and politically dangerous. In such a colonial and increasingly authoritarian context, “ignoring” could be seen as a strategy of ensuring individual and community security vis-a-vis multiple socio-economic and environmental stressors.Finally, this case study is another reminder of the well-known caveat that the cultural assumptions and social biases of us, the researchers, should not cloud our understanding of other people’s thoughts, actions and agencies. In our ethnography of local perceptions of environmental change, we strive to acknowledge that the people of Bykovskiy are most knowledgeable about environmental and other processes in and around their community. Thus, this is another call for the integration of local observations and experiences into scientific models of climate change (compare Callaghan et al.


Previous studies have argued that the relationship between health expenditures and health outcomes is more significant among the poor than the non-poor. However, public spending alone does not improve health status. Quality of governance is considered not only as an important determinant of health outcomes but also of the efficiency of public expenditure on health. In low-income countries, barriers to quality service provision can be observed, which may explain the effects of health expenditures. Therefore, this paper aims to identify the relationship between health expenditures and maternal and child mortality in Madagascar and the potential bottlenecks in the flow of funds for maternal and child health.Using panel data, fixed and random effect models for the 22 regions of Madagascar over the period 2010 to 2017 were used. Then bottlenecks related to the flow of funds for maternal and child health were identified.The results reveal that, on the one hand, funding for maternal health, mainly constituted by equipment endowments for health facilities, significantly contributes to the improvement of maternal health . On the other hand, child health financing, often realized through transfers of funds to the health system, does not affect children’s health . The bottleneck analysis illustrates that the transferred funds can suffer from delay or misappropriation and only few parts reach beneficiaries.Equipment endowments contributed more to health improvement and would be more effective than monetary financing. Public funding, particularly in low-income countries, has an important role in achieving universal health coverage (UHC) and improving health. Indeed, investments in health and infrastructure contribute improving health status –4. The eGovernance is a key to improving health sector performance and achieving UHC . MeasureMadagascar is a low-income country where access to health care remains difficult . In 2019In Madagascar, according to the World Health Organization (WHO), in 2019, 10% of the health expenditures come from the private sector, 41% from households, and 48% from the government. Public health expenditures are mostly financed by external funds. They were between 58% and 72% from 2009 to 2015. The budget allocated for health is below 10% of the state budget.The major health problems in Madagascar remain the resurgence of epidemic diseases such as plague and polio, high maternal, neonatal and child mortality, high level of malnutrition, and increase of non-communicable diseases . MaternaThis paper aims to assess the effects of health expenditures on maternal and child health considering the case of Madagascar. Is there a relationship between health expenditures and maternal and child mortality? Considering the regional disparities in mortality, what are the potential bottlenecks in the flow of funds for maternal and child health? Indeed, some studies showed that in maternal and child health programmes, these are the bottlenecks of concern: administrative process, funding flow, access, and clinical practices –24. In oIn Madagascar, no study on this subject has yet been carried out. In 2019, the objective was to have a maternal mortality rate of 300 per 100,000 live births and a child mortality rate equal to 35 per 1,000 live births [Madagascar is administratively subdivided into 22 regions and 119 districts. Then, different levels constitute the health system in Madagascar: the central level, the regional level, and the district and community levels. The Ministry of Public Health (MOH) is the central coordinator. At the regional level, the MOH is represented by the Regional Health Offices (RHO) and the District Health Offices (DHO). They implement and supervise the health programmes.Graphical and empirical analysis are performed to study the relationship between health expenditures and maternal and child mortality. Bottlenecks analysis is focused on funds for child health immunization and grants for maternal health.National health expenditures and mortality data from 2000 to 2017, are taken from the WHO database. Thus, because of the low number of observations, a graphical analysis is carried out. The figure shows the evolution of healthcare expenditures (per capita USD) and the maternal  and child mortality rate  over time (2000–2017). Health expenditures are classified according to their origin: by public and private funds. Public financing is composed by government funds for health and external financing distributed by the government while private funding is the household contribution and voluntary prepayments.As the distribution of funding differs from one region to another, it is important to verify whether regions that have spent more on health have a better health indicators than those with a lower level of expenditures.Health expenditures and health indicators of the 22 regions are available over the period 2010‒2017. Then, the effects are determined from fixed and random effect models, and are presented as follow:Where,Yit is the variable representing the maternal and child mortality for region i at period t. Health indicators at the regional level come from the MOH database .Hit represents the health expenditures per capita of region i at period t. Regional health expenditures per capita come from the Ministry of Finance and Budget’s Integrated Computerized Public Finance Management System (SIG-FP) from 2010 to 2017. It includes public expenditures and external funds that flow through public channels into national health systems. Promotive or preventive spending for maternal and child health from Technical and Financial Partners (TFPs) funds is included in these data, such as for the purchase of mosquito nets, vaccines, delivery kits, etc. It is worth nothing that there is no separate information about Maternal Health Expenditures and Child Health Expenditures. They are included in the H. This is a limitation of our study, as the data in Madagascar do not allow to consider funds for maternal and child health separately. However, there are cross-cuttting activities that could affect both maternal and child health . With private and households expenditures not being included, the aim is to see whether the allocation of public and external funds effectively improves the health of the mother and child.Xit are the control variables. Similar to Novignon et al. (2012), variables related to disease prevention and disease prevalence are considered as control variables [Fit, the prenatal consultation PCit, and the delivery at health facilities Dit. Child health indicators are the prevalence of the three main childhood diseases  and the immunization coverage. Family planning utilization Fit, the prenatal consultation PCit, and the delivery at health facilities Dit can positively affect maternal health, then decrease maternal mortality [Eit by region is introduced. Indeed, according to Akinkugbe and Mohanoe (2009), enrolment rates can affect health status [it is considered. This variable comes from the Global Data Lab. The IWI is based on twelve assets. These assets include seven consumer durables , access to two public services (water and electricity) and three housing characteristics . The IWI is scored from 0-100, with 0 representing households with none of the assets and 100 representing households having all assets.n et al. 012, variSince the regions observed belong to the same country, we assume that the coefficients of the variables are similar. Thus, the only sources of heterogeneity can come from the constant. Therefore, two cases can be distinguished: the case which individual effects are deterministic constants terms (fixed-effects model) or the case which they are assumed to be the realizations of random variables of finite expectation and variance (random effects model). The Hausman specification test confirm whether it is a fixed or a random effect model. Then, the models are as follows:Y1it for maternal health and Y2it for child health; α is the individual effect; β and δ are the coefficients and ε the error term.To test the robustness of our results, Generalized Moments Method (GMM) is used. The advantage of this method is that it solves the problems of simultaneity bias, reverses causality and omitted variables . The GMMThe bottlenecks analysis concerns:The transfer delays: A delay occurs if the difference between the expected transfer date and the date of the funds reception exceeds ten days knowing that the activities schedule iscommunicated in advance by the MOH.The funding gap and reallocations: A funding gap is considered when the amounts obtained by the beneficiaries are less than the budget. In this case, the expenditure is recorded in the central level account as committed, although it has not reached the beneficiaries. Reallocations occur when beneficiary reallocates the funds they received to solve other problems.The lack of monitoring or control of funds: Monitoring must be carried out systematically. According to WHO, health facilities, DHO and RHO should respectively be monitored every two, three and six months.The bottleneck analysis is based on two types of data:Survey data on the use of funds for immunization. These data are from UNICEF (2015) and from the results of the GAVI Financing Audit . These data are the only ones available but they are representative. In fact, the UNICEF surveys covered ten regions of Madagascar. Two districts per region were selected, one with a high immunization performance and one with a low performance. Similarly, at the district level, four health facilities were selected, two had high immunization performance and two were among the lowest. UNICEF survey and GAVI financing audit consider all levels of the health system.Information on the dates on which funds were sent and received is available in these data from UNICEF (2015). To identify delays in receiving funds, we calculated the difference between these two dates. The UNICEF (2015) survey also asked whether any reallocations had been made. Then, data on the number of checks carried out at health facilities, the DHO and the RHO are also available. A comparison between this information and the WHO standard was then made. For the funding gap, information in the GAVI audit report carried out in 2017 were used.Interviews on the use of government funds for maternal health care that were conducted in 2019 with some officials at the RHO and the DHO. In fact, the 2019 Supplementary Finance Act allocates a budget line for “maternal and child survival” including safe motherhood, adolescent reproductive, and family planning services. Two regions where maternal mortality remains high (Vatovavy Fitovinany and Atsimo Atsinanana) and two regions among the lowest  were considered.It was asked whether the managers have ever received in-kind donations or funds for maternal health. How often they receive these funds or donations. When did they last receive funds or donations? What are the obstacles to obtaining them? Questions were asked about the different types of bottlenecks.The Fig. The results in Table The results of our model Table  shows thMaternal and child mortality and disease prevalence are expected to be low when the preventive care is effective. In our case, the indicators available related to prevention activities at health facilities are on contraceptive coverage, prenatal consultation, delivery in health facilities, and immunization coverage for children. Delivery in health facilities significantly reduce maternal mortality, but contraceptive coverage and prenatal consultation are not significant. The use of these three services remains low and differs by region. Since 2010, the situation has not changed. In fact, the average prenatal consultation rate was from 64.9% in 2010 to 63.3% in 2017 and from 25.9–25.6% for the delivery in the same period. For contraceptive coverage, the average coverage rate is less than 25%. School enrolment also affect maternal mortality: the higher the school enrolment rate, the lower the maternal mortality rate.As for child health, the average immunization coverage rate is not yet satisfactory. At the regions, it ranges from 54.7–73% over the period 2010‒2017, and at national level, it was 67% in 2010 and 70% in 2017. Therefore, the effect of immunization coverage is not significant. Even though malaria, ARI and diarrhoea are the main causes of child mortality, a rise in malaria prevalence causes a slightly significant increase in mortality, and ARI and diarrhoea do not affect child mortality. It is the same case for school enrolment.Descriptively, the two regions with the highest IWI values, i.e. the richest, have the lowest maternal and child mortality rates . However, Table Using the GMM method, similar results were obtained. The effects of health spending on maternal mortality are negative and significant , while the effects on child mortality are not significant . For the two models, the p-value of the Sargan test are higher than the margin of error of 0.05 (respectively 0.87 and 0.55), so, the null hypothesis cannot be rejected, instruments are valid.Bottleneck analysis concerns the transfer delay, the use of funds, and the control of the use of the allocated and the received funds. Concerning the transfer delay, the allocated funds generally arrive later than the expected start date of activities. Public funds arrive one to six weeks after the expected date of receipt of funds. They are mainly intended for the purchase of consumables, fuel necessary for the fridge to conserve the immunization products and immunization campaigns. Then, in order to meet the schedule established by the MOH, the heads of health facilities carry out the activities with their own funds.In general, the received amounts correspond or exceed the forecasted amounts. The budget execution rate for immunization is around 95% at central level and 100% at regional level. There was no reallocation of funds. The received funds are fully spent and considered as insufficient . However, audit carried out by the GAVI in 2017 at central level shows a misappropriation of funds from GAVI Alliance financing between January 2013 and December 2016 amounting to US$769,062, and a misuse of an amount totalling US$866,198 was recorded. This expenditure was recorded centrally and therefore included in our data but was considered ineligible or never reached the beneficiaries.Controls required by WHO is respected for the RHOs and the DHOs. At the community level, the number of controls led by DHO depends on the distance where the health facilities are located. Consequently, health facilities close to the district are controlled several times a month while health facilities in remote areas have never been monitored . The maiAs mentioned above, maternal health benefits from very few cash transfers but benefit mainly from material endowments . According to seven DHOs surveyed, these donations are provided by the TFPs (one DHO does not know the source of the received donations).Donations are not regular but depend on the TFPs. Thus, managers are just informed that they will receive materials in few days. The last donation was in 2018 for one DHO, 2017 for two DHOs and before 2016 for five DHOs. Over the past five years, no monetary funding other than for MCHW has been received. From the RHOs and DHOs surveyed, the received funds consist mainly to finance child health programmes. As said earlier, although the ‘maternal and child survival’ has a specific budget line in the supplementary finance acts; only the central level benefits from this fund. Thus, according to the eight DHOs surveyed, the main bottleneck identified in terms of maternal health is the lack or absence of funds for the maternal health promotion.Our results are in line with those of Filmer and Pritchett (1999) who studied the case of poor countries including Sub-Saharan African and non-poor countries. According to these authors, the relationship between health expenditures and health outcomes depends on the composition and efficiency of health spending. They argue that public health spending ensures effective health services provided by the public sector, promoting the consumption of effective health services and thus improving health status . ChangesGupta et al. (2003) in studying the case of developing countries have argued that public expenditure is more effective among the poor than the non-poor. However, public spending alone does not improve health status. Governments must also ensure that health interventions reach their intended beneficiaries . TherefoMoreover, funds for health are very low in Madagascar. Indeed, they represent only 5% of the government budget in 2017. Then, it is the funds for administration and human resources that are the highest (40–60% of expenditures) . Thus, aThese situations affect the quality of services and reduce the effectiveness of the health programmes. Indeed, health facilities could not invest on equipment and on medicines with the attributed funds. For maternal health, in Madagascar for example, according to a study conducted by USAID in 2018, only 51% of health facilities have access to essential elements for antenatal care . Then, no health facility had all the basic elements for obstetric and neonatal care . For child health, only 1% of them had different types of basic vaccines with basic materials . Finally, regarding medicines, only 47% and 54% of health facilities had essential medicines for mothers and children  respectiHowever, the reduction of maternal and child mortality cannot depend only on attribution of specific funds. Structural determinant such as the geographical accessibility, insufficient number of caregivers and health facilities  and thenInvestment in healthcare is important for both short- and long-term benefits. Therefore, allocating more funds to health and using these funds optimally would improve health and save lives . ConsideFollowing the Abudja Conference, Madagascar have to increase the public health expenditures to at least 15% of the government budget. In addition, it is necessary to ensure optimal allocation of resources, to make health services accessible to all by implementing effective health care programmes. Optimal allocation of funds means ensuring the availability of essential equipment and medecines at the basic level and increasing the quality of the services by building staff capacity of the health facilities, particularly in rural areas. It is also necessary to ensure enhanced monitoring, supervision and audits carried out at all the levels, especially the DHOs, which are the main fund managers. It is also necessary to promote a better allocation of human resources.In addition, considering the high degree of budget centralization, more autonomy is needed for the implementation of the part of the budget at the district and primary levels. Thus, a redistribution of funds must be processed, according to the geographical distribution of population and considering its poverty.Madagascar implemented Universal Health Coverage (UHC) in 2015. It is "the situation in which people can obtain quality health services with costs that do not cause financial difficulties for users" . However, the implementation of the National Health Solidarity Fund (NHSF) in two pilot regions was only effective in 2018. NHSF members contribute  to benefit from the Minimum Package of Activities offered by health facilities .The main objectives of the UHC are “the financial protection of users, through health insurance system (prepaid system), the effective availability of the quality health services and the reduction of the population’s exposure to the risks affecting health through promotional and preventive activities” . One of the ways to promote UHC is thus to promote local care by the use of community health workers (CHWs) which are close to the population. Their missions are to raise awareness for care, to ensure immediate management of simple cases and to refer to the health facility in case of serious illness.The main challenge for the UHC is its large-scale implementation. Considering the low budget capacity of the government to support health facilities’ expenses, the UHC is still uncertain.Our paper has some limitations. Firstly, the studied period is limited to 2000–2017 as only these data are available at regional level. Secondly, maternal and child expenditures are not distinguished. The data relate to total health expenditures. However, as argued, there are cross-cutting expenditures, such as human resource expenditures, which consider both maternal and child health as well as health in general. Thirdly, health expenditures data in this paper refer to expenditures recorded in the Ministry of Finance and Budget’s Integrated Computerized Public Finance Management System (SIG-FP) from 2010 to 2017 . There may be parts of off-budget data not considered. Finally, as it has been argued that there are other determinants that can explain maternal and child mortality, we have only included in the model those available by region during the studied period.This paper shows that public funding, particularly through external funding distributed by the government, contributes the most to the improvement of maternal and child health. However, equipment endowments contribute more to the improvement of the health situation and would be more effective than monetary financing. Indeed, only the relationship between health expenditures and maternal mortality is significant, although maternal health programme does not receive cash funding. Donations distributed to pregnant women during prenatal consultation and delivery has a direct impact on the use of maternal services.Nevertheless, maternal mortality is still high and reflected in a rather low level of delivery at health facilities. Therefore, to further encourage attendance at health facilities, distributing these donations must be followed by complementary measures, including sensitization, regularity of donations, improvement of the quality of the service, and free medical costs for prenatal visit and delivery . Indeed,Regarding child health, interventions could be more effective if the bottlenecks are addressed by reinforcing monitoring and supervision of the use of funds at all levels of the health system. Therefore, making funds more equitably accessible to the controlling units is necessary.