Government Response to the UK Network
on Sexual & Reproductive Health & Rights' Submission,
"Keeping Sexual and Reproductive Health on the Agenda",
to the International Development Select Committee
1. INTRODUCTION
1.1 The Department for International Development's
(DFID) purpose is to eliminate poverty and to work with developing
countries to achieve the Millennium Development Goals (MDGs).
Improving health is a central objective. Poor health is closely
associated with poverty; it is an aspect of poverty—in that
poor health is impoverishing—as well as a consequence of
it.
1.2 The right to good health is a fundamental
human right, but one denied to over one fifth of the world's population.
But there is a growing evidence—for example that captured
by the Commission on Macroeconomics and Health—to show that
better health contributes to economic security and development,
to expanding people's opportunities and life chances, and to safeguarding
livelihoods. Ensuring better health is therefore an important
development strategy, as well as an end in itself.
1.3 DFID regards reproductive health as
an essential and inseparable element of good health. We believe
that the best way to deliver this is for people to be given the
right, freedom and support necessary to enable them to take full
individual and personal control of their own fertility and reproductive
health.
1.4 Reproductive health continues to be
a key priority for DFID and we remain firmly committed to the
1994 Cairo International Conference on Population and Development
(ICPD) target of achieving access to reproductive health for all
by 2015. We are disappointed by the attempts of a small number
of states to roll back international consensus on the reproductive
health and rights of the poor. The Government will continue to
work with the international community to ensure that reproductive
health receives the priority it needs.
2. DFID'S WORK
ON REPRODUCTIVE
HEALTH
2.1 Whilst there is no MDG specific to reproductive
health, DFID believes that population and reproductive health
issues are fundamental to efforts to tackle poverty and achieve
the MDGs. Reproductive health especially embraces three health
related MDGs—those to reduce child mortality, improve maternal
health, and to combat and prevent HIV/AIDS. Without progress in
improving access to reproductive health it is unlikely that these
MDGs will be met.
2.2 Reproductive health, which encompasses
maternal conditions, HIV/AIDS and other sexually transmitted infections
accounts for a major proportion of overall ill-health. But reproductive
health is important for other reasons. Women, and especially poorer
women, suffer disproportionate reproductive ill-health and are
denied choice and opportunity. Reproductive health also encompasses
the services for family planning, contraception and childbearing
that make an important contribution to increasing women's choice
and opportunity, and in preventing unplanned or unwanted pregnancy.
Family planning services also provide an important chance to address
sexual health and in particular to increase women's access to
methods that help prevent HIV infection. DFID believes wholeheartedly
in the right of individuals to control their own fertility.
2.3 DFID works with partners to increase
access by poor people to good quality reproductive and sexual
health care and services, including those focused on improving
maternal health outcomes, providing contraceptive choice and ensuring
availability of condoms, and preventing and treating sexually
transmitted infections.
2.4 Our spending on health in developing
countries and on reproductive health is increasing. In addition
to the increases already reported in bilateral expenditure for
£38.4 millon in 1997-98 to £206.6 million in 2001-02,
commitments to reproductive health activities have also risen,
from £184.2 million in 1999-2000 to £260 million in
2001-02.
2.5 In 1997-98 spending on health and population
was £117.4 million; in 2001-02 it was £197.4 million.
Reproductive health spending, including on HIV-AIDS in 2001-02
was over £220 million. Commitments of new resources—funds
allocated to support reproductive health activities—have
increased from £184.2 million in 1999-2000 to £260 million
in 2001-02. This excludes bilateral commitments in 2001-02 of
£388.2 million toward action to lower maternal mortality,
£394.4 million on HIV/AIDS and £615.4 million on essential
health care.
2.6 DFID will continue to work to influence
the international policy environment. Here the climate is challenging:
a determined attempt is underway to undermine and roll back the
consensus on reproductive health and rights established at the
ICPD. DFID will work to defend established and agreed policy by
forming alliances with others and basing our arguments on sound
evidence.
Maternal health
2.7 Of the more than 500,000 maternal deaths
every year, 99% occur in developing countries. Each year more
than 50 million pregnancy-related complications lead to long-term
illness and disability. Essential interventions are: skilled attendance
at delivery; referral for complications; community understanding
of pregnancy danger signs; communication and transport schemes.
To reduce the death rate of mothers during pregnancy and childbirth,
governments agreed at the 1999 ICPD+5 UN Special Session that
by 2005 at least 40% of all births should be assisted by skilled
attendants where the maternal mortality rate is very high, and
80% globally. By 2015 these rates will increase to 60% and 90%
respectively.
2.8 DFID attaches great importance to learning
and sharing lessons from successful developing country strategies
to improve health outcomes, particularly of the poor. DFID's ability
to feed country experience into international policy making, using
our network of in-country health experts, is widely recognised
as one of our strengths. We are further contributing to the international
effort by:
— strengthening World Health Organisation
(WHO) to draw upon country level experience, in order to set standards
and disseminate best practice;
— supporting knowledge programmes which
examine the effectiveness of interventions and disseminate best
practice; and
— supporting the recent work of the
Commission on Macroeconomics and Health, which has assessed the
global evidence of the effectiveness and cost-effectiveness of
interventions to improve health.
2.9 Lessons learnt as a result of these
efforts are used to help developing countries develop and refine
their own multi-sectoral national programmes and plans for better
health and poverty reduction. This is increasingly done in the
context of Sector Wide Approaches and Poverty Reduction Strategies.
2.10 WHO are the leading international agency
and we are supporting their efforts to determine the most effective
and cost-effective safe motherhood packages. We are ourselves
funding research designed to identify the most effective interventions
to help reduce maternal mortality and morbidity in the developing
world, including trials of Vitamin A Supplementation and Magnesium
Sulphate for Pre-Eclampsia.
2.11 We are also drawing lessons from the
safer motherhood programmes we support in Nepal, Malawi, Kenya,
Pakistan and Bolivia.
2.12 The evidence indicates that improving
and sustaining the quality of midwifery and obstetric services
is very likely to result in reduced maternal mortality. Evidence
also shows that strengthening health systems is also a key prerequisite
for improving safe motherhood. DFID has committed over £1
billion to this work since 1997.
2.13 There are nearly 300,000 maternal deaths
in Africa each year. Sub-Saharan Africa has the highest maternal
mortality ratio in the world—100 times greater than in the
West. A poor mother in a poor country is 500 times more likely
to die in childbirth than is a rich woman in a rich country. Globally,
maternal health conditions represent the leading burden of disease
for women of reproductive health age, with the burden of this
ill health falling disproportionately on the poor. Strengthening
maternal health services to improve access, in the context of
health systems development, constitutes an important strategy
for poverty reduction.
2.14 DFID is engaging with, and contributing
to, international efforts around maternal mortality reduction.
We are making significant investments in the evidence base for
maternal mortality reduction and ensuring that the outputs are
accessible to policy makers and programmes in Africa.
Abortion
2.15 Around 13% (65,000) of maternal deaths
each year are caused by unsafe abortions. Inadequate access to
contraception—unmet demand—is the principal cause
of women seeking abortions. ICPD agreed that in no case should
abortion be promoted as a method of family planning. But it also
agreed that where abortion is not against the law, it should be
safe, and that in all cases women should have access to services
for managing complications arising from (unsafe) abortion.
2.16 DFID recognises that unsafe abortion
is a major cause of maternal mortality and morbidity and is a
reflection of the inadequate access thousands of women have to
quality contraceptive services. It is estimated that one in every
150 abortions lead to death in Africa, compared with one in every
85,000 in the West. Programmes aimed at reducing unsafe abortion
are supported in Nigeria and South Africa.
2.17 Where legal, and available as a matter
of uncoerced individual choice, we support activities to improve
the quality, safety and accessibility of abortion services. These
might include, for example, the training of health personnel in
safe abortion techniques and post-abortion care; the provision
of drugs and equipment for health facilities; improving the conditions
under which services are provided; the provision of information
to health personnel and women; and the development of plans and
guidelines to improve service quality. Where the private sector
is an important source of service provision, mechanisms to improve
its quality and affordability for poor women are important. DFID
would want to ensure that abortion was available within a broader
constellation of reproductive health services, including post-abortion
family planning counselling and services, to help women avoid
unwanted pregnancy and repeat abortion.
2.18 We support measures to improve access
to effective and high quality post-abortion care to deal with
the complications of spontaneous or induced abortion. This might
include, for example, the training of health personnel; provision
of drugs and appropriate equipment such as manual vacuum aspiration,
to enable more health facilities to deal effectively with complications
requiring emergency treatment; and provision of information to
health personnel and women on post-abortion care.
2.19 In many instances abortion may be legal
within limited or highly restricted grounds, at least to save
the life of a woman. Greater awareness among policy-makers, national
health authorities and health personnel of the circumstances in
which abortion is allowed and of the consequences arising from
the complications of unsafe abortion, such as the burden of maternal
ill-health associated with unsafe abortion is important. National
health authorities may also examine and implement the policy options
for reducing maternal mortality and morbidity resulting from unsafe
abortion, within both the public and private sectors.
2.20 We support the Ipas Programme to improve
access to safe abortion and post-abortion care with £4.5
million over four years and the Alan Guttmacher Institute's work
on documenting the incidence and impact of unsafe abortion with
$0.65 million over three years. We supported WHO's work to develop
technical and policy guidance for health systems, which resulted
in guidance on abortion (not yet published).
Young people
2.21 The sexual and reproductive health
needs of over 1 billion young people—the largest generation
in human history—are largely being overlooked. Young people
in many countries are becoming sexually active at an earlier age
and young people are most at risk of sexual infection. Half of
all new HIV infections are in the 15-24 age group. Five million
teenage women undergo abortions every year. Yet UNAIDS reports
high levels of ignorance of issues related to HIV/AIDS.
2.22 At the UNGASS for Children, the US
emphasised the role of abstinence. The EU has sought to highlight
also the importance of equipping young people with the reproductive
health information and services needed to protect themselves if
(and when) they do commence sexual relations.
2.23 Education is an indispensable vehicle
for the promotion of gender equality, which is at the heart of
safe sexual and reproductive health care and practices. Moreover,
young people need good health and sex education to enable them
to make informed responsible decisions to protect their health
and safeguard their future. They need information about gender,
sex, sexuality and health and personal safety. The evidence is
also clear that young people who have been provided with responsible
sex education tend to delay the onset of sexual activity. When
they do begin sexual activity, they need friendly and responsive
health services they can afford.
2.24 We are supporting the Population Council's
partnership in support of adolescent girls' transition to a safe,
self-determined, and productive adulthood (£5m). We fund
a £1.65 million knowledge programme with Southampton University
researching young people's sexual health in developing countries.
Family Planning
2.25 Estimates suggest that 350 million
couples worldwide lack access to modern family planning methods,
and as many as 150 million women want to prevent or delay pregnancy
but are not using any method of family planning.
2.26 The aim of family planning programmes
is to enable couples and individuals to decide freely and responsibly
the number and spacing of their children and to have the information
and means to do so.
2.27 DFID is one of the leading bilateral
providers of condoms and other forms of contraceptives to developing
countries. We are also supporting a number of male and female
condom social marketing programmes. We are helping the United
Nations Population Fund (UNFPA) to provide the widest achievable
range of safe and effective family planning and contraceptive
methods, including condoms to prevent HIV/AIDS. In January 2001,
we provided UNFPA with a grant of £25 million to help meet
immediate needs for reproductive health commodities, including
condoms, in a range of countries facing immediate shortages. We
have increased our core annual funding to UNFPA from £15
million to £18 million.
2.28 With support from DFID and USAID, Kenya
has achieved one of the largest reductions in total fertility
(30%) over the last 10 years through a combination of female education
programmes and increased availability of reproductive health services,
including condoms through social marketing programmes.
2.29 We support two knowledge programmes
(£1.875 million each) that aim to improve reproductive health
services through research.
HIV/AIDS
2.30 HIV/AIDS is reversing the life expectancy
gains made in the last 40 years. In many sub-Saharan Africa countries,
life expectancy is 20 years or more shorter than it would be without
AIDS. More the 55% of those infected are women. Teenage girls
are infected at five to six times the rate of their male counterparts.
The main burden of care for those infected with HIV falls on women.
2.31 It is estimated that 60-80% of African
women with HIV have had only one partner, but were infected because
they were not in a position to negotiate safe sex or prevent their
partners from having additional sexual partners. This is why new
technologies such as the female condom and microbicides are an
important step forward. They give women the power to protect themselves
from unwanted pregnancies and sexually transmitted infections.
DFID has committed £16 million (over five years) to the Medical
Research Council's Microbicide development programme.
2.32 DFID invested over £200 million
in bilateral programmes in 2001-02 for HIV/AIDS-related projects
and $200 million over five years to the Global Fund to Fight AIDS,
TB and Malaria. We have committed £25 million to support
the International Partnership against AIDS in Africa, and £14
million to the International AIDS Vaccine Initiative. We currently
support programmes to tackle sexually transmitted infection and
HIV activities in 39 countries. We are engaged in intensive bilateral
action in Ghana, Kenya, Malawi, Mozambique, Nigeria, South Africa,
Tanzania, Uganda, Zambia, and Zimbabwe. Our country-level work
largely supports national policies and strategies, primarily through
support of multisectoral HIV/AIDS plans.
3. DFID'S WAY
OF WORKING
3.1 The way that DFID works at country level
is changing. Most of DFID's assistance in health and reproductive
health is channelled through bilateral country programmes. But
DFID, with many others, is moving away from supporting its own
projects and programmes, and is instead working to ensure its
resources are channelled to assist national health sector priorities
and budget processes, based on partnerships to build capacity
and enhance impact.
3.2 Increasingly, DFID is supporting country
Poverty Reduction Strategies (PRSs) as a way to strengthen social
sector services and delivery, pooling its financial resources
with those of other donor agencies within the government's overall
financing envelope. PRSs are instruments for coordinated government
led action with broad based participation, focused on delivering
key outcomes (based on agreed indicators), and providing the basis
for long-term strategy and sustained investment.
3.3 DFID works through Sector Wide Approaches
and Direct Budget Support as ways of supporting countries' Poverty
Reduction Strategies. We are working across the board to strengthen
countries' own systems for reporting against their poverty reduction
targets and progress towards the Millennium Development Goals,
including through the UN Millennium Project. This includes reporting
on reproductive health outcomes as factors in improving health
overall. We champion reproductive health issues, including through
our support for UNFPA, at a country level.
3.4 Within these processes it is important
to ensure that sufficient attention is given to reproductive health
issues, for example the assured supply and availability of reproductive
health commodities. In many circumstances DFID is also continuing
to ring-fence support for reproductive health and HIV/AIDS work,
including for example social marketing programmes. DFID looks
also to UNFPA to champion reproductive health within country health
and social sector development processes (and to be the UN advocate
for reproductive health and rights, including within country MDG
progress reporting).
3.5 We believe that civil society organisations
can be important in delivering reproductive health services in
country, and our country programmes often fund such groups as
part of their overall strategy. However, our long-term goal is
to encourage governments themselves to take responsibility for
the provision of these services.
4. FUNDING THROUGH
DFID
The Civil Society Challenge Fund
4.1 The aim of the CSCF is to support initiatives
which strengthen the capacity of poor people, living in developing
countries, to better understand and demand their rights—civil,
political, economic and social—and to improve their economic
and social well-being. Successful initiatives will empower poor
people, strengthening their ability or opportunity to speak for
themselves, do things for themselves and make demands of those
in power. Funding is provided on a competitive project by project
basis to UK CSOs who must be working as partners in initiatives
led by local "southern" CSOs, community or faith groups,
etc.
4.2 We do not ring-fence funding under the
Civil Society Challenge Fund for activities in particular sectors.
Projects in the health sector have to compete against projects
in education, environment, agriculture and so on. We consider
each project on its own individual merits and make decisions based
upon criteria such as appropriateness of approach, innovative
nature and risk.
4.3 The CSCF prioritises support to civil
society and in particular to NGOs working in development that
take rights-based approaches. NGOs were involved in the consultation
process that lead to this change. DFID funds numerous NGOs to
undertake service delivery projects through our country programmes.
4.4 Under the Joint Funding Scheme (JFS)
ODA provided 100% funding for service delivery projects in the
reproductive health field. This was primarily due to the fact
that we recognised that fundraising for these services could be
difficult.
4.5 When we moved to the CSCF it was decided
that, as the reproductive health programmes being supported were
no longer concerned with service delivery, this exemption from
matched funding should not be continued. However, we recognised
the problems this move from 100% to 50% funding could have on
NGOs and therefore introduced a stepped approach whereby in each
funding round the level of support reduced from 85% to 70% and
eventually to 50%. A project agreed under the 85% round would
be funded at 85% for the duration of the project (up to five years)—similarly
for the 70%.
4.6 In 2002-03 we are funding 18 CSCF and
17 JFS reproductive health projects with a combined annual value
of £2.06 million. Our funding through the CSCF for reproductive
health is increasing: £0.38 million in 2000-01, £1.04
million in 2001-02 and £1.67 million in 2002-03.
Partnership Programme Agreements
4.7 DFID agrees Partnership Programme Agreements
(PPAs) with civil society organisations in the UK with which it
has significant working relationships and shared objectives. PPAs
are strategic level agreements, which set out the overall framework
for DFID's work with the organisation linked to funding. Individual
DFID departments and country programmes can also negotiate separate
arrangements for collaboration, including additional financial
support for specific activities within the overall PPA framework.
Expressions of interest are sought, and then using objective criteria
and taking advice from departments across DFID, we select what
we consider to be the most promising candidates for preparation
of a full PPA agreement.
4.8 For the current round we have received
39 Expressions of Interest. Of these, three are from NGOs in the
reproductive health sector (International HIV/AIDS Alliance, International
Family Health and MSI). We are in the process of appraising these
39 applications, in liaison with other DFID departments, and hope
to make decisions by mid May. It is still too early to make any
comment on the likelihood of any of these applicants being taken
forward for PPA negotiation. This decision will be taken on the
published criteria:
— contribute to the achievement of
the Millennium Development Goals;
— demonstrate specific added value
from working with DFID; and
— are innovative and contribute to
a broad overall portfolio of work addressed by the PPAs.
5. US GOVERNMENT
POSITION
5.1 The United States is pursuing a strongly
illiberal line on reproductive health issues at various fora including
the UNGASS on Children in New York, the World Health Assembly
and the WSSD prepcom in Bali. This is part of a sustained (and
well-resourced) effort to undermine and roll back consensus on
reproductive health and rights reached in particular at the Cairo
and Beijing UN conferences.
5.2 The US is seeking to characterise reproductive
health services as promotion of abortion. Whilst unsafe abortion
accounts for about 20% of all maternal deaths in developing countries,
ICPD agreed a careful position on abortion:
— in no case should abortion be promoted
as a method of family planning;
— any measure related to abortion can
only be determined by national legislative process; and
— where abortion is permitted it should
be safe.
5.3 So it is up to countries to decide if
and to what extent abortion is a part of the reproductive health
care and services available. But we should bear in mind that it
is unlikely that the MDG to lower maternal mortality will be reached
without progress in addressing unsafe abortion.
5.4 DFID is concerned the conservative stance
of the US and its allies could be potentially very damaging, given
that:
— efforts to prevent HIV/AIDS will
be hampered without improving access to reproductive health information
and services.
— Preventing the spread of HIV/AIDS
is essential to the achievement of all the MDGs.
— reproductive health services and
care are vital also for lowering maternal and child mortality,
and to promoting gender equity and the rights of women to reproductive
choice.
5.5 Some organisations that provide key
reproductive health care assistance are threatened by the rise
in opposition by reactionary groups to their work. The UNFPA is
the largest UN provider of sexual and reproductive health assistance
to developing countries and is a key DFID partner. The Fund provides
support to enable millions of women in developing countries to
go through pregnancy and childbirth more safely. UNFPA has been
the subject of a campaigns by conservative groups aimed at undermining
confidence in the organisation. This has been characterised by
unsubstantiated accusations of, for example, support for enforced
abortion, sterilisation and family planning in several countries.
Similar attacks have been directed at DFID in recent years over
our support for UNFPA. We have robustly defended out policy. Encouragingly,
a visit by three UK MPs (including Edward Leigh) to China in April
2002 unanimously concluded that UNFPA was a force for good and
a catalyst for change in reproductive health policy and practice
in China.
6. RECOMMENDATIONS
FOR DFID
6.1 The UK Network on Sexual and Reproductive
Health and Rights recommended three significant areas for action:
— DFID should once again take an international
leadership role on sexual and reproductive health and rights.
— DFID should work more closely with
UK sexual and reproductive health and rights NGOs on policy formulation.
— DFID should ensure that UK sexual
and reproductive health and rights NGO expertise is utilised to
the full in supporting southern NGOs.
6.2 On the first, we have continued our
international leadership role. We will continue to this role,
including through our support for UNFPA. We have lobbied hard
in recent international fora, where the international consensus
was at risk of being rolled back.
6.3 On the second, we work with NGOs and
others on formulation of a wide range of policy areas. We have
number of teams in policy division working in which reproductive
health issues are critical. Of particular importance are the service
delivery team and the HIV/AIDS team. Both of these teams will
be open to NGO engagement and participation in their policy work.
6.4 On the third, our country programme
managers take forward partnerships with civil society in developing
countries including local NGOs, who have an important role to
play in this area, particularly where governments do not take
on their full responsibility. They work with a range of partners
to achieve their goals at country level.
2 May 2003
The following is a list of current reproductive
health programmes (over £1 million) funded by DFID:
Nigeria |
Sexual and Reproductive Health programme; life planning education programme; HIV/AIDS programme.
|
| Kenya | Family health programme; HIV /AIDS programme; safe motherhood demonstration project.
|
| South Africa | Reproductive health programme; social marketing of condoms; Soul City multi media initiative.
|
| Mozambique | Social marketing of condoms.
|
| Zambia | HIV/AIDS and reproductive health programme.
|
| Uganda | Support for TASO—AIDS Support Organisation.
|
| Malawi | Sexual and maternal health programme.
|
| Tanzania | Safe motherhood programme; family planning programme; support for health sector reform including sexual and reproductive health.
|
| Zimbabwe | Sexual and reproductive health programme.
|
| Ghana | Ghana HIV/AIDS programme.
|
| Mozambique | HIV/AIDS and maternal health programme.
|
| Sierra Leone | Strengthening reproductive health provision.
|
| Ethiopia | Social marketing of condoms.
|
Africa Regional (Ethiopia,
Rwanda and Burundi)
| Support to International Partnership
Against AIDS in Africa.
|
Southern Africa Development
Co-ordinating Committee
| Regional HIV/AIDS Programme. |
| Central America: regional | Improving sexual and reproductive health services.
|
| Bolivia | Health and Sexual Education programme
|
| Peru | Reproductive Health programme.
|
| Russian Federation | STD programme; HIV/AIDS programme; support for Russian Family Planning Association.
|
| China | HIV/AIDS programme.
|
| Bangladesh | Reproductive health and disease control project; contraceptive social marketing; HIV/AIDS programme; CARE-RASTTA Bondor STD/HIV project.
|
| India | Support for National AIDS Control Programme; Orissa reproductive health project.
|
| Nepal | Reproductive health programme and rights-based response to HIV/AIDS.
|
| Pakistan | Reproductive health programme; social marketing of condoms; private sector population project; community based family planning project.
|
| Asia Regional | HIV/AIDS prevention in Asia.
|
| |
| 
