Appendix: Government response
Introduction
DFID warmly welcomes the IDC Report and is grateful
to the Committee for the interest they have generated in this
key issue and for the helpful way in which the various hearings
were conducted. The report provides valuable guidance and has
undoubtedly helped to increase the profile of this subject, not
just inside DFID, but also internationally.
The global maternal mortality burden
[Paragraph 8] Such is the uncertainty about the
real scale of maternal mortality, particularly in sub-Saharan
Africa and Asia, that whilst the number of maternal deaths for
2005 is cited as 536,000, the figure could be as high as 872,000.
Many studies have found a tendency for maternal deaths to be under-reported
and we fear that the higher figure could indeed be nearer the
truth. Moreover, using national averages to assess the magnitude
of the problem often masks enormous differences between areas
and groups of women.
We share the IDC's concern and agree with this conclusion.
This is why DFID is continuing to invest in, and apply, research
(for example by the Initiative for Maternal Mortality Programme
Assessment—IMMPACT) that helps to better measure maternal
mortality through a range of low-cost and appropriate measurement
tools. It is very important that these new tools and approaches
are shared with governments and implemented at country level and
this is why we are encouraging IMMPACT to disseminate this research
internationally and at country level.
DFID has provided £500,000 to the Health Metrics
Network (HMN) between 2006/07 and 2008/09 to enable improved measurement
of maternal mortality and better tracking of MDG 5—particularly
through supporting the development of technical guidance and for
advocacy for measuring pregnancy-related mortality in the census.
DFID is also working at country and global levels to ensure the
additional MDG 5 target (universal access to reproductive health
by 2015) can be well monitored—and has funded consultancy
work to support the development of appropriate monitoring indicators.
In reality, as was pointed out in the Lancet report,
vital registration of all births and deaths is what is needed
to ensure the rights of children (to citizenship and entitlements)
as well as to cost effectively monitor maternal deaths. The UK
government will be lobbying for scaled-up global efforts to register
every birth and death and certify every cause of death during
key fora in 2008 and beyond. In the UK, compulsory registration
of births and deaths, which highlighted the scale of the problem,
led to public concern and pressure to reduce infant and maternal
mortality.
The key bottleneck: a failure of advocacy and
political will
[Paragraph 14] Over the course of the inquiry,
we have been saddened by the stagnancy of MDG 5 and the fact that
so many women continue to die during pregnancy and childbirth.
A clear message from the evidence we took was that a key bottleneck
in securing progress on maternal health is a failure of advocacy
and a lack of political will.
The lack of political will to address women's sexual
and reproductive health and rights over the past two decades has
directly contributed to the global collective failure to prevent
maternal deaths. DFID recognises that the need for greater political
will and action on maternal health has never been greater. It
is the top priority in DFID's maternal health strategy. The UK
Government is also working to ensure that we are not a lone voice.
This is an international priority that demands an international
response.
The Government believes advocacy needs to take place
on several levels; to promote greater national and local awareness
and ownership of the actions needed by governments and community
groups; to boost the international response with other donors
and multilateral agencies; and to engage high level political
actors. DFID's annual Progress Reports on maternal health have
demonstrated increased advocacy at all levels, though much remains
to be done by all agencies.
But there has been progress during 2007. In launching
the International Health Partnership in September 2007, the Prime
Minister signalled the UK's clear intention to help lead an international
drive for stronger national health plans and systems to deliver
better health services. The Women Deliver Conference, in London
in October and the Norwegian Prime Minister's Health MDG Campaign
marked a turning point for advocacy. The UN Secretary General's
meeting in September 2008, bringing together heads of state to
galvanise action to achieve the Millennium Development Goals,
is a crucial milestone.
The UK Government is determined to seize the opportunities
presented to us to build on the current momentum to ensure effective
action on tackling maternal deaths. The Government also continues
to support the Partnership for Maternal, Newborn and Child Health
(PMNCH) and the White Ribbon Alliance (WRA).
[Paragraph 16] We believe that lack of progress
towards MDG 5 is a global collective failure. Responsibility for
this belongs at both international and national levels. Donors
and national governments carry a particular responsibility to
heighten awareness both of the unacceptability of the situation
and of the urgent need for greater political will for progress.
The responsibility to act lies not with one sector but across
sectors—the Ministry of Finance, for example, as well as
the Ministry of Health—and with a whole range of actors,
from UN agencies to grassroots groups at village level.
We entirely agree and welcome the call for a multi-sectoral
response, particularly involving Ministries of Finance. We are
pleased that the IDC has acknowledged DFID's own advocacy through
its dedicated maternal health strategy, the launch of the IHP,
high quality research on maternal health and its rights-based
approach. DFID cannot achieve progress alone and we welcome the
emphasis on other agencies and governments. We are working with
governments, NGOs, the UN and the private sector to address MDG
5 and will do more to raise the profile across national governments.
Girls' and women's education
[Paragraph 24] Girls who are not in school are
having their right to education undermined and are at increased
risk of early marriage, domestic violence and HIV/AIDS. We urge
DFID to ensure that the interdependency between maternal health,
gender inequality and education is acknowledged and acted upon
in its own strategies for these three areas as well as in national
country development plans.
We entirely agree and welcome the emphasis on girls'
education. The work of sectors outside of health, particularly
education, social welfare, justice and transport, all play a key
role in reducing maternal deaths.
Our Girls' Education Strategy paper states "Educating
girls helps to make communities and societies healthier, wealthier
and safer, and can also help to reduce child deaths, improve
maternal health and tackle the spread of HIV and AIDS. It
underpins the achievement of all the other MDGs".
Gender-based violence
[Paragraph 26] The DFID-funded project to address
gender-based violence towards pregnant women in Nepal and Bangladesh
is achieving promising results and this approach should be communicated,
and, where relevant, replicated. Contraceptive services and counselling
by trained health workers should be integral parts of such projects.
We agree with this recommendation. DFID's funding
through the International Planned Parenthood Federation (IPPF)
has resulted in important findings from these programmes in Bangladesh
and Nepal, which will have key lessons for other country programmes.
DFID is also funding two Research Programme Consortia to research
around violence against women, sexual and reproductive health
and women's empowerment. These will also provide important recommendations
for policy and programmes.
Access to family planning and counselling is crucial.
These can be provided by trained health workers, in clinic settings,
and by trained community distributors where there is no local
clinic.
Socio-economic empowerment
[Paragraph 29] Microfinance and microcredit schemes
have been shown to work well in empowering women socially and
economically and can be used to promote better health and uptake
of care. We recommend that DFID build on the success of projects
such as the Intervention with Microfinance for AIDS and Gender
Equity (IMAGE) in South Africa, which added gender, violence and
HIV/AIDS components to existing microfinance schemes and promote
relevant opportunities for replication and adaptation to improve
maternal health.
We agree with this recommendation. A number of programmes,
funded by DFID and other agencies, have demonstrated this is a
promising area for future development. Cash transfer schemes,
now under way in India and Bangladesh, are demonstrating increased
uptake of services for deliveries in health facilities, and in
time will improve access to emergency obstetric care. The cost
of emergency obstetric care can be catastrophic for poor families.
Strengthening civil society's capacity to hold
governments to account and influence policy
[Paragraph 37] DFID deserves credit for its support
to strengthening civil society's capacity to hold governments
to account for maternal health care. However, we believe that
the Department could do more to ensure citizens are appropriately
involved in the national policy-making process, including for
example appropriate engagement in auditing government statistics
and measuring progress on maternal health.
We agree that a strong civil society response is
important to hold governments to account and note that the evidence
submitted jointly by NGOs to the IDC states that DFID does "support
the voices of the poor, civil society and the marginalised".
DFID strongly supports the view that civil society
should engage in national policy making processes and our Civil
Society Challenge Fund provides resources for a wide range of
agencies to engage in these activities. There is scope to do more,
particularly on maternal health issues. Some examples of what
is being planned include DFID's support at the local level to
the White Ribbon Alliance (WRA) in Malawi and Zambia and Orissa.
DFID provides ongoing support to UNICEF for advocacy on maternal
health in three States in India: Bihar, Rajasthan and West Bengal.
Local NGOs are also enabling citizens to advocate for improved
services, holding government to account. In Malawi, the WRA has
been raising its concerns about the high levels of maternal mortality
in parliament.
Ensuring pro-poor health financing
[Paragraph 43] User fees for maternal health care
almost always hit the poorest women hardest and we believe that
there is a strong case for their removal in favour of universal
free care. We believe that DFID should continue to support countries
to abolish user fees. We recommend that, when doing so, DFID and
other donors should help ensure that other revenue sources—for
instance, the tax base or additional donor funds—are identified
in order to support the expanded demand for care. We believe that
governments, when considering free care, need to identify the
main financial barriers for women (for instance, transport), particularly
the poorest, and seek to address these using financing options
which are sustainable and most relevant to the country's circumstances.
User fees are not a good way to finance health systems
and the UK Government White Paper, "Making Governance Work
for the Poor" (July 2006) gave a commitment to support those
governments who wish to remove user fees. In some countries, where
a high proportion of health services are provided by the private
sector, this is more complex to achieve. However, when requested
by partner governments, DFID will continue to provide support
to abolish user fees for basic health services and help governments
tackle other barriers to access, including discrimination against
women. In Burundi for example, additional funds have been provided
to assist the government to support the expanded demand for care.
We agree that more work with Ministries of Finance and Health
is needed to ensure that national resources and donor funds are
directed at removing financial barriers to accessing maternal
health.
[Paragraph 44] There is evidence that cash transfer
or voucher schemes can work in encouraging women, particularly
the poorest and those living in remote areas, to give birth in
facilities with a skilled attendant, rather than at home. We recommend
that DFID prioritise support to efforts to identify, implement
and evaluate context-specific options for reducing financial barriers
to maternal health care.
We agree with this recommendation and have been encouraged
by early results, for example in Nepal, demonstrating some progress
in reducing financial barriers through cash transfers or voucher
schemes. DFID is funding schemes to ensure that the most marginalised
women can access services. In Bangladesh, DFID is funding WHO
to assess the impact of a Ministry of Health and Family Welfare
scheme to give vouchers to 100,000 pregnant women, to determine
whether objectives have been achieved, prior to scaling up. In
India, preliminary reports from the government's new Maternity
Security Scheme (the Janani Suraksha Yojana) suggest that it is
helping more women to give birth in health facilities. Under this
scheme a payment (to help cover the costs of transport) is made
to pregnant women in the poorer states for each institutional
delivery. A payment is also made to the village health worker
to accompany the woman in labour. The findings from these new
schemes will influence the policy of DFID and other agencies in
the future.
A rights-based approach
[Paragraph 46] We believe that DFID deserves credit
for its rights-based approach to maternal health. However, the
Department must ensure that the approach is accompanied by adequate
funding and implementation strategies. To ensure that the approach
is fully implemented at programme level, we believe that DFID
should support monitoring frameworks which assess how effectively
country programmes are applying a rights-based perspective.
We are pleased that the IDC has given credit to DFID
for its rights-based approach to maternal health. DFID has a system
of Country Governance Analysis, as a key component of its country
strategy approval processes, which includes a human rights assessment.
The National Audit Office report on Budget Support (February
2008) has recommended that DFID develop better systems to
assess and monitor human rights in development partnership agreements
and country programming. In response to this, we are strengthening
the human rights guidance to cover assessment, implementation
and monitoring. We believe this will enable country programmes
to better implement DFID's rights-based approach in all its work,
including on maternal health.
This is underpinned by corporate procedures to ensure
staff carefully consider human rights issues in their decision-making.
DFID Directors are all required to give assurances that
policies, practices and procedures pursued in their Divisions
comply with the Human Rights Act and that managers at all levels
implement them in operating practices and procedures.
In an effort to ensure rights-based approaches are
given profile at international level, DFID has provided £200,000
start-up funds to the International Initiative on Maternal Mortality
and Human Rights that was launched at the Women Deliver Conference
in October 2007.
Unsafe abortion
[Paragraph 52] Unsafe abortion is responsible
for tens of thousands of women dying each year and is a highly
neglected public health challenge. We agree with DFID's approach
of not trying to impose abortion decisions on countries but seeking
to support civil society where interest in changing the law and
improving services already exists. In countries where abortion
is illegal, we believe that DFID should continue to look for opportunities
to help ensure women are aware both of the circumstances in which
abortion is permitted and of the safe services that are available
to them.
The UK Government has been leading in actively promoting
efforts to prevent unsafe abortion, and in focussing attention—and
challenging policies—on this issue. We will continue to
seek opportunities (in countries where it is appropriate) to inform
women that abortion is legal and that safe services are available,
as we are doing in countries such as India and Cambodia, and increasingly
in Africa. Yet still an estimated 5.5 million women in Africa
undergo an unsafe abortion each year (WHO). DFID continues to
encourage other agencies, particularly EC members, to actively
support the provision of safe abortion services.
[Paragraph 54] The hugely oversubscribed first
call for funding from the Safe Abortion Action Fund (SAAF) demonstrates
the size of the need for funds to improve abortion services. We
agree that DFID should continue to advocate for new donors to
contribute to the Fund and if, following evaluation results, there
is sound evidence for the effectiveness of the SAAF, we believe
that DFID should also consider a substantial increase in its own
support for the Fund.
DFID and other agencies reaffirmed their commitment
to provide additional support for the prevention of unsafe abortion
at the Global Safe Abortion conference, held in London in October
2007.
In response to a very high level of demand for funding,
particularly from African countries, DFID Africa Division has
approved an additional £1 million to the Safe Abortion Action
Fund (on top of the original £3 million) plus a £6.5
million contribution to IPAS. These investments aim to: strengthen
regional organisations and networks that advocate for safe abortion;
support advocacy and production of policy relevant research; have
an impact at country level and regional level on policy change
and service delivery; and increase utilisation of high quality,
safe abortion and post abortion services.
DFID's core funding for the International Planned
Parenthood Federation continues to support all five of IPPF's
strategic areas of work: adolescents, HIV/AIDS, (safe) abortion,
access to sexual and reproductive health (SRH) services and advocacy.
The UN: challenges and opportunities in its current
approach
[Paragraph 60] It is far from clear to us how
the UN divides up responsibility for different aspects of maternal,
newborn and child health. The overlapping remits between agencies
have contributed to a lack of confidence in the UN as a global
leader. Whilst maternal health is multi-factoral in nature and
requires input from several agencies, we believe that a clearer
delineation of each UN agency's role needs to be set out and communicated
widely
This issue has been recognised as a problem for several
years and DFID has raised the need for more effective coordination
and clear delineation of responsibilities with the agencies concerned.
There has been some progress in the past year. With encouragement
from DFID and others, the three agencies (UNICEF, WHO and UNFPA)
have been negotiating at a central level to agree coordination
of labour for MDG 5. We understand that agreement has been reached
but the outcome has not yet been formally publicised by the UN.
We also believe that roles need to be effectively delineated at
country and regional level, as well as at the centre.
Too often the central-level policy decisions do not
filter down effectively to the country level. We find that an
agency's capacity to lead on a specific area of maternal health in-country
is dependent on the level of priority given to it by the
Head of Office and the level of staff competency, rather
than the policy direction. This results in an unsatisfactory
situation where an agency leading on maternal health in one country
is unable to do so in another. We are pressing for agencies to
better track the implementation of their strategic priorities
and for greater accountability from the country offices to the
centre and national stakeholders.
We agree that capacity to address MDG 5 needs to
be strengthened across all three agencies.
[Paragraph 65] Fragmentation amongst UN agencies
has slowed progress on MDG 5 and constrained the UN's ability
to provide global leadership on maternal health. We urge DFID
to continue to press strongly for concrete actions that will sharpen
co-ordination between UN agencies, including the rapid roll-out
of the 'One UN' programme, and the appointment of official maternal
health 'champions' within the UN.
We agree, and this is fully in line with DFID policy.
Future support to UN agencies will be managed through performance
frameworks to track specific activities to progress towards the
MDGs. The performance frameworks will enable us (and other donors)
to hold UN agencies to account and directly link our funding to
results in thematic areas and their strategic priorities.
Under the proposed delineation of responsibilities,
UNFPA will be accountable for the global advocacy role on unsafe
abortion and commodity supply for maternal health (including family
planning) and WHO will be monitored against progress towards its
medium term strategic plan (MTSP) which includes objectives on
health systems.
The performance frameworks will also monitor the
agencies' effectiveness at delivering their strategic priorities
including staff performance and results based management.
In Bangladesh DFID, in partnership with the EC, is
contributing £11 million over 5 years to a joint UNFPA-WHO-UNICEF
programme to accelerate progress on maternal and neonatal health
which has already brought clarity on UN roles.
Margaret Chan, WHO, Thoraya Obaid, UNFPA, and Joy
Phumaphi, World Bank, have acted as champions on maternal health
for their respective agencies. UNICEF is in a point of transition,
going through an organisational review, but we will encourage
such a champion in future.
The Partnership for Maternal, Newborn and Child
Health
[Paragraph 70] Whilst we appreciate the need to
balance membership of global partnership boards according to capacity
and shifting priorities, we were concerned to hear that DFID has
resigned from the Board of the Partnership for Maternal, Newborn
and Child Health, particularly at a time when the need to accelerate
progress towards MDG 5 is so acute. We urge DFID to return to
the Board as soon as staff capacity permits, and in the meantime
to work closely with the Norwegian Government to ensure DFID's
leverage and push for co-ordination is retained within the Partnership.
DFID has not resigned from the Board of the PMNCH,
but has rotated off and is now represented by Norway. This rotation
is similar for a number of international boards, working in partnership
with others, and is fully consistent with the Paris Declaration
principles regarding donor harmonisation. The Norwegians are leading
on a major initiative on maternal and child health, which has
strong support from the UK, and we feel it is appropriate for
them to represent us on the PMNCH Board. We keep in regular contact
with the Norwegians and with the PMNCH secretariat, particularly
on technical matters, and have recently funded capacity strengthening
work to enable PMNCH to better articulate and implement its global
advocacy strategy.
The Global Campaign for the Health MDGs
[Paragraph 74] DFID deserves credit for spearheading
the International Health Partnership. We were pleased to see this
practical application of the Paris Declaration on Aid Effectiveness
and hope it will help both recipient countries and donors to maximise
development assistance for health. DFID must maintain its leadership
role and help drive the IHP's implementation phase, ensuring that
parallel donor efforts to strengthen health systems are delivered.
DFID has been fully supportive of the group of eight
leading global health agencies (the H8) taking forward the leadership
of the IHP. The H8 consists of the World Bank, WHO, UNFPA, UNICEF,
UNAIDS, the Global Fund to fight AIDS, Tuberculosis and Malaria
(GFATM), the Global Vaccine Alliance (GAVI) and the Bill and Melinda
Gates Foundation. This has further ensured coordination and alignment
of these critical agencies around strengthening health systems.
Although the UK launched the IHP, it is keen for the IHP to be
a global initiative supporting broader global (rather than DFID)
health objectives.
The UK attended the second meeting of the H8 in January
2008, and continues to maintain a role in political leadership.
With encouragement from DFID, Margaret Chan of WHO has agreed
to arrange a briefing on the IHP at the next World Health Assembly
in May 2008. This will present an opportunity for participating
governments to describe progress to date, as well as non-IHP country
governments to make informed decisions over possible future engagement.
DFID will continue to take a role in encouraging IHP member countries
to bring new partners into the IHP.
[Paragraph 75] Greater national ownership of health
policies, as envisaged by the IHP, is dependent on effective advocacy
for improved health by governments. We recommend that DFID use
its leadership role to ensure that governments and both national
and international civil society groups are fully involved in the
implementation of the IHP so that successful advocacy for improved
health takes place in tandem with improved aid effectiveness.
DFID fully supports both government and civil society
having a strong role in the IHP at country and global levels.
Both global and national level civil society groups contributed
to the first meeting of IHP Country Teams, in Lusaka from February
28th-March 1st. WHO and the World Bank are
currently consulting with civil society groups to determine how
best to deepen the civil society role in the IHP. DFID will continue
to support strong engagement, not only in implementing the IHP,
but also in holding IHP signatories to account, so that they demonstrate
the behaviours needed for improved aid effectiveness.
[Paragraph 76] We recommend that DFID and the
other organisations involved in the IHP take steps to ensure that
the process of reviewing pilot countries is managed promptly and
efficiently. Assuming successful reviews emerge, the IHP should
then be extended to other interested countries as soon as possible.
A key part of the IHP is to minimise additional reporting
requirements from countries. We agree that a review is required
and are delighted that WHO and the World Bank have agreed to commission
an external review. They will report back in September 2008.
The Global Fund to Fight AIDS, TB and Malaria
[Paragraph 83] We believe that DFID and other
donors should build on a series of opportunities at the Global
Fund to Fight AIDS, TB and Malaria—its new Director, gender
strategy and membership of the International Health Partnership—and
should encourage the Fund to support more maternal health care
interventions which have direct relevance to these three diseases
as well as to health systems strengthening.
DFID has learned much about the effectiveness of
Global Health Partnerships (GHPs) over the past few years and
how they can best help to add value. We know that countries must
be in the driving seat for health planning, but that technical
assistance is important to ensure integration of issues such as
maternal health, HIV and sexual and reproductive health and rights
(SRHR). Since the Fund can only give support on the basis of the
proposals presented to it, this integration is essential.
The recent move by the GFATM to increase its support
for health systems (and for health workers) is significant, as
functioning health systems are core to improvements in maternal
health. GFATM's membership of the Health 8 group within the IHP
demonstrates further progress and improvements in harmonisation
amongst donors.
[Paragraph 85] We believe that the Global Fund
needs to communicate more clearly its willingness to accept funding
proposals for maternal, sexual and reproductive health programmes—particularly
those integrated with HIV/AIDS, TB and malaria interventions—to
countries seeking funds. DFID should use its Board membership
to help encourage a closer dialogue between the Fund and its recipients
so that there is a clearer understanding of how the Fund's resources
can be spent.
We agree that there needs to be a clearer understanding
of how the Fund's resources can be spent to reflect countries'
own needs. At the GFATM Executive Board meeting in November 2007,
the Board approved a significant increase in the size of the Secretariat,
a large proportion of which will be directed to operations,
so that this closer dialogue can take place. As Board members,
we will want to see that this increase in secretariat size is
translated into improvements in GFATM performance on the
ground, including on maternal health. The new window of support
for health systems will result in some improvements in maternal
health services.
The Japanese Presidency of the G8
[Paragraph 87] We were pleased to hear that DFID
is engaging with Japan regarding its Presidency of the G8 in 2008.
DFID should support Japan to realise its pledge to make health—and
maternal health especially—a key priority for the Presidency.
This should include advocating for this prioritisation amongst
other G8 members.
For the G8 summit this year, Japan is looking to
balance efforts on HIV and AIDS with those on maternal and child
health. During the preliminary G8 negotiations with the Japanese,
DFID continues to push for greater clarity on accelerated action
on maternal mortality reduction.
We are continuing to advocate at a high level on
maternal health amongst other G8 members. In the March 2008 State
Visit, the joint UK-France summit communiqué states "As
signatories to the International Health Partnership, the UK and
France are today committing to ensure that our work to strengthen
health systems will focus on achieving demonstrable reductions
in maternal mortality."
The UK's role in stepping up advocacy
[Paragraph 88] We are pleased that DFID recognises
the need to step up its efforts on international advocacy. We
will keep a watching brief on how these efforts are translated
into action during 2008, especially at the UN General Assembly
meeting on the MDGs in the autumn.
Point noted, we welcome IDC interest on this matter.
[Paragraph 89] We agree that supporting specific
maternal health champions and change agents in developing countries
is a good idea. We recommend that DFID pursue its discussions
about empowering such champions with the Elders Group.
DFID will continue to seek and support champions
at all levels for maternal health. We are delighted that Sarah
Brown has agreed to be the Patron of the White Ribbon Alliance
and that Gordon Brown is a member of the Global Leaders Network
for MDGs 4 and 5, which is led by Prime Minister Stoltenberg of
Norway. The UK has not followed the example of some other countries
by appointing an "Ambassador" for high profile programmes
(such as for HIV and AIDS).
[Paragraph 90] The scientific research community
is an advocacy mechanism in its own right and should be supported
by donors so that it mobilises itself more effectively. This is
particularly important within developing countries where research
can be applied practically as a way to inform and monitor government
policies for maternal health.
We agree. DFID has a strong track record of funding
for research, both internationally and within less developed countries.
A new Research Strategy for DFID is close to being finalised.
[Paragraph 91] We agree that focusing intensified
global advocacy efforts around existing processes, such as the
2008 Japanese G8 Presidency and the UN General Assembly's meeting
on the MDGs in the autumn of 2008, is likely to be more effective
than creating a separate global fund for women's health.
Point noted.
What works in preventing maternal deaths: the
example of Nepal
[Paragraph 95] We applaud DFID for its contribution
to the Nepal Safe Motherhood Project and Support to Safe Motherhood
Programme, which have included a range of interventions relevant
to maternal health in Nepal over a decade that has witnessed progress
in reducing maternal mortality. We urge DFID to support independent
comprehensive evaluations of this experience, with a view to sharing
lessons in the region and globally.
We agree that independent evaluations of approaches
to reducing maternal deaths are an essential part of lesson learning
and informing policy, whether the work is funded by DFID or other
donors.
In Nepal, as in other countries, DFID implements
an on-going system of internal annual and mid-term reviews. Findings
from these reviews are shared with advisers and key partners at
retreats, continuing professional development days and at regional
events.
Independent reviews of components of the Nepal SSMP
have been held. For example, the Maternity Incentive Scheme (MIS)
is being assessed by the London School of Hygiene and Tropical
Medicine (LSHTM).
Key lessons learned from the Equity and Access Programme,
the part of the SSMP that is ensuring the poorest are able to
reach services, was presented to the OECD in London recently.
Similar calls were made for such comprehensive reviews to be shared
within the region, something we would encourage.
DFID's research partners are encouraged to share
published results in a way that is easily accessible to all, not
just by publishing in learned academic journals. DFID's Central
Research Department has particularly encouraged the Research Programme
Consortia (RPC), "Towards MDG 4 and 5", to help it develop
an effective communication strategy.
DFID advisers regularly share experiences through
documentation, as well as through being part of teams that evaluate
maternal health programmes in countries. The annual Maternal Health
Progress Report to Parliament documents lessons learned and is
shared with our development partners and the international agencies.
[Paragraph 98] We urge DFID to look closely at
options for replicating successful approaches from Nepal where
appropriate, and to identify factors relevant to scaling-up and
transference. We appreciate that success is often context-dependent,
but believe the DFID-funded approach to supporting women's groups,
as in Nepal, is worthy of particular consideration wherever relevant.
DFID agrees that replication of successful approaches
is important, taking into account the particular context in the
countries concerned. A number of maternity financial incentive
schemes are being implemented in South Asia including Nepal, Bangladesh
and India. DFID is supporting evaluation of these programmes,
to determine what works in particular contexts. (See also response
to the Paragraph 44 recommendation above.) DFID is looking forward
to receiving and disseminating the conclusions of the research
on women's groups in Malawi and Nepal, which will also be relevant.
What works in strengthening health systems: boosting
human resources
[Paragraph 103] We were concerned to learn the
extent of the global shortfall in health workers, particularly
the lack of midwives. Boosting the numbers of midwives worldwide
will be central to the achievement of MDG 5. Increasing the availability
and quality of training opportunities for midwives is therefore
of paramount importance. DFID should consider supporting action-oriented
research into where human resource shortages and training needs
are particularly acute and the options for addressing them in
the short, medium and long term.
We agree with this recommendation and are supporting
the International Federation of Gynaecologists and Obstetricians
(FIGO) and the International Confederation of Midwives (ICM) to
research and identify key issues to address the shortage of midwives,
along with our broader support to the Global Health Worker Alliance
(GHWA). Our UN partners, specifically UNFPA and WHO, have been
holding global consultations on this issue and we are supportive
of their approach. Although a global problem, the midwifery crisis
must be addressed country by country, in each context. In Nepal,
for example, negotiations with the professional associations and
government have led to the development of a new cadre of midwives.
In Pakistan, priority is being given to developing a new cadre
of 10,000 community midwives over the next five years along with
strengthening of midwifery schools and increasing the number of
midwifery tutors.
Sub-Saharan Africa has 25% of the global burden of
disease, yet it has only 3% of the world's health workers. Thirty-six
countries in Africa are confronting critical shortages, with fewer
than 2.3 health workers (doctors, nurses and midwives) per 1,000
people. DFID is pressing for increased numbers of health workers—especially
in Africa.
We will advocate for the G8 to commit to support
the scale-up of health workers, in-line with the WHO recommendation
of at least 2.3 health workers per 1,000 people. WHO estimates
that this level of coverage by health workers will enable an 80%
coverage rate of deliveries by skilled birth attendants, as well
as providing more people able to administer medical tests, diagnose
and provide treatment. Figures will vary country to country and
we will continue to encourage governments to focus on national
requirements for skilled birth attendants appropriate to reach
MDG 5.
[Paragraph 105] We believe that DFID and other
donors should find new ways to help governments encourage health
professionals to provide quality services in remote and rural
areas. This should include supporting civil society to lobby for
better salaries and conditions for doctors and midwives working
outside urban areas and to ensure the necessary infrastructure,
supplies, transport and equipment are in place to enable these
professionals to provide prompt and effective care.
We agree that more needs to be done to enable health
workers to work safely and effectively in rural areas. The issues
are complex. To retain health workers in remote rural areas, they
need terms of service which will enable them to earn a living,
along with arrangements for housing, education for children, and
job opportunities for partners. Staff retention in urban areas
has traditionally been easier because these support services are
more readily available. DFID engages in provision of budget support,
which is designed to meet the wider needs for all basic health
services, including salaries, transport, equipment, drugs and
consumable supplies.
DFID support to the White Ribbon Alliance is enabling
midwives to raise concerns about their conditions of service.
The WRA has supported midwives in Tanzania to lobby government
and demonstrate to raise awareness of maternal health and the
difficulties that midwives face—as women and as midwives—in
providing care in remote areas.
[Paragraph 107] DFID deserves credit for its support
to the Emergency Human Resources Programme in Malawi, for which
initial results show expanded staff numbers and better uptake
of training. We recommend that DFID move swiftly to support the
replication, where appropriate, of efforts to address human resources
problems as soon as conclusive results are available.
The Malawi programme is showing early signs of success.
DFID will certainly be adapting, as appropriate, the lessons learned
from the Malawi EHRP, once conclusive results are available and
disseminating best practices to other country programmes.
Increasing the availability of equipment and supplies
[Paragraph 109] We were concerned to hear about
the lack of even very basic supplies and medicines in many developing
countries. We recommend that donors, including DFID, work with
the World Health Organization to advocate with national governments
for national Essential Drugs Lists to contain drugs such as magnesium
sulphate, which are crucial to maternal survival.
The lack of basic supplies is a result of the budget
constraints experienced by countries (or lack of prioritisation
on health), and also arises from health systems that are too weak
to effectively deliver the drugs and supplies to the health facilities
where they are needed. As discussed above, DFID provides budget
support to help governments address these shortages and ensure
long-term predictable financing that enables Ministries of Finance
to enter into long-term supply contracts and drive down the costs
of procuring drugs and supplies.
The WHO essential drugs list is an important instrument
and is designed to encourage countries to procure generic drugs,
rather than proprietary drugs that are very much more expensive.
The WHO list includes magnesium sulphate, a low-cost drug which
is highly effective in preventing maternal deaths from eclampsia.
Where a country has limited resources, priority tends
to be given to the drugs most used by health staff. In some countries,
although magnesium sulphate had been purchased, it was not actually
being widely used by midwives or doctors, and supplies went out
of date. Although the drug is cheap and effective, there can be
dangerous side effects. Without access to emergency resuscitation,
health workers may be reluctant to take the risk of managing serious
side effects in isolated areas. Strong health systems, including
well trained staff with access to a functioning referral systems
(transport and communication) are needed to ensure that patients,
particularly in remote rural areas, have access to the essential
drugs they need.
[Paragraph 112] In addition to insufficient quantities
of essential drugs, many countries have widespread shortages of
other pre-requisites for maternal health and services, including
adequate blood and family planning supplies. We believe that DFID
should seek to build political commitment within countries to
ensure that these crucial supplies are appropriately funded within
national health plans and budgets. The Department should also
campaign internationally for a reversal in declining budgets for
family planning supplies and services.
DFID will continue to support the development of
strong national health plans that include improved access to blood
transfusion and family planning commodities. Budget support and
Sector Wide Approach (SWAp) are processes of negotiation and prioritisation
with government and other donors to reach a consensus on what
is needed across the health sector, with regular review and revision.
DFID is fully supportive of increasing budgets for
family planning, both at country level and globally. DFID allocated
an additional £100 million, over five years, to improve commodity
supplies and family planning services. DFID will again lobby for
increased funds for family planning at the G8 (as it did effectively
in 2007), but also funds partners, such as IPPF, to provide services
and campaign for greater access.
Balancing the demand and supply-side of care
[Paragraph 115] In order to achieve efficiently
functioning health systems, there needs to be a balance of demand
and supply-side approaches. We believe that DFID needs to ensure
that its support for demand and supply-side approaches is flexible
and reflects the needs of specific contexts, and that it is consistent
with broader health systems strengthening in countries. Where
budget support is being used, DFID and other donors should retain
oversight of national programmes to ensure this balance is achieved.
Monitoring systems need to be capable of tracking this balance.
DFID-supported maternal health programmes in Asia
and Africa have placed considerable weight on balancing demand
and supply side interventions. For example, in Malawi new knowledge
on the cultural barriers to good sexual and reproductive heath,
including HIV and AIDS, arose from the Safe Motherhood Project
research. This led to innovative communications tools, including
the use of radio and drama, significantly increasing demand for
maternity services.
In Pakistan DFID will launch a Research and Advocacy
Fund (£11.5 million) to foster rights-based approaches and
test innovative proposals for demand-side financing.
Where DFID does not have separate programmes, but
provides support though budget support, we work closely with other
partners (i.e. UN or another donor such as the Netherlands), to
highlight any imbalances, as well as conducting regular reviews
In line with Paris Declaration principles on donor
harmonisation, DFID takes the lead role in some sectors in each
Public Service Agreement (PSA) country but other funding agencies
lead where they may have a comparative advantage. DFID liaises
closely but it is not possible or desirable for us to lead in
all countries on the health sector. We are also working towards
more effective partnerships with the UN.
Working in conflict-affected and fragile states
[Paragraph 120] We believe that maternal health
should be an essential and integral part of all humanitarian responses.
Women in conflict settings are more at risk of poor maternal health
and have fewer—or no—services available to them. We
recommend that DFID advocate within the UN cluster system—both
amongst other donors and the lead agency, the World Health Organization—for
maternal, sexual and reproductive health to be prioritised in
humanitarian emergencies.
We agree with this recommendation. There has been
increasing concern about the sexual and reproductive health and
rights (SRHR), particularly of young women, especially in conflict
and humanitarian situations. We are raising the profile of these
issues within the global health cluster working along with other
partners. For example, we have recently ensured that questions
around SRHR have been included in updated DFID guidelines to NGOs
seeking funding for work in humanitarian situations.
WHO leads the health cluster in humanitarian situations
and sets the strategic direction and priorities for the health
response in close collaboration with the government (where possible).
We are planning to work with WHO to ensure that SRHR should be
a core component of the cluster's strategic response. The health
cluster needs to work closely with the Ministry of Health to ensure
alignment of sensitive issues within the overall national strategy.
[Paragraph 122] We believe that DFID should go
beyond immediate emergency relief and build on its ability to
work on sensitive issues such as abortion, for which there is
greater demand in conflict-affected and fragile settings and which
urgently needs support. Efforts should be made to ensure that
maternal care is a core part of both DFID's and national health
programmes from the outset. A long-term dual approach that seeks
to strengthen or re-build systems whilst continuing some aspects
of emergency care is likely to work best.
We agree that sensitive issues such as abortion should
be addressed in conflict situations, where feasible, and that
the post-disaster relief and rehabilitation period can provide
a significant opportunity to open up negotiation on sensitive
SRHR issues.
DFID believes that working on SRHR in conflict-affected
and fragile states is about ensuring a full range of comprehensive
information, supplies and services to women and men, including
to adolescents, who are particularly vulnerable.
DFID has learned that much will depend upon the context
of the emergency. In Nepal, for example, support from DFID enabled
the passing of legislation on access to safe abortion, as well
as the rapid scale-up of services, throughout the period of conflict.
In the DRC, the current emphasis is on establishing basic services,
given the extreme weakness of the health system and the lack of
trained health personnel. In Sierra Leone, DFID acted swiftly
to support the government to develop a sexual and reproductive
health policy, as a first step in planning wider post-conflict
maternal and child health inputs.
[Paragraph 124] We believe that DFID should learn
from what has worked in terms of supporting maternal health programmes
in fragile, conflict and post-conflict settings and share this
knowledge appropriately elsewhere. This should include successful
examples from DFID's own programmes, such as recent experiences
in Nepal, Sudan and Afghanistan.
A key lesson from this IDC report has been the need
for DFID to be more effective in disseminating our experience
in maternal health in several ways. Within DFID and among our
key international partners and civil society, there are opportunities
for this experience to be more widely shared. However, a proportion
of this high quality work, although supported by DFID, is implemented
by other agencies (UN, NGO, etc) or by government and we will
do more to actively encourage them also to share in appropriate
ways.
The need for improved health information systems
to monitor progress
[Paragraph 129] Supporting improved health information
systems in developing countries is of crucial importance to identifying
and sustaining successful policies for maternal health. We believe
that DFID should continue to support initiatives addressing weak
information systems, such as the Health Metrics Network and Immpact.
DFID should ensure that its programmes include a focus on strengthening
national capacity to collect, analyse and use maternal health
data.
All DFID maternal health programmes, or health sector-wide
approaches (SWAps), support national efforts to monitor progress
on the health MDGs. The capacity to collect, manage and use maternal
health data is variable and support has been provided either specifically
for maternal health [Malawi, Nepal) or across the health system,
particularly where budget support is provided.
DFID is a Board Member of and provides financial
support to the Health Metrics Network (HMN), which works to improve
the collection, analysis and use of appropriate data. The HMN
is currently being evaluated and we will consider future support
in light of the evaluation findings.
The Initiative for Maternal Mortality Programme Assessment
(IMMPACT) has successfully achieved its objectives and has made
a significant contribution. DFID and other funders have encouraged
the development of Ipact, which is an independent consultancy
arm of IMMPACT, to implement research findings in various countries,
as requested by governments.
[Paragraph 130] The opportunities to highlight
and address the urgent need for improved data that arise through
various international initiatives, such as the International Health
Partnership, should be seized and championed by DFID. The use
of maternal indicators as a basis for financing decisions, for
example, is likely to be a powerful stimulus to countries to improve
maternal health itself.
We agree with this recommendation and note that some
countries are at an early stage of developing health information
systems and few countries have yet reached the more sophisticated
stage of effectively using data to educate financial decisions—arguably
it is only recently that the UK has started to achieve this standard.
Undoubtedly, this is the direction of travel.
DFID is championing the use of indicators of maternal
health as core to assessing overall improvements in health systems
and services—for example in the International Health Partnership
(IHP). The proposed framework for monitoring and evaluation of
the IHP includes, among the output indicators, the coverage of
maternal and child health services including skilled birth attendance.
Impact indicators include both maternal and child mortality rates.
In Burundi the IHP has already helped influence health
reforms on MDG 5. The Memorandum of Understanding/country compact
has agreed that two of five indicators directly relate to maternal
health, the percentage of births "in a health care environment",
and increases in couple years of protection.
[Paragraph 131] Helping countries to monitor maternal
deaths and the quality of care through routine audit systems will
help to focus policies. We believe that DFID should help share
lessons from developing countries that have successfully implemented
audit systems of maternal deaths.
We agree that auditing maternal deaths is important,
helps to focus policy and enable steps to improve service delivery.
Innovative work on maternal death audit, that we have supported
and helped disseminate, includes that done in the Malawi Safe
Motherhood Project (SMP).
DFID's current mix of aid instruments and policies:
financing strategies
[Paragraph 135] We were pleased to hear that DFID's
funding to maternal health will increase to over £50 million
in 2008. DFID's additional financing for family planning through
UNFPA and its funding for research are particularly welcome.
Point noted.
[Paragraph 136] We reiterate our recommendation
from Paragraph 122 that, in order to strengthen health systems,
aid to maternal health should be predictable and long-term, especially
in fragile and conflict-affected states.
We agree, point noted.
Budget support and maternal health
[Paragraph 140] We believe that delivering support
to maternal health through budget support is appropriate and will
assist the predictability of aid. However, better tracking is
needed of the extent to which the funds contribute to improved
maternal health outcomes. DFID should explore specific mechanisms
to ensure this, including giving support to public expenditure
reviews of government budgets—especially those involving
civil society—and making maternal health a specific headline
indicator for budget support. The choice of measures of maternal
health will be crucial, in terms of their availability, accuracy
and ability to reveal inequities, and we recommend that DFID takes
a lead role internationally in ensuring the most appropriate and
effective selection.
DFID has been encouraging the use of maternal mortality
ratios (MMR) (or a proxy indicator, such as number of institutional
deliveries, or proportion of deliveries with skilled birth attendant)
as a key tracking indicator for budget support programmes and
has particularly stressed this approach in work on the IHP. Our
experience is that this will help raise the profile of maternal
health and place the onus on countries (and funding agencies)
to take MMR far more seriously, thus increasing political attention
to the issue. However, the choice of the actual indicator needs
to reflect the country context, especially if a maternal health
indicator is already being monitored by the government.
DFID's human resource capacity
[Paragraph 144] We were reassured to hear that
DFID country programmes will be exempt from headcount cuts due
to efficiency savings. However, we were concerned to hear the
views of a number of witnesses that DFID staff working on maternal
health were frequently overstretched. There is evidence that DFID's
human resource capacity to drive the maternal health agenda is
constrained, both in-country and within DFID Headquarters. We
believe that, as one of the most off-track MDGs—and one
needing urgent progress—maternal health should be a priority
area for staff resources within DFID. We reiterate our recommendation
from our report on DFID's Annual Report 2007 that, in order to
focus development assistance where it will have the greatest effect
on poverty reduction, DFID will have to make some difficult decisions
about withdrawing from some countries or sectors. We look forward
to contributing to this decision-making process as part of our
future work.
At the IDC hearing, Parliamentary Under-Secretary
of State Vadera gave assurances that country and regional programmes
in the poorest countries were receiving priority for staff resources.
Since March 2004, in line with other UK Government Departments,
DFID staff numbers have fallen by 12%, with many of these reductions
in administrative staff. The Organisation for Economic Co-operation
and Development (OECD) Development Assistance Committee (DAC)
peer review of DFID last year praised us for "a golden age
of growth and achievement". DFID has also scored very well
in the recent Whitehall Capability Review.
DFID has to work within the reality of UK policy.
However, addressing the MDGs, including maternal mortality reduction,
is a stated priority. DFID's operations to address maternal health
are expanding in Asia and there is also planned expansion in Africa.
The IHP process will rationalise how and where donors engage,
and will bring opportunities for more effective division of labour
at country level. DFID is also exploring options for wider division
of labour, for example with Norway rotating on to the Board of
the PMNCH, and the Netherlands now representing DFID on the Board
of Roll Back Malaria and STOP TB.
Looking forward, the Comprehensive Spending Review
settlement means that for the next three years the budget for
staffing in country offices, where most of our health advisers
are based, will increase modestly in real terms. DFID country
programmes will be exempt from headcount cuts resulting from the
requested efficiency savings. In UK-based departments, administration
cost budgets will fall. However, we will be aiming to protect
professional capacity in front line services as far as possible.
DFID's comparative advantage
[Paragraph 147] We agree that DFID has a comparative
advantage in working on sensitive issues such as unsafe abortion.
Whilst we reiterate our view that abortion is a national issue,
we believe that DFID should challenge governments which seek to
restrict access to contraception services and safe abortion. This
should include working with international and national advocacy
and rights-based groups to communicate the facts about preventable
deaths and disabilities from unsafe abortion.
DFID policy is to actively encourage governments
to review legislation where abortion is illegal, pointing out
the consequence of such legislation is almost always a significant
increase in unsafe abortion, resulting in subsequent increases
in severe complications and maternal deaths. Advocacy work and
services to provide safer abortion have been a comparative advantage
for DFID, as the IDC has noted, and will continue to be a major
focus of our work in SRHR and we will continue to work closely
with leading NGOs and civil society organisations (such as IPPF
and MSI) on this subject.
[Paragraph 150] Identifying DFID's role within
the international drive to meet MDG 5 also relies on establishing
the limits of the Department's contribution. DFID cannot do everything.
Part of its approach should focus on supporting other actors,
especially the UN, to play their part. DFID's next maternal health
strategy—which we believe should be produced sooner rather
than later—should set out a clear and focused approach that
seeks to engender more realistic expectations of its work from
other aid organisations and set out what it cannot, as well as
what it can, achieve.
We agree and there are plans to update the Maternal
Health Strategy. Preliminary work will start later in 2008 and
the revised strategy will be completed during 2009. Policy and
Research Division, in liaison with regional and other divisions,
will develop a Position Paper on meeting the unmet need for family
planning, which could form part of the updated Maternal Health
Strategy.
Re-appraising priorities
[Paragraph 151] We believe that DFID needs to
re-assess its work now—whilst reaching MDG 5 by 2015 is
still a possibility—and identify specific areas in which
it can immediately 'add value'. 2008 is a year of opportunities
to catalyse progress on MDG 5 but DFID needs to reflect first
on where it can best contribute to global efforts.
DFID Ministers have already called for advice on
how DFID can increase efforts on maternal health. As discussed
above, DFID is also engaging at high level to give greater prominence
to maternal health issues in the G8 summit and the UN MDG summit
in September 2008. There has also been strong leadership on this
subject from the Prime Minister's office, particularly in the
recent discussions with French authorities, during the State Visit.
[Paragraph 153] We believe that the three pre-requisites
of family planning, emergency obstetric care and skilled birth
attendance must remain at the centre of DFID's work.
DFID agrees that these three priorities are essential
effective interventions and would also add the prevention of unsafe
abortion.
[Paragraph 154] Countries such as Honduras show
that when maternal health is made a national priority, and a strong
focus is given to emergency obstetric care, skilled birth attendance
and family planning, maternal mortality can be reduced substantially
in less than a decade. We believe that DFID and other donors should
prioritise supporting other countries to emulate this success,
which will help ensure MDG 5 is within closer reach by 2015.
Point noted. We agree that Honduras provides a very
useful example and should be included in efforts to disseminate
best practice, described above.
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