House of Commons - International Development

Select Committee on International Development Fifth Report

3 SECURING POLITICAL WILL: GLOBAL STRATEGIES FOR MATERNAL HEALTH

55. Women's health is both their individual human right and of critical importance to a country's social, economic and political development. Yet it is rarely a political priority, even though world leaders signed up in 2000 to meeting MDG 5. Progress on MDG 5 is vital to the achievement of MDG 4 which is seeking to reduce child mortality[119]and to most other MDGs.[120] As we said earlier, we believe the lack of progress on MDG 5 represents in large part a failure of international advocacy and of political will at national level to prioritise resources and interventions to improve maternal health.[121]

56. Evidence submitted jointly by NGOs saw 2007-08 as a crucial year to galvanize international efforts to improve maternal health, with new leaders appointed in several G8 countries and within a number of the multilateral bodies working on health, including the World Bank, the World Health Organization and the Global Fund to Fight AIDS, TB and Malaria.[122] 2007 marked 20 years of the Safe Motherhood Initiative, a global advocacy movement to reduce maternal deaths, with a key international conference ('Women Deliver') and a chance to re-group and find ways to drive progress on MDG 5.[123] This chapter will draw upon evidence submitted to our inquiry to explore the reasons why international advocacy has thus far failed to ignite sufficient political commitment to ensure action, and assess how DFID could strengthen the global effort and boost political will.

The UN: challenges and opportunities in its current approach

57. Witnesses believed that the UN bears significant responsibility for the lack of global leadership and political will for improving maternal health.[124] A number of UN agencies, including the UN Population Fund (UNFPA), the UN Children's Fund (UNICEF) and the World Health Organization (WHO) have remits that include maternal health. DFID's health spend through these agencies for 2002-03 to 2006-07 is substantial and is set out in Table 1. DFID is one of the largest donors to UNFPA, was the second largest donor to UNICEF in 2006 and is the largest donor to WHO.[125]

Table 1 DFID expenditure on health through UN agencies

UN agency	DFID funding 2002-03 to 2006-07
UN Population Fund (UNFPA)	£77 million plus an extra £100 million over 5 years, announced in October 2007
The UN Children's Fund (UNICEF)	£94.3 million
The World Health Organization (WHO)	£146 million
The Partnership for Maternal, Newborn and Child Health (hosted by WHO)	£1.25 million[126]

Source: Ev 90

58. UN agencies were criticised by a number of witnesses for being fragmented and incoherent: no single agency leads on maternal health and there is a lack of definition over respective roles.[127] Maternity Worldwide believed that the UN used an inconsistent approach across continents and countries.[128] Written evidence submitted by YozuMannion stated:

129

The Network on Sexual and Reproductive Health and Rights highlighted the duplication of effort and poor co-ordination within the UN agencies. WHO, for example, has two separate departments with overlapping remits, Making Pregnancy Safer and Reproductive Health and Research, and also hosts the Partnership for Maternal, Newborn and Child Health.[130]

59. Thoraya Obaid of UNFPA insisted that the remits of each agency were clear, but to us the list of roles seemed confusing:

131

Ms Obaid said that on health more generally there were not just three but eight agencies trying to work together: the 'H8' coalition additionally includes the Global Alliance for Vaccines and Immunisation, the Global Fund to Fight HIV/AIDS, Malaria and TB, the World Bank and the Gates Foundation.[132]

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 has 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.

61. Richard Horton, Editor of The Lancet, believed that the UN was failing to drive advocacy efforts not just at the global level but at the level of civil society. He said that the UN system, "frankly, does not work very well" and thought that DFID could play a "vital role, an increasing role, in trying to mobilise that global leadership which is absent now."[133]

62. When we asked about how DFID could seek to bolster the UN's approach, Baroness Vadera agreed that there is a lot more "the UN could do in terms of impact and effectiveness." She agreed that fragmentation has affected progress towards MDG 5, particularly as reaching the Goal is so dependent on strengthening health systems, for which co-ordination is important.[134] She said that DFID continues to "press very hard" for improved co-ordination between the UN agencies.[135]

63. However, the Minister did see some signs for optimism within the UN, pointing out that the UN was trusted on the ground by countries which, particularly on sensitive issues, made it more effective.[136] Further, Baroness Vadera believed UNICEF and UNFPA to be showing "some signs of improvement."[137] She also said that there was now a group of three women leaders at the top of WHO, UNICEF and UNFPA who could act as champions for maternal health.[138] However, these leaders' remits clearly extend far beyond maternal health. We thus felt identifying specific champions to act as ambassadors for maternal health within the UN agencies would be useful and could have the added benefit of uniting UN efforts towards MDG 5.

64. The Minister also highlighted the DFID-funded 'One UN' Programme—a process being piloted in eight countries aiming for greater cohesion at the country level through one UN programme, one UN budgetary framework and one UN leader.[139] She was cautious about how long it would take to extend the programme beyond the initial pilot countries: "possibly" by 2010 seven to eight more countries would have rolled out the programme, but this depended on the evaluation of the eight pilots during 2008.[140] Thoraya Obaid of UNFPA also implied that extending this programme would take some time: "The [UN] General Assembly has taken a decision to study the eight pilots to see what we have learnt from them before proceeding further."[141]

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.

Other major global initiatives

66. Over the last few years, concerns about parallel donor structures for the health MDGs and about the UN's weak global leadership have brought about the creation of a number of international partnerships aiming to unite global efforts. As Thoraya Obaid of UNFPA told us, "We cannot have so many different initiatives that the countries themselves cannot deal with them."[142] Two recent partnerships have aimed specifically to co-ordinate and strengthen international advocacy for health: the Partnership for Maternal, Newborn and Child Health and the International Health Partnership.

THE PARTNERSHIP FOR MATERNAL, NEWBORN AND CHILD HEALTH

67. The Partnership for Maternal, Newborn and Child Health (PMNCH) was launched in 2005 to help harmonise and strengthen international efforts towards MDGs 4 and 5. It brought together three previously overlapping health partnerships: the Child Survival Partnership, the Healthy Newborn Partnership, and the Partnership for Safe Motherhood and Newborn Health.[143] The Partnership has three key aims:

Accelerating coordinated action at global, regional, national, sub-national and community levels;
Rapid scaling-up of proven cost-effective interventions; and
Advocacy for increased commitment and resources.

68. The Partnership, hosted by WHO, has more than 80 members including UN and multilateral agencies, partner countries, NGOs, professional associations, bilateral donors and the academic community. DFID helped to establish the Partnership and provided funding of £1.25 million between 2005-2008.[144] The PMNCH does not itself disburse funds but offers advocacy and technical support. It has four main areas of activity co-ordinated by international working groups: Advocacy, Country Support, Effective Interventions, and Monitoring and Evaluation.[145]

69. Despite being created primarily to address poor co-ordination amongst global maternal health actors, the Partnership was accused in written evidence from World Vision of failing to work in a co-ordinated manner:

146

The submission went on to encourage DFID to "engage fully and take a leadership role within the PMNCH", a view reiterated in the evidence submitted jointly by other NGOs.[147] Yet DFID resigned from the PMNCH Board at its most recent meeting in Addis Ababa in December 2007. Dr Stewart Tyson from DFID said that this was simply due to DFID's pragmatic approach of rotating its membership of international boards in partnership with other donors.[148] However, Dr Tyson also said that DFID does not have the capacity to continue to serve on the management boards of all the global partnerships.[149] The Norwegian development agency will represent DFID on the Board for now.

70. Balancing internal capacity constraints with DFID's international leadership role for maternal health is likely to get more difficult as civil service headcount restrictions continue to affect DFID. Fulfilling a pivotal role in this key international partnership, particularly during the initial years—when the Partnership will be at its most fragile—will certainly be less feasible if DFID does not sit on its Board. As Dr Francisco Songane of the Partnership told us, sitting on the Board allows donors to "exert influence to change the way institutions behave."[150] We will return to the issue of DFID's staff capacity for maternal health in Chapter 5. 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.

THE GLOBAL CAMPAIGN FOR THE HEALTH MDGS

71. This international campaign was launched in September 2007 and brings together several inter-related initiatives on the health MDGs, including the International Health Partnership, the Norwegian-led Network of Global Leaders, the Global Fund to Fight AIDS, TB and Malaria (which we will assess in the following sub-section) and the advocacy and communications drive Deliver Now for Women & Children, co-ordinated by the PMNCH.[151] This sub-section will focus primarily on the International Health Partnership, which has been led by the UK.

72. The International Health Partnership (IHP) was launched on 5 September 2007 as a way to help aid agencies work together more effectively on the three health MDGs, thereby reducing duplication and the time needed at country level to process individual donor demands and meet reporting requirements.[152] The IHP does not disburse funds but is a co-ordinating framework aimed at making the aid process simpler and more effective for both recipient countries and donors themselves—a practical attempt to implement the 2005 Paris Declaration on Aid Effectiveness within the health sector.[153]

73. The UK played a strong role in the creation of the IHP and the launch was announced by the Prime Minister. Eight 'first wave' pilot countries are participating initially.[154] These countries sign a compact that involves commitments from them and the donors, including measurable targets that are agreed by both. Evidence we received from NGOs said that the compact needs to ensure the active involvement of national and international civil society and professional organisations, who could help to track progress of the compact in line with the Global Health Partnership Principles.[155]

74. The UK's leadership in launching the IHP was widely recognised in the evidence we received.[156] However, evidence from the Peoples' Health Movement and Global Health Watch Secretariat was concerned that the IHP will be hard to deliver, especially given that it does not bring with it major new finance and that "operational guidance" in-country may be constrained given DFID's own headcount restrictions.[157] Evidence also highlighted that the IHP will only be possible to implement effectively if the necessary resources—health staff, medicines and supplies—and a functioning health system exist at country level.[158] It was significant that Baroness Vadera also emphasised to us the importance of implementation in connection with the IHP.[159] 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.

75. Marie Stopes International said that the IHP's proposed shift towards greater government ownership of national health plans "further intensifies the importance of effective advocacy in-country."[160] As we said in Chapter 1, advocacy is a key tool in empowering women to achieve their right to health and in creating the momentum to prioritise resources for maternal health such as sufficient numbers of health personnel and improved hospitals and clinics.[161] Such advocacy relies on commitment from governments to put maternal health high on the political agenda, and on the recognition that different government ministries need to work together to enable this.[162] However, evidence from the UK Network on Sexual and Reproductive Health and Rights perceived there to have been a failure to involve civil society and national governments—in both developed and developing countries—in devising and implementing the IHP.[163] 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.

76. There were also concerns about the initial limitation of the IHP to eight pilot countries. Dr Francisco Songane of the Partnership for Maternal, Newborn and Child Health said:

164

Baroness Vadera said that the eight countries represent a wide range of contexts and that there is interest in joining the IHP from many countries.[165] DFID was trying to encourage the same countries participating in the 'One UN Programme' initiative to join the IHP in the spirit of co-operation (although we noted that the only country participating in both initiatives currently is Mozambique).[166] The Minister also said that there was no need to wait for the reviews to be completed and that DFID was flagging up the IHP principles to countries not currently involved so that they could begin to look at them.[167] 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.

Seizing opportunities

77. A number of new openings and opportunities for addressing the failure of advocacy and the lack of political will for improved maternal health came to our attention over the course of the inquiry. In this section we assess how DFID and other donors can capitalise on these opportunities. We also consider specific ways in which DFID could help step up global advocacy efforts for maternal health.

THE GLOBAL FUND TO FIGHT AIDS, TB AND MALARIA

78. One institution which we believe could contribute more to global efforts on maternal health is the Global Fund to Fight AIDS, TB and Malaria, an international financing mechanism aiming to increase resources for the three major infectious diseases. The Fund operates as a partnership between governments, civil society groups and the private sector. Since its inception in 2001, the Fund's first two rounds of grant-making have issued US$1.5 billion of funding to support 154 programmes in 93 countries worldwide. DFID sits on the Fund's Board and is a key donor to the Global Fund, having committed £359 million through to 2008.[168]

79. Historically, policy and financing strategies for HIV/AIDS, TB and malaria on the one hand and sexual, reproductive and maternal health on the other have developed separately.[169] This has resulted in HIV programmes diverting resources earmarked for maternal health in some settings; for example, in South Africa where midwives were moved from maternity care to work on prevention of mother to child transmission of HIV.[170]

80. The accepted approach is now to support the integration of the two issues, given the series of intersections between them. HIV positive women are four times more likely to die in pregnancy or childbirth than women without HIV infection.[171] More than two million HIV positive women become pregnant each year and face a higher risk of succumbing to infectious diseases such as tuberculosis and malaria—in terms of incidence and severity—than non-HIV positive mothers. Furthermore, pregnancy itself increases the risk of HIV infection; this is thought to be due to a combination of physiological and behavioural factors.[172]

81. The implementation of integrated responses to HIV and sexual, reproductive and maternal health has been disappointing thus far, including in programmes funded by the Global Fund.[173] This is despite the fact that integrated interventions can address the two issues very effectively, through, for instance: condom provision; prevention of mother-to-child transmission of HIV; and reproductive health programmes for adolescents and young people.[174] Ensuring that screening and treatment for sexually transmitted infections including HIV are available at family planning clinics is of key importance. Attending such clinics is often routine for women and thus the stigma attached to HIV testing is removed.[175] Witnesses agreed that the Global Fund should do more to support integrated HIV, maternal, sexual and reproductive health interventions, for instance the training of skilled birth attendants.[176]

82. There are signs that that this lack of integration may be about to change: DFID itself has a well-integrated maternal health and HIV programme in Zimbabwe,[177] and a number of national proposals submitted to the Global Fund in 2007 incorporate sexual and reproductive health programming in addition to HIV.[178] At the Fund's most recent Board meeting it was agreed that a gender strategy would be developed, enabling a closer link between the Fund's work and maternal and women's health concerns.[179]

83. Baroness Vadera felt that generally there were new opportunities to work with the Fund. Whilst she was frank about "the fact that we have some issues" with the Fund—she even said that the Fund "fixated" her—she spoke encouragingly of the new Director, Dr Michel Kazatchkine.[180] Further, the Minister was pleased that the Fund had signed up to the IHP, a step that she believed would increase DFID's and other donors' ability to engage with the Fund.[181] 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.

84. Peter Godfrey-Faussett of the Global Fund emphasised to us that the Fund uses a demand-driven process. He believed it to be the role of donors, rather than the Fund, to advise partner countries on improved integration between HIV/AIDS and reproductive/maternal health strategies: "The Global Fund does not decide what countries should ask for [...] it is more up to DFID, WHO, more technical agencies, to be encouraging countries with what they could apply for."[182] He thought that engaging countries in a closer dialogue about their priorities would help here.[183] He said that strengthening health systems—a key condition for progress in improving maternal health as well as fighting infectious diseases—was "an entirely legitimate use of the Fund's money" but that "to date countries have not availed themselves of that resource as they might."[184]

85. Whilst we appreciate that it would be inappropriate for the Fund to control the nature of applicants' proposals, it seemed to us that the Fund could do more to encourage proposals for funding of maternal, sexual and reproductive health projects. Baroness Vadera believed that the Global Fund was open to funding such interventions but that this willingness needed to be made clearer to countries.[185] 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.

THE JAPANESE PRESIDENCY OF THE G8

86. Japan has said that it will use its G8 presidency in 2008 to lead an international health drive aiming to get the world back on track in meeting the MDGs.[186] Baroness Vadera told us that this is likely to include a specific focus on health systems and maternal mortality.[187] Japan will host the G8 summit in July 2008 and has also invited African leaders in May for the fourth summit of its Tokyo International Conference on African Development (TICAD) initiative.

87. In his oral evidence, Richard Horton suggested that DFID should engage with the Japan G8 agenda to ensure a focus on maternal health:

188

Baroness Vadera told us she had met with the Japanese G8 'Sherpa' and had "influenced" his speech about the importance of maternal health. She said she planned to visit Japan in February 2008.[189] She was hopeful that the other G8 members would agree to make health a priority in 2008.[190] We hope that her successor will now follow this initiative. 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.

THE UK'S ROLE IN STEPPING UP ADVOCACY

88. In addition to the two specific opportunities outlined above, we believe there are several other ways in which DFID could help step up global advocacy efforts for maternal health. Baroness Vadera agreed that political leadership and advocacy for maternal health were "very central" in 2008 and that DFID needed to "up its game" and "push harder in terms of international advocacy". She said that the Prime Minister is keen to push on MDG 5 specifically during 2008, including at the UN General Assembly meeting on the MDGs in the autumn.[191] 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.

89. The Minister emphasised that, in parallel with global efforts, advocacy for maternal health was needed within countries.[192] She thought one route to supporting this would be to establish champions for the issue and told us that DFID was talking to the Elders Group—a network of 12 men and women including Nelson Mandela and Archbishop Desmond Tutu created to address global problems by offering expertise and guidance—about how to establish champions.[193] DFID already supports national civil society groups which train 'change agents' and lobby senior political and traditional leaders to support health, for instance the Change Agent Programme at the Health Reform Foundation of Nigeria.[194] 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.

90. Richard Horton of The Lancet believed that the scientific research community could play a major role and mobilise itself more effectively in strengthening advocacy efforts, especially in-country where "science for civil society" can have a profound impact.[195] This kind of science did not mean "stuff that goes on in the lab or even clinical trials", but practical research applications and monitoring of government policies so that countries can work out why women are dying and how to prevent deaths.[196] This could act as "a kind of accountability mechanism [...] I do not say it is about shaming, but it is about naming, and in a very public sense."[197] 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.

91. What Baroness Vadera did not support was the establishment of a 'global fund for women's health', a call that had emerged from the Ministers Forum at the October 2007 'Women Deliver' conference. She believed another separate, parallel structure would only create further confusion and that a global advocacy campaign built around the Japanese G8 and the other initiatives set out above was far more sensible.[198] We believe this to be the correct approach. 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.

119 Ev 84-87. Because deaths of newborn babies around the time of birth form nearly 40% of total under-five deaths, efforts to reach MDG 5 overlap significantly with efforts to achieve MDG 4. Back

120 Ev 86 Back

121 See Paragraphs 14-16. Back

122 Ev 110-111 Back

123 Q 134 [Richard Horton] Back

124 Q 128 [Richard Horton] and Ev 163 Back

125 Ev 100 Back

126 Ev 229. Figures for DFID expenditure from May 2005 to the present. DFID has contributed: £240,000 from May 2005-December 2006 as an initial contribution; £10,000 in specialist management consultancy support in August 2005; and £1 million towards the current Partnership workplan and the cost of advocacy for the Women Deliver conference. Further specialist management consultancy support and DFID's future support are under consideration (Ev 229). Back

127 For instance, Q 128 [Richard Horton]; Ev 228; Ev 163; and Ev 131 Back

128 Ev 163 Back

129 Ev 228 Back

130 Ev 219 Back