House of Commons - International Development

Select Committee on International Development Fifth Report

5 THE CHALLENGE FOR DFID

132. This chapter will consider the implications for DFID of the challenges and opportunities for maternal health discussed above. This will include a focus on how DFID funds and administers its country programmes that address maternal health, and how effectively the Department deploys its own human resources on maternal health issues. Finally, the chapter will examine DFID's work in relation to other international agencies, and assess whether the Department prioritises and harmonises its work on maternal health effectively.

DFID's current mix of aid instruments and policies

Financing strategies

133. As we stated in Paragraph 11, DFID spent £16 million on maternal and newborn health in 2005-06 (within a £385 million total spend on health),[303] a figure which we were told had since "doubled and will double again [...] to over £50 million by next year [2008]."[304] However, the share of international aid for health directed towards maternal health is relatively small. Globally, Official Development Assistance (ODA) for maternal, newborn and child health represented approximately 16% of total global ODA to health, and approximately 2.5% of total global ODA, in 2004. As we said earlier, the majority of funds are provided by a handful of donors: 14 donors contributed 90% of total ODA to maternal, newborn and child health in 2004, and just four donors accounted for 51%—the World Bank, USAID, DFID and UNFPA.[305]

134. Baroness Vadera told us that a significant portion of DFID's increasing maternal health budget would be directed to major reproductive and maternal care programmes in India and Pakistan. Ghana would also benefit through a Sector Wide Approach (SWAp) for health and Sierra Leone would see extra funds to help re-build its health system.[306] Additionally, £100 million for UNFPA was announced by DFID in October 2007, to be spent on family planning.[307]

135. An aspect of DFID's financing that was welcomed in evidence was its support to research; the Towards 4+5 Research Programme Consortium said that DFID is "one of the biggest bilateral donors (in terms of funds and visibility) for research activities in maternal and neonatal health", and welcomed the fact that DFID is willing to "take risks with research" by financing research on innovative interventions, for example the women's group trial in Nepal that we discussed in Paragraphs 96-98.[308] 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.

136. However, it is clear that overall financing for maternal health is currently insufficient. As we said in Paragraph 18, a further US$14 billion needs to be found for maternal, newborn and child health if the international community is to reach the US$25 billion estimated as necessary to ensure that a basic package of health services is available to all.[309] Whilst several witnesses perceived DFID's financial contribution to maternal health to be relatively low, and that further funds should be allocated immediately,[310] more evidence focused on the need for all donors to provide predictable, long-term financing.[311] Predictability of aid is important for strengthening health systems and supporting the costs of health workers' salaries and training.[312] As we have said, conflict-affected and fragile areas have a particular need for longer-term funding to enable the re-building of systems.[313] Baroness Vadera told us that DFID's use of predictable, long-term financing gives it a comparative advantage amongst other donors.[314] 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.

BUDGET SUPPORT AND MATERNAL HEALTH

137. One approach to improving the predictability of aid is through the use of budget support: direct contributions by donors to national governments that provide long-term and flexible finance. Sometimes funds are paid directly into the budgets of health ministries through health sector budget support. DFID uses budget support in nine of its 16 health programmes in sub-Saharan Africa, and in five programmes in Asia.[315] DFID's Annual Report 2007 states, "Increasingly, DFID's support to reduce maternal mortality is delivered through general budget support or health sector budget support."[316]

138. For either general or sector budget support, DFID does not earmark funds for sub-sectors such as maternal health: governments themselves make decisions about such allocations. This is, of course, the right approach given that budget support seeks to enable countries to set policies and financing strategies themselves. But as DFID itself admits, the use of budget support

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Thoraya Obaid of UNFPA told us that it was important that maternal health does not "fall between the cracks" when support is given in the form of budget support.[318]

139. The view of Dr Tim Ensor from Immpact was that budget support for maternal health "makes a lot of sense" because maternal health is to a large extent a systems issue that is difficult to address through 'vertical' or project-based programming. However, he was concerned that the effectiveness of budget support is dependent on the capacity of governments and civil society to track expenditure and ensure funds are allocated to specified sectors. He said:

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Dr Ensor suggested that strengthening the use of public expenditure reviews—especially ones with civil society involvement—would help summarise how public money is spent and thus help ensure the effectiveness of budget support. He highlighted an example in India of civil society involvement in training people to undertake expenditure reviews.[320]

140. Baroness Vadera said that one way to make it easier to track budget support and ensure improved maternal health outcomes would be to make maternal health a specific headline indicator for budget support. The Minister highlighted that maternal health is often used as a proxy for measuring the strength of health systems, and thought that it might be "a better tracker of the effectiveness of the health system" than traditional headline indicators such as immunisation rates.[321] 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's human resource capacity

141. Another point raised in evidence in connection with DFID's increasing use of budget support was that it relies on in-country staff for its effective delivery. However, DFID, like all departments, is currently subject to civil service efficiency targets—which have entailed an 11% headcount cut for DFID since 2004 and thus constrained staff numbers within the Department.[322] Catharine Taylor of health consultancy HLSP told us:

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Baroness Vadera told us that, whilst DFID's Headquarters is subject to a 5% headcount reduction, in-country programmes will be exempt from restrictions and two-thirds of such programmes will even see a staff increase of 1%.[324] Thirty-nine of DFID's 53 health advisers are currently based in-country.[325] The Minister was confident that DFID had the necessary staff complement to drive forward maternal health in 2008. She said "everybody is always stretched and we are working in a field where the need is, in one sense, endless."[326]

142. Whilst we were reassured to be told that health advisers working in-country will not be subject to reductions, we are concerned by the implication that being "stretched" is acceptable and not counter to the effectiveness of DFID's operations. Immpact told us that DFID staff are already "frequently overstretched by the volume and range of work they must undertake". Immpact also said that, in Ghana, DFID interests are looked after by another national agency due to capacity constraints.[327] The Towards 4+5 Research Programme Consortium was concerned that high staff workloads could adversely affect the ability of DFID to interact with the academic community, both in developing countries and in the UK.[328] We have already commented that DFID has resigned from the Board of the Partnership for Maternal, Newborn and Child Health partly due to capacity constraints and is now being represented by the Norwegian Government.[329]

143. In our report of November 2007 on DFID's 2007 Annual Report, we registered our concern that headcount restrictions will act as a constraint on DFID's work, particularly in the poorest countries and fragile states. We said that we believe DFID needs to make some difficult choices about withdrawing from some countries or sectors so that it can focus development assistance where it will have the greatest effect on poverty reduction. We discussed examples of the options facing DFID, for instance reducing staff in countries which are performing well, so that staff in more challenging countries can be increased or funding specialist staff within country budgets thus also helping to strengthen capacity. We also highlighted the risks inherent in these options.[330]

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.

Managing expectations of DFID's work and aid harmonisation

DFID's comparative advantage

145. One route to maximising DFID's resources for maternal health, both human and financial, is ensuring that they are prioritised and harmonised in line with other donors' activities. Spending UK aid funds in the most cost-effective manner relies on DFID working to its strengths, seeking to be focused, avoiding duplication and complementing existing international strategies. Integral to this approach is identifying and acting upon DFID's comparative advantage amongst other donors.

146. As we said in Paragraph 122, Baroness Vadera believes DFID's comparative advantage is being able to "do and say difficult things: that we are able to champion something that not many countries easily champion" (for instance, access to safe abortion).[331] We agree that DFID's willingness to work on sensitive issues such as abortion places it within a select band of donors. It is also clear that other donors in this grouping—chiefly the Scandinavian and the Dutch agencies—do not have the same reach as DFID in terms of budgets or overseas programmes.[332]

147. As we have made clear, we do not believe that abortion decisions should be imposed on countries from the outside; however, we do believe that DFID—as one of the few donors actively to promote efforts to prevent unsafe abortion—should challenge restricted access to contraception services and safe abortion and encourage governments and donors to think hard about the fact that unsafe abortions are the third highest cause of maternal deaths.[333] It may be difficult for donors and international agencies to challenge cultural attitudes and gender bias but we who live in more liberal societies must not shy away from championing fundamental women's rights. 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.

148. UNFPA estimates that meeting the existing demand for family planning services would in itself reduce maternal mortality and morbidity by at least 20%.[334] It follows that those who deny women the right to access contraception, whether through negligence or active policy, are effectively condemning millions of women a year to death or disability.[335] This is a fundamental issue of human rights.

149. Identifying where DFID's comparative advantage lies is also about highlighting what DFID cannot do—and that it cannot do everything. If progress towards MDG 5 is to be scaled up over the next 5 to 10 years, DFID must help ensure that all global actors are playing their part. For example, this must include supporting the Japanese to realise their pledge to focus their 2008 G8 leadership on global health. It should also involve helping to streamline the currently fragmented UN approach to improving maternal health.

150. From the evidence we received, it was clear that there is an expectation that DFID can do everything, from publicising good practice to improving monitoring systems to implementing professional development for health workers in developing countries.[336] This is unrealistic. There is a need for DFID to 'manage expectations' and communicate clearly that it cannot single-handedly drive progress on MDG 5 on all fronts. The fact that it has a dedicated maternal heath strategy is an asset; when a revised strategy is due—and we think this should be sooner rather than later—DFID should ensure that it sets out a clear and focused approach that highlights the limits of its contribution to maternal health, as well as its current and projected activities. 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 sets out what it cannot, as well as what it can, achieve.

RE-APPRAISING PRIORITIES

151. Many witnesses believed that 2008 was a crucial year for maternal health, with over 20 years having elapsed since the launch of the Safe Motherhood initiative, the mid-point to the MDGs just passed and with new leaders in place to galvanise progress.[337] Baroness Vadera told us of DFID's plans to capitalise on the opportunities in 2008 and have a big "push" on MDG 5 this year.[338] But DFID will only be in a position to do this if it has a clear vision of its priorities and where its contribution is most needed. 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.

152. This re-appraisal of priorities will require DFID to conduct a robust analysis of other donor efforts and of where the need is greatest. But the 2015 MDG deadline is now very close, and the simple goal should be to identify strategies that will reduce deaths fastest whilst ensuring that changes are sustainable. These strategies are well understood by DFID: family planning, emergency obstetric care and skilled birth attendance. But securing the delivery of this essential package remains elusive for many countries. Just seven years from the MDG deadline, countries such as Nigeria, Lesotho and Zambia are going backwards rather than forwards in terms of the number of births attended by a skilled professional.[339]

153. Thus 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. Witnesses were clear that establishing basic human and physical health care infrastructure within countries was still at the centre of the challenge facing governments and donors. This will enable more skilled birth attendants to work in adequately equipped health facilities that can provide emergency obstetric care.[340]

154. Countries such as Honduras show how quickly maternal mortality ratios can be improved when basic maternal health policies are made a national priority. In 1990, the mortality ratio (MMR) was 182 per 100,000 live births. This was addressed through a strong focus on emergency obstetric care, a robust referral system for women with complications and an increase in the number of births with a skilled attendant. Government prioritisation, in combination with donor support, helped bring about a reduction in the MMR to 108, a fall of 38% in 7 years.[341] 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.

303 This figure excludes budget support and contributions to multilateral agencies such as the UN. DFID, Maternal Health Strategy-Reducing maternal deaths: evidence and action, Second Progress Report (April 2007), p.8. Back

304 Qq 271- 272 and Ev 229. DFID spent the following amounts on maternal health: £16.2 million in 2004/05, £18.7 million in 2005/06 and £21.9 million in 2006/07. Projected spending for 2007/08 is £53-54 million (an extrapolated figure based on planned future expenditure as funds begin to be spent under new maternal health projects) (Ev 229). Back

305 See Paragraph 11 and Ev 151 Back

306 Q 272 [Baroness Vadera] Back

307 DFID Press Release, 18 October 2007, 'UK Pledges £100 Million and Calls on World Leaders to Cut Maternal Deaths' and Ev 229 Back

308 Ev 150 Back

309 Ev 113 Back

310 Ev 126; Ev 157; and Q 14 [Dr Francisco Songane] Back

311 Ev 139; Ev 110; Ev 202; Q 54 [Dr Grace Kodindo] Back

312 Ev 177 Back

313 See Paragraphs 121-122 Back

314 Q 258 [Baroness Vadera] Back