| The global maternal mortality burden
|
| | |
| 1. | 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. (Paragraph 8)
|
| | |
| The key bottleneck: a failure of advocacy and political will
|
| | |
| 2. | 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. (Paragraph 14)
|
| | |
| 3. | 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. (Paragraph 16)
|
| | |
| Girls' and women's education
|
| | |
| 4. | 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. (Paragraph 24)
|
| | |
| Gender-based violence |
| | |
| 5. | 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. (Paragraph 26)
|
| | |
| Socio-economic empowerment
|
| | |
| 6. | 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. (Paragraph 29)
|
| | |
| Strengthening civil society's capacity to hold governments to account and influence policy
|
| | |
| 7. | 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. (Paragraph 37)
|
| | |
| Ensuring pro-poor health financing
|
| | |
| 8. | 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. (Paragraph 43)
|
| | |
| 9. | 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. (Paragraph 44)
|
| | |
| A rights-based approach |
| | |
| 10. | 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. (Paragraph 46)
|
| | |
| Unsafe abortion |
| | |
| 11. | 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. (Paragraph 52)
|
| | |
| 12. | 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. (Paragraph 54)
|
| | |
| The UN: challenges and opportunities in its current approach
|
| | |
| 13. | 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 (Paragraph 60)
|
| | |
| 14. | 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. (Paragraph 65)
|
| | |
| The Partnership for Maternal, Newborn and Child Health
|
| | |
| 15. | 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. (Paragraph 70)
|
| | |
| The Global Campaign for the Health MDGs
|
| | |
| 16. | 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. (Paragraph 74)
|
| | |
| 17. | 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. (Paragraph 75)
|
| | |
| 18. | 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. (Paragraph 76)
|
| | |
| The Global Fund to Fight AIDS, TB and Malaria
|
| | |
| 19. | 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. (Paragraph 83)
|
| | |
| 20. | 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. (Paragraph 85)
|
| | |
| The Japanese Presidency of the G8
|
| | |
| 21. | 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. (Paragraph 87)
|
| | |
| The UK's role in stepping up advocacy
|
| | |
| 22. | 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. (Paragraph 88)
|
| | |
| 23. | 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. (Paragraph 89)
|
| | |
| 24. | 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. (Paragraph 90)
|
| | |
| 25. | 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. (Paragraph 91)
|
| | |
| What works in preventing maternal deaths: the example of Nepal
|
| | |
| 26. | 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. (Paragraph 95)
|
| | |
| 27. | 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. (Paragraph 98)
|
| | |
| What works in strengthening health systems: boosting human resources
|
| | |
| 28. | 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. (Paragraph 103)
|
| | |
| 29. | 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. (Paragraph 105)
|
| | |
| 30. | 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. (Paragraph 107)
|
| | |
| Increasing the availability of equipment and supplies
|
| | |
| 31. | 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. (Paragraph 109)
|
| | |
| 32. | 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. (Paragraph 112)
|
| | |
| Balancing the demand and supply-side of care
|
| | |
| 33. | 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. (Paragraph 115)
|
| | |
| Working in conflict-affected and fragile states
|
| | |
| 34. | 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. (Paragraph 120)
|
| | |
| 35. | 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. (Paragraph 122)
|
| | |
| 36. | 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. (Paragraph 124)
|
| | |
| The need for improved health information systems to monitor progress
|
| | |
| 37. | 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. (Paragraph 129)
|
| | |
| 38. | 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. (Paragraph 130)
|
| | |
| 39. | 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. (Paragraph 131)
|
| | |
| DFID's current mix of aid instruments and policies: financing strategies
|
| | |
| 40. | 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. (Paragraph 135)
|
| | |
| 41. | 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. (Paragraph 136)
|
| | |
| Budget support and maternal health
|
| | |
| 42. | 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. (Paragraph 140)
|
| | |
| DFID's human resource capacity
|
| | |
| 43. | 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. (Paragraph 144)
|
| | |
| DFID's comparative advantage
|
| | |
| 44. | 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. (Paragraph 147)
|
| | |
| 45. | 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. (Paragraph 150)
|
| | |
| Re-appraising priorities |
| | |
| 46. | 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. (Paragraph 151)
|
| | |
| 47. | 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. (Paragraph 153)
|
| | |
| 48. | 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. (Paragraph 154)
|
| | |
