Memorandum submitted by Cara International
Consulting Ltd (Joint NGO and interested stakeholders[1])
Every minute of every day a woman dies through
preventable causes related to pregnancy and childbirth. 99% of
these deaths occur in developing countries.
"Women are not dying because of diseases
we cannot treat. They are dying because society has yet to decide
that their lives are worth saving"i
BACKGROUND TO
THE CONSULTATION
AND THOSE
INCLUDED
There are moments in time when the right voice
at the right time can really change the world. This is one of
those times. This inquiry can make a difference. By using this
inquiry to highlight what needs to be done, by whom and when,
we can influence four new leaders. The new UK Prime Minister,
the new heads of WHO, the World Bank and the Global Health Fund.
These actors can galvanize enormous financial and technical support
for mothers, and their children, but they need to know that society
believes these women and children are important. This inquiry
can help let them know that stakeholders consulted all agree that
maternal health is essential. The health and well being of mothers
affect the health and well being of communities as a whole.
2007 is also a good time to reflect on lessons
learned from twenty years of implementing the Safe Motherhood
Initiative, which has enjoyed small scale progress but without
sufficient political support to ensure its successes are sustained
universally. On 18 October 2007, there will be an international
conference entitled "Women Deliver" that will bring
together developing country actors to harness such lessons. The
IDC could attend this meeting or seek written or oral evidence
from its participants; they will be sharing positive experiences
and challenges for maternal health all over the world, while planning
how to ensure maternal health becomes a political priority globally.
The White Ribbon Alliance are launching an exhibition at the Royal
College of Obstetrics and Gynaecology (in Regents Park) on 17
October entitled "Stories of Mothers Lost".
For these reasons The Making Pregnancy Safer
Department in the World Health Organisation contracted Cara International
Consulting Ltd, to take advantage of this window of opportunity
to support as many stakeholders as possible to have their voice
heard both for the IDC and the "Women Deliver" meeting.
Many NGOs and academics were invited to participate in this consultation
through either completing questionnaires based on a modified version
of the IDC inquiry questions, sharing their own submissions to
the IDC, taking part in interviews, and focused group discussions.
Cara International Consulting held a one day consultation on 6
September 2007 to share submissions to date and to gain consensus
on the most important issues. This report is the result of that
process.
Cara International Consulting Ltd wishes to
thank all those who contributed, either through their networks
or individually. These include the following organisations: Action
for Global Health, Cara International Consulting Ltd., Community
Health Action Group, FIGO, Health Unlimited, UCL—ICH, Interact,
Interhealth, Keele University, LSHTM, Merlin, MSF, MSI, Partnership
for Maternal Child and Newborn Health Advocacy Group, People's
Health Movement, Plan UK, Save the Children UK, Maternity Worldwide,
Maternal Health Sub group of SRH group, UK Sexual and Reproductive
Health Group, White Ribbon Alliance, Women and Children First,
and World Vision UK. As this is a consultation document the views
incorporated in the larger document reflect many actors and may
not be the views of all the respondents; however the main points
captured within the executive summary were agreed by those stakeholders
who attended the consultation meeting in London on 6 September.
This report aims at ensuring that every mother
and woman counts. To ensure that the next maternal health inquiry
tells a more positive story. We hope you will support the women
who never get a voice and act upon the recommendations in this
report, we will be happy to provide oral testimony to support
any part of this report.
FACTS REGARDING
MATERNAL HEALTH
Every year, 50 million women give birth without
the help of a skilled attendant.[2]
More than 500,000 women die every year as a result of difficulties
during pregnancy or childbirth.[3]
In sub-Saharan Africa, a woman's risk of dying from such complications
over the course of her lifetime in one in 16, compared to one
in 3,800 in the developed world.[4]
Women continue to die due to preventable causes like anaemia,
eclampsia, infection, haemorrhage, obstructed labour and the complications
arising from unsafe abortions. In addition to the women who die,
many thousands are left injured or infertile after childbirth.
The continued reduction in social spending in
developing countries over the last thirty years has left many
health systems in a weak state without adequately trained, supported
and resourced health workers. This is one reason why women cannot
access maternal and reproductive health care. Lack of political
commitment to maternal and reproductive health is another reason
for the failure for sustained progress in maternal health outcomes.
However, maternal health is also affected by social determinants
such as poverty, gender inequity, low levels of female literacy
and formal education, early marriage, teenage pregnancy, conflict
and HIV. Poverty and ill health are inextricably linked, especially
in the case of maternal health. This is due to many factors such
as hard to reach areas being left without adequate health services,
lack of transport facilities to seek care in an emergency, lack
of resource mobilisation responsibility within the household,
the high cost of maternal health inpatient care and lack of decision
making power to seek care when required due to socio-cultural
factors such as gender and religion. Health care fees can also
push women into further poverty. In the 2005 World Health Report:
Making every mother and child count WHO estimated that 100 million
people each year are pulled into poverty though paying for health
careii: In this report WHO suggested that maternal and child health
needed to be viewed as a continuum of care between the home through
the community to the health centre and finally when required to
the hospital.
Amanita, from Kailahun district in Sierra Leone,
has had seven children, but only one has survived. "They
all died as babies," she says. "Some of them we could
not take to the clinic because we had no money. I took others
to the clinic, but waited to see if they would get better first
because we had no money. They all died." iii
Satta, from Kailahun district, Sierra Leone,
couldn't afford to go to the clinic to have her baby. "When
the time came and I had the pain of giving birth I went with my
mother to a traditional midwife," said Satta. There were
complications with the birth and the midwife said Satta needed
to go to the clinic. "It was night and we walked there,"
said Satta. "People carried me in their arms. I was hurting
so much. At the clinic, I had the baby. It was dead." Satta's
mother had to borrow 80,000 leones (£20) from friends so
she could pay the clinic bill. She earns a subsistence living
through casual work and collecting firewood to sell. "We
have no idea how we will pay the money back," she says. "I
feel bad because we didn't get the baby and we had to pay a lot
of money."
In Sierra Leone the cost to a patient of a caesarean
section is the UK—equivalent of £10,000iv, access to
this services may have saved both mothers children.
EXECUTIVE SUMMARY
International health, health systems, reproductive
health, HIV and more recently maternal and child health, have
captured the political spotlight in the last few years, thanks
to the leadership of DFID, the UK government, and its partners,
WHO and civil society activists. NGOs and civil society have finally
been listened to and a large percentage of people in the UK and
worldwide have called for an end to preventable maternal and child
deaths. This call for action has been supported by the realisation
by politicians and policy makers that the world will not meet
the health related Millennium Development Goals established in
2000, without radical, urgent changes to health and economic policies
and increased and sustained political support. To help achieve
this goal DFID supported the fledgling Partnership for Maternal
Child and Newborn Health (PMCNH), encouraging partners to support
an integrated approach to maternal and child health through a
continuum of care. The partnership aims to combine advocacy, reality,
and technical expertise with effective interventions and evidence
based solutions through nationally owned plans and programmes
to achieve increased political financial and technical support
to improve maternal child and newborn health in developing countries.
DFID and the UK government have also wholeheartedly
supported global efforts towards increasing aid effectiveness
and harmonisation. They have consistently supported national led
programmes to strengthen equitable access to health care while
creating opportunities, in selected countries, for civil society
and the voices of the poorest to feed into health policy determination.
DFID are one of the few health stakeholders actively attempting
to implement the Paris Declaration of 2005. DFID must be congratulated
for this.
In 2005 the UK government was instrumental in
orchestrating global agreement in the UN to add another goal to
MDG 5 (The original MDG 5 goal was to reduce by ¾ the number
of women dying from pregnancy related causes, by 2015). The new
goal seeks to achieve universal access to reproductive health
services by 2015; however, indicators for measuring this goal
have not yet been agreed. The UK government needs to continue
to lead the way in ensuring that global commitments to reproductive
and maternal health agreed in 2005 are financed and implemented
through rights based equitable approaches especially in DFID funded
programmes. In order to achieve these goals there needs to be:
Increased and sustained political will—with
DFID retaining a strong voice.
Increased support for and listening to voices
of the poor, civil society and women themselves.
Urgent increase in long term predictable funding
to support equitable and pro-poor health policy implementation
and strengthening health systems, including the training and retention
of more skilled birth attendants, to provide essential maternal
and reproductive health care including emergency obstetric care.
Support to reduce the social cultural political
economic and communication barriers which prevent women from accessing
health services.
Increased prioritisation for maternal and reproductive
health services especially in fragile states and complex emergency
situations.
Without these changes we will reach 2015 knowing
that we have failed another generation of potentially powerful
women from leaving their mark on the world, because we did not
act fast enough to implement solutions we know can make a difference.
To support these changes we request that parliament
ensure that:
1. DFID be given enough resources and political
support to continue its pressure on global actors to prioritise
maternal, child and newborn health. One way of achieving this
would be for DFID to take a leadership role in the new Partnership
for Maternal Child and Newborn Health. DFID also needs to continue
to support the normative roles within WHO so that technical support
for maternal health will available to programmes as they require
it.
2. DFID continue to support the voices of
the poor, civil society and the marginalised being included in
health policy determination, implementation and monitoring. DFID
has led the way with UK civil society and supporting national
based civil society groups to hold their governments to account,
however, civil society are concerned that the most recent Health
Partnership launched on 5 September had little input from civil
society in its planning, this needs to be urgently redressed.
There is also concern that if DFID continues to channel increased
resources through partner agencies like the World Bank, DFID's
"value added" of implementing pro-poor health systems
through rights based framework will be lost. UK development funds
need to prioritise the often overlooked principles of rights and
equity so that they reach the poorest populations who need help
the most. DFID should establish more flexible funding pools to
enable civil society to apply for resources to hold DFID, donors
and national governments to account for promises made in regards
to prioritising health for all.
3. DFID continue to invest technical and
financial resources into implementing pro-poor health policies
and strengthening developing countries health systems. Global
ODA (Overseas Development Assistance) has increased in recent
years but by only half of what was estimated as needed in 2001
by the Commission for Macroeconomics and Health. At that time
they estimated that by 2007 we needed to be investing $27 billion
in ODA; the present amount reaches just $14 billion. DFID would
need to double its GNI on ODA from 0.43-0.1% to invest its share
of ODA.v Yet although there have been increases in health aid,
this has mainly targeted vertical disease specific programmes,
which have led to a skewing of national priorities and a lack
of health resources for building strong health systems. This trend
needs to change, and DFID needs to ensure that more of its health
aid supports maternal health, emergency obstetric health care
and health systems strengthening. It is important that DFID maintains
sufficient technical capacity to support the effective implementation
of pro-poor health policies. This will require an urgent re-think
of the current downsizing of technical advisers in DFID's head
office and in the field.
4. DFID continue to invest in replicating
successful evidence based programmes. For example, emulating their
innovative emergency human resource programme in Malawi in other
countries facing similar human resource constraints or supporting
more countries to implement pro-poor health financing policies
as in Zambia where DFID has supported the abolition of health
care fees at point of use in rural areas. This has led to increases
of over 70% in health care utilisation in some rural areas. Or
their comprehensive support of community health programmes, including
women's groups, and health systems support in Nepal, to bring
about reductions in maternal death rates. DFID needs to invest
more robustly in the collection of baseline and impact data in
relation to DFID supported national programmes, to ensure that
they can measure the impact of their support on improving health
outcomes for women and children especially for the poorest populations.
Such evidence is essential if DFID is to convince other donors,
policy analysts and international health actors to replicate their
innovative health programmes.
1. How can donors (specifically DFID) catalyze
progress towards MDG 5?
1.1 Financing
— The shortfall for funding maternal
child and neonatal health is still at least $14 billion—if
we are to reach the promised $25 billion estimated as necessary
to ensure a basic package of health services is available to all.
Donors must begin to be held accountable for fulfilling their
long held promises to close the funding gap by investing their
promised 0.7 % of GNP in ODA and completing debt relief promises.
— More long term predicable aid needs
to be committed to by donors, especially for health systems and
human resources for health.
— Civil society need to be supported
to hold Developing countries accountable for their promise to
allocate 15% of national spending on health as agreed in the 2001
Abuja agreement.
— Increase availability/accessibility
of funds for NGOs involved in improving maternal and newborn health
globally.
1.2 Policy
— Poverty Reduction Strategy Papers
(PRSPs) need to reflect maternal health as a priority and be closely
aligned to national budgets as set out in the five year Mid-term
expenditure frameworks (MTEFs) and National Health Accounts.
— Move away from vertical programmes
to health systems strengthening programmes.
— Support more countries to move away
from health care fees at point of service.
— Support more health system strengthening
programmes.
— Support the training and retention
of more skilled birth attendants.
— Support short, medium and long term
human resource solutions.
1.3 Political Commitment
— Galvanize global support for maternal
health through increased funding, implementing pro-poor health
policies and tracking health system and human resource targets.
— Encourage the integration of maternal
health programmes with disease specific programmes like HIV, and
Malaria.
— Work closely with civil society.
— Work more closely with health professional
organisations and advocates.
1.4 Research
— Support more operational research
in reducing the bottlenecks to delivering effective health services
to the poor and hard to reach populations.
— DFID is one of the bilateral donors
who spend the most money in maternal health. However, with the
move to general support money, it is difficult to quantify how
much money is spent on maternal health by DFID. We need better
tools to track maternal health spending and uptake estimations
on the present financing gap.
— Donors need to improve data on maternal
mortality, and be willing to fund maternal morality studies in
certain contexts.
— Fund more civil society and academic
partnerships to carry out operational research and then to support
the moving the policies and knowledge into practice.
— Undertake an analysis of successful
health programmes supported by DFID in the last 10 years which
led to improved maternal health outcomes.
2. How effectively is DFID working to ensure
EMOC is available and accessible with adequate numbers of skilled
birth attendants?
2.1 WHO
DFID supports WHO's normative work in maternal
and child health. DFID supported the development of policy briefs
to accompany the 2005 World Health Report on Making every mother
and child count and they have recently supported WHO and partners
to develop standards for maternal health competencies (working
with the ICN, ICM and FIGO). These are all important steps towards
supporting nations to strengthen their systems, however without
more financial and technical support nations will find it impossible
to implement these guidelines and standards.
2.2 Professional organisations (RCN RM FIGO ICN
ICM WMA BMA)
DFID needs to work more with relevant health
professional organizations to strengthen capacity and to promote
partnership between professional organizations south to north,
south to south.
DFID presently support the BMA to carry out
international health advocacy work in the UK.
2.3 European Union
Although the EU has comparable maternal health
policies to DFID in relation to supporting EMOC, they have dramatically
decreased their health aid this year focusing predominantly on
the GFATM, infectious diseases and human resources for health.
So their expenditure is not in line with DFID led pro-poor global
health policy and practice.
2.4 PMCNH /International Health Partnership
DFID has led the way in both these initiatives;
EMOC is featured as a key intervention to promote maternal health.
However, DFID needs more midwives and technical health advisers
to support these countries as they move from policy to implementation.
DFID also needs to encourage WHO to increase the number of nurses,
midwives and social development experts they contract at HO and
the country and regional offices. There are excellent examples
where progress is being made in programmes such as the DFID Malawi
emergency health worker programme and the John Hopkins supported
Zambia maternal health programme, the World Vision and Save the
Children UK EMOC programmes in Afghanistan and the multiple programmes
carried out by MSF in conflict affected countries like the Congo,
Sierra Leone, and Liberia. Lessons learned from these successful
EMOC programmes need to be harnessed and shared with policy makers
and national ministries and their partners.
2.5 NORAD's Global Business Plan
DFID and the UK government have worked closely
with Norway and the PMCNH to shape the global business plan, but
ultimately the money is not enough to support the roll out of
EMOC, to all the areas that need it in selected priority countries.
Also the selected countries are high population countries that
would help to bring the MDG targets back on track; however funds
need to reach the countries with the highest maternal death rates
like Niger and Sierra Leone.
Maternal morality data needs to be updated urgently,
in a recent study conducted by MSF in DRC they found maternal
death rates ten times higher (5,200 deaths per 100,000 live births)
than the national reported average of 520 deaths per 100,000 live
births.vi
3. How effective is DFID in mainstreaming
maternal health across related policies?
3.1 Health Systems
— DFID has been instrumental in putting
the strengthening of health systems on the international agenda,
and making the case for maternal health as a health system issue.
— DFID has funded programmes to research
how much strengthening health systems benefit to maternal health,
but this programme funding has been cut by 40%.
— DFID has also been instrumental in
requesting that the implementation agendas of maternal, neonatal,
and child health be further integrated at international level,
in order to facilitate work at country level.
— Although DFID is the best of the
donors for funding pro-poor programming. DFID need to establish
alternate mechanisms for funding innovative social justice work
(and ensure it is tracked and measured effectively) in health
to measure the impact of improving social development on health
outcomes—there are some DFID programmes starting to do this
(eg in Nigeria) but there is still a long way to go between DFID
HO policies and implementation of DFID funded programmes in countries.
3.2 Maternal health and HIV
— One area really requiring more integration
is DFID voice in HIV regarding maternal health. Many HIV programmes
still do not treat syphilis through HIV programmes as they have
been set up to distribute ARVs, missing opportunities to treat
STIs like this can lead to more neonatal deaths and in the long
run more HIV. Such stipulations can be made easily when establishing
programme funding calls. (More work is also required in relation
to HIV treatment for pregnant women and children)
— PMTCT activities need to be integrated
into health systems including antenatal and obstetric systems
and become more decentralised with greater attention placed on
ensuring HIV positive women are placed on HAART therapy post delivery
once their CD4 count reaches less than 350.
— It is essential to extend PMTCT services
into conflict and fragile states integrated into the ANC and obstetric
care programmes with interpersonal and counseling training given
to health workers.
— All services including diagnostics
must be free at the point of access so the most marginalised women
can access these life saving services.
3.3 Maternal Health and Malaria
— Much more work is required on integrating
maternal health into malaria programmes (so there are not stand
alone IPT programmes rather than malaria funds are utilised to
strengthen Antenatal Care and deliver free anti-malarial treatment
and bed nets to all pregnant women. This money is in the GFATM
but DFID could do more to use their channels to make sure that
there is better integration of maternal health into vertical programmes
(especially in the programmes that they fund)
3.4 Aid effectiveness and pro-poor health financing
— DFID has developed a strong maternal
health policy based on rights which are not always followed through
into programming and funding.
— DFID has led the way on pushing the
issue around equitable health financing however their programmes
do not always reflect their policies (eg DFID should not fund
programmes where equity is not considered). This is really true
for maternal health, the cost of accessing services is a real
barrier to accessing health care, DFID should be funding more
programmes which demonstrate this. Even their programmes in Zambia
(following abolition) did not have strong HIS systems establish
to measure the impact of abolition on maternal and child health
this is essential to be able to persuade other health stakeholders
about the efficacy of such prop-poor policies on health access
and utilisation.
— DFID should establish mechanisms
for DFID country offices to support country based international
and national civil society and health activist groups more so
that they can hold their governments to account for health promises
(including health budgets and prioritising health access for the
poor and for women and children.)
4. How is MDG 5 being supported and prioritized?
4.1 Technical support
— The number of DFID health advisors
at central level (and within countries) has been greatly reduced;
this is having a negative effect on health policies and pro-poor
practices in the countries where DFID has pulled out. If DFID
cannot support more health advisers due to civil servant cuts
then they could fund senior level health advisers through NGOs
to support the strengthening of national systems.
— There are few DFID Health Advisers
with real expertise in maternal health (How many DFID advisers
are midwives?). DFID and WHO need to increase the number of health
workers included in policy determination (both in country and
in HO).
— Although maternal health has had
higher visibility most countries are still prioritizing medical
or community health programmes rather than increasing the number
of skilled midwives.
— Although MDG 5 is now being included
as a priority for plans and policies there is little real evidence
of increased access to skilled attendants (and even when we do
have the health workers other demand side barriers will need to
be addressed before utilisation increases like economic and socio-cultural.
4.2 Financial support
— Maternal health does not have a global
fund, and the partnership is not a money dispensing institution.
However, not clear how all the money generated specifically for
maternal health can be dispersed to countries.
— Many countries have developed maternal
health road maps but to fund these all we need to invest the $25
billion agreed at the 2005 G8 meeting and this money needs to
strengthen health systems and increase the number of health workers
especially nurses and midwives.
— Globally there is still an unhealthy
balance of health funds supporting behaviour change programmes
without supporting the policies which may create an enabling environment
for societal changes.
— Too many health programmes and funds
are based on vertical disease specific targets—which means
that the high visibility of health systems becomes rhetoric unless
indicators are established and real pressure is placed on vertical
programmes to adhere to and implement the principles established
for Global Health Partnerships at the High Level Forum in 2005.
— There is also more work needed to
harmonise aid dialogue and PRSP indicators for basic services
and mid term expenditure plans and National Health Accounts.
5. Is DFID's approach to supporting the 2006
MDG target of universal access to reproductive health effective?
5.1 Policy change
— DFID must be commended for its role
in getting the 2006 MDG target agreed, they also spent a lot of
time and effort getting the global reproductive health policy
approved at the 2006 World Health Assembly—despite enormous
pressure from the US to change this fundamentally DFID remained
strong and the Global RH policy was approved by over 180 countries.
— DFID also developed a strong rights
based maternal health strategyvii which incorporates tackling
the many complex barriers to improving utilisation of reproductive
health services
— However, now that DFID has these
policies in place they need to emulate their excellent policy
and legal work in Nepal and Ghana in the area of reproductive
health and invest in supporting civil society and women's groups
to call for national changes in their legal frameworks and in
the strength of health systems.
— DFID needs to continue its leadership
in this area and ensure that indicators are established and tracked
with support from civil society and women themselves to monitor
progress in this new MDG goal. The indicators need to include
uptake of family planning, number of teenage pregnancies, treatment
of STIs, access to HIV prevention care and treatment, and utilisation
of health services as a whole.
— DFID have the right policies and
plans they now have to expand the countries they support to implement
these.
— This is one area where DFID must
support equitable access indicators as well as ensuring they support
local civil society to hold their governments and global institutions
to account.
— HIV is now the leading cause of maternal
death in some SSA countries like Zimbabwe and Botswana. More efforts
need to be made to harmonise and align HIV programmes with an
integrated approach to reproductive and maternal health.
— DFID should collect and develop a
successful programme report which can encourage other donors and
nations to prioritise this essential area, again there is a strong
need to link social development work with this programme, this
happens in too few areas. One country where DFID are investing
in linking health and social development more closely is Nigeria,
support needs to be given to ensure that the social development
aspects of the programme are as effectively supported and financed
as are the technical aspects and that qualitative research is
given as much support and quantitative household surveys etc.
5.2 Funding
— DFID also funded NGOs whose funding
for reproductive health was negatively affected by the US gag
rule by creating a funding pool to counteract the US law.
— DFID's new funding for reproductive
health programmes in Pakistan, Zimbabwe, India, Nigeria and Sierra
Leone are all positive steps in the right direction.
— UNFPA have launched a global campaign
to end obstetric fistula (DFID donates over $80 million to UNFPA
to carry out work like this).
6. Is progress being made on reducing the
number of women dying from unsafe abortions?
6.1 Advocacy and leadership
— DFID had led the donors in supporting
global attention on reducing deaths from unsafe abortions and
challenging policies and laws which act as barriers to progress
in this area.
— Until there are more reproductive
and maternal health services available free at the point of access
gains in this area will be slow. The Lancet maternal health series
reported that 50% of women in the West African studies did not
seek care due to lack of cash. The supports work carried out by
Save the Children UK in East and Central Africa and work by MSF
in the Great Lakes Region of Africa.
— NGOs are doing some of this work
but again there is a need for country led advocacy for policy
changes to ensure women have access to effective and comprehensive
health services and that more girls are supported to remain in
school through secondary levels as there is a direct link between
onset of sexual activity and age of first pregnancy with formal
education.
— The age of marriage should also be
increased and social development and women's programmes could
be funded to help catalyze societal change.
6.2 Funding and progress
— Globally, it would seem that progress
is slow and there is ample scope for more initiatives to be developed
and supported. However, it seems there is limited funding available
for work in this area. A positive development is the launch of
the IPPF managed, DFID supported, Safe Abortion Act Fund (which
has promises of $11.9 million) received 222 applications in its
first call for funding. This fund should help reduce the unmet
need and support essential work in this area (unsafe abortions
account for over 20% of maternal deaths and need to be addressed).viii
In a study of 12 hospitals in three SSA countries almost all of
the maternal deaths in early pregnancy were due to unsafe abortionsix.
— There has been some progress and
some retrogression in Latin America as reported from NGOs.
7. Is effective family planning being supported
in the countries you work in to support maternal health?
7.1 Advocacy and leadership
The uptake of family planning is affected by
many factors from health service availability, to pressure from
husbands, cultural norms and religious beliefs. When health systems
have collapsed they cannot meet the needs of women. Equally evidence
is clear that the more formal education women attend the more
likely they are to seek out and utilise family planning methods
hence it is logical to understand that there is still an enormous
unmet need for family planning especially in the poorest nations,
however, by simply providing the commodities does not ensure women
will use them. More work in needed on reducing the legal, household,
economic, religious and socio-cultural barriers that still prevent
too many women from utilising family planning when they may chose
to do so.
DFID has been a global advocate for women's
right to space their children or decide not to have any. They
must continue this leadership while supporting NGOS and UNFPA
to continue their innovative research and how to sustainability
deliver family planning to the women who want to use it, while
also supporting social development programmes which can help create
enabling environments for societal change reducing the socio-
cultural barriers. Dialogue needs to continue with religious and
political groups that do not allow women to have the choice to
access family planning, progress is happening but very slowly.
7.2 Adolescent friendly services
Another specific group requiring special attention
is adolescents, more resources need to be channelled to ensure
they have access to family planning as well as other reproductive
health services including places they can go to discuss relationships,
and their reproductive and sexual health. Adolescents have much
higher maternal death ratios and can be a good indicator of the
strength and responsiveness of the health system. The Child and
Adolescent Health department have been supporting legal and policy
changes in countries in this area to ensure that adolescents are
seen to have the right to appropriate services, they need to be
supported to continue this excellent work. NGOs also need to be
supported to train health workers in youth friendly integrated
programming.
7.3 Global Policies
Family planning is one of the four pillars of
improving maternal health (along with antenatal care, skilled
attendant delivery and access to emergency obstetric care). These
four elements need to be integral to health system development
and must include the voices of women and younger girls and men
in the planning implementation and evaluation of services.
7.4 Sexual based gender violence
Finally in the case of rape or sexually based
gendered violence as occurs in households, communities and as
part of conflict tactics, donors need to ensure that access to
contraception which prevents unwanted pregnancy is available along
with counselling. Health workers need to be trained more effectively
in this area.
8. How effective do you think DFID is in working
with bilateral and multilateral donors, NGOs and other stakeholders,
to improve maternal health?
8.1 Supporting harmonisation without losing
DFID's voice on equity
— Harmonisation support has left DFID
powerless in many countries where their leadership could have
led the way to national change.
— DFID has put the most effort time
and support to link and support others, however sometimes these
harmonisation efforts have led to a loss of DFID voice regarding
a focus on pro-poor policies—DFID needs to ensure that harmonisation
does not mean a loss of the only real voice for equity in health
policy for a
— DFID works with World Bank a lot
but this is one case where all their pro-poor policies are ignored
and DFID is then associated with programmes and policies which
do not support pro-poor access.
— DFID works well with WHO and the
new PMCNH—they have been instrumental in bringing this group
together.
8.2 DFID needs to continue to support the voices
of the poor and civil society
— DFID brings together NGOS and civil
society voices often but funding advocacy positions (or operations
research surrounding pro-poor health access) at country level
would help more NGOs to implement the policies that DFID and civil
society have drafted—this has occurred in DFID's HIV work
but not many other programmes.
— DFID need to bring NGO's and academics
together more—so that research programmes becomes operation
research and that they are reaching the most vulnerable—also
DFID needs to support more sharing and recognition of qualitative
research There are internal issues re: DFID linking effectively
between teams and between countries and head office.
— DFID country offices do not link
well with research programmes. And vice versa.
9. What leadership is the UN providing in
addressing maternal health and how well coordinated is its agencies?
— Individual initiatives by UN agencies
continue with little evidence of collaboration or coordination
and Health Professional Organizations are only slowly being recognized
as important to systemic sustainable change.
— Multiple UN agencies have remits
which include maternal health. In the past activities have been
fragmented and at times competing. For example, WHO has two departments
with a focus on maternal health—Reproductive Health and
Research, Making Pregnancy Safer—and has experienced frequent
changes in leadership for maternal health. The situation has been
exacerbated in the past by poor relations with those working on
child health at WHO.
— This situation is better now than
it was. The recent formation of the Partnership for Maternal,
Newborn and Child Health (PMNCH) represents an attempt to improve
further co-ordination across various agencies involved in maternal
and child health. However, PMNCH does not disburse funds (and
has very limited support itself). If substantially increased funds
for maternal (and neonatal/child health) are generated, what mechanism
will ensure that they are disbursed in a co-ordinated and rational
way?
10. How effective is DFID in addressing the
socio-economic barriers to women's empowerment and the low status
of women in relation to maternal health
— DFID's maternal health strategy highlights
issues such as gender inequity, domestic violence, inequitable
health systems, power imbalances at the household level, low literacy
levels and the impact of poverty and paying for health care on
poverty however more financial and technical leadership is required
by DFID to make progress in this area.
— DFID has funded research on the impact
of Women's groups on health outcomes in Nepal.
— Health financing research and advocacy
has led the way in real progress and change in five countries
this is one of the biggest positive socio-economic impacts DFID
has support in the last five years.
— Rights based policies are a step
in the right direction but more funds are need for DFID and their
partners to implement this policies and to measure the positive
impact that this type of programming can have on societal change.
— Social development aspects to health
programmes in Nigeria are a good start but DFID needs to start
ensuring that all health programmes try and address social development
issues and that this is not through communication and IEC material
but rather work with communities to create enabling environments
for them to hold their own leaders and health system to account
while also supporting advocacy for reducing out of pocket expenditure
and gender inequity.
— Funding NGOs with academics to measure
the impact of such social development programmes is a step in
the right direction.
11. How can the international community improve
maternal health in crisis and conflict settings?
11.1 Political commitment
— More predictable long term aid and
Twin track funding to ensure that basic services are supported
while policies and systems are developed.
— Investing in people is essential
support more NGOs to move beyond adhoc training and encourage
programmes that build health worker and health system capacity
for the long term.
— Take a Rights-Based Approach.
— Support implementers who will understand
the Context and build local ownership and trust.
— Focus on health systems as a whole:
vertical approaches can be distorting, particularly where existing
health systems are weak.
— Support more research in fragile
states with NGOs and academics to measure what is having the most
impact.
— Support more health workers to be
trained in the management of health in complex emergencies and
fragile situations (perhaps link with NGOs and a university and
the NHS to train health workers).
11.2 Policy
— There needs to be more focus on developing
a policy to improve maternal health in crisis and conflict settings.
Organisations like FIGO are prepared to work with DFID on developing
such a policy.
— Develop policies that state that
all DFID funded programmes need to prioritise the poor and ensure
that essential health services are free at the point of access.
— Include those providing basic services
in policy determination.
— Better training of DFID and partners
in child rights programming and sexually based violence so that
channels can be established to reduce vulnerability and protection
of women and children in all DFID priority countries.
— Support programmes which will build
national capacity.
11.3 Voice and accountability
— Share information and Use appropriate
communication.
— Reach Marginalised communities: Build
on what exists.
— Develop accountability mechanisms
with most vulnerable especially women & children -Support
civil societies to have an input this may require funds for transport
to get to meetings.
— Support innovative southern based
solutions to skills gap and support more countries to reduce the
gap (as in Malawi).
12. Recommendations
12.1 Political
The newly launched international Health Partnership,
launched on September 5th by the UK and German governments and
development partners will only be help to improve maternal health
if sufficient resources are invested at country level to support
national health systems, including increasing the number of skilled
birth attendants employed, trained, resourced and supervised.
The compact needs to ensure full and active involvement of national
and international civil society and professional organisations.
These groups an also be supported to track progress of the compact
goals inline with the Global Health Partnership Principles.
To get the maternal and child health MDGs back
on track REQUIRES making politics work for the poor in the developing
countries. More support must be given to ensure Voices of poor,
and marginalised including women and civil society groups feed
into policies, plans and services relating to maternal and child
health care. This requires a shift in attitudes to the poor. Persuading
the various stakeholders of the need for changes in the way they
think and act is the role of strategic communication. Donors can
help: through addressing the issues in the policy dialogue and
through offering to help build local capacity on strategic communication.
Support programmes that give voice to women
(as "rights holders"), especially those who are particularly
marginalized so that their cultures, perceptions and needs are
better understood. Also work with "duty bearers", giving
them a greater capacity to respond to the challenges they face,
encouraging accountability mechanisms that enables them to listen
and respond to women concerning their health rights.
Support effective communication strategies by
and for women and those who support maternal health rights.
12.2 Financing and Aid Effectiveness
Establish funds to move pro-poor policies into
action.
Fund research into DFID pro-poor programmes
so that we have evidence to show impact and change perception
in international health arena.
Support research that focuses on how to overcome
the barriers of accessing services of minority groups such as
indigenous women, and then use the research findings to advocate
for change.
DFID could support NGO evidence being included
in the four workstreams being undertaken to prepare for the 2008
High level forum on Aid effectiveness in Accra. DFID should also
encourage WHO to support NGO involvement in their report on donor
orphans in health, which looks at the distribution of health aid
in relation to need. DFID also need to encourage WHO to include
civil society when determining indicators and bench marks for
measuring progress in health aid so that measures include health
systems, health financing and equity of access, socio-political
and legal changes as well as progress in pro-poor policy implementation
and accountability.
If a global health focused technical advisory
group is to be established to monitor progress on health aid effectiveness
(in line with the Paris Declaration of 2005) it would need to
have northern and southern civil society voices feeding into it.
DFID could fund NGOs to maintain global score cards based on agreed
indicators for global health partnerships as indicated within
the Principles for Global Health Partnerships.
12.3 Technical and Policies
Continue to develop a Rights based Approach
to maternal health, building on the DFID January 2005 Maternal
Health Strategy.
Place greater emphasis on equity issues, recognising
that nationally conceived maternal health systems will not be
an appropriate mechanism to meet the needs of all women.
Work closely with WHO and partners but do not
water down principles of equity and voice of the poor.
Support national health systems to source an
adequate and reliable supply of health-related equipment and medicines.
This need to be delivered by adequate numbers of appropriately
trained and rewarded health care workers. It must also ensure
that the particular health needs of women, including access to
contraception, emergency obstetrics and safe abortion, are given
the priority they so clearly deserve.
REFERENCES
i Mahmoud Fathalla (2007) Stories of Mothers
Lost White Ribbon Alliance 2007 submission to consultation
ii WHO (2005) Making every mother and child count:
World Health Report 2005 WHO Geneva
iii Regina Keith and Peter Shackleton (2006)
Paying with their Lives: the cost of illness for children in Africa
Save the Children UK
iv Regina Keith and Peter Shackleton (2006) Paying
with their Lives: the cost of illness for children in Africa Save
the Children UK
v Action for Global Health 2007
vi MSF (2007) Maternal Mortality Study In DRC,
submitted to IDC consultation
vii DFID (2004)Reducing maternal deaths: evidence
and action DFID UK
viii DFID (2007) DFID's Maternal Health Strategy,
reducing maternal deaths evidence and action: second progress
report
ix Lancet Maternal Health Series September 2006
as reported in DFID's 2007 Maternal Health Strategy, reducing
maternal deaths evidence and action: second progress report
1 Listed in paragraph 4. Back
2
Global Health Council Maternal and Child Health 2006. Back
3
United Nations The Millennium Development Goals Report June 2007. Back
4
United Nations The Millennium Development Goals Report June 2007. Back
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