House of Commons - International Development

Select Committee on International Development Written Evidence

Memorandum submitted by Marie Stopes International

Marie Stopes International works through a partnership of agencies in 40 different countries working to improve sexual and reproductive health. Together, the partnership has almost thirty years experience of providing maternal health services in developing countries across four continents. We welcome this inquiry as an important opportunity to highlight the urgent need to address both lack of progress on MDG5 and also the ongoing neglect of essential, life saving health services for women that affects many poor regions throughout the globe.

1. INTRODUCTION

1.1 Globally, complications that arise during pregnancy and childbirth kill one woman every minute.[136] Numbers who suffer severe or permanent injury are unknown, but it is estimated that every year brings 100,000 new cases of obstetric fistula alone—a condition causing chronic incontinence and hence tragic social consequences for the women and girls affected.[137]

1.2 These deaths and injuries are concentrated in low-income countries. Pregnancy and childbirth causes a lifetime risk of death of one in sixteen for women in sub-Saharan Africa—a level of mortality that would be considered cataclysmic in any developed nation. Yet the issue is not just that globally so many women die from pregnancy but that so many die from a pregnancy they did not want. In Latin America and the Caribbean, for example, 35 to 52% of adolescent pregnancies are unplanned.[138]

1.3 The means of addressing high maternal mortality is well known. The five "big killers", together responsible for over 75% of maternal deaths, are haemorrhage, infection, unsafe abortion, eclampsia, and obstructed labour, all of which are treatable or preventable by skilled attendance at birth and emergency obstetric care (EmOC).

1.4 Furthermore, it is estimated that 25-35% of all maternal deaths could be prevented simply by providing contraception to women who want it.[139] Effective family planning programmes tend to halve average birth rates, so it follows that such interventions could in fact have an even greater impact on maternal mortality for areas currently without access to contraception.[140] This, together with its low cost and capacity to reduce the need for more expensive medical services, makes contraception the most cost-effective maternal health intervention.

1.5 Despite global recognition of these means of reducing maternal mortality, MDG5 has remained the most stagnant of the MDGs. Maternal mortality has not fallen since 2000 in much of sub-Saharan Africa, South Asia, West Asia, Latin America and the Caribbean, with some countries and areas even experiencing negative change.[141] Why has progress been so poor? The answer is twofold:

1. Funding for family planning had fallen since 1995.

2. The basic infrastructure for healthcare systems has long been marginalised from aid finance.

2. MATERNAL HEALTH AND FAMILY PLANNING

2.1 Family planning is unique in its capacity to reduce demand on health systems to provide much more expensive and resource intensive services including post-abortion care, pre- and post-natal care, EmOC and assisted deliveries. For example, one study across several Latin American countries estimated the cost to the state of preventing one unwanted pregnancy through contraception at US$133 but also estimated the savings from services prevented at US$1,600.[142]

2.2 As Jeffrey Sachs highlighted in his plan to achieve the MDGs, providing access to family planning commodities and information also offers means of:

— Reducing infant and child mortality,

— Reducing income poverty,

— Empowering women to participate in economic and political spheres,

— Improving access to education for girls and women,

143

2.3 Yet Donor support for family planning has actually fallen in absolute dollar terms from $723 million in 1995 to $442 million in 2004.[144]

2.4 While financial support for "population assistance" has increased exponentially since the International Conference for Population and Development (ICPD) in 1994, the vast majority of the new money has been for HIV/AIDS. But while family planning constituted 55% of population assistance in 1995, this has dropped to only 9% in 2004.[145]

2.5 We perceive that this decline in support for family planning has significantly undermined efforts for a global reduction in maternal mortality and will continue to do so until rectified. We urge the IDC to impress upon DFID the importance of a central place for family planning in new policies and advocacy for maternal health including in the International Health Partnership and in the Global Business Plan led by Norway.

DFID Support

2.6 There is much to commend in DFID support for maternal health including family planning. Examples such as Nepal (see case study below) and others indicate that, where relations with partner governments are strong, DFID has capacity to push through the maternal health agenda to make a real impact on mortality levels. Ongoing DFID advocacy for the new target under MDG5 for universal access to reproductive health services is also of great value to global ambitions to reduce maternal mortality.

2.7 But DFID financial support is difficult to appraise. Ongoing contributions to the United Nations Population Fund (UNFPA) are commendable, but total DFID spending on family planning is obscured by an amalgamation of the accounts with HIV/AIDS spending.

2.8 Furthermore, direct expenditure for maternal health appears to be quite low. The DFID Annual Report for 2007 lists maternal health expenditure excluding budget support as only £16 million in FY2005/06 of a total health spend of £200 million—in itself quite a low proportion of the total £2.5 billion bilateral spend.[146] This is perhaps best reflected in DFID Programme Partnership Agreement (PPA) allocations, none of which support agencies specialising in maternal health or reproductive health.[147]

2.9 Both the inability to measure trends in DFID support in family planning and also the apparent low level of expenditure on maternal health seem incongruous with DFID policy statements that identify reproductive and maternal health as key strategic priorities.[148] We urge the IDC to impress upon DFID the need to ensure that accounting and spending reflect agreed institutional priorities. We propose a new budget line for maternal health, against which DFID could measure its expenditure on a) family planning, b) EmOC and skilled assistance with delivery and c) safe abortion services.

DFID In-Country Advocacy

2.10 DFID advocacy in-country for health system strengthening, maternal health, sexual reproductive health rights and women's rights can—and does—play a key role in securing high level "political will" to address maternal mortality. It is therefore a matter of concern that DFID is under pressure to reduce its staff headcount.[149]

2.11 The strong and continuing lobbies against safe abortion services and for abstinence intensify the ongoing need for DFID to maintain and strengthen its own health advisory role in countries. We urge the IDC to emphasise the importance of country offices retaining the human resources necessary for effective advocacy at the country level. There is no contradiction between supporting greater government ownership and maintaining an evidence-based advisory role in the formulation of national health plans.

Civil Society Advocacy and Campaigning

2.12 Civil society advocacy can create legislative change and a policy environment conducive for improving maternal health and DFID commitment to supporting grass roots advocacy is admirable. The Civil Society Challenge Fund (CSCF) has enabled a number of startlingly effective advocacy projects such as the Marie Stopes Clinic Society "DHARA Programme".

2.13 The DHARA programme is recognised for having used grass roots advocacy methods, including the creation of local civil society groups to monitor delivery of public health services at the local level, to affect both extraordinary qualitative improvements in services and hence also a significant increase in attendance at family welfare centres.[150]

2.14 However, there are serious limitations on what can be sustained with the CSCF £500,000 cap over a fixed maximum five-year period. This effectively prevents the roll out of successful local level programmes to larger scale. We strongly recommend that DFID review its CSCF programmes for examples of best practice. Good results should be rewarded with continued funding beyond the existing five-year limit.

Maternal health in humanitarian emergencies

2.15 Maternal health needs do not diminish in emergency settings. Yet an acceptable response to maternal health needs in emergencies is often obstructed by the misperception that humanitarian efforts can only afford to prioritise low cost and lifesaving interventions. This attitude neglects both the potential of family planning to prevent maternal deaths and also the realistic guidelines that exist for implementing effective maternal health services.

2.16 The Minimum Initial Service Package (MISP) is a SPHERE endorsed standard for humanitarian actors, outlining the reproductive health interventions—including EmOC and skilled assistance at birth—required in the onset phase of emergency. It further details how develop more comprehensive services as the emergency stabilizes.[151]

2.17 The fact that the humanitarian response rarely succeeds in providing adequate maternal health and family planning services is both unacceptable and remediable. Humanitarian agencies need to improve their capacity to deliver reproductive health services in emergencies and humanitarian donors must support and encourage them. The UN humanitarian coordination system must also afford greater priority to reproductive health: The "health cluster", as currently defined by the Inter Agency Standing Committee, must give greater recognition to reproductive health as a core focus area. DFID advocacy could be catalytic here, particularly if employed in its relationship with the World Health Organisation (WHO) which leads the health cluster.

2.18 Furthermore, given the ongoing inadequate support for reproductive health in emergencies, we urge CHASE to track its own grant allocations to programmes which include reproductive health services. There is also a need to ensure that CHASE includes reproductive health issues in the initial needs assessment stage of humanitarian interventions.

3. HEALTH SYSTEM STRENGTHENING

3.1 While difficult to quantify, it is widely accepted that a significant proportion of donor finance for health is delivered through vertical funding streams. Whether for HIV/AIDS, vaccination programmes or the promotion of abstinence, these mechanisms share a limitation: Having been earmarked by donors for a specific purpose they have limited value in strengthening the essential infrastructure upon which all health services ultimately depend. Such infrastructure includes:

— Adequate numbers of trained and paid health staff.

— A sufficient, reliable and well distributed supply of health commodities and equipment.

— The requisite number of health facilities including hospitals and local clinics and an efficient referral procedures between them.

— Good administrative systems including for providing sanitary conditions.

3.2 It easy to see the link between maternal mortality and weak infrastructure. The provision of good maternal health services relies upon the ability to provide women with access to:

— Skilled birth attendants.

— Contraceptives, magnesium sulphate and other basic commodities.

— Blood transfusion, swiftly when required.

— A sanitary environment and sanitised equipment to prevent infection.

Commodity supply systems

3.3 Health commodities are an essential part of any health programme and, for reducing maternal mortality, include magnesium sulphate for treating eclampsia and all modern contraceptives. Many of our partners observe that state-run family welfare clinics are often forced to turn away a large proportion of clients simply because they have run out of the basic commodities needed to provide the health service required.

3.4 These shortages occur even in cases where the central government has notionally agreed to provide free commodities equal to demand in all state-run clinics. In practice, the supply of commodities to clinics will be both insufficient in its quantity and erratic in its delivery. This is usually due to a combination of inadequacies in:

— Forecasting, procurement and record keeping.

— Storage depots and their facilities.

— Haulage fleets and transport infrastructure.

3.5 It is important to consider that the inability to provide a client with commodities is not only a problem in itself, but also deters such clients from visiting again—particularly those who have travelled long distances—contributing to under utilised resources during times when commodities are available.

3.6 Non-state health providers also suffer from this deficiency. Without means of obtaining government supplies NGOs have to try and procure their own, but the difficulties in registering generic commodities frequently prove prohibitive. National Drug Authorities, especially in Africa and the Middle East, have a reputation for taking months, sometimes years, to register generic commodities and for requiring incentives to do so. Similarly, port authorities have a reputation for bureaucratic inefficiencies that leave health commodities in warehouses, indefinitely awaiting clearance. These obstacles can and do hinder Ministry of Health efforts to procure commodities as well as those of private sector agents.

3.7 Unless the bottleneck of commodity insecurity is removed, objectives such as; releasing new funds for basic health services, harmonised funding behind single national health plans, and even the recruitment of greater numbers of health workers, will have at best only a limited impact on scaling up service delivery.

3.8 In countries where DFID is supporting SWAps and basket funds, DFID should continue to advocate for the earmarking of sufficient funds for the supply chain and specifically for family planning commodities. Funds for the supply chain often tend to suffer when specific donor support is withdrawn in favour of overall budget support so we further recommend supply systems as a key issue for DFID advocacy.

The International Health Partnership (IHP)

3.9 The recent announcement of the IHP comes as a welcome initiative.[152] Its three aims—to better harmonise donor funding; to better support country-led health plans; and to improve health systems as a whole—would all enable recipient governments to invest more in health infrastructure if realised. We congratulate DFID on the initiative and on having secured the signatures of the Global Fund for AIDS, TB and Malaria and the GAVI Alliance on the IHP Compact.

3.10 The goal of the IHP to encourage vertical donor programmes and financing mechanisms (such as GFTAM) to better support basic health infrastructure is highly relevant to commodity supply systems. Vertical mechanisms focus exclusively on the commodities relevant to their specific diseases and hence tend to contribute to the neglect of the overall commodity supply system. The IHP should be used to encourage vertical funding mechanisms towards giving support for the overall national supply chains for all essential medicines and commodities.

3.11 The IHP proposes a shift towards greater government ownership of national health plans which, while welcome, further intensifies the importance of effective advocacy in-country. We refer again to our recommendations re DFID human resources for advocacy on health and for supporting civil society. We also note that the most effective results are achieved where advocacy at the two levels operate in tandem, as witnessed in the Nepal case study below.

Case Study: Nepal

3.12 In 1996, Nepal was burdened with one of the highest levels of maternal mortality, with an MMR of 539 maternal deaths per 100,000 live births.[153] This can be attributed to the inter-action of several factors including:

— Low access to family planning.

— High incidence of child marriage.

— Abortion illegal.

— Very low access to ante-natal care, skilled assistance during delivery and EmOC.

3.13 Lack of access to contraception leads to demand for abortion despite its illegality. Methods of "back-street" abortion in Nepal—as in other developing countries—include drinking poisonous "remedies", pushing substances such as bleach into the uterus, inserting sticks and other sharp objects and heavy pelvic pummelling, all of which frequently result in life threatening complications.

3.14 In 1997, DFID supported the roll out of the "Nepal Safer Motherhood Initiative" (NSMI). The programme—managed by UK health consultancy "Options"—was successful in supporting the Nepalese government to exponentially expand and improve maternal health services. NSMI focused its activities around:

— Policy development, including "paramedicalisation" where nurses and other mid-level providers are trained to provide EmOC services previously exclusively provided by doctors.

— Service delivery, including staff training courses and improving infrastructure.

— Behaviour change communication for health-users, including use of a wide range of media advertising new services available.

3.15 The creation and implementation of NSMI coincided with a period of high profile and sustained civil society-led campaigning calling on the government to deliver health services for safe motherhood and for the legalisation of abortion. Not only did this compliment NSMI efforts in its policy dialogue with government but it also led, in 2002, to the legalisation of abortion.

3.16 The roll out of safe abortion in Nepal has been efficiently managed. HMGN took the decision to incorporate the capacity of the non-state sector in order to begin delivery of safe abortion services as quickly and as widely as possible. MSI partner, Sunaulo Parivar Nepal (SPN), was well placed having been providing post-abortion care services in country since 1994. Its network of clinics were contracted by HMGN to provide safe-abortion services in 60 of Nepal's 75 districts and services have also been coordinated in ten further districts. This utilisation of non-state sector capacity has enabled safe abortion services to be rolled out rapidly and cost-effectively.

3.17 The Nepal Demographic Health Survey 2006 found MMR to have fallen from 539 in 1996 to 281 ten years later. We congratulate DFID on its strong role in this achievement.

3.18 Events in Nepal suggest that MDG5 is not too ambitious: A 75% reduction in maternal mortality ratios is possible by 2015. We draw the following further conclusions from both Nepal and also the experience of other MSI partners:

Incorporating the Non-state Sector

3.19 Often forgotten or ignored, incorporating the non-state sector into national health strategies can make a significant contribution to scaling up delivery on the health MDGs and building public sector capacity. By contracting out, governments can utilise the facilities, staff and expertise of non-state providers to deliver health services efficiently, cost-effectively and as part of a government led national or district-level strategy.

3.20 In Tanzania, for example, Marie Stopes Tanzania (MST) is contracted to periodically provide family planning services from public health facilities. This arrangement also enables MST to train local public-sector health staff in effective family planning procedures and so improve public sector capacity in this important area.

3.21 We urge the IDC to applaud DFID on including mention of the non-state sector in the IHP Compact and to emphasise the importance of maintaining this focus. However, we feel DFID could do more here at country level. In Pakistan, for example, where 70% of women go to the non-state sector for their health services, only 17% of DFID financial support reached non-state health providers in 2006.[154]

Paramedicalisation

3.22 "Paramedicalisation"—where mid-level health service providers are trained and permitted to perform medical procedures previously confined to doctors—offers a significant means of increasing the capacity of a health system to provide services. Trials by MSI in South Africa and Vietnam of almost 3,000 manual vacuum aspiration procedures found that first trimester abortions performed by appropriately trained health professionals who are not doctors do not suffer from increased incidence of complication.[155]

3.23 We recommend that DFID advocate at both international and national levels for paramedicalisation of procedures such as EmOC, caesarean-section, anaesthesia and safe abortion services as a key policy for health system strengthening.

4. SUMMARY OF RECOMMENDATIONS

4.1 The low proportion of direct DFID expenditure on maternal health points to a need for DFID to better align expenditure with its stated intent to prioritise maternal and reproductive health. We recommend a new maternal health budget line for DFID that would include expenditure on a) family planning, b) EmOC and skilled assistance with delivery, and b) safe abortion. This would facilitate a commitment to annual increases in expenditure in these three key areas for maternal health.

4.2 The global decline in donor support for family planning since 1995 requires urgent attention. We urge the Select Committee to impress upon DFID the importance of making family planning a key priority for advocacy and to use the IHP in support of family planning wherever possible.

4.3 The International Health Partnership is a welcome initiative that has the potential to make significant advances in global health and towards achieving MDG5. For the IHP to succeed it should continue to include focus upon improving commodity supply systems and the incorporation of the non-state sector as key issues for health system strengthening.

4.4 DFID advocacy has a successful track record on winning political will to address maternal mortality in partner governments. We urge the IDC to protect DFID from pressures to reduce staff numbers that may weaken DFID capacity for advocacy.

4.5 Civil society can and should play a powerful role in generating political will. We urge DFID allow greater flexibility in its Civil Society Challenge Fund to support effective programmes beyond the first project cycle.

4.6 The commodity supply system is an essential component of a well functioning health system. In countries where DFID is supporting SWAps and basket funds, DFID should continue to advocate for the earmarking of sufficient funds for the supply chain and specifically for family planning commodities.

4.7 Paramedicalisation offers a significant means of increasing the capacity of health systems. We recommend that DFID advocate for the paramedicalisation of relevant medical procedures at both national and international level.

4.8 Incorporating the non-state sector into national health strategies can contribute significantly to scaling up health service delivery and to building public sector capacity. DFID and the IHP can support health systems by encouraging optimal use of the non-state sector in national health strategies.

4.9 DFID has identified reproductive health as a key priority, but it must extend this policy to its humanitarian portfolio. To address the ongoing neglect of reproductive health (RH) services in humanitarian emergencies, DFID must:

(a) Advocate for greater priority for RH within the health cluster led by WHO,

(b) Monitor its own performance by tracking CHASE grants for RH programmes,

September 2007

136 UNICEF, UNFPA, WHO (2004) Maternal Mortality in 2000. Back

137 UNFPA (2004) State of the World Population. Back

138 de Bruyn, M, and S Packer. 2004. Adolescents, Unwanted Pregnancy and Abortion: Policies, Counseling and Clinical Care. Chapel Hill, North Carolina: Ipas. Back

139 Global Health Council (2002) Promises to Keep: The Toll of Unintended Pregnancies on Women's Lives in the Developing World. Back

140 Cleland, John et al (2006) "Family planning: the unfinished agenda" in The Lancet, Sexual and Reproductive Health, October 2006. Back

141 DFID Annual Report 2007. Back

142 Cochrane S and Sai F (1993) "Excess Fertility" in Jamison DT et al Disease Control priorities in Developing Countries 1993. Back

143 Sachs, Jeffrey (2005) Investing in development; A practical plan to achieve the MDGs UN Millennium Project. Back

144 UNFPA (2006) Financial Resource Flows for Population Activities in 2004. Back