Memorandum submitted by Merlin
ABOUT MERLIN
1. Merlin is the only UK specialist agency,
which responds worldwide with vital healthcare and medical relief
for vulnerable people caught up in natural disasters, conflict,
disease and health system collapse. Merlin's aim is to ensure
that vulnerable people who are excluded from exercising their
right to health have equitable access to appropriate and effective
healthcare.
2. This aim is inspired and underpinned
by the World Health Organisation (WHO) declaration[156]
that "the enjoyment of the highest attainable standard of
health is one of the fundamental rights of every human being without
discrimination of race, religion, political belief, economic or
social condition". In support of this aim, Merlin works in
partnership with global, national and local health agencies and
communities to strengthen health systems and build community resilience
to better prevent, mitigate and respond to health outcomes.
This response focuses on a few key areas highlighted
by the Inquiry's Terms of Reference.
MAINSTREAMING MATERNAL
HEALTH
3. In Merlin's view, DFID is working effectively
to mainstreaming its maternal health priorities within the broader
health policy framework. The department's focus on strengthening
health systems prioritised in the new health policy (2007) as
a mechanism for improving maternal health outcomes is welcome.
In our view, progress towards the health MDGs can only be achieved
by working in support of national health plans aimed at strengthening
the effectiveness of the health sector and not through single
issue interventions.
4. DFID cites maternal mortality as the
best single indicator of the effectiveness of a country's health
system. Merlin welcomes this focus on maternal mortality as a
key indicator. Maternal mortality impacts significantly on newborn
and child health—a child is 2 to 3 times more likely (than
other children) to die if its mother dies—however this focus
on maternal health is not reflected in the same way by other donors
or international institutions. DFID is in a good position to influence
other donor priorities in this area and Merlin would welcome their
efforts to do so.
5. The priorities set by the maternal health
strategy in 2004—to raise the profile of maternal mortality,
find ways to scale up interventions address socio-economic barriers
to access and develop and apply new knowledge—remain critical
areas for development. DFID's second progress report (2007) recognises
shortfalls in achieving these and acknowledges that further progress
will require significant investment in human resources for heath
and support for health services over the long term. Merlin fully
endorses this approach; current humanitarian mechanisms are typically
short term (12-18 months), and are inappropriate to support long
term investment in human resources. While DFID's policy commitment
to long term support is welcome this must be supported by appropriate
long term funding mechanisms.
6. The challenge (for DFID and all health
actors) is to translate these policy commitments at headquarters
level to effective programming and financing mechanisms at country
level, particularly in fragile states. Engaging with partners,
particularly at local level must continue to be a key priority
for DFID in the area of maternal health. While the approach of
working with Governments has its advantages in terms of political
commitment and broad scale of operations, it can lack the depth
of partnership, commitment to equity and empowerment that Civil
Society Organizations (CSOs) can offer. Failure to secure involvement
of these stakeholders, which includes women themselves, will result
in slow progress. CSOs can play a pivotal role in addressing the
"three delays"; they often have the depth of relation
with communities to design and implement strategies around understanding
of local context and the issues faced by communities.
ENGAGING WITH
BILATERAL AND
MULTILATERAL INSTITUTIONS
7. DFID seeks to, and has been effective
in, influencing international partners in accordance with its
pro-poor agenda. The challenge for the department will be to maintain
this influence in the face of growing multilateral disbursements
(eg through the World Bank). DFID has rightly developed a reputation
as a strong advocate for the poor and there is some concern that
this voice could be diluted. The proposed reductions in staffing
levels are also cause for concern as ODA disbursements increase.
8. Merlin welcomes DFID's call for the number
of global health initiatives to be rationalised and welcomes the
introduction of the new International health Partnership. Global
Health Initiatives should support strengthening of health systems
that deliver health services more broadly.
EMERGENCY OBSTETRIC
CARE
9. In considering the broader determinants
of maternal health, DFID's strategy (2004) has a strong focus
on the provision and strengthening of emergency obstetric care
at BEOC/CEOC[157]
level. While this focus is important, it is vital that DFID interventions
promote the continuum of care at community/household level, where
women are at greatest risk from two of the "three delays":
the delay associated with the decision to seek care; the delay
in arrival at the point of care and the delay in the provision
of adequate care. It is important that mothers are able to recognise
danger signs, be aware of the services available and how to reach
them. A Knowledge Practise Coverage Survey carried out by Merlin
in Ayeyarwaddy Division, Burma in December 2005 (see Annex) showed
that only a very small proportion of mothers knew about maternal
related (pregnancy, delivery and postpartum) danger signs. This
finding is not untypical and a holistic approach is needed to
address all of these key delays as one entity, not just a focus
on emergency obstetric care.
10. While the first two "delays"
require action at the household and community level, addressing
the third delay alone—by improving capacity for emergency
obstetric care at the health care level—is unlikely to be
effective if there is no community demand for services. This emphasis
on creating demand for services sits well with DFID's policy objective
of promoting good governance and enabling local people to call
health service providers to account.
AVAILABILITY OF
TRAINED STAFF
TO MEET
MDG 5
11. Merlin welcomes the department's strong
commitment to promote and support the development of human resources
for health. The lack of human resources for health is one of the
most serious constraints to achieving the health MDGs, particularly
within the context of fragile or transitional contexts. The rise
in the burden of communicable disease combined with chronic under
investment in health systems means that many countries face acute
health systems collapse.
12. Access to appropriately trained health
workers for many women during pregnancy and childbirth is poor.
Evidence from Merlin's programmes in Ayeyarwaddy Division, Burma
focusing on determinants of maternal health shows that most deliveries—up
to 89%—occur in the home, attended by unskilled and untrained
birth attendants, most commonly by "traditional birth attendants"
(see Annex). There is considerable discourse about the use of
unskilled TBAs; the challenge in many fragile states is that human
resource development is currently at very low levels. In Merlin's
view alternative solutions, such as developing core competencies
might be considered and the department could support innovative
approaches to training and development.
13. DFID has made clear commitments to supporting
10 year plans for health system support, with particular note
to strengthening human resources—including development and
training, recruitment and retention. The department has demonstrated
a willingness to support existing health staff by providing financing
for incentives for health workers in underserved areas or where
governments are unable or unwilling to pay salaries. In the absence
of predictable financing for the health sector, donor support
for incentives payments is a viable way of supporting recruitment
and retention of health workers. The difficulty is that DFID's
policy approach in this area is not supported by other key donors.
Conflicting donor approaches vis-a"-vis support for incentives/salaries
means that at field level health facilities in one area might
receive support for incentives while neighbouring facilities supported
by a different donor do not. The tendency for donors to split
areas geographically can lead to practical inconsistencies and
impact on people's ability to access health care.
REFERENCES
Reducing maternal deaths: Evidence and Action.
A strategy for DFID. DFID (2004).
Eliminating World Poverty. Making Governance Work
for the Poor. DFID (2006).
DFID's Maternal Health Strategy. Reducing maternal
deaths: Evidence and Action. Second progress
Report. DFID (2007).
Working Together for Better Health. DFID
(2007).
September 2007
156 As reflected in the WHO constitution (1946),
Alma Ata Declaration (1976) and World Health Assembly (1998). Back
157
Basic Essential Obstetric Care and Comprehensive Essential Obstetric
Care. Back
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