Memorandum submitted by the Peoples' Health
Movement and Global Health Watch Secretariat
SUMMARY
The major challenge to reaching MDG5 is the
failure to translate existing recommendations, strategies and
policies into effective implementation. The major barriers to
effective implementation are:
— poor stewardship and strategic management
of the health sector, compounded by the proliferation of external
health initiatives, macroeconomic conditions and health sector
reforms that have fragmented and weakened public health systems;
and
— a lack of basic health care resources
in the form of:
— skilled health workers; and
— health care facilities that are accessible,
equipped to provide a safe delivery environment, including referral
to centres with comprehensive emergency obstetric care facilities.
For these reasons, this submission focuses on
DfID's need to emphasise the more basic issues of health systems
development as a pre-requisite for maternal health improvement.
We also emphasise that improving maternal health
services extends beyond achieving a reduction in maternal morbidity
and mortality:
— it will have a significant positive
impact on child health and HIV transmission;
— because it requires "fixing"
the health system as a whole, maternal health programmes can act
as a catalyst for wider health sector development;
— it can act as a catalyst for female
empowerment and improved family planning; and
— it often requires the explicit targeting
of the poorest and most marginalised sections of society.
However, too little of the external funding
directed at the health sector is allocated to maternal health.
The IDC should encourage DfID to take an even more active stance
in improving maternal health.
Compared to other donors and global health initiatives,
DfID provides important leadership in the health sector. Spearheading
the International Health Partnership (IHP) is also a welcome initiative.
But the IDC should interrogate DfID's plans for operationalising
the IHP and question the wisdom of DfID cutting back on its technical
staff at a time its budget is increasing.
Although there is general recognition of the
importance of training and retaining health workers in developing
countries, there is little in the way of concrete action. One
notable exception is Malawi's Emergency Human Resource Programme
(EHRP). But this has not been replicated elsewhere. The IDC should
ask for a full briefing of the EHRP; and why this approach is
not being replicated elsewhere. There is also important HR policy
research that needs to be funded.
One of the underlying causes of maternal mortality
is poor health sector stewardship and weak health systems management
capacity. Governments, donors and external health initiatives
continue to fail to address these shortcomings. Initiatives aimed
at strengthening public sector stewardship and management capacities
have too often been fragmented, piecemeal and short-lived. The
failure to develop civil society capacity to hold government and
public administrations to account is another concern. DfID should
take some leadership in this area. However, this requires a long-term
strategy, rather than a quick-fix approach; and it requires strategies
that do not involve the export of "new management fads and
practices" from developed countries.
Finally, as far as research is concerned, we
would like to call for more implementation research. This
is research that informs policy makers and managers in real-time
about what is and isn't working, and why. It focuses on how to
promote the uptake and successful implementation of evidence-based
interventions and policies that have already been identified.
FULL SUBMISSION
1. Who we are
1.1 The Peoples' Health Movement (PHM)
is a loose but broad network of civil society organisations from
many different countries, mostly in the South. It was established
in 2000 following the first Peoples Health Assembly held in Bangladesh
as a counterpoise to the official World Health Assembly. While
it is organised as a fluid network of social movements and civil
society constituencies, PHM is guided by a Steering Council of
health professionals, many of whom work as senior public health
practitioners; academics; and policy analysts. Many of those on
the Steering Council have spent many years working in health care
delivery institutions in rural and under-resourced settings. The
views and policy positions of PHM are based on the core principles
of the 1978 Alma Ata Declaration on Health. PHM also works closely
with a number of the more established NGOs in the health sector.
1.2 The Global Health Watch (GHW)
is an initiative billed as an alternative world health report.
The first report was launched in 2005, and the next report will
be published in May next year. One of the ways in which it is
"alternative" is that it reports on the state of global
health, as well as on what is and isn't being done about global
health. This includes a critique of the policies, programmes and
actions of donor organisations and global health institutions.
2. Preface
2.1 This submission does not cover all the
questions for which evidence was requested. Rather it highlights
a number of fundamental issues related to maternal health.
2.2 Three recent publications have also
highlighted many of the challenges and recommendations for improving
maternal health (listed in the footnote below) and conclude that
the major problems are not due to a lack of technology, clinical
knowledge or programmatic know-how.[158]
The major problem is a failure to translate recommendations, strategies
and policies into effective implementation.
2.3 The major barriers to effective implementation
are:
— poor stewardship and strategic management
of the health sector, compounded by the proliferation of external
health initiatives, macroeconomic conditions and health sector
reforms that have fragmented and weakened public health systems;
and
— a lack of basic health care resources
in the form of:
— nurses, birth attendants and clinicians
capable of providing obstetric care, and in particular, emergency
obstetric care; and
— health care facilities that are accessible,
equipped and able to provide a safe delivery environment, including
referral to health centres with comprehensive emergency obstetric
care facilities.
2.4 For these reasons, this submission emphasises
the need to address the more basic issues of health systems development
as a pre-requisite for maternal health improvement and the
attainment of MDG 5.
2.5 Having said this, two other important
interventions that must be taken on board include:
— Social interventions to improve the
status of women and girls.
— Appropriate interventions to reduce
high fertility rates in many countries.
3. But first, does maternal health need to
be prioritised and given greater attention?
3.1 The answer to this question is a resounding
Yes.
3.2 The estimated burden of maternal mortality
and morbidity caused by poor maternal health services is generally
well known. The importance of improving maternal health services
also extends beyond that of reducing maternal morbidity and mortality:
— Improved maternal health services
will have a significant positive impact on child health (by reducing
neonatal mortality and facilitating improved immunisation services
and feeding practices), and on HIV transmission (by increasing
the uptake of HIV testing and counselling and reducing vertical
transmission rates).
— Because there is no quick-fix, technological
solution to improving maternal health outcomes and because it
requires "fixing" the health system as a whole, maternal
health programmes can act as a catalyst for wider health sector
development.
— A comprehensive maternal health programme
can also act as a catalyst for female empowerment and improved
(and appropriate) family planning, both of which would have large,
indirect positive impacts on health and development.
— Unlike some other disease priorities,
action to significantly reduce maternal mortality often requires
an "explicit strategy" to target the poorest and most
marginalised sections of society (disease-based programmes on
the other hand have a better chance of achieving MDG targets without
always having to be as "pro-poor").
3.3 Too little of the present external funds
directed at the health sector is allocated to maternal health
service improvement. We hope that the IDC will encourage DfID
to take an even more active stance in improving maternal health,
and that it does so in a way that promotes the multiple benefits
described above. DfID can help generate and encourage more research
and development programmes focussed on maternal health and help
ensure that they are designed with a strong and coherent "health
systems" approach.
3.4 There is also a need for strong leadership
at the global level. In our opinion, WHO needs to be strengthened
to play this role. WHO is the technical agency best placed to
marry the twin objectives of maternal health care improvement
and health systems strengthening. Its maternal health programme
is currently inadequately staffed and inadequately funded. Its
mandate and authority is has also been weakened due to changes
to its working environment. This must change.
4. The broader context of development assistance
and global health initiatives
4.1 Compared to other donors and global
health initiatives, DfID provides important leadership in the
health sector. Among other things, DfID is recognised for having
a strong and progressive position on promoting country-led processes;
supporting comprehensive national health planning and appreciating
the importance of health systems strengthening, particularly in
light of the recent and current focus on vertical, disease-based
programmes. DfID is also one of the few donors to demonstrate
a clear understanding for the need to repair, rehabilitate and
develop the broken public sector health systems of many countries
and the weak institutional capabilities of Ministries of Health.
It is also helping to advocate for greater attention to be paid
to maternal health.
4.2 DfID's spearheading of the recently
announced International Health Partnership (IHP) has raised the
strategic importance of strengthening health systems and reducing
the costly effects of unco-ordinated global and external health
initiatives. This is a welcome step in the right direction. The
success of efforts to improve maternal health in some recipient
countries could depend on the IHP working. However, the principles
and aims of the IHP will be hard to implement—especially
given the lack of funding and operational guidance directed at
managing these partnerships. The IDC should interrogate DfID's
operational plans for ensuring that the rhetoric and agreement-in-principle
of the IHP will be converted into real and effective change.
4.3 It is also worrying that at a time when
DfID is spearheading the IHP and preparing to increase its health
spending, it is cutting back on its technical staff. There are
serious concerns as to whether DfID will have the capacity to
deliver on its strategies and policies for global health. If the
increase in DFID spend is to match its principles, policies and
strategies (including it promotion of maternal health), a serious
re-think about the levels and capacity of DfID staff is required.
4.4 It must be understood that while many
other actors may have joined the IHP and/or stated a commitment
towards strengthening health systems and promoting equity, the
actual policies, programmes and actions of these actors (eg other
bilateral donors, the World Bank, the Gates Foundation, the Global
Fund) can differ considerably, and not infrequently, demonstrate
contradictions. DfID should demonstrate its leadership within
the global health landscape by facilitating greater discussion
about these contradictions.
5. Getting the basics right
5.1 Maternal health improvement is absolutely
dependent on the availability of skilled health providers. Countries
with a high maternal mortality ratio also suffer from a lack of
skilled and motivated health workers. Although there is now international
recognition of the importance of training and retaining health
workers within developing countries, there is little in the way
of concrete action being taken to address this problem.
5.2 One notable exception is Malawi's Emergency
Human Resource Programme—a comprehensive six-year programme
supported by DfID—that takes a five-pronged approach:
— Improve incentives for recruitment
and retention of public sector and not-for-profit mission hospital
staff through a 52% salary top-up for 11 professional and technical
cadres, coupled with a major initiative to recruit and re-engage
qualified Malawian staff.
— Expand domestic training capacity,
including doubling the number of nurses and tripling the number
of doctors in training.
— Use international volunteer doctors
and nurse tutors as a short-term measure to fill critical posts
while Malawians are being trained.
— Provide technical assistance to bolster
Ministry of Health capacity in human resources planning, management
and development.
— Establish robust human resources
monitoring and evaluation capacity.
5.3 In addition, the programme explicitly
recognises the importance of improving policies on postings and
promotions; career development; and incentives for deploying staff
to underserved areas. Embedded within this comprehensive HR programme
are plans to train, recruit, deploy and support midwives and other
cadres of health worker essential to reducing Malawi's MMR which
currently stands at about 1,000 per 100,000 births.
5.4 Malawi's EHRP is one of the most positive
uses of external donor funding support—and one that goes
to the heart of many of the problems witnessed in high-mortality
countries. If countries can develop and implement a coherent and
comprehensive HR plan for the health sector, many problems will
be resolved.
5.5 But the comprehensive approach to the
EHRP has not been replicated in other countries. Furthermore,
there may be problems related to the implementation of the EHRP
due to a lack of operational research and evaluation to identify
bottlenecks and problems as they occur; a lack of civil society
involvement in monitoring the programme; and the continued "brain
drain" of health workers out of the public sector (into the
private sector, local NGO projects and to other countries). The
IDC should ask for a full briefing of the EHRP in Malawi; and
why this approach is not being replicated elsewhere.
5.6 There is important policy research that
needs to be funded to improve the human resource crisis. DfID
should consider working with the Global Health Workforce Alliance
and the Alliance for Health Policy and Systems Research to support
this research. This research includes conducting detailed studies
of the current number of midwives and birth attendants in countries;
the policies and practices for the enrolment of students; the
capacity of local training institutions; the structure, content
and length of training; the cost and quality of training; and
the nature of the labour market for midwives (describing, for
example, the pay and income of midwives within the local, national
and global market, and how this affects migration and career choices).
Similar research on non-physician clinicians, clinical officers
and medical assistants would also be useful.
6. Strengthening maternal health programmes
in-country
6.1 One of the underlying causes of maternal
mortality in many countries is poor health sector stewardship
and weak health systems management capacity. Governments, donors
and external health initiatives continue to fail to address these
shortcomings. Initiatives aimed at strengthening public sector
stewardship and management capacities have too often been fragmented,
piecemeal and short-lived. While some attention has been focussed
on training individuals, not enough has been done to help catalyse
change at the level of organisational culture and political stewardship.
The failure of civil society to develop its capacity to hold government
and public administrations to account is another omission. The
recent inclination towards vertical programmes and the expansion
of the private sector has placed many countries in a vicious cycle:
weak public health systems encourage greater use of vertical programmes
and NGO projects, which in turn undermine public health systems
further.
6.2 While not everything can and should
be done by the public sector, public sector failures have to be
fixed if maternal health is to improve in the poorest countries.
We hope that DfID will take some leadership in this area. However,
this requires a long-term strategy, rather than a quick-fix approach;
and it requires the adoption of strategies that do not involve
the export of "new management fads and practices" from
developed countries. Basic public administration skills and the
core building blocks of a coherent bureaucracy are desperately
needed in many countries.
6.3 DFiD has funded and helped implement
a number of country-based safe motherhood programmes in the past.
Some of these programmes have been reasonably embedded within
a health systems approach. Some have also been funded for relatively
long periods of time (up to six years). But not all of these programmes
have been as effective as one would have hoped. There are lessons
to be learnt about how such programmes can be designed and implemented
more effectively in the future. However, the principles of funding
and supporting country-based maternal health programmes remain
sound. We would like to see DfID making commitments to supporting
such programmes in more countries.
6.4 As far as research is concerned, while
some traditional forms of research remain valuable to add to the
existing evidence base of effective interventions, there is a
need for more forms of implementation research. Implementation
research can be seen as research that informs policy makers and
managers in real-time about what is and isn't working, and why.
It focuses on how to promote the uptake and successful
implementation of evidence-based interventions and policies that
have already been identified. It is a general term for research
that focuses on the question "what is happening?"
and "why is it happening as it is?", taking
into account the specific social, political and health systems
characteristics of countries.
6.5 Well-designed `implementation research'
and rigorous evaluation is a vital part of policy development
and implementation, health systems strengthening and community
development. This is an aspect of global health development that
remains under-funded and under-valued. DfID can help close this
gap. It is also important to bring together the research and programmatic
arms of DfID's work.
7. Financing
7.1 Financing for maternal health needs
to increase. This is obvious. More skilled birth attendants working
in adequately equipped health facilities will require additional
funding. Some of this funding will need to come from internal,
domestic resources. Much will need to come from external sources.
But what is not needed is a new global fund for maternal health.
There are already too many streams of unco-ordinated funding entering
low income countries. Additional funding for the health sector
should be, as far as possible, harnessed towards establishing
(in an equitable manner) the basic human and physical health care
infrastructure within in countries—including the HWs needed
for maternal health care and facilities needed to permit safe
childbirth. With the basic infrastructure in place, countries
might then need some additional programmatic support that would
focus on strengthening the organisational, management and professional
capacities to deliver effective MCH services. But this could be
funded and organised through existing structures.
8. Development assistance in the broader context
of the global political economy
8.1 Finally, while the focus of this submission
has been on development finance, or health sector `aid', the more
fundamental problems associated with the structure and outcomes
of the global political economy cannot be ignored. Poverty at
the household level is a major underlying determinant of premature
and avoidable mortality across the world. And poverty at the country
level is a major cause for dysfunctional health systems. Current
measures of income poverty (which focus on the $1/day threshold
and which use accounting methods that systematically undercount
the breadth and depth of poverty) do not reveal the extent to
which the structures and systems of the global political economy
require radical reform. Development assistance in the context
of a massively unjust political economy and in the context of
perverse subsidies from poor to rich countries (in the form of
skilled human resources, cheap labour, low corporate tax rates
or under-priced raw commodities) can be viewed as a distraction
from the fundamental business of constructing a fairer global
political economy, from which many health benefits would flow.
14 September 2007
158 The 2005 World Health Report-Make Every Mother
and Child Count; The Millennium Project (MP) Task Force on MDG
4 and 5 report-Who's got the power? Transforming health systems
for women and children; and The Lancet special issue on maternal
health. Back
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