Memorandum submitted by Save the Children
UK
BACKGROUND
1. Save the Children UK was invited to provide
evidence on maternal health in fragile states as part of a stakeholder
consultation held by the UK International Development Committee.
This document is intended to complement the verbal evidence given
during the inquiry and to address the specific questions which
form the basis of the inquiry. It is neither meant to be comprehensive
of all issues discussed during the inquiry, nor to be exhaustive
on maternal health issues in fragile states. It simply intends
to provide a few concrete suggestions on maximising the impact
of DfID's work on maternal health in fragile states.
2. Maternal health outcomes in fragile
states are almost invariably bad: maternal mortality has been
estimated at 1,600 per 100,000 live births in Afghanistan, 1,700
in Somalia, 2,000 in Liberia, 1,700 in Southern Sudan.[166]
Maternal mortality in fragile states is 2 and half times higher
than in countries with similar income levels. Multiple factors
conspire to determine these outcomes in fragile states, including
a near-total collapse of health services, high fertility, a low
level of education and empowerment of women, low priority given
to the health status of women by society.
3. Save the Children places great emphasis
on maternal and child health, recognising the right to
health of the mother and the child as inalienable human rights.
This is reflected in programmes in multiple countries in Africa,
Asia, Latin America to improve maternal and child health, and
strengthen health systems in general. Improving maternal health
outcomes is not only an imperative goal in itself, but it is also
fundamental as part of child survival strategies: a child
whose mother has died of AIDS, for instance, is four times more
likely to die than a child whose mother is alive.[167]
4. Fragile states present peculiar challenges
that should be taken into consideration when analysing strategies
to catalyse change in health service provision: these include
the deterioration or collapse of public management systems and
governance structures, migration of health workers to safe areas
of the country or abroad, a contraction of the resource envelope
available for basic social services, the emergence of multiple
and frequently poorly coordinated aid mechanisms and management
structures, which lead to fragmentation and inefficiency. Looking
beyond the health system, worsening education opportunities, economic
decline and the exacerbation of gender-based discrimination and
violence all contribute to the deterioration of maternal health
outcomes in fragile states.
SUMMARY OF
KEY ISSUES
AND RECOMMENDATIONS
1. Improving maternal health outcomes can
only be achieved through an overall strengthening of health
systems, in particular in fragile states where health services
and management systems are frequently in a state of near-total
collapse. Health sector reform and health system building are
processes that typically take place over a long period of time,
and which therefore require long-term political and financial
commitment.
2. There is increasing recognition of the
role civil society organisations can play in strengthening
health systems and improving maternal health outcomes: they can
be the main vehicle of service provision where national governments
are not able or not willing to provide services themselves; they
can contribute to holding governments to account; they can advocate
for a higher recognition of women's status, and for greater rights
to reproductive and maternal health services; they can provide
technical assistance and various forms of support to health systems;
they can build the capacity of national institutions, both in
the government and in the civil society, to better address maternal
health needs; finally, they can pilot new approaches and conduct
operational research on best practices and promising approaches
which can be then rolled out at national level. Without adequate
support, however, the unique contribution civil society organisations
make can be lost. While it is true that in certain countries direct
support to government mechanisms and financial channels may represent
the most cost-effective and sustainable strategy to support the
development of health systems, attempts should be made at striking
a balance that allows at the same time establishing strong
and accountable government mechanisms and maintaining a vital
civil society sector to support and complement the governments'
action.
3. While most of the interventions needed
to improve maternal health outcomes are likely to have an impact
only if sustained over long periods of time, a relatively easy
to implement intervention that could represent a quick-win
could be to reduce financial barriers to health services utilisation
by moving away from payment at the point of use. DfID could
play an important role by ensuring that the countries and the
institutions it supports, such as the World Bank, display better
consistency among their policy commitments, financial commitments,
and programming.
RESPONSE TO
11 SPECIFIC QUESTIONS
1. How can donors (specifically DfID) catalyze
progress towards MDG 5?
1.1 Improving maternal health outcomes requires
an effective and equitable health system. DfID's focus should
therefore continue to be on strengthening health systems as
a whole rather than supporting discrete components of service
delivery. What this means concretely at country level varies according
to the context. The newly launched International Health Partnership
could provide the framework for supporting health system development
and better donor coordination in this regard. Typically, the main
challenges encountered by health systems in fragile states relate
to poor governance, weakened or inexistent management systems,
opaque financial flows, insufficient human resources in rural/
remote areas, and absence of referral systems. DfID should also
use its key role in the IHP to ensure that civil society is given
adequate recognition and support in its significant contribution
to achieving MDG5.
1.2 In addition to building effective health
systems, making maternal health services a political priority
and empowering women may require a particular emphasis in terms
of advocacy and legislation.
1.3 DfID can also contribute through operational
research to expanding the evidence base on what interventions
and approaches work well, and investigating the role that provision
of basic social services can play in maintaining peace and in
nation-building.
1.4 Donors' (and DfID's) role relates not
only to assisting countries in providing adequate financing levels,
but also in encouraging governments to strengthen their political
and financial commitment, and be accountable on
provision of health services.
2. How effectively is DfID working to ensure
Emergency Obstetric Care is available and accessible with adequate
numbers of skilled birth attendants?
2.1 DfID's work to support the availability
of maternal health services in developing countries is commendable;
a particular mention must be made to the programmes that attempt
to address the human resource crisis, such as the emergency human
resources programme in Malawi, the collaboration with the NHS
to slow down migration of health workers, and partnerships with
the Global Health Workforce Alliance and the Federation Internationelle
de Gynecologie et Obstetrique. Addressing systematically the human
resources shortage, however, can only be done within a broader
context of civil service and health sector reform at the country
level, and through the introduction of adequate financial and
non-financial incentives to encourage recruitment, proper
management and retention of qualified human resources. This in
turn requires dramatic improvements in governance and management
systems.
2.2 The focus on training traditional birth
attendants should be definitely abandoned, since it has been shown
to be ineffective.[168]
Fragile states in particular invariably lack qualified midwives.[169]
Prioritising training of skilled birth attendants even
before the crisis is over can lay the foundations for revamping
maternal health services in the post-crisis period.
3. How effective is DfID in mainstreaming
maternal health across related policies?
3.1 DfID has been very instrumental in placing
the global debate on maternal health services in the broader context
of health system strengthening, equitable health financing and
aid effectiveness. Also the effort to link maternal health with
newborn and child health is a positive step, although the integration
between maternal health and HIV programmes could probably be improved.
In order for these global policies to translate into real change
for women, DfID should consider playing a more prominent role
at the country level, engaging directly with health sector
partners in health policy debate.
4. How is MDG 5 being supported and prioritized
into countries' overall health care provision?
4.1 Through its support to government budgets,
health sector programmes and discrete initiatives on maternal
health, DfID is playing an important role in making maternal health
a priority for health service provision. The focus on global health
programmes, initiatives and special funds makes it difficult for
maternal health services to be adequately supported at country
level. DfID should leverage its position as a leading global
financier and advocate of health services and health reform more
generally to ensure maternal health services have the prominence
they deserve in national level programming. This requires deployment
of health advisers and a greater voice at country level.
5. Is DfID's approach to supporting the 2006
MDG target of universal access to reproductive health effective?
5.1 DfID's work at global level to
support the right to reproductive health services is commendable.
Also many interventions conducted at country level, such as the
support given in Sierra Leone to the development of a sexual and
reproductive health policy, are positive initiatives. Progress
on availability of reproductive health services is however hard
to track, and access to family planning services remains worryingly
low in too many countries. Fragile states present the additional
challenges of deficient health care networks and human resources
to deliver services, a suppression of demand for social and cultural
reasons, and a frequently low priority granted to women's issues
and reproductive health in particular women's status and reproductive
health in particular. DfID should advocate, directly or indirectly
through its partners, for the right to reproductive health
services.
6. Is progress being made on reducing the
number of women dying from unsafe abortions?
6.1 DfID has played a leading role in focusing
attention on maternal deaths arising from unsafe abortion complications.
The legal, cultural and financial barriers present in many countries
make this area one where progress is likely to be slower than
in other areas of sexual and reproductive health. The issue is
further complicated by the absence of or gaps in information systems
in many countries that can document objectively the extent of
unsafe abortions and monitor their trend and their impact on maternal
mortality. This problem is even more acute where abortion is legally
and/or socially and culturally restricted, women's status is low,
service provision weak and health information systems virtually
absent, as is the case in most fragile states.
6.2 Is effective family planning being supported
in the countries you work in to support maternal health?
6.3 Fragile states are characterised by
dismally low levels of uptake of family planning: for instance
the percentage of women who use modern ways of family planning
is 3.6% in Afghanistan, 3.9% in Sierra Leone, 4.4% in DRC, 6.9%
in Sudan.[170]
In addition to improving the performance of dysfunctional health
systems, major cultural, educational and societal challenges need
to be overcome. Only a long-term sustained effort, aimed at addressing
all these determinants, within the health system and outside,
can create the right conditions for change.
6.4 More generally spending on family planning
has stagnated over the last decade, and major advocacy efforts
will be needed to bring a core mass of stakeholders of the global
health arena behind a common vision on family planning before
significant progress can be made.
7. How effective do you think DfID is in working
with bilateral and multilateral donors, NGOs and other stakeholders,
to improve maternal health?
7.1 DfID is a major global player in international
health, both in relation to its role as a financier and in relation
to its policy and advocacy work. As such it has the capacity and
the opportunity to demand greater accountability from the
partners it supports, whether they are beneficiary governments,
other bilateral donors, international multilateral institutions
or non-governmental organisations.
7.2 Efforts toward harmonisation and
alignment, in line with the Paris Declaration and the International
Health Partnership, should not allow DfID's voice and support
of pro-poor policies to be diluted. This calls for greater
involvement in policies determined at country level: support to
government mechanisms and financial channels should be an occasion
to engage beneficiary governments in a constructive dialogue on
improving governance and service provision, and not a justification
to drop uncomfortable or potentially controversial issues off
the development agenda.
7.3 DfID can play a more active role in
ensuring that international financiers in the health sector and
governments move away from user fees as a financing tool,
as it has been amply demonstrated that paying for health services
at the point of use is both inefficient and inequitable, and represents
an important barrier to increased utilisation.[171]
DfID in particular should ensure that the international institutions
it supports, such as the World Bank, translate their global
commitments to pro-poor policies into programmes at the country
level which do not include user fees as a financing instrument.
Also some interventions supported by DfID at the country level
could be made more consistent with DfID global position on payment
at the point of service.
7.4 DfID's commitment to support maternal
health services could translate in an increasingly prominent role
in this area, playing a leading role not only with like-minded
European donors, but also by re-engaging USAID in a dialogue
on reproductive health policies after the American presidential
elections of November 2008.
7.5 NGOs can play an important role in
several aspects of maternal health in fragile states and in developing
countries more generally. They can be the main vehicle of service
provision where national governments are not able or not willing
to provide services themselves; they can contribute to holding
governments to account; they can advocate for a higher recognition
of women in society, and for greater rights to reproductive and
maternal health services; they can provide technical assistance
and various forms of support to health systems, in particular
at sub-national level where the capacity and the presence of UN
agencies and bilateral donors is more limited; they can build
the capacity of national institutions, both in the government
and in the civil society, to better address maternal health needs;
finally, they can pilot new approaches and conduct operational
research on best practices and promising approaches which can
be then rolled out at national level. There is increasing recognition
of the positive role civil society organisations can play; this
is not accompanied, however, by adequate support in terms of resource
allocation, a problem which has been exacerbated by the recent
shift in focus to supporting government systems through budget
support mechanisms. While it is true that in certain countries
direct support to government mechanisms and financial channels
may represent the most cost-effective and sustainable strategy
to support the development of health systems, attempts should
be made at striking a balance that allows at the same time
establishing strong and accountable government mechanisms and
maintaining a vital civil society sector to support and
complement the governments' action.
8. What leadership is the UN providing in
addressing maternal health and how well coordinated are its agencies?
8.1 The work of health UN agencies is characterised
by uneven levels of effectiveness and capacity, in particular
at country level; as a major financier of these agencies, DfID
could improve the situation by demanding greater accountability,
more transparent management processes, and competency-based recruitment.
8.2 While they are sometimes effective in
advocacy, standard setting, procurement and coordination at national
level, UN agencies are more rarely able to be effective actors
at the sub-national level (districts, provinces), where health
services are managed and the health system inter-faces with communities.
9. 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?
9.1 At global level DfID's policies and
maternal health strategy recognise the importance of gender imbalances,
socio-economic determinants of poor health and inequitable financing.
Translating the right policies in place at global level in the
right programmes at the country level will require however stronger
efforts, a more vocal role at country level and more emphasis
on inter-sectoral coordination.
10. How can the international community improve
maternal health in crisis and conflict settings?
10.1 Strengthening and expanding health
systems requires sustained efforts over a long period of time.
Commitment of political and financial support should be taken
with a time horizon of 5 -10 years or more. A balance must be
struck between strategies that allow achieving change rapidly
(such as contracting out health services to NGOs, as done in Afghanistan)
and building long-term sustainable health systems led by accountable
governments.[172]
10.2 In many cases a twin track approach
is warranted, with the combined support of long-term system
building and the continuation of emergency relief operations until
alternative mechanisms are in place. The role of contracting out
of health services should be further explored, not only in relation
to the capacity of this model to deliver rapid change, but also
in relation to the long-term feasibility strategy of this strategy
to create building blocks of a health system.
166 WHO (2004) Maternal Mortality in 2000-Estimates
developed by WHO, UNICEF and UNFPA, WHO Geneva. Back
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Basia Z, Whitworth J, Marston M, Nakivingi J, Ruberantwari A,
Urassa M, Issingo R, Mwaluko G, Floyd S, Nyondo A, Crampin A.
(2005) HIV and Mortality of Mothers and Children: Evidence From
Cohort Studies in Uganda, Tanzania, and Malawi. Epidemiology.
16(3):275-280. Back
168
WHO, World Health Report, Making Every Mother and Child Count,
2005, WHO Geneva. Back
169
Pavignani E, Colombo A. (2007) Analysing disrupted health
sectors : a toolkit. Module 11: human resources. World Health
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170
Pocket world in figures, 2008 edition, The Economist,
2007. Back
171
James C, Morris S, Keith R, Taylor A. 2005. Impact on child
mortality of removing user fees: simulation model. British Medical
Journal; 331:747-749. Back
172
Palmer N, Strong L, Wali A, Sondorp E. Contracting out health
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