House of Commons - International Development

Select Committee on International Development Written Evidence

Memorandum submitted by the UK Network on Sexual and Reproductive Health and Rights Maternal Health Working Group

The UK Network on Sexual and Reproductive Health and Rights (the Network) is formed of UK based NGOs, academic institutions and independent experts with an interest in sexual and reproductive health and rights (SRHR) in developing countries. The Maternal Health Working Group of the Network focuses on maternal health with a particular interest in UK Government policy in this area.

The Maternal Health Working Group welcomes the opportunity to feed into the enquiry and have wherever possible tried to ensure that our input is in line with our Southern partners' experiences in the field. We would like to thank the following partners:

— In Cambodia we would like to thank Noun Sopheak (Health Unlimited Advocacy Co-ordinator) and the indigenous women of Ratanakiri Province who took part in the research into maternal health.

— In India we would like to thank Sarita Barpanda (Technical Advisor for Interact Worldwide) for her guidance and for co-ordinating the inputs of: Dr P K Senapati (Retd Director Health Services, currently Consultant MCH, Government of Orissa); Dr Suresh Mishra (Deputy Director, Drugs Control, Previously specialists in DFID PSPU, Orissa), Dr P K Das (Consultant RCH I & II), Dr H N Patnaik, (Retd Executive Director, initiated the NIPI in Orissa) and Dr Annapurna Mishra (Deputy Director, Orissa State AIDS Control Society).

— In Bangladesh we would like to thank Dr Kishwar Azad of the Perinatal Care Programme, Diabetic Association of Bangladesh (DAB).

— Thanks to Martha Bokosi (Programme Manager), Dr Ruth Lawson (Director), Cornelia Wakhanu (Midwife trainer), Jared Opodu (Midwife trainer) of Maternity Worldwide Ethiopia for their inputs and for facilitating discussion with their colleagues throughout Eastern Africa.

SUMMARY

The Maternal Health Working Group has concentrated its efforts in answering the questions set by the IDC on the role of the health system and sector in combating maternal mortality and morbidity. However, we believe that maternal health is a development issue that requires a multi-sectoral response. In this respect issues such as women's empowerment, law reform to safeguard their rights such as to inheritance, greater involvement in governance systems and girls education are all key. We hope that future inputs to the IDC will allow us to explore these elements further.

1. How donors—and DFID specifically—can catalyse progress towards MDG 5

1.1 DFID's role at the international level. We welcome DFID's renewed focus on strengthening developing country health systems as evidenced by their new health strategy,[175] their support for the "Global Business Plan on MDGs 4 and 5"[176] and the launch of the new International Health Partnership. There is ample evidence that robust and properly planned and implemented, fully staffed health systems with adequate supplies of skilled birth attendants,[177] medicines, supplies and commodities are crucial to improving maternal health outcomes. We commend them for their leadership in this area and for their support at the international level to catalyse action on stemming maternal morbidity and mortality, for example, through the Partnership for Maternal, Newborn and Child Health.

1.1.2 However, as maternal health advocates we have concerns about the process and content of the International Health Partnership.[178] In brief, we are concerned about:

— The lack of transparency in the development of the International Health Partnership both at the international and national level.

— The failure to involve civil society and national government beyond Departments of Health/Development in the North and South in its formulation, in proposed mechanisms for the creation, implementation and scrutiny of national health plans and bi-lateral donor involvement.

— The lack of clarity of how the International Health Partnership will ensure the supply of human resources, medicines, supplies and health commodities.

— Indicators to track success. Particularly in tracking performance on the new target under MDG 5 to ensure universal access to reproductive health by 2015, universal access to comprehensive HIV/AIDS services by 2010 and in improving upon the internationally agreed indicators under the MDGs to measure maternal health given their current inadequacy.

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1.1.2.1 Questions remain unanswered regarding the fit between the International Health Partnership and the Global Business Plan on MDGs 4 and 5. The process of taking these two initiatives forward appears to be happening without adequate cross referencing, without the proper involvement of the recipient countries and in isolation from civil society advocates. This has led to an apparently rushed process, with confused messaging and a lack of buy in from other crucial partners in the process.

1.1.3 Ensuring financing for global health. We agree that it is vitally important that health financing and policy is harmonised and country owned in line with the Paris Declaration. In addition, more rational and efficient use of Official Development Assistance for health would no doubt improve the state of developing country health systems. This would appear to be a key aim of the International Health Partnership, and one that we support. However, there is international consensus that the health MDGs cannot, and will not, be met without a considerable increase in the financing available for health investment in developing countries. We commend DFID's support for innovative financing mechanisms to improve child health such as the International Financing Facility for Immunisation (IFFIm) but note that there has been no comparable commitment to securing the health of women and mothers. The Commission on Macroeconomics and Health[180] estimated that donor disbursements to global health would need to reach US$6 billion by 2002. In fact they only reached US$3.5 billion. By 2007 disbursements should have reached $US27 billion. Despite increases in the proportion of Official Development Assistance for health we are still some way from the target. For the UK to meet this "fair share" contribution they would need to more that double the percentage of GNI allocated as official development assistance for health from 0.043% to 0.1%.[181]

1.2 DFID's role at the national level. Civil society play a key function at the national level in ensuring that appropriate targets are set and monitoring progress towards them. This has been recognised by the Partnership for Maternal, Newborn and Child Health in their governance structures at national level which are working to co-ordinate maternal, newborn and child health plans and ensure congruence with other national health planning and financing mechanisms. To play an active role civil society need support from national government, this must be factored into planning processes and must be financially supported. This is not always the norm. For example in Orissa, in India, our colleagues have found that the Joint Review Monitoring is an important tool which helps in identifying the gaps in the health programme. However last year's Joint Review Monitoring findings have not yet been actioned and there is a strong need for support in developing and establishing an internal monitoring mechanism of civil society which could asses whether Government and donor goals are being achieved and set a timetable for the achievement of missed goals and build the capacity to implement it. We believe that this is an area in which DFID can add value.

2. How effectively DFID is working with recipient countries to make emergency obstetric care available and to ensure that adequate numbers of skilled birth attendants and other staff are being trained to meet MDG 5, and are integrated within a robust health system. The steps DFID is taking to mainstream maternal health across related policies

2.1 Ensuring transparency with regard to spending at the national/state/district level. Where DFID has pushed for action on health system strengthening the results of this work are not always transparent to the rest of government or to civil society. For example our colleagues in Orissa report that DFID was a key ally in the Orissa Health Sector Plan to support human resources, infrastructure, medicines, Information and Education Communication/Behaviour Change Communication etc. Despite having a budget of RS. 20 crores little is known outside the Health & Family Welfare Department about whether or how this money has been spent.

2.2 Ensuring that the role of the community, community level health system and traditional birth attendants is well understood, supported and rationalised within the broader health system. Whilst every pregnant woman should be provided with care from a skilled birth attendant (SBA) (one with formal training from a recognised medical, nursing or midwifery school) traditional birth attendants (TBAs) and other community workers still play an important role in linking the community with the formal health system in many settings. Within health system financing there is a need to ensure adequate investment at the community level as it is at this level that the first two of the three delays take place. This financing should be used, in part, to strengthen referral and linkage with other community structures such as TBAs and the formal health system.

Although the training of TBAs has not directly led to reductions in maternal mortality they have had some positive impact in terms of neonatal health[182] and can play a vital role in referring women to skilled attendants. Our colleagues from India note that TBAs are still being supported in 14 Districts through the NAVAJYOTI scheme by Government of Orissa where the infant mortality rate is high and this initiative has been successful in not only reducing the rate of maternal mortality but has also been a strong initiative for maternal health. As reported at a dissemination meeting on "Scaling Up Community Mobilisation activities to improve maternal and neonatal health in Bangladesh",[183] while official policy in Bangladesh is that TBA training has halted it is doubtful that the target of 13,000 trained SBAs by 2010 (in Bangladesh) will be achieved (2,500 are now trained). TBA training is still being carried out in Bangladesh and TBAs will continue to operate whether or not Government wants them to.

In Ethiopia our partners report concerns about the efficacy and practical implementation of alternative community-based initiatives such as the Health Extension Package Workers; particular concerns include the low numbers of HEPWs, the lack of integration of the HEPWs at community levels and poor retention rates which undermines training and referral networks. Given that WHO's model of health systems includes the community as a key component we would call upon DFID to undertake research to better refine our understanding of the optimum role community structures and TBAs can play in improving health outcomes and that this is recognised and supported in national plans.

2.3 Mainstreaming. There is a need to actively promote and fund more inter sectoral agreement and practice as core factors to help mainstream maternal health across related policies. DFID can support with funding this but also through supporting the development of mechanisms for capturing and sharing learning and for piloting specific projects. The HIV/AIDS sector has useful models for integration and for improving stakeholder engagement.

3. How DFID is supporting the 2006 recommendation by the UN General Assembly for an MDG target for universal access to reproductive health

3.1 We commend DFID and the UK Government more broadly for the leadership role that they have played in bringing about the new target under MDG 5. However we have concerns that the indicators under this new target have still not been agreed and that they are subject to a great deal of scrutiny and criticism from governments who do not recognise the full spectrum of sexual and reproductive rights, for example the United States. Until indicators are in place there will be no impetus to measure progress towards the new target. We would suggest that DFID continue to negotiate strongly for robust and appropriate indicators in this area in its role at the UN and in negotiations with other bilateral actors.

3.2 DFID can also lead the way in ensuring that the success of the International Health Partnership is, in part, judged by its ability to stimulate progress towards universal access to reproductive health.

3.3 Furthermore, DFID could support the target by better communicating its existence to stakeholders both inside and outside government.

3.4 DFID have been very supportive in a limited number of countries (notably India and Malawi) where large scale programmes have shown some encouraging steps towards universal access to broad range of RH care. However it is not yet possible to comment on how this support can or will be rolled out to other programmes/projects.

4. The progress being made in reducing maternal deaths from unsafe abortion?

4.1 Where abortion is illegal, unaffordable or inaccessible, incidence of unsafe abortion is invariably high. Methods of unsafe abortion include; drinking poisonous substances or dangerous quantities of alcohol, inserting sticks and other sharp objects into the uterus and severe pelvic pummeling. Such methods are thought to be responsible for about 13% of global maternal mortality.

The key reason why women continue to risk their lives with unsafe abortion—despite its illegality—is desperation. Many fear that pregnancy outside wedlock will lead to them being ostracised from their family and community. Others are so poor that they literally cannot afford to feed another child and fear for the nutritional health of their existing children. These factors mean that thousands of women choose to face the risks of unsafe abortion every year.

Legalising abortion, together with the roll out of access to safe abortion services, is therefore key to reducing these deaths. Recent successes include Mexico City and Nepal. However, pressure against the right to choose means that access to abortion has become even more restricted in some countries including Nicaragua.

4.2 When the opportunity to support safe abortion emerges, it is important that donors take it. The Maputo Plan of Action represents a huge opportunity in Africa, calling as it does for legislative reform to address unsafe abortion and having won the endorsement of the Africa Union Executive Committee in January this year. We urge DFID to advocate for the implementation of the plan in all of its stronger partnerships with African administrations and to provide financial support where appropriate.

5. How effective family planning is being promoted as a way to improve maternal health

5.1 Family planning prevents unintended pregnancies, many of which are unwanted. Unwanted pregnancies lead to abortion, many of which are unsafe in the developing world. Unsafe abortion is a leading cause of maternal death and ill-health. Family planning is critical to improving maternal health and needs to be a key strategy at the national and international levels to reduce unsafe abortion and maternal mortality. The current "unmet need" for sexual and reproductive health, care, education, information and services is enormous. "One in three deaths related to pregnancy and childbirth could be avoided if women who wanted effective contraception had access to it".[184] Indeed, "it is notable that contraceptive prevalence is low in countries with high maternal mortality".[185] UNFPA estimates "that meeting the existing demand for family planning services would reduce maternal mortality and morbidity alone by at least 20%".[186] Unsafe abortion can lead to long-term disability and maternal death. Indeed "around 13% of all maternal deaths are caused by unsafe abortion."[187] Family planning is, therefore, a key factor in the fight against poor maternal health and needs to be promoted as a preventative method for reducing maternal mortality.

5.2 DFID is a key supporter of family planning. They work with key governments, decision-makers and agencies to promote family planning as a way of improving maternal health. They also show leadership in a variety of international health initiatives such as the Partnership for Maternal, Newborn and Child Health (PMNCH) and the recently launched Global Campaign for the Health MDGs. They also advocate with key UN agencies and have increased their funding for a number of NGOs that provide reproductive health care services and commodities. Likewise, DFID is a member of the Reproductive Health Supplies Coalition (RHSC) which was set up to provide global leadership in making essential reproductive health products available to developing and transitional countries.

5.3 Despite the clear link between maternal health outcomes and family planning we believe that DFID could do more in-country to capitalise on the positive effects of the provision of family planning services. Our Southern partners have commented on the need to ensure that the infrastructure exists to support promotional and behaviour change communication work particularly in terms of health commodities, adequate supplies of human resources and appropriate community level structures. Universal access to reproductive health of which family planning services are a component is reliant on reproductive health commodity security. Without appropriate choices or the necessary quantity of commodities, sexual and reproductive health programmes will fail. The lack of adequate supplies in many countries is a result of funding and supply shortfalls. However, other problems exist which increases the level of unmet need: these include; "Inadequate forecasting of supply needs; a lack of adequate distribution systems in-country; regulatory, tariff and tax barriers that hinder the importation and provision of supplies by the public and private sector; inefficient use of public funds and a duplication of efforts and/or inadequate co-ordination among donors, governments, NGOs and other agencies in relation to commodity funding and delivery".[188] We believe that DFID should play an enhanced role in advocacy at the national, regional and global levels to encourage political leadership in this area to ensure that family planning is appropriately placed within national health plans and budgets.

6. How effectively DFID works with bilateral and multilateral donors, NGOs and other stakeholders to promote maternal health

6.1 Relationship with the Reproductive Health and Research Department at WHO. DFID has been instrumental in supporting the existence of the Reproductive Health and Research Department including arguing for earmarked funding for this area of work when it has been under threat. We hope that this is a Department that they will continue to champion.

6.2 Relationship with the Partnership for Maternal Newborn and Child Health. DFID is one of the founder donors and an active participant in the Partnership for Maternal, Newborn and Child Health. The Partnership has the potential to stimulate advocacy for maternal health services and should be supported to play a role in the roll out of the "Global Business Plan on MDGs 4 and 5" and the International Health Partnership.

6.3 DFID's support to UNFPA. DFID has stepped in to fill funding gaps and to support UNFPA in the creation of the new target under MDG 5. This support should be sustained, strengthened and better communicated. DFID also has a part to play in building the capacity and monitoring the effectiveness of UNFPA.

6.4 The US Government. US policies such as the Global Gag Rule and restrictive programming with regard to HIV and AIDS undermine maternal health. DFID could play a more active role in promoting an evidenced based approach to these issues and filling financing gaps in the manner that they have with the Global Safe Abortion Fund. They should be advocating to and leveraging support from like minded donors to this end.

6.5 DFID's relationship with the World Bank. DFID's approach of spending more money with decreased staff at the centre and periphery make it likely that its budget for health system strengthening will increasingly be channelled through the World Bank. Given the World Bank's recent record on sexual and reproductive health, when first drafts of the Population and Nutrition Strategy failed to include a sexual and reproductive health and rights focus, and the difficulty in tracking positive health outcomes from central budgetary support, this strategy should be given more thought. The World Bank is not renowned for its pro-poor strategy and supports user fees that often inhibit access to health services, particularly for the poorest. In addition, channelling funds through the World Bank will reduce accountability between DFID and the British taxpayers who are concerned that their funds are spent effectively.

6.6 The Global Fund to fight AIDS, TB and Malaria and the integration of sexual and reproductive health. There is evidence to show that the integration of sexual and reproductive health components to HIV policies and programmes strengthens health outcomes yet this is a not yet a priority of Global Fund programming and financing. The UK Government has played a part in propagating this approach[189] and has been very supportive of efforts to integrate sexual and reproductive health in the HIV/AIDS components of country co-ordinated proposals submitted in July 2007 by Country Coordinating Mechanisms (CCM) for the 7th Round of funding by the Global Fund.

As a major donor, supporter and Board member, DFID should call for further technical guidance on SRH-HIV/AIDS integration to be outlined in the Guidelines for Proposals issued by the Global Fund, beginning with Round 8. The Guidelines must reflect the importance of SRH-HIV/AIDS integration, but the Monitoring and Evaluation (M&E) Toolkit provided by the Global Fund for potential grantees must do the same.

Within and in addition to its current efforts to define the Global Fund's role in strengthening health systems, the Board should be explicit in its support for SRH-HIV/AIDS integration by approving Guidelines that include SRH-HIV/AIDS integration and outline the funding opportunities for SRH-HIV/AIDS integration. There should be clarification that Health System Strengthening aspects of all proposals can include human resources, commodities, supplies and infrastructure for SRH.

Additionally the Technical Review Panel (TRP) must consider SRH integration as an "essential component" in HIV/AIDS proposals. This will, in part, be accomplished through a concerted effort by WHO and other agencies that provide technical support to the TRP to emphasise the many entry points for SRH-HIV/AIDS integration, the range of relevant interventions, and the positive outcomes these can have on HIV/AIDS and other diseases.

6.6.1 Additionally we have concerns about the lack of gender sensitivity in much of the Global Fund's policy and practice. For example, our partners report that many of the CCMs only have one place for the representation of people living with HIV and often this is taken by men meaning that issues of importance to women living with HIV, such as sexual and reproductive health and maternal health are inadequately represented. DFID is in a position to influence at Board level for gender specific monitoring processes.

6.7 The UK Government as part of the European Union. The European Commission has recently lowered its financing to sexual and reproductive health as part of the streamlining of health related budget lines through the Investing in People initiative and a reduction in financing for health as a proportion of overall ODA.[190] The UK Government should play a leadership role in ensuring the European Commission provides fair financing for the Global Fund for AIDS, TB and Malaria whilst maintaining and strengthening its financing to health system strengthening and sexual and reproductive health. We look forward to seeing how the UK Government positions itself with regard to the new plan for MDG Contracts (to make general and budget support work better for the health MDGS) and how they co-ordinate this approach with the new International Health Partnership.

6.8 The IMF. We are concerned that the policies of the IMF are restricting developing country government wage spending because of fears of a lack of fiscal space.[191] In part fears around fiscal space could be addressed through longer term, more predictable international development aid which DFID should move toward by expanding the number of countries that it has 10-year partnerships with and exploring ways to make binding financial commitments for the duration of the agreements. As the 4th joint largest donor to the IMF DFID should advocate for the removal of pressure on public budgets and to open up greater fiscal space for health spending.

7. What leadership the UN is providing and how well co-ordinated its agencies are

7.1 Coordination issues. We are concerned at the potential for lack of co-ordination between the UN agencies working on maternal health. In WHO alone there are three separate departments with overlapping remits: the Making Pregnancy Safer Team, the Department of Reproductive Health and Research and the Partnership for Maternal, Newborn and Child Health. Across the UN family there are some issues that are inappropriately prioritised or covered by more than one agency such as the procurement and promotion of condoms or maternal health services for women living with HIV and AIDS. DFID has had a major focus on UN reform overall and should play a role in advocating for rational and streamlined policy and programmatic guidance in these areas.

8. How DFID is addressing socio-economic barriers to women's empowerment and the low status of women in relation to maternal health

8.1 We welcome DFID's policy focus on tackling the low status of women. We agree that "underlying the failure to solve the problem lie broader social, cultural and political factors: the low status of women and the low priority given to their health, the failure to assure their rights to appropriate care, and the lack of political commitment to address the problem".[192] In the Second Progress Report on Maternal Health (April 2007)[193] three areas of progress are noted in relation to addressing wider social and economic barriers to maternal health; support to innovative financing mechanisms to scale up basic services; support to a workshop on FGM and other harmful traditional practices; presentation of evidence linking poverty and maternal health. In the "looking forward" section of the report (paragraphs 67-77) there is an assertion that the DFID priorities remain valid, but there is no explicit reference to women's status.

DFID has made women's empowerment and gender equality a high level commitment at the centre of its work. Therefore it now has a comparative advantage over other donors in its mission to strive to help developing countries to achieve gender equality and women's empowerment. Thus, we consider that addressing socio-economic barriers to women's empowerment and the low status of women in relation to maternal health should be a key point of implementation of DFID's Gender Equality Action Plan[194] by:

— Ensuring that all DFID's maternal health partnerships and funding are reviewed in light of a gender analysis and that these partnerships include a commitment to tackling the gender inequalities.

— Providing the gender champions and the Equity & Rights teams with the adequate power, support and budget to carry out their work—especially supporting the AIDS and Reproductive Health team.

— Ensuring that gender is a key consideration when monitoring and evaluating these partnerships and funding commitments; this includes the proper training for AIDS and Reproductive Health Team and Equality & Rights Team to carry out the gender equality analysis.

— Supporting country offices to review their partners in the response to maternal health to better promote gender equality and women's empowerment. Partnerships with organisations working in these areas should be prioritised.

— In funding civil society (eg through the Civil Society Challenge Fund and Governance Transparency Fund), ensure that there is a greater focus on health equity and women's leadership in health sector governance.

— Incorporating indicators set in the Gender Equality Action Plan into indicators set for the Maternal Health strategy eg increased reference to gender issues, in particular inequality and empowerment, within policy papers, practice notes and guidance notes, increased proportion of new policy products that address gender inequality and women's empowerment.

8.2 An essential factor that is missing from the DFID analysis is equity in the access afforded maternal health services by marginalised groups. National strategies also need to include an analysis of the needs of different groups within each country.

CASE STUDY ON INEQUITY OF ACCESS TO SERVICES

A Health Unlimited study in the Ratanakiri Province of Cambodia[195] demonstrated that indigenous women experienced particular barriers in accessing maternal health services beyond those experienced by the general population. These included:

— Discrimination by service providers. This was not only due to their position as women but that as indigenous women they were typified as "backward, uneducated and stubborn".

— Language barriers. Women were found to be significantly less likely to be able to speak Khmer. They therefore relied more on husbands/relatives to speak for them in accessing services.

— Ritual obligation. This caused delays in accessing services as ritual sacrifice to ancestor spirits have to be performed before leaving village.

— Confidence in the health service. Due to the discrimination that they faced in the formal health setting indigenous men and women had more confidence in traditional birth attendants than in the government service providers.

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Community recommendations for the improvement of access to government health services included that:

— TBAs should be present in Health Centres, alongside midwives.

— No male staff should be involved.

— Staff should speak the local language.

— Families should be able to make animal sacrifices at the health centres.

Training should be provided for government health staff on ethical and culturally appropriate behaviour.[197]

9. How the international community can improve maternal health in crisis and conflict settings

9.1 According to OCHA, in 2003, 200 million people were affected by natural disaster and 45 million people were in need of life saving assistance due to complex emergencies. The majority of these people find themselves unable to access national health services and therefore fully depend on humanitarian relief efforts.

9.2 Many of these efforts however, largely overlook the sexual and reproductive health needs of affected populations. The critical importance of SRH care to reducing maternal death and morbidity is well documented and recognised by the international community. Yet, the humanitarian community continues to fail to ensure the inclusion of SRH service delivery as integral part of the humanitarian response.

9.3 SRH needs are particularly acute in countries emerging from conflict or natural disaster. Health systems in these countries are often characterised by damaged infrastructure, limited human resources and lack of capacity to provide health services, including sexual and reproductive health (SRH). In addition, stewardship of the health system in these countries is often weak and service delivery fragmented as a result of proliferation of NGOs. Moreover, general health NGOs may not have the experience, knowledge or commitment to deliver SRH according to internationally agreed standards.

9.4 In sum, major maternal health challenges in emergency settings that require urgent attention from the international community, including DFID, are:

— Ongoing lack of focus or priority given to SRH service delivery within a humanitarian response by key national and international actors, including; host governments, the UN system, donor governments and health focused NGOs.

— Lack of skilled staff in SRH service delivery, equipment, supplies, means of communication and transportation.

— Lack of access to life-saving SRH services, in particular emergency obstetric care (EmOC) and family planning.

9.5 There is a consistent need to push for the inclusion of SRH as part of the humanitarian response. Some progress has been made over the years in this area with some policies and guidelines in place. What is now required is a concerted drive to translate policy into action.

9.6 In this regard we welcome the inclusion of language on SRH in the new CHASE Humanitarian Funding Guidelines for NGOs (to be released in October) as an important step in encouraging agencies to include SRH in their humanitarian programmes. As a next critical step, DFID should to monitor it own performance in supporting humanitarian SRH programmes by tracking its grant money allocated to programmes that include SRH service delivery.

Moreover, DFID should use its influence at both national and international levels to ensure the incorporation of SRH as an integral part of humanitarian policy and action. More specifically, DFID should:

— Work with the humanitarian co-ordination system of the United Nations to ensure that SRH needs are adequately addressed from the outset of an emergency by ensuring that SRH becomes a core focus area of the Health Cluster as part of the Cluster Approach.

— Encourage humanitarian health focused agencies operational in emergency settings to develop the necessary human resources to set up and run effective comprehensive RH programmes in emergency settings from the outset of every emergency.

— Work with host governments, most notably the Ministries of Health and Finance to prioritise SRH as part of the humanitarian response and ensure its inclusion within national policies, budgets and action plans.

— Work with key partners on the ground (MoH, UN agencies and NGOs) to ensure the availability of skilled SRH health staff, appropriate equipment, supplies, means of communication and transportation, to enable access and quality SRH service delivery, including EmOC and family planning.

175 DFID (2007) Working Together for Better Health www.dfid.gov.uk/pubs/files/health-strategy07.pdf Back

176 Tore Godal (2007) Concept paper in relation to the development of the Global Business Plan to accelerate progress towards MDG 4 and 5 http://www.who.int/pmnch/events/2007/gbpconceptpaper.pdf Back

177 The term skilled attendant refers to an accredited health professional-such as a midwife, doctor or nurse-who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns. Traditional birth attendants (TBA)-trained or not-are excluded from the category of skilled health-care workers. In this context, the term TBA refers to traditional, independent (of the health system), non-formally trained and community-based providers of care during pregnancy, childbirth and the postnatal period. http://www.who.int/reproductive-health/global_monitoring/skilled_attendant.htmldefinitions Back

178 For more detail please see Annex 1 Evidence to the Department for International Development Consultation on "A new health access initiative: delivering the health MDGs" The UK Network on Sexual and Reproductive Health and Rights with inputs from the Maternal Health Working Group 20 August 2007. Back

179 For example, indigenous people, people living with HIV, young people, sex workers, sexual minorities, injecting drug users, people in prisons, internally displaced people, migrants and refugees. Back

180 Commission on Macroeconomics and Health (2001) Macroeconomics and Health: Investing in Health for Economic Development www.cid.harvard.edu/cidcmh/cmhreport.pdf Back

181 Action for Global Health (2007) Health Warning www.actionforglobalhealth.eu Back

182 Lawn, J E, Tinker, A, Munjanja, S P and Cousens, S. Where is maternal and child health now? Lancet, 28 September 2006. Back

183 Meeting hosted by DAB, Women & Children First and ULC, Dhaka 10 September 2005. Back

184 Facts about Safe Motherhood, UNFPA at http://www.unfpa.org/mothers/facts.htm [accessed 7 August 2007]. Back

185 Annex 9.6, The important issues in developing a national plan on maternal mortality reduction, Dr Pang Ruyan, Regional Adviser, MCH/FP/WPRO, at http://www.who.int/reproductive-health/publications/RHR_02_2/ax6.pdf Back

186 Women's Health and Empowerment: A Key to a Better World, Statement by Thoraya Ahmed Obaid, Executive Director, UNFPA, Monterey, California, USA, 12 May 2003, at http://www.unfpa.org/news/news.cfm?ID=343&Language=1 Back