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
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 network welcomes this new focus upon the
need to strengthen national health systems and the opportunity
to be part of the consultation to shape its design and function.
We concur that better donor co-ordination, transparency,
accountability and long- term investments are necessary to strengthen
health systems. We are pleased to note that the new health access
initiative aims to allow recipient countries to set health priorities
and control the allocation of health budgets accordingly. We are
particularly interested in how this health access initiative could
stimulate progress towards the achievement of MDG 5 on improving
maternal health and also have benefits for other health objectives
such as MDG 6.
However, we believe that the content of the
new health access initiative could be strengthened and that efforts
could be made to improve the consultation process. We look forward
to continuing dialogue on the points outlined below.
1. THE LINKS
BETWEEN SRHR AND
WELL FUNCTIONING
HEALTH SYSTEMS
A focus on SRHR within the new health access
initiative is imperative. Well- functioning public health systems
are key to the provision of comprehensive sexual and reproductive
health (SRH) and all other health services. If we are to meet
MDG 5 by 2015 we must build health systems that can deliver antenatal
care; emergency obstetric care; post-partum care; family planning
counseling and commodities; nutrition; integrated HIV prevention
and treatment services and access to safe abortion and post-abortion
care. Because it is so reliant on clinical infrastructure progress
on maternal health is a good test of the competence and strength
of a health system and can be used as an indicator for health
system strengthening.
The provision of comprehensive SRH services
strengthens development processes. This has implications for attainment
of the other MDGs particularly: those related to health, eradicating
extreme poverty and hunger, promoting gender equality and empowering
women and ensuring environmental sustainability. This link was
acknowledged by the World Summit in 2005 when Heads of Government
agreed to establish a new target under MDG5 to achieve universal
access to reproductive health by 2015. This target was called
for by the UN Secretary-General in his report of 2006 and the
UN Inter-Agency Expert Group was subsequently asked to propose
a set of indicators to measure progress in its implementation.
Proposals for such indicators are: contraceptive prevalence rate,
unmet need for family planning, adolescent birth rate and antenatal
care visits.
The Network welcomes the leadership that the
UK Government has shown in supporting the new target and indicators.
We are hopeful that they will maintain this position and that
it will be reflected in the health access initiative. Current
indicators for MDG 5 are inadequate, particularly in tracking
maternal deaths that occur during delivery and the post-partum
period. Therefore the health access initiative will need to pay
greater attention to this area and we look forward to providing
further comment on this as the health access initiative's operational
plan is developed.
Reproductive health conditions continue to be
the second-highest cause of ill health globally after communicable
diseases and the differences in reproductive health between the
rich and the poor—both between and within countries—are
larger than in any other area of health care.[198]
Lack of access to SRH services for those who need them most replicates
patterns of social inequality.
— The Network recommends that the health
access initiative explicitly works towards the target of universal
access to reproductive health by 2015 under MDG 5 and uses the
indicators proposed under this target to measure its progress
towards strengthened health systems. Indicators that better assess
progress on combating maternal mortality, particularly during
delivery and the post-partum period, should augment these. We
also suggest that the initiative's success is tracked by indicators
that measure equity of access to health services particularly
for women and the most marginalised.
2. THE RELATION
OF THE
HEALTH ACCESS
INITIATIVE TO
THE GLOBAL
BUSINESS PLAN
ON MDGS
4 AND 5
The new health access initiative appears to
be connected to the Global Business Plan on MDGs 4 and 5. The
concept note states that the initiative "builds upon a number
of past and ongoing efforts to increase external support for health
and improve harmonisation and alignment of that support"
and lists the Global Business Plan. Yet it is unclear how the
two mechanisms will work together in practice and how donors will
ensure that they do not lead to over-burdensome reporting and
management requirements on developing country governments. If
the new health access initiative is intended be subsidiary to
the Global Business Plan it needs to clearly outline how broad
health systems strengthening efforts would ensure maternal health
outcomes.
— The Network recommends that the relationship
between the health access initiative and the Global Business Plan
on MDGs 4 and 5 is better defined and harmonised in such a way
that maternal health remains a focus in health system strengthening
without over burdening recipient governments. The Network also
recommends more consultation on the Global Business Plan before
it is launched.
3. FINANCING
FOR HEALTH
The new health access initiative "will
not establish a new health financing mechanism". We agree
that more could be done to make existing health financing work
better through co-ordination, developing country leadership and
priority setting and greater flexibility. However better co-ordination
alone will not deliver the health MDGs. Even the relatively modest
predictions of the Commission on Macroeconomics and Health[199]
of adequate financing to meet the health MDGs have failed to be
met.[200]
In terms of reproductive health the cost of fulfilling the demand
for quality contraceptives and condoms alone is projected to rise
from $1 billion to $1.8 billion between 2004 and 2015. In 2002,
donor support for contraceptives amounted to $197.5 million—a
12% decline from the previous year.[201]
This suggests that there should be greater emphasis on ensuring
donor buy-in for the initiative, particularly on those donors
who provide a large proportion of global health financing including
the EC and the US.
— The Network recommends that the UK
government offer greater clarity within the mechanism of what
can be achieved through the improved use of existing resources
and where financing gaps need to be filled and provides leadership
in meeting these resourcing requirements. The UK Government should
also make it clear when existing financing commitments for health
will be met.
4. ADDRESSING
THE CONSTITUENT
ELEMENTS OF
HEALTH SYSTEM
STRENGTHENING
Ensuring ready access to health-related equipment,
drugs and commodities is an essential element of health systems
strengthening. This requires strengthened systems for procurement
and registration, including transparency on the registration of
generics. Failures to predict the type of commodity needed and
where it will be needed, weaknesses in quality assurance and logistics
for example, inadequate storage and badly planned distribution
programmes also limit commodity availability. Security in reproductive
health supplies requires the capacity to forecast, finance, procure
and deliver high-quality and reliable supplies and services over
the long term.[202]
Adequate numbers of appropriately trained and
motivated health workers are vital to the delivery of health services
and a prerequisite to health systems strengthening. Yet 57 countries
face a critical shortage of health staff equivalent to a global
deficit of 2.4 million doctors, nurses and midwives.[203]
Midwives in particular often have only a limited number of the
skills that define a fully-qualified midwife and cannot be expected
to save pregnant women's lives without adequate training. Health
system planning and equitable and integrated service delivery
in fragmented systems with multiple service providers requires
robust and joined up management systems. Health system planners
need adequate training to ensure that national policy is implemented
appropriately at the periphery. This is particularly true in the
case of reproductive health services where health management personnel
at the district and local level may lack the technical, managerial,
and financial skills needed to deal with their new responsibilities
and they may consider reproductive health less of a priority than
central government.[204]
— The Network recommends that the health
access initiative "compact" pays more explicit attention
to these challenges related to the constituent elements of health
system strengthening.
5. SUPPORTING
RECIPIENT GOVERNMENTS
TO DECIDE
HOW HEALTH
SERVICES ARE
BEST PROVIDED
We are pleased to note that the health access
initiative recognises the role of the non-state sector in the
delivery of health services. We believe investing in public health
systems through medical schools and training for public health
workers and providing adequate salaries and incentives for public
sector workers should be a priority. National plans must adequately
recognise, incorporate and support the contribution of the private
sector (profit and not for profit) in service delivery, in capacity
building of state-run services and taking leadership in the development
and monitoring of health policy.
— The Network recommends that the health
access initiative ensures that decisions on health policy and
services are determined at national level and guided by the national
context, with the first priority being public health system strengthening.
6. THE IMPORTANCE
OF MEANINGFUL
CONSULTATION WITH
CIVIL SOCIETY
UK Government guidelines suggest that during
the formulation of policy, departments should consult widely throughout
the process, allowing a minimum of 12 weeks for written consultation
at least once during the development of the policy and ensure
that the consultation is clear, concise and widely accessible.[205]
Given the clear links between strengthened health systems and
SRH outcomes we were disappointed that the Network was not involved
in earlier discussions on the health access initiative. Furthermore,
the timeline of less than 7 days for written comment is extremely
short and does not allow for discussion with our colleagues in
developing countries or other donor countries.
— As the process of developing the
health access initiative moves forward the Network recommends
that the consultation process is strengthened, broadened, given
sufficient lead-time and made more transparent.
20 August 2007
198 UNFPA (2005) State of the World's Population
2005 http://www.unfpa.org/swp/2005/english/ch4/index.htm Back
199
Commission on Macroeconomics and Health (2001) Macroeconomics
and Health: Investing in Health for Economic Development www.cid.harvard.edu/cidcmh/cmhreport.pdf Back
200
The Commission on Macroeconomics and Health 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%. Action for Global Health (2007) Health Warning
http://www.actionforglobalhealth.eu/content/download/6272/33180/file/AFGH_Report_UK.pdf Back
201
UNFPA Securing Essential Supplies: Fast Facts www.unfpa.org/supplies/facts.htm Back
202
UNFPA (2002) Reproductive Health Essentials Securing the Supply
Global Strategy for Reproductive Health Commodity Security, UNFPA
www.unfpa.org/upload/lib_pub_file/39_filename_securingsupply_eng.pdf Back
203
WHO (2006) Working together for health: the World Health Report
2006 www.who.int/whr/2006/whr06_en.pdf Back
204
Dmytraczenko, T, Rao, V and Ashford, L (2003) Health sector
reform: how it affects reproductive health, Population Reference
Bureau Policy Brief www.measurecommunication.org Back
205
Cabinet Office (2004) Code of Practice on Consultation http://www.cabinetoffice.gov.uk/regulation/documents/consultation/pdf/code.pdf Back
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