Memorandum submitted by YozuMannion Limited
How can donors "and DFID specifically"
catalyse progress towards MDG 5?
1. It is now clear that MDG 5 will not be
met in most low income countries and especially those in Sub-Saharan
Africa. This was mentioned in the speech by Douglas Alexander
at the launch of DFID's new International Health Partnership on
5 September 2007. More worryingly is the lack of any real evidence
of progress in many countries where the maternal mortality rate
is highest, this being an indication of the need for rethinking
global and country strategies. In some the deterioration of the
situation is further cause for concern and this is particularly
pertinent in several countries that are emerging from conflict
or classified as fragile states.
2. The policy environment among donors and
UN agencies is an area where much work has been done. DFID has
led the way and is one of the few donors with a defined strategy
and one that actively works to encourage others to do the same.
However the translation of this policy and strategy into implementation
is the area where a new catalyst is required. Getting the aid
management right is of course important but often the result is
good policy and donor/government collaboration but continuing
poor services and low utilisation rates in particular amongst
the poor and rural communities.
3. The increasing tendency over the last
decade is to view maternal health as a medical issue and focus
more or less exclusively on medical solutions or interventions
such as EOC, malaria prophylaxis and post abortion care. This
is often prioritised in donor and UN strategy documents in the
sections that focus on solutions and intentions. Where progress
has been made and sustained for some time, such as Nepal and Bangladesh,
the strategies have been more comprehensive and multidimensional,
going beyond medical interventions (although including them as
they should) to include girls' education, work on increasing the
age of marriage and first pregnancy, family planning and abortion
services and efforts to reach out to young people. These multidimensional
approaches are necessary and must replace the growing tendency
to view pregnancy as an illness. Recent challenges that potentially
prove counter-productive to maternal and reproductive health global
programming include: low priority given to birth spacing and contraceptive
commodities by US funded agencies as guided by the US Congress;
inadequate funding for reproductive health and gender based violence
in conflict and post-conflict countries; and, lack of sustained
support for a public—private sector health service delivery
that will ensure appropriate cross referral systems and quality
emergency obstetric care.
4. DFID and other donors need to invest
in implementation in a way that effects change. This requires
more focused and resourced action than is currently the case.
The last DFID Maternal Health report (2005-06) shows only £16m
of direct funding. This is insufficient particularly given the
lack of investments by others. The champion role played by DFID
at policy and aid architecture levels needs to be moved to effect
implementation. The arguments that resourcing is in reality much
higher due to sector and increasingly budget support mechanisms
is unconvincing in terms of translating into better maternal health
outcomes.
5. Most importantly tackling maternal health
issues needs to be done with a focus on young people. It is an
agenda that cuts across many issues in society and should not
be centred in the medical domain. It is about empowerment of young
women and girls, female literacy, male involvement, sexuality
education and youth services. Most maternal deaths are among the
poorest in the poorest countries but searching for a reference
to either youth or maternal health in existing Poverty Reduction
Strategy Papers and Policies is an unrewarding task.
How effectively is DFID working with recipient
countries to make emergency obstetric care available and ensuring
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?
6. The move to budget support in many key
countries where DFID has traditionally funded considerable health
programmes, including ones focusing on maternal and reproductive
health such as Nepal and Malawi, means that direct influence at
the sector level is diminished. The agencies and partnerships
that are supported to take up the issues at sector level are not
proving effective enough to influence government budgetary allocations
and/or the provision of adequate resources. DFID's approach has
moved towards getting the aid management processes "right"
rather than engaging in more "down-stream" technical
implementation issues. A major constraint across the health sector
in many countries but particularly in sub-Saharan Africa is the
chronic lack of skilled health professionals. This is known, recognised
and yet action remains limited due to reluctance to directly engage
in issues that involve substantial recurrent costs. As is frequently
argued this should indeed be an issue for national budget allocations
but where this remains stubbornly low, often around the 3% level,
then resources for personnel including skilled birth attendants
will remain inadequate.
7. Establishing a stronger link to governance
issues is critical. Progress on maternal health issues is, as
for other things, linked to political will. This is clear in countries
where progress has been made such as Vietnam, Honduras, Egypt
and Sri Lanka. DFID can take a more proactive role in health and
maternal health in particular within the EU following the "Division
of Labour" discussions.
8. DFID has been a leading donor in this
field but has also been referring back to the success of the Nepal
Safe Motherhood Programme for a number of years. Despite the programme's
success in working closely with the Government in a programmatic
approach, this model has not been replicated. Lessons from the
unsustainable Safe Motherhood model implemented by DFID in Malawi
have been drawn but have not been widely published for others
to learn from. DFID appears to be reluctant to fund more implementation
programmes which involve working closely with Government—as
demonstrated in Nepal— while also designed to focus on implementation
that accelerates change in service provision and utilisation.
DFID provides large amounts of funds to UN organisations but these
are not implementation agencies by their nature.
What steps is DFID taking to mainstream maternal
health across related policies?
9. There is some discussion on integrated
approaches but this is slow and limited. The heady days of the
Cairo Consensus are now all but over. The disease-specific focus
of political debate has led to most donors prioritising Malaria,
TB and HIV/AIDS through such mechanisms as the Global Fund, Roll
Back Malaria and Stop TB. Only in the last year or so has more
attention been placed on the need for building health systems
and ensuring integrated approaches and some would argue that this
is a result of the lack of progress in rolling out the disease
by disease approach. Little funding now is given to family planning
which provides simple and effective means for spacing deliveries,
delaying age of first birth and other important factors linked
to improving health of mothers and their children. However flawed
at the point of delivery, UK domestic policy expects services
to be planned and work in a joined up way "joined up thinking
for joined up government". This does not seem to be pursued
with such rigour in UK overseas policy. So as DFID and many others
push for budget support on the one hand and disease specific interventions
on the other, progress on issues central to MDG5 are inadequately
addressed as they need a more holistic approach.
How is achieving MDG 5 being prioritised and integrated
into countries' overall healthcare provision?
10. Maternal deaths are relatively rare
occurrences and still not given high priority by most governments.
Unless the political interest and will is present the General
Budget Support approach will have little impact on the Maternal
Mortality MDG in the vast majority of the poorer nations where
maternal mortality and morbidity are highest. More work is needed
to develop the debate on issues such as how maternal health links
to the burden of disease, the importance of healthy women to the
economics of the household and the health of young children. This
is not new but clearly the current messages and arguments do not
have an impact on Ministries of Finance and other key government
departments that control budgets.
What progress is being made in reducing maternal
deaths from unsafe abortion (which account for 13% of all maternal
deaths)?
11. DFID is supporting safe abortion through
the "global safe abortion fund" being implemented by
IPPF. This is an important step and DFID should be applauded for
this step, particularly in the face of political opposition to
safe abortion by some donors. In addition, DFID in Cambodia is
funding a safe abortion programme; again this is likely to have
an important impact on provision of safe abortion in that country.
DFID is supporting UNFPA and should now apply more influence to
direct their thinking in relation to the abortion agenda; UNFPA
should be campaigning for the rights of women to access safe abortion.
How effectively is family planning being promoted
as a way to improve maternal health?
12. Family Planning funding is not sufficient
and has been an area of neglect now for many years. UNFPA and
many non-governmental groups have been highlighting this actively.
There are avoidable contraceptive shortfalls in many countries
that would greatly support the position of women wanting to have
more control over when and how many children to have. The international
organisation around this issue is advancing but progress is slow
in establishing an effective and well resourced global response.
And yet the recent G8 Parliamentarian's forum on HIV/AIDS in Berlin
(May 2007) highlighted the frustration of parliamentarians, service
providers, advocates and others at the lack of attention being
given to integrated approaches, including family planning. The
increased resources for the treatment and care of people with
HIV and AIDS are far out stripping that for prevention activities.
This lack of funding for sexual and reproductive health with a
youth focus is short sighted and will be counter productive not
least as the numbers of people with HIV and AIDS will continue
to rise.
How effectively is DFID working with bilateral
and multilateral donors, NGOs and other stakeholders to promote
maternal health?
13. As it is for so many sectors, DFID is
a key participant and leader in the international debate on maternal
health. However, it is widely recognised the MDG 5 is off target.
The new International Health Partnership announced last week does
not address this adequately or urgently enough. DFID should lead
the thinking and direct resources towards more integrated and
focused responses with a youth focused programme supported by
several funders; at the same time acknowledging the need to allocate
funding where the policy and budgetary framework within a country
is inadequate.
14. DFID should try to influence the EU
to improve their RH theme funding provision. The EU decision to
include RH funding into its Investing in People theme, but then
channelling 75% of the funding through the Global Fund in effect
reduces the amount of funding to RH and focused it on the disease
specific agenda.
What leadership is the UN providing and how well
co-ordinated are its agencies?
15. DFID should be encouraging UNFPA to
take a more focused and energised leadership role on youth centred
programmes that have the potential to impact on maternal health.
They should be strengthened to re-establish strong family planning
and maternal services programmes.
16. The UN organisations are too caught
up in their internal politics and interagency issues that they
are not focussing on achieving their goals, but rather are diverted
by trying to promote their agencies interests. UNFPA, UNICEF and
WHO should be supported to define more clearly their respective
roles and responsibilities with regard to maternal health and
joint working arrangements. DFID should also offer more TA to
improve their institutional effectiveness and continue to push
the process of reform that requires a more results- based approach.
17. With the growing trend towards global
health partnerships and collaborations, including the larger initiatives
such as the Global Fund for HIV/AIDS, TB & Malaria, GAVI,
IAVI and many more, bilateral governments need to monitor the
balance between their direct budget support and their contributions
to such global programs. Currently, the majority of global health
funds are deployed vertically with limited opportunity to capitalise
on integrated efforts to ensure that basic health services are
delivered. DFID's role as a major donor to these large funds and
many other global health programs can be further strengthened
through collaborative monitoring of development efforts. Joint
assessment and evaluation teams will enable increased impact on
key indicators such as MDG 5. Attention through the new International
Health Partnership, the existing Paris Declaration and other harmonisation
efforts should be given to streamlining the recent proliferation
of global health partnerships and initiatives to reduce overlap
and unnecessary expenditure on maintaining all the respective
Boards and management structures. UN agencies should be playing
an active role in country co-ordination mechanisms, engagement
in introduction of the Sector Wide approaches in post-conflict
countries and humanitarian co-ordination efforts including the
Common Humanitarian Fund (CHF) to ensure effective and efficient
deployment of complementary direct and indirect funding support
for service delivery.
Has the international community improved maternal
health in crisis and conflict settings?
18. The record is not impressive. The crisis
and conflict zones are places where women are suffering greatly
from violence and other abuse with the lack of access to services
being the norm. The international community needs to do more to
tackle issues around legislation and action. Providing the legislative
environments and making these widely known and acted upon is a
priority. Establishing effective forms of accountability is a
prerequisite to creating the security needed for action on improving
the health and well-being of women in crisis areas. As so clearly
seen in Darfur the international community is failing badly in
many instances as it is unable to provide either security or access
to services. As countries emerge from conflict the UK and others
should redouble efforts to start well co-ordinated programmes
that bring services to those in need as soon as possible.
19. Southern Sudan is an example of a post-conflict
country that has an MMR of 2037/100,000 (Sudan Household Health
Survey 2006). With an ANC rate of 14% and an escalating incidence
of unsafe abortion and miscarriages due to wife beating in pregnancy,
this picture provides a snapshot of the absolute morbidity that
women face in war affected communities. DFID is engaged in supporting
health system strengthening through a pooled funding mechanism
managed by the World Bank, with an investment of $225 million
over three years to facilitate the transitional development phase
of the Southern Sudan health sector. The transition efforts have
being challenged by the lack of any clear exit strategies for
humanitarian donors and service delivery agencies, leaving a serious
vacuum in health service support at all levels of the health system.
This is one of many countries where DFID can play a key role through
mobilising adequate technical advisory services to facilitate
capacity building of government health service managers, in order
to deliver a decentralised health system.
20. Another example worth highlighting is
that of the Democratic Republic of the Congo which has received
limited funding for Gender Based Violence programs in the past
five years despite many studies demonstrating the growing levels
of gender based violence across Eastern DRC. DFID increased its
budget support for health systems strengthening but due to inaccessibility
and lack of community based initiatives these services are not
reaching the women who are most at risk of maternal and reproductive
morbidities.
14 September 2007
Supplementary memorandum submitted by the
Department for International Development
Breakdown of DFID contributions to the Partnership
for Maternal, Newborn and Child Health
£240,000 from May 2005 to December 2006
as an initial contribution.
£10,000 specialist management consultancy
support in August 2005, in response to a specific request for
governance support.
£1,000,000 towards the current Partnership workplan
and cost of advocacy around the landmark "Women Deliver"
Conference.
Total £1,250,000.
Further specialist management consultancy support
under consideration. Future support by DFID also under consideration.
DFID actual and projected spending on maternal
health (directly targeted initiatives)
£16.2 million 2004-05
£18.7 million 2005-06
£21.9 million 2006-07
£53-54 million** 2007-08 (extrapolated
figure based on planned future expenditure as new maternal health
projects start spending)
(**Note: the £100 million announced for
commodity supply would NOT be included under this figure as the
programme would be coded as commodity supply).
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