Written evidence submitted by Save the
Children UK
INTRODUCTION
Save the Children UK is the world's independent
children's charity. We are outraged that millions of children
are still denied proper healthcare, food, education and protection.
We are working flat out to get every child their rights and we're
determined to make further, faster changes.
Save the Children UK established a small programme
in Nigeria in 2001. The early focus was on getting children actively
involved in shaping the decisions that affect their lives in Kaduna
State. Today, Save the Children has started work in seven States,
all in northern Nigeria, focusing on providing basic health care
and protecting children from abuse and exploitation. This document
is intended to address a few specific issues which form the basis
of the inquiry. It is not intended to be comprehensive of all
the issues discussed, or to be exhaustive of the developmental
and governance challenges facing Nigeria. It is simply intended
to provide a few suggestions on maximising the impact of DFID's
work in Nigeria, and concentrates on challenges related to four
themes:
— Rural poverty and rural livelihoods.
— Voice and accountability.
GOVERNANCE, INCLUDING
REGIONAL AND
LOCAL GOVERNANCE
1. DFID's strategy in Nigeria recognises
that a complex series of governance challenges constrain developmental
outcomes. DFID's identification of the three critical structural
barriers to change in the Drivers of Change Analysis (lack of
accountability, absence of non-oil sector growth, and poor public
resource management) is grounded in sound conceptual analysis
and reflects a solid understanding of the country's political
economy, power relations, and drivers of change. However, the
challenge of how to best operationalise results remains.
2. Save the Children welcomes DFID's new efforts
in prioritising and channelling their efforts through focusing
on governance in weaker and fragile states and acknowledges the
importance of engaging local authorities in delivery service to
allow states to derive legitimacy.
BASIC SERVICE
DELIVERY
3. Primary health care services in Nigeria
are in a state of collapse. An improved supply-side response is
a pre-condition for increasing utilization. DFID is playing a
leading role in shaping the way health resources are used and
allocated, issues of staffing and management, and service quality.
While this approach has much to commend it, the real test of the
investment is what it means for the poor, particularly at the
community level. DFID has the capacity and the opportunity to
support health policies and the development of service delivery
models aimed at the household and community level, not simply
those aimed at improving health facilities.
4. The cost of health services is an important
constraint for the poor and explains much of the inequality in
utilization in Nigeria. There are staggering differences in health
outcomes according to wealth quintiles. The percentage of pregnant
women in the poorest quintile that are receiving antenatal care
is less than 30%, while it is 75% for the richest quintile. Children
and infants among the poorest 20% of the population are three
times more likely to die than those among the richest 20%.[11]
Therefore, a major barrier to health care access is its affordability.
Out-of-pocket payments for health services can be a decisive factor
in pushing households below the poverty line. Out-of-pocket payment
is recognized as the most regressive form of health financing,
and a very significant barrier to the utilisation of even basic
health services, in particular by the poorest.[12]
5. The Nigeria health system is characterised
by severe managerial weaknesses, and the uneven performance of
its supply chain is one of the most prominent flaws. In order
to improve drug availability, many states have set up revolving
drug funds (RDFs), in which, after an initial capital investment,
pharmaceutical products are replenished with resources generated
through the sale of drugs to patients. DFID has also supported
the establishment and running of RDFs in Nigeria. International
experience has shown that revolving drug funds do not provide
sustainable solutions, and that linked exemption schemes targeted
at the poor are administratively intensive and difficult to bring
to scale.[13]
While RDFs can improve availability and affordability of drugs
in best-case scenarios. They cannot adequately ensure equitable
access in areas with high levels of absolute poverty.
6. Save the Children UK acknowledges that
DFID, in many ways, can be seen as a model donor in relation to
pro-poor health financing[14]
and an important influencer of national governments as well as
bi- and multilateral institutions. Improving poor people's access
to healthcare, and by extension the health of mothers and their
children, will require greater attention to sustainable and pro-poor
health financing. Revolving drug funds could further increase
barriers to healthcare access by the poor and thus be in contradiction
with its overall drive to improve health equity.
7. The quality of basic education is insufficient
to respond to the demands of children, their parents, and the
labour market. Together with the World Bank, DFID is playing a
leading role in improving the quality and provisioning of educational
services in northern Nigeria, included the improvement of community
involvement in educational facilities. This is a pre-requisite
for sustaining increased demand for educational services.
8. The cost of education among households
with school-going children represents about 12% of total household
expenditure. For poor households with students the burden is even
higher, representing close to 16% of total expenditure.[15]
The majority of children that do not have financial access to
primary school are concentrated in rural areas of the North. The
opportunity cost of sending children, particularly girl children,
to school is also an important barrier to access. Reducing cost
barriers to education will be critical for reducing gender disparities
and achieving the Millennium Development Goals.
9. DFID's Social Protection Policy Framework
has suggested demand side support to poor and vulnerable households
as a means of breaking the constraint of utilizing health and
education services. DFID should use this opportunity to leverage
its global expertise and facilitate greater attention to the role
social protection measures can play in increasing demand for goods
and services on the part of the poor.
THE ROLE
OF CIVIL
SOCIETY AND
THE ROLE
OF DFID'S
SUPPORT FOR
DEVELOPMENT OF
VOICE AND
ACCOUNTABILITY
10. DFID clearly recognizes the voice and
accountability elements to governance, but has tended to under-emphasize
them in practice. Non-governmental actors have played limited
roles in basic services and governance programmes in several priority
states of DFID investment, particularly in the North. The new
suite of state and local government programmes will begin to re-dress
this under-investment, but care needs to be taken not to over-rely
on a limited number of large "issue based" advocacy
projects. Adequate skills building, supporting internal and external
accountability, and the overall organizational strength of non-governmental
actors will require a coherent shared approach among service providers
at State and LGA levels. In the Nigerian context, where the lack
of external accountability is one of the three critical constraints
to reaching the MDGs, DFID is encouraged to demonstrate the same
long-term commitment to building the influence and capacity of
non-governmental actors as it does to state and local governments.
RURAL POVERTY
AND LIVELIHOODS
11. Children in very poor households display
very high levels of education deprivation, in terms of school
attendance, completion and literacy and numeracy rates, as well
as very poor health status. The education and health status of
these children is highly associated with the ability of household
members to raise income. Child sensitive development depends not
just on higher growth but on how the growth is created, ensuring
that the poorest groups benefit to a greater extent. The incidence
and depth of poverty is greater in rural areas, and poverty is
disproportionately concentrated among households whose primary
livelihood is agriculture. Agricultural households have the highest
poverty head count and the highest poverty gap. The agricultural
population in the northern regions is much poorer than the agricultural
population in the southern regions. Income inequality is also
higher within the north of the country than within the south.[16]
12. Insufficient livelihoods account for why
children are not in school, are not taken to a health centre when
they are sick or are forced to work to contribute to household
income or family obligations. Non-oil economic growth will be
achieved through improving the investment environment, and DFID
has made progress in this area. The extent to which future growth
will be pro-poor will depend on whether the livelihood constraints
for the poor are directly addressed. An improved understanding
of labour markets, migration patterns, and diverse livelihood
strategies needs to contribute to improved policymaking and economic
investments. Measures may also need to be tailored to marginal
areas, such as Jigawa, where poverty incidence is highest and
the social indicators are exceptionally poor. The envisioned investment
in social differentiation and exclusion analysis, if linked to
building a knowledge base on the livelihood strategies of the
poor, has the potential to support greater programme impact.
POLICY COHERENCE
AND UK GOVERNMENT'S
APPROACH
13. The size of the aid portfolio is significantly
increasing. Sufficient managerial resources will be required to
oversee and coordinate such a complex and diverse portfolio. Achieving
synergies across sectoral programmes and ensuring direct DFID
engagement at State levels may require greater investment in managerial
capacity, including staffing. Programmes are generating useful
information and lessons learned, but dissemination and adoption
beyond immediate programme partners will require enhanced attention
to knowledge management.
14. In Nigeria, technical assistance driven programmes
reflect the fact that financial resources are not always the most
critical constraint in improving government performance. Assessing
the relative efficiency of how technical assistance is deployed,(including
the comparative appropriateness of long and short term technical
assistance inputs), will be important for ensuring the best value
for money in technical assistance contracting mechanisms.
May 2009
11 Nigeria Bureau of Statistics and the World Bank
(2007). National Poverty Assessment (draft). Back
12
James C D, Hanson K, McPake B, Balabanova D, Gwatkin D, Hopwood
I, Kirunga C, Knippenberg R, Meessen B, Morris S S, Preker A,
Souteyrand Y, Tibouti A, Villeneuve P, Xu K. (2006) To retain
or remove user fees?: reflections on the current debate in low-
and middle-income countries Appl Health Econ Health Policy; 5(3):137-53. Back
13
Cross P N, Huff M A, Quick J D, Bates J A (1986). Revolving Drug
funds: Conducting Business in the Public Sector. Social Science
and Medicine. 22(3):335-43. Back
14
DFID (2007). Working Together for Better Health. Back
15
Nigeria Bureau of Statistics and World Bank (2007). National
Poverty Assessment (draft). Back
16
National Poverty Assessment 2007. Back
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