Written evidence from Marie Stopes International
1. INTRODUCTION
One of the largest international family planning
organisations in the world, Marie Stopes International (MSI) uses
multiple delivery channels to reach its clients, including static
clinics, community volunteers, work-based initiatives and refugee/IDP
camps. This approach to service delivery has enabled the organisation
to reach millions of underserved people and provide vital morbidity-
and mortality-preventing services. In 2010 MSI served 7 million
family planning clients.
As a sexual and reproductive health and rights specialist
agency, MSI's written evidence is made with respect to the linkages
between DFID's new Framework for Results for improving reproductive,
maternal and newborn health (RMNH) in the developing world, and
its work in fragile states and humanitarian settings. This submission
addresses two of the three key areas identified in the IDSC press
release pertaining to this inquiry:
— The
key development priorities DFID and other Government Departments
should be addressing in fragile and conflict-affected states;
— The
most effective mechanisms for delivering aid and the role of DFID's
focus on results in fragile and conflict affected states.
MSI congratulates DFID on the inclusion of RMNH among
its key development priorities in fragile and conflict-affected
states. In this submission, MSI presents evidence that working
with non-state providers to reach clients in fragile and conflict-affected
states can be one of the most effective mechanisms for delivering
RMNH services and achieving results in these circumstances. Evidence
is drawn from MSI's experience of working in fragile and conflict-affected
states, including through the RAISE Initiative. Furthermore, this
submission highlights mechanisms that can serve the key duel objectives
of meeting immediate needs and building state capacity. Suggestions
are given for mechanisms for delivering aid in fragile states
with negligible private sector and fragile states with a stronger
private sector, including the Basic Package of Health Services,
outreach, social franchising and voucher schemes.
We congratulate DFID on its decision to address health
in fragile and conflict-affected states. We also applaud its global
leadership on addressing unsafe abortion and reducing unmet need
for family planning. We commend DFID for its support of the Health
in Fragile States Network which has contributed to the growing
evidence base of the value of addressing health in CAF states,
both as a component of state-building and to address the Millennium
Development Goals (MDGs).[11]
1. Reproductive, Maternal and Newborn Health—a
key development priority in conflict-affected and fragile states
"Fragile state" is a term given to situations
in which, usually as a result of prolonged conflict, the government
cannot or will not provide the services or stewardship needed
to ensure equitable access to essential public services including
healthcare.[12]
Fragile states are home to one sixth of the world's population,
or one billion people, yet, they account for a third of maternal
deaths and half of the world's infant deaths. Addressing RMNH
in fragile states is essential in pursuing the Millennium Development
Goals. Progress towards MDG5 in fragile states is negative.[13]
1.1 Conflict and humanitarian crises complicate
access to RMNH, and RMNH 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 RMNH.
1.2 The 2008 Millennium Development Report, identified
the large and growing unmet need for family planning in sub-Saharan
Africa and associated high fertility rates in that region to be
undermining "related goals, such as reducing child mortality,
hunger and malnutrition, and increasing primary education enrolment".
1.3 Reproductive health related conditions remain
the lead cause of death and illness for women in developing countries.
From this high baseline, evidence from a variety of conflicts
show that maternal mortality ratios increase sharply in conflict
settings. The more heavily conflict affected eastern DRC, for
example, has a maternal mortality rate of 1174 per 100,000 live
births as opposed 811 in western DRC.[14]
Similarly, while the lifetime risk of dying in pregnancy or childbirth
in Sub-Saharan Africa is 1 in 31, in DRC this increases to 1 in
24 and in Sierra Leone to 1 in 21.[15]
1.4 High incidence of rape in conflict affected
settings—sometimes as a tactic of war—also point to
the heightened need for sexual and reproductive health services.
The UN Security Council Resolution 1888 (2009) affirms that "effective
steps to prevent and respond to acts of sexual violence can significantly
contribute to the maintenance of international peace and security",[16]
and demands the cessation of sexual violence with immediate effect,
yet there is no action plan or dedicated budget to either attempt
to mitigate gender based violence or to provide clinical services
for its survivors.
1.5 In many fragile and conflict-affected states
user fees, payable at the point of service delivery, may be a
barrier to services, particularly for the poor and underserved.
2. Funding for Reproductive Maternal and Newborn
Health in Conflict Affected and Fragile States
2.1 The World Bank recommends that international
assistance is sustained for a minimum of 15 years to support long-term
institutional transformations.[17]
However, volatility of aid flows is a major problem in fragile
states, with aid flows twice as volatile as those to other developing
countries.
2.2 A study to track disbursements of funding
for reproductive health in eighteen conflict-affected countries
found that funding for reproductive maternal and newborn health
makes up approximately two percent of ODA to conflict affected
countries included in the study, of which approximately 50% was
for HIV/AIDS activities and less than 2% was for family planning.[18]
2.3 An update of this study, which tracked official
development assistance as recorded in the Creditor Reporting System
and Financial Tracking System, found that DfID was the second
largest bilateral donor for RH in absolute USD terms—$59.29
million in 2009, which represents approximately 3% of DFID ODA
for that year.[19]
3. Mechanisms for Reproductive, Maternal and
Newborn Health Delivery
The main challenge in addressing health needs in
fragile states is to respond to immediate basic health needs while
ensuring long-term institution building for strengthening the
health system. A combination of weak health systems, lack of government
leadership and poor health indicators make it imperative to build
state capacity, while at the same time delivering core services.
Where state capacity is far from the level required
for universal access to essential services, contracting non-state
actors for service delivery represents an effective route for
meeting immediate health needs. We present the Basic Package of
Health Services, outreach, social franchising and voucher schemes
as delivery models.
3.1 Basic Package of Health Services
3.1.1 In many post-conflict states there are
large gaps in access to services. The Basic Package of Health
Services (BPHS), which comprises the key human resources, facilities
and equipment needed for the provision of basic health services
allows for the rapid scale up of services whilst strengthening
government capacity. By defining a strong role for government,
as has been the case in Afghanistan and Southern Sudan, in managing
the contracts with non-state providers, the system strengthens
state capacity to provide public services through non-state providers.
3.1.2 An extensive evaluation found that in weaker
health systems, districts that contracted out services to the
not state sector delivered care more efficiently and equitably
than those that remained under government control.[20]
3.1.3 The BPHS can use non-state sector expertise
to provide rapid expansion of health services, in contrast to
often delayed expansion of state health provision. It is an effective
method of delivering services in countries that have weak public
health systems and very few private sector health providers. The
work can be contracted out to non governmental organisations or
some services can be supported or provided by the state. For example,
the Afghanistan Ministry of Public Health is contracted to provide
BPHS through existing government mechanisms in 3 of the country's
34 provinces.
3.2 Outreach
3.2.1 Outreach has proved a very effective mechanism
for delivering family planning services in fragile states, particularly
in rural and remote areas. Distance to health facilities can be
a barrier to accessing services. By taking the service to the
client, rural populations are able to access health services which
would otherwise be too far for them to reach.
3.2.2. By working with the district health officials
and working in existing health facilities, the outreach services
are aligned with national government agenda and priorities.
3.2.3. The data presented in Figure 1 below,
show the increase in knowledge and use of family planning in five
districts in northern Uganda served by mobile outreach teams.[21]
Marie Stopes Uganda provided mobile outreach services at government
health centres, providing long term and permanent methods of family
planning. The differences in spontaneous knowledge and ever use
of family planning are statistically significant difference between
baseline (in 2007) and endline (in 2010).
Figure 1
KEY INDICATORS FOR FAMILY PLANNING KNOWLEDGE
AND USE IN FIVE DISTRICTS IN NORTHERN UGANDA
3.3 Social Franchising
3.3.1 In many fragile and conflict- affected
states such as Sierra Leone a diverse array of small, independent
health care providers operating within the private sector offer
services where state capacity is unable to meet local requirements
alone. In such settings, programmes that harness these private
providers to deliver key services at a requisite quality level
and at an affordable fee to low-income users have been demonstrated
to rapidly improve access to RMNH services.
3.3.2 In DRC, Population Services International
affiliate organisation Association de Santé Familiale (ASF)
has developed a social franchise called Reseau Confiance
which delivers a variety of family planning services. The network,
which aims to reach women in the lowest wealth quintile, covers
10 of the 11 provinces in the DRC and is further expanding. Despite
challenges in meeting the demand and a low retention rate of clinicians
and pharmacists that affects the system as a whole, the franchise
has succeeded in providing over 1.4 million clients with family
planning services from 2009-10 (inclusive). Other successes include
the establishment of a hotline and the training of clinical staff
in the insertion and removal of implants.
3.4 Voucher Schemes
3.4.1 As mentioned above, user fees may be a
barrier to the utilisation of health services. Subsidising services,
either through support to providers (supply side) or patients
(demand side) can be an effective alternative to user fees.
3.4.2 Voucher schemes enable governments and
private providers to work together to provide, regulate and monitor
services which are free at the point of delivery. In Uganda, for
example, MSI worked as a management agency with donors including
KfW, the Government of Uganda and the World Bank to ensure that
vouchers for STI and maternal health services were provided to
women at a significantly reduced fixed cost. Established voucher
schemes are providing good results, such as that in Kenya which
ensured that 60,000 babies were safely delivered and 12,000 long
acting family planning services were provided between June 2006
and October 2008
BlueStar Sierra Leone
The Marie Stopes BlueStar Healthcare Network in Sierra
Leone has been able to reach young, marginalised and poor men
and women through a combination of social franchise mechanisms
and a voucher scheme. Through networks of independent providers
such as the ones described above, MSI is able to ensure that good
quality services can be made available at a very low price to
targeted groups in the community through the use of vouchers.
To date, this approach of utilising non-state providers
has generally been perceived as a "stop gap measure"
required only until a comprehensive, nationwide network of government-run
health outlets has been developed. Given how far many fragile
and conflict-affected states are from providing universal access
to health care through government-run outlets, we urge DFID to
recognise the role of non-state providers in meeting long-term
health needs.
According to a recent World Bank report on conflict,
security and development, reducing the risk of continuing cycles
of violence requires a willingness to try new ways of doing business
in humanitarian, development, security and mediation assistance
in order to help build national legitimacy. Countries that have
experienced fragility, it reports, have often succeeded in early
confidence building measures through a pragmatic blending of policy
tools and by calling on non-state capacity, both civic and international.[22]
The report maintains that the private sector is crucial for long
term development in countries coping with violence. "Outreach
to the private sector can help build a sense of the long term,
which is critical for planning, investment in the future, and
sustainable growth".[23]
4. Capacity Building
4.1 Capacity building of state and non state
providers is essential to enable and expand the provider base
for health service delivery.
4.2 Working through existing mechanisms such
as the country Health Cluster as well as with individual government
ministries and professional bodies will enable gaps and training
needs to be identified and addressed.
4.3 Training of service providers in clinical
skills is an essential gap which needs to be addressed.
4.4 Training of relevant government officials
as well as direct service providers is effective in ensuring support
at the administrative level for newly skilled providers.
CARE INCREASES UPTAKE
OF FAMILY
PLANNING DRC
Working with community mobilisers, local organisations
the government at district, provincial and national levels, CARE
was able to improve access to reproductive health services in
Maniema health zone, Kasongo. Through training of health workers
in short and long term methods of family planning combined with
a multi-pronged behaviour change communication strategy, ever
use of contraception significantly increased.
Figure 2
KEY INDICATORS FOR FAMILY PLANNING KNOWLEDGE
AND USE IN MANIEMA HEALTH ZONE, DRC
RECOMMENDATIONS
Recommendation 1: Continue
to show leadership in RMNH, including addressing unsafe abortion.
Recommendation 2: Strengthen
mechanisms such as the BPHS, outreach, social franchising and
voucher schemes which are effective vehicles for delivering health
services.
Recommendation 3: Increase
leadership in exploring how governments in fragile states, through
forming partnerships and contracts with non-state providers, can
develop state capacity and guarantee the provision of public services.
Recommendation 4: Support
country level health cluster to develop and implement policies
which will increase access to health services. All relevant actors,
including WHO, UNICEF, WFP and UNFPA, international NGOs and national
governments need to take responsibility for the implementation
of RH services in fragile and conflict-affected states
Recommendation 5: Assess
local capacities and identify how best to build upon and use these
capacities to ensure a long-term, sustainable strategy for health
service delivery and health system rebuilding. A systematic approach
to local capacity building should include SRH clinical training
and supervision, organisational strengthening, and network building.
Recommendation 6: Continue
to show commitment to addressing health in conflict affected and
fragile states, with long term funding. And to ensure that RMNH
services are available to vulnerable populations, such as internally
displaced the urban poor and those living in remote and rural
areas.
May 2011
11 Health System Reconstruction: Can it Contribute
to State Building? Health in Fragile States Network. October 2008.
http://www.healthandfragilestates.org/index2.php?option=com_docman&task=doc_view&gid=32&Itemid=38
(Accessed 11 May 2011) Back
12
High Level Forum on the Health MDGs: An overview note, Paris 14-15
November 2005, p.1 (http://www.hlfhealthmdgs.org/Documents/HealthFragileStates.pdf) Back
13
Wold Bank global monitoring Report 2009 p 17. http://siteresources.worldbank.org/INTGLOMONREP2009/Resources/5924349-1239742507025/GMR09_book.pdf
(accessed 11 May 2011) Back
14
Coghlan, B. et al (2006). "Mortality in the Democratic Republic
of Congo: A nation wide survey" in The Lancet 367 (9504):44-5
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)67923-3/fulltext Back
15
Trends in Maternal Mortality: 1990-2008, WHO 2010. http://whqlibdoc.who.int/publications/2010/9789241500265_eng.pdf
(Accessed 11 May 2011) Back
16
United Nations Security Council, Resolution 1888 (2009) September
2009, pp 3 Back
17
World Development Report 2011: Conflict, Security, and Development,
The World Bank, pp 194 Back
18
Patel P., Roberts B., Guy S., Lee-Jones L., Conteh L., 2009. Tracking
Official Development Assistance for Reproductive Health in Conflict-Affected
Countries. PLoS Medicine, 6(6): e1000090 doi:10.1371/journal.pmed.1000090
Back
19
Internal Report Tracking Official Development Assistance for RH
in Conflict Affected Countries 2003-09. Methodology described
in: Patel P, Roberts B, Conteh L, Guy S, Lee-Jones L. A review
of global mechanisms for tracking official development assistance
for health in countries affected by armed conflict. Health
Policy, Volume 100, Issues 2-3, May 2011, pp. 116-124 Back
20
Bhushan I et al (2002) in Palmer N, Strong L, Wali A and Sondorp
E, Contracting out health services in fragile states, British
Medical Journal 2006;332;pp.718-721 Back
21
Summary Report of The RAISE Initiative Evaluation in Northern
Uganda. Marie Stopes Uganda, December 2010 Back
22
World Development Report 2011: Conflict, Security, and Development,
The World Bank, pp 118 Back
23
World Development Report 2011: Conflict, Security, and Development,
The World Bank, pp 122 Back
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