Written evidence from Merlin
1. Merlin is pleased to submit this response
to the International Development Select Committee's inquiry on
working effectively in fragile states.
2. Merlin is the only UK specialist agency, which
responds worldwide with vital healthcare and medical relief for
vulnerable people caught up in natural disasters, conflict and
disease and health system collapse. Merlin's aim is to ensure
that vulnerable people who are excluded from exercising their
right to health have equitable access to appropriate and effective
healthcare.
3. Key Points highlighted by this submission:
— I. Merlin
welcomes the prioritisation of health and humanitarian need in
addition to other critical areas in DRC as set out in the recent
Bilateral Aid Review (DFID, 2011). We look forward to the forthcoming
DRC country strategy—translating those commitments into
action.
— II. There
is no single "one size fits all" mechanism to deliver
aid in fragile states. Aid mechanisms should seek to deliver:
longer term predictable aid, be flexible enough to adequately
support the relief to recovery transition, have strong administrative
structures, be able to ensure financial probity and be based on
accurate assessed need.
— III. Investment
in and support to national institutions to deliver services is
critical. For the health system this means meeting essential health
needs and supporting the capacity of the state to deliver on its
responsibilities. A strong effective health system is critical
to a country's resilience.
— IV. Merlin
welcomes DFID's focus on governance and security; strengthening
security in DRC is an essential element to improving health outcomes
in the longer term, particularly in eastern provinces.
— V. Merlin
is developing guidance for health NGOs on engagement in fragile
states.
KEY DEVELOPMENT
PRIORITIES IN
CONFLICT AND
FRAGILE STATES
4. Merlin welcomes and strongly supports DFID's
commitment to the Democratic Republic of Congo as set out in the
department's Bilateral Aid Review (DFID, 2011). In that review,
DFID announced six priority areas for engagement in DRC: Health;
water and sanitation; humanitarian needs; governance and security;
poverty, hunger and vulnerability; wealth creation; and, education.
From Merlin's perspective the coalition government's prioritisation
of fragile states is critical to progress against and achievement
of the health-related MDGs. The reality is that, despite significant
and sustained global political and financial investment in health
generally over the past decade, in countries like DRC health indicators
are worsening.
5. Merlin has worked in DRC since 1997 and during
that time has witnessed successive humanitarian crises in the
conflict-affected eastern provinces and despite pockets of improved
access to health care and an improvement in the indicator for
maternal health, there has been a decline in the overall national
health situation for the Congolese people. In 1997 the mortality
rate for under-five year-olds was 185 (per 1,000 live births);
by 2010 this had increased to 199. Average life expectancy has
fallen over the same period from 52.2 years to 48 and DRC has
slipped down the Human Development Index from 142 to 168 (out
of 169 countries).
THE MOST
EFFECTIVE MECHANISMS
FOR DELIVERING
AID
6. Merlin supports the Humanitarian Emergency
Response Review's (Ashdown, 2011) finding that from a funding
perspective, the humanitarian system is not serving the needs
of affected people as well as it might. Merlin's experience is
that there is no "one size fits all" funding mechanism
that meets the needs of all conflict affected and fragile states,
but factors that contribute to an appropriate funding environment:
(a) Funding
that supports a longer-term vision and is predictable
— (i) In
conflict affected or fragile states where chronic crises occur
over years, or even decades, six and 12 month humanitarian
funding cycles are frequently inadequate. Health outcomes will
not be improved through short term intervention alone; there is
need for longer term planning and investment.
— (ii) In
Maniema Province, DRC DFID has provided humanitarian funding to
Merlin to support Kindu Hospital since 2002. However, until 2009
this project was funded through successive 12 month tranches requiring
a viable exit strategy. In Kindu this means that a valuable period
each year has been spent planning for a potential withdrawal of
healthcare provision and leading to interruptions to normal activities
such as staff training and the rehabilitation of the maternity
and surgical wards (Merlin, 2007). Predictable and timely disbursements
would mitigate disruptions such as these and longer-term planning
would offer better value for money for donors than short term
successive projects.
(b) Funding that is flexible, needs based
and adequately supports the transition from relief to recovery
— (i) In
DRC Merlin's programmes cover a range of geographical areas with
very different levels of development status. Maniema province
for example has shown greater levels of stability than North Kivu
in the east allowing a shift to development programming which
is crucial for supporting lasting peace. North Kivu in contrast
remains highly unstable with continuing humanitarian needs of
Internally Displaced Populations (IDPs).
(c) Effective administration and financial
probity are critical
— (i) DFID
currently disburses humanitarian aid to DRC through the pooled
fund (PF) mechanism (the Common Humanitarian Fund). The PF applies
to projects included under the Humanitarian Action Plan (HAP)
which outlines the annual strategic and operational plan for the
UN and partners' humanitarian assistance in the DRC. However successive
administrative challenges, poor working financial practices and
delays in clearing funds has led Merlin to reluctantly withdraw
from the process and we no longer apply for money from the PF
in Maniema province. If the PF is to be an effective mechanism
in DRC it is essential that its performance and internal processes
are effectively and systematically monitored and reviewed.
DFID'S
EFFORTS TO
STRENGTHEN GOVERNANCE
AND NATIONAL
INSTITUTIONS TO
DELIVER SERVICES
7. The recent HERR highlighted the importance
of strengthening resilience at country level—so that countries
can better prepare for, cope with and respond to humanitarian
emergencies. Merlin believes that a strong effective health system
is critical to a country's resilience. In conflict affected and
fragile states, building-in resilience requires action by DFID
in three key areas:
(a) Support to strengthen the stewardship
and management functions of the health systems
— (i) Long
term sustainable delivery of health care requires that the state
is able to take responsibility for the performance of the health
system. In DRC although the Ministry of Health is responsible,
in principle, for policy stewardship of the health system, in
practice in some Provinces enforcement is poor and the Ministry
lacks autonomy and capacity to decide, orient and direct health
policy. Merlin is currently working with the Ministry of health
to support its national health financing strategy process. In
April Merlin supported the MoH to host a workshop to take forward
the results of its February stakeholder's meeting; helping to
clarify the "road-map" process and assign roles for
different stakeholders.
(b) Support to national health planning, particularly
in human resources for health
— (i) A
comprehensive health plan, encompassing human resources planning,
is a fundamental feature of an equitable health system and critical
to its resilience in all countries. Merlin's Hands Up for Health
Workers campaign is advocating for national health workforce plans
in fragile states and would urge DFID to take action to support
workforce plans at national level.
(c) Support to communities to build resilience
in health
— (i) Community
level health structures play a critical role in supporting the
delivery of health care, particularly during times of crisis.
8. Merlin welcomes DFID's support to governance
and security (DFID's support to the certification process for
mining goods is essential to this). Across the Kivu provinces
in the east, insecurity and violence remains a constant for large
sections of the public, particularly women, and this insecurity
continues both to create humanitarian needs and negatively impact
on humanitarian access. Over 1.7 million internally displaced
people remain unable to return home and getting assistance to
the most vulnerable IDPs and those communities that host them
is becoming ever more challenging. In 2010, UN OCHA documented
202 attacks in DRC against humanitarian worker a 10% increase
from 2009 (ONGI, 2011).
9. Merlin is calling for the protection of health
and humanitarian workers in conflict situations. Although health
workers are legally protected under International Humanitarian
Law, increasingly they are targeted by warring factions with little
or no legal redress. At this year's World Health Assembly Merlin
will be calling for support for health workers and urging DFID
to lobby other WHO members to strengthen international compliance
with Geneva Conventions to protect health and humanitarian workers
in situations of conflict. A report carried out by Merlin looking
at the impact of insecurity on health workers across 13 countries
affected by conflict in the last 5 years found that almost
all those interviewed said that personal security was constantly
in their thoughts. 85% said that they felt insecurity "significantly
impacted" on their ability to do their work (Newport, 2010).
In 2008, 260 humanitarian aid workers were killed, injured,
or seriously injured in violent attacks (HPG, 2009) - but even
this figure doesn't reflect the full extent of the issue as many
incidents against health workers are simply unrecorded.
WORKING EFFECTIVELY
IN DIFFICULT
ENVIRONMENTS: DFID STAFFING
10. The Committee has previously looked at the
conditions of service of UK (DFID) staff in insecure environments
such as Afghanistan; the challenges faced and the need to build
up a cadre of staff with experience of living in insecure environments
(House of Commons, 2008). Merlin concurs with the view that this
experience is critical—enabling DFID staff to better understand
the complexity of the challenges facing humanitarian actors at
district and local levels in very remote locations. In 2010 DFID
visited Merlin's project site (Kindu) in Maniema province. This
visit was critical in that it helped DFID to better understand
the huge logistical constraints in Maniema Province, the exceptionally
low capacity of the health system and often negative influence
exerted by local officials. Many of the Ministry of Health facilities—which
Merlin supports—are extremely remote; some populations are
accessible only by motorbike and fuel is not readily available;
failures in the cold chain result in significant losses (even
when they are reported). Visits are also valuable to both parties
in that they can improve performance levels—identifying
issues early that need to be addressed.
OTHER
11. The Committee may wish to be aware that,
based on learning from our health programmes, Merlin is currently
in the final stages of publishing guidance for NGOs "core
principles for engagement by NGOs in fragile states". Merlin
would be happy to share this with the Committee in due course.
REFERENCES
Ashdown, P. (2011) Humanitarian Emergency Response
Review.
ONGI, Comite de Coordination des Organisations Non
Governmentales Internationals (2011) Briefing Notes to the Emergency
Response Coordinator.
DFID (2011) Bilateral Aid Review: Technical Report.
House of Commons (2008) International Development
Committee. Reconstructing Afghanistan: Government Response to
the Committee's Fourth Report of Session 2007-08 (HC 509).
Merlin (2007) Democratic Republic of Congo: Merlin's
Role in Strengthening Health Systems.
Newport, S. (2010) Report on the impact of insecurity
on health workers and health service delivery, Merlin.
Humanitarian Policy Group (2009) Providing Aid in
Insecure Environments: Trends in violence against aid workers
and the operational response (2009 Update).
UNDP Human Development Report (1997) Human Development
to Eradicate Poverty.
UNDP Human Development Report (2010) Pathways
to Human Development.
May 2011
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