House of Commons - DFID's programme in Zambia - International Development Committee

DFID's programme in Zambia - International Development Committee Contents

4 Human and Social Development

21. The largest part of DFID's spending is directed at human and social development, which includes health, water and sanitation, education and cash transfer programmes.

Health

22. The Government of Zambia has recently published a National Health Strategic Plan 2011 to 2015 (NHSP).[28] It seeks to provide 'the strategic framework for ensuring the efficient and effective organisation, coordination and management of the health sector in Zambia' for the next five years ending 2015.[29] DFID has a number of major programmes which are aligned to the priorities of the NHSP, including ones on reproductive, maternal and newborn health; malaria; and HIV/Aids.

MATERNAL AND REPRODUCTIVE HEALTH

23. The maternal mortality ratio (MMR) in Zambia is 591/100,000 live births[30], putting it seriously off track to achieve Millennium Development Goal 5 (target of 162/100,000 live births). The main causes of death are post-partum haemorrhage (34%), infection (13%) and obstructed labour (8%).[31] High HIV prevalence also exacerbates maternal mortality. Zambia's HIV prevalence rate is 14%, the 7th highest in the world, and each year 82,000 newly infected people join the existing pool of 1 million people living with HIV.[32] Finally, c. 30% of maternal mortality results from unintended pregnancies leading to unsafe abortions.[33] Almost 30% of adolescent girls in Zambia (15-19 years) have been pregnant and a teenager is twice as likely to die in pregnancy than someone over 20 years.[34]

24. The NHSP aims to increase access to integrated reproductive health and family planning services and thereby, reduce MMR from 591 per 100,000 live births in 2007 to 159 by 2020. The Plan also aims 'to mainstream the provision of comprehensive adolescent friendly health services at all levels, so as to reduce their vulnerability'.[35]

25. The Zambian Government strategy is strongly supported by DFID. 'Improving maternal mortality outcomes' is a top priority for DFID.[36] The DFID Minister informed us:

26. The three programmes the Minister referred to are:

· The Scaling Up Family Planning programme (also known as Support for Family Planning) implemented by ABTS Associates[38] which will build the capacity of the public and private sectors to deliver family planning services and directly provide services in the most under-served districts, spending about £15million over 2011/12-14/15.

· The International Health Partnership programme which is overcoming the barriers that prevent women accessing maternal and neo-natal health care services.

· The Intensifying HIV Prevention programme will address existing prevention gaps by increasing demand for and access to effective, integrated prevention services, including couples counselling and testing and male circumcision services, spending £11million over 2012/13-15/16.[39]

27. Reducing unintended pregnancies has benefits over and above reducing maternal mortality. In 2007 Zambia had a fertility rate of 6.2 births per women, which has improved little over time, is higher than most other countries in the region[40] and one of the highest in the world. The fertility rate masks wide variations with a lower rate in urban areas and a higher rate in rural ones. 42% of pregnancies are unintended.[41] The population of Zambia has increased from 3 million people in 1964, to 13.2 million in 2010.

28. On our visit to Zambia, we met several organisations involved in family planning, including Marie Stopes International (MSI), which submitted a memorandum with a number of recommendations, including:

· DFID should use its influence with the Government of Zambia to change practices which reduce access to contraception:

There is a need to improve access to long-acting and permanent methods of family planning (LAPM); there is an acute shortage of doctors in Zambia, particularly in rural areas acute, yet many LAPM, such as contraceptive implants, are restricted by national health policy to provision by doctors only. Doctors and nurses and midwives should be allowed to provide LAPM; and

To permit clinics, particularly non-state providers, to publish basic information to the public about the availability of the services they offer.

· Since the Zambian Government's expenditure on Reproductive Health is substantially below what is required for Zambia to achieve its MDG5 targets, particularly for the large rural population and for services accessible to Zambia's 'large youth cohort', DFID should 'focus upon the following areas for additional strategic investment':

'Mobile Reproductive Health services for rural communities' and

Youth-focused initiatives to raise awareness of the availability of Reproductive Health services and reduce social stigma.[42]

29. The DFID Minister agreed about the need to improve access to LAPM, but pointed out that:

30. DFID also assured us that it was focused on adolescent girls and young women

31. Since our visit DFID has made a number of changes. First, it has decided to increase spending on reproductive maternal and newborn health in 2012-13 by £5.5 million. Secondly, its headline results outlined in the Operational Plan have been changed from 'the number of additional couples using modern methods of contraception, attributed to DFID' in the May 2011 update to 'the number of additional women using modern methods of family planning through DFID support' in the May 2012 update.

32. Maternal mortality in Zambia is appallingly high and its reduction is a key priority for the Government of Zambia. A major cause of high maternal mortality rate is lack of access to reproductive health. There is a particular need for contraceptive implants, which are restricted by national health policy to provision by doctors only. We recommend that DFID encourage the Government of Zambia to allow clinicians other than doctors, including nurses, midwives and community health assistants to be trained to provide Long-Acting and Permanent Method contraception. We welcome DFID's decision to increase its spending on reproductive, maternal and newborn health and recommend that it be focused on rural areas and young people. We recommend that the increased expenditure be continued from 2012-13 into future years.

GENDER

33. High maternal mortality and high levels of unintended pregnancies are associated with the low status of women in Zambia. Women are disproportionately affected by poverty Zambia ranks 124 out of 137 countries in the UN's Gender Inequality Index. Violence against women persists; half of all Zambian women report having experienced physical violence since age 15. Women and girls' participation in decision-making remains low.[45]

34. DFID published a Zambia Gender Strategy Paper in 2011 and supports a number of programmes to address gender issues. These include spending £0.75million from 2012-13 to 14-15 to scale up USAID's 'A Safer Zambia' programme which will help tackle gender-based violence. DFID will spend £8.5million between 2011-12 and 2015-16 to support an Adolescent Girls Empowerment programme (aka Safe Spaces programme) which is to be implemented by the Population Council.[46] This aims to empower 10,000 10-19 year old girls to 'build their health, social and economic assets'. DFID states it 'will result in fewer early unintended pregnancies, reduced early marriage, lower rates of HIV and other sexually transmitted infections and fewer school drop outs'.[47]

35. The Committee visited the Kamwala girls school in Lusaka where we were able to see an impressive presentation of the benefits of the Safer Spaces programme. The main component consists of weekly group meetings in schools where girls discuss sexual and gender-based violence, rights and responsibilities, HIV and sexual and reproductive health, financial education, and life skills. The programme includes a longitudinal study to test the longer term impact on adolescent girls' empowerment.

36. Violence against women is at an appalling level in Zambia. We met girls involved in an impressive Adolescent Girls Empowerment Programme and recommend that DFID increases spending on this programme if it proves over time to be as effective as we think it likely to be.

HUMAN RESOURCES

37. The main priority for the Zambian Government, which the Permanent Secretary at the Ministry of Health emphasised when we met him, is an improvement in human resources in the health sector.[48] Moreover, while Zambia needs more skilled clinicians, it is still losing trained people to other countries, in particular to South Africa, Botswana, and other neighbouring countries[49]; the biggest brain drain is nurses.

38. DFID recognises that human resources are the number one challenge in the health sector and is assisting the Zambian Ministry of Health develop its community health worker (aka community health assistants) strategy. Through the Clinton Health Access Initiative, DFID supports the development of a professional cadre of community health assistants to bring information and services to the most rural. The community health assistants are from local communities, often with acute shortages of doctors and nurses. They are given a certain level of clinical training to work in particular on the management of malaria, child and maternal health, and other common preventable health conditions. The Ministry of Health states that

39. DFID also supports post graduate nurse and doctor training as well as a new nutrition BSc degree through the Tropical Health Education Institute (THET) at Imperial College, London, which is part of the Zambia UK Health Workforce Alliance.[51] In the meeting with the Permanent Secretary at the Zambian Ministry of Health we discussed how the UK Government might expand its role in training health professionals. The Permanent Secretary informed us that Zambia needed technical expertise and would welcome UK doctors and nurses to train Zambians.

40. Stephen O'Brien, the DFID Minister, encouraged qualified doctors, nurses, midwives and technicians to go to countries like Zambia for three or six months, either at a young age or in midcareer as part of their professional development, or in retirement. He also thought UK clinicians had a role in training Zambians:

41. We strongly support the Zambian Government's emphasis on increasing the number of clinicians. We welcome the Minister's enthusiasm for encouraging links between UK and Zambian health professionals and universities, in particular to help train their Zambian colleagues. We recommend that DFID provide small amounts of funding to facilitate this.

Education

42. Zambian Government funding for education increased from around $200m in 2000 to $600million in 2010. The budget for 2012 is almost $1 billion. Over the last decade 26,000 more teachers have been deployed and 19,000 new classrooms have been built. Primary enrolment doubled from 1.6m to 3m and access became almost universal at 97%.[53] In DFID's Report and Accounts for 2010-11 Zambia received a green traffic light for net enrolment in primary education, meaning that the MDG had been met or was on target to be met in 2015.[54]

43. However, net primary enrolment has declined and in the DFID Annual Report and Accounts for 2011-12 the traffic light had turned to red, indicating that Zambia was seriously off track against the MDG indicator.[55] This may be a statistical blip, but there are other problems with education. As access has increased, quality has suffered. The average pupil-teacher ratio has remained at around 50-1. Most schools now operate in two or three shifts per day with children in lower grades (aged 6-10) spending just 3 hours in school each day.[56]

44. For all the problems in primary education, on our visit our attention was drawn particularly to secondary, tertiary and vocational education. Education is free up to the age of 14 (grade 7)[57], but not thereafter; this obviously restricts access. Several prominent reports have stressed the importance of secondary and tertiary education. The Commission for Africa's 2010 Report Still Our Common Interest noted that since its initial report in 2005 investment in higher education had not improved - contributing to a continued shortage of trained teachers, doctors and other key professionals. It also observed that the 2005 Commission report 'appears to have been more successful in helping to revive interest in investment in infrastructure than in resuscitating support for higher education'.[58]

45. The Committee received a submission from Jon Morton, Founding Partner at the Institute for Developing Markets[59] (IDM) and previously Deputy Principal at Henley Management College, who informed us that from his experience the increasingly important challenge expressed by Governments in sub-Saharan Africa and the private sector was how to get local people managing local operations and how to improve professional middle management, which are the backbone of any emerging economy. He argued that 'the solution to these challenges lies in talent development - but there is little or no institutional leadership, management or professional development outside of South Africa'. IDM is establishing a new educational institution targeted to respond exactly to these challenges. Morton claimed DFID could play a role in this essential development opportunity through the support of public and private sector leadership, management and professional education.[60]

46. 20% of DFID budget support is estimated to go towards education (around £30million since 2005). Beyond general budget support DFID is not currently an active donor in the education sector and other donors take the lead. DFID spending was planned to decline from £10million in 2009-10 to £5million in 2014-15. However, in the DFID Operating Plan 2011-15 (May 2012 update) education spending in for 2012-13 is to increase to £9million from the £6.5million projected a year earlier.

47. We asked DFID about secondary and tertiary education and the training of a business class. We were told:

48. We recommend that support for secondary, tertiary and vocational education be a priority for DFID's education expenditure. We welcome DFID's decision to pay more attention to this following our visit. In its response to this report, DFID should outline in more detail both its plans to help the Government of Zambia make improvements in these areas and how it will work with the British Council and other bodies to do this.

49. There is a lack of competent middle management across the Zambian economy in the public and private sector. We recommend that DFID look at how to assist Zambia make improvements to business education.

28 Republic of Zambia, National Health Strategic Plan 2011 to 2015 (NHSP) Back

29 NHSP, p ix Back

30 Ibid. Back

31 Ministry of Health; The Zambia 2008 Countdown to 2015 Conference report. Held 20^th - 21^st August 2008, The Mulungushi International Conference Centre, Lusaka, Zambia. Back

32 Ev 29; on HIV/AIDS see Ev w10-14 (RESULTS UK and International HIV/AIDS Alliance) Back

33 Ministry of Health Standards and Guidelines for reducing unsafe abortion morbidity and mortality in Zambia, May 2009. Back

34 Information provided by DFID Zambia Back

35 NHSP, p 47 Back

36 DFID, Annual Report and Accounts, 2011-12, p 71 Back

37 Q 58 Back

38 A private, for-profit company, based in the USA, that is one of the world's largest employee-owned research and consulting firms Back

39 Ev 29; the figure for the HIV Prevention programme was provided by DFID in June 2012 (see Table one) Back