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> 8. Non-state actors
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How should we work with private and other non-state actors?
How should we work with private and other non-state actors more to deliver successful reproductive, maternal and newborn health outcomes? For instance, who should we target to work with, what more could we do at global and country level, and how could we go about building better links and relationships?
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Our thanks for all the comments submitted. All of the ideas and suggestions put forward will feed into our new policy, helping to shape the direction of our work.
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DFID should be congratulated for supporting the public sector efforts to strengthen systems of care. In an ideal world, NGOs would not be needed in the health sector. However where the public sector struggles to meet demands for care, NGOs can be effectively enlisted to provide specific support to the development of public sector programs. The traditional NGO model that focused on providing direct services to relatively small populations is being (and should be) replaced by collaborative approaches to NGO support of MOH efforts. Those approaches focus on working closely with ministries of health to assess their needs for support, and then working together to develop the specific approaches to providing it. Genuinely collaborative efforts can take advantage of the NGOs’ advantage in flexibility and innovative approaches, while the promoting sustainable programs that only ministries of health can provide.
The presence of safe and low cost emergency transport is essential to enable prompt referral of women in labour and thus increase the proportion of facility births.
Non-state actors have a role to play in ensuring the availability of such transport. In Nigeria much work has been undertaken with the National Union of Road Transport Workers (NURTW) which has subsequently led to the referral of literally thousands of women each month. The Emergency Transport Scheme as it is known, encourages NURTW drivers to volunteer their vehicles for women in labour without means of reaching a health facility. Drivers are trained in the maternal danger signs, how to lift a pregnant woman into the vehicle, the importance of minimizing delay and basic first aid. Drivers who transport pregnant women are rewarded by being offered “priority loading” back at the taxi park thus saving themselves many hours of waiting. This solution significantly reduces the time and cost required for women to reach facilities – two well known and significant pre-determinants of maternal death.
This NURTW project in Nigeria is just one example of how non state actors can work to support referral of pregnant women. Other examples include the use of roadside flags by communities in Ghana, private sector ambulance services in India and work undertaken by civil society in Zambia to distribute bicycle ambulances.
Gary Forster,
Head of Programmes,
Transaid
In many countries, the private sector is a significant source of abortion services – both safe and unsafe. It is therefore very important to engage the private sector in ensuring that the services they provide are high-quality and that women can afford them.
In addition, collaboration with civil society is essential for working on abortion, since it is such a stigmatized issue and stigma is largely locally defined. Community insights and involvement are critical to designing effective interventions that will lead to greater understanding and, ultimately, dismantling of abortion stigma, which will support the goal of ensuring that women and girls who need to end unintended pregnancies can do so safely.
I am against abortion, and against abortion being used as birth control. I feel that the proper, incorrupt infrastructure should be laid down in the various developing countries to deliver proper life saving and life improving healthcare and educaion to women and their families. I believe the above mentioned would go a long way towards imroving w0omens’ and childrens’ health without the need for abortion unnless the pregnant woman’s life is in grave danger. We must get away from making women think its best to kill their unborn child.
Suzanne Jamieson.
CMF has links with over 150 of our members working in NGOs and faith based organisations (FBOs) across the breadth of the developing world, and anecdotal evidence suggests that many of the most effective and innovative developments in healthcare provision are coming through such ‘non-state actors’.
Church based organisations, including traditional mission hospitals and clinics, and more innovative primary care projects, are major players in healthcare across much of the developing world. In sub-Saharan Africa such groups are providing a significant proportion (and in some countries, the majority) of health services, including maternity services (Pear E, Chand S et al, African Christian Health Associations: Joining Forces for Improving Human Resources for Health, USAID, The Capacity Project 2009).
DFID must engage constructively with these FBOs if it is to have a significant impact on developing services to address maternal mortality.
But we believe it goes deeper than this. ‘The failure to understand the influence of religion in African health worlds, or the failure to reflect on certain assumptions of Western health worlds threaten the important work of organizations like WHO.’ (ARHAP and World Health Organisation Research Project: Zambia and Lesotho (2006) http://www.arhap.uct.ac.za/research_who.php). As CMF has stated elswhere in this consultation, in most parts of the world, religion forms the underlying worldview that shapes beliefs about health, the role of women and childbirth, and attitudes to maternal and newborn health and health services. This is borne out by the experiences of our members in Africa, Central and South Asia, rural East Asia, Latin America and elsewhere.
DFID must work with faith leaders, religious scholars and faith communities as well as FBOs if it is to have a real impact in tackling maternal mortality. Only a faith based approach, taking into account sacred texts and traditions can be really effective in mobilising religious communities and religious assets to change religiously based attitudes to the health, status and wellbeing of girls and women.
In response to Mary Anne Mercer (above), NGOs often have a special contribution to make in sustainable development (including healthcare), even in “an ideal world”. With the best will in the world and all the resources of a Western capitalist economies, state-run public sector health systems can be hugely wasteful, bureaucratic and sclerotic. In developing countries, they may also suffer from chronic corruption and mismanagement.
NGOs are not all perfect but are likely to be more entrepreneurial, delivery-focussed and responsive to local communities. DFID should work with the presumption that relevant, specialist and successful NGOs will be involved in programmes and DFID should assess the contribution and value-added of public sector/state players at least as stringently as it does NGOs. The billions of development aid wasted or misappropriated over the years through poorly governed “direct funding” (to incompetent/corrupt regimes) makes one weep for the poor who might have been helped/saved otherwise.
I would caution that use of NGOs, and especially private companies should be done very carefully. After all, many of these companies are providing a service as part of a business. It therefore, for example, means that an abortion provider is going to have a hidden agenda of increasing the abortion rate in order to maximise profit, which is somewhat distasteful
Private sector and NGO services should be enhanced to becoming part of the solution instead of remaining part of the problem. They usually have the entrepreneurial spirit to make things work, the will to be flexible to changing circumstances. When given a chance to contribute to national strategy implementation, given the correct checks and balances, private sector and NGO services (inclusive of church operated networks of clinics and hospitals) are able to make a substantial contribution to MDG’s, inclusive of maternal and child health. DFID should focus on the establishment of a supportive environment for PPP around maternal and child health service delivery. This involves building capacity in the private sector and NGO sector, but equally building capacity in the public sector- to assure efficient control and regulation mechanisms.
Innovative demand side health solutions provided through the private sector can complement state health delivery mechanisms very effectively. This is particularly so where private sector health service provision is relatively strong in areas where the delivery of public sector services is challenging, such as the West of Uganda. We have run a successful maternal health voucher project through the Government of Uganda for nearly three years, targeting the poor who, for the price of a loaf of bread, can redeem their voucher for antenatal care and safe delivery services at their nearest accredited private provider. The advantage being that the services are costed, and the quality of services measured and monitored. so far 56,000 vouchers have been sold, and we have seen private providers begin to develop their own networks, and build their own capacity (eg. new words, ambulances etc) to provide services to the poor. Ultimately, such a scheme can pave the way for social health insurance, or at least provide learning for the evolution of government health service provision.
We suggest that DFID considers working with non-governmental organizations delivering nutrition programmes to increase funding for maternal nutrition as well as HIV/AIDS organizations in high burden countries. Some of the questions we are trying to answer are very important. However, local knowledge and experience should not be forgotten in the drive to find solutions. The women and mothers who will benefit from the assistance of the British government should be involved in the consultation process in terms of what they need and how it can be best delivered to them. Participation needs to be a key component of the planning, implementation and monitoring stages of project cycle management. Potential stakeholders should include National Women’s groups, faith-based groups, youth groups and national health care workers and families as a whole.
Any successful program that addresses their sexual and reproductive health must include proactive outreach and involvement of Civil Socuiety as advocates, experts and in service delivery. This work must recognise the importance of civil society for service delivery, especially with marginalized and vulnerable populations.
In many developing countries as in Bangladesh the structural pattern of the existing health service is quite sound but the quality of services is poor. Basically more attention has been paid to physical infrastructure than on quality of services. One of the criteria of Primary Health Care is that the health service system should be managed and coordinated at local levels. One of the best ways to achieve this is, along with existing system, setting up of a Rural Health Team at union levels. The team would comprise of two Female Health Assistants (FHA), one male Health Assistant (HA), one Ward Monitor (WM), one Family Welfare Assistant (FWA) and a Skilled Birth Attendant (SBA). The team would be headed by a local person having significant position and communication link in the union. He may be regarded as Union Representative. Hence:
• The health management system should be managed and
coordinated at the local level by constituting a Rural Health
Team (RHT)
• The RHT would maintain liaison between health centres and
health receivers.
• The RHT should be institutionalized. An emergency fund could
be created and maintained through the charging of Tk.10 per
month from the health service receivers
• The RHT would monitor the accountability of health service
providers at local levels.
• A monthly meeting should be arranged with the members of
RHT of each union at Upazila Health centre (UHC). In such
meetings accountability of health service providers (i.e.
attendance rate of doctors and other health workers at Union
Health & Family Welfare Centre (UHFWC) and Mother-Child
Welfare Centre (MCWC); behavioural pattern with the patients,
distribution of medicine, quality and quantity of services
provided by the FHA, HA, FWV, etc.) and the problems faced by
the health service providers could be discussed. The regulation
of such meeting should be submitted to DG office through
Upazila Health and Family planning Officer (UHFPO)
• Training on timely identification and management of
complicacies in pregnancy and child birth should be given to
FHAs and SBAs
• Women should be informed about danger signs of pregnancy
• The RHT should be an integral part of maternal health referral
chain
• The cost of transportation, SBA’s remuneration etc. should be
borne by the RHT at child birth
• The hospital delivery charge should be exempted for poor
women
• Ayurvedic, Uniani and other traditional medicine should be
integrated into the medi-care system and training should be
given to personnel related to such sectors. Healers of each
systems could be affiliated with the RHT
• Motivation and awareness raising programmes should be
strengthened through monthly meetings, advocacy campaigns,
mass media, pictorial cards etc.
• Collaborative linkage between the Gov. and non- state health
service providers should be strengthened.
DFID can help to set up the Rural Health Team and work with non-state actors.