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Asia and the Pacific Consultation on

Maternal Health and Rights 13-15 August 2009 Bali, Indonesia

Organized by

Asian Forum of Parliamentarians on Population and Development (AFPPD) UNFPA Asia and the Pacific Regional Office With special support from the

Indonesian Forum of Parliamentarians on Population and Development (IFPPD)


Table of Contents

Background..........………………………………………………………….... 1 Summary and Conclusions ……………………………………………….....

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Inaugural Session …………………………………………………………....

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Session 1: Keynote Address ……………………………………………….....

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Session 2: The Right to Maternal Health in Asia and the Pacific ………….....

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Session 3: Budgetary Allocations for Maternal Health ………………….......

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Session 4: Quality of Maternal Health Care ………………………………....

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Session 5: How Political Will Translates into Fulfillment of Rights: The Example of Sri Lanka ……………………………………........

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Session 6: The Role of the Media in Advocating for and Monitoring Implementation of the Right to Maternal Health …………….......

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Session 7: Country Level Action Plans……………………………………...... 21 Session 8: The Role of Regional Level Strategies in Supporting National Action on Maternal Health: Key Elements for Regional Action Plan ………………………………………….......

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Concluding Session ……………………………………………………….....

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Annex 1: Agenda ………………………………………………………........

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Annex 2: List of Participants ……………………………………………...... 28 Annex 3: Country Action Plans ………………………………………….......

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Asia and the Pacific Consultation

Maternal Health and Rights 13-15 August 2009 Bali, Indonesia


Background

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he Asia and the Pacific Region contributes to approximately 44 per cent of the world’s maternal deaths. Of these, 35 per cent are in South Asia. Several reports on progress towards achieving the MDGs in Asia and the Pacific have highlighted the fact that it is unlikely that the region will reach the targets for MDG5: to improve maternal health, by 2015. Many women in these parts of the world go through a pregnancy uncertain of whether they will survive childbirth, which should be a time of joy. Yet, the interventions to prevent needless deaths during pregnancy and childbirth are well known – maternal mortality and morbidity are preventable. Nevertheless, many women continue to die due to poor access to and quality of maternal health services. High maternal mortality is an indicator of weak health systems, unable to deliver necessary and critical services. The marginalized and excluded suffer disproportionately from higher rates of maternal mortality and morbidity, with financial barriers limiting access to life-saving services. Governments in the region have made efforts to reduce the financial barriers to enable poor women to access services, as well as life-saving services, but overall allocations for maternal health still remain low. Persistent gender inequality is also an important factor in limiting women’s access to the information and services that will save their lives. There has been increasing recognition globally of maternal health as a human right, most obviously as a right to the highest attainable standard of health. During the Consultation, which brought together parliamentarians, media and resource people, a human rights framework was applied to discussions to inform advocacy strategies for improving maternal health. The three main focus areas of the Consultation were on: (i) maternal health as a reproductive rights/human rights issue; (ii) budgetary allocations for maternal health; and (iii) quality of care. The objective of the meeting was to develop country-level action plans, with focus on selected constituencies, to advocate for increased allocations for maternal health and to identify innovative strategies to enable utilization of quality services by the poor and excluded populations, including through developing partnerships between parliamentarians, media and other key stakeholders. It is hoped that this Consultation provides a foundation for an Asia and the Pacific Countdown to 2015 meeting.

Asia and the Pacific Consultation

Maternal Health and Rights 13-15 August 2009 Bali, Indonesia


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Organization The Asia and the Pacific Regional Consultation on Maternal Health and Rights was organized by the Asian Forum of Parliamentarians on Population and Development (AFPPD) in close collaboration with the UNFPA Asia and the Pacific Regional Office (APRO), with special support from Indonesian Forum of Parliamentarians on Population and Development (IFPPD). A total of 82 participants attended the Consultation, including Mr. Anand Grover, the UN Special Rapporteur on the Right of Everyone to the Highest Attainable Standard of Health, parliamentarians, media experts, representatives of multilateral organizations, decision-makers, legislators, scholars and experts from 16 countries. The Consultation was held between 13 – 15 August 2009 in Bali, Indonesia. The sessions included presentations, round-table discussions and country-level group work.

Asia and the Pacific Consultation

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Summary and Conclusions

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he speakers at the inaugural session: Dr. Zahidul Huque, UNFPA Representative to Indonesia, Hon. Dr. Sugiri Syarief, Director General of the National Family Planning Coordinating Board of Indonesia, Hon. Dr. Pinit Kullavanijaya, Senator of Thailand and Secretary-General of AFPPD and Ms. Nobuko Horibe, Regional Director, UNFPA APRO, highlighted the critical role of right to health in achieving reduction of maternal mortality. In the key note session on International Human Rights Mechanisms and Maternal Health, Hon. Ms. Shirin Shamin Choudhury, Minister of Women and Children Affairs, Bangladesh, the Chair of the session introduced “good maternal health” as a right of every woman. Mr. Anand Grover, UN Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Health, in his key note address, elaborated on the recent resolution of the Human Rights Council on “Preventable Maternal Mortality and Morbidity and Human Rights”. He highlighted the importance of adopting a rights-based approach in addressing maternal mortality, its role in enabling citizens to stand up and claim their rights and thus enforce States to put mechanisms in place to protect rights.

Asia and the Pacific Consultation

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The Roundtable Discussion: Challenges and Opportunities in Implementing a Rights-Based Approach highlighted the commitments governments have made towards achieving MDG 5 and the various interventions they are undertaking. The challenges identified included poor access to services especially in remote areas, poor infrastructure, poor quality of services and inadequate budgetary allocations. Lack of recognition of maternal health as a human right also was highlighted. The session on Investing in Maternal, Newborn and Child Health – The Case for Asia and the Pacific was led by Dr. Flavia Bustreo, Director, The Partnership for Maternal, Newborn and Child Health, and Mr. Ian Anderson, Advisor and Principal Economist, Health Services Delivery, Asian Development Bank. Investing in Maternal, Newborn and Child Health: The Case for Asia and the Pacific, was presented, reflecting the inadequacy of allocations, inefficiency of the health system in implementing the current limited resources for maternal health, newborn and child health, as well as how little it costs to provide a core package of maternal and newborn health. The presenters highlighted the importance of investing in maternal and newborn health and how such investments will contribute to achieving MDGs. The investment case provides guidance on where, when, why, what sequence and how much to invest in public expenditures and demonstrates the benefits of the investments. Parliamentarians from selected countries participated in the Roundtable Discussion: Strategies for Advocating for Increased Budgetary Allocations for Maternal Health. Among the key challenges identified was the lack of recognition of the importance of investing in health, particularly maternal health. The parliamentarians reported that the investments in maternal health were abysmal and suggested a few strategies for increasing allocations. The session on Ensuring Quality of Care in Maternal Health Care Services as a Right presented by Dr. Saramma Thomas Mathai, Regional Team Coordinator and Maternal Health Advisor, UNFPA APRO, reported on the dismal scene of maternal health in Asia and the Pacific and the reasons for the lack of progress of MDG 5. The presentation also covered rights of clients and providers and recommendations on what parliamentarians can do to improve maternal health in their respective constituencies. The next session was on How Political Will Translates into Fulfillment of Rights: The Example of Sri Lanka, with a presentation by Hon. Nimal Siripala De Silva, Minister of Health and Education of Government of Sri Lanka. He highlighted how Sri Lanka has managed to reduce maternal mortality from a high rate of 500 per 100,000 live births to 40, in a short time period through investments in health and education. He emphasized the importance of free health services, inclusion of socio-cultural determinants in maternal and newborn health programmes, and community participation. He concluded by saying that maternal health should be a political challenge and not just a health challenge. The session on The Role of Media in Advocating for and Monitoring Implementation of the Right to Maternal Health was led by Ms. Katja Iverson, Media Specialist, UNFPA Information and External Relations Division. She presented five key points for successful media campaigns to place maternal health on both the political and the public agenda. Asia and the Pacific Consultation

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During the session on The Right to Maternal Health in Asia and the Pacific, Mr. Rajat Khosla, a Human Rights Lawyer and consultant with UNFPA APRO, presented the preliminary findings from a survey of maternal health policies and strategies of selected countries in the Asia and the Pacific region from a reproductive rights-based perspective. The review covered issues such as formal recognition of reproductive rights and maternal health as a human right in national policies and strategies, adequacy of resources allocated for maternal health, quality, accessibility and acceptability of services and effective accountability mechanisms. He identified the gaps that contribute to lack of progress in reducing maternal mortality. Recommendations for action were provided that included focus on disadvantaged groups, rights-based perspective in planning health services, strengthening health systems, human rights, and monitoring and accountability through registration of maternal deaths.


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The round table that followed on The Role of the Media in Advocating for and Monitoring Implementation of the Rights to Maternal Health included media experts participating in the workshop. They highlighted the challenges in reporting on maternal health and also inadequate knowledge on maternal health. They provide some excellent recommendations for improving coverage of maternal health in media. The following two sessions focused on country level action plans and elements of a regional action plan for maternal health and rights. Major elements identified by the plans are the following: • Advocacy for maternal health • Improving access of the poor and excluded groups • Community mobilization and support • Strengthening health system management at the district levels • Promotion of deliveries by skilled birth attendants

• Monitoring the reach of services • Monitoring existing laws and developing new laws • Role of media • Capacity building

During the concluding session, several of the participants underscored the importance of the theme of the workshop and their plans for sharing the action plans with other colleagues in the countries they represent. Mr. Wasim Zaman, Executive Director, International Council on Management of Population Programmes (ICOMP) highlighted some of the key issues raised such as well as pointed out the importance of management and leadership role of parliamentarians. He also pointed out the continuing state of inequalities in the region that is unnecessarily leading to deaths of women during pregnancy and childbirth. Hon. Minister Nimal Siripala de Silva, Minister of Health and Education, Government of Sri Lanka encouraged countries in the region to promote the right to maternal health and also to share successful experiences with countries in the region. Ms. Nobuko Horibe, Director, UNFPA APRO, highlighted the importance of addressing social, economic and cultural elements along with health system issues if maternal mortality is to be reduced. She emphasized the need for male involvement as well as the involvement of community leaders. She also assured technical support by UNFPA to parliamentary fora in the region. The session was closed by vote of thanks by Mr. Shiv Khare, Executive Director, AFPPD and committed AFPPD support in furthering the cause of maternal health and rights.

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Maternal Health and Rights 13-15 August 2009 Bali, Indonesia


Inaugural Sessions

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Dr. Zahidul Huque,

UNFPA Representative to Indonesia

Honorable Dr. Sugiri Syarief, Director General of the National Family Planning Coordinating Board of Indonesia, BKKBN expressed sincere gratitude to AFPPD and the UNFPA Asia and the Pacific Regional Office for organizing the Consultation. Country-level progress towards the MDGs can be achieved through increasing political commitment of the leaders, national financial resources and establishment of strong partnerships. Improving the health of women and children should not be seen as expenditure but as an investment, an investment not just in individuals but in society. The window of opportunity exists now with broad multistakeholder agreement on what interventions are required under the framework of a proper health system. Improvement of data and data analysis is needed to Hon. Dr. Sugiri Syarief, ensure successful interventions. This should be a joint effort of the government Director General of the National Family Planning Coordinating Board of Indonesia including parliamentarians, civil society organizations and the private sector. Indonesia’s policies and strategies in reducing the levels of mortality and improved the quality of life consist of four points: 1) Improve access to and the scope of cost-effective quality maternal and newborn health care, based on evidence and data; 2) Effective partnerships through cross-programme and crosssector cooperation, which conduct advocacy to maximize the allocated resources and improve on making pregnancies safe through planning and coordination of activities; 3) Encourage and empower women, families and communities through improving knowledge to ensure healthy behaviour by using maternal and newborn baby health care; 4) Enhance programme management through surveillance, monitoring, evaluation and financing systems. Honorable Dr. Pinit Kullavanijaya, Senator of Thailand and Secretary-General of AFPPD highlighted the international technical cooperation in improving maternal health. The parliamentarians must integrate and emphasize maternal mortality and mobility initiatives in cooperation arrangements and encourage and participate in the exchange of promising practices and technical assistance to strengthen national capacities. Parliamentarians should exercise their legislative duties to synchronize national laws and administrative measures with international commitments and human rights obligations.

Hon. Dr. Pinit Kullavanijaya, Senator of Thailand and Secretary-General of AFPPD

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r. Zahidul Huque, UNFPA Representative, Indonesia gave welcoming remarks. He emphasized that maternal health is a human right and is entrenched in the Universal Declaration of Human Rights as well as in the International Covenant on Economic, Social and Cultural Rights, the Convention on the Elimination of all forms of Racial Discrimination, the Convention on Elimination of all forms of Discrimination Against Women and the Convention on the Rights of the Child. Many countries still have high numbers of women and newborns dying during pregnancy and childbirth. He hoped that the sharing of experiences from different countries would advance women’s right to maternal health and promote gender equality. He cited the example of the Indonesia UN Country Team Working Group on the Right to Health, as a key mechanism within the United Nations in Indonesia for joint action and coordination on issues concerning the right to health, including maternal health.


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Ms. Nobuko Horibe,

Regional Director, UNFPA APRO

Asia and the Pacific Consultation

Maternal Health and Rights 13-15 August 2009 Bali, Indonesia

Ms. Nobuko Horibe, Director, UNFPA Asia and the Pacific Regional Office mentioned that maternal mortality and morbidity are preventable. Improving maternal health also requires social interventions. No community can get out of poverty and no development effort can be successful when human rights and gender equality are neglected. Ms. Horibe also emphasized the important link between MDG5- improving maternal health, and MDG8 –global partnership for development, in generating wider support for women’s rights, including the right to health and sexual reproductive health and to be free from violence and discrimination in families and communities.


Session 1: Keynote Address International Human Rights Mechanisms and Maternal Health: A Global Perspective on the Right to Maternal Health

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Maternal Health in the Asia and the Pacific Region: Achieving the Right to Health

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r. Grover highlighted the implementation and enforcement of right to health, and within that is the right to maternal health. He emphasized that it necessarily poses the essential question, “Why adopt a rights-based approach in addressing maternal mortality?” Applying a rights-based approach allows people to stand up and claim their rights and this makes it very essential to link the right to maternal health with the enforcement mechanisms in place. The question is how we can enforce this right to maternal health, particularly States’ obligations, and how to fulfill their obligations in this regard. In the constitutions of different countries if the right to health, including the right to maternal health care, is made a fundamental right, then these rights can be directly enforceable. Another way could be to bring the right to health care, food, shelter within the right to life, which is a civil and political right that is enforceable Mr. Anand Grover, through the judicial system. That could be one way of enforcing the right to health UN Special Rapporteur on the Right care. To address the issue of discrimination in health care, the right to equality can of Everyone to the Enjoyment of the be applied, which would give judges a scope to enforce the right directly. It is also Highest Attainable Standard of Health important to frame legislation and adopt the strong policies to promote maternal health care. These are innovative and different ways in which human rights can be used to promote maternal health. He added that safe sex, abortion and women’s decision-making power are closely interlinked with empowerment of women and particularly with economic empowerment. It is therefore essential to take an integrated approach by encompassing the right to life, right to health, right to maternal health, right to equality and non-discrimination together.

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he Honorable Ms. Shirin Shamin Choudhury, Minister of Women and Children Affairs, Bangladesh introduced Mr. Anand Grover, UN Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Health. In her speech, she introduced maternal health as a human right. The right to life, not only guarantees protection against arbitrary killing, but also encompasses a minimal decent life ensuring food, shelter, health care and education. Thus the ‘right to health’ is very much within the right to life. Maternal Hon. Ms. Shirin Sharmin Choudhury, mortality is therefore a grave violation of the right to life and the right to health. Minister of Women and Children Affairs, Bangladesh Behind every maternal death is a mother in dire need of health care. Concerns have been expressed at international levels in various international conventions and, State parties ratifying these conventions have obligations to respect, protect and fulfill these rights. In accordance with international conventions, States are developing laws and policies to promote reduction of maternal mortality, but the goal is yet to be achieved. She noted that the representatives of various countries in the region present are all striving to ensure safe motherhood, and expressed the hope that the Consultation will shed light on what can be done to actually help mothers in our countries to achieve their right to life and care.


Session 2: The Right to Maternal Health in Asia and the Pacific Asian Forum of Parliamentarians on Population and Development

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A Rights-based Review of Maternal Health in Asia and the Pacific

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r. Khosla presented the preliminary findings from a survey of maternal health policies and strategies of selected countries in the Asia and the Pacific region from a reproductive rights-based perspective. The high maternal mortality ratio in the region is largely attributed to the absence of skilled birth attendants at delivery, poor access to emergency obstetric care in case of complications and no reliable referral systems. There are several human rights that may be cumulatively or interactively applied to advance safe motherhood. The review asked several key questions: (1) do policies actually have a formal recognition of reproductive rights, including maternal health as a human Mr. Rajat Khosla, right; (2) are the resources that are allocated for maternal health adequate; (3) Human Rights Lawyer and consultant with UNFPA APRO are maternal health care services available, accessible, acceptable and of good quality; and (4) are there effective and transparent accountability mechanisms? While there are some policies that are designed to improve maternal health and reduce maternal deaths, there are gaps that diminish the likelihood that these policies alone are sufficient to make significant progress in reducing maternal mortality.

Gaps in efforts to reduce maternal mortality Inadequate allocation of resources Lack of reliable data Unavailability of providers in public health facilities Lack of access to family planning services Accountability Availability, accessibility and quality of maternal health services Cultural sensitivity Underlying determinants

Conflict in the country

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Too little budget allocated for health overall, holding back the formulation and implementation of maternal health policies and strategies. Many countries lack systems to monitor maternal mortality, making it difficult to plan effective strategies to prevent maternal mortality. The health workforce crisis means that there are not enough providers in public facilities, usually rural and disadvantaged areas suffer disproportionately. A human rights-based approach calls for access to comprehensive family planning services. Unmet need for family planning is a leading cause of maternal mortality. A human rights-based approach to maternal mortality requires effective, accessible, and transparent monitoring and accountability mechanisms. There is a wide differential between rural and urban areas in terms of the availability, accessibility and quality of maternal health services. A human rights based approach requires that maternal health workers must be sensitive to the issues of ethnicity, culture and gender. A human rights based approach to maternal mortality is not just about health care but also includes entitlements to other social, economic, cultural and political determinants such as access to clean water, sanitation and transportation. Conflict in the country has impeded progress leaving facilities vacant or unsupervised.


Recommendations for action: five areas to focus on in promoting maternal health using a human rights-based approach. 10

MDG5 is to improve maternal health with a target of reducing maternal mortality by three quarters. However, the national statistics of countries can be misleading as improvements in national health indicators can mask the deteriorating situation in some of the disadvantaged groups. Human rights, therefore, require that as far as possible all relevant data are disaggregated not only by age and sex, but also by social, economic and geographical backgrounds. This helps in monitoring the situation of marginalized groups such as women living in poverty, indigenous peoples, and minorities.

2) Planning from the perspective of human rights

Effective planning is absolutely critical; this is however one of the weakest elements in countries with high rates of maternal mortality. Health planning in preventing and reducing maternal mortality is complex and includes many elements such as situation analysis, impact assessments and inter-sectoral coordination, among others. The Committee on Economic, Social and Cultural Rights, in charge of monitoring the compliance of the Covenant on Economic, Social and Cultural Rights, recognizes strategies and plans of action for improving maternal health as core obligations arising from the right to health.

3) Strengthening of health systems

In many countries interventions for reducing maternal mortality are narrow and vertical, which are not suitable for the long-term development of the health system. By drawing resources and overloading the capacity of the health system, vertical interventions may even jeopardize the progress towards long-term effectiveness. However, vertical interventions have their values, but it is important to ensure that the design of these include human rights values and contribute to strengthening the quality of health systems. The need to address the issue of inadequate numbers of skilled health workers and their equitable distribution cannot be emphasized enough. Human resources for maternal and newborn health, particularly obstetricians and midwives, are in crisis in many of the resource poor countries. Unless the issue of the health workers is carefully addressed, the target for MDG5 will not be met.

4) International obligations

It is important to underscore the fact that States have obligations to take steps individually and collectively through international assistance and cooperation towards the full realization of various rights, including the right to health. Depending on the availability of resources, developed countries have an obligation to do all they can to help developing countries to realize their right to health, including right to maternal health. The Committee on Economic, Social and Cultural Rights confirms that donors should give particular priority to helping low-income countries to realize and fulfill their obligations and the Committee clarifies that reduction of maternal mortality is a core obligation as stated in the General Comment 14.

5) Monitoring and accountability in registering of maternal deaths

This is an absolutely crucial element of programmes for preventing and reducing maternal mortality. Often in developing countries maternal deaths are not properly recorded. Monitoring of maternal deaths is important in order to assess the scale of maternal mortality, its causes and whether the measures that are being taken to address the problem are appropriate. However registering maternal deaths is only the starting point. A human rights-based approach requires that causes of deaths and the factors that led to them are identified, in order to refine strategies for reducing maternal deaths.

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Maternal Health and Rights 13-15 August 2009 Bali, Indonesia

Asian Forum of Parliamentarians on Population and Development

1) Focus on disadvantaged and marginalized groups


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Roundtable Discussion: Challenges and Opportunities in Implementing a Rights-Based Approach

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his session included brief presentation by selected parliamentarians from the participating countries, on the status of maternal health in their countries and the challenges and opportunities in implementing a rights-based approach. The following paragraphs are a summary of the presentations.

Cambodia

The maternal mortality rate is still high (472 per hundred thousand live births). The Cambodian Government has adopted various policies and laws in order to promote the rights of women to health and to prevent domestic violence. The Government has allocated a budget to work on these issues and though it is very limited, it has been increasing from year to year. Challenging Participants from Cambodia issues include access to services in remote areas, which lack infrastructure and access to skilled birth attendants. Parliamentarians together with the Government have been monitoring implementation of the programme and have worked to raise awareness of the laws in order to promote women’s awareness on their rights to maternal health.

India

70 percent of the people of India live in villages, yet 80 percent of medical facilities are located in urban areas. The Majority of the medical colleges are based in 5 states - Maharashtra and four southern states. It is difficult to generalize the status of maternal health using the indicators at the national level as the indicators at state level are different. Significant geographical disparities exist in India as do ethnic, cultural and gender differentials. There is recognition of various rights of people such as right to education, employment, health, etc., but the question is on the implementation of these Participants from India rights. How can people realize these rights for themselves? Funds are not a problem in most situations, if there is political stability, political will and the commitment of the bureaucrats, it is possible to achieve results using a rights-based approach.

Indonesia

The Government is concerned about rights, and health is a very fundamental right. In Indonesia, MMR was 450 in 1970 and 200 in 2008. The Government is aware that most causes of maternal death could be avoided if women had access to services or contraception. Indonesia has a law on health, an additional law – number 23 of 1992 – is being amended and it includes reproductive health and reproductive rights. The

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Participants from Indonesia

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Lao PDR

The maternal mortality rate is very high in Lao PDR, the contraceptive prevalence rate is very low (32 per cent) and the total fertility rate is also high. The utilization of antenatal care and the proportion of deliveries by skilled birth attendants are very low. A significant proportion of deliveries are at home. The Government gives priority to rights to maternal and child health. The mother and child have the rights to survive, to develop, to access education, health and social services and to economic participation. Women have the rights to make decisions concern- Participants from Lao PDR ing birth spacing. However, the problem in Lao PDR is transforming laws and decrees into practice implementing the laws. This is especially important in the context of very low resources, poor infrastructure and low accessibility. The role of the parliamentarians is to advocate with local governments and to promote community participation.

Nepal

The Nepal Parliament has 197 women out of 601 members. The interim constitution of 2007 includes the right to maternal health and rights. However, there are problems of adequacy of budgetary allocations and distribution of the budget to remote areas. Nepal also has challenges in terms of reporting expenditures from various sources (Government, NGOs, private sector). It is difficult to staff health centres in remote areas, especially given the security and social instability of the past.

Participant from Nepal

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Asian Forum of Parliamentarians on Population and Development

budget for the Ministry of Health, especially for maternal health, has been increasing yearly. Indonesia hopes to achieve the MDGs. Regarding family planning, the Government has increased the budget for family planning programmes from Indonesian Rupiah 700 billion in 2007 to 1.6 trillion. Indonesia still has problems to motivate women to use contraceptives.


Pakistan

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The Government is improving in maternal and child health care and family planning through education and awareness programmes. The first community based programme for family planning and primary health care started in 1994 and successfully provided maternal health care services at the grassroots level, including reporting of all maternal and child deaths. There are still challenges, especially as the country is at war Participants from Pakistan against terrorism and extremist groups, who target women. It is difficult for the Government to reach all women and provide quality maternal health care. Parliamentarians who are in a good position can sensitize other parliamentarians to the issue.

Papua New Guinea

Participants from Papua New Guinea, Cook Islands, Australia and New Zealand

Maternal Mortality is very high in Papua New Guinea, between the demographic health surveys in 1996 and 2006, the maternal mortality figures have doubled, which is a wake-up call. The rights of women to access to health are not being achieved because of very poor delivery of health services. There is a need to strengthen the health service mechanism in the country, where the majority of the people live in remote areas. The situation of adolescent girls and the rights of the adolescent girls have been neglected. Gender inequality is another factor, of the 109 members of parliament there is only one woman parliamentarian. The civil society lobby has not been strong on issues of reproductive health and maternal mortality. The budget for maternal health is less than one percent of the total health budget. Partnerships with churches and NGOs in delivering services need to be strengthened. In 2008 the PNG Parliamentarians on Population and Development was established – the members have become interested in family planning and maternal mortality. The Minister of Health has established a ministerial task force on recommendations. Asia and the Pacific Consultation

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Philippines

The Congress is in the process of enacting Reproductive Health Law. The Bill is comprehensive, health-oriented, rights-based and adequately funded. It enables the creation of a supportive environment for couples and women to have the freedom of informed choice, to allow the optimum freedom to embrace family planning methods that are medically safe and effective, and legally permissible. The improvement of maternal health as a human right is one of the focus areas of the Bill because the miracle of life should not result in the tragic death of so many women nationwide.

Timor-Leste A small nation that became independent only in 2002 has 19 women parliamentarians out of the total of 65 members of parliament. Maternal mortality is high (660 deaths per 100,000 live births). The main problems are lack of access to maternal health services, skilled attendants at birth and access to emergency obstetric care. In the country’s efforts to reduce maternal mortality, the first step is health, which is free for all citizens. For 2009, the budgetary allocation for maternal and child health programme is $300,000, which the representatives from the country felt is adequate as the country is small. To respond to the lack of access to

Participants from Timor- Leste

health care services, a strategy for increasing access to midwives through the establishment of a midwifery school in 2008 has been developed. In addition, to promote deliveries in health facilities, delivery rooms are being built in health centres. Emergency obstetric care is a national priority. Periodic reports are presented to CEDAW. Timor-Leste is in the process of formulation of a domestic violence law.

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Asian Forum of Parliamentarians on Population and Development

Participants from Philippines


Session 3: Budgetary Allocations for Maternal Health Asian Forum of Parliamentarians on Population and Development

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Investing in Maternal, Newborn and Child HealthThe Case for Asia and the Pacific

Dr. Flavia Bustreo, Director, Partnership for Maternal, Newborn and Child Health

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r. Bustreo presented the Investing in Maternal, Newborn and Child Health: The Case for Asia and the Pacific, which has been prepared by the Maternal, Newborn and Child Health Network for Asia and the Pacific—a partnership of ten agencies1 — developed to highlight the need to accelerate progress, estimate the costs of maternal, newborn and child health (MNCH) interventions, mobilize additional resources to what is already being allocated and spent, and present an approach and methodology for developing country-specific investment cases.

Flavia Bustreo,

Director, The Partnership for Maternal, Newborn and Child Health

Making the case for increased investments in MNCH is important for Asia and the Pacific as the region represents a high share of the global Maternal, Newborn and Child burden of disease, with inadequate financing and coverage of MNCH interventions. Progress related to MDGs 4 and 5 – to reduce child and maternal mortality and achieve universal access to reproductive health, is not very encouraging in many countries – some are stagnating and some are showing early warning signs. There are a number of important reasons to invest in MNCH in Asia and the Pacific, especially given the current financial crisis. Investments in MNCH are an investment in human rights, social justice and economic growth. Investing in maternal, newborn and child health makes economic sense – households with healthier and better nourished mothers and children spend less on healthcare. Also, investing in MNCH benefits the health system. Parliamentarians have an important role to play in promoting maternal and child health through: representing the voices of women and children; legislating to ensure universal access to essential care; budgeting for MNCH; advocating nationally and internationally for the MDGs; and monitoring implementation of policies that advance maternal and child health.

Mr. Ian Anderson, Adviser and Principle Economist, Health Services Delivery, Asian Development Bank

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arliamentarians are in a special position to influence budgets; with the Investment Case for Asia and the Pacific, parliamentarians are equipped with arguments to convince ministries of finance and treasury to invest in MNCH.

Why invest in MNCH? – it is what development is about. Many countries in the Asia and the Pacific have high economic growth, we know what works in terms of reducing maternal mortality, but yet the outcomes are not good. This indicates that something is wrong with the policies. Expenditure on health in Asia and the Pacific is low, and in addition, the quality of expenditure is poor because most of the expenditure is money that people spend on health directly out of their pockets, which leads to increased poverty and increased inequity. Simply investing more is not enough – since most health systems are inequitable, increased allocations will only further increase inequality. 1

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Mr. Ian Anderson,

Adviser and Principal Economist, Health Services Delivery, Asian Development Bank

ADB, AusAID, Bill & Melinda Gates Foundation, JICA, PMNCH, UNFPA, UNICEF, USAID, World Bank, WHO


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The expenditures per person are inadequate, inefficient, and inequitable, incentives are not matched with outcomes, and implementation and expenditures are incomplete as they do not cover certain areas such as family planning and antenatal care. Investments in MNCH make economic sense. About one third to one half of the total growth in Asia and the Pacific can be attributed to good population and health investments, including family planning. Investments in women, particularly adolescent girls, prior to pregnancy positively affect their health and the health of their children down to the third generation, in terms of productivity. The Investment Case for the first time provides guidance on where, when, why, what sequence and how much should be invested in public expenditure, and tells you what the expenditure will do. It makes budgets bankable with the ministry of finance, shows the demand- and supply-side of the expenditure, and suggests political visible quick wins, as well as longer-term investments.

Roundtable Discussion: Strategies for Advocating for Increased Budgetary Allocations for Maternal Health Parliamentarians from selected countries participated in this roundtable, outlining the challenges and strategies to increase allocations for maternal health. The summary is presented below.

Bangladesh

has made significant progress in ensuring maternal health care with particular emphasis on reducing maternal mortality and infant mortality. Resource constraints are not the main issue, it is the prioritization of the budget, and whether health care, especially maternal health, is given the highest priority. It is not lack of policies; there is a maternal health policy and various other policies that are related maternal health. Based on these policies, strategies are developed and implemented. In this context, adequacy of the budget allocation is very important. The target for the budget allocation for the health sector is ten percent by year 2010, out of which, 40 percent is expected to be allocated to poor districts. Parliamentarians have a major role to play in ensuring adequacy of budgets: • During the pre-budget stage, parliamentarians can discuss with key stakeholders and identify their special needs particularly in relation to maternal health and reducing maternal mortality. • Make constructive suggestions in ensuring required allocations and increasing the allocation, stressing the vital need for such an increase and providing justification. • Advance constructive criticism on proposed budgets for maternal health, with emphasis on needs to further increase allocations.

Asia and the Pacific Consultation

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Asian Forum of Parliamentarians on Population and Development

Participants from Bangladesh


Indonesia is rich in natural resources, but still a large number of people live in poverty. Therefore the

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focus is pro-poor, with the Ministry of Health and the parliament giving more attention to the poor for maternal and child health issues. Regarding the budget, most of the budget is for health services, about 50 percent are for curative services and 50 percent for prevention. The budget for maternal health includes a range of services: antenatal care, immunization of children, and contraception after delivery, which divides the budget into many items. Furthermore, the budget is divided across many ministries. The parliament has plans to increase the health budget. In the future, Indonesia would like to develop a law on national social health services so that health services are free for everybody.

Philippines has been successful in ensuring budgetary allocations for maternal health care, but the

challenge has been that despite the allocation, the effective utilization of funds has been deterred by the Catholic Church. Funds have been used mainly for supporting natural family planning. There has been a reduction in maternal mortality, but this does not commensurate with the investment made. Parliamentarians are working to pass the Reproductive Health Bill.

India – as 80 percent of the population lives in rural areas, a National Rural Health Mission has been created to increase access of the rural people to services. Through this, the Government is emphasizing the development of infrastructure, but it should be matched with increase in budgetary allocations. The parliamentarians, especially women parliamentarians, have an important role to ensure that the budget is used for improving the health of the public, particularly women’s health, and must fight for increased allocations for women’s health. India practices gender resource budgeting which involves every ministry, but there is much left to do. At the village level, services are not reaching women. There are dispensaries, health centres and hospitals, but no doctors.

Asia and the Pacific Consultation

Maternal Health and Rights 13-15 August 2009 Bali, Indonesia


Session 4: Ensuring Quality of Care in Maternal

Health Services as a Right Dr. Saramma Thomas Mathai, Regional Team Coordinator and Maternal Health Advisor, UNFPA APRO

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Dr. Saramma Thomas Mathai, Regional Team Coordinator and Maternal Health Advisor, UNFPA APRO

Maternal mortality is an indicator of the poor functioning of the health system, including poor infrastructure, lack of equipment and supplies, shortage of skilled human resources. Inequities in access are clear by the huge differentials in utilization of skilled birth attendants and life-saving Caesarean sections in case of complications. Besides health system gaps, maternal mortality is also an indicator of social injustice. Women and their families, particularly those who are poor and socially excluded, cannot realize their rights to health and survival due to a host of social, cultural and political factors. Analysis of quality of maternal health care as a human right starts with the three inter-related delays: (1) in decision to seek care; (2) in reaching the appropriate facility; and (3) in receiving appropriate high quality care. Linked to the above delays are the rights of clients. The rights of clients include access to accurate, appropriate, understandable and unbiased information; access to services- geographically and financially; and the right to privacy, confidentiality and treatment with dignity during provision of services. Providers also have rights to enable them to deliver quality services. These include the right to continuous improvement in knowledge and skills; adequate equipment, supplies and infrastructure; and supportive supervision. Parliamentarians have a role to play in ensuring quality of maternal and newborn health services:

• Ensure that MDGs 4 and 5 are a high priority in national development plans, thus holding governments accountable for the international commitments they have made; • Advocate for women’s health and rights; • Advocate for more resources; • Build accountability of the health system, including monitor the reach of services (e.g. ask ministry of health for regular reporting); • Encourage all partners – parliamentarians, government, civil society and private sector– to intensify and sustain participation in achieving MDGs 4 and 5; • Facilitate debates locally and at state, district and province levels; • Create special funds for enabling poor women to access services (funds for services, transport, etc.); • Monitor the implementation of national laws and acts such as the marriage act, registration of deaths so that all maternal deaths are known. The media also has an important role to play in mobilizing commitment to save mothers through reporting on maternal deaths and also social audits of these deaths.

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hen a woman in Asia becomes pregnant, her survival cannot be assured. The Asia and the Pacific region has a long way to go in meeting the MDG 5 targets. National figures mask intra-country differences, with maternal mortality and morbidity clustered around poor and rural populations. Safe motherhood is a vital social investment and necessary to achieving the MDGs, not just MDG 5. Maternal mortality and neo-natal morality are correlated; maternal mortality also leads to higher rates of death of children. The loss of a mother – the main investor in social development – leads to higher school dropout rates and increased risk of unwanted pregnancy among adolescent girls. Maternal death and disability also impact family earnings. The majority of maternal deaths are preventable. Cost-effective interventions for reducing maternal mortality are well known, yet a huge number of mothers die unnecessarily during pregnancy and childbirth.


Session 5: How Political Will Translates into Fulfillment Asian Forum of Parliamentarians on Population and Development

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of Rights: The Example of Sri Lanka Hon. Minister Nimal Siripala de Silva, Ministry of Healthcare and Nutrition

T

Hon. Nimal Siripala De Silva,

he Honorable Minister presented the experience of Sri Lanka in reducing maternal mortality in a short time period through investments in health and education. Maternal deaths should not be looked only as a health issue but also as a development and a rights issue. In Sri Lanka the maternal mortality rate was very high – over 500 deaths per 100,000 live births 5 decades ago and was reduced to 100 by the mid-1970s, and now to 40. Sri Lanka managed to achieve millennium development goals in maternal mortality and infant mortality ahead of the target date.

Minister of Health and Education of Government of Sri Lanka

There were a number of key factors to the Sri Lanka’s success: • There was strong political will that has been consistently demonstrated by the Governments formed by various political parties. • The Government’s policy to provide free education and free health to all the people as an investment for development of a healthy and literate work force has been critical for the economic development of the country. • The Government’s focus on education and training of key health personnel for MNH to ensure a skilled, efficient and responsive workforce. • Inclusion of socio- economic determinants of maternal and child health through intersectoral action has added value to the health system ensuring equity and is an additional factor for achieving good indicators of maternal health. • Participation of women and communities in the design and implementation of programmes and policies contributed to the improvement of health and welfare of women. • All women, irrespective of their geographical locations and social and cultural background, have access to comprehensive, sexual and reproductive health information and services, including maternal and child health. • Advocacy and recognition of maternal health as a political challenge as much as medical and health challenge.

Asia and the Pacific Consultation

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Session 6: The Role of the Media in Advocating for and

Monitoring Implementation of the Right to Maternal Health Ms. Katja Iverson, Media Specialist, UNFPA Information and External Relations Division

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• A strong network of powerful individuals and organizations who care about maternal health, working together not just at the global level but in every country. At the global level, one can see this coming together through the H4, the White Ms. Katja Iverson, Media Specialist, UNFPA Information and Ribbon Alliance, Women Deliver, and some big organizations pushing the issue. External Relations Division

• Identify stakeholders in every country, who can place maternal health on the national agenda. • Come to agreement on the solution – there is already a good level of agreement on the three key elements to improve maternal health: family planning, skilled birth attendants and emergency obstetric care. • Have a clear proposal of what to do, including costing. It is necessary to have facts and figures to back the case. • Identify prominent supporters. Support of prominent people – politicians, celebrities, academia, corporate sector, etc. – is useful in drawing attention to the issue. • Facts and figures: develop political, economic arguments on what needs to be done and why. • Cases and faces: numbers are important, but we also need to tell the stories, who are these women who are dying? • Events that can draw attention to the issue. • Media coverage that can draw attention to the issue. • Resources for advocacy and communication, both human resources and money.

What can the media do?

The media can put a focus on maternal health, report on maternal health, mobilize politicians and the public around promoting maternal health, and act as a watch dog. News stories can and do result in changes in policy and budget. Things that facilitate coverage are news hooks (e.g. events, campaigns, political cycle), field visits, clear messages and spokespeople, executive summaries, media kits and international attention. In covering maternal health, it is important to treat it as a development and a rights issue, not just a health issue. Both the big picture as well as the individuals affected should be highlighted. Be sure not to make the problem seem hopeless. Do not expect one story to solve the problem.

Roundtable Discussion on the Role of Media in Advocating For and Monitoring Implementation of the Right to Maternal Health This list represents the common themes that emerged during the roundtable discussion in terms of challenges faced by media in reporting on maternal health:

• Fighting for enough space and time to report on maternal health; • Often stories about women dying come under crime; • Journalists are not able to fully comprehend the stories to write in-depth articles; • Journalists are not trained to cover health issues; • Sources of information are very limited; • Information provided uses too much jargon. Asia and the Pacific Consultation

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e live in a public world, where policy is very public. Topics that are kept quiet do not make it on the political agenda, or the public agenda. This is why we need to look not just at the media, but also at political agenda setting. If we are going to be successful, we need:


Session 7: Development of Country Level Action Plans

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D

r. Saramma Thomas Mathai, Regional Team Coordinator and Technical Adviser, UNFPA APRO provided suggestions for the country action plans based on the discussions from the preceding sessions.

The objective of the country action plans was to identify concrete actions that parliamentarians and media can take to impact on maternal health in their selected constituencies, regions or divisions. In developing the country action plans, suggestions were provided for activities to include: • Conducting social audits to explore the obstacles a woman faces to reach a hospital; • Promoting deliveries by birth attendants; • Mobilizing support for community insurance schemes for the poor; • Monitoring whether services are reaching the people; • Building accountability in the health system; • Facilitating debate locally at the state level or division level on issues such as maternal health; • Capacity building for parliamentarians and media. *Detailed country action plans can be found in Annex 3.

Asia and the Pacific Consultation

Maternal Health and Rights 13-15 August 2009 Bali, Indonesia


Session 8: The Role of Regional Level Strategies in Supporting National Action on Maternal Health: Key Elements for Regional Action Plan

O

ut of the country level action plans, key elements of a regional action plan emerged, made up of 10 major themes. These themes, along with specific suggestions from country action plans, are provided below.

1) Advocacy for maternal health

a. Establish a national committee of parliamentarians for maternal health. b. Create a core group of committed legislators, for advocacy. c. Establish a high level committee on maternal health. d. Strengthen inter-ministerial coordination for maternal health. e. Conduct oversight by the House of Representatives’ Committees on Health and MDGs through a resolution. f. Include maternal health in the legislative –executive committee for Debt-for-MDGs. g. Include policy issues on maternal health and reproductive health to be included in election platforms. h. Organize Special Session to discuss MH in sub-national assembly, national parliament. i. Discuss at national and sub-national levels on conventions signed. j. Advocate for increasing budgetary allocations for maternal health. k. Advocate for a policy to make each maternal death notifiable and facilitate systematic Maternal Death Audits. l. Conduct social audits of maternal deaths (includes participation of opinion leaders). m. Raise awareness about impact of child marriage on health of the young mother during pregnancy and also on development. n. Facilitate dialogue between stakeholders and opinion leaders through debates. o. Share lessons learned with other countries with similar population characteristics. p. Share maternal health action plan (developed in Bali) with other stakeholders who can contribute in implementation and monitoring.

2) Improving access of the poor and excluded groups

a. Geographical focus within the overall national plan for strengthening maternal health services to improve the access of the poor and excluded groups to quality services. b. Strengthen the ongoing interventions for reducing financial barriers or introducing new ones to enable poor women to access skilled care at birth. c. Parliamentarians monitor implementation of health equity and other funds. d. Review of implementation of maternal health voucher schemes to ensure that the rights holders get their full entitlement. e. Initiate insurance schemes for maternal health that cover emergency obstetric care. f. Create budgets at district level for the poor.

Asia and the Pacific Consultation

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22 Asian Forum of Parliamentarians on Population and Development

Dr. Saramma Thomas Mathai captured important issues from country presentations which formed the key elements of a Regional Action Plan.


3) Community mobilization and support

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a. Mobilize funds through local mechanisms including donations. b. Social mobilization to promote maternal health and family planning as rights. c. Involvement in social audits of maternal deaths. d. Advocate for utilization of maternal health services especially by the poor & excluded groups. e. Create community support groups for creating awareness on importance of skilled care during pregnancy and childbirth.

4) Improve information on maternal deaths

a. Study maternal death statistics per region. b. Conduct community maternal death audit leading to national social audits.

5) Strengthen health system management at the district levels

a. Strengthen ambulance services. b. Provision of accommodation, transport, security and other facilities for peripheral staff. c. Upgrade facilities to provide 24/7 emergency obstetric care with adequate skilled human resources, supplies and equipment, particularly in rural and remote areas.

6) Promotion of deliveries by skilled birth attendants

a. Allocate additional funding (for training as well as salaries). b. Support development of community skilled birth attendants (SBAs). c. Strengthen linkages of community with SBAs and referrals to SBAs. d. Provide mobile phones to SBAs to enable them to seek advice in case of emergencies and for timely referrals. For example provision of mobile phones to Lady Health Workers to enable them to provide support. e. Develop regulatory mechanisms for SBAs and monitoring the implementation of regulations. f. Introduce advanced midwifery training in selected countries where the capacity exists.

7) Monitoring the reach of services

a. Monitor whether the Government facilities are offering services they are expected to deliver. b. Formation of a health care commission to monitor the reach of services, including whether the reach is equitable. c. Establishment of a system of rewards and punishments for efficient delivery of maternal health services.

8) Monitor existing laws and develop new laws

a. Conduct follow-up studies of/analysis on existing laws and regulations (such as age at marriage). b. Assess the need for amending or formulating new local regulations (example: new law on safe motherhood in Nepal). c. Enforce the implementation of laws and regulations by development principle/technical guidelines. d. Review of the Midwifery Act.

9) Role of media

a. Build partnership with parliamentarians and develop joint action plans. b. Strengthen the forum of journalists on population, RH and gender at the national level and establish the forum at the district level. c. Report on positive and negative issues. d. Publish issues on maternal health in key newspapers. e. Create awareness about maternal health, gaps in services, etc through traditional media and radio. f. Mould public opinion and create demand for entitlements related to maternal health including lapses on part of governments.

Asia and the Pacific Consultation

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Media at the national, provincial and district levels: g. Be an active partner to disseminate information related MNH straight to grassroots communities. h. Identify partner parliamentarians, government officials and CSOs. i. Link with Executive Secretary who will facilitate interviews with govt. officials, parliamentarians.

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10) Capacity building

a. Nominate a focal point for media and parliamentarians on maternal health. b. Conduct regular training/ workshops at district level with technical support. c. Organize study tours to countries with a similar health situation or socio-cultural issues to learn best practices. d. Share information through electronic media. e. Train media to report sensitively on maternal deaths.

Asia and the Pacific Consultation

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Session 9: Concluding Session Asian Forum of Parliamentarians on Population and Development

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M

r. Wasim Zaman, Executive Director, ICOMP, in his closing comments noted that when talking about rights in relation to service provision, it is not easy. Money is certainly important, but it must be put in the right place, with the right people, and monitored in the right way. We also need to ensure that the international community does not forget Asia and the Pacific– even where countries are progressing very well economically – because there is work that remains to be done. Management and leadership are very important – not just the leadership at the top, but the leadership of parliamentarians, the leadership of the bureaucracy to ensure that the people who need it have the right expertise. We have unfinished business, particularly in dealing with inequalities, Mr. Wasim Zaman, Executive Director, International which is not acceptable and must be addressed. It is necessary to look at real Council on Management of Population access, real quality and real services to the right people in the rural areas particuProgrammes (ICOMP) larly. There is data for everything, but when decisions are being made, the right data is very rarely on the table whether it is in the rural areas or in the parliamentarian building. We need to strengthen the use of appropriate and accurate data. We also need to focus on male involvement, not just for the politics of it, but for real awareness building, for real connections, real things happening with the male participants and also services for boys and men. In his summary speech, the Honorable Minister Nimal Siripala de Silva, Ministry of Healthcare and Nutrition of Sri Lanka, appreciated the organizers for the arrangement of the Consultation. The participants had the benefit of listening and exchanging information. He noted that there is a lot of talent within our region, within our own cultures, within own philosophies, and we can evolve programmes for maternal health. The concept of the right of women to better maternal health facilities, the right to information and reproductive health facilities, etc. may come from the facilitators, but in our own countries and our own region, we must have our own programmes. In her closing remarks, Ms. Nobuko Horibe, Director APRO reminded participants that we must be aware that there are many other elements – social, economic, cultural elements – that need to be addressed to really come to the desired result we want to see with reduction in maternal mortality, and this should be reflected in the action plans. She also emphasized that male involvement at all levels is important when we are addressing women and young women who deliver. We have to target men, husbands and community leaders so that they should be involved in the further development and implementation of the action plans. UNFPA and other UN agencies can provide technical backstopping and serve as a resource for parliamentarians in their efforts to reduce maternal mortality. Mr. Shiv Khare, Executive Director, AFPPD gave vote of thanks to all the parliamentarians, the resource persons, the Indonesian Forum of Parliamentarians and UNFPA. AFPPD will provide support to the countries in preparation of their respective country programmes.

Asia and the Pacific Consultation

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Annex 1: Agenda AGENDA Thursday, August 13

Conceptual Framework for Promoting Maternal Health

9:00-10:00

WELCOME REMARKS

Dr. Zahidul Huque UNFPA Representative in Indonesia Hon. Dr. Laode Ida, MP Deputy Speaker of the Upper House, Indonesia Hon. Mr. Sugiri Syarief Director- General, National Family Planning Coordinating Board of Indonesia (BKKBN) Hon. Senator Dr. Pinit Kullavanijaya Secretary- General of AFPPD Thailand Opening Address Ms. Nobuko Horibe Director, UNFPA Asia and the Pacific Regional Office (APRO)

Session III: Budgetary Allocations for Maternal Health Objective: To review the current investments in maternal health, emphasizing equity in terms of availability and accessibility of services to ensure coverage of the most vulnerable and marginalized populations. Investing in Maternal, Newborn and Child Health- The Case for Asia and the Pacific Dr. Flavia Bustreo Director, Partneship for Maternal, Newborn and Child Health Mr. Ian Anderson Advisor and Principle Economist, Health Services Delivery, Asian Development Bank

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14:00-15:30

Roundtable Discussion: Strategies for Advocating for Increased Budgetary Allocations for Maternal Health Facilitator: Dr. Zahidul Huque UNFPA Representative in Indonesia

10:00-10:30

Coffee Break

Coffee Break

10:30-11:00

Session I:Keynote Address International Human Rights Mechanisms and Maternal Health: A Global Perspective on the Right to Maternal Health

Session IV: Quality of Maternal Health Care

Mr. Anand Grover Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Health

11:00-13:00

15:30-15:45

Objective: To ensure that efforts to increase access and availability of maternal and newborn health services through expansion of coverage go hand in hand with efforts to improve acceptability and quality of services.

15:45-17:00

Ensuring Quality of Care in Maternal Health Services as a Right Dr. Saramma Mathai Regional Team Coordinator and Technical Adviser on Maternal Health, UNFPA APRO

Session II: The Right to Maternal Health in Asia and the Pacific Objective: To examine the state of the right to maternal health in the participating countries and identify achievements and gaps. A Rights-based Review of Maternal Health in Asia and the Pacific Mr. Rajat Khosla Consultant

Dinner Reception

18:00 onwards

Roundtable Discussion: Challenges and Opportunities for Implementing a Rights- Based Approach to Reducing Maternal Mortality and Morbidity (MMR) Facilitator: Ms. Suneeta Mukherjee UNFPA Representative in Philippines 13:00-14:00

Lunch

Asia and the Pacific Consultation

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Asian Forum of Parliamentarians on Population and Development

DAY 1

Asia and the Pacific Consultation on Maternal Health and Rights


AGENDA

DAY 2 Asian Forum of Parliamentarians on Population and Development

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Planning for Country Level Action

Friday, August 14

9:00-10:00

Session V: How Political Will Translates into Fullfilment of Rights: The Example of Sri Lanka Hon. Minister Nimal Siripala de Silva Ministry of Healthcare and Nutrition, Sri Lanka Discussion

10:00-11:00

Session VI: The Role of the Media in Advocating for and Monitoring Implementation of the Right to Maternal Health Objective: To share examples and identify ways that the media can support efforts, including activities of parliamentarians, to ensure implementation of the right to maternal health. Panel Discussion: The Role of the Media in Advocating for and Monitoring Progress in Achieving MDG5 Facilitator: Ms. Katya Iverson Media Specialist, UNFPA Information and External Relations Division

11:00-11:15

Coffee Break

11:15-12:45

Session VII: Country Level Action Plans Objective: To develop country action plans with a focus on selected constituencies to advocate for increased allocations for maternal health

13:00- 14:00 Session VII (cont’d) 14:00-15:30 15:30-15:45 Session VII (cont’d) 15:45-17:00

DAY 3

Lunch Country-based Working Groups: Development of Country Level Action Plans Coffee Break Sharing of Country Level Action Plans Expectations for Follow-Up at Country Level

Elements of a Regional Action Plan on Maternal Health

Saturday, August 15 9:00-10:30

Session VIII Discussion: The Role of Regional Level Strategies in Supporting National Action on Maternal Health: Key Elements for a Regional Action Plan

10:30-11:00

Closing Ceremony

11:00-11:30

Group Photo

Asia and the Pacific Consultation

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Annex 2: List of Participants

BANGLADESH Dr. Shirin Sharmin Choudhury Member of Parliament, State Minister, Bangladesh Mrs. Chemon Ara Begum, MD Member of Parliament, Bangladesh Mr. Iqbal Sobhan Chowdhury Editor, The Bangladesh Observer Dr. Zaman Ara National Programme Officer, UNFPA Bangladesh Ms. Asma Akter Programme Associate, Advocacy and Gender, UNFPA Bangladesh CAMBODIA Mrs. Ho Naun Member of Parliament, Chair of the Committee on Public Health, Cambodia Mr. Min Sean Member of Parliament, Vice-Chair of the Committee on Public Health, Cambodia Mrs. Krouch Sam An Member of Parliament, Commission on Legislation and Justice, Cambodia Mr. Heang Thul Deputy Director of International Department, Cambodia Ms. Sophanara Pen Communications Associate, UNFPA Cambodia Dr. Sokun Sok Programme Manager, UNFPA Cambodia Ms. Mom Kunthear Reporter, Cambodia COOK ISLANDS Mr. John David Tangi Member of Parliament, Cook Islands FIJI Mr. Alifereti D. Bulivou Dr. Wame Baravilala Adviser on Reproductive Health, UNFPA Pacific Sub-Regional Office

INDIA Ms. Mabel Rebello Member of Parliament, Jharkhand, India

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AUSTRALIA Ms. Claire Moore Chair, Australian Parliamentary Group on Population and Development Senator, Australia

Ms. Viplove Thakur Member of Parliament, Himachal Pradesh, India Mr. Ram Narain Meena Member of Parliament, Rajasthan, India Mr. Manmohan Sharma Executive-Secretary, IAPPD Mr. Urukram Sharma Journalist Mr. Rajat Ray Senior Advocacy and Communication Officer, UNFPA India Dr. Sunil Thomas Jacob State Programme Coordinator, UNFPA India INDONESIA Mr. Sayed Fuad Zakaria Member of Parliament, Chairman of IFPPD Aceh and the next of DPRRI, Indonesia Dr. Hetifah Sjaifudian Sumarta Member of Parliament, Indonesia Dr. Sumarjati Arjoso Member of Parliament, Indonesia Dr. Sri Hermiyanti IFPPD Ms. Nelita General Officer, IFPPD Dr. Sugiri Syarief Director-General, BKKBN Dr. Eddy Hasmi Director of International Training and Collaboration, BKKBN Dr. Kasmiyati Deputy for Training and Development, BKKBN Ms. Rita Widiadana Journalist, Indonesia Dr. Zahidul Huque Representative, UNFPA Indonesia Mr. Samidjo Samidjo National Programme Officer, Advocacy, UNFPA Indonesia Dr. Melania Hidayat National Programme Officer, RH, UNFPA Indonesia

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Ms. Maria Endah Hulupi UNFPA Indonesia

Mr. Edcel Lagman Congressman, Philippines

LAOS Prof. Dr. Phonethep Pholsena Member of Parliament, Professor, Doctor, Vice Chairman of Social and Cultural Committee, Laos

Ms. Janette Garin Congresswoman, Philippines

Mrs. Chanhthoum Latmany Member of the National Assembly, Vice-President of Lao Women’s Union, Laos Mr. Bounfeng Phoummalaysith Deputy Director General of the Cabinet, Ministry of Health, Laos Mr. Douangchanh Xaymounvong National Programme Officer, UNFPA Laos Ms. Della Sherratt Senior Midwifery Consultant, UNFPA Laos NEPAL Mrs. Kamala Thapa Member of Parliament, Nepal Mr. Naresh Newar Editor, Nepal Mr. Ramji Dhakal Reproductive Health Coordinator, UNFPA Nepal Ms. Anna Adhikari Communications Officer, UNFPA Nepal Dr. Vinit Sharma Regional Adviser on Maternal Health, UNFPA Sub-Regional Office, Kathmandu NEW ZEALAND Ms. Naomi Williams Project Coordinator, NCPPD/ Family Planning International

Dr. Junice L. D. Melgar Philippines Mr. Ramon San Pascual Executive Director, PLCPD Ms. Rina Jimenez David Columnist, Philippines Ms. Suneeta Mukherjee Representative, UNFPA Philippines Ms. Rena Dona Assistant Representative, UNFPA Philippines Dr. Hendry Plaza Programme Officer on Reproductive Health, UNFPA Philippines Ms. Ana Maria Leal National Programme Associate, UNFPA Philippines Ms. Arlene Alano Information officer, UNFPA Philippines Ms. Maria Regina Emilia Jimenez David Information officer, UNFPA Philippines PAPUA NEW GUINEA Dame Carol Kidu Member of Parliament, Minister for Community Development, Papua New Guinea Hon. Francesca Semosa Deputy Speaker, Bougainville House of Representatives, Papua New Guinea

PAKISTAN Mr. Saeed Elahi Member of Parliament, Chairman Chief, Pakistan

Dr. Gilbert W. Hawalyer Assistant Representative, UNFPA Papua New Guinea

Ms. Humera Alwani Member Provincial Assembly, Sindh, Pakistan

SOLOMON ISLANDS Ms. Polini Boseto National Programme Officer, UNFPA Solomon Islands

Mr. Kamal Siddiqi Editor Reporting, Pakistan Dr. Jamil Ahmad Chaudhry Provincial Coordination Officer, UNFPA Pakistan PHILIPPINES Ms. Darlene Magnolia Ricasa Antonino-Custodio Congresswoman, Philippines Asia and the Pacific Consultation

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THAILAND Dr. Pinit Kullavanijaya Senator, Professor of Medicine, Secretary-General, AFPPD, Thailand Dr. Anan Ariyachaipanich, Senator, Chairman, Thailand


TIMOR-LESTE Ms. Virgilio Maria Dias Marcal Member of Parliament, Timor-Leste

Dr. Domingas Bernardo Programme Officer, UNFPA Timor-Leste RESOURCE PERSONS Mr. Nimal Siripala de Silva Minister of Health and Nutrition, Sri Lanka Mr. Anand Grover UN Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Health Mr. Ian Anderson Advisor and Principal Economist, ADB Dr. Flavia Bustreo Director, PMNCH Mr. Wasim Zaman Executive Director, ICOMP UNFPA - APRO Ms. Nobuko Horibe Regional Director

Mr. Stefano Palazzi Regional Security Adviser

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Ms. Galanne Deressa Programme Specialist

Asian Forum of Parliamentarians on Population and Development

Mr. Francisco Martins Da Costa Pereira Seronimo Member of Parliament, Timor-Leste

Mr. Rajat Khosla Consultant, UNFPA APRO

UNFPA-NEW YORK Mr. Stan Bernstein Senior Policy Adviser Ms. Katja Iverson Media Specialist and Campaigns Coordinator AFPPD Mr. Shiv Khare Executive Director Ms. Salakjit Nakduang Programme Associate Ms. Maria Kardashevskaya Programme Associate Mr. Oleg Shovkovy Programme Associate Ms. Jirapa Rerkphongsri Accountant, AFPPD

Dr. Saramma Thomas Mathai Regional Team Coordinator and Maternal Health Advisor

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Annex 3: Country Action Plans Asian Forum of Parliamentarians on Population and Development

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BANGLADESH Action Plan for the Years 2009-2010 Promotion & Protection of Maternal Health & Rights and Prevention of Maternal Mortality 1) Formation of a National Committee for Protection and Enforcement of Maternal Rights, involving parliamentarians, media professionals, civil society, private and corporate sectors, by adopting the following measures: • Mobilization of resources; • Implementation of Action Plan; • Monitor progress of national policies related to maternal health and rights; • Monitor quality of services, reach of services, utilization of funds, etc.; • Address poverty alleviation by adopting an integrated approach with particular emphasis on the plight of women 2) Adopt a pilot scheme selecting 6 districts from 6 divisions with particular focus on districts consisting of ultra poor and hard-to-reach women: • Capacity building; • Training of community skilled birth attendants; • Implement midwifery training programme; • Render quality health services to women through community clinics, Upazial Health Complexes, Family Welfare Centres; • Educate all pregnant mothers on antenatal and post-natal care; • Community support groups to facilitate access of women to MH services through local government involvement; • Introduce community insurance scheme in the pilot districts for poor women to access maternal health services. 3) Support awareness creation initiatives through orientation counseling and social mobilization: • Facilitate scaling-up of existing demand-side interventions, e.g. maternal voucher scheme and maternity allowances programme operating at the national level in piloting districts. 4) Facilitate formation of Community Support Groups. 5) Promote and strengthen facilities for protection of maternal health under the Public Private Partnership (PPP) initiative. 6) Role of the Parliamentarians: • Sharing the experience the Consultation on Maternal Health and Rights and the action plan with parliamentarians and media professionals; • Policy advocacy to make each maternal death notifiable and facilitate systematic maternal death audit; • Roundtable discussion with parliamentarians and media on maternal health & rights; • Regular interaction with regional parliamentarians and media professionals for experience sharing and exchanging views; • Increase inter-ministerial coordination and collaboration for ensuring women’s rights; • Sharing information with media professionals and parliamentarians through newsletter, emails and regular interaction; • Training of media professionals on a right-based approach to reporting 7) Role of Media: • To encourage and promote media coverage and campaign on maternal health and rights; • Training of media professionals how to write and report on maternal health and rights without and stigma and prejudice; • Involvement of the media as partner to implement the country action plan; • To promote and involve the alternative media, new media and cultural groups 8) Support is needed from: • Standing Committee of the Parliament; • Concerned Ministries of the Government; • Technical and Financial Support from the Government, Development Partners, Donors; • APRO and AFPPD; • UNFPA Media and Communication Branch (Local and HQs)

Asia and the Pacific Consultation

Maternal Health and Rights 13-15 August 2009 Bali, Indonesia


CAMBODIA Action Plan for Parliamentarians and Media in Response to Maternal Health and Rights

No.

2

3

Who

Time Frame 2009 Q4

2010

Sensitization on advocacy skills for maternal health and rights for MPs and media – selected constituencies. Feedback from women and children focal points and beneficiaries – priority selected province where the MMR remain high or unchanged. Monitor the effectiveness of the implementation of the maternal health and rights and related laws and conventions: 1-Sensitization/consultation meeting with key ministries, women and children focal points and beneficiaries – priority to remote and marginalized provinces – piloting. 2-Fact finding on maternal death cases. 3-Mobilize, promote and encourage the continuation of the equity fund at the national level. 4-Mobilize community support to create the financial contribution to the maternal health for the poor through pagoda fund and commune council fund. 5-Promote deliveries by skilled birth attendants, family planning services.

MPs Media

MPs Media

Q1 & Q3

Dissemination results event

MPs Media

Q4

Budget 2009

Total

32

2010

Asian Forum of Parliamentarians on Population and Development

1

Activities

INDIA Addressing Child Marriage in Rajasthan from Theory to Practice Proactive Partnership – a Joint Commitment of Legislatures and Rajasthan Patrika (newspaper) 1) First steps for proactive partnerships: • Seed funds: - UNFPA - Rajasthan Patrika - State Government of Rajasthan • Technical support: - UNFPA - Supported by UNRC’s office and IAPPD • Blueprint of Action by October 2009 2) Key roles of partners: • Legislators - Create a group of like-minded legislators - Advocate in the assembly, to addressing causes for child marriage - Propose formation of a core group of officials from different departments to work on a common platform

Asia and the Pacific Consultation

Maternal Health and Rights 13-15 August 2009 Bali, Indonesia


Asian Forum of Parliamentarians on Population and Development

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• Rajasthan Patrika - Gather evidence on issues around child marriage - Work closely with legislators to generate large share of voice for constructive reporting

• UNRC’s office/IAPPD - Mobilize support to the initiative amongst legislators - Broker partnerships between concerned MPs and MLAs to assure single-minded initiative - Take this initiative to other states

• UNFPA - Facilitate orientation workshops and provide latest data and analysis - Provide local support through the UNFPA State Office at Jaipur

INDONESIA Country Action Plan Situational analysis of maternal health in Indonesia • Indonesia population: 228 million • Lack access to health services • Uneven distribution of health workers • MMR 228/100,000 live births • Unmet need: 8% • Abortion: 2 million cases (74% married women) • Challenges - Lack of regulation - Lack of law enforcement - Lack of awareness among parliamentarians, government and the public KEY ACTIONS 1) Social audit: Identify challenges PARLIAMENTARIANS • Parliamentarians (IFPPD) to develop special agenda on maternal health and rights. Areas without IFPPD presence need to develop Executive Secretary (inter-party forum) with networks, including with local governments, the media, academicians, CSOs, community-based organizations to do assessment and analysis (local specifics) – to proactively collect data and information to determine MHR priorities. Aceh, East Kalimantan and Central Java for pilot areas. • Promote NGO involvement for advocacy.

MEDIA at national, provincial and district levels • Act as active partner to disseminate information related MNH straight to grassroots communities • Identify partner parliamentarians, government officials and CSOs • Link with Executive Secretary who will facilitate interviews with government officials and parliamentarians • Strengthen forum of journalists on population, RH and gender at the national level and establish the forum at the district level • Media training to enhance their knowledge and reporting skills • Strengthen forum of journalists on population, RH and gender at the national level and establish the forum at the district level

2) Promote skilled birth attendants • Parliamentarians at the central level need to continuously advocate for regulation at provincial and district level to extend the contract of the existing midwives and recruit them as civil servants • Central parliamentarians actively advocate for favorable regulations/policies, budget and programmes for maternal health and FP: adequate midwives and supplies, at the provincial and district levels • Community empowerment to stimulate service utilization 3) Community insurance schemes • Parliamentarians to encourage allocation from the district budgets to cover the poor not registered or not covered by the central government. Develop national health insurance, which enables cross-subsidy in health services between the haves and the poor. • Network with parliamentarians from different Commissions (infrastructure/transport, women’s empowerment, health, public services) Asia and the Pacific Consultation

Maternal Health and Rights 13-15 August 2009 Bali, Indonesia


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5) Facilitate debates • Media function as watchdog: selecting the right media for discussions, information dissemination, monitoring government policy regulations at national, provincial and grassroots levels. For example, national media for policy discussions on maternal health and rights, local media for educating at the grassroots level. • Parliamentarians, government officials, CSO, NGOs, religious and community leaders and media engage in continuous discussions 6) Monitor implementation of existing laws/ regulations • Conduct follow up studies of analysis on existing laws and regulations • Assess the need for amending or formulating new local regulations • Enforce the implementation of laws and regulations by development principle/technical guidelines 7) Capacity building • Parliamentarians at all levels: organize orientation sessions or regular technical support from technical agencies, especially for newly elected parliamentarians, on RH, maternal and child health. Develop a list of resources persons • Visits to media offices • Media: knowledge training for young journalists and advanced sensitization for senior editors 8) Follow-up action • Quarterly review of the progress, the barriers, the challenges in maternal health and rights for solutions

Asia and the Pacific Consultation

Maternal Health and Rights 13-15 August 2009 Bali, Indonesia

Asian Forum of Parliamentarians on Population and Development

4) Monitor the reach of services • Parliamentarians need to promote good governance, transparency and accountability. Mechanism: parliamentarians partner with relevant stakeholders, especially district health offices to improve data availability and utilization for budgets and programmes to close the gaps in access to services • Reward and punishment based on periodic assessment of the health workers’ performance • Establish hotline and mechanism for filing of complaints and complaint handling at the Executive Secretary • Conduct periodic monitoring visits • Public education at community level • Media: conduct periodic field trips


NOTES


NOTES


NOTES


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Maternal Health and Rights:Asia and the Pacific Consultation  

Maternal Health and Rights:Asia and the Pacific Consultation

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