December, 2016 - SUPPORT Summary of a systematic review | print this article |

Does international aid improve maternal and reproductive health?

The adoption of the Paris Declaration on Aid Effectiveness in 2005 represented a global agenda to improve aid management and delivery. Its impact on maternal and reproductive health, particularly on the relevant Millenium Development Goals (MDGs), is an important issue in terms of global health strategies for low income countries. This review evaluates the impact of the Paris Declaration by assessing available evidence of how aid delivered under the Paris Principles impacts on development outcomes, focusing specifically on maternal and reproductive health (MDG 5).

 

Key messages

  • It is uncertain whether aid delivered under the Paris Principles or without conforming to those principles improves maternal and reproductive health outcomes.
  • Aid supported interventions to improve maternal and reproductive health should include an evaluation plan.

 

Background

The Millennium Development Goal 5 (MDG 5) aimed to improve maternal and reproductive health outcomes by: a) reducing the maternal mortality ratio by 75%; and b) achieving universal access to reproductive healthcare, by 2015. The adoption of the Paris Declaration on Aid Effectiveness in 2005 represented a global agenda to improve aid management and delivery, partly in order to address the slow progress towards the MDGs. The principles can be summarised as: Ownership – developing countries set their own development strategies; Alignment – donor countries and organisations bring their support in line with these strategies and use local systems to deliver that support; Harmonisation – donor countries and organisations coordinate their actions, simplify procedures and share information to avoid duplication; Managing for Results – developing countries and donors focus on producing and measuring results; and Mutual Accountability – donors and developing countries are accountable for development results.




About the systematic review underlying this summary

Review objectives: To compare the effects on Millennium Development Goal 5 outcomes of aid delivered under the Paris Principles and aid delivered outside this framework.
Type of What the review authors searched for What the review authors found
Study designs & interventions

Studies had to present empirical research (qualitative or quantitative), i.e. contain primary dataInterventions: aid delivered under the Paris Principles, aid in general, or directly comparing both.

Interrupted time series (1 study), pre test post test (17), secondary data analysis (5), process training methodology (1), retrospective analyses (3), unclear (1), and qualitative components (3)

10 studies for aid delivered under the Paris Principles, and 20 for aid in general

Participants Donors and receiving developing countries

Bilateral donor agencies: USAID (8 studies); Canadian International Development Agency (1); DFID (4).

Multilateral agencies: World Bank (8). Large number of donors (5). Non governmental organisations: CARE (1); Bill and Melinda Gates Foundation (2); Save the Children Australia (1); PEPFAR (1); MotherCare (1)

Settings Studies had to refer to developing countries or regions.
China (3), Honduras (2), Indonesia (3), Uzbekistan (1), Egypt (3), Nicaragua (1), Botswana (1), South Africa (1), People’s Democratic Republic of Lao (1), Tanzania (2), Cameroon (1), Bangladesh (2), Nepal (2), Ghana (2), Uganda (1), Madagascar (1), India (1), Pakistan (1), Guinea (1), Burkina Faso (1), Timor Leste (1), Rwanda (1), Zimbabwe (1)
Outcomes Maternal mortality ratios, births attended by skilled birth personnel, contraception prevalence, adolescent birth rate, antenatal care coverage, unmet need for family planning, trends in maternal and reproductive health

Maternal mortality ratio or rate (MDG 5.1): 12 studies

Births attended by skilled birth personnel (MDG 5.2): 17 studies

Contraceptive prevalence (MDG 5.3): 15 studies

Adolescent birth rate (MDG 5.4): 1 study

Antenatal care coverage (MDG 5.5): 14 studies

Unmet need for family planning (MDG 5.6): 2 studies

Date of most recent search: August 2010
Limitations: This review has important limitations.

Hayman R, Taylor EM, Crawford F, et al. The impact of aid on maternal and reproductive health: a systematic review to evaluate the effect of aid on the outcomes of Millennium Development Goal 5. London: EPPI Centre, 2011.


Summary of findings

The review included 30 studies from 23 developing countries, including aid delivered under the Paris Principles (10 studies) and for aid in general (20 studies).

1) Aid delivered under the Paris Principles

The 10 studies covered a mixture of aid modalities, including budget support, sector budget support, multidonor trust funds, soft loans, silent partnerships, pooled funding and projects.

  • It is uncertain whether aid delivered under the Paris Principles improves maternal and reproductive health outcomes because the certainty of this evidence is very low.

Aid delivered under the Paris Principles.

People: Donors and receiving developing countries.
Settings
:  Bangladesh, China, Egypt, Ghana, Honduras, Indonesia, Tanzania, Lao People’s Democratic Republic.
Intervention
Aid assumed to be compliant with the Paris Principles*
Comparison
No aid
Outcomes Impact Certainty of the evidence
(GRADE)
Maternal mortality ratios
The impact on maternal mortality ratios of aid delivered under the Paris Principles is uncertain.


Very low

 


Proportion of births attended by skilled personnel
The impact on births attended by skilled personnel of aid delivered under the Paris Principles is uncertain.


Very low

 


Contraceptive use The impact on contraceptive use of aid delivered under the Paris Principles is uncertain.

 

Very low

 

Adolescent birth rate No studies found by the review.  
Antenatal care coverage The impact on antenatal care coverage of aid delivered under the Paris Principles is uncertain.


Very low

 

Unmet need for family planning The impact on unmet need for family planning of aid delivered under the Paris Principles is uncertain.


Very low

 

GRADE: GRADE Working Group grades of evidence (see above and last page)

* The activities in the included studies started before the Paris Declaration and are assumed to be compliant with the Paris Principles

2) Aid in general

The 20 studies included for this intervention did not adhere or it was not possible to ascertain their adherence to the Paris Principles.

  • It is uncertain whether aid delivered with no conformity with the Paris Principles improves maternal and reproductive health outcomes because the certainty of this evidence is very low.

Aid in general

People: Donors and receiving developing countries.
Settings
:  China, Indonesia, Uzbekistan, Egypt, Nicaragua, Botswana, South Africa, Tanzania, Cameroon, Bangladesh, Nepal, Ghana, Uganda, Madagascar, India, Pakistan, Guinea, Burkina Faso, Timor Leste, Rwanda, Zimbabwe.
Intervention
: Aid in general.
Comparison
: No aid
Outcomes Impact Certainty of the evidence
(GRADE)
Maternal mortality ratios
The impact on maternal mortality ratios of aid delivered with no conformity with the Paris Principles is uncertain.

 

Very low
Proportion of births attended by skilled personnel
The impact on births attended by skilled personnel of aid delivered with no conformity with the Paris Principles is uncertain.

 

Very low

Contraceptive use The impact on contraceptive use of aid delivered with no conformity with the Paris Principles is uncertain.

 

Very low

Adolescent birth rate The impact on adolescent birth rate of aid delivered with no conformity with the Paris Principles is uncertain.

 

Very low

 

Antenatal care coverage The impact on antenatal care coverage of aid delivered with no conformity with the Paris Principles is uncertain.

 

Very low

 

Unmet need for family planning The impact on unmet need for family planning of aid delivered with no conformity with the Paris Principles is uncertain.

 

Very low

 

GRADE: GRADE Working Group grades of evidence (see above and last page)

 


 

 

 

 

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY

Many of the studies were conducted in low-income countries.

 

  • The Paris Principles have been increasingly applied to aid for low-income countries, but there is very low certainty about their effect on maternal and reproductive health.

 


Local management or control capacities in low income countries might influence the assurance of the Paris Principles application in practice.

 

  • Ownership of aid supported programs targeting MDG 5 targets may be questionable in countries that do not have national health plans that included MDG 5 targets.
  • Capacity building of local teams is an important issue to take into account, to the extent that long term sustainability of programmes supported by aid is a goal.
  • The attention to other areas of the local or national health system can be unintentionally diminished because of the need to manage the work demanded by donors’ aid programmes.

 


EQUITY
No equity outcome or considerations were explored in the review.
If health programmes or interventions supported by aid do not consider impacts on equity, they could increase inequities.
ECONOMIC CONSIDERATIONS
No economic related findings were explored in the review. Socioeconomic determinants were only considered as confounding factors in the analyses.
Aid programmes should consider whether the amount and length of aid is sufficient to achieve intended goals and the economic sustainability of interventions after the aid ends.
MONITORING & EVALUATION
The certainty of the evidence for aid interventions in low income countries is very low.

Future aid supported interventions in maternal and reproductive health need to have a well structured evaluation plan aiming to explore the effects on important outcomes, including the impact on other areas of the health system, families’ lives and society when relevant. As randomised trials might be difficult to carry out, interrupted time series studies should be considered, with sufficient baseline data, detailed descriptions of the aid intervention characteristics (including the amounts of aid and country internal funding and the length of funding), the socio political context, and the primary outcomes.


*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low income countries. For additional details about how these judgements were made see:www.supportsummaries.org/methods

 

Additional information

Related literature

 

Hsu J, Berman P, Mills A. Reproductive health priorities: evidence from a resource tracking analysis of official development assistance in 2009 and 2010. Lancet. 2013 May 18; 381 (9879):1772-82.

 

Hsu J, Pitt C, Greco G, Berman P, Mills A. Countdown to 2015: changes in official development assistance to maternal, newborn, and child health in 2009-10, and assessment of progress since 2003. Lancet. 2012 Sep 29; 380 (9848):1157-68.

 

Grépin KA, Leach Kemon K, Schneider M, Sridhar D. How to do (or not to do). Tracking data on development assistance for health. Health Policy Plan. 2012 Sep; 27 (6):527-34.

 

Piva P, Dodd R. Where did all the aid go? An in depth analysis of increased health aid flows over the past 10 years. Bull World Health Organ. 2009 Dec; 87 (12):930-9.

 

Ravishankar N, Gubbins P, Cooley RJ, Leach Kemon K, Michaud CM, Jamison DT, Murray CJ. Financing of global health: tracking development assistance for health from 1990 to 2007. Lancet. 2009 Jun 20; 373 (9681):2113-24.

 

This summary was prepared by

Cristian Herrera. Department of Public Health and Evidence Based Healthcare Program. Pontificia Universidad Católica de Chile. Chile.

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by: Rachel Hayman and Paolo Piva.

 

This review should be cited as

Hayman R, Taylor EM, Crawford F, et al. The impact of aid on maternal and reproductive health: a systematic review to evaluate the effect of aid on the outcomes of Millennium Development Goal 5. London: EPPI Centre, 2011.

 

The summary should be cited as

Herrera C. Does international aid improve maternal and reproductive health? A SUPPORT Summary of a systematic review. December 2016. www.supportsummaries.org

 

Keywords

evidence informed health policy, evidence based, systematic review, health systems research, health care, low income countries, developing countries, primary health care, international aid, donors, maternal and reproductive health.

 

This summary was prepared with additional support from:

 The Unit for Health Policy and Systems Research of the Evidence Based Health-care Program, Faculty of Medicine, Pontificia Universidad Católica de Chile. Chile.

 


 

 

 

 

 

 

 

 



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