Contribution to international development: report 2021 to 2023

2. Health

In line with SDG 3, IDF-supported projects in health contribute to the building of resilient systems, and the provision of urgently needed interventions, to improve health outcomes for vulnerable communities across our partner countries.

2.1 ODA Spend – Programmed Health Projects

During 2021-23, we continued to fund a number of projects focused on SDG 3, including:

• Towards a Dental School for Malawi – the MalDent Project delivered through the partnership between Kamuzu University of Health Sciences (KUHeS). and University of Glasgow seeks to address the problem of the small dental surgeon workforce in Malawi by establishing a successful Bachelor of Dental Surgery degree at KUHeS. Prior to the start of the programme, there were a total of 49 dentists in Malawi, with 40 of those practicing privately, meaning a dentist/patient ratio of 1:419,000 (compared to UK 1:2,000)^[8][9]. The first cohort of students commenced their studies in August 2019, there are currently 118 (48 female) students enrolled on the programme, Malawi’s first cohort of dental surgeons expected to graduate in December 2024. (Please see our 2017/2018 Report for a case study on this project);^[10]
• First aid and renewable energy solutions for communities in Zambia's Central Province, delivered through First Aid Africa, to provide increased access to emergency care for the people of Chitambo district in Zambia’s Central province, including provision of solar panels for Chitambo Hospital. (Please see our 2018/2019 Report for a case study on this project); ^[11]
• PrevENT: Community ear and hearing care and rehabilitation of disabling hearing loss, delivered through CBM, to contribute and support the strengthening of Zambia’s national Ear, Nose and Throat [ENT] strategy plans through its timely alignment with the Ministry of Health’s National ENT Strategic Plan 2016-2020. (Please see our 2019/2020 Report for a case study on this project);^[12] and
• Moving towards sustainability: strengthening rural health facilities, upskilling providers and developing mentoring capacity to support roll-out of cervical cancer ‘screen and treat’ services across Malawi (MALSCOT), delivered through the partnership of Edinburgh University and Nkhoma CCAP Hospital Malawi (Please see our 2019/2020 Report for a case study on this project).

Projects are explored in more detail for the period of this Report through our Case Studies below.

2.2 Case Studies

Case Study H1: Community Action and Service Access for Maternal, Newborn and Child health ‘CASA’ project, Lilongwe, Malawi – St John Scotland and St John Malawi.

In line with the priorities of the Scottish Government International Development Strategy, CASA educates pregnant women, new mothers with infants, and children under five about basic health issues. By contributing to the improved maternal and child survival and health, St John are making a difference to sustainable household practices for safe motherhood and child health. In remote villages, where health services are unavailable, St John volunteers and local health staff run outreach clinics, bringing services to some of the country’s most hard to reach areas.

Key milestones reached by the project in 2021-2023:

• Safer motherhood outreach to households reached 9,978 priority beneficiaries: pregnant women, mothers with newborns and partners. This was 166% of St John’s target of 6,000 in 2021-23.
• CASA has conducted and supported 240 outreach clinics in remote villages (Kauma, Chiuzira and Chimbalanga areas) together with local clinics, ‘nurses and Health Surveillance Assistants (HSAs’)’. These clinic consultations exceeded the 2021-23 target by 15.5%.
• Through the District Health Office (DHO) and District Health Management Teams, CASA has supported and facilitated the elections and training of new Health Advisory Committee (HAC) members in all the three health facilities. The HACs – which were established at the beginning of project in 2018 and include community volunteers – continue to assess the functionality of health facilities and ensure community health needs are prioritised when reporting to DHO authorities.

Key Learning In The Project

A new ‘Track and Trace’ initiative tracked follow-up appointments made by referrals from volunteers in the community to their local health facility. This initiative helped to improve the referral uptake on ill/malnourished children, pregnant women attending ANC and other services. CASA has continued to encourage volunteers in conducting regular follow-ups with beneficiaries to determine if they have attended a service they were referred to.

Quote from a Community Leader: “In my catchment area under Chimbalanga, the population is over 4000 with about 900 households. Today, I am happy to say almost 90% of this population are accessing health services through outreach clinics done by St John Malawi in collaboration with our local clinic. Outreach clinics are consistent, people do not walk long distances to access health service, as a result it gives the community members more time to do other community development activities in the areas”.

Case Study H2: Building cutting-edge laboratory and research capacity in Malawi and Zambia – University of Glasgow, Kamuzu University of Health (KUHeS) Sciences and The University of Zambia (UNZA)

This project, recognised as an exemplar of global north-south partnership, has leveraged Scottish and African institutional expertise to develop two cutting-edge clinical laboratory facilities at KUHeS, Malawi and UNZA, Zambia. The initial project developed the “Blantyre-Blantyre Research Lab” – a state-of-the-art facility that has significantly boosted evidence-based research and training programmes, as well as contributing to medical interventions and health policy in Malawi, Scotland and Zambia. Owing to the significant impact driven forward by this project, the project was extended to a second phase – developing equivalent facilities and expertise at UNZA in Zambia. By bringing internationally-renowned expertise in non-communicable and infectious diseases together this project has successfully instituted a significant step change with wide ranging, positive impact. This project has prioritised investment into building and harnessing technical expertise from within the partner institutions in Malawi and Zambia, to create a sustainable pipeline of research and innovation capacity in Africa, for Africa, by Africans.

Impact - Malawi/KUHeS

Since becoming fully operational in 2023, KUHeS has a fully functional state-of-the-art facility equipped with cutting-edge scientific equipment. This will allow partnership and engagement with global researchers, advance KUHeS’ reputation and create opportunities for income generation through grant applications with new collaborators, pharma and from solar power initiatives.

Impact – Zambia/UNZA

As part of the Scottish Government’s response to supporting Zambia recover from COVID-19, the First Minister committed funding of £1 million to establish a state-of-the-art research laboratory which will empower Zambian experts in the field of vaccinology and parasitology. The announcement of this tailored support for Zambia was made by the First Minister in April 2023, when he met with the President of the Republic of Zambia, Hakainde Hichilema during his visit to Edinburgh. The new facility, hosted by the University of Zambia, focuses on life-saving research and increased access to vaccines in the country.

Impact - Scotland/University of Glasgow

This project has had major positive impact on research collaboration and development. Furthermore, the project has facilitated further collaboration with Scottish Universities and KUHeS, leading to a number of impactful and cross-cutting research projects.

Impact – Contributing to global health research

The laboratory facilities have been recognised as an important game-changing resource for Malawi and Zambia. The expansion of the initial project to include integration with partners in Zambia at University of Zambia has enormous potential for global scientific research and data sharing. The project has been an impetus for south-south collaboration, it has broken down barriers and showcased best practice, what works and what doesn’t in a spirit of collaboration with and within Africa. Now nearing completion, the new laboratory at UNZA will create a ground-breaking three-country collaboration in scientific research between the universities in Scotland, Malawi and Zambia, helping our partner countries to build back stronger and fairer from the pandemic.

Impact – Economic and climate

The solar installation project at both laboratories have brought jobs, training and economic opportunity to both Malawi and Zambia. In particular, as a direct impact of the solar installation KUHeS has rolled out solar power to four of its sites in Malawi. The Blantyre-Blantyre installation demonstrated solar power could be successful in an education setting, leading to a step-change in thinking, gave opportunity to women engineers and promoted diversity.

Impact – Gender

From the project's inception, there has been a focus on providing training and development opportunities for young engineering graduates, particularly women interested in STEM fields, in Malawi and Zambia. The involvement of women engineers has been pivotal in fostering sustainable development and empowering young electrical engineering students. In line with commitments to advance gender equality, training was provided for women solar engineers, and it was ensured that women made up 50% of the team.

Professor Paul Garside, University of Glasgow, said: “The Blantyre-Blantyre research projects have been an amazing success story for Malawi, Zambia and Scotland and demonstrate the importance and impact that true partnership, at every level from government to individual, can have”.

The First Minister, Humza Yousaf, commented: “The COVID-19 pandemic highlighted the importance of countries working together across continents to jointly tackle global health challenges. This initiative, led by Zambian and Malawian expertise, with Scottish Government support, will improve health outcomes in these countries as well as produce research that will contribute to global good.”

Case Study H3: HPV Funding Project: Global Alliance for Vaccination and Immunisation

Cervical cancer is one of the biggest threats to women and girls in our partner countries. It caused 342,000 global deaths in 2020, with 90% of those occurring in low- and middle-income countries. Cervical cancer up to 90% preventable through Human Papillomavirus (HPV) vaccination^[13]. The HPV vaccine is the key intervention towards achieving the World Health Organisation’s global strategy to eliminate cervical cancer. To achieve that goal, by 2030, 90% of girls should be fully vaccinated with HPV vaccine by age 15^[14].

In 2023, the Scottish Government announced £712,000 from the IDF to support expanded access to the HPV vaccine in Malawi, Rwanda and Zambia. The funding was awarded to the Global Alliance for Vaccination and Immunisation (GAVI) due to the organisation’s extensive operational capacity to deliver an immediate and effective supply of HPV vaccines in our partner countries. GAVI is a renowned Swiss Foundation with international institution status, which helps vaccinate more than half the world’s children against deadly and debilitating infectious diseases.

Funding provided by the Scottish Government has contributed towards GAVI's goal of inoculating 86 million girls with the HPV vaccine by 2025. As of 2023, GAVI have achieved immunisation coverage of 98% in Rwanda, 86% in Malawi and 82% in Zambia^[15].

2.3 ODA Spend – IDF Funding in Response to COVID-19

The COVID-19 pandemic, still at its height during the period of this Report, overwhelmed even the most resilient health systems and affected most IDF-supported projects, with a small minority unable to continue.

In response the Scottish Government developed a strategy for COVID-19 response in line with that of our partner countries’ governments.

In the initial months, April to July 2020, we worked with partners to undertake a rapid ‘COVID-19 Impact Assessment’ of our entire ID portfolio, followed by monthly progress reporting, which all partners in receipt of IDF funding were required to complete. As part of this monthly reporting, grant holders were required to notify the Scottish Government of any risk to planned activities and/or budget due to COVID-19 impact:

• this process enabled IDF funds to be closely monitored and managed according to project need and ability to use the funds, which resulted in the need to continuously reprofile spend at project and programme level into 2021 and 2022;
• through this process we adopted a flexible grant management approach: when notified of potential risk to delivery, we worked with partners to pivot funds to enable ongoing project activity, for example through the purchasing of PPE for projects such as the MALSCOT (Malawi cervical cancer) project, and necessary digital infrastructure;
• in some cases, projects were unable to continue delivery, resulting in project underspend: examples of projects that reported a necessary pause in project activity in certain years during COVID-19 were; work undertaken by Police Scotland on gender-based violence, improving child protection and supporting governance in Malawi and Zambia^[16]; and the Comic Relief Levelling the Field Initiative on improving the economic wellbeing of women and girls in all three of our African partner countries;
• we also reinvested this underspend within the IDF resulting from the impact of COVID-19 into other projects supported by the Scottish Government that needed additional funding to enable continued safe delivery. Projects which received additional funding during 2020/21 were: Kids OR initiative in Zambia for PPE; St. John Scotland in Malawi for PPE; the University of Glasgow and Malawi College of Medicine to procure COVID-19 test kits; and the University of Glasgow MalDent project to purchase digital devices and data bundles for remote teaching at the Malawi College of Medicine. More detail was given on this in our 2019/20 Report.

In the next phase of our COVID-19 response, we then looked to support other initiatives through further strategic partnerships, again reallocating and reinvesting funding that had been freed up due to COVID-impact, for benefit of our partner countries. This focused firstly on supporting the delivery of life-saving personal protective equipment (PPE) and ventilators before contributing to equitable vaccine rollout and online learning across the Global South.

Our quick and effective work in support of our partner countries during the pandemic was made possible by the reallocation of over £3.5 million of IDF funding to contribute to COVID-19 efforts of Malawi, Rwanda and Zambia. We took steps to ensure that our COVID-19 response strategy was directly aligned to that taken by our partner countries through regular consultation, and by directly funding their own national vaccination programme partner organisations such as UNICEF.

During the pandemic, Scottish Ministers regularly updated Parliament and published several documents providing information on our approach to COVID-19 response and on the impact of COVID-19 on IDF spend. This Chapter refers in particular to, and provides an update on, the Cabinet Secretary for Constitution, External Affairs and Culture’s letter of 6 June 2022 to the CEAC Committee, as well as the Minister for Culture, Europe and International Development’s supplementary letter of 9 June 2022. These letters, alongside regular press releases throughout the reporting period, addressed specific questions on funding decisions and, in particular, non-competitively awarded funding addressed in Chapter 1 of this Report.

Case Study H4: Directly Supporting Partner Country COVID-19 Response: UNICEF

Driven by the Scottish Government’s commitment to partner country-led development, during 2020-22 we supported the vaccine programmes of our partner governments of Malawi, Rwanda, and Zambia. We did this through providing £3.5 million in grant funding, awarded on a non-competitive basis, to the UN-mandated organisation with the most operational capacity to deliver vaccination programmes – the United Nations International Children’s Emergency Fund (UNICEF) – over 2020/22. As above, it is common for donors to award Multilateral organisations, like UN agencies, grants directly rather than by competition.

UNICEF was chosen and awarded due to being the existing delivery partner in our partner country governments’ national vaccine programmes, as well as being a trusted multinational organisation. This funding reflected Scottish Ministers’ enduring commitment to partner country-led funding, by directly supporting their asks and contributing to their needs on vaccine equity.

This £3.5 million total funding to support vaccine programmes of our partner countries was awarded in two separate tranches:

• In November 2020, Minister for International Development announced^[17] £2 million in funds from our 2020/21 IDF budget through UNICEF to address the impact of the pandemic on children in Malawi, Zambia and Rwanda. The funds were equally divided between each country to be used to meet each country’s specific needs, including contributing to UNICEF’s work in: preparing health systems for the distribution of the COVID-19 vaccine; the procurement and delivery of 13.8m vaccines across Malawi, Rwanda and Zambia; and the support of water, sanitation and hygiene, child protection, health care, immunisation, nutrition and education.
• In February 2022, building on the previous grant funding, Minister for International Development announced^[18] additional funds through UNICEF, with £1.5 million to support equitable access to COVID-19 vaccines and therapeutics in our three African partner countries directly. It was targeted to ongoing COVID-19 vaccination responses supporting both COVID-19 vaccination programmes and the strengthening of the health systems in Rwanda, Zambia and Malawi, through the provision of equipment, resources and technical support in response to the pandemic. In addition, the funding contributed to:
  • the identified priority of delivery of at least 6.5 million vaccine syringes in Rwanda, to ensure the availability of sufficient vaccination equipment;
  • in Zambia, working to strengthen their cold chain storage for vaccines and improve the healthcare system's ability to deliver oxygen; and
  • in Malawi, work was undertaken to expand the capacity of the existing oxygen generation plant at Kamuzu Central Hospital. Funding was also provided for Health Systems Strengthening, purchasing urgently needed supplies, both relevant for Malawi’s COVID-19 response and the parallel cholera outbreak, such as oral rehydration salts, IV fluids, antibiotics, cannulas, water purification tablets and WASH (water, sanitation and hygiene) supplies.
• In Malawi and Zambia, UNICEF also worked to provide information about, and build confidence and acceptance of, the COVID-19 vaccines at community level – a vital part of the programme which reached over nine million people.

Case Study H5: Transportation of Vital Medical Equipment: Kids Operating Room

In 2021, we provided a grant to Kids Operating Room (KidsOR), a Scottish-based global health charity, in order to distribute vital equipment to treat COVID-19 patients in Africa. In recognition of KidsOR’s particular expertise in transporting medical equipment to Malawi, Zambia and Rwanda, we awarded this IDF funding on a non-competitive basis (see also c.1 on “how we work”).

We provided a total of £577,295 to enable KidsOR to purchase, transport and install 300 Oxygen Concentrators and accessories (100 each for Malawi, Rwanda and Zambia). In August 2021, NHS Scotland also provided 41 surplus ventilators worth £734,553 to our African Partner Countries, with the Scottish Government grant covering the transportation costs during July-September 2021.

Scottish Government funds enabled the transportation of a donation of £14 million worth of PPE equipment (25 shipping containers) to Malawi, Rwanda and Zambia through the NHS Scotland Global Citizenship Programme. KidsOR also raised a further £1m to support transport of the PPE from the Wood Foundation, Pula Limited, Postcode Trust, and Delta Philanthropies. In each case, KidsOR also contributed their staffing resource to enable this large-scale donation from Scotland of O2 concentrators, ventilators, and PPE needed for our partner countries’ COVID responses. These PPE supplies, which included FFP3 masks, goggles, and visors, were sent via KidsOR to Uganda, Sierra Leone, Senegal, Botswana, Mozambique and Zimbabwe, in addition to Malawi, Rwanda and Zambia.

Case Study H7: Extra Funding for COVID-19 Response

In November 2021, the Scottish Government committed extra funds worth £1.5 million to support the COVID-19 response of the governments of our partner countries. Projects that have been supported include installing an oxygen plant facility in the Chitambo Hospital in Zambia, funding for work at the Kamuzu University of Health Sciences in Malawi to help identify new variants of the virus.

In addition, support from the Humanitarian Emergency Fund has gone towards COVID-19 response efforts for vulnerable communities in countries such as Syria, Yemen, Somalia, South Sudan, Afghanistan, and the Democratic Republic of Congo.

2.4 Health Policy Initiatives Post-2021 Review

Our work to deliver on our commitments to prioritise health investment within our future international development work was also developed during the period of this Report. In line with our International Development Principles, we consulted our partner country governments and wide-ranging international development stakeholders.

To deliver on our commitments to increase and improve our future support to our partner countries, during the reporting period we commissioned evidence (published in January 2024) to inform the development of new health programming from 2024. This new phase of health work will focus on non-communicable diseases and supporting our partner countries to accelerate progress on health systems strengthening.

In September 2023 we announced our first funding activity as part of our new health programme, committing up to £2.5million to the UN Health4Life fund over the next five years. Our funding will support Global-South-led advocacy, action and leadership on the prevention of NCDs. The Scottish Government have been invited by the WHO to take a technical and strategic leadership role within the fund. We are working actively with partners to increase resource mobilisation and coordination to tackle NCDs in our partner countries. Further information about our new Health programme can be found at 11.4 in this Report.

2.5 Cross-Scottish-Government Policy Initiatives

In line with our commitments on policy coherence for our health work, and commitments to ‘do no harm’, wider Scottish Government policy initiatives developed and adopted during this period that contribute to international development include:

Global Citizenship in NHS Scotland

The NHS Scotland Global Citizenship Programme supports an NHS Scotland Global Citizenship Community of over 450 NHS staff who undertake a wider variety of global health work with partners around the world. Short case studies of the type of activity that the Community participates in is presented in the virtual storybook ‘NHS Scotland Global Citizenship: Stories of People, Partnership and Place’ published in 2021. The Community is represented by a national network of Global Citizenship Lead Champions from across NHS Scotland.

You can find out more about the NHS Scotland Global Citizenship Programme at www.scottishglobalhealth.org.

Key deliverables of the NHS Scotland Global Citizenship Programme in 2021-23 included:

• Publication of NHS Scotland Active Global Citizenship resources to increase knowledge and understanding of the UN SDGs within NHS Scotland. See Case Study H8 below.
• Establishment of the Quality Improvement for Health Partnerships Programme between NHS Scotland and the Health Ministries of Malawi and Zambia. The Partnership aims to guide and support health partnership activity between Malawi, Zambia and Scotland by ensuring it is aligned to need and delivered in a way that is effective, ethical and sustainable. See Case Study H9 below.
• NHS Scotland Global Citizenship conferences were held virtually in 2021 and 2023. Speakers and attendees joined from across Scotland and internationally. Conference themes included climate change, quality improvement in health partnership work and tackling power imbalances in global health.
• The annual Scottish Health Awards global citizenship category recognises the dedication and commitment of health and social care staff who participate in high quality, ethical and sustainable global health work with partners in LMICs. Podcast conversations with the finalists provide an opportunity to hear their experience of global health work and the projects they are involved with.

Case Study H8: Active Global Citizenship in the NHS

Active Global Citizenship within NHS Scotland is based on three key principles: the understanding that inequity leads to health inequality; poverty causes poor health; and climate change is a public health emergency.

In 2020-21, the NHS Scotland Global Citizenship programme partnered with Edinburgh-based education charity Scotdec, and the Bridge 47 – Building Global Citizenship network to develop a range of resources to support NHS staff to engage with the SDGs.

The NHS Scotland Active Global Citizenship resources are available from www.scottishglobalhealth.org/active-global-citizenship/

Case Study 9: Quality Improvement for Health Partnerships Programme

In 2022, the Scottish Government/NHS Scotland and Malawian and Zambian Health Ministries established the Quality Improvement for Health Partnerships Programme.

The tripartite partnership between the three governments seeks to build on Scotland’s long-standing international development relationships and further support the existing South-South connection between Zambia and Malawi on health.

The Partnership adopts the approach set out in the WHO Twinning Partnership for Improvement with the WHO represented on the strategic steering group for the programme.

Priority areas of collaboration include building capacity in quality improvement and improving patient safety in key areas.

As well as virtual meetings, partners have had the opportunity to meet in-person in Scotland in 2022 and Malawi in 2023.

Learning from the Partnership has been shared at the International Forum on Quality and Safety in Health Care (2022), at the WHO Global Quality Rounds series (2023) and at the NHS Scotland Global Citizenship conferences (2021 & 2023).^[19][20]

Case Study H10: Donating Medical Equipment Report – Do No Harm

In 2021, the Scottish Government’s Chief Medical Officer for Scotland commissioned KidsOR, a Scottish global health charity, to lead a review of the standards required for donations of medical equipment to LMICs.

The review sought the views of both donating and receiving partners and resulted in the publication of a new ‘Donating Medical Equipment Report: 10 Step Guide and Checklist’ to provide a clear roadmap through the important considerations for a safe and effective donation. Training workshops were delivered in 2023 through the Scottish International Development Alliance and NHS Scotland Global Citizenship Programme.

The resources, which are intended for anyone involved in or thinking about getting involved in the donation of medical equipment, are available from: www.gov.scot/publications/chief-medical-officers-donating-medical-equipment-report/documents/.