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CORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 1075-i House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE INTERNATIONAL DEVELOPMENT COMMITTEE
Tuesday 16 October 2007 MRS THORAYA AHMED OBAID and DR FRANCISCO SONGANE Evidence heard in Public Questions 1 - 62
USE OF THE TRANSCRIPT
Oral Evidence Taken before the International Development Committee on Tuesday 16 October 2007 Members present Malcolm Bruce, in the Chair John Battle Hugh Bayley Richard Burden James Duddridge Ann McKechin Sir Robert Smith ________________ Witnesses: Mrs Thoraya Ahmed Obaid, United Nations Population Fund (UNFPA) Executive Director, UN Under-Secretary-General, and Dr Francisco Songane, Director, Partnership for Maternal, Newborn and Child Health, gave evidence. Q1 Chairman: Good morning. It would be helpful if you gave an introduction about who you are and your background for the record. Thank you for being here. I appreciate you are here for other reasons as well but it is fortunate for us. Mrs Obaid: Thank you for having us here today. I am Thoraya Ahmed Obaid and I am the Executive Director of the United Nations Population Fund. I have been in this post since 2001, basically working on our areas of concern, which are population and development, issues of data and statistics and so on. A major part of that is promoting sexual and reproductive health. We work in almost 140 countries where we have country offices. Our staff doing this work are one-third international and two-thirds national. Dr Songane: I am Francisco Songane. I am the Director of the Partnership for Maternal, Newborn and Child Health. I am a medical doctor, an obstetrician and gynaecologist. I started this job in February of last year. The Partnership for Maternal, Newborn and Child Health is a new partnership which was launched in September 2005 as a way of harmonising and co-ordinating activities around maternity, newborn and child health. As you may be aware, there were three partnerships addressing children: the Child Survival Partnership, the Safe Motherhood and Newborn Partnership and the Healthy Newborn Partnership. Of course all these things are interrelated, particularly when we are on the ground. We do all these things together. It was found useful to merge these partnerships and form one. That is how we were created. Before I became the Director of the Partnership last year, I was the Minister of Health in Mozambique from January 2000 up to January 2005. Before that, I worked as an obstetrician in district and provincial hospitals and in the central hospital co-ordinating activities in maternal and child health. Q2 Chairman: Thank you for that. The Committee did make a very interesting visit to Mozambique 18 months ago and we saw some of the co-ordination that was going on there, which was good, although we were not particularly looking at aspects of health; it was more about general development. It was an interesting and worthwhile visit. This is the first formal evidence session that we are taking in this inquiry, which we have undertaken fundamentally because of all the MDGs,[1] this is the one that most often turns up and causes most concern as to why that should be and why it is proving so difficult to get it on to target, and indeed in some cases it appears to be going backwards rather than forwards. I wonder if you can perhaps give us a general feel, both of you, as to why you think that is. We had an informal teach-in last week when we saw some of the challenges and heard about them. What came out of it all the time was that two things are needed: one is resources in a whole variety of different ways; and the other is political will. I have probably put those the wrong way round in the sense that the resources are no use if they are not backed up by political will. I wondered if you could give us your thoughts on that: which is the greater and where you think the problems lie. Perhaps I can push this a little bit further. If it is political will, whose political will needs to be jacked up? By definition, as you have already said, there are quite a lot of initiatives - our own government has taken initiatives - but none of it seems to make any difference. That may be political will on some kind of round the world platform but it does not translate to realities on the ground. I wondered if you could give us a flavour of what you think. Is it political will or resources? Where is the problem? What do you think might move us forward? Mrs Obaid: Political will is certainly a very important part. It is political will on both the national governments as well as on the donor side. On the national governments, basically - I think my colleague, Francisco, can testify as a health minister - the investment from the national budget into the health sector is not as it should be to meet all the needs. From the donor side, we know that to deal with maternal health, and particularly maternal death and maternal mortality, there are three interventions: family planning, emergency obstetric care and skilled birth attendance at birth. In terms of family planning itself, I will give you some figures. We know that there are 200 million women who would like to plan their families but they have no access to contraceptives to be able to plan. If a woman can plan the spacing and number of her children, then her survival will be much greater. In terms of investment, in 1995 of population assistance as a whole, 55 % was going to family planning and in 2004, the figure was 9 %, so investment in family planning including contraceptives has gone down, which means one of the three interventions to save mothers is not there. That is a political commitment issue, which is to invest in terms of ensuring that contraceptives are available. Q3 Chairman: If I could press you on that, is that commitment or is there prejudice? Mrs Obaid: From the donors' side it is commitment but also competing demands; that is part of it. It tends to shift from one area to another. That is why now that there is the new initiative by DFID[2] in terms of health sector reform and health sector support, we need to ensure that this will go on, as they say in their strategy, for 10 to 20 years, with consistent support for that. That is one thing. The second, which is related to our work, is the whole issue of gender. That is one of the MDGs, the issue that women are of low status; they are not a priority politically; and the whole issue of maternal health and gender empowerment is not yet on the political agenda at the national level. There is that exclusion also: denial of rights and not enough recognition of the human rights of women, and certainly health is a human right. This is the second challenge: political commitment on the health issue. The third one is the capacity of the health system to deliver. Here, as we are talking about health systems, we are talking at the national level, but women die at the community level where the poor are, and therefore the ability of the health system to deliver primary health care and to create a package of reproductive health that takes women throughout their reproductive age is a very important component and there is not enough investment there. Dr Songane: Thank you for that good introduction by Mrs Obaid. This is an important occasion and we welcome it profoundly, particularly now that you are marking 20 years of the Safe Motherhood Initiative this week here in London. We have a conference with the title "Women Deliver" exactly to address these concerns. A committee is trying to go into the details. Political will is very important. We need this political will at all levels: at the country level and internationally. Things are happening but they are not happening fast enough and not with the comprehensiveness we would like to see. As my colleague has said, there are three important deprivations. There is no doubt that access to family planning, skilled attendance at delivery and prompt access to emergency obstetric care when needed are crucial. If we do not put these things in place, there is no way we can lower the high levels of maternal mortality. We can make an assessment through the publication this week of the paper in The Lancet on estimates of maternal mortality. Sadly, we have not made progress. The figures we had in 1987 when the Safe Motherhood Initiative was launched in Nairobi are exactly the same today. Half a million women die every year, which is one woman per minute every day. That is the picture. Why have things not changed? It is partly because the political commitment which was required to bring about this change was not at the level of the challenge; secondly, it is because there has been too much talking and concentration on activities which were regarded as simple, cheap and easy to do. In particular, there was a push to train traditional birth attendants only and no proper attention given to the need to increase the number of skilled attendants at delivery and the number of institutions providing the services in order to allow women to be there and be taken care of by a skilled attendant. You need a small maternity unit. The emergency obstetric care was not there. I can judge by the experience I went through in my own country. As I said, I am an obstetrician by training; I worked in the district, provincial and central hospitals. I remember well the long tedious discussions we had with many funding institutions, including the World Bank, to convince them in the Eighties that we needed to increase the number of maternity units and the number of district hospitals offering emergency obstetric care in order to provide better outcome. Q4 Chairman: That is an important point. What you are saying is that in the context of Mozambique, for example, there was political will within the country but international institutions did not respond appropriately. Dr Songane: Exactly; it took a long time for them to change and adopt a different approach and agree that they should fund the kinds of interventions we were advocating. It is important to know that. In terms of the overall co-ordination internationally, if you wanted additional resources to get the services improved, to train more staff in the procedures of which they should have profound knowledge to take care of women, you would have a hard time as compared to the resources to train traditional birth attendants. It is not that the traditional birth attendants are not needed; they are important but that has to be put in context as part of a team where there is a continuum from what they get at the house in the village and in the community and they bring the woman to the nearest maternity unit or where there is a station where she could have a midwife or a nurse. This is the process. In terms of resources, the resources are needed internally in countries and internationally to add to what we are doing now. The issue of additional resources has not been addressed properly. There has been resistance to putting resources where they are needed. For instance, the WHO[3] World Health Report of 2005, which addressed maternal, newborn and child health, pointed out that we need an additional US$ 9 billion per year to address the basic services in maternal, newborn and child health and we are not near that figure. Then The Lancet issued a series on maternal health in October last year. There was an exercise to assess how ODA (Official Development Assistance) is doing in different countries. Sadly, we found that only 2 % of ODA is going to maternal and child health. If you break these figures down you get the staggering figure of only half a billion that is going to maternal health and newborn health. There is neglect in terms of maternal health. This is the situation we have to change. There is a new momentum and Britain is part of that. We should commend the UK on the initiative to try to get things fixed. The International Health Partnership which was launched here in London has to be seen within the context of the whole effort which is made to address MDGs 4 and 5, relating to child and maternal health. This is being done together. The honourable Members of Parliament will know that this is about the UK, Norway, Canada, the Gates Foundation and various countries, be they donors or countries in need. The Partnership for Maternal and Child Health provided a platform to reach out to a wider membership. These are the things we have to build on. Last month there was an announcement in New York at the launch of the Global Campaign for the Health MDGs by the Prime Minister of Norway and the Prime Minister of the Netherlands of US$ 1 billion over 10 years from now as additional money from Norway and US$125 million for three years as additional money from the Netherlands. We have to seize and build on these things. I am sure that this week at the Women Deliver Conference we will add to that and it will be the focus of conference. We hope to get ministers of health and the ministers of planning and other leaders worldwide to come to terms with the issue that we have to remove this shame; we have to take a different stand and address this as a human rights issue and say that it is not permissible when we know what to do, when we have the resources and when women are dying in the same number as in 1987. Q5 Hugh Bayley: In relation to maternal and child health, what are the respective responsibilities of UNFPA, WHO, UNDP[4] and UNICEF[5]? Who is responsible for what? Mrs Obaid: WHO did an exercise, all of us together, to discuss where we are. They produced a nice graph of the continuum of services, which we are all in the process of agreeing upon. Each one of us agreed on where we can play the role of a focal agency. For example, family planning is UNFPA; antenatal care is UNICEF; skilled birth attendants, is UNFPA, which includes midwives as well; emergency obstetric care is UNFPA and UNICEF jointly (we work together on that); post-partum and care of mothers, et cetera, is UNFPA; and management of newborns is UNICEF. In a sense, UNICEF gets the children and we get the mothers but there is an overlap when we are talking about emergency obstetric care and we do that together. WHO is very much the normative; WHO sets standards for us; they do the protocols and guidance notes and we work with them on that. They provide technical assistance to governments but in the field they are not as operational as UNFPA and UNICEF and we consider them as our reference points basically. Of course the World Bank deals with the whole area of finance, strategic planning, poverty reduction strategies and so on. We want to ensure that within these national processes maternal health finds a place. We try to be at the table to be able to advocate with the governments when these big funds are being allocated that appropriate funds go to UNFPA. UNDP does not necessarily deal with issues of maternal health. They deal with issues of governance as a whole where systems are in place to deliver. It is really the three organisations - WHO, UNFPA and UNICEF - and we are working together. We already have a coalition or a partnership among the three of us to continue to work together with an agreement that whoever has the most resources at the country level should be the lead agency. For example, in family planning, we are a lead agency but that does not mean we are doing it alone; it means we are supposed to catalyse whoever is on the ground to work with us, whether they are NGOs,[6] bilaterals or UN agencies, and of course to support governments in that. That is how we are trying to function with one another. Q6 Hugh Bayley: It seems to me that the fragmentation is part of the problem. Why does not the UN grasp the nettle and simply merge the three agencies? There needs to be a clear strategic lead and it does not seem to me, despite attempts at co-ordination, that that really exists. Mrs Obaid: The way the UN is set up, if you are not co-ordinating, including them will not solve the problem. Already there are two important things happening to address exactly what you are saying. One of them is that now we have a group called the H8. All the agencies working in the area of health have a commitment to work together and to hold each other accountable for what we are committing. That includes GAVI[7] on vaccination; the Global Fund on HIV/AIDS, Malaria and Tuberculosis because it is sexual reproductive health that is related to HIV; the World Bank; the Gates Foundation; and of course UNICEF, WHO and UNFPA. The main purpose of this coalition of the H8, the eight agencies working on health, is to get together to do exactly that, to ensure that at the country level co-ordination is taking place, that there are comparative advantages in certain areas and therefore we can deliver. DFID is very much involved in is delivering as one and the eight pilots that are happening at country level. Those are led by the resident co-ordinator; often that is UNDP. Here Vietnam is an example where we have one programme with input from everybody; both budgets are allocated together as is the leadership in the different areas so that we are not doing fragmented programmes but rather an integrated programme that looks at poverty. When you look at poverty, you are also looking at population size, at the bulk of young people who want jobs and healthy lives, and also at sexual reproductive health needs that are not being addressed. As you look at reproductive health, you are looking at issues of gender, empowerment and violence against women. What is important at the country level where that take place is the fact that we can deliver as one. Now we have eight pilots for the 'One UN' Initiative. The General Assembly has taken a decision to study the eight pilots to see what we have learnt from them before proceeding further. Lots of the decisions are also Member State decisions that are made in the General Assembly that impact on all of us. Q7 Hugh Bayley: It seems to me that politicians need to take a share of the blame because we set up all these agencies. We have the benefit in the UK of having one government development agency. We have mentioned already four separate UN agencies plus the World Bank plus a global fund plus GAVI. All are funded with governmental money. I suppose the Gates Foundation is not. Is the problem that we get so little money down to clinics in the field because we are supporting all the dozen or so international bureaucracies full of officials, full of policy planners, full of conference members? Should we not be cutting away the bureaucracy to enable what limited money is available - hopefully it could be more money - to actually provide more emergency obstetric care? Mrs Obaid: Actually, you are moving that way. Many of the donors are going for budget support. There is money flowing to governments. It is important to ensure that the budget support itself includes maternal health. That is the challenge for all of us. Part of our role in these countries is, as I said, to ensure that sexual reproductive health does not fall between the cracks. This issue is still sensitive - politically sensitive, socially sensitive, culturally sensitive and religiously sensitive - and often it does fall between the cracks. We have made a great deal of effort even to buy a seat for example in health sector reform where we pay into that so that we will be at the table to ensure that the issues of sexual reproductive health and maternal health are on the table. Governments have an important role in this; donors have an important role; and national governments also have an important role to play. Part of this movement is to ensure health sector reform. When we talk about health systems, we do not remain at the national level, as I said before, but there is a push to go downwards. In terms of size, and you have mentioned bureaucracy, I specifically indicated where we are in terms of UNFPA; we are one-third international with 210 staff members and the rest are national. The whole organisation has one thousand staff members. Our numbers are not at six or seven thousand like other organisations. The whole idea is to move the dialogue to the national level where there are the skills to do the work. There is emphasis now on the new aid modalities, the Paris Declaration on aid effectiveness, to look at capacity-building at the country level so that at some point they will not need us. They need their own people to develop. If I can diverge a little to return to what Dr Songane has said, the issue here is not just money; it is the fact that some national capacity has been lost; either people are not trained or they migrate if they are well trained. In this whole area of human resources in the health system, no matter how much money you pour in, you do need the system in place and people who are not only trained but enjoying good working conditions. Things are always greener outside. The whole area of retaining them, training them and giving them incentives, including social status to remain, is a big challenge. I believe DFID is now experimenting in Malawi in the whole area of human resources. That is something we should all look at, analyse and learn from because we have to go that way. We should emphasise national capacity. Chairman: I do not want in any way to constrain your replies because they are extremely helpful but we do have a second evidence session. I ask colleagues to keep their questions short. I do not want in any way to hold you back. Q8 John Battle: I want to explore the MDG targets. It is acknowledged that for the MDG 5 target there has been no progress, deterioration and reversal. In 2006, Kofi Annan announced that there would be a new reproductive health target under MDG 5 "to achieve universal access to reproductive health services by 2015". It is as if another target has been tagged on to the original one. What is the status of that and has it been formally agreed? How will it work? Are there timetables and pathways now for implementation to get this MDG lifted from being the lowest achiever to one of the highest? Mrs Obaid: Thanks to DFID and other donors as well as the co-operation and alliance with the UN organisations especially UNFPA and the NGO Co-ordinate, the target has now been approved. The report of the present Secretary General has come out. It has been presented to the General Assembly and now the target has been approved by the General Assembly. We are working on the indicators. There are already proposed indicators for it. We hope by March that the indicators will be finalised and become officially part of what the national governments have to report on. The struggle we had previously to get a target is now practically finished. Importantly, it is politically finished. Now we need agreement on the indicators and then to put it to the national governments for reporting. Q9 John Battle: Is there a plan to get that target to catch up with the others. Is there a timetable and a percentage to get it increased? Mrs Obaid: The deadline is 2015. We want to be able to decrease maternal mortality by 75 % by 2015. Dr Songane: Part of your question covers why MDG 5 is lagging behind. The issue is that not enough attention has been paid to this aspect and it has not been done comprehensively. We very much welcome the agreement of this target in terms of health. We are looking to family planning as one important intervention. We have to see family planning within the context of the whole of reproductive health. If women do not have this at the primary health care level, how can they access the Pill and other means of contraception in order to avoid a multiplicity of pregnancies? The more pregnancies you have, the more prone you are to the risks. There is another important aspect that we have to address within the context of an overall health plan. As Mrs Obaid has said, it is important to make sure that maternal and child health issues are put into the country plan. This brings me to what Mrs Obaid said earlier, that things happen at the country level. We need to gain acceptance that countries should lead the process. The UK should be commended on the approach it is taking with regard to giving this back to the countries so that they can track the process. We need to exert pressure. Some institutions in Britain have seats on the boards of these big institutions and you could exert influence to change the way institutions behave, particularly at the country level. Britain is part of the Global Fund and part of GAVI. It donates money to the institutions. It could exert pressure on those institutions to make sure that they do not cause problems at the country level with various mechanisms, ways of reporting and protocols to access the money. Let us all take the country plan as our guiding document and all of us accept that this should be the guiding document. If there are insufficiencies, then the representatives of the different partners at the country level should work together with the country to improve the situation and facilitate the work of the country. If we could get that help from Members of Parliament to change the situation, that would really be wonderful. Members of Parliament may realise the neglect to which this report has referred. One important thing it shows is that where there is slight progress is amongst the countries that are doing better. In the countries which are really doing badly, there is no change at all; the situation is getting worse. That means that the neglect is such that those countries are not managing to get to the bottom of the problems. We need to move quickly. The other plea is that within this International Health Partnership framework which is being suggested we should take as many countries as we can. It is important to learn from pilots but we need to make sure that all the 75 high burden countries move quickly to reach the assigned targets under the MDGs. It is not enough to take seven or eight countries to start with and assess them at the end of 2008. We have to learn from the process already in place in many countries. Numerous countries have done this but they did not go further because they did not get backing or resources. Our drive is to take on this process. We should not accept that these figures will only be improved by 2015. We have to do what we know that we should be doing. We know the causes of death and disability; we know the aggravations at work. It is possible to deliver and to train people to do this. We can do it. Q10 Sir Robert Smith: You have emphasised the need for skills and a lot of the written evidence has said that skilled intervention at the time of birth and just after birth can make a huge difference to survival rates and reaching these goals. Has any estimate been made of the number of extra trained health professionals needed to reach the millennium target? Dr Songane: It is a huge number. Last year the World Health Report was devoted to human resources. It was estimated that an additional 300,000 nurses and midwives will be needed as a minimum to address the issue of maternal health. The other finding reported in the document I have referred to is that the place where we have the highest burden is where resources are lowest. The highest figures for mortality are in Africa. Africa has 24 to 25 % of the burden of disease world-wide and less than 3 % of all the world-wide health workforce. In terms of resources, with this burden Africa has less than 1 % of the overall resources for health. Q11 Sir Robert Smith: That is the figure for midwives and nurses. Is there a figure for specialist doctors? Mrs Obaid: The figure from WHO is 700,000 more midwives in 57 countries where there are critical shortages. There is a global deficit of 2.4 million doctors, nurses and midwives altogether. Dr Songane: This is a critical issue. We see this within the context of health systems. These are critical interventions. If we do not have the people to run the programmes, there is no way forward. Q12 Sir Robert Smith: Is there any strategy developed or in practice to try to encourage or increase the number of midwives and obstetricians working in the developing countries? Mrs Obaid: We are certainly working with the International Confederation of Midwives and there is a strategy in place to train midwives in many of these countries. We are also working with the International Federation of Gynaecology and Obstetrics. It is a joint effort to do exactly that. As we have said, part of the problem is that even if these people are trained, if they do not have good working conditions and financial incentives, they will migrate. They are wanted. That is why it is very important to change the social status of midwives to ensure that they have good financial compensation and good working conditions. There is an experiment in Malawi by the UK and it is important to look at that. Not only are they topping salaries and training but they are bringing in volunteers to fill in while the midwives are being trained. They are also building housing in some communities to make it attractive to live in the rural areas. This is an integrated and complex issue. Dr Songane: May I add this to the issue of training? We should not wait while we are training doctors. There are ways of bringing the skills needed to people who are not specialists, who are not doctors, and train them in life-saving procedures, be they midwives, nurses or assistant medical officers. That is being done in Mozambique, Tanzania, Malawi, and Burkina Faso, to cite a few countries. There are publications on this. This came out in the British Journal for Obstetrics and Gynaecology and the WHO Bulletin and the Human Resources Bulletin showing that they are as effective as specialists in providing emergency obstetric care. Those nurses and assistant medical officers can be trained to give those services. We build as we go along: it is ideal to reach a certain level but we need to find out how to deal with existing resources to make sure that the care we are providing is safe and of quality. Q13 Hugh Bayley: How many developing countries have effective manpower, i.e. training plans, for health workers that identify the numbers they will need in different disciplines and match training to that? Is there a problem for instance with the emphasis on universal medication for HIV/AIDS that one agency will tip in a salary incentive to get people to transfer from maternal and child health to AIDS work? How do you overcome that problem of one international agency in effect poaching staff from another international agency? Dr Songane: That is a very good question. It addresses the issue of how the different institutions operate at the country level. If we accept co-ordination and know that we are there not to raise the flag of HIV, malaria or tuberculosis but to be part of the building of the health system and to address that country's plan, then whatever resources we bring, we should put those to the use of the country under the leadership of the government. That is a major undertaking. If everyone agrees to do that, saying that there are these resources and they will be used only for HIV, then paying more to poach staff could be minimised. I think that is the way to do it. It needs a change in attitude in the various institutions and an acceptance that this should be done under government leadership. If you want to address HIV/AIDS without addressing the development and strengthening of the health system, you are bound to fail. You cannot secure the person who is under ARVs.[8] That patient needs proper care, home care and social support. If you do not build in all these things, you cannot be sure that he or she will live a normal life and that person could die anyway, even with ARVs. It is not with HIV alone; we do have other elements, particularly the subject we are discussing today. In maternal and child health we have more burden than HIV, Aids, tuberculosis and malaria together but yet that is not recognised as an issue in terms of the number of deaths and number of disabilities. It is not recognised because it is not fashionable or a flag raising matter to be seen as good to provide money for maternity and child health. That is why we are quite pleased to be getting this hearing and this commitment from Members of Parliament in the UK to help us to raise the voice of those women and children. Countries have plans. The issue of the long-term plan is that of predictability of funding. We have a plan today; we are thinking about two or three years. After those two or three years, we do not have the resources we were counting on three years previously when we wrote the plan and to know how to build on it. Let us revise this plan and make a new one. The new way of doing business is to provide the country with the possibility of predicting the money they have and do their long-term planning. We should address the development process of that country. Sustainability of resources is another element to make sure that if they plan ahead for 10 years, they know that they will have the money to get the workers they trained today making progress in their careers. Progress in their career is a very important element if we want to pay attention to the status for the workers themselves. As Mrs Obaid has said, working conditions and proper salaries form another element. I would put that in this context. Mrs Obaid: Can I add that the traditional way of supporting governments is by vertical programmes, and this is already happening. You support family planning alone and you support HIV alone. Now we are moving towards linkages; that has been adopted. It is within the UK strategy. All of us have come together to integrate sexual reproductive health plans with HIV because they are related. There is no way to look at HIV and not at sexuality and reproduction. By integrating those, you are increasing the workforce. If you train the family planning people in HIV/AIDS and vice versa, you will then have increased the human resources base that addresses communities and works on that. That is one way of doing it. Family planning is a long story that has been quite successful in the past. You build on the institutions that already exist and go with them. The reason we want to integrate is that there is mother-to-child transmission. Often the child gets the treatment and survives but the mother does not get the attention and she dies. We say that if you integrate these, then you will catch the mother very early if she is HIV positive and you start working with her and you do not wait for delivery and for retrovirals. We were very pleased when we saw in the UK strategy that it is talking about exactly what Dr Songane has said. They are saying that investment in the health sector should be long term, 10 to 20 years. There should be predictability of resources and of course monitoring and ensuring accountability over a longer period because this kind of change does take a long time. Q14 James Duddridge: Our principal role as a select committee is to hold the Department for International Development to account. On maternal health where our Department for International Development works, if we could send our minister away on two, two-day trips, one to a country and one to an international donor, to learn best practice, which country and with which donor would you suggest the minister spends time? Dr Songane: That is a tricky one because then we risk missing the countries that are doing well. The committee has visited Mozambique. I do not say this because I am Mozambican but the minister should definitely visit Mozambique. I am just talking about what we have done there. Mozambique is one of the countries. Another country is Tanzania. Uganda is another country we could suggest if we are talking about Africa. If we go to other places like Sri Lanka, the state of Kerala in India or Vietnam, they are now coming up quite strongly and quickly. Take Egypt and the Maghreb area: Egypt is moving quickly in terms of improving the figures and addressing in a comprehensive manner, although it is a Muslim country, maternal health and the figures are coming down quickly. That is one of the leading examples. Go to Latin America. Take Honduras or what Bolivia is doing with insurance schemes to make sure that women are not dying in childbirth. There are different examples we can list. In terms of institutions, I would highlight the progress which we are seeing now at GAVI, the Global Alliance for Vaccines and Immunization. There is now a drive to make sure that the distortion the different funding agencies cause is changed. I would plead with the Members of Parliament to help us address the issue of other institutions. We know very well the problems that are caused by the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria in countries. It has been a nightmare in some countries where they are putting in the largest amount of money. Because of the power to influence the process in countries through the amount of money they have, they are causing many disturbances in the normal processes. The UK could play a very important role there. Lastly, perhaps you could recommend additional money for DFID to help us address this issue so that women get support from DFID. I think we should see more being done at country level. DFID is clear about the way the money should be spent going to the countries; we need to get these resources at a substantial level. It is good to do things in a different way, to be co-coordinated and streamlined by doing one country plan but additional money is needed. Even in my country, Mozambique, we have progressed. We are almost reaching the Abuja target of 15 % of the budget allocated to health. Now it is around 12 to 13 % depending on the waves, but we need to do more and additional money is needed. If whatever is started is not consolidated, then there is risk of a breakdown and a return to square one because the economies and the institutions are not strong. We need to address this issue. It is like having an elephant in the room when the discussion on health systems takes place; everyone moves away because it is a huge subject, but this is basis. If we do not address the health systems, there is no way we can move the agenda in terms of health. Those countries which are successful are addressing the issue of health systems. Money is needed. DFID is well positioned to help this process through because they have demonstrated that they do what they say they will do. Mrs Obaid: May I add two quick points? One is in terms of best practice. This is where DFID can give support. We do have the H8 and GAVI is a member. GAVI has decided to move into looking at the health system and not do a vertical programme of just vaccination. All the H8s are talking to each other about how to move together to be able to support health systems and work within that. No money is needed there. It is about us agreeing and moving forward. Because MDG 5 on maternal health and MDG 4 have become so focused, there are many initiatives coming up. The national governments are saying that they cannot handle too many processes, that we should integrate the processes. We cannot have a Canadian initiative and a Norwegian initiative. There is the important International Health Partnership promoted by Gordon Brown. There is no money there but it is a framework that will get all of us to look at how these initiatives work together and how they can support health systems. It is a co-ordinating framework more than additional money. I think we need to emphasise that. We cannot have so many different initiatives that the countries themselves cannot deal with them. We have to integrate the initiatives to help and feed into the national health plans, as Dr Songane has said. Q15 James Duddridge: So the recent UK initiative is more than another initiative. It sounds to me like an initiative that brings together initiatives, exactly the opposite of what you are wanting. Mrs Obaid: I am saying that it is very important that these various initiatives that bring money in are co-ordinated and support the national health plans. The International Health Partnership promoted by the UK is really, as you say, a framework to ensure that these are all co-ordinated and that there is joint accountability in what we are doing. Q16 Ann McKechin: We have been speaking this morning about the danger of a plethora of international initiatives. I think there is some concern that this new initiative announced in September does not really make specific reference to maternal health sufficiently. It speaks about global systems in the round, and yet it will now have to co-ordinate with GAVI and with Dr Songane's initiative and with a whole range of other multilateral bodies. I wonder if we have got to the critical mass when we have to say stop and we need to rationalise the number of initiatives we actually have. In that context, I wonder whether you think that there is a growing danger of maternal health not deliberately but indirectly just beginning to be pushed back out. People will look at things which are easier to define to donor communities. It is easier to define vaccinations; it is easier to define antiretroviral drugs, but it is much more difficult to define accurately reproductive advice and facilities. Mrs Obaid: Thank you very much for raising this question because we are one of the co-signatories to the initiative. We have been continually saying that there has to be reference to reproductive health in the agreement. Finally, it is there. I was at the launch of this initiative. In the discussion I had to bring up sexual and reproductive health and say that when you talk about mothers, there is sex somewhere in that. You cannot talk about mothers out of the air. We need to push this all the time and advocate it to ensure that whenever we are talking about MDG 5, we talk about the bigger picture of reproductive health before a woman becomes pregnant. Her health will impact on the pregnancy and the child. This is about nutrition, education, the complex way she lives, her access, customs and traditions, et cetera. I agree with you that in this larger initiative there always has to be voice and action to ensure that sexual reproductive health is an integral part of these initiatives. It was mentioned at the launch of the International Health Partnership agreement and we would push for that. Q17 Ann McKechin: Going a bit further, you say it is in the agreement and it is in the text but is there some agreement about what proportion of the funds raised under this initiative will go to issues such as preventative health? In our own health systems, prevention always gets cut away rather than drugs or treatments. So are we going to say it is 10 % or 25 % that needs to be in health prevention? Dr Songane: You have raised a very important question. The Partnership for Maternal, Newborn and Child Health provides the platform for development of this process. We should see this in the context of a global campaign for health MDGs. The whole campaign was built with various pillars. One of the pillars was supposed to address the so-called global health architecture: how we do business, how we liaise with countries, how we avoid the disturbances we are causing. Another pillar was to see what we do to address specific issues on maternal and child health. When that was launched, the lead person was the Prime Minister of Norway. Our campaign was launched at the same time on 26 September called "Deliver now for women and children". The campaign started in New York. We have to take this campaign to the regions and to the countries to make sure that we do raise the issue and ensure that the resources are put in. It is a very important aspect and we must ensure that we are not distracted by discussions about global health architecture which could cause us not to put in the money, resources and drive where they should be. "Deliver now for women and children" will be the conduit through which we have to address this issue but we need the whole context because the International Health Partnership is supposed to provide the new drive for the global health architecture and how we do business. Your question and another one earlier are about countries receiving clarity. It is important to emphasise that this is the first time that leadership at a high level has addressed the issue of what are we doing in countries where we are probably causing more harm than good. Together the Prime Minister of the UK and the Prime Minister of Norway are saying that we should reflect on this. It is the very first time this has been dealt with at a high level of political leadership. I agree with the caution of Members of Parliament. We should not build this initiative as a big institution. We should not drive this in that process. It is a platform for discussion and we have quickly to get the different players really to change their attitudes and show the countries that they are changing the way they do things. If they admit that at country level different institutions are going in and doing their own thing and so they are not doing any good, that will be another addition to the partnership. You are absolutely right: we have to address the countries' priorities and have the country plans as the lead documents, and stop the proliferation of different initiatives. All the resources should go there. I would be glad to hear in the upcoming cycle of board meetings of GAVI, the Global Fund and our own institution that they are addressing the issue of what we have to change immediately so that next year the countries will have a new picture of the Global Fund and a new improved picture of GAVI - GAVI is doing well, as I have said - and other institutions addressing what the countries are asking for. Stop this proliferation and accept that the country planners will deliver the documents. Work with us so that the various groups do not function in a different manner. Q18 Chairman: It is a big challenge. Louis Machel said last week that in Tanzania there were 600 health projects of under €1 million every year. He asked how the Tanzanian Government can do that and why are those not co-coordinated. It is a big challenge but I take your point. Mrs Obaid: Can I raise one more initiative of which the UK is a member and that is the G8? They have committed themselves in 2007 to $1.5 billion of funding for maternal and child health and voluntary family planning. Your role, that of the Government of the UK, in this G8 initiative would be to ensure exactly what Dr Songane has said, that funds are pushed in the direction of the national roadmaps for maternal health. We cannot say 10 % or 20 % because it depends on the country. If we feed into the roadmaps of maternal health at the national level, then the appropriate resources have to go to prevention as well as treatment. Q19 Richard Burden: Of the around 600,000 women who die each year from pregnancy-related causes, about one in eight of those will die through issues related to abortion-related complications. The concentration of those problems tends to be in those countries that have the most restrictive abortion laws. Obviously this has been in the news quite a lot over the last few days. Given the fact that those countries count for about 26 % of the world's population, how do agencies like yours deal with that? The UN operates on the basis of building consensus but there is this glaring issue there where a significant number of countries have laws that apparently run completely counter to trying to improve maternal health and women's health in the way that you are trying to achieve. How do you deal with that? Mrs Obaid: Actually as you have said, death from unsafe abortion is the third cause of death in Africa, for example. Also it is not only death, it is the issue of disabilities that are associated. You have a larger number of women then suffering, not only dying but having disabilities, including infertility. For us as an intergovernmental multilateral organisation we are mandated by our Member States to abide by what was agreed upon in Cairo, which is paragraph 8.25 and we have learned it by heart because we are asked about it all the time. Basically our mandate is, one, to ensure that abortion is not used as a family planning method; and that where it is legal, which is all countries except four, all countries have some sort of conditions under which abortion can be done; where it is legal it should be done under good medical conditions. This means that our role as the United Nationals Population Fund is basically, one, to provide data, analysis and the numbers based on evidence of what is happening in that area. Often they do not have the numbers. One is to give evidence to the countries, so that they have to understand the impact of unsafe abortion. That should lead them to take correct decisions in terms of that issue. In Cairo the consensus is that the decision on abortion is a national decision - it is not imposed from outside - so you have to work within that communication. The second one is when we strengthen the health system capacity to prevent abortion, have family planning, have planned pregnancies, you are decreasing the possibility of abortion, but working with health systems to ensure that we are developing the capacity to deal with the consequences of unsafe abortion, as well as post-abortion care. We are the United Nations Population Fund - this is what our Member States have told us are our limits. However, there are NGOs; we have partner NGOs who work in that area. As you know, the UK has established a fund for safe abortion, which is managed by IPPF.[9] We have our counterparts who have the ability to move in that direction. Our role is limited to dealing with the complications of unsafe abortion, providing data, developing the skills in the health sector to deal with that and, of course, helping the governments make the correct national decisions by providing evidence on the impact of unsafe abortion. Q20 Richard Burden: Is there any evidence that it is working? I understand what you are saying, that the decisions are national decisions, but if you see your role as collecting the data to look at the incidence of unsafe abortions in particular countries, firstly, if I am right that the highest incidence of those are in those countries with the most restrictive laws, where technically abortion may be legal but in practical terms it is illegal, if that is where the concentration is and you present those countries with that evidence, what happens? Does it have any impact? Mrs Obaid: I agree with you - we know it is a serious issue we are trying to deal with. The issue is not only where it is legal it can mean "illegal" in a sense, but also there is no information about the rights of women who have problems or will even meet the criteria. This is an area that is dark, let us put it that way. Women do not know that if they have a problem they can access these services. Even when they have unsafe abortions they do not know that they can go to the health system to save their lives; and if they do they are badly treated. It is just not simply the access and having the right; it is the whole system where it is a taboo. You are penalised if you have an unsafe abortion. Women are penalised and so on. I remember Fred Sai, who is an African from Ghana and a leader in the area of sexual reproductive health, said that the only human organ that has entered the penal system is the uterus. It is a very strong statement when we realise what we are saying. What we tell governments when we work with them, at least where it is working, where it is legal, is to let us ensure that the health system can provide lifesaving --- but then you need the civil society to inform and to advocate, so women know that they can have this access. This is still a dark hole. We are all working on it. It is not an easy one because you also have other groups that are anti-rights for women to access safe abortion. Dr Songane: I concur with you fully. The other element here which is important, even in those places where it is legal, is the stigma. To be seen as someone who went to seek those services for the society is still a bad thing. This stigmatisation is important to the woman. As you say, to inform people, if we bring the statistics or whatever we have and show to the country, not only to the leaders but the public, and say, "This is the situation. It is a complex issue but we cannot hide. We have to deal with it. It is accounting for about 13 % of the deaths, apart from the disabilities, so this has to be addressed". The other element before the departmental committee is to use you as leaders to help address this issue. What is complicating now is the threat from some countries to remove resources for basic care because you just mention reproductive health, you just mention abortion. You did not do anything wrong but because you put that word in one of your papers you might get as a consequence the withdrawal of resources. This is being said publicly without any counterargument from the same level of institution. We ask you as Members of Parliament, this country is taking the right address in relation to abortion, but you should help us to counter those arguments of threat, of intimidation, not leaving the countries addressing their own issues. This is a much worse situation we are being faced with now. Even institutions, which should provide that technical advice and direction to the countries, are shy and afraid of putting those things on the table to discuss. We need to come out of this and say, "This is a problem and we have to act". The issue of the target of the sexual reproductive health services available to all women is a fundamental issue if you want to address abortion. Why do you have abortion: because there is a pregnancy. You should avoid the pregnancy. Where will the woman or the girl get the means to avoid the pregnancy without contraception, without local reproductive health services, without the services for the youth? The group of 15-17 teenage mothers are most at risk from abortion and from complications of pregnancy and we are not providing the services for them to avoid running into that risk. Those are the issues. It is a comprehensive issue, but it is complex. We are not dealing with it in a light manner, but it has to be addressed. We would ask you for your support. Q21 Hugh Bayley: The question of empowering women of course is absolutely essential and it does not apply just to abortion, it applies to pregnancy, it applies to family relations, childbirth and child health. My question is: how do you, first of all, empower women's knowledge about these things; and, secondly, and I would say more importantly, money is power; if you are talking about empowering women you just put money, resources, into women's hands; how do you do that? Should you have a pregnancy kit for every woman, which includes a $20 note? How do you actually give women power to control the resources which are there for obstetric and maternity services? Mrs Obaid: If I can quickly refer to a previous question. What Dr Songane has said is true. Since 2002 one major donor has not paid UNFPA any voluntary contributions. That is a fact. The words "sexual and reproductive health" are interpreted as euphemisms for abortion. That is an issue we face on a regular basis. Q22 Richard Burden: Can we know which donor that is? I think we may have an idea, but just for the record. Mrs Obaid: It is the United States. The other issue that is really very worrying is that now there is quite an attack on sex education in schools for young people. If you take that out of the school and you just have education on abstinence only and so on, we are further endangering teenagers in terms of early pregnancies etc. This is a new environment and we all have to deal with it. In terms of how do we empower women to be able to have the economic power that you are saying, we at UNFPA do some work with others who have the knowledge and the skills to do economic schemes of different types. We try to partner with ILO[10] and others who can do that; lots of the NGOs; and microcredit and so on is part of our work but we look where there is microcredit and we integrate sexual reproductive health information and services in it and so on. Also empowering women is having the money, but part of it is having the knowledge that it is her right, and that is dealing with the socio-cultural issues; and for the community to be able to understand that right to health is a right and women have to have access it. That requires working at the community level and working with local leaders, with the religious leaders and different ones to be able to get the message through the local set-up, to understand the rights of women to health education income etc. One area that we have not touched at all, and that also is the disempowering area, is the issue of sexual violence against women, especially in fragile states or conflict areas. That is the most disempowering element. The fact that we get countries where such violence takes place and perpetrators are still loose is a very tragic thing. Here I think the UK can help in ensuring that support is given not only to women who are victims of sexual violence but also that there is prevention of violence, which means working with the military; with the police, which we do, to educate them about it and so on. If you want to empower them the first thing is that they should stop being violated. That is a long process that a few countries are focussing on but not sufficiently to be able to empower women. That is the other side of your question. We empower through economics, through education, through partnerships, microcredit whatever, but we also have to deal with what is disempowering them - which is domestic violence and violence against women in wars and conflicts and so on. Chairman: Can I thank both of you. It is clear to the Committee that you are two very powerful champions of the rights of women in this area. You have challenged us, I guess, to some extent to join your campaign. All I can say is that the Committee is quite shocked really about the statistics and, much more to the point, the individual suffering that is hidden within these statistics. That is one of the reasons we want to do this report so that in some small way we can perhaps increase awareness and reinforce what our Government is trying to do in this area and internationally. Thank you very much, fortuitous as it was that this conference was taking place, for coming to give this evidence - I think it has been extremely helpful as a start to our Inquiry. I thank you both very much for coming. Witness: Dr Grace Kodindo, Assistant Professor of Emergency Obstetrics Care, Mailman School of Public Health, Columbia University, gave evidence. Q23 Chairman: Thank you very much, Grace Kodindo, for coming in. Some of us did have an opportunity to see the first part, we did not see all of it, of the Panorama film of Chad in which you very much featured. I can say that I think it was powerful and moving, but also shocking in particular to me that people were not only required to pay but literally had to go and find the drugs while a woman was potentially dying under your care. That that sort of situation and that sort of trauma should exist I think is something which is important that we are aware of. I am very grateful and we are very grateful to you for coming to give us your personal testimony, if you like, about the challenges that you face and, of course, about the extraordinary good work you do in very, very challenging circumstances. I just wondered if, by way of introduction, you could give us some feel for the challenges you do face. In particular, our understanding is that one out of 11 women in Chad will die as a result of complications of pregnancy; that Chadian women have on average 6.7 children, which I think people in this country would find fairly stark, and yet only 25 % of them get any kind of trained assistance during childbirth and much lower in rural areas. What do you see from your experience drives the high mortality rate that your country suffers? You heard the previous discussion about poverty, ignorance, lack of knowledge and the lack of skills and the supplies within the infrastructure; but from your personal experience what do you think is the central problem driving this; what do you think are the key areas which are causing this very high and tragic mortality rate? Dr Kodindo: Firstly, I would like to thank you on behalf not only of women from Chad but women from all developing countries, especially ones from sub-Saharan Africa, from South Asia and also Latin America. I would like to thank you for the opportunity to hear our voices and, hopefully, to help our country to take action to improve our health. I would like to introduce myself. My name is Grace Kodindo. I am an obstetrician and gynaecologist. I have been working for the last 30 years in Chad first as a general practitioner, and then as an obstetrician and gynaecologist. Indeed, at the same time as I was working in Chad, I was also working for Columbia University as a monitor to implement emergency obstetric care. For the last six months I have also been working, again for Columbia University, in a programme called RAISE,[11] to improve the access to reproductive health for women refugees. What are the causes of maternal deaths in our countries? I would like to say that in our countries, just like the situation was in Europe, in North America, one or two centuries before, people die from the same causes you had here in Europe. In the 30s you started to have technology like Caesarean section, anaesthesia, blood transfusion; and then in the 40s you discovered antibiotics and then contraceptive methods, and then you started to make this available to all women everywhere; even the poorest of women in the West now can have access to them. That is not the situation in our country. So we need this kind of basic care with appropriately trained staff to be available to all women in our countries and we will come to the same result that you have reached here in Europe and in America. The problem is for that we need a stronger health system. My colleagues before me have said the same thing, because only a strong system can really provide all the basic drugs, even a drug that is cheap in the West like magnesium sulphate. This is the drug to treat eclampsia. You would not believe that it is still not on the list of essential drugs in many African countries - not only in Chad; I have seen that in Cameroon, in Nigeria, in Ethiopia. Two weeks ago I was in the Congo and they do not have that and this is a cheap drug, and this is the one drug that can treat eclampsia which is one of the main causes of maternal death in our countries. In many of these places that I have visited they do not have a functioning health system; they do not have a blood bank or anything like that. Haemorrhage is one of the first causes of maternal death; when a woman is bleeding it will only take two hours and she may die from that. When there is no blood to transfuse her she will die. If a woman is living in a very rural area, in remote places, with no transportation, sometimes the relatives have to take them on their shoulders and walk two or three days before reaching a health facility. She may die in the meantime, or if she does not die the baby will die. If she survives she will end up with a fistula. You had fistula in the West in the past. The first fistula hospital was in New York but it has been closed because you have produced care to all women everywhere but we still do not have that in our countries. If there is no action taken on that we still have a long way ahead of us. For a woman to end up with a fistula, and if you know what a fistula is - it is a hole in the vagina that produces a leakage of urine or faeces continually for the woman, and the woman smells so bad that sometimes the husband just leaves them, and their families just leave them and they are left as social outcasts. You still have a lot of these cases in Chad, Nigeria, in Sudan and Ethiopia even in 2007. The same problems are still there because we do not have a strong enough health system. In the film you have a 12-year old girl dying from an unsafe abortion because the access to family planning is still a luxury in many of our countries, especially in the rural area. In cities a woman may have access to family planning, but in rural areas it does not exist and it is not only in Chad. In June I was in Ethiopia, I went to the Tigray region and in the rural area they do not have that; no EmOC;[12] no family planning, and this is how the West has reduced maternal mortality. In the West we have maybe one woman out of 47,000 dying, whereas in Chad we have one out of 11. In Mali we have one out of 10. In Sierra Leone, in Afghanistan, we have one out of eight. You can see the difference. It is basic technology. It is not something complicated - I am talking about blood transfusions, Caesarean sections, some drugs like magnesium sulphate, only basic things that you have plenty of here in the West. Q24 Chairman: What comes across loud and clear is that, as you put it and our previous witnesses put it, you need a functioning health service and more resources. In a sense it is a silly question but it is the huge number of resources across so many countries, and taking your own country, and given your professional qualifications, skill and experience, if you were to identify one particular thing from your standpoint that would most advance the cause, what would it be, or is that a naïve question? Dr Kodindo: We need to increase our skills as providers and to increase the coverage of the work on this, especially in the remote areas, the rural areas. These kinds of people we really need to give them a very large widespread coverage of these basic things. We can take one health centre in a rural area with just a nurse; we do not need a doctor or a specialist. This example has been done in Burkina Faso, a nurse with two years' training in obstetric skills can be posted there with a few drugs, only antibiotics, IV[13] fluids and magnesium sulphate, to give the first basic treatment when there is any complication and then to help in referral. This is another problem, the referral system in Africa. It is not only a shortage of the skill provided but the referral system. This is why maternal mortality prevention will not only be a problem for the Minister of Health, it is a multidisciplinary problem. The Minister of Finance should help to give some incentives. The thing is these are very, very poor countries and the salaries are very low and as human beings these people need to have some incentive to be retained. Many African staff have immigrated but if you can train this medical provider and give them some incentive they will return. They need a medical environment and need to have some incentive because they have lots of families to raise. If they have that in these areas and you have roads, and means of transportation to take them to the referral hospital, and also have drugs and blood banks functioning, it should be functioning. As you have seen in my film that hospital is the referral hospital for the country and we have no blood bank functioning. Even syringes are needed, you would not believe it, there is nothing there. Syringes, needle catheter, they have to go outside to buy that. This is encouraging the nurses or doctors to start to steal things and go and buy them because if the hospital has nothing they will just steal and do some business with that. It is not helping the honesty in these places. The hospital really has nothing to help save a woman's life, women continue to die. The solution is very simple, just like you have proven in the West: in many countries in Asia and Africa which are doing well, as Dr Songane was saying, it is because they have strengthened the health system and they have also improved the access. The health system may increase but if the access is not there it will not happen. There are many problems with access. It is not only the lack of roads, but the financial access and the cultural access. Like in Chad, more than 80 % of women are illiterate so they cannot even make decisions for themselves. They need to be educated to improve their utilisation of the health service that will be strengthened, hopefully, in the future. I will give you one example that happened in Senegal. They have given some training for a literacy course to women in rural areas and they have trained them to recognise that they have their own right to defend. They did not even know they had a right to talk about whether to say yes or no. After that training without anyone telling them to come back, they came back in the morning and said, "Now we know that we can talk about our health we are going to put an end to female genital mutilation". That was only one literacy course. They have learnt that they have their own rights. They need to be educated. One other problem in our country is the condition of the woman. There is a very low status for women. The woman is good for being married and having children and that is all. She should have as many children as God gives. There is no limit. She does not even have a choice to limit the children. She has as many as God will give her. If she dies in the meantime they will say that God has also brought the death. Nobody will be shocked by that. All this is related to the condition of women. Maternal mortality prevention should be something multi-disciplinary, multi-sectoral, and should not only be the problem of the Minister of Health. They are not able enough to put an end to that. Q25 Richard Burden: Can we explore the issue of access to basic medicines. You mentioned particularly about magnesium sulphate as being very effective in eclampsia. Objectively magnesium sulphate should not be difficult to get hold of; it should not be very expensive. Dr Kodindo: It is very cheap. Q26 Richard Burden: It is very effective. Dr Kodindo: Yes. Q27 Richard Burden: Given the incidence of eclampsia in Chad what needs to happen to make sure, for example, that magnesium sulphate could be freely available; and what internationally do we need to do to try to make sure that happens? You may want to expand to other basic medicines, but that one just seems quite a simple one but just is not happening. What do we need to do to make it happen? Dr Kodindo: Firstly, accordingly to WHO this is the most effective drug for eclampsia. I think it should be included in the list of essential reproductive health drugs in all countries. It should be put in the political programme for reproductive health. The governments should start to import them. Until now even in sub-Saharan countries it is not even on the list of essential drugs in the countries, so they are not buying them, and these are very cheap drugs here. Q28 Ann McKechin: Can I just clarify, that is the individual list of the Chadian Government; or is this a universal list of central drugs? Is this the Chadian Government's decision about what essential drugs are? Dr Kodindo: No, this is from WHO. WHO has a list of essential drugs. Q29 Chairman: It is not on the WHO list? Dr Kodindo: That is recommended as the best drug for eclampsia. It should be on the list of each country. It is not on the international list of essential drugs, and this should be on the list so that the Government can start to import the drugs. Q30 Hugh Bayley: Is it possible to put an economic cost on what it would cost to ensure a safe childbirth environment for a child in a developing country; and then run a global campaign and say, in the same way there should be universal medication at $200 per person for anybody with HIV, there should be a global campaign and there should be $10 or $20, whatever it costs, per child to be used in the health system? Who could give us that information? Dr Kodindo: There is the Taskforce on MDG 5. My colleague Lynn Freedman is working on the Taskforce for MDG 5, and she has said that £4.5 billion per year could provide all effective intervention for maternal and newborn cases to 95 % of the world's population. Q31 Hugh Bayley: How many births are there per year globally? Dr Kodindo: 136 million.[14] Q32 Sir Robert Smith: You were talking about some of the solutions in rural areas and highlighting also how skilled intervention makes a huge difference to outcomes. I just wondered in terms of priority and stepping stones to try to improve the situation, is it mobile health workers, or is it training the local midwives, or even at a more basic level is it improving the transport so that the pregnant woman can get to a more major centre? Dr Kodindo: Yes, I think that in a rural area we should start with some basic medical care, so that we do not need to have even a fully trained midwife; you can train mid level providers. In the health centre it should be nurses only. They should be provided with a few basic supplies and drugs; and they should be connected with the hospital where the mid level surgical technician, just like Mozambique, can provide the higher level technology like a Caesarean section. Even with these basic things it may make all the difference. Q33 Sir Robert Smith: You think that basic intervention locally is probably more practicable than trying to get transport so people go to a more skilled centre? Dr Kodindo: Yes. The health centre will provide basic obstetric care. If the woman arrives and she is already fitting and has eclampsia, the nurse there can start to give her magnesium sulphate. If she is bleeding she may start to receive some IV fluids and then put her in a position for her to travel. When they arrive in the referral system they will be in better condition and have even more chance to be saved. Sometimes they arrive in this condition which is already very, very bad, and it is very difficult to save their lives. We need to have a two-level health system and a means of transportation. Three months ago when I was in Ethiopia, women were living on the mountains and deep down in the valley there were no commercial cars, so sometimes they would just sit on the road waiting for an eventual car to go by, and that may take days. In an emergency there is no way - she or the baby would not survive. In the Congo it is the same problem. It is a huge country; the roads are very bad; there is no means of transportation; so accessibility is the real problem, plus the weakness of the health system. In the east of Congo when I was there two weeks ago there was one hospital covering the whole area. In this hospital they had only two delivery kits and sometimes three or four women went into labour at the same time. They did not even have time to sterilise the delivery kit before delivering another woman. This is an area where they have a high incidence of HIV pregnancies. When we strengthen the health system to prevent maternal deaths we are also strengthening to prevent the spread of HIV. If in this hospital they have the steriliser, they have more delivery kits, it will play on those things. It will help to save a woman's life and help prevent the spread of HIV. Women in this condition are coming to deliver and they will go back with HIV contamination. Q34 Ann McKechin: Dr Kodindo, I think we can imply from what you have said this morning that the Government of Chad really places no priority at all on the status of women and the empowering of them. The question for donors such as DFID is, what steps can they take to improve sexual and reproductive health in countries such as Chad, where they face a government which places very little or no priority on it and where there is a very different cultural ethos around the issue of women? In what way do you think that donors can try to fund other civil society groups which are pressurising for the improvement of women? Are there women's organisations which exist generally where we can try and put these messages across? Which do you think is the best way donors can help? Dr Kodindo: There are many things that they can do. The first step in empowering a woman is by improving their health. If we improve their health we will give value to their life. When we give value to the life of a woman, by preventing them from dying or having bad health, we give value to her life, and this is the first step in empowering a woman. DFID can also have some pressure on the government of the countries because until now it is sad to say but there is not much value to the life of a woman. You would not believe it but in many of our countries there is even no accounting of a woman's death. When I was in the Congo two weeks ago they had one labour room and we saw a register with 26 rows; even a row for placenta weight; but there was not one row for maternal deaths. They are not even counting maternal deaths. So, firstly, to have them start counting maternal deaths. Make audits on the maternal deaths and take action on that. Maternal deaths should not be something which is just a fact of life. It should be counted and audited. Q35 Ann McKechin: You think that that should be a condition of any aid that is given by donors? Dr Kodindo: Yes. Q36 Ann McKechin: That there should be proper statistical data? Dr Kodindo: Yes. Then there should be a cutting of the level of the maternal mortality in these countries. They should do something about that. Women should not be left just like that. What you have said about the women's organisations I like that because maternal mortality to me is a human life issue. The woman has the right to life. If we are left with a woman dying we are violating the human right to life. The woman has the right to good health. If you are letting them have a fistula, we are violating their right to good health. This is a question I want to ask you: why in the West when there is a risk of violation of human rights, especially political human life does it make headlines and people talk about it and are shocked, why not if it is about a woman's death? This is also a violation of human life. It should also make people react and judge and put some pressure on the government to start to do something. Q37 Ann McKechin: It is about issues of governance or human rights in developing countries, and if we give funding then the issue of maternal rights and issue of women's rights are at the forefront? Dr Kodindo: Yes, exactly. This shows them that the woman's life counts. It should not just be discounted. Q38 John Battle: I want to ask you a particular question really about blood banks and blood donation, perhaps inspired by the film, because part of the drama of the Panorama film was watching the blood go down in the packet and there is no new blood coming in. I was reflecting on the film. There was a brilliant book by a sociologist in Britain called The Gift Economy in which he tried to spell out that one way of ensuring that society held together was that people did not sell their blood but gave blood to ensure that they or their families when they needed it would find there was a supply there. Quite a few people in Britain carry cards and give blood. If the blood banks go down there are appeals on television and people go from work, queue and give blood. I do give blood but the only time I cannot give blood is if I have visited a country with malaria. I want to know, is there a specific reason why that gift economy cannot work in African countries? Is it a scientific problem because of malaria? How could that problem and the lack of blood availability and blood banks be addressed? Dr Kodindo: I do not think it is because of malaria. There is a very bad idea of giving the blood. In some places they think that if a man gives blood he will become impotent. There is some cultural belief. They think that if you give blood you will lose weight. Some cultures do not believe in talking about that. I remember the time when they used to provide some sandwiches to people and give them some food and people used to come to give blood. Maybe people should be more sensitised about that. Right now it comes down to the relative to give blood. If there is no relative then there is no way to give blood. Q39 John Battle: Do governments not campaign or press it on blood banks? Dr Kodindo: No, the government is not really campaigning. Q40 John Battle: They do not see it as their job as ensuring there is a blood bank to back-up a clinic or hospital? Dr Kodindo: Exactly. This is why I am saying there should be a stronger commitment from the government on this problem of maternal mortality. If there is a real commitment and a real political will to address the problem of maternal mortality they will do all this, factor that, go along with the prevention of maternal mortality and lack of blood transfusion. If there are blood transfusions in hospital it will not only benefit the women but the men and everybody. Q41 John Battle: Let me ask you, is there a better blood bank in cities than in rural areas? Do the rich get access to blood? Do they store their own blood to make sure they have got a supply, because not everyone can guarantee perfect health and never needing some blood? Dr Kodindo: In rural areas in most African countries they do not have blood banks. They do not have it. This is why many women are still dying from haemorrhage. The rich people, as you have said, they have a way and they also rely on the relative. Q42 John Battle: They rely on their relatives as well? Dr Kodindo: Yes. In some countries the International Red Cross is also providing some blood. In Ethiopia the Red Cross is one provider for blood. Q43 Sir Robert Smith: On this blood issue, obviously there are all the cultural and other logistical issues. Is there also the practical expense and reality that you need to have storage, refrigeration and all that management? Dr Kodindo: Absolutely. Q44 Sir Robert Smith: In a sense fresh blood donated at the time it is needed is an easier thing to manage than long-term storage? Dr Kodindo: Yes. Of course this is logistically is very important. Q45 John Battle: That is why you would have queues of people at the time of a crisis outside a hospital giving blood, but if there is no pressure to do that ----- Dr Kodindo: There is no pressure. Q46 John Battle: Is the World Health Organisation pressing? Which of the UN agencies understands the need for there to be blood supplies and actually actively campaigns for it? Dr Kodindo: This is why I think the role of the UN is very important in telling the government to make all that effort and campaign and to try to reduce maternal mortality and address the causes of maternal mortality. Q47 John Battle: What I am specifically asking, just as for tackling some diseases - for example, I am thinking of the campaign for polio, the World Health Authority pushed very, very hard to get a very simple measure through as a means, and there were some cultural resistances - does the World Health Authority press for there to be blood available and for countries to take that seriously? Dr Kodindo: Yes. That will really help to put pressure on them. Q48 James Duddridge: Of emergency obstetric cases, what proportion are a result of abortions, attempted abortions or unsafe abortions, in Chad and generally? Dr Kodindo: The proportion of deaths from unsafe abortion is very, very high in Chad. Generally it is about 13 % globally. In Chad I would put it as maybe the second cause of maternal deaths, especially among adolescent teenagers. These are the ones with the least access to the contraceptive method. Q49 James Duddridge: What are the medical complications, and how can they be treated? What do you need to be able to treat people presenting? Dr Kodindo: Haemorrhage and infection, so we need antibiotics. For those who have seen that film of mine the 12-year old girl needed to have antibiotics and a blood transfusion but since we did not have them in the hospital her mother had to buy it. The small capital that she has she spent it in the first 24 hours buying, first, a small syringe and IV fluids. When it came to stronger antibiotics, which are much stronger against anaerobic infection, she just could not buy them. Only antibiotics will treat the post-abortion infection. Q50 James Duddridge: Can you tell us more about the abortion laws in Chad and any proposals to change those laws? Dr Kodindo: Chad, like many African Francophone countries, has inherited the law of France, some 1920 law, so abortion is illegal in Chad. Until now there is no talk about that. I am only a doctor. I do not know much about that. I can only talk about services that can help me save a woman who has had an unsafe abortion. This is what I need to save their lives. Being only a health provider I have really no power on that. There is no talk about changing it. It is the old law of France from 1920. Q51 James Duddridge: Is there anything more that can be done to reduce maternal mortality in countries where the law restricts abortion? Dr Kodindo: Again, as I told you, I work in countries but I cannot talk about changing the legal system. This is not really what I am supposed to do. I am just a health provider. For me when any woman who comes because of an unsafe abortion, or a spontaneous abortion, what I should do is treat them and try to save their life. I cannot change the legal systems of the countries. Q52 James Duddridge: How formalised is the system of unsafe abortion? Who actually carries out the abortion? How formal is the system in various countries? Is it done at the local village level by family members, or is it a paid service although illegal? Dr Kodindo: This is the big problem. Usually since it is illegal they do not go to the national health system; they use some people in their city. It is done in very bad conditions. When they are brought in it is the worst complication and we have to deal with that and sometimes you cannot save them. For some of the women we have to do major surgery on them in order to save them, like a hysterectomy. Q53 James Duddridge: Are there some countries where it is illegal for proper medical professionals to intervene where there has already been an attempt at an unsafe illegal abortion? Dr Kodindo: No, we do not have this problem, not in Chad. As a health professional you just have to provide the appropriate treatment to the patients. You have no right to refuse to treat her because she has had some induced abortion. Q54 Hugh Bayley: First of all, what do you think is needed to change what donor countries and the governments of developing countries and international agencies are doing to catalyse change to give us a chance of meeting the MDG goal by 2015? Dr Kodindo: It is a really important question because MDG is lagging. There is always something to start now. This is an urgent situation. The donors should work with the government and they should start up a real commitment - a commitment that should be translated into concrete actions, like putting some pressure on the governments to start to adjust and implement. We know what to do to prevent women from dying, and these are technologies that are not even sophisticated. It is possible to reduce maternal mortality. It has been shown here in the West; it has been shown in many countries that my previous colleagues have talked about - North Africa, Egypt and many of these countries. They should start having long commitments, a real commitment that should be translated into investing in infrastructure; also providing for supplies, and very simple basic supplies; antibiotics; magnesium sulphate; very simple supplies and drugs; work on the roads; work of the Ministry of Transportation; educating; and developing human resources, and the mid level human resources because you may not have enough specialists. You need the skills and medical care to cover the area where access is very difficult now like the rural area. Focus on these places, the rural area and the displaced person with the situation of insecurity and extreme poverty. Increase the coverage of these areas and it will make some change. In a few years you will see the change for yourself, but it is very difficult to achieve and we need a long-term commitment. It may not take days or months to register a reduction in maternal mortality; it may take more than that. This is why we need a really long-term commitment and accountability. Q55 Hugh Bayley: It seems to me as a politician that if you want to drive an administrative and political change you need a very, very clear idea of what it is that you are trying to do. In this session I have become aware that this is a very complicated problem, with many difficult inter-related things - education, family relationships, medical interventions and so on - but also many, many agencies involved in the field. It seems to me that there is great confusion about what the priorities are. Your answer to an earlier question, helped by Dr Songane behind you, put a very simple idea into my head. You tell us that it would cost 4.5 billion to provide safe childbirth for 95 % of the world's population. Dr Songane tells us that there are just under 150 million children born a year - that is $30 per child. $30 per child born in the world would provide safe childbirth for 95 % of children. Should we start at least with a campaign that says to each developed country government, "Unless you stump up $30 per child; put it into a fund controlled by women locally, which is transparent and open, you are not going to meet this target"? Is that too simple? $30 per child, should that be the campaign? What I have calculated, you say that some economist has worked out that $4.5 billion would provide safe childbirth for 95 % of children. Dr Songane tells us that there are 150 million children born a year, slightly fewer, but roughly. If you divide the amount it costs for safe childbirth by the number of births, it would cost about $30 per birth. Should we not just have a global target that the government of every developing country puts $30 per childbirth - they can estimate in Chad how many children are born a year? Dr Kodindo: We have about 10,000 deliveries per year. Hugh Bayley: For a community with 10,000 deliveries the government would need to provide a fund of $300,000. Chairman: In the UK we provide a maternity allowance so would that help if you actually gave women money, for example? Q56 Hugh Bayley: You have taken the idea even further than I have, but that is probably one way. So long as you find a way of averaging out between the cost of a Caesarean. What I am saying is: should we encourage all the agencies here to launch a campaign that will pledge, whether it comes from donors or country governments, $30 per birth? Dr Kodindo: I think we should try. We should start to do something. Q57 Chairman: I think the point behind Mr Bayley's question, and I think Ann McKechin was making the point, is that, sadly, in some countries you give the money to the government and it does not seem to get through to the women who need it. If you actually gave it to the women themselves who were pregnant in some form or another in a way that was guaranteed access you may cut through some of these problems - whether it is lack of will, corruption, or whether it is because at least you empower the women in a practical sense. The kind of people that we saw in your film having to go and buy blood, drugs and so forth, for a start with transport they would at least have some basic means of doing it, and not have to go to their husband or somebody else and get permission because they could actually do it themselves. Would that make a contribution to solving some of the problems? Dr Kodindo: Yes, but I still think the health system should be strengthened. Without a stronger system nothing much can be achieved. We still need to invest in the health systems. Q58 Hugh Bayley: I take your point about diverting money. Dr Kodindo: The corruption is a reality, especially in a country where the maternal mortality is high. If you have to restrict the money because of that then we are not really helping the problem of maternal mortality. Q59 Hugh Bayley: If you actually handed out bank notes the money would not be spent on maternal and child health, it would be spent by the men for good or bad other things. I understand it has to be kept within the health system, but somehow we need to focus people's attention on the fact that, compared with universal medication for HIV, this is a cheap and doable problem? Dr Kodindo: Yes. This is why something should be done. Of course it is something that can be achieved; it is possible. You have shown it here. It is possible. It is not even asking for super-technology, as I say; but it is possible if only the donors and the government have the same commitment. If they have the same will and they have an integrated strategy, coordinated strategy within the donors and within the government, we will see the result. This is why something should be done, and now. Q60 Hugh Bayley: How then would you get women's control? If you persuaded the Government of Chad, for example, or any other country, to allocate to the local maternity and child health fund $30 per birth, how would you give women of child-bearing age the control? How could you make that fund accountable to the women? Could you realistically set up a mothers' committee for each clinic in your country? Dr Kodindo: Yes. Q61 Hugh Bayley: How would you get the managers? You could require the managers to issue a notice, and put on a board of a clinic for those who could read to see that $300,000 has been made available for this clinic. How would you give them control over the money? Dr Kodindo: Some organisation of women; some group of women, to start to educate them and then show them how to manage it. Q62 Chairman: We might explore that with some other witnesses. What I do want to say is that I think your personal testimony is extremely valuable to us. Some of us have seen the film - I certainly have seen it. I think what concerns us, and you have summed it up in a simple sentence really, is that all of these things can be done, and they can be done affordably, and yet this is the MDG that is the most off course. In a sense, you are telling us from practical experience that it is really a disgraceful lack of will both nationally and internationally by the people who matter. Dr Kodindo: Yes. Chairman: I think Dr Songane has demonstrated that this is a job for men and women, very much so, although clearly women who wish to rise up and fight for themselves will find people who can support them. I think what we value from you is somebody who is actually having to struggle in a very practical sense in the field and faced real tragedies every day, and the frustration of knowing that those individual tragedies are avoidable. We would just like to thank you very much indeed for coming along and giving us this evidence. I hope when we finish this inquiry that we will have made some contribution to identifying some of the key buttons to press that might just help certainly the UK to do what it can to really bring this MDG back on track. I do not think any of us should walk away from this accepting that it is not possible; it clearly is possible. It is a matter of getting the right decisions in place. Thank you very much indeed, you have been extremely helpful. [1] Millenium Development Goal (MDG) [2] the Department for International Development (DFID) [3] World Health Organisation (WHO) [4] the United Nations Development Programme (UNDP) [5] the United Nations Children's Fund (UNICEF) [6] Non-governmental Organisation (NGO) [7] the Global Alliance for Vaccines and Immunisation (GAVI) [8] Antiretroviral (ARV) [9] the International Planned Parenthood Federation (IPPF) [10] International Labour Organization (ILO) [11] Reproductive Health Access, Information and Services in Emergency Settings (RAISE) [12] Emergency Obstetric Care (EmOC) [13] Intravenous (IV) [14] Dr Songane volunteered this information from the Public Gallery. |