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CORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 66-i House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE INTERNATIONAL DEVELOPMENT COMMITTEE
Tuesday 13 November 2007 DR TIM ENSOR, MR ALEC CUMMING and DR SAM ADJEI DR TONY FALCONER, DR MONIR ISLAM and DR NYNKE van den BROEK Evidence heard in Public Questions 63 - 119
USE OF THE TRANSCRIPT
Oral Evidence Taken before the International Development Committee on Tuesday 13 November 2007 Members present Malcolm Bruce, in the Chair John Battle Hugh Bayley John Bercow Richard Burden Mr Stephen Crabb James Duddridge Ann McKechin Sir Robert Smith
________________ Examination of Witnesses
Witnesses: Dr Tim Ensor, Principal Consultant (Health Economics), Oxford Policy Management and Senior Lecturer, Immpact project, University of Aberdeen, Mr Alec Cumming, Chief Executive Officer, Immpact project, University of Aberdeen and Dr Sam Adjei, Principal Consultant, Ghana Health Service, gave evidence. Q63 Chairman: Good morning to you gentlemen. Thank you very much for coming in to help us with our second session of public evidence on our inquiry into maternal health. I wonder, Mr Cumming, first of all, if you could introduce yourself and your team and then after that it might be helpful if you gave us a brief introduction to what Immpact has actually been doing and how it is set up. Mr Cumming: Thank you very much, Chairman. I am Alec Cumming, the Chief Executive Officer of the Immpact project. I have been in that position since 2004. Prior to that I was chief executive of an NHS Trust and had worked in the NHS for 30 years. On my immediate left is Dr Sam Adjei who is the Chief Consultant to the Ghana Health Service but who worked with the Immpact project as a visiting professor in international health at the University of Aberdeen until last year. So we have had a long close association with Dr Adjei. On my far left is Dr Tim Ensor who is a health economist who works with the Immpact project. He is based in York and also works with the Oxford Policy Management Group, but in this context he is here to represent the experience and interests he has with Immpact. Q64 Chairman: Thank you for that. If you could then give us a brief history of Immpact and what you have been doing. Mr Cumming: Immpact was established in 2001/02. It was set up with funding from the Gates Foundation, from DFID,[1] from USAID[2] and from the European Community, with total funding amounting to £20 million. The aims of Immpact were to identify evidence of what is effective or what would be effective in reducing maternal mortality and also to enable that effectiveness to be measured by ensuring that we can actually count the number of women who die because the statistics were, and remain, very poor in this area. So it was established in 2001/02 to look for evidence of what is effective and during the subsequent five years we have worked extensively particularly with three countries, Ghana, Burkina Faso and Indonesia, to assess the effectiveness of strategies implemented in these countries and to identify universal messages from these strategies. We are now in a position to share that evidence which I guess is why we are here. Q65 Chairman: Thank you very much. That is extremely helpful. As you know, the more you look at this issue the more people say that having an effective health infrastructure is a crucial part of it. DFID, where possible, does provide budget support to governments towards things like providing their own health service and education. How effective is budget support in delivering, and how can you ensure that there is a direct correlation between supporting the health service and improving maternal health? Mr Cumming: I think my colleagues will answer that in more detail. I would reinforce the desirability of supporting health systems. It is quite clear from the evidence we have gathered that the key to improving maternal health is to improve health systems. Maternal health depends on good operating health systems and therefore, wherever possible, the best route to improving maternal health does lie in systems support. That cannot apply in every country's circumstances, but wherever possible, as DFID indeed do, we believe that systems support is the correct approach. Dr Ensor: Obviously there are challenges with implementing systems of budget support, particularly with regards to the monitoring. The monitoring tends to be much more general than the monitoring you would get with project support. The key point that Alec made is that maternal health is something that affects the whole system. It is very difficult to set up vertical programmes that are only targeted at maternal health outcomes because maternal health tends by its nature to be something that covers the whole system. It is very difficult to set up individual projects that are only focusing on maternal health. Budget support for maternal health makes a lot of sense. The problems occur with monitoring budget support for maternal health in the same way that problems occur with any kind of budget support or any other health or indeed any other kind of programme. That is where the systems with the governments that we are working with are just not adequate to deliver the kind of broad, independent monitoring indicators required to provide the information on how the money is being used. In addition to the narrow maternal health monitoring indicators that are needed to monitor the outcome of maternal health programmes I think it is also important to put in place systems that allow much more general monitoring of public expenditure. If you do not have a system of public expenditure reviews that report on how money is spent and then used throughout the system it is very difficult to ensure that you are going to get good outcomes at the end of it. I think the point here is that in order to make budget support work you need both the independent indicators to monitor maternal health and you also need the much more general public expenditure framework and monitoring indicators to allow the system to function properly. Q66 Chairman: Dr Adjei, I think DFID were involved in supporting the health service in Ghana. You have had direct experience of that. How effective were they? Dr Adjei: DFID supported us very effectively. I must say at the outset that we at the country level tend to look at the health sector as one. We do not distinguish between the interventions and what is called systems because when you do that you create two health political parties, one the interventionist group and the other the systems group and it is not particularly helpful to us at a country level. We are interested in the strategies for service delivery and in integrating those strategies as much as the systems that are required to support the delivery of the interventions. We like to look at them as a whole. I think that is how we have been working with DFID. We would discuss the health system in the context of what are the priority interventions and then what are the important systems issues relating to technical resources or planning or even addressing poverty and looking at the resources that are required for women to access services. It has been quite effective in the sense that we can look at all the interventions that are critical and look at what the support system is that is critical to carry the interventions forward. Over the years we have had these health sector reforms going on and we have been dialoguing together. We have set up the systems to be able to track performance from the district right through to national level in terms of how the interventions are performing, like immunisation or access to maternal and child services, as well as tracking the human resource needs that are required for these, tracking logistics, tracking the financing and how funds are dispersed together as a team and we do independent reviews on an annual basis. We have monthly discussions with our donor partners, including DFID, we have business meetings on a quarterly basis and twice a year we have major summits where we bring all the donors and the governments and other sectors that have an interest together to look at the evidence and review the evidence that has been generated in the country. We even field independent review teams to look at what our performances have been in the previous years and bring this to the table. Q67 Chairman: You are talking about the Ghana Health Service. In the evidence you say that the release of funds by DFID has been unpredictable and erratic, that DFID closed its health offices in Ghana without discussion and this created a vacuum in the policy dialogue and deprived the health sector of good quality technical support. Dr Adjei: This has been the problem within the past few years. Where it has been very, very difficult - and this came up during our review and our dialogue and our discussions with a view to reducing transactional costs - is that DFID closed its office in the country without discussion and the Ministry was really concerned about that because they felt that having DFID at the table and discussing together was very important for us, passing on that responsibility to another government and it seemed not to have worked very well. So we were concerned about that. Now is the budget period and so this week we are having a meeting with all our donors, but it has always been difficult to confirm the monies that are coming in. People will pledge and say okay, we will give you so much, but when the time comes we have not really had the releases that we have been promised or been expecting over the past two or three years. It has been quite erratic over the last couple of years. It has been improving over the past few months, but that has been the problem. Chairman: I think that is something we may want to ask DFID about themselves directly when we have them here to give evidence. Q68 Hugh Bayley: I am interested in looking at what the priorities should be for DFID in terms of strengthening the health system as a whole or providing specific programmes and interventions on maternal and child health. If you look at their published statistics, overwhelmingly their spend is on health systems, excluding budget support. They spend a sum of almost £400 million on health overall, but only £16 million is spent on maternal and newborn health. In your evidence you say "the temptation to target resource through vertical initiatives, experienced by our Ghanaian colleagues, needs to be resisted by DFID and as far as DFID can influence them, by other donors."[3] It seems to me that DFID has the right policy, but you are saying it is not happening on the ground. Mr Cumming: The reason for expressing ourselves so strongly is that maternal health, as I said earlier, does depend on a functioning health system. You cannot provide emergency obstetric care without having blood banks, without having decent transport for patients and without having sufficient hospital beds for emergency cases. These are all independent indicators of a functioning health system and it is not impossible, but it is difficult to see, if the governance of the country is adequate, that there is a case for vertical intervention in these circumstances. The temptation clearly is that you can guarantee returns if you put money in for a specific purpose and monitor the achievement of that purpose, but the experience of our colleagues in Ghana and elsewhere is that that undermines the efforts of local health services to develop the whole service and distorts priorities. Although clearly more is needed to be spent on maternal health, in our view and in our experience that should be in the context of supporting health systems, where the governance of the country permits the spending to be tracked and DFID to have confidence that the money is being properly spent. Q69 Hugh Bayley: You seem to be saying 80 % of the money should be channelled through the government and taken from the basic health system, but you may have some particular initiatives in a particular clinical discipline or other that you would want to support. The last time the Committee was in Ghana was probably about four or five years ago and we visited the Kintampo Health Research Centre just before the tragic death of the technical director, Paul? Dr Adjei: Paul Arthur. Q70 Hugh Bayley: He was an inspirational doctor. They were doing a lot of work on very, very cheap interventions, high doses of Vitamin C, which had a big impact on neonatal morbidity if I remember correctly. Are those lessons being taken on board? Have those lessons been fed in to the protocols for maternal and child health in Ghana? Do you need targeted funding for relatively cheap but effective interventions of that kind or would you still say "put the money in the health system and let the Ghanaian health system decide the priorities"? Dr Adjei: The maternal assessment on Vitamin A will be completed next year. On the child health side, that is part of the overall package of interventions that we deliver to children. It is integrated as part of the primary healthcare package of interventions. We like to look at it as a whole so that the districts get the funding to organise how they deliver that without somebody coming in with the money and saying they should go out there and just give Vitamin A to the kids. The districts can organise it together as part of their whole healthcare delivery arrangements. That is how we would like to have resources organised. Q71 Hugh Bayley: Has the government or the Department of Health in Ghana published any reports on the impact of spreading out this therapy more widely? Dr Adjei: The annual review process will describe in detail all the interventions and how they are carried out and it will take measurements on implementing child nutrition. We do have evidence to show that the nutritional status of children has improved for a couple of years now. Hugh Bayley: If you could share it with us that would be helpful. Q72 Ann McKechin: I want to continue on this issue of integrating vertical funding with overall health systems. The Global Fund to Fight AIDS, Tuberculosis and Malaria obviously takes up a huge amount of donor funding. To what extent do you believe that government and donors alike are sufficiently alert to the need to integrate this properly with maternal health systems, and what has been your experience in countries such as Ghana as to whether or not there have been any problems about that issue of integration? Mr Cumming: I would reiterate that insufficient resources have been made available to tackle maternal health. It is the single biggest measurable difference in health status between the developed and the developing countries. We clearly do not want to get into a debate of HIV/AIDS versus maternal health, but maternal health above all requires functioning health systems and is the least susceptible of all the conditions to vertical funding. In that sense its interests may not coincide with interests in tackling the specifics of HIV and AIDS and that is a problem because these priorities are set externally by governments and by donor agencies when they give money for these specific purposes and to that extent it is a distortion, one would have to say. Q73 Ann McKechin: I wonder if Dr Ensor has any comments about how integration of these systems is working in practice. Dr Ensor: International agencies are generally quite good at working together at one level. They are pretty good at working together in investing in primary care. Where I think that international agencies are much weaker at working together is at the hospital level. One of the reasons for that has been that primary healthcare has become such a political necessity to invest money in and rightly so because that is where most diseases can be tackled, but as a result the secondary level tends to be a bit neglected. This maybe does not directly answer your question because you are asking about general donor co-ordination perhaps. My observation would be that certainly in a couple of countries in Asia where I have been working the emphasis from the donor side is all about putting money into the primary level. The government is left on its own to try and do the best it can with the secondary care level. Q74 Ann McKechin: Would this be one of the reasons why mother to child transmissions of HIV, for example, are still very high, because there has been such an emphasis on the primary care level rather than at delivery? Dr Ensor: It could be. The other related observation to this is that I have observed that a number of development partners, possibly DFID in some countries but certainly some of the other European development partners, have then begun to realise that coverage for catastrophic care is important, that coverage for things like Caesarean sections and other emergency obstetric needs are important and they have begun to think how they can develop almost parallel systems of financing and sometimes delivery. So the government is struggling along trying to develop its district hospital structure and you end up with a parallel structure. I think that is an important issue for the development community. Bangladesh is a good example of this where there has been far too little focus on that level by developing partners. Q75 Mr Crabb: Let us move on to the issue of user fees for maternal health services. What complementary policies should donors like DFID be promoting and supporting in those countries which are looking to abolish user fees in order to ensure that lost revenues are replenished? Dr Ensor: It is very difficult. When we are looking at user fees we should not only focus on the fees that are faced by the user once they have reached the health facility. It varies from context to context, but in some contexts by far the greatest burden on households is the cost of getting to the facility, having to give up time, having to travel. Nepal is a very good example of this where studies have shown that 60 % of the cost is in getting to the facility. Any policy for free delivery has to focus on the main financial barrier. In Nepal it is transport. In other countries it will be other things. A policy needs to begin with the biggest barrier. I think the second part of that is that in a resource-constrained environment it is very tempting to target and probably some sort of targeting is almost inevitable. You cannot implement a policy that allows free delivery in all circumstances for everyone immediately. However, the type of targeting is very important. The experience with individually based targeting where you try and work out who is rich and who is poor on an individual basis does not have a very good pedigree. It has worked more or less in some countries, but in many contexts it has not worked well. I think the experience from Immpact and from elsewhere suggests that in designing a careful policy of targeting there is almost a hierarchy of targeting that begins by looking at the poorest areas and targeting those areas with universal obstetric care. That will mean the rich in those areas benefit, but the cost of targeting areas tends to be much less than if you try and work out at an individual level who is rich and who is poor. The second part of it is that for emergency obstetric care individual targeting does not work well at all because there is plenty of evidence that shows that even the non-poor can be pushed into poverty as a result of large charges. Our evidence from Indonesia, for example, shows that without free emergency obstetric care at a couple of district hospitals 13 % of users would have been pushed into poverty if they were not exempt. They were the near poor that would have been pushed into poverty. The beginnings of any user fee policy must be, firstly, to look at the biggest financial barrier and, secondly, to look at the type of targeting, and then thirdly, which is perhaps where you started from, to ensure the resource flow. Maybe Sam would like to say something about this on Ghana. The Ghanaian policy for providing free delivery care failed almost entirely because the funds that were promised at the national level were not properly channelled to the facility level. Q76 Chairman: Have you looked into the role of providing, for example, maternal grants, in other words to give a woman who is pregnant a sum that would help her to cover transport or other costs? Has that been looked into? Dr Ensor: That is interesting. One of the problems with that is that the grant is not used for the right purposes. However, the Nepal intervention is actually very interesting in this area. The cost of transport is around 60 % of the overall cost to users. The Nepal Government a couple of years ago developed a policy that pays a cash amount to every woman that reaches a health facility. If she gets to the facility she gets money in her hands and it offsets the cost of transport. A full evaluation of that is yet to be done, in fact it is ongoing. Early results from the management information systems suggest that skilled attendance is increasing. We will wait to see whether it is directly caused by the system of grants to women. Dr Adjei: User fees account for almost 20 % of their expenditure on health and if it is to be abolished then you have to find a way of replacing it because that is a minus of revenue for the hospitals using the procurement of grants and essential supplies. We started off with an exemption policy and a lot of the units supported that and we were paying from the debt relief money, but that became unpredictable. We were running out of funds from the debt relief money to pay for the exemptions. Now we have started an ambitious health insurance system so that we can get women enrolled into the health insurance system as a way of covering their costs for deliveries when they come in. Quite a number of them get exempted because of the nature of the laws. You can get exempted, but you have to go and get enrolled and get a card and then you are able to access insurance funds to cover your costs. One of the interesting observations is that the women come to the paediatric clinics four times and you have a coverage of about 80 %, but less than 50 % come to deliver. The difference for a long time between the two was the deliveries that are charged to it. Now that we are taking out the charge for the delivery we are hoping the utilisation rate will go up because it is within the same facilities that the prenatal and the deliveries take place. If they can come four times then perhaps they would come for delivery. We are already beginning to show that the exemption policy has increased uptake. There are still issues about the quality of the services and some cultural factors that we have to deal with as part of the overall policy of removing fees. We will have to go with information and education and ensure the poor have the confidence to use those services because if they go there and they are discriminated against because they are poor then they will not go even if the fees are removed. I guess the policy that I am talking about is support to ensure that other mechanisms come into play to provide for the cost of removing the exemption from the woman of having to pay. Q77 Mr Crabb: What kinds of costs are built in to the user fees? Do they tend to be made up of drugs costs, other supplies, salary costs? Dr Ensor: It varies considerably. If we are talking just about the facility costs, then the salary costs might be anything between 30 and 50 %, the drugs costs might be another 30 % and then the rest is the overheads and that is a supply side cost. In addition to that you have whatever demand side costs there are, such as transport, which, as I have indicated, can sometimes be the dominant cost in certain contexts. Q78 Mr Crabb: Are you aware of any work that has been done to try and identify average costs for a birth in the developing world? Dr Ensor: Yes. It varies enormously. The figures that I have seen show overall aggregates fall by continent and also for individual countries. The supply side cost is between perhaps $30 and $100 per birth. Obviously it is much higher where there are complications. Q79 Sir Robert Smith: I want to pursue a bit more the issue of cash transfers or vouchers. In societies where women's status may not be that strong is there a concern that whilst the cash is made available to them they do not then get the ability to control it in that direction? Do vouchers have an added advantage in that they are for women? Dr Ensor: There are pros and cons. Clearly with just giving cash to a family you run the risk that it will not be used for the right things. If you can somehow condition that cash, for example in Nepal you do not get the cash until you reach the facility, then that guarantees that at least the woman has got there and it is basically mitigating the cost of transport and provides some extra incentive. Vouchers lose that problem. In certain contexts I think vouchers can be appropriate. The problem with voucher schemes is that often they require the development of a parallel infrastructure, ie administration, that adds a lot to the cost. There are a number of examples. Bangladesh has a system of vouchers now for reaching a facility and they have three levels of committee which, firstly, filter the women because it is only targeted at poor women, so they have to decide who is poor, and then once the woman has received the care they allow the transfer of resources from a fund to the facility and also to practitioners in certain cases. With all of that you are adding an extra parallel structure. It is obviously not sustainable beyond the end of project funding unless somehow that structure can be absorbed within government. Sometimes - and I think this is true in Bangladesh - the parallel structure has not been created in order to serve the needs of the poor or to develop competition, but it has basically been set up to circumvent what is seen as a very bureaucratic and unyielding government system of financial distribution, so you create your own system, but that has problems. Q80 Sir Robert Smith: Alec? Mr Cumming: I just wanted to pick up the associated point. One of our key findings is that even if we were able to provide three pillars of a sound system to address maternal health, that is family planning, skilled attendance at delivery and access to emergency obstetric care, we have accumulated a great deal of evidence that unless we identify in an individual country's circumstances what it is that acts as a barrier to the poorest women accessing these facilities the provision of the facilities by themselves will not work. So we should not rule out any means of achieving that, and Tim is identifying possible means. Clearly the best means is if it can be system-wide support, but the crucial thing is that unless we are able to ensure that the poorest women can access facilities then we will not achieve MDG 5. There are huge discrepancies between the maternal death rates for the poorest women and the richest women in developing countries. In Peru, for example, the level of maternal mortality is eight times as high in the lowest income quintile as in the highest. Generally speaking in the countries we are looking at it is two and a half to three times. Unless the issue of addressing access by poor women is tackled then we will not succeed in achieving MDG 5. Vouchers, cash systems, supply-side provision, demand-side subsidies, all need to be looked at depending on the individual circumstances of the country, but what should drive it is ensuring that the poorest women in society are enabled to access facilities. Q81 Sir Robert Smith: The advantage of cash over vouchers is that the person can be more flexible. There are so many costs, whether it is drugs, blood or the transport, that if they could maybe get a neighbour to help with the transport then they have got some in reserve for other things. Dr Ensor: Yes. There were real doubts in Nepal when they introduced the cash a couple of years ago whether facilities would simply have the ability to manage cash because you have got to have the cash available when the woman goes for the delivery. If you think of a remote area of Nepal, perhaps at that time controlled by Maoists, there were severe doubts that they would have the ability to secure cash and I think those are very real problems. If you can get over that it does offer a more flexible and simpler way of directing resources. Q82 John Bercow: Dr Ensor, in respect of vouchers you highlight the problems of bureaucracy and cost. I wonder if I can just ask you about two other issues and specifically your view on them as between cash and vouchers. One is the question of the scope for corruption. I do not know whether the scope is greater with cash, as one might think, or with vouchers, but I would be interested in the evidence based view or in any anecdotal impressions you have got on that point. The second is the issue of stigmatisation and what one might call transparency, but transparency in a bad sense rather than a good sense. Ordinarily when one talks in international development terms or public policy terms about transparency it is normally magnified as an objective to be sought, but in this context I mean more branding people. Although the service to be accessed is a service for which it is perfectly reasonable that people should get support, I wonder whether in the context of the society it might contribute to labelling, abuse, discrimination, dehumanisation or whatever. I do not know if you have got a sense of that. Certainly in the very, very different circumstances of our own society and in relation to a different area of policy, namely the provision of support to certain categories of asylum seeker for example, it is sometimes said by critics, amongst whom I would number myself, that providing vouchers to people is, frankly, a rather inequitable way in which to proceed. Dr Ensor: There may well be good evidence. I am not aware of good evidence one way or the other on the ability to corrupt either a voucher or a cash system. I think it is present in both systems. I am not sure which is more or less likely to be corrupted. In terms of the stigmatisation, I think that is an issue. It is a slightly tangential example, but in Vietnam, certainly when they introduced insurance, which was a kind of voucher for primary care for the poor in the 1990s, many hospitals just refused to take it. They much preferred to receive user charges where they could charge what they liked. I think the other observation there is that if you target poor areas rather than poor individuals then the problem of stigmatisation is probably lessened. If you say there are vouchers for every woman that lives in this area that happens to be poor then the relative stigmatisation of individuals disappears a little. Q83 John Bercow: Dr Ensor, you have shown a prescience bordering upon a psychic quality which is greatly to be admired because I was going to come on to the question of insurance schemes. Are you arguing that intrinsically such insurance schemes would fail to reach poor people or should donors, such as DFID, in a sense refine and improve the model to ensure the community insurance schemes for maternal healthcare hit their target? Dr Ensor: I think it is possible for community insurance schemes to hit their target. I do not think you can expect community insurance schemes to be sustainable in that you expect people that contribute to cross-subsidise those that do not contribute. The overwhelming evidence is that that does not work. If you are paying into a voluntary scheme then individuals are reluctant to make that much of a subsidy to the costs of other people's care. If you want it to work then you have got to be prepared to fully fund the same kind of coverage for the poor as is funded by individuals that are not poor. There is a colossal amount of evidence on community insurance and each scheme varies. Most community schemes do not cover normal deliveries because it is a predictable event. There is a problem with predictable events. Many also do not cover complex obstetric care because it is so expensive and community schemes tend to have small reserves so there is a problem there. That is not to say you cannot do it through community insurance, but it may not be the best vehicle to provide for the sort of very complex demands of obstetric care. Mr Cumming: The stage that Immpact has now moved to - and it is in the final year of its activity - is in fact to work with governments in the three countries in particular that we have worked with to assess the most appropriate strategy to ensure that maternal mortality is reduced. We have the example of an insurance based scheme in Ghana, in Indonesia different sorts of insurance based schemes, and in Burkina Faso a rather different approach. We intend to go back. As both Dr Ensor and I have said, there is no single answer to this. It will very much depend on the social, cultural and governance status of individual countries, but our intention is to work with governments to identify those strategies which are going to be effective and then we hope to publicise universal messages from that work. Q84 John Battle: I want to return to a point that was made earlier on about the budgets and monitoring the budgets. What is a maternal health budget? How does it get there? Why I am haunted by that question is that it seems to me budgets to improve maternal health may have to fund hospitals in an integrated way and even transport. The reason MDG 5 seems to be so far behind other MDGs is you can clearly identify provision of anti-retroviral drugs or mosquito nets, but in this area the budget seems so diffuse. How do we know it is ever going to get there? I was at a conference of the Voluntary Service Overseas and they were having a conversation north and south and it was suggested that rather than sending doctors and teachers, what were really needed were good lawyers, IT specialists and accountants to track and monitor the money. I want to ask you about that tracking and monitoring of the money. What can be done in-country by civil society to track the money effectively to make sure it reaches the parts that need to be reached? What could DFID do more of to ensure that that was a priority? Dr Ensor: There are some very good regular public expenditure reviews accompanied by those less regular public expenditure tracking studies which summarise how money is spent in the public sector and even in the non-public sector and then look at whether the money actually reaches the facilities. Those tools are well publicised by DFID in some countries. What extra could be done is regularising those tools. There are a few examples where governments themselves or Ministries of Health themselves undertake annual public expenditure reviews, but there are not many of them. Usually it is something that is enforced from outside, often by the World Bank but also other agencies. Encouraging a home grown public expenditure review is a very useful tool. The second part relates to the second part of your question and that is the role of civil society. Unfortunately civil society has not been involved very much in using those tools, at least in my experience and the countries I have worked in. The public expenditure tracking studies, for example, are often extremely sensitive. They are often done reluctantly by governments because donors want them carried out. The one that was done in health and education in Bangladesh, for example, took several years to really see the light of day and to be properly disseminated because it raises sensitive issues. I believe there are now some examples in India where civil society is actually involved in training people to undertake these studies and civil society are involved in those processes. I agree with you that that is one area where DFID could pursue more - I believe they are already - in pushing the role of civil society in the use of those tools. Mr Cumming: I am slightly concerned at the first bit of your question, lawyers and accountants rather than health professionals. Tim is entirely right, we need good systems for tracking, but there is a gross deficiency of health professionals in many countries. John Battle: I am not trying to set one against the other. I am just trying to raise the status of lawyers and accountants! Q85 Chairman: Were we not told in Chad that 1 % of the budget reaches the end result? Dr Ensor: There is a lot of evidence on that now in different countries. John Battle: Even the theme is becoming a little bit of an 'in' word, a bit trendy. You have got participatory budgeting and civil society monitoring and budgeting even in the north is only beginning to happen. Perhaps I could just ask if there is information about the Indian example that would be helpful and maybe we will encourage DFID as well as the government in-house to encourage the civil society monitoring as well and look to see how they can develop instruments and we could do a bit more here as well. Q86 Chairman: If there is any information on that it would be helpful. Dr Adjei: In Ghana what we do is at the beginning of the budget year we all have targets set around expenditures, for example that 42 % of expenditure would be at a district level for different programmes and then at a regional and then at a national level. At the end of the year when the audit is done we can track and see if we are achieving these budgets. Then you can do costing studies within the various levels to look at where the money is spent in each area so that you can know exactly how the funds that went, for example, to the districts were spent because they will keep records of everything within the system. The support for that kind of expenditure to be done by the institutions themselves has always been the way to assess whether donor funds have been used appropriately. In addition we have independent audit systems which we agree with the donors and they will bring together independent auditors and they will go through the books and make sure that the funds are reaching where they should be, and then the public accounts systems bring to the public how funds that have been allocated to the governance sector have been spent and on what. It is a system that has been growing very slowly but importantly in ensuring accountability and the proper use of funding that comes into the system. Q87 Hugh Bayley: I have been provoked by your comment to ask about nutrition. Do you have any idea about the cost-effectiveness in terms of maternal and child lives saved per dollar spent by putting money into better nutrition as opposed to into health? I am old enough to remember queuing up with my ration book for welfare support in this country. If you were to introduce food interventions, perhaps not so much in Ghana but in parts of Africa that have suffered severe food shortages in recent years, what sort of food interventions would you put resources into? Mr Cumming: That is not something that our project has looked at. We have made the point about the link between poverty and maternal health and clearly nutrition is one of the factors that lead to the very, very heavy levels of maternal mortality in the poor, but I cannot answer that question. Dr Adjei: At the moment the bigger problem area has got to do with anaemia in pregnant women. Much of the emphasis has been on more nutritional supplements, iron tablets and folic acid tablets to address anaemia because that is the greatest risk. If the anaemia is very bad and the woman has a small bleed then they can go into shock very quickly. The emphasis has been on nutritional supplements for pregnant women who come to us. Then there are associated factors like malaria in pregnancy which also causes severe anaemia very quickly. Making sure that you prevent malaria in pregnant women by treatment is one of the ways to address the problem. The government has started work in the whole area of nutritional messages called regenerative health. It is a new programme that is targeting pregnant women and what they must eat and the locally available foods that have been studied and are rich in nutrients for pregnant women to keep them well. That has also been promoted of late. Q88 Sir Robert Smith: Just thinking about previous evidence sessions and some of the briefings we have had. Is not the reality that in relation to the survival rate for mothers in childbirth it is actually being able to intervene at the time of the birth that makes the dramatic difference? Dr Ensor: Yes. I am not sure I can offer very much on the nutrition angle. I do not think you would pitch the two together in an analysis of cost-effectiveness because both are needed and as you say, many of the deaths are because you cannot deal with the emergency as it occurs. Better nutrition certainly helps the final outcome, but the infrastructure for that emergency care is also important. Q89 Hugh Bayley: Maybe it would have a bigger impact in terms of years of life gained with children rather than with the mothers. Dr Ensor: Yes. Mr Cumming: The main causes of maternal death are not directly nutrition related. Dr Adjei: It is the haemorrhage which is the problem because if it is bleeding you have to intervene with the bleeding, but to the person who is anaemic and who loses a small amount of blood very quickly, that is where the link with nutrition comes in. You have better haemoglobin levels during pregnancy. Q90 Hugh Bayley: Iron tablets rather than food rations? Dr Adjei: Yes. Basically, that has been the approach but also malaria is a major cause of anaemia in pregnant women so that is also another one to deal with. Q91 John Bercow: How widespread has the uptake been of Immpact's new tools for measuring maternal mortality such as the Sampling at Service Sites methodology? Mr Cumming: They are only now being publicised so the uptake at the moment has been internal within the project. The aim now is that we are offering them as a public good. We published a revised version of the Immpact toolkit to coincide with the major conference, which I think you are aware of, that happened last month, Women Deliver. Subsequent to that there was a huge amount of interest in these tools and we are arranging for a series of training courses in the use of the tools with colleagues in developing countries. We expect to see these tools used widely. So far though they have strictly developed within the project. Given the huge cost benefit - for example, in the Sampling at Service Sites technique - compared with the population - wide surveys and given the very dubious nature of the evidence just now on maternal death, it is really important that these methods are publicised and made widely available. That is the aim. Q92 Chairman: The effect of these methods is that you are identifying a worse situation. Mr Cumming: It varies a little but generally speaking we are finding that levels of maternal mortality are higher than those that are officially recorded. Q93 Chairman: You talked about the project being in its final year. What is its current situation? You have done the work. You are presumably now putting forward recommendations. What is DFID's engagement? Is there an absolute timescale? In other words, is it all going to come to a definite end? Mr Cumming: The project was funded for a specific purpose, to identify evidence of what is effective at reducing maternal mortality. We have done the work. The last stage of what we are doing should be to prove that it works by going back to individual countries to work with them in developing strategies. The funding that we have from DFID, the Gates Foundation, USAID and the EC[4] will be fully exhausted by the end of August of next year. We do think a project should have a beginning, a middle and an end and it will come to an end at the end of August. There is a need to continue with research into maternal health, both in terms of measurement and in terms of effectiveness, but that would represent a new phase and we are in discussion with DFID about that. DFID are very positive about supporting the work that we do in making sure that our findings are implemented and they have said that if we come back with proposals for further research then they and others will be interested in that, but that is for us, to go back to them and make the case for further work. Q94 Chairman: Will you be producing a final report on the project and, if so, is there a time frame? Mr Cumming: Yes. We are working on that right now. The emphasis of that report is on freeing the poorest women in society from barriers which stop them attaining care. We expect to produce a draft of that by about the end of the year and to publish it in the spring of next year. Chairman: I think that will be extremely helpful. Those of us on the Committee who have embarked on this report, to be honest, have been absolutely shocked to the core about both the figures and the appalling suffering and indeed major social consequences in terms of orphaned children and fragmented societies and indeed the interesting point that it can contribute to conflict and social breakdown. In other words, it is a fundamental contributor to poverty. Anything that helps focus on practical measures that can address this is much more significant than just isolating it as a single factor. Yes, it is terrible for women. Yes, it is terrible but it has much wider repercussions than people think. I am sure that your work is extremely helpful in understanding the problem and perhaps coming up with solutions and I hope our report may help contribute to that as well. Can I thank you all for coming in and helping us with our inquiry. Examination of Witnesses
Witnesses: Dr Tony Falconer, Senior Vice-President, Royal College of Obstetricians and Gynaecologists (RCOG) International Office, Dr Monir Islam, Member, International Executive Board of RCOG International Office and Director, Making Pregnancy Safer, World Health Organization (WHO), and Dr Nynke van den Broek, Senor Clinical Lecturer in Reproductive Health, Liverpool School of Tropical Medicine and Director, RCOG International Office, gave evidence. Q95 Chairman: Can I welcome the three of you. You have obviously been here for our previous evidence and have heard what issues we are exploring. We are grateful to you for coming in and giving us your expert advice. Just reading the background brief, it is clear that your organisation effectively sprang from these problems in the now developed world. Obviously we are interested in the extent to which what we might call the crisis or the shame of the developing world can be addressed. Could you introduce yourselves and say who you are and what your qualifications are for our record? Dr Falconer: I am Tony Falconer. I am basically a practising clinician, obstetrician and gynaecologist in Plymouth. I have recently taken over the responsibilities of senior vice-president of the Royal College of Obstetricians and Gynaecologists. The principal brief of that job is international affairs. Our Royal College, as you said quite rightly, was instigated 77 years ago in response to the magnitude of maternal death in the United Kingdom. We are an international organisation. About 50 % of our members and fellows come from overseas, principally in the developing world, so we have a massive training, teaching and supervisory responsibility for that part of the world. Recently the International Office has also developed very close relationships with Liverpool and that has enabled us to become, I suppose rather late in the day, rather more adventurous about some of these very major issues that your inquiry is highlighting. Dr van den Broek: My name is Nynke and I am a trained obstetrician and gynaecologist. I am a Fellow of the College of Obstetricians and Gynaecologists, trained in this country. I have spent most of my working life working with resources projects, mainly in sub-Saharan Africa but also in Asia. In 2001 I joined the Liverpool School of Tropical Medicine as a senior clinical lecturer and my work combines improving delivery of clinical services research with evaluation and management of programmes. I lead a small team in the School and, as you all know, the Liverpool School of Tropical Medicine is the oldest school of tropical medicine in the UK. Dr Islam: I am Monir Islam. I am the director of Making Pregnancy Safer, a department in the World Health Organisation in Geneva. I am also a member of the executive board of the Royal College and that is our collaboration. We are responsible from our department with global responsibility of maternal health. Q96 Chairman: Thank you for that. It is extremely helpful just to have that brief introduction to your own backgrounds. As you can see, what we are looking into is, in practical terms, how DIFD and donors like DFID can be more effective in helping developing countries to deliver improved maternal services. What do you think that an organisation like DFID could do that would help strengthen health systems in ways that would deliver results? In other words, are we talking about developing the infrastructure network, developing the expertise, the human resources, providing the drugs or the monitoring of all of that to make sure it happens, because we have evidence of resources being put in but not actually getting to the people who need them. We have had anecdotal and specific evidence for example in Chad of essential drugs simply not being available in the country. Could you give us a flavour of where you think the priorities are? They are probably everywhere but have you some thoughts as to how they can be channelled down and focused effectively by the intervention or support of an organisation like DFID? Dr Falconer: Your question is very penetrating but I guess, from the position I am coming from - we will have different positions - it would be human resources. The bottom line of what I have heard in the previous hour is that the thing that really is missing in most of the provision of health care to labour in women overseas is people with the skills. The position that we are coming from I think is a multidisciplinary one to training. Our principal responsibility in the Royal College has always been training. Over the years we have been active in training doctors. We have a huge membership overseas, organised in networks. For instance, if you look at an old fashioned map, most of the countries that are pink on that map will have representative committees and large numbers of members and fellows, so there is a certain standard and quality for provision of care with the doctors in those countries. I think now we need to be more adventurous in this because the evidence is that SBAs[5] are the critical, key player in terms of provision of primary health care to women. New models need to be looked at for how you train other health care professionals. That is the position I come from. The issue you raise about drugs I guess perplexes most of us because the major obstetric drugs - be it oxytocin, although that has a problem because that has to be kept in the fridge - but, if you look at magnesium sulphate, it is dirt cheap. There is no provision in terms of care and how you manage that and it just bewilders me why provisions for that are so problematic. People who have spent much more time overseas will be able to answer those questions, but that should not be a major difficulty. The last point that you made I think is incredibly important, which is quality assurance and having some audit on what is going on. Nowadays we need to get into the situation where, whatever interventions we do, whether they are training or whatever, there is an audit trail on those so that we have evidence of good practice. Nynke, I am sure, will talk about some of the courses that we have delivered overseas in terms of training people. Dr van den Broek: That is right and I think I agree with the previous evidence that you need to have a functioning, good health system to be able to have equitably distributed maternal health services. I am encouraged that there is increased advocacy for this because that is needed. MDG 4 and 5 have not been highlighted. Malaria, HIV and TB have been much more prominent. Perhaps it may be easier to solve them. It is quite clear that there are insufficient good quality services available worldwide for women who are about to deliver or who have complications of pregnancy delivery. You cannot really develop one without the other. If you can use the development of a good system and that is management, governance, finance, all the things that we know you need in a health system, the infrastructure, the drugs but also the governance and focus on making sure that at least a minimum number of health services are available for maternal health, then you can see how one influences the other. You will make a real difference and there is evidence for that. It is very clear that the two key health services, if you like, that are needed are skilled birth attendants and essential or emergency obstetric care and they are very well defined. That is what I would go for and unfortunately that is more complicated than saying "we are only going for drugs". You need to address the spectrum. Q97 Chairman: I kind of expected you would say that. It is really trying to see how these things fit together from your point of view as professionals. Dr Islam: We discussed this morning whether DFID should provide budget funding or vertical funding. It would be good to provide budget funding but with some indicators to ensure this funding is being utilised for priority activities. There has to be a monitoring system because if you are providing only the budget funding without any indicators or control then the money can go anywhere. How then will you ensure that money is going to be spent on the health system? The maternal mortality rate is one of the indicators for a functioning health system. I would like to see improvement of maternal health become an indicator to assess how countries are using the funds. If you add those indicators, then budget funding would be a good thing. To give an example, when DFID funded a project in Nepal on maternal health, they had improved the system making surgical procedures and blood transfusions available. This improved system not only helped maternal health but also other programmes. In road accidents blood transfusion is necessary, surgical expertise is necessary, the system could be used. The health workers with surgical training were there to provide services in those cases. So I would suggest incorporating some indicators in budget funding. Then, also some vertical funding needs to be available. Last week I was in Zimbabwe and I visited one of the midwifery training schools. The school did not have the necessary books. They have only one midwifery book and 120 students are using the same book. One book costs nowadays $29 million Zimbabwean which is nearly $29 US. It is now $950,000 Zimbabwean for $1 US. We changed in one day from $800,000 to $950,000 Zimbabwean for $1 US. You can understand what is really happening. The books are not there. The number of faculty members has gone down. There are supposed to be seven or eight faculty members in that training school. They have only three. They do not have the right number of trainers. They do not have books or dummies and the charts are old because the funds are not there. I was so surprised to see that the students are really willing to learn and to contribute to the nation, but those necessary supplies are not there. We need to look at how we can improve the training facilities and providing the training. Then look at part of the supply side of it, particularly in maternal health. Oxytocin, magnesium sulphate and antibiotics are the most needed supplies. These are a few things which are necessary for maternal health. More importantly, DFID and particularly the parliamentarian group can also look at investment issues in developing countries like Malawi, Zimbabwe or Chad. The developing countries should not only be looking at what money they are getting from DFID but need to look at what they themselves are investing to improve maternal health. The countries need to also look at how the national budget is being allocated. What are the priority areas? This year with the UK Parliamentarians in Westminster, we got the parliamentarians from 15 developing countries and discussed how parliamentarians can raise that issue in their own parliament to increase their investment on maternal health and in other social sectors. That also needs to be there. The last issue that I would mention for DFID's support is the monitoring system because today if you ask the polio programme they will be able to tell you exactly where polio is coming from, where the outbreak has happened, but for maternal health the monitoring system is still very weak. We need to really invest more on the monitoring system and see how at the district level they can use the monitoring system data for planning, not only to send it to the national headquarters for a report to come out after four years and it has not been used. They can improve how districts use data for their own planning purposes. In those areas, I think DFID has done good work and DFID's support for maternal health is really tremendous. We need to look at all those things and decide how we can provide funding support. Q98 Hugh Bayley: I just wonder what role there is for the private sector to make a contribution to reducing maternal deaths in developing countries? Dr van den Broek: Many countries are addressing this issue because it is recognised that in a number of countries the private sector is, if you like, going up, which generally means that people with more money have better access to care. The report we compiled brings that out a little bit from people working in various countries, looking at different mechanisms with which you can make use of the skills and expertise, which are more available in the private sector, and distribute them more equitably. There are small scale projects where this is happening, where members of staff are doing both, some private and some more public orientated. There are bigger projects in districts where private hospitals adopt smaller hospitals and make a very close link. There are also other problems with the private sector in that they might not be helping. I think they should be regulated, especially with regard to for example Caesarean section rates or quality of care that is being given, so not perhaps for evidence based care but for financial incentives. There needs to be better international regulation of such institutes who will want to be highly accredited and seen to be doing the right thing. This has recently been approved for example in Sri Lanka, where at the moment less than 7 % of deliveries are happening in private facilities. They are looking for regulation but there is no international guideline either from the UN bodies or from us, so there are opportunities and I think the time is right to address this. It is too simple to give one simple answer but it is no longer okay to ignore that the private sector is growing, including for maternal health. Dr Falconer: It is a very interesting question and an analogy with our own system. There is an inherent conflict here. If you look at where medical personnel are in many of these under-resourced countries, they will be in the major conurbations and they will be doing some private sector work. You cannot maintain these staff in the rural locations. One of those conflicts is that they get paid so poorly in their basic hospital salary that they have to do private practice. Certainly my experience of visiting many of these people is that they have to work in the evenings and through the night to make their money. In terms of what impact that makes in the totality of health care, I would think it is probably relatively small in those countries. Q99 Chairman: It does not have a political fall-out? Some of the statistics we have seen are that in quite a lot of these developing countries what you might call the elite, the better off, do not suffer all these dreadful maternal deaths and problems so they do not perhaps see the need to fight for those who do. Dr Falconer: This is again going back to the training issue in terms of who should you train. If you train people who do a Caesarean section who are not doctors, then they will not be attracted because they cannot charge that fee. Again, in terms of where you put your resource, you may be better not to train people like me. Dr Islam: We need to also look at the issues of the private sector. Of course the private sector has to play a bigger role but there are issues coming out that we need to look at while considering the private sector. Because out of pocket expenditure is high and going up why not invest in the private sector? Then we need to look at the out of pocket expenditure. A poor man: is he buying health or remedies? If somebody has had a cough, a poor man, he does not go to check whether he has TB but he goes to buy a cough mixture, just for the remedy. If this poor man has got a high temperature, he does not go and check whether he has malaria or pneumonia. He goes for Paracetamol. They are buying, spending their own money, just for temporary remedies but they are not buying health. This is out of pocket expenditure. Looking at only the amount of out of pocket expenditure and then saying, "Okay, out of pocket expenditure is so high, like in India 60 % of total health expenditure is out of pocket expenditure, therefore we should go to a private sector." That should not be the argument. We need to look at the private sector which needs to play its role but at the same time we should not be avoiding investing in the public sector. The public sector has provided support for a long time and we need to look at why the quality of services is going down. Private sector salaries and NGO sector salaries are higher than public sector salaries. So we need to look at the other issues, at why the public sector is not functioning before we say forget about the public sector. Q100 Sir Robert Smith: On the scale of the human resources issue, in previous evidence we were told about the need for 2.4 million health workers, including 700,000 midwives. Dr Songane emphasised that mid-level providers like midwives, nurses and medical officers can be as effective as specialists in providing emergency care. What aspects of emergency obstetric care can be carried out by a specially trained nurse without requiring a doctor's intervention? Dr Falconer: It depends on the level to which she is trained and how astute she is but if you look at the real life threats in terms of eclampsia, in terms of haemorrhage, there are first aid things that you can do and I think that is in that evidence in terms of putting up magnesium sulphate if you deal with an eclamptic patient. That is quite within the roles of all midwives and, if you can, transferring the patient to a safe place for confinement but again, if you do not have that, just that intervention by itself will probably save that patient's life until they deliver. Haemorrhage is a more complex issue because massive haemorrhage requires supplementation, or may require supplementation, with blood and that obviously is not available. Doing a Caesarean section again is a variable thing particularly in many of the African countries. The majority of Caesarean sections are not performed by medical people at all and the data is very encouraging. Also, it is much - can I say this word here? - cheaper. There is good evidence. Q101 Sir Robert Smith: The outcomes are successful? Dr Falconer: Yes. The quality of the research is difficult to evaluate but certainly in pure numbers it looks as though Caesarean sections done by medically qualified doctors and those done by what they call, I think, clinical officers, are very similar. In terms of what responsibility we have this end, we still come back to base. We have a major training issue responsibility and you have always got to have leaders. You have to have people who can train people out there and essentially you will never get away from that. There is a need for a core of medically qualified people in any of these countries. Historically, that was a responsibility enjoyed by this country. Sadly, at the moment, the door has been slightly shut because International Medical Graduates are not able to come to the United Kingdom. That may open up again because the number of British graduates has gone up so high, but in our discipline we still rely hugely on people coming from overseas. What we need are structures so that people can come temporarily to get the training access to the qualities that we enjoy and then they have to go back. That is the difference. Dr van den Broek: Without a doubt there are eight clear single functions of emergency or essential obstetric care. All those eight functions - i.e., putting up IV[6] or anti-convulsants or oxytosis, the manner of removal of the placenta, assisted delivery, vacuum aspiration for incomplete miscarriage or abortion, Caesarean section and blood transfusion - they can all be performed, the first seven, by nurse midwives and are in practice performed by nurse midwives, if they are there. Very often they are not necessarily legally covered to carry out some of these skills and they have very little training in these skills. Tony alluded to it earlier. There is a need to build the capacity and the skills of this cadre of health staff, apart from increasing the numbers, because I think I fully agree there are insufficient, but to encourage them and to improve the quality of care they are delivering. Caesarean sections: again, you do not need an obstetrician or gynaecologist to do a Caesarean section. You might want them occasionally to look at the quality and training of doing a Caesarean section and worldwide of course most women are not getting Caesarean sections in time and there are insufficient people and resources to provide them. There is a huge human resource issue there but skills upgrading is being discussed in many countries and there are various models for doing this but I would say it needs a lot more attention and close monitoring of what happens if you improve people's skills, the effectiveness of delivering the care, the quality of care and whether the numbers of people coming to the institution for delivery and for emergency complications go up because they know when they go there they will get good quality, effective care. Dr Islam: We also need to look at all those initiatives that are good. We need to have human resource planning. Sometimes the countries are deciding because they want to do something "in the meantime", what they need to do, but are not looking at the long term issues: their legal issue, their employment issue, their retention issue, their career issues. There are a lot of issues they need to look at. Whenever the countries are thinking of creating a cadre for certain work, we need to really look at all those issues and develop a long term human resource plan. The countries need support for this. Bangladesh now are giving training for community midwives. It was decided by the previous government. Another government might come and disrupt it completely, it has happened before. There is an instance like that, so we also need to look at human resource planning which is long term so that there are no disruptions and you don't lose more money and time rather than gaining anything. Q102 Hugh Bayley: Could I look at the tier of health workers below that, the community based people, traditional birth attendants? What should they usefully be doing and how can their training be supplemented to ensure that they provide high quality care? Do they need equipment kits? Dr van den Broek: This is a big, international debate which is probably why you are asking the question as well. The current strategy - and there is good evidence for that strategy - is that we need a skilled birth attendant at the time of delivery because that is when most of the maternal deaths and therefore the neonatal deaths occur. There is international agreement about the definition of what is a skilled birth attendant. It is a professionally trained person and then you can agree to deal with at least the basic social care. The traditional birth attendant - there are various names and various cadres - is generally not able to provide that. Even with a certain degree of training, they almost need a minimum of 18 months' training and then they become a sort of public health midwife like in Sri Lanka, as opposed to traditional birth attendants. The role of the birth attendant is probably - many countries are thinking about this both in Asia and, I believe, in sub-Saharan Africa - more of one in the community to help with emergency preparedness and to help so that the woman is able to prepare for her delivery and then seek skilled birth attendants, most usually at the facility. There is definitely a role for the TBA.[7] Different countries have different strategies for what that should be. Dr Islam: I can give an experience of mine working in a village health complex in Bangladesh. A woman came after three days of labour with hand prolapsed. I examined that woman. The vulva was swollen, smelling like anything. She had a high temperature. The hand was hanging outside and the skin came off of the hand of the baby because for three days they were pulling the baby by the hand. That is what we are talking about: delivery by mother and mother-in-law or TBAs. If we look at the causes of maternal death, number one is the haemorrhage, what would a TBA be able to do at home if somebody is bleeding? Next one is the eclampsia which is a fit. What can a TBA do? The next one is sepsis. Sepsis is happening. Pregnancy and childbirth is a normal, physiological phenomenon. If you do not do anything, 80 % of the delivery will happen normally, but 20 % will need some support, just to give you an example. Today, in many countries where there are no skilled birth attendants or midwives, the complication rate is 40 or 50 % because we are introducing complications because we have no trained people. Untrained people are making our burden higher. When you are talking about the normal delivery at home, you need trained persons with many more skills. When deliveries happen at the facility we have a lot of other people who can provide additional support. But when you are delivering at home, even in the UK when you are talking about home delivery, you need many more trained persons, much more access to other accommodations, transport and other things. The TBAs, according to all the metanalysis done so far, really did not improve maternal health or maternal mortality. They did not. What we are looking at is a collaboration with the TBA? Yes. Investment? Maybe not. We should be investing in the right strategy. In 1987 the same issue came up: TBA or not TBA? Then there were forceful arguments: "skilled birth attendants take time, in the meantime we need to do something" and in the last 20 years we did not really invest in the right strategy; we invested in TBAs. We need to look at the long term issue. We need to invest in the right strategy. Yes, TBA can do some collaboration, some support, psycho-social support and also support of the baby, but delivery and childbirth is a complex issue and particularly at home. It is a much more sophisticated issue which cannot be done by TBAs. Q103 Hugh Bayley: What proportion of births in Bangladesh perhaps or in rural Africa are attended by a skilled birth attendant? Dr van den Broek: In sub-Saharan Africa skilled birth attendance is between 40 and 60 %. Each country has its own data. In Malawi, it is 45 %. I recently looked. Kenya I think is slightly higher but within Kenya or within Malawi you have non-equitable distribution so you might have areas where it is very low, where there are very few ---- Q104 Hugh Bayley: My prejudice would say you are talking about urban Africa, are you not? Dr van den Broek: No. That is the average figure. In urban Africa it might be much higher. Q105 Hugh Bayley: Exactly. That is what I am saying. If it is 40 % coverage, then most children in urban areas would have a skilled birth attendant and few mothers in rural areas would have. Dr van den Broek: In urban areas it is more than 50 % generally, yes. Bangladesh I do not know about. Dr Islam: I think you are pointing in the right direction. We need to look at the urban area. In most of the countries, the rich people will reach MDGs, not the poor people. Why should we be providing poor options for poor people and all the higher options for rich people? The politicians in the country need to decide the right strategy. Every woman should have the right to the best care during pregnancy and childbirth and the best care would be a skilled birth attendant and access to emergency obstetric health care. What are we trying to say? The government and the politicians have to take the decision. Yes, it will take time but the decision has to be made today. Q106 Ann McKechin: Can I follow on with the issue of geographical spread of medical experts and the problem of trying to incentivise the doctors and skilled employees to work in rural areas? I wonder if you could give me some indication of what actions you think have worked in trying to incentivise that? What are the key components? Is it issues of salary? I think you mentioned, Dr Islam, that also there would be an issue of the general conditions in which people are living and also the back-up they receive. I just wonder whether or not you can point to any good examples which you think DFID should be supporting. Dr van den Broek: Generally health care providers the world over are the same. If you can provide them with good housing - in many countries, the government provides an increased housing allowance if you live in a rural area or the government builds houses in rural areas - then it becomes more attractive. Also, nearby education or extra salary to deal with having to send your children further away for education, for example. There is a number of incentives that can be used. I would have to ask our human resource expert. I have not recently read the report on which countries have the best and the most successful initiatives. I only know anecdotal evidence from the various countries. The one we most recently discussed is the one in South Africa where young doctors are made to work in district hospitals. I was talking to one of my colleagues from South Africa in the last month and that sounds like a very good idea. I always thought it was a good idea, but if the working conditions are not adequate, if the supervision is not adequate, they actually find it very difficult to function to the extent that they would like to function, just having come out of medical school. They become very demoralised and I understand there is quite a high suicide rate and depression amongst these people. Again, there is not a very straightforward solution. In north Nigeria, where we visited, it was quite clear that doctors said, "We need extra salary if we are to work out in that particular state because it is two hours away" and a certain amount of commuting was being done which was making it difficult to ensure 24/7 coverage with maternal health services. That seemed to be an incentive that was working relatively well, so different strategies I think. Dr Islam: I go back again to 1979 when I had finished my medical education and I was posted to a village health complex. I went and I joined at the complex but some of my friends, because they had higher connections, managed to change their assignments. Why am I saying this? Because this is a question of good governance. If the doctors know that they will be in a village complex for a certain period and will not be rotting there for a long, long time they will go there. So it is not only the salary; it is other incentives. If you go and work, you have to work in a village three years or four years after graduation. If you do that you have access to higher education. You will be able to apply your higher education. That would be an incentive. Talking about accommodation and other things, that is also an issue. In India, in Himalchal Pradesh, where in the winter there is snow, nobody can go out. What the Chief Minister decided was that any doctors going there, working in the winter season, would get one year's salary more as an incentive. Their children will have the education facilities. There are a lot of other incentives you can provide. Salary increases will not be easy to provide because there is a public service issue. But there are other ways of providing the incentives. Mostly, we need to have a fair system so that individual doctors and nurses understand that even if they have a protest they will have it fairly because everybody is doing their duties. But it is not really happening because of an absence good governance. Dr Falconer: The brain drain is what you are alluding to. If you talk to doctors in the United Kingdom on whom our health service has relied, as you know, 40 % of the infrastructure is made up by people who trained overseas. If you look at countries like Mozambique, I think Mozambique has 750 doctors now in the whole country. My hospital in Plymouth I think has more doctors than the whole of Mozambique, just to put it in perspective. If you ask these doctors from overseas, "Why do you come to the United Kingdom?" you can imagine. You get free health care. You get good schooling. You have political stability and you can externalise money back to your roots. Many of these doctors are externalising large amounts of their salary, so they are far more effective in terms of their infrastructure responsibilities and they are different to us. I have to be very careful in what I am about to say because I think many people have gone into medicine for totally altruistic reasons or certainly they used to, and now it is a business for many of these people. Q107 Ann McKechin: I think that is a distinction. Perhaps in some countries you mentioned there was compulsion. In somewhere like China, Nicaragua or the Communist regimes, people were compulsorily sent out or in the past people went out based on religious motivations. It seems it is trying to get the right mix of finance and other support. Dr Falconer: I am slightly naïve on this and what DFID can and cannot achieve but whether you can develop contracts for certain of these countries overseas to say, "Yes, we will take you for a short time, a two year block. We will train you and you can acquire these quality standards that you want to take back" and they have to go back. There are models for that sponsorship scheme but it may be that that should be developed further and you could top slice a certain number of training opportunities in the United Kingdom and, say, fill those with people from the countries that we want to develop and then send them back. Dr van den Broek: I also wonder whether personally I can add to that, having visited most of these countries. I realise that we in positions of leadership and maybe power do not pay enough attention to these rural areas. It is much more difficult to get there, to go and see what is happening. I am not sure that these people always feel valued or part of the system and that is partly to do with us and how important we make services in the periphery. It is very easy to concentrate on the urban assessment, the urban needs and so on. Chairman: We saw evidence of that when we were in Malawi. We visited a rural hospital which was desperately poorly staffed and equipped with a huge number of patients and you could see that. Q108 John Battle: You have opened up the whole question of the global economics of it. It is interesting that you helpfully open it by raising the question: is health care a business because, if private hospitals or care homes in Britain are recruiting nurses, I met a midwife in a care home looking after older people precisely because she could send more money home as remittances to her village. She believed that was doing more good than working in her village as a health care midwife. We have heard in a previous session about - I think it was 2.4 million overall total shortage of health workers, absolute shortage, and included in that figure are 700,000 midwives. I just wondered where the debate would go in terms of: you cannot just have a fair system in one country, can you? Global economics, whether it is telephones or whatever, as the jobs fill around the world, what more could we do perhaps to encourage not just sponsorship but exchanges? Do you think in the wider world of medical care that, if I dare said the ethics of exchange or the idealism of it, is still there and would work where trained people here also went there and vice versa - could that be opened up in a new way? Dr Falconer: Nynke is the expert on ethics. I am not good on ethics but I will talk about the exchanges a little bit because historically that was the very pattern that used to happen. I am an example. I worked in Zambia and in South Africa. Very many did. That model needs to be developed. If the opportunities can come for people to come to the United Kingdom, many of our trainees' whole lives would be transformed by working in the developing world. You ask which countries do we have an association with? I am just talking now of the RCOG. All our roots are with the old Commonwealth, rightly or wrongly. They are beginning to change a tiny bit but if you look at India we have a massive presence of people there. If you look in South Africa, we have a big presence there. In east Africa we have a much smaller presence but those are the countries, so inevitably, because we have little infrastructures there, that is where we would look to. Dr van den Broek: I did not know I was an expert on ethics, but we are very concerned about this issue of brain drain. I am not a global economist but I did some Economics at O level. I thought if you had enough nurse midwives the world over then you would not have this issue of us having to poach and America having to poach. We really must put more emphasis on training a higher total number of people. Yes, there need to be incentives for them to stay, maybe bonding, quick employment, proper salary, proper status, but I suppose legally and ethically you cannot stop people moving around. Perhaps we do not want to stop people moving around but the bottom line, as I understand it, is there are insufficient health care providers, particularly midwives. Maybe we should strive for that primarily. Dr Islam: There were some interesting discussions in 2005 on brain draining where all the ministers were there and discussing the issue. Some countries from Africa were asking for compensation but the Philippines were saying, "No, do not stop our brain drain because that is our foreign currency". So we cannot stop people moving and everybody has the right to move around. There is no one solution to this issue. What I was talking about in Zimbabwe - the training issue. Can we think about improving the faculty and training schools so that they can have enough people trained there which they can have and also fulfil the demand of in the USA, the UK and everywhere where there is high demand for this cadre of people. In the UK or the USA nobody is very willing to go for midwifery and other training. If you have freedom of movement, you will not be able to say you cannot move, so we need to look at where is the best way. The country really needs more investment on training at the country level and good quality training. Dr van den Broek: There is good evidence coming out of Malawi, where DFID has said, together with other donors, that there are ways to improve training in country by exchanges of tutors but also strengthening our midwifery schools and all cadres of staff in addition to supplementing of incomes which you will know has been done in Malawi. I was just reading that report. It is available to read. It discusses the issue of the whole structure and support of human resources once they are trained, so they need to be available to be trained. There needs to be a minimum of education so you can have the right quality people to go into training. Once they are trained they need to be immediately deployed, not having to wait for two years for a contract from the Ministry of Health. They need to have in-service training. There is a whole model by which this can be implemented, which I understand has been evaluated as part of the general evaluation of sector wide approach in Malawi by DFID. Q109 John Bercow: You mention Malawi and of course the Malawi Emergency Human Resources Programme running over a period of six years is one means by which DFID is seeking to address the problem of low human resources capacity and brain drain. You refer to improving the rate in Malawi and that prompts the question - or at least you give the impression of being open minded about it - what evidence exists to support the use of emergency schemes of this kind and what dangers, if any, do they carry? Dr van den Broek: We have talked to the human resource experts, because this is not really my particular area of expertise. I understand that the jury is still out whether the £52 million from DFID and then another £50 or so million from the Global Fund, over a period that I think started in 2004 and is meant to go on to 2010, has had an effect. The bottom line is it is quite difficult apparently to monitor what happens to such monies, a 52 % increase in 11 cadres of staff in health provision as opposed to the rest of the public health sector, because of the way the monies were administered. They were either part of basic salary or part of allowances. I understand it is easier to monitor if they are part of allowances. There is a desperate need, now that this has happened in Malawi - I think it was meant to be a test case - still to commission a separate report just to look at that issue, to come up with lessons learned because the jury is out and the answer is not that simple. It seems to have done some good and some not so good. Q110 John Bercow: It raises the associated question of whether, even if there is a benefit from such a targeted initiative, there might not also be a displacement effect. This of course is very much a feature of the political system in a great many countries. It is a feature of democratic policy in a sense that the people who lose out might well be disparate and in a number of different locations and not even be aware of the fact of their losing out and therefore disinclined or unable to protest about the fact that they have lost out; whereas the beneficiaries of the targeted intervention are likely to say, "Three cheers". Dr van den Broek: That is true. Two of the immediate criticisms, if you like, of the way it was handled in Malawi: one, it was not immediately transparent to all the cadres of health care workers how and when this was going to happen; two, it would seem - but you should really get a proper report from the human resource people evaluating it - that the people at the top got 800 % on places and the people at the bottom got 150 or something. Please do not quote me on the figures. It is not that simple to just pour £52 million into a government and say, "Go ahead" along with other things like finance. There is this huge issue as to the capacity of ministries to monitor a huge amount of money and there is insufficient accounting probably. Chairman: We had one anecdote from a nurse in Malawi who said that she got a 52 % uplift in her salary which was quite helpful but, on the other hand, the government had made education free and the standards had fallen so low that she was now having to pay school fees which were more than the pay increase, which I think is John's point about unintended consequences and their subsequent effects. Q111 Hugh Bayley: First of all, on Dr van den Broek's comment about training in relation to the brain drain, I am all for improving the volume of the numbers of people training in developing countries but surely, if you really want to deal with the brain drain, you should be substantially increasing the number of doctors, nurses and sub-degree level nurses who train in this country. Leaving aside the intellectual exchange in training issues, which we want to retain, the immigration rules say you can only appoint a Philippino nurse if you cannot find a British nurse. Dr van den Broek: I absolutely agree. There need to be enough midwives worldwide to look after women who are pregnant and need to deliver. Q112 Hugh Bayley: Maybe one of our recommendations should be that UK training of health personnel should be a manpower/person power plan that affects our training? Dr van den Broek: Yes. Maybe use that experience. Also, maternal deaths are happening in resource poor countries on the whole. I agree entirely but can we use that experience then to also help resource poor countries improve their training and their numbers so that we are sharing. Dr Falconer: The only plea I would make is that we are British personalities and we should be leaders in many aspects of health care, as we are in many other things. If you are going to influence countries, you have to maintain an opportunity for those people to come over and work and be influenced by us, whether they are midwives, nurses, doctors or whatever. I support entirely your philosophy. If, as it should be, you provide for our own needs within the United Kingdom, you have no need for external people. We still need to maintain a two way dialogue and flow. One of the dangers of where we are currently going that I am a bit scared about is that that two way dialogue may stop because we just have to protect our own people, and literally I do mean protection because you may have medical unemployment for the first time ever in the United Kingdom in the very near future. I maybe wrong. Ann McKechin: That would encourage them to go elsewhere. Q113 Hugh Bayley: I agree in principle although I do know that, even if you take somebody for a one or two year training programme with the expectation that they will go back, they may well find they are better trained and more marketable in some third country rather than going back. Dr Falconer: I accept that. I am talking institutionally now. The advantage that we have is that, when they go back, they are always part of our organisation and the quality standards - we have not talked about this at all today - that we produce are not just applicable to British women. They are applicable internationally and when you travel overseas and you talk to doctors who are members of our institution what is the one thing they really like? It is that they can go on a computer if they have access to it and get the clinical standards. We talked a little bit about eclampsia earlier. We have very good guidelines and those can be translated everywhere. Q114 Hugh Bayley: Why is it so important to have good statistical data on maternal deaths? You have said in your evidence it would be good to adopt a look alike to the UK confidential inquiries approach. What would that look alike look like stripped down to its bare essentials in a developing country and why is that different from what is available now? Dr Falconer: 1952 was the first production of the confidential inquiry into maternal death. That is still today used as the hallmark in many countries of the world as the paragon of audit. That does not answer your question specifically to overseas but that is what it starts from. Dr van den Broek: Your first question is why statistics, because I have heard numbers talk probably more than not having numbers. It is very difficult to collect maternal health or maternal death numbers, as you have heard already. In some ways it might be a better effort to look at why mothers are what these audits are all about. There is good evidence especially from South Africa where they have really started on a very good national confidential inquiry system. From that they have identified exactly what the problems are and have used that to focus intervention and focus budgets to address those issues that are still not in place, which is why mothers die. Sri Lanka has also a very good maternal death audit system but it is in the field, so there is a self-evaluation of every maternal death by health care staff involved or community staff. At the district level, that brings up all the issues that need to be addressed to stop this, hopefully, happening next time. The problem in Sri Lanka is they have not reached the national level and they are not producing beautiful reports, but they are doing it. Then there are countries like Tunisia, if you like, where everything is there but birth registration, death registration. The private facilities are somehow outside of the system but the majority is there. Again, if they had a little bit more effort and understood the importance of this, they could produce these statistics almost or at least why are these women dying in our countries still. That would help to address the problem. Dr Islam: We have issues if you look globally. Only 35 or 40 % of countries have got death and birth registration and causes of death reporting, so the other people are not reporting. I always like to give an example. When I was getting married in Holland, they wanted my date of birth registration certificate and I gave my school certificate. That was my date of birth certificate. They said, "No, we want something from your birth registration in Bangladesh", so I had to call my mother. "Can you please give me my date of birth registration?" Then the person in the register called me. "Can you tell me when is your date of birth?" so I had to tell her what was in my school certificate. There was no registration. That is the situation we are talking about. Why statistics really? It is necessary. A demographic and health survey has been carried out in 78 countries and they publish very good documents. It is being used at a national level but what we are doing now is some secondary analysis of those data like in Zimbabwe, like in Zambia, like in Chad. What we are doing now is to see the difference between urban and rural births, access to skilled birth attendants, Caesarean section and other things. What is the difference between different districts? Are all the districts performing the same or not? What is the difference between rich and poor? If we do the secondary analysis, then we can say where we really need to put our attention. That is where the statistics are necessary to really plan where we should be putting more emphasis. Is it universal coverage for everybody or do urban slum areas we need more attention or do rural areas we need more attention? The data will provide you with that and the data also provide you with support for advocacy purpose at the national level and at the global level. Q115 Hugh Bayley: Who should take the lead - should it be the World Health Organisation - to ensure that a reasonably competent minimum set of data is collected in each country? You have cited a couple of examples, Sri Lanka and South Africa. Rather than British donors using the Royal College's model in a few hospitals where they work and a different system being used in a different region, somebody has to look at it strategically, have they not? Which should be the agency that leads this globally? Dr Islam: There is a global initiative which has been supported by different donors and also by DFID, the Health Metrics Network. The Network is looking at how they can improve the statistical data collection and analysis that are used at the national level. The Network is housed in the WHO. The partnership for maternal and child health is also housed in the WHO. We realise the monitoring system is not really working. That is why we are trying to improve that system at the country level. From our side and from our department, we are trying to develop the country level, as well as the district level, monitoring and evaluation system. Q116 Chairman: There is just one final issue, thinking of our own experiences in the countries we visit. Rural areas are very rural. The roads are very rough so many, many people are living not only a long way from any existing infrastructure but one suspects quite a long way from any potential infrastructure. The question you have is: in reality, is the only option for those people that they have skilled birth attendants in their community and an expectation of home births and possibly some process of identifying risks that you can identify prior to delivery but not obviously being able to transfer at the point of delivery very far. What is the priority? Is it to get women to be where they can actually get full clinical intervention or is it to try and give them the best you can in home delivery circumstances, knowing that that is still going to leave some of them at a risk that is not able to be addressed? Dr van den Broek: It is an interesting point that is put to us quite often. Where we have done surveys of districts or regions to see what facilities are there, generally there are quite a large number of facilities, structures, some degree of staff, but none of them are fully functioning. Often, there are a lot of different facilities; none is properly functioning. It needs to be rationalised in line with at least a minimum agreed by the UN bodies of full basic emergency obstetric care and one comprehensive for half a million people. That can be done, maybe not with the minimum, but it is a focused approach. That can be mapped out and carried out, together with making sure that women of course can access these facilities because, yes, there are issues of roads. There are very imaginative ways of dealing with emergency transport, motor cycle ambulances, stretchers. My experience is mainly in sub-Saharan Africa so areas like Afghanistan and the mountains of Nepal are a different case, yes, but in sub-Saharan Africa where a lot of maternal deaths are happening there are good examples of combining equitable distribution of especially the basic facilities, where at least the basics can be done by the nurse midwife and then transfer to a hospital which might take a little bit longer, plus transporting the patient. Q117 Chairman: You are implying it would be a big mistake to try and trade one against the other. You really have to try and make sure they are both pursued together? Dr van den Broek: I think so and that has been the struggle because people always want to hear it is this one, single thing. Q118 Chairman: No. We want to know what you think. Dr van den Broek: Our experience tells us that that is what we have to aim for. Dr Islam: If you look at Africa where most women, 80 % or more, will come for antenatal care one time, two times or three times, walking all the way, but they do not come for delivery. Why? Because the quality of care they receive at the facility is abysmal. Sometimes supplies are not there. If you have seen that film on Panorama, Dead Mums Don't Cry, drugs and supplies are not there, so the woman does not want to come. The options we are giving women are either you die at home or you die at the facility, so they decide to die around their family. That is the issue we need to look at, the quality of care. The other issue is what Nynke said, a different type of transport. What we have done before is build a maternity waiting room, to have a facility near the main facility where women can come one month or 15 days before and they rest and do some type of work and, when due, they go to the main facility to deliver. There are different ways of looking at it. There is no single way we can reduce maternal mortality. If our goal is to reduce maternal mortality there is no other way but to provide skilled care and emergency obstetric care. Q119 Sir Robert Smith: How quickly, once you provide the skill, would the message get back to communities that they can now trust the services provided? Dr van den Broek: Very quickly. A month, I would say, but it is true that enough care and enough quality care. Dr Islam: If you look at Botswana, that got independence in the 1960s, at that time Botswana had a low percentage of delivery by skilled birth attendants or at the facility. Today, 98 %. If you look at the local tradition, they managed to change because they are providing reliable, quality care. That is why women are coming there. It was nice to work for ten years in Botswana because of the quality of care they are providing, so it is possible. Chairman: Thank you. That is extremely helpful to our inquiry. You have really taken us through those issues with a great degree of clarity as well as your own expertise both as professionals but also with real experience in dealing with the countries that we are most concerned about. I really want to thank all three of you very much indeed. It has been a really helpful session.
[1] Department for International Development (DFID) [2] United States Agency for International Development (USAID) [3] Ev 10 [4] the European Commission (EC) [5] Skilled Birth Attendants (SBAs) [6] Intravenous (IV) [7] Traditional Birth Attendant (TBA) |