CORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 66-ii

House of COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE

INTERNATIONAL DEVELOPMENT COMMITTEE

 

 

MATERNAL HEALTH

 

 

Thursday 22 November 2007

MR RICHARD HORTON and MS BRIGID McCONVILLE

MS AASHA PAI and MR GIORGIO COMETTO

Evidence heard in Public Question 120 - 176

 

 

USE OF THE TRANSCRIPT

1.	This is a corrected transcript of evidence taken in public and reported to the House. The transcript has been placed on the internet on the authority of the Committee, and copies have been made available by the Vote Office for the use of Members and others.
2.	The transcript is an approved formal record of these proceedings. It will be printed in due course.

 

Oral Evidence

Taken before the International Development Committee

on Thursday 22 November 2007

Members present

Malcolm Bruce, in the Chair

John Battle

John Bercow

Mr Stephen Crabb

James Duddridge

Ann McKechin

Jim Sheridan

Sir Robert Smith

 

________________

Witnesses: Mr Richard Horton, Editor, The Lancet, and Ms Brigid McConville, White Ribbon Alliance, gave evidence.

Q120 Chairman: Can I bid you good afternoon and thank you for coming in on this inquiry into maternal health that the Committee is carrying out. We have had a considerable amount of evidence. We have already taken some formal evidence, and I would not say the Committee is yet expert, but we are beginning to get to grips with the issues of what is an extremely demanding international ambition which we are falling a long way short of achieving. I wonder if, for the record, you could briefly introduce yourselves and then we can perhaps proceed with some questions.

Ms McConville: I am Brigid McConville. I am a journalist. I was elected to the Board of the White Ribbon Alliance for Safe Motherhood in 2005. The White Ribbon Alliance is a unique international grass roots advocacy organisation based in developing countries. We have got 14 country alliances; we have got members in 91 countries. Our basic approach is that this is a social and political issue and that advocacy is the key to moving the whole issue forward, and the main problems are rooted in the low status of women and that the voices of the poor, especially poor women, are not being heard.

Mr Horton: My name is Richard Horton. A long time ago I used to be a practising doctor, but no longer. I edit a medical journal, The Lancet. We have a particular interest in international health issues, very broadly, and what we have tried to do over the last three years or so is bring together teams of international scientists to focus on neglected issues, of which maternal health and sexual reproductive health are two very important domains, to try and generate new evidence to inform the global and country debate around solutions to these challenges.

Q121 Chairman: Thank you very much for that. One of the things that have been said to us is that the ideal solution to the problems of maternal mortality is an established health service infrastructure on the ground that women can access, but that is a long way from where many developing countries are. There seems to be a debate about whether the emphasis should be on providing the services or actually helping with what their rights are and supporting their demand for the services. I wondered if you could comment on whether you think that the DFID[1] approach has got that balance right or whether there is a need for reassessment of where the emphasis should lie and whether or not you accept what we have been advised, that DFID's record on this is, generally speaking, good, but feel free to make any comments that you think appropriate about your judgment of DFID?

Ms McConville: We feel that DFID has done an excellent job in many ways, especially in funding governments, and also DFID has supported the White Ribbon Alliances to some extent. Our point of view would be that, unless there is demand for services in communities, women will not have access to them. For instance, I do not know if you have heard the expression "the three delays"; that is one way of describing the difficulties that a women will face. For instance, if she goes into labour in Burkina Faso and she starts bleeding, that is a medical emergency, but there will be a great delay for her seeking help because she will perhaps think, for a start, that it is a matter of witchcraft, and after that, when they finally get round to moving her to a health facility, it could be a 30, 40 kilometre journey to the health facility. If she does not have any money to pay for the care that she will need when she is there, she will not be able to go. If she does not have her husband's permission, or in some countries her mother-in-law's permission, all those delays will prevent a woman in the community from seeking care and, unless we address those delays, even if the best services are there, she is not going to get to them. So, one is no good without the other would be our view.

Mr Horton: I think you point out actually a dilemma that has in many ways split the maternal health community in an extremely damaging way, because it has caused confusion about advocacy. Should one take the line, as many would say is the ideal solution, of a facility-based intrapartum care solution or (but maybe it is an and) have community based solutions? In terms of DFID's role, when you look across the array of donors out there, I would say that DFID has played an outstanding role in trying to get the balance right between those. It is a very hard balance, because you always end up upsetting one group or other, and they do, unfortunately, divide into groups rather clearly. The DFID approach, as far as I see it, has been to support very strongly the policy of facility-based intrapartum care but also to support very valuable research based in the United Kingdom into the efficacy, the impact, of community-based solutions; and over the last three years there has been a gradually accumulating evidence-base to show that women's groups in communities can be extraordinarily powerful in reducing maternal mortality, newborn mortality where you do not actually require facility-based intrapartum care.

Q122 Chairman: Is that by providing support in the community for the mother?

Mr Horton: Exactly right. It is about building up knowledge and social capital awareness and a demand from women in communities for maternal health services and local knowledge about very simple things related to hygiene. DFID has pursued this dual approach to try and accumulate knowledge, on the one hand, about community-based solutions that pursue a more political target of a policy of intrapartum care.

Q123 Chairman: So you say that DFID is good at identifying and, indeed, even encouraging the local communities and the women in the communities especially to express themselves. I do not know if that is Brigid's area, but that is the real key. You have kind of sat on the fence and said they do it, but I just wondered: are they proactively doing it?

Mr Horton: There is a divide between DFID's role in countries and DFID's role at the centre. I am talking about DFID's role at the centre in supporting the creation of a strong and robust evidence-base that can then lead advocacy for community-based solutions.

Ms McConville: I would say that DFID has supported some excellent projects. This is one that I received from DFID. It is a short participatory film project. I will give you copies later. You will see here there is a community of mothers and midwives making their own film. This film was then shown in the communities outside the local hospitals. That raised the profile of the issue and of the women involved in those communities. It then went to the capital, Dar es Salaam, where it was shown in the Parliament building. The Minister of Health was there; all the leading figures were there. That raised its profile again. It then became a film that was shown on TV. The White Ribbon Alliance rang around all of the parliamentarians and said, "Watch this film and ask questions of the Minister tomorrow", and they did that in Parliament and that was a tremendous amount of pressure to improve human resources for maternal health. That is an example of a very successful project, but it has not been sustained. I think the other point I would like to make is that DFID is funding governments, which we welcome. However, governments do not hold themselves to account. Who is going to hold those governments to account? As MPs, you know how that works. You do need civil society to ask the questions. I can tell you that White Ribbon Alliance members in many countries are going out to the facilities and finding out who is there, and they might find that the Government has said there should be two or three midwives and, in fact, there is only a caretaker. They are bringing back the statistics and raising the pressure on governments to fulfil their duties and they are also then working with governments on policies and plans for the future. So I would like DFID to support that.

Q124 Chairman: Do you think that it could do more on that front?

Mr Horton: It could do more on supporting civil society, yes.

Q125 Jim Sheridan: Just on the community-based service facilities or, indeed, qualified staff, particularly in rural areas, and I have extremely limited experience: it is extremely difficult to get facilities or services or, indeed, qualified staff to move out of the city centres, if we can call them that, into the rural areas because most of the qualified people either want to emigrate to some other country or they want to stay where they are. The main reason for that, particularly if they have a family, is there are no education facilities for their children, and that is the reason why they do not move to the rural area. Is there anything that DFID can do to incentivise qualified people to move from the urban areas to the rural areas in order to deliver maternal services?

Ms McConville: You are absolutely right that that is a major barrier. Of course people who have qualified and worked very hard to get there are then reluctant to go off into remote and possibly insecure districts. I think that DFID can certainly help civil society and lobby government for perhaps better salaries and better incentives to work in those rural areas. Certainly in Tanzania they have been very successful. There has been a five-year advocacy campaign to persuade the Government to employ and deploy more skilled birth attendants to the rural areas, and I can provide you with those figures, if you would like. They are quite stunning. That steady pressure has been very successful and, in some health facilities where no women were going to give birth, there are now 30 in a short space of time, and in places where there were two healthcare workers there are now four or six. So that steady pressure on government, if DFID can back civil society to help bring that pressure to bear on governments, I think is the way forward.

Q126 Chairman: That is a slight difficulty for DFID - I do not mean it is one that they cannot take on board - as to what extent are you responding to community needs or stirring them up or trying to manage them. In terms of the practicalities, how can DFID do that in a way that is ensuring that they are genuinely getting the response of the community rather than, even if unintentionally, manipulating or directing it?

Ms McConville: I was part of the Women Deliver team planning the conference that was on recently; there were some advocacy people in New York saying, "We need to start a global movement." There is a global movement. All over the developing world there are people who are the people with the ideas, with the experience, with the energy. They are the people who know the problems. They are the people who know the solutions. They are the social entrepreneurs of their generation. They are often midwives who have had the tragedy of working with women who have died in childbirth, and that never leaves you. They are already working very, very hard, and this has not started with DFID, it started in those countries with those local people. In India, where the White Ribbon Alliance has been tremendously successful, for instance, there was a march to the Taj Mahal, I think in 2000 or 2002, and thousands of people attended that march. It grew and grew - parliamentarians, media and film stars were involved. That made such a big impact on government that they then invited the White Ribbon Alliance to work with them on planning and policy changes, and there was a tremendous shift there in that the staff, and even the auxiliary nurse midwives who were previously not allowed to perform certain life-saving skills, were then licensed to do so; that work is continuing and the White Ribbon Alliance is now working with government in six states. There are six state alliances as well as the national one. So, I would say that is not a matter of DFID stirring things up; there is already a tremendous amount of energy and activity that needs to be supported.

Mr Horton: Yes, I think that is right. I will try and place it in a broader context, because there is a danger of having a series of vertical programmes here. One of the things that DFID is doing very well and is being encouraged to do even more is to help persuade governments to support the health system more generally. It is not just about maternal health here. There is a whole series of issues for which the health system has to be strong in financing human resources stewardship in order to cover, including maternal health but also many other areas, so I would be careful about singling out one exclusively. If you go to a health facility in Northern Ghana, there will be a doctor there who is trying to cover surgery, paediatrics, maternal health, a whole range of things - just one person covering a huge area. It is that broad-based general budget support for the health system that has to be the focus, and that is, indeed, what DFID has been pushing strongly.

Q127 Sir Robert Smith: You have already touched on the balance between facility-based and community intervention. In September 2006 you carried an article by Anthony Costello and others that in the long run the ideal solution is the facilities based but in the short run medium term community interventions can make a difference. I think you said in an earlier answer that DFID were already funding research that was showing that community interventions could make a difference.

Mr Horton: They funded Anthony Costello's work.

Q128 Sir Robert Smith: Is this the only research, or is there other research that you could point us to that shows, in the short term, that having that community-based intervention would make a difference?

Mr Horton: This is one of the problems. There has been a lack of evidence about the community-based support. There are vitamin A trials going on, community-based interventions, women's group interventions; there are something like four clinical trials that are currently in progress in Asia and Africa, some of which are being done by Anthony Costello, many of which are being supported by DFID. So we are accumulating knowledge right now as we are meeting to try and answer this question, but to my mind this dichotomy that is being created is a false dichotomy. You need dual approaches. You are not going to solve this by a purely top-down building clinics and facilities. You have got to mobilise the grass-root support in villages if you are really going to tackle this as well, and I think that that policy message has not been strong enough out of UN agencies. I think there is a real problem in UN agencies over this. We have a UN system that, frankly, does not work very well. There is no single technical agency that leads on maternal health; it is divided amongst many. There is a paralysed partnership on maternal, new born and child health right now, and so we have a problem there in terms of global leadership, and I think DFID can play a vital role, an increasing role, in trying to mobilise that global leadership which is absent right now.

Q129 Sir Robert Smith: In mobilising the community to demand so that there is better delivery, is there an ethical dilemma in maybe raising the expectation of the community that that is what they need and, in a sense, creating a demand so far ahead of any supply that you are actually----. Is there an ethical dilemma there?

Mr Horton: I think if you go to villages and you just sit with village elders, with women and talk about the predicament they face, those kinds of dichotomies I personally have not seen; maybe others have. What you see is just a desire to take control of decisions about their health, to get access to services to which they do not have access and to find the best way to do the best they can for their families, their children and their community. These nuances that we talk about are really not very strongly evident in the villages that I have visited, which is why I think we need to be ruthlessly pragmatic about what we can do and not let ourselves fall into what are sometimes ideological traps: we must only follow this course because that is the ideal, that is the rights-based approach that says you must have this and nothing less will do. We need to be a little more, as I say, pragmatic about solutions.

Ms McConville: I would back Richard up on that. What comes to mind for me is that, when you go to villages and you listen and talk with the people about what is going on, you will get a sense of how incredibly hard people will try to save mothers' lives, how difficult it is, the dangers and the perils that they face - long journeys through the night, down rough roads where there are security problems, sometimes carrying women on wheelbarrows or on stretchers, sometimes for days on end, a woman who is in agony, who is bleeding and dying. Often men get blamed for not giving enough support, but the number of husbands who have contributed to our Stories of Mothers' Lost exhibition and talked about their terrible grief at losing wives, fathers who have lost daughters. It is a whole community thing, and I think really that we have to all work together to support the people in communities, who are very intelligent and determined people, who are tremendously resourceful up against barriers that we can hardly imagine and they will do anything that they can to save the lives of their mothers, and we are letting them down, frankly, by not providing the health system that they need to make that possible. Why is it that there is no road for them? Why is it that there is no form of transport? Why is it that there no magnesium sulphate in the first health centre that they get to? It is as cheap as table salt. In an age where we have had astronauts on the moon for decades, it is a disgrace. We need to work together to make sure that we back the energy of those communities with an equal commitment to make sure that those lives can be saved.

Q130 Sir Robert Smith: Magnesium sulphate came up last time we took evidence. No-one could quite understand why something so basic---. It is not particularly rocket science.

Mr Horton: No.

Ms McConville: I can give you a view on that. It is that women are not valued around the world. A woman's life is of very little consequence, unfortunately, in many, many cultures, and that is the bottom line of all this and this is why this is a political issue. For a very long time it has been seen primarily as a health and a technical issue, and of course that is true, and we do need the health solutions, we do need the health systems, but the key to this is the advocacy to make that link, to convince the people who have power in communities (and that is usually men) and in governments to value the girl child, to value women. Girls do not get fed in the same way that the boys get fed around the world. Girls do not survive. They do not get educated. They do not get employment. They do not get health services. That is the level, and we can take the lead on that, I think, internationally.

Q131 Ann McKechin: Brigid, you spoke about a network of groups within developing countries who are advocating for change, but on the other hand Richard was speaking about the failures of, for example, the UN system at a global level. What do you consider should be the priority of advocacy currently for maternal health? Should it be based on developing governments or should it be focused at a global level? How much priority do you give to each?

Ms McConville: I think we have had quite a lot of international advocacy over the years. There are many UN departments with their own communications people who have run campaigns and so on. What we have not had is sustained and long-term support for the advocacy needs of developing countries, and that, I think, is where we need to focus now. For instance, White Ribbon Alliance has an alliance in Orissa, in India, one of the poorest states. I heard recently that they had managed to gather a petition of 35,000 people: many of those will have been thumbprints. That is a massive petition by any standards. I said, "Have you got a photograph of that so we can use it on the website and publicise it?" They did not have a camera. They were asking us, "Please can you help us with our advocacy needs?" Here we are: "A 1999 World Bank survey asked 60,000 people living on less than a dollar a day to identify the biggest hurdles to their advancement. It was not food, shelter or healthcare, it was access to a voice." People are always asking us, there is a great demand, for more and more alliances all the time. Advocacy is what we see as the key, and this is what will unlock the process in moving forward. So, yes, we would ask DFID to focus more on civil society organisations.

Q132 Ann McKechin: Richard, where do you think the priorities should be based?

Mr Horton: I am not going to disagree with Brigid, of course there needs to be a civil society approach, but there is a huge space that needs to be filled on the global side. We must not pitch one programme against another programme - it is very important not to do that, so do not get what I am about to say wrong. It is about increasing the envelope of funding, but if you look at the attention that is given to HIV/AIDS in the world today through incredibly successful advocacy and then you look at the place of women and maternal health, there is a disparity. I am not arguing against HIV/AIDS, but I am saying that we have to get the balance slightly different to where it is right now.

Q133 Ann McKechin: This would seem to follow on from Brigid's argument about the position of women and the lack of power that they have.

Mr Horton: Right, but if you had the G8 focusing on women in Japan next year---. The Foreign Minister of Japan is making a speech on Sunday at a conference where he is going to start laying out his strategy in the run up to G8 next year. Japan is desperate to engage the world to help it shape its position for G8 next year, particularly on health, and you have got the Foreign Minister talking about health, so there is an opportunity for DFID to help shape the G8 agenda and get women as a much higher priority.

Ms McConville: You are all parliamentarians. You all know how important it is when the NHS comes up at election time when there is something wrong with your local hospital or there is something wrong with the ambulance service. As far as I know, there has never been an African election in which health is a major issue. That is a telling point, is it not?

Q134 Ann McKechin: I think that shows in the share of the budget that is sometimes allocated. Can I ask you briefly about the Women Deliver Conference in October 2007 and whether or not you think it was effective in responding to the issues raised by women and health professionals in developing countries, including midwives, about the priorities that need to be set over the next few years?

Ms McConville: I would welcome the approach of the Women Deliver Conference. It framed the issue in terms of a political meeting. I think that was a very wise and a very good move. From our point of view, it would have been better if more voices from developing countries were involved in the planning and perhaps there could have been better listening to those voices during the meeting itself. There was a sense that it was rather the same old same old, but lets move on in a positive way.

Mr Horton: I think Women Deliver was an opportunity for the maternal health community to regroup. It was a very important moment. Twenty years of Safe Motherhood had not worked, and the whole issue had to be reframed, and the beauty of Women Deliver, in the very title Women Deliver, it was about reframing the whole question of maternal health in the context of women, not motherhood, and that opens up so many more opportunities for progress on advocacy and technical solutions and so on. It gives you an entry into the women's movement which, if you just focus on Safe Motherhood, there was dissociation between the two. It allows you to think of women as political and economic citizens, not just about people who produce babies. I think Women Deliver gave us an opportunity to create a different frame of reference for maternal health which now is our responsibility to work from. It did not come up with a magic solution, but it was a very important step-change in our thinking.

Q135 John Bercow: What role should scientists and scientific journals play in advocacy for maternal health? I am possibly playing devil's advocate and possibly not. Is there any possible conflict of interest, in a sense, with primacy of scientific principles of independence and impartiality?

Ms McConville: I would say that as the White Ribbon Alliance we are a coalition, so we welcome what everybody has to bring to the table from whatever sector they come, whether it be faith-based, individual, media, government, UN agency or academics and scientists. Over to you.

Mr Horton: Science is political. How a democracy chooses to spend its money and which areas it chooses to spend its money on are political decisions, not just scientific decisions. So the idea that science is somehow immune from politics would be a fundamental mistake, I think. The responsibility, therefore, is on scientists to try and select what areas they are going to study and journals to do the same, to look for gaps in the evidence, to look at what the priorities might be, should be, in the world and bring those scientists together to focus on generating the best evidence so that it can be used as a platform for advocacy. Advocacy, without some kind of reliable, robust knowledge-base underpinning it, is empty advocacy. I see our role, one of many thousands of journals, as trying to bring those scientists together to create that foundation of knowledge on which advocacy can be built. I would say the one additional thing is that if you sit down with these scientists who have dedicated their careers to this, they are fantastic advocates but they do not see themselves as advocates particularly, but you get some of these people out on the stage talking with ministers - I have sat in rooms where you have the Minister of Health from Mozambique or Nigeria sitting right next to a scientist who has done work in their country -that interplay is fantastic. You can see how ministers will imbibe the science. They demand the science, they need the science to formulate strong policies; so it is a question of bringing them together, and I think what journals can do is to help create the climate for those kinds of interchanges to be made. I think science has been far too removed from the policy process before. It is part of democratic accountability.

Q136 John Bercow: To what extent then is policy, in practice, either of developing countries or, indeed, of our own, genuinely evidence-based? Can I pick up on the metaphor that you used as you viewed, I think you meant in developing countries, ministers imbibing the science, so to speak, the informed outpourings of the scientists? To what extent, having undertaken their imbibing, has that influenced their future choice of menus when implementing policy? In other words, do they actually take note? It is one thing to be inspired there and then, but do they take note to such an extent as to change policy?

Mr Horton: I can give you one set of examples related to maternal health but focused on child survival. A few years ago we were involved in producing a similar series to the one that we sent you on child and newborn survival. There is no question that bringing that knowledge-base together helps inform ministries of health in continents like Africa. The problem is that ministries of health on their own are quite weak, of course; so we cannot do it all. What you are trying to do is provide the ministries of health with that knowledge but then also trying to influence presidents and prime ministers. Building that social, that political movement you have to include both groups, and I think conferences like Women Deliver can be valuable because it brings the finance ministers, ministers of interior, presidents and prime ministers together with ministries of health to change their culture. On our own, of course we cannot do it.

Q137 John Bercow: Thank you for that, Mr Horton. May I follow up on one of the initial observations that Brigid made when this question began or in response to earlier questions, namely the importance or lack of importance attached to women within society, particularly in the developing world? I do not know whether you think, because some reference was made to welcoming evidence from scientists and contributions from a whole variety of actors on the stage, including faith groups, that the presence in a room, or the delivery of a very effective scientific paper by an expert scientist to a minister in a developing country government can in any way match or counteract the sort of cultural or even religious influences under which that minister would normally act. To put it very simply, if there is a natural lack of interest in these matters or, dare I say it, even an attachment to what we would consider very outdated ideas of women's importance or lack of it, can that attitude be atoned for when distinguished science is presented?

Ms McConville: I think distinguished science can form the foundation, the bedrock, for the work that will follow. I think those maternal mortality figures, in particular, the data is very important. We hear over and over again, a woman has been buried in the garden and not even counted, and that has been one of the problems when work has begun on so-called Safe Motherhood. One of the first things that happens is the counting starts and then the figures look bad, they look work worse, and it does not look like a good return on the investment, but once those figures are in place, things can move. Jeremy Shiffman, who has done some leading work on advocacy, has worked out some of the key issues in how advocacy has changed issues around the world. For instance, in Guatemala a reproductive age mortality survey was one of the major factors in moving things forward in that country, so I think data can be tremendously important. I will give you a slightly different perspective. One of our leading advocates in Africa, working within her own country, a senior figure in the government said to her, "What is all this fuss about? Here we have one woman crying. A few women are dying and one woman is making a fuss." That is the response she got at her own government level. Women are up against that all the time. I have worked as a journalist in developing countries. It is very hard sometimes to find a space in which women can make themselves heard. You find yourselves crowded out by men, very often. Women face a lot of barriers and they may not feel safe to express themselves. If you have a leading figure in a movement like the White Ribbon Alliance who is seen on TV, as our co-ordinator from India, Aparajita Gogoi - she was on the stage at the Clinton Global Initiative - that is an amazing role model for other women in India. I think there is a matter of solidarity there and a matter of leadership that can inspire and give courage to other women, but we need these things together. It is not either/or.

Mr Horton: May I be allowed to add one very brief codicil. I want to be very clear what we mean by science. By science I do not mean stuff that goes on in the lab or even clinical trials. Monitoring and evaluation of what governments are doing, creating league tables. Are governments investing in health? Are they meeting the Abuja Declaration? What are the financial flows? How are they using that? That is the sort of science I mean.

Q138 John Bercow: It is output driven.

Mr Horton: Yes, and that is the kind of accountability mechanism that the scientific community can provide. There is nothing more worrying to a minister than being held up as not meeting some international norm. I do not say it is about shaming, but it is about naming, and in a very public sense, and that can make a difference.

Q139 Chairman: Is The Lancet a campaigning scientific journal?

Mr Horton: I jolly well hope so. It was founded in 1823 by somebody who was a campaigning doctor at the time and he became a Member of Parliament in the end and fought for the coroners' courts in the UK and for public health and sanitation law. I think what The Lancet is trying to do now is reinvent itself in a global setting.

Q140 Jim Sheridan: I am delighted that the scientific profession are acting in the pragmatic way in which you are suggesting, but picking up the point that Mr Bercow made about faith groups and various religions, is there the same potential conflict there amongst faith or religious groups, particularly when we talk about birth control and maternal services?

Mr Horton: That is a really tough one, is it not? The Catholic Church, for example, provides a huge amount of the care services for people living with HIV in Africa, and if you took a completely negative view of faith-based care services, you would pull the rug out from the care of millions of people on the continent, so one has to be very careful about how one frames this point. My experience is that we sometimes put faith groups in little boxes and stereotype them. I know a lot of people who are from faith communities, who work in science, for example, who might have a personal view about abortion but will be part of a movement that will argue very strongly for harm reduction, which means providing safe abortion services; so I would be quite cautious about accepting any stereotypes. I find, again, that when it come to issues like this people are actually very pragmatic.

Chairman: There is an interesting poll in today's papers, Catholics For Free Choice, which is identifying that the Catholic Church is rather divided on that issue.

Q141 Mr Crabb: Mr Horton, in your Healthy Motherhood piece as part of the maternal survival series last year you issued a call for the professionalisation of maternity care to be made an absolute priority. To whom were you laying down that challenge? Who was the relevant audience?

Mr Horton: Policy-makers. There is no question about that. I think one of the problems within the medical community---. First of all, I think the medical community can be an extremely damaging obstruction to some of these issues, because we as doctors sometimes think that it is only doctors who can provide solutions, and it is not, there is a whole set of community health workers out there who are much more likely to be offering solutions than doctors are, but the professionalisation, the improvement in skills, that message still has not been more forcefully made to policy-makers and I think the medical community can be an extraordinarily important lever in making that message heard more loudly. The medical community is an advocacy community in its own right, and I think it can mobilise itself more effectively to make those messages.

Q142 Mr Crabb: Can you give us some thoughts on why professional attendance at birth has remained so stagnant in Sub-Saharan Africa and South Asia over the last 15 years?

Mr Horton: I think that comes down to Brigid's point again about the failure of advocacy. You do not need more research to prove this, these are messages that are well known, but we have not been able to make the case strongly enough that professionalisation of care, skilled birth attendants, emergency obstetric care, facility-based care, is an absolute priority.

Ms McConville: I think that is somewhere that we can really show that we have been very successful in working with communities. For instance, in countries like Tanzania only just over half of women give birth with any kind of skilled attendant, and that mirrors the figure for the whole world. It is just extraordinary in this day and age. Fifty per cent of women all around the world are still giving birth, probably at home, alone or with a mother-in-law or a neighbour, with no skilled person at all to help her if she gets into difficulties; but the journey from there to skilled care is a long and social one. The roots of her getting from A to B lie in the community, in her own empowerment, in her own education, in the amount of information she has, in the power she has to make decisions for herself about her own healthcare. Those are social issues and it is only community mobilisation that can bridge that gap up to the health centre. There has been this debate for many years about traditional birth attendants versus skilled birth care, and the evidence is overwhelming that skilled birth attendants are the answer to this issue. However, we can work with traditional birth attendants to encourage them to come with women to the health facility. It is not a question of excluding the community, excluding and blaming those people who do not have those skills. We can work with them to bring women to health facilities.

Mr Horton: It is making connections outside of the health sector. This is not just a health solution we are looking at. Work done in Bangladesh, for example, shows that reductions in maternal mortality are tightly linked to improving educational status for women. In the educational sector, MDG 2, on education, there are vital links that are made. Again, we must not pigeon-hole health, we must look across the multiple sectors.

Q143 James Duddridge: What is the most effective contribution civil society and grass roots organisations can have for advocacy on maternal health? You mentioned a number, but what are the most effective levers?

Ms McConville: The most effective levers in terms of?

Q144 James Duddridge: In terms of their advocacy work. Who are the most effective people to target and with what methods? Rather than simply talking about advocacy overall, who do they target and how?

Ms McConville: I think there are various levels and, as Richard is saying, we cannot have one against the other. We cannot divide them up; we have to look at the issue in the whole. We have to have community-based advocacy; we have to work very closely with families. We have to have men on board; we have to have husbands and mothers in law. One of the things that we do in India, for instance, is Safe Motherhood classes for young couples and, at the end of it, the husband, if he graduates, will tie a white ribbon in the hair of his new bride to show so he has made that pledge to care for her in the future. We can also then have representatives on local health committees; so that district level is often very, very important; that is where a lot of decisions are made about healthcare. So we have White Ribbon Alliance members represented and asking questions on those committees, and then, at national level as well, we need to be pursuing the policy-makers in government. By the way, health ministers often welcome that pressure, because they need to advocate within their own governments for more funds for maternal health. In Burkina Faso, for instance, the White Ribbon Alliance there persuaded the Government to hand over a further 10 % of the health budget to maternal health, which was then spent on facilities, training, community awareness raising and sensitisation, and so on. I would not prioritise one against the other; I think we have to work right across the spectrum.

Q145 James Duddridge: Presumably with a limited budget, White Ribbon individually, or globally with a limited budget for advocacy or maternal health services, choices have to be made. Perhaps another way of expressing the question is: of the White Ribbon budget, the advocacy budget, where do you spend that? What of it is the grass roots? For example these classes for fathers and families: what percentage, broadly speaking, is for the advocacy at an international level and at a country level?

Ms McConville: When you talk about the White Ribbon Alliance budget, a lot of our people are actually volunteers. Many of our co-ordinators are not paid. We often work within other organisations, we are given a home within another organisation, and then we survive on projects, but many of our co-ordinators knock on doors for several years before they get any pay at all. The other point to make, I think, is that different countries and even different regions within countries will have very different priorities, so our alliances will decide within those countries what they should work on in an autonomous way. In India, for instance, I have told you about the new laws that were steered through to enable nurse midwives to perform. In Tanzania the priority was human resources. There was a tremendous shortage of skilled birth attendants. There was also an unemployment issue in Tanzania, so the focus there was on persuading the Government to hire staff immediately. The step forward has been made in that the Government now immediately employs graduates from the medical and midwifery schools, so they go straight to work, whereas before they were waiting around for interviews and then disappearing. So that was their target. In Indonesia the issue was to alert villages. Communities raised awareness so that families would know the danger signs in pregnancy and plan ahead, and they would have some funds ready for transport. A similar thing happened in Malawi, where White Ribbon Alliance members joined forces with the police service. The roads there are often atrocious and there is very little transport, so you would often find women giving birth on the road or walking to a facility many, many kilometres. They worked together with the police to set up a small fund so they could use the police transport to get to a health facility and beyond. For us it really depends on what the issue is in that particular country and the decisions that are made within that country.

Q146 James Duddridge: Earlier you gave quite a powerful example of being asked by some Indian ladies (there was a petition of 35,000) for a camera, something as basic as being able to capture the moment. How are local groups best supported by international organisations such as yours, or is it really, as you are saying, driven on a country by country demand-led basis? Is there a model perhaps for what other international networks can be doing to assist local groups?

Ms McConville: I think we are a unique organisation in that we have got going within the last nine years and we have absolutely mushroomed, and the demand for the Alliance is growing all the time. We do not have any sustained or core funding, except for a small team that runs a kind of hub, a secretariat. If you like we are almost the inverse of a UN organisation where we are very, very big and extensive at grass roots but we do not have any sustained or steady funding sources, and certainly that is where we could do with some help.

James Duddridge: Message received!

Chairman: A straight answer to a straight question.

Q147 John Battle: I rather liked Richard's broader definition of science. I am interested in what might be in your term "the science of civil society"? I think we have massive questions to ask, not only developing countries but also here, about representation, role and voice, not least to ensure that the poor are heard rather than spoken for. I wonder if I could ask you: how do we turn positive anecdotes, personal community stories, into analytical evidence that can be used to drive the argument and the advocacy forward? Bridgid, you gave us some examples: I think a film that was taken in Tanzania, Burkina Faso, the health budget; you mentioned Indonesia and Malaysia; but can those success stories of community mobilisation be turned into a source of analytical evidence to push the arguments further forward? Where would we go to get them and who could put them together?

Ms McConville: Jeremy Shiffman. I have got a summary of a piece that he did in Insight Magazine. He is a leading researcher from the USA and he is saying that advocacy is the key, and he has done an awful lot of work on this, and he says that the degree to which political leaders actively pay attention and allocate resources to this issue varies according to the amount of pressure that is put upon them within developing countries by advocates, and he has got chapter and verse about how that works. He says, "National advocates have achieved varying degrees of success in promoting the cause and they were most successful when they" (and he has given one example) "organised focusing events such as national forums to promote the cause, including a march to the Taj Mahal in 2000 organised by the White Ribbon Alliance of India", and a couple of other examples there, and he is saying, "Advocates must develop political not just technical strategies".[2] So the research is there. There is also Wim Van Lerberghe at the WHO[3] has published papers about how that worked in Europe. We have got where we have got because of sustained political pressure and advocacy over the years.

Q148 John Battle: I am tempted to say that, in terms of poverty in the UK, Europe and America, we are not there yet.

Ms McConville: No, I think there is a very important point there, which is that in every society there is a marginalised group and it is those groups that we need to reach, and we have that same problem. The maternal mortality rate in America is shockingly high. Those are usually the black and Hispanic communities. It is the same pattern.

Q149 John Battle: I think in my neighbourhood in the inner city I kind of jib at the notion of the hard to reach people because they are there all right, it is that others talk about them as the hard to reach; but what I am saying about that, Brigid, is to push this idea. Can we get the analysis from the local to the centre? Can we really tune in? Let me ask a particular example. DFID is funding, I think, research in Nepal, for example. Can we get from that research, just in the same way---. I do not know the two people you have referred to, and that is very helpful, but the Alinsky Institute, for example, in Chicago and all the work they did on community campaigning to push civil society in the west, has that research in Nepal given us the kind of evidence to say that community mobilisation has brought tangible improvements in maternal health and we can document it, list it and tabulate it so that we are in Richard's domain of science, not to play that off against you, and the science is fused with the advocacy to become an unstoppable argument in terms of demanding justice for the poor, not least women, who pay the highest price of all everywhere?

Mr Horton: The answer is absolutely, unequivocally, yes, and DFID has funded this research. It is back to Anthony Costello again. Let me just give you an example of his work. What has he done? He has done a randomised trial to show that women's groups can reduce maternal mortality, newborn mortality. He goes on to show that that is a cost-effective intervention being afforded by the health system, and then he has done, effectively, anthropology, looking at the care-seeking behaviour of women, reporting that in a very conventional, rather boring way in a boring medical journal like The Lancet that can be used by Brigid and her colleagues as the mechanism for advocacy, doing exactly what you say. That is science for civil society, so that it can be recognised as robust evidence at a ministerial level but it has that texture, that quality, that means something and is not just numbers in an abstract sense.

Ms McConville: The whole function of an Alliance is to bring everybody together with those complementary perspectives that we can build on and move forward together.

Q150 John Battle: And build the commonsense for change.

Ms McConville: Exactly.

Q151 Chairman: Thank you for that. You have already mentioned, Brigid, your Stories of Mothers Lost. You made reference to it and gave one or two points from it. First of all, is that still on its travels?

Ms McConville: Yes, indeed.

Q152 Chairman: What are the sort of key points? In a sense one can judge what it is, but can you just tell us a little bit more about what is in it and how it is focused to get these results?

Ms McConville: Yes, by all means. In fact I have brought you all a folder that you can take away with you. The exhibition is a collection of fabric panels. We put the word out to our members in all our countries and asked them each to submit a number of stories from those communities, the story of a mother who has died in pregnancy or birth, and the result was absolutely stunning. We expected 50. We had some funding from the UNFPA[4] for that. We got over 120 in the space of a few months. I am glad to be able to say that our partner in the UK has been the Royal College of Obstetricians and Gynaecologists International Office, and they very generously lent us their premises for setting up the exhibition. We launched that - you were all invited actually - in October and we had a tremendous audience, over 250 people, and this is where we can do things differently in the Alliance. We had not only the medical and health community and the development community, but we had media people, theatre people, music people, ordinary citizens - the whole spectrum came to that event. We had asked Mrs Sarah Brown if she would open that event for us, and she said that she could not do that but instead she would invite us to a reception at Number 10 Downing Street. So, two days later, we took 20 of the panels, the stories, into Number 10 and we invited, again, a very broad range of people, and our advocates included such women as Judi Dench and Diana Quick and we had some top media people as well, executive editors of our national papers, we had some top music people and some people from the business and corporate communities. We also had Douglas Alexander, and we had our singer Stara Thomas, the pop star. I think what was wonderful about that was that we were able to bring stories of women who have died. Normally those stories are never heard - that woman has gone - her story is not heard. The community told her story. These are the poorest of the poor. Those stories were brought right into that hub of power and influence and I am tremendously proud of that, and most of our co-ordinators from Africa and India, many of them, were there, and I think that was a tremendous accolade and a tremendous boost to their morale. We are following up all of those leads and all those connections that we made at that time. We also are very pleased to announce that we now have funding from the Bill & Melinda Gates Foundation to take the Stories of Mothers Lost on an international tour. So that is going to be the focus of an international advocacy campaign. Our next port of call is Washington DC in April, which is the World Bank and IMF[5] meeting, so we want to influence policy-makers there, after that we go to Japan for the G8, and we hope again to make sure those voices are heard in the highest places, and after that we go to South Africa, which I believe is the World Economic Forum. So we have got three major political meetings to which we will be taking the panels as evidence.

Q153 John Battle: Just a suggestion, as well as the excellent work there. In this room we saw the Panorama film which was in the early sessions of our inquiry. I showed that film in my own neighbourhood and Sure Start Group in an area which has some of the worst records of maternal health in Britain. The response was fantastic. I would like to suggest, if it was possible, for the international exhibition as well as aiming at the world economic fund, the policy makers, also to be used to build support on the ground floor level to push the policy makers from solidarity from the base as well.

Ms McConville: Absolutely. Obviously we cannot take the panels to every place but we are making a film about the exhibition. Some of the footage was taken by the communities as they put their pieces together and I should tell you also that there was a tremendous amount of advocacy in the putting together of those panels. For instance, in some communities in Pakistan, young people got together in the making of the panels and pledged a commitment to Safe Motherhood and signed pledges. In one other area there were 25 media articles alone around one particular story. In Uganda there was a TV programme. Parents were filmed by the graveside of their daughter, talking about her death and that film was on television, so already those panels have had a tremendous advocacy effect in the communities. The panels, by the way, will go back to those communities at the end of their job. To build that connection in the UK we are also very keen to do that.

Q154 John Battle: Perhaps the department that is in charge of the Sure Start programme should be alerted to your campaign and push it through Sure Start.

Ms McConville: That would be wonderful.

Q155 Chairman: Thank you very much. When we embarked on this inquiry, obviously the first thing we did was to get a briefing on the context. The context is appalling. It is the most off track MDG. The figures are variable but there are more than half a million women dying in childbirth and many, many more millions of people are affected by the consequences of that and the very poor progress towards dealing with that. That is part of the reason we are doing the inquiry to see whether or not we can focus on this. Your evidence has been extremely helpful. You have given us some very powerful evidence in terms of what you feel works and what you feel is the right approach. It is a very subjective thing but how optimistic are you? It is not a question of physically doing it. Both of you say of course we can do it. We can mobilise world opinion and the people who need to make those decisions including in the developing countries. We need to do it. How optimistic are you?

Ms McConville: My view would be that this is a really important time in history. We have had 20 years of the Safe Motherhood initiative with shamefully little progress. However, at the moment there is a tremendous amount of pressure from the governments of the UK and Norway. There is also a building global movement at grass roots level. We are getting closer to the target date of the Millennium Development Goal. If we can bring those together now, if we can bring top and bottom levels together, we have a tremendous opportunity, but we can only do that if we really respect and listen to the voices of the people in the countries where those issues are problematic.

Mr Horton: I am extremely optimistic. In the past five years we have scaled up advocacy, resources and political commitment to child survival. I think we can do the same over the next five years for maternal health more broadly. We have a lot of the knowledge in place. We have a lot of the leadership in place. It is a question of making connections between those two, between the politics and the knowledge. If we get that equation right, we can make incredible progress at country level.

Chairman: That is a very positive note on which to end your evidence. Thank you very much indeed. It has all been very clear and helpful.

Witnesses: Ms Aasha Pai, Acting Regional Director, Africa and Latin America, Marie Stopes International, and Mr Giorgio Cometto, Health Adviser, Save the Children UK, gave evidence.

Q156 Chairman: Thank you both very much for coming to give evidence to us. You obviously have heard the evidence we have just had. You are particularly focusing on conflict situations in fragile states but I wonder, for the record, if you could please introduce yourselves?

Ms Pai: I am Aasha Pai. I am Acting Regional Director for Africa and Latin America for Marie Stopes International. MSI is one of the leading sexual and reproductive health organisations working globally in 38 countries. Last year we served five million clients and particularly in terms of humanitarian work we have an initiative working with Columbia University called RAISE[6] which is really looking at trying to be a catalyst to change the way that reproductive health is seen in crisis situations. This goes from a very practical level in terms of integrating reproductive health with the work of health care NGOs[7] and other humanitarian NGOs, also to making a more enabling environment for funding and for policy change on the issue.

Mr Cometto: My name is Giorgio Cometto. I am a physician. I have worked in the last few years in east Africa and the whole of Africa in managerial, policy and advisory positions with international NGOs, a bilateral donor in the World Health Organisation and very recently I joined Save the Children UK as a health advisor based here in London. Save the Children UK, as you might know, is a leading global NGO working for the protection of the rights of children and their carers and it has operations in over 30 countries, in Latin America, Africa, Europe and Asia.

Q157 Chairman: Last year the Committee did a report on conflict and post-conflict reconstruction. We are not expert on anything in this Committee but we do try to inform ourselves and focus on certain issues. Obviously we have seen some of the devastating effects that conflict has in general terms on women and children in particular. I wonder if you could give us a little bit more insight into why, in that situation, maternal health is particularly badly affected by conflict as opposed to the destruction of a health service or the lack of it or inability to get about. It means that all health issues are a problem but why and in what ways is maternal health particularly badly affected by conflict and post-conflict situations?

Ms Pai: Very particularly in conflict situations you have quite a lot of gender based violence so we are looking at rape being used as a weapon of war. We are also looking at domestic violence. Refugees may be coming from areas where you have high levels anyway but in those high stress situations we see an increase of domestic violence. You have these situations where women are being raped, being raped systematically, being raped simply when they want to walk to get water, to get fire wood for their survival needs; but also an increased level of violence in their own relationships coupled with being forced to sell sex in many situations in order to just get their basic needs met. In these ways you see that the reproductive health needs you have anyway are far more acute in terms of the depth but also in terms of the scale because, in many refugee and displaced people camps, the majority of the people who are there are women and children. When you have maternal mortality and maternal morbidity, you see that affecting straight away most of the people that you have there in the population and children being affected when their mothers are dying or suffering from disabilities as a consequence of poor maternal health.

Q158 Chairman: I would just comment in passing on our conflict report. In reality, we saw in the Panzi Hospital in the eastern Congo the victims of systematic and abusive rape. We have seen in the camps in northern Uganda the whole issue of poor support. Just having come back from Afghanistan, we were told that 80 % of women are subject to domestic violence within their relationships. So there are just three examples of countries which the Committee has visited which have come out of conflict where those facts have been brought to our attention. It does reinforce what you have said.

Mr Cometto: That is the case also in other settings. In Liberia for instance it has been estimated that between 60 and 75 % of women of child bearing age have been forced into sex at some time or other during the period of conflict. Gender based violence is a big part of the reasons. It should be emphasised that conflict and immediate post-conflict situations usually are characterised by a near total collapse of health systems. Maternal mortality relates very directly to the status of health systems and the capacity of women to access health services. This relates both to the supply side and the demand side. In many cases access can be constrained by security problems. A generally intimidating climate can suppress demand from the women so there are multiple dimensions in conflict that directly pose an increase in maternal mortality. Considering the groups of fragile states and other low income countries with a more stable political environment, the maternal mortality ratio is up to 2.5 times higher in fragile states or else it is equal, so there are really significant elements that determine higher maternal mortality in fragile states.

Q159 Sir Robert Smith: Given that challenge, what do you think donors such as DFID can do to ensure that issues like maternal health, reproductive health and gender issues are dealt with systematically at that time of conflict affecting countries and these fragile states? Is there any specific strategy?

Ms Pai: DFID has been a leading donor in terms of humanitarian issues. DFID has also been a leading donor in terms of gender and reproductive health but where I think more can be done is to bring those two together. When you look at a crisis situation from the outset, you should be looking at the needs of reproductive health and consider them to be as essential as any other health issue. If you look at all of the things we just talked about in terms of maternal mortality and morbidity from the onset of the emergency we have to put the systems in place so that you have basic emergency obstetric care, for example, so that you can deal with these situations from the beginning. Also, we need to look at the complexity of programming that is required. If you are talking about different groups of people from different places, you have a lot of socio-cultural issues as well and if you are talking about places like Afghanistan, as you would have seen on your visit, it is so important for example to have women doctors providing care for women, for them to access service. All these things are incredibly sensitive and require slow funding that trickles over time, that is constant over a long term. You need to have a concerted effort over time to be able to transform situations and make a difference. At the programming level DFID could do more to bring that together also through specific mechanisms, such as through CHASE.[8] Now there is language that has been added to include reproductive health and to encourage NGOs to apply for funding through that mechanism, but more could be done to make sure that their programming does include reproductive health and that there are some tracking mechanisms to see that the money that is being allocated for these NGOs is increasing over time.

Mr Cometto: I would like to emphasise that post-conflict reconstruction programmes are long term endeavours. It is quite frequent to witness a pattern in terms of aid disbursement into post-conflict settings. In the immediate post-conflict period, there is a gap between the time emergency funding is scaled down before recovery and development mechanisms pick up. This has been documented in several countries all over the world. DFID acknowledges this. For instance in a country like South Sudan, they set up a basic services fund, acting as a bridging gap measure for this period. This, in my opinion, is best practice that other donors should look at. What specific strategies and answers are to be put in place? It probably depends from country to country. What can be realised is that these are long term endeavours. The answer lies in strengthening health systems as a whole and also recognising the important role that civil society has to play in particular in settings like fragile states and in an area like maternal health and reproductive health. We broadly concur with the strategy of prioritising the strengthening of government structures and the adoption of government mechanisms for disbursement and for building up health systems. Having said that, it should be acknowledged that in certain countries government structures are not in place and governments may not be able or, sometimes, willing to provide what is needed. In these cases, probably civil society has a role to play also in terms of service delivery. Even when that is not the case, even when a government is effective in providing service, there is anyway a residual role for civil society in terms of advocacy, capacity building and piloting different approaches that can fit into the general policy at country level.

Q160 Sir Robert Smith: In the emergency funding phase, how are things at the moment?

Mr Cometto: You refer specifically to the case of southern Sudan?

Q161 Sir Robert Smith: No. In the emergency funding phase post-conflict, how does maternal health cope at the moment?

Mr Cometto: My experience, which is limited to two or three countries post-conflict, I would say that it is quite fragmented. Multiple partners intervene sometimes with overlapping mandates. A lot of the funding is still structured according to vertical lines in vertical structures. It is something that usually comes during the recovery and development stage, but typically the emergency relief phase is characterised by severe inefficiencies.

Q162 John Battle: I wonder whether funding, a trickle over time, to develop a health system is not irreconcilable with a fragile state. There seems to be a complete incompatibility. Do you think you could identify at what point in a post-conflict situation donor attention should move from emergency support to strengthening health systems. Sierra Leone was one of the places I visited with the Committee.

Mr Cometto: We would recommend pursuing a twin track approach. It is very difficult to recommend a specific point in time, whether country specific or when emergency funding should be scaled down. Something that has happened a number of times and has been documented for instance in Liberia or in the mountain region of Sudan is a severe contraction of service delivery right after the conclusion of the hostilities. Probably the wisest approach in my opinion would be to scale down emergency relief once something else is available. That usually takes a minimum of two or three years before something is put in place.

Q163 John Battle: To follow the scientific approach of the previous conversation, are there types of information or data that can be collected to inform policy makers and monitor progress in that context so that you maybe cannot identify a moment on 26 April at 4.30 but rather can we identify some key indicators and data that we can work from to say to donors, "Look, there is an area here now where we could give more support to health systems and move away from emergency funding as a result of a crisis or conflict"?

Mr Cometto: I believe that a lot of information has been published, in particular from countries that have shown better results than others. For instance, Afghanistan features quite prominently in the literature in the light of its faster than usual results in delivering improvements in outcomes. I am not familiar with a particular person or a particular set of publications that looks specifically at these points. Usually, a lot of the evidence is published at country level and rarely does it fit into global debates, but there are units, for instance the World Health Organisation, and other departments that look specifically at conflict or post-conflict situations. Another example is the London School of Hygiene and Tropical Medicine. They are an important source of information and they are a leading global partner in determining, publishing and assimilating evidence on this.

Q164 John Battle: I was incredibly encouraged by the positive responses to the Chairman's questions about the hope for the future in the last session. I wonder if we could look at health care in a positive way. I once went to Kosovo right at the end of the conflict. I observed and was part of a deal where an Albanian and a Serb started to work together as two electrical engineers repairing a power station. They were discussing politics and theology when they did it but it got it up and running. It was a moment when repairing a power station was a catalyst for peace in the neighbourhood. Could provision of basic health services act as a tool or a catalyst for promoting peace and stability in fragile states? Could we look at it in that context?

Mr Cometto: I suppose it is possible to look at it that way. As a matter of fact, the association between the provision of social services and peace and stability or conflict on the other side has been made in several settings. Establishing a causal link between the two might be harder than a general type of association but it is probably an area which further research and better evidence could help.

Ms Pai: Any kind of investment to any social services could very potentially have that effect. You also see that in fragile states, if you can focus on working with NGOs, that is one thing. Maybe you are going to have a stop gap service that can be provided. Going back to what was said before about also working on the capacity building and advocacy issues at the same time, it is an investment not just around immediate needs but around avoiding potential conflicts in future because you are addressing the needs that people have. Again, it is about not putting health in a particular box but looking at overall development.

Q165 Chairman: Is it not extraordinary in the situation with DRC?[9] Everybody happily - I say "happily" using a very ironic term - talks of it being the worst conflict worldwide since the Second World War in terms of the numbers of deaths. A figure of four million was quoted, but when you ask how did these people die most of them were not killed in conflict. They died of disease and lack of access to health care and so on. From your engagement in other conflict states, is there something wrong with the international community that it does not understand that what is needed in a post-conflict situation is prioritising the delivery of those kinds of services? The specific issue we had as a Committee was engaging with ECHO,[10] who were proposing at the time to withdraw funding from the Panzi Hospital on the grounds that the conflict was over. The Panzi Hospital was full of people who were coming in every week, women who had been mutilated and savaged and yet somehow the international community said, "Well, there is no conflict so there is no need for further funding." The point I am making is, from your perspective, should the international community respond better and to what extent do you argue that case?

Ms Pai: Absolutely. If you look at reproductive health specifically and ask the questions about how or why is it different in emergency situations, of course we have a lot of evidence to show that. The point is that reproductive health is a fundamental right anyway, whether you are in a crisis situation or not and of course the needs are more acute when you are in crisis situations. We make a lot of unhelpful distinctions around what is conflict, what is post-conflict, what is development, what is not, what is crisis and what is not when in fact these are basic human needs and basic rights that we as an international community are ignoring, whether it is a crisis situation or whether it is not. We need approaches where we can look at working with NGOs and funding NGOs, look at making the work of NGOs less fragmented by funding larger NGOs and funding smaller NGOs who can come together and have more of an impact at the same time that we fund governments and civil society to influence policy change. We simply have to work on all fronts. I just do not see it any other way.

Q166 James Duddridge: This Committee recently returned from Afghanistan and you have touched on Afghanistan and the need for women doctors in particular in Afghanistan. That might be one of the challenges but what are the other challenges particularly in Afghanistan in relation to maternal health? From both your organisations' perspectives, how well are DFID doing in addressing some of the challenges and what more should they be doing going forward?

Ms Pai: In Afghanistan particularly, apart from the women health care providers, you have the same kind of security issues that you have anywhere else. The cost of being able to provide services and at the same time have security for your staff is incredibly high. Then you have all the other issues that you have already when you have damaged infrastructure and poverty. The costs are incredibly high and donors are not always willing to go as far as they need to go in order to address all the issues. DFID can play a really strong role in terms of influencing other donors as well. The interesting thing about Afghanistan, I understand, is that if you look district by district, because you are having to work through NGOs as well as doing some work through government, you can see big differences district to district, depending on the donor who is there and depending on donor policy. For example, where you have USAID working, you do not have the same attention to reproductive health issues and you can see the gaps in services. Where you have other donors, you see that there is that influence. With DFID's influence in terms of reproductive health, not just in Afghanistan but in other places, it can show what can be done if you put that attention onto the issue, funding NGOs, getting the money in but also influencing other donors in order to do the same thing so that you do not end up having these very fragmented situations where you are not addressing the issue.

Q167 James Duddridge: In provinces in Afghanistan where the Americans control, will they provide cover and allow people to come in from international organisations looking at reproductive health? Will the American military facilitate that?

Ms Pai: I am not sure about that actual access issue in terms of those districts but what I do understand is that, whatever is happening, the result is that you do not have the services. It may just be a question of funding and not access. The way I understand it is that certain donors are funding certain districts, so it could just be that there are not other donors present and that is why you do not have that reflected.

Mr Cometto: I was one of the NGOs that were subcontracted out to run health care services in one of the provinces in Afghanistan. I do not know if you are familiar with the aid architecture in health in Afghanistan but basically it was decided that a basic package of health services would be subcontracted according to geographical regions. The three main financiers would be the World Bank, USAID and the EC.[11] The Save the Children province was in USAID and to a certain extent it is correct that the different donors have placed different emphasis on certain components. The issue of reproductive health being less of a priority for USAID as compared to other donors is a factor, although there was an attempt at national level from the point of view of the Ministry of Health to achieve a standardisation of the service that would apply across all the regions. As far as I know, there is not a problem of access to areas that are directly controlled by the Americans.

Q168 Sir Robert Smith: We visited a hospital in Lashkagar in Helmand where British money had built an accommodation block for trainee midwives to live in while they were being trained. Because they thought USAID were going to provide money to train the midwives, the block was empty while we were there because at the time USAID had run out of money. Because the block was there it looked like USAID were going to deliver the money. Presumably, that highlights the coordination. There are a lot of players there and maybe greater coordination is needed.

Mr Cometto: To be fair, in the hospital that Save the Children UK managed, which was funded by USAID, we did not do training of midwives so perhaps that was a localised problem.

Ms Pai: Undoubtedly where you have that better coordination you have much better results. Now that you have some moves for example with the WHO to be a coordinator amongst humanitarian organisations in terms of health, the key there is making sure that what you see is part of the basic package of health services with reproductive health, particularly emergency obstetrics.

Q169 Ann McKechin: I wonder if I could ask for your comments about how effective you think the UN cluster system has been. The Committee visited Pakistan last year where we obviously had a chance to talk to people about the cluster approach after the earthquake. I wonder how you think DFID could best support humanitarian actors, especially in an emergency, and whether the cluster system has any benefits.

Ms Pai: I certainly think it has benefits because in so many other places what you have is a complete lack of coordination. In the UN agencies you have lots of different NGOs, everybody doing their own thing to the extent of carving up districts and doing very different things in different places. Absolutely from a principle point of view that would make sense. Further to that, DFID again could use influence there to stress the needs of maternal health and reproductive health in those situations and even beyond having a health cluster that is coordinated, but specifically within that have something that is for reproductive health which is also a coordinated mechanism.

Mr Cometto: I agree with this perspective. In many ways DFID is to be commended for its commitment and for putting in place policies that most technical people would largely agree with. If something can be suggested to do more, it would be to strengthen the role that DFID plays at country level. Sometimes there is a sort of hands off approach operating mainly from multilateral agencies or NGOs, whereas perhaps DFID could play a stronger role in terms of leadership and engagement with other partners.

Q170 Ann McKechin: I wonder if either of you or both of you perhaps could give us some examples of success stories in providing effective health services. You have talked about best practice. What do you think are the key factors in that success?

Mr Cometto: If we talk about fragile states in particular, in my experience the list of success stories is not very long unfortunately. Afghanistan usually comes up as one of the best examples of quick improvement in health outcomes. To a certain extent, this can be ascribed to a bold decision that was taken by the Ministry of Health early in the reconstruction process of sticking to a more limited role in terms of coordination and oversight of the health system but subcontracting the provision of health services to non-state providers. This translated into massive improvement in terms of health service utilisation indicators and child mortality saw a dramatic improvement. It was reduced from 257 per 1,000 to a little more than 190 per 1,000 in the space of five years. Likewise, there has been an improvement in skilled birth attendants and antenatal care attendants. In terms of maternal mortality it has not yet been possible to document such a dramatic improvement. Whether this is an example that can be adopted successfully in other countries in other contexts remains to be seen. Despite the obvious appeal of the approach, there are also setbacks that have been identified, such as a hypothetical lack of sustainability with such a strategy and, to a certain extent, conflicts of dynamics between non-state providers and the government itself, especially at provincial level. A similar approach has been adopted for instance in southern Sudan as well with still to be documented results, but in other countries that have successfully moved from a conflict situation to a more stable type of environment the time frame typically has been much, much longer. For instance, in Mozambique, it took 10 years before significant improvements could be documented. It should probably be acknowledged that these processes take time. Sustained effort, sustained commitment and prioritisation of maternal reproductive health can achieve results.

Ms Pai: I agree with the point about when you go to an emergency at the beginning and the way that you view what is considered to be an essential or a basic health package, how important that is. If you say that from the beginning emergency obstetrics, post abortion care and family planning are all fundamental parts of that package, then you can go a long way with that. In terms of more specific examples of success stories, in northern Uganda where we have been working for many years we have seen great success in terms of the demand and supply side when it comes to these reproductive health issues. We are working in a few clinics in the areas where we have a whole lot of displaced people's camps and we are doing a lot of outreach. There are many organisations working there. Part of this RAISE initiative is to work with these other organisations that were not ever doing reproductive health. We are training them in reproductive health areas so that their health providers can do counselling and also provide services in these areas. We have seen thousands of clients coming in and demanding family planning which has been quite an amazing thing to see. Even in these conflict situations, often people say that women have perhaps lost children so they are not interested in using family planning because they are quite desperate to have more children. Of course, that is going to be true for some women but for a lot of people they are in situations in displaced people's camps in northern Uganda for years and years. That becomes their life. They also see that having too many children too close together results in all kinds of problems as well, so there is a very high demand not just for limiting the number of children but also spacing births. We have seen through our outreach people coming and also changing people's ideas. This is where the advocacy comes in. DFID has been funding through the Civil Society Challenge Fund for us to work with the police and the local military and work at the district level, so that at the same time while you work at a national level and you try to make sure that the policies are there - often the policies are already written there - it is about getting people to put money behind those policies and get that to happen at a district level. We also work through committees whereby our staff will go to the district health meetings and say, "We understand that there has been an allocation for reproductive health. We do not see it here in your district. Where is it? Why is it not here? Why is it, when I go to my local public facility, there is nobody there providing the service?" We are trying to work to help that through this advocacy but also by providing services in the meantime, taking our teams and going to work in the public facilities. This is where I think it is really important to look at the public/private initiatives of NGOs working together with government and the demonstration effect that has. We have our own clinics. That is fine and good but they are only in certain areas. If we can go and work where there are already government facilities, perhaps not well staffed, without supplies etc., if we can bring our teams there, we can work with the one nurse who is there, who is completely demotivated and does not have anything to work with. That is also building up her skills and that is providing many more points of service delivery for people.

Q171 Chairman: You have partly answered the question I was going to ask. If you look at the European experience in the Second World War, it tells you that people do tend to postpone children at a time of crisis. This is why we had a low birth rate during the war followed by a boom afterwards. The first question which you partly answered was the role of family planning, not least because in the wider context of maternal health it has been pointed out that if women are under pressure they do not necessarily want to have children but do not have an option and if there is difficulty feeding the family they have so they are underfed and under-nourished, vulnerable and not easily accessible to services, how important is family planning? That seems to be a classic case where you need to be alongside women and say, "I want it." Somebody has to be there to fight for it. I was interested in what you said about Uganda because, having been twice to northern Uganda last year - it may be my fault or the view that we took - what disappointed me about the camps was the total lack of any visible facilities for almost anything. You said you were working there successfully, so how are you delivering those services when there does not seem to be much in the way of clinics or any other kind of facilities, in spite of the fact that sometimes tens of thousands of people were living in a camp and you would have thought it would be easy.

Ms Pai: Absolutely. Our particular model has been an outreach model. We have clinics that are located just outside of where the camps are. Our medical teams use those as a basis and move in and out of the camps. We have to work with the other NGOs that are there. This is a good collaboration with other NGOs who are there, who are not particularly providing reproductive health, also going to the public facilities which are already there. In some cases they are in an absolutely shoddy condition and it does not look like a place where you would want to provide any services. This is how we work in other countries as well. If you bring in a medical team and you can provide a sterile environment, it can just be a small room and you can provide family planning; you can provide post-abortion care for women who are suffering from the consequences of unsafe abortion. There is a whole lot of things you can do. Going back to your question about family planning, it is absolutely critical but again in emergencies it is always seen as something that is second or third tier because the immediate benefits are intangible. There are a lot of studies that show, if you spend one pound on family planning, you will lose so many problems; you will save £10 on other services. Apart from the fact that women want to limit births, also looking at what happens when women do not have access to family planning and they are faced with unwanted pregnancies, we know that women all over the world, in conflict situations or not, do extraordinary things to end an unwanted pregnancy. The consequences of that in terms of maternal mortality are staggering. If it is 25 or 30 % outside of crisis situations, the stats go up to 50 % if you are talking about emergency situations. You also have to look at emergency contraception, at post-abortion care for when women take matters into their own hands and at safe abortion, where it is legal and you are able to provide it.

Q172 Chairman: How do you coordinate? Marie Stopes is almost a world leader in this and people would know what your sphere is but Save the Children has a broader remit. Your own survey said that coordination was not right and the skills were not always there. What should be done to try and ensure that in these conflict situations NGOs can cooperate and the sexual reproductive health element can be built into that? Does it require an agreement to give some leadership to certain ones? How does it work? Otherwise, if you are all doing your own thing in your own boxes, you could get in each other's way.

Mr Cometto: In my opinion, the issue of positive reconstructive leadership is key. The government plays a very important role in these issues and therefore it is important to exercise sufficient advocacy at a higher level in government to ensure that reproductive health and maternal health becomes a political priority for the country; that comes before the coordination of operational activities at country level. That is something that in many countries, in my experience, is lacking, the perception of the needs at political level and the perception that these represent a priority for the population. As other speakers have said, in certain areas advocacy is really key to the development of successful solutions to problems at the local level. In terms of coordination of activities, again the role of government is essential. It is only the government that has sufficient clout and political weight to mandate how coordination should work. One reason why Afghanistan is considered in international aid circles a successful example in terms of health is that the government gave very strong directions and indications, demanding that the contracting of health services for instance happened on a geographical basis. An organisation now for instance is responsible for a whole area and that means at the hospital level, the primary health care facility level, the community level, everything; whereas in many other contexts you have multiple actors operating, frequently stepping on each other's toes in the same area and that obviously leads to duplication and inefficiency.

Q173 Chairman: What do you think DFID could usefully do in terms of relating to NGOs in helping to deliver better priority towards sexual and reproductive health generally but obviously in post-conflict situations? Do either of you feel there is more they could do, whether in terms of their country programmes, resource or overall policy or whatever you think is appropriate? What do you think DFID could do differently or better that might help deliver your objectives in this field?

Mr Cometto: Building on what I was saying before, we do believe that NGOs have a strong role to play in this area of maternal health, in particular in conflict or post-conflict settings. This relates not only to service delivery but also to other areas, advocacy, capacity building etc. That requires resources and to a certain extent sometimes the balance which is struck between strengthening government structures and keeping a lively civil society sector to exercise a watchdog function or to fill some of the gaps that the government is unable to fill, in terms of resource allocation, is in our opinion struck too much to the side of the government. That is something that could be considered.

Q174 Chairman: To acknowledge your role, in other words, a little bit more?

Mr Cometto: Definitely. If you want NGOs to do something, you also have to back that up.

Ms Pai: I absolutely agree with that. Again, I really think it should not be seen as an either/or. If you fund NGOs, it does not mean you cannot fund government and vice versa. Also, to look at the ways where NGOs work with government, where NGOs are able to enter into agreements where we work in public facilities and help bring up the skills of providers there, where we are able to build the capacity of government providers through more formal training. Also, through advocacy. That is absolutely key. Where DFID has in certain countries - whether in crisis situations or not - decided that reproductive health is a priority, it becomes a priority at every level. I also think that what has been great to see with the Civil Society Challenge Fund is the recognition that it is not just advocacy that should be funded but also the service delivery. This speaks to the question that was raised earlier: are you creating demand where there are no services? Is that not fair and unethical to do that, to work only on that front? I would say to continue that funding, becoming more of a leader in terms of combining. DFID is a leader on one side and on the other but to bring together humanitarian funding and the reproductive health funding is most critical.

Q175 Chairman: Does it matter to you whether they do it as a partnership with the government of a country? In other words, saying let us bring in these NGOs as part of your service delivery programme, or would you prefer DFID to say, "That is providing support but we will provide direct support." Does it matter to you which way it is done?

Ms Pai: Certainly, practically, the direct support to NGOs makes a big difference. If you say the money is going to go to direct budget support, we say that some of that should go to NGOs and there should be encouragement or policy around work with NGOs and government, the mechanisms are of course very difficult. If it comes down to the government saying, "Fine, okay, we will subcontract NGOs to do various things", if all your money is going through there, at the end of the day, not all your money is going to come out the other direction for the NGOs. NGOs are going to spend a lot of time just trying to get paid for the services that they are providing and that they are willing to provide. I think that as much as DFID wants to support sector wide approaches, direct budget support and all of that, you have to work at the same time on both fronts and at the interface between NGOs and government.

Q176 John Bercow: It may be that I am being quite obtuse about it but just for purposes of clarification, when you say that if and where DFID decides that reproductive health care shall become a priority it does, do you mean that that is so because of DFID's stated expenditure intentions or because it is able to exert some other influence?

Ms Pai: I think it is both. The two go hand in hand. Other donors will look to DFID. Because DFID is spending the levels of funding that it is spending on humanitarian issues but also reproductive health separately, if in a particular country DFID says, "In this emergency situation, we see that reproductive health is essential and we are going to fund it through all the means we just talked about in terms of capacity building, advocacy, service delivery, both governmental and non-governmental", then it does have an impact. There is influence that can be used with other donors and governments also change their policies.

Chairman: Thank you both very much indeed. It has been an interesting afternoon for us in what is a really challenging environment. Both you and the previous witnesses have given us something positive as well as a challenge. We will take some more evidence. At some point we have to put this all together and come up with some recommendations. This goes for our previous witnesses as well: if anything occurs to you on reflection, after this evidence session, that you feel you want to stress or bring to our attention, I hope you feel completely free to contact our Committee staff and feed that in because we are anxious to get the most up to date and the most relevant input. Thank you very much.

 

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[1] Department for International Development (DFID)

[2] Jeremy Shiffman, Generating political priority to reduce maternal mortality, id21 insights, vol 11 (2007), p5

[3] World Helath Organization (WHO)

[4] United Nations Population Fund (UNFPA)

[5] International Monetary Fund (IMF)

[6] Reproductive Health Access, Information and Services in Emergencies (RAISE)

[7] Non-governmental Organizations (NGOs)

[8] Conflict, Humanitarian and Security Department (CHASE)

[9] the Democratic Republic of Congo (DRC)

[10] the European Commission's Humanitarian Aid department (ECHO)

[11] the European Commission (EC)