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CORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 66-iii House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE INTERNATIONAL DEVELOPMENT COMMITTEE
Wednesday 5 December 2007 PROFESSOR PETER GODFREY-FAUSSETT, PROFESSOR CHARLOTTE WATTS and MS CATHARINE TAYLOR
Evidence heard in Public Questions 177 - 247
USE OF THE TRANSCRIPT
Oral Evidence Taken before the International Development Committee on Wednesday 5 December 2007 Members present Malcolm Bruce, in the Chair Hugh Bayley John Bercow Richard Burden James Duddridge Ann McKechin Jim Sheridan Sir Robert Smith ________________ Witnesses: Professor Peter Godfrey-Faussett, Chair, Technical Review Panel, Global Fund to Fight AIDS, TB and Malaria, Professor Charlotte Watts, London School of Hygiene and Tropical Medicine and Ms Catharine Taylor, Lead Specialist for Maternal Health, HLSP, gave evidence. Q177 Chairman: Good morning, ladies and gentlemen. Before we go into the session I would just like to say that we have as a committee each year marked World AIDS Day by taking some particular evidence. This is obviously part of our inquiry into maternal health but focuses particularly on the impact of HIV/AIDS in that area. The Committee was not actually here on 1 December; this is the closest date to it. The point that I feel sure this will bring out is that, clearly in those countries where HIV is prevalent, the impact of that on maternal health is pretty closely linked. One or two figures which have been highlighted are that HIV positive women are four times more likely to die in pregnancy or childbirth than women without HIV; HIV positive women face a higher risk of infectious diseases, such as TB and malaria, and yet less than 10 % of pregnant women with HIV are estimated to be receiving any anti-retroviral therapy; and in 2005 more than half a million children were newly infected with HIV through mother to child transmission. So pulling these things together is clearly significant. I think the point we have already identified in this inquiry is that too often maternal health is one thing, malaria is something else and HIV/AIDS is something else and yet pulling them all together is clearly logical; so what we are looking at is how DFID[1] and the Global Fund can actually help in that process as well as the other issues such as gender inequality and sexual violence, which aggravate the problem. It is just to put those issues in context and connect it specifically to the Committee's annual commitment to acknowledge World AIDS Day and make a contribution to that. With that preamble, I wonder if the panel, for the record, would perhaps introduce themselves and then we can go into the more specific questions related to the inquiry. Professor Watts: Shall I start? Good morning. My name is Charlotte Watts. I am from the London School of Hygiene and Tropical Medicine. I am not an expert in maternal health but I have been working for many years on HIV, in particular gender issues around HIV, and I head a research centre working on gender-based violence and health. Ms Taylor: Good morning. My name is Catherine Taylor. I work for HLSP, which is a consulting firm that specialises in health system strengthening in low and middle income countries and I am the lead specialist in maternal health. My background in maternal health is that I worked in the NHS for 14 years as a midwife and as a midwifery tutor and then overseas for 15 years on a number of long-term projects working in maternal health, reproductive health and, more recently, HIV/AIDS. I have just taken over the Programme Manager post in South Africa for the DFID funded multi-sectoral programme for HIV/AIDS. Professor Godfrey-Fausett: Good morning. My name is Peter Godfrey-Faussett. I am a professor of international health also at the London School of Hygiene and Tropical Medicine, but I am here really standing in for the Global Fund to Fight AIDS, TB and Malaria. I serve as the Chair of the Technical Review Panel for the Global Fund, which is the body that recommends to the Board of the Global Fund which projects should and should not be funded. I am glad to say that to date the Board has always accepted our recommendations. Our role on the Technical Review Panel is independent of the Global Fund and, when the Global Fund were asked to come and give evidence to the Committee, they, unfortunately, were not able to send one of their technical people and so they asked if I could come and speak to the issues. They pointed out to me that I was entitled to speak, as I do for the Technical Review Panel, as an independent witness rather than formally representing the views of the Global Fund, but I know the processes of the Global Fund very well because I have been deciding what to recommend for funding over the past four years. Q178 Chairman: Thank you very much for that. On the general review that this Committee has done on the progress towards the targets on HIV, the concern has been that the target was set for 2010, not interim targets, and to the extent that there are interim figures available, they do not look like being on a line that would achieve those targets. There has been some increase, apparently, in those receiving treatment from anti-retroviral therapy. It has gone up from 7 % in 2003 to 12 % at the end of 2004 to 20 % at the end of 2005, but that still leaves about 4.7 million people in Africa who need anti-retroviral therapy who are not receiving it, and, as I said in my opening remarks, less than 10 % of pregnant women living with HIV/AIDS are receiving necessary treatment, even though it is demonstrated that if they do their survival rates are much higher. Very specifically in the context of the Department for International Development, what can DFID do to improve access to anti-retroviral therapy that they are not doing already specifically to ensure that pregnant women who have HIV can get access to the drugs that they need, given the evidence is quite clear that, if they do, it greatly increases their survival rate, so it not only reaches the HIV/AIDS target, it also delivers on one of the Millennium Development Goals which is most off track? Professor Godfrey-Fausett: Shall I kick off. I think that the environment around care for HIV changed hugely, of course, with the arrival of anti-retroviral drugs, and we have seen a massive scaling up of treatment for people living with HIV with anti-retroviral drugs in poor parts of the world, so the numbers have gone up a lot. I think that the emphasis on providing treatment for people living with HIV has, to some extent, distracted attention from what was happening before those big treatment programmes started going. In particular, the early programmes on prevention of mother to child transmission started usually with the assistance of UNICEF,[2] who led the first pilot programmes, and they have not continued to scale up. I think that is because people's attention has been more focused on getting treatment out to adults who need it. Q179 Chairman: You think it is that. In other words, you reach the easiest people first and it is harder, without the infrastructure, to reach more or actually the will has diminished? Professor Godfrey-Fausett: No, I think it is a matter of focus. It may be a matter of the resources available in ministries of health and other relevant ministries to provide, but if you take, for instance, the example of Zambia, where I have worked and lived for many years and which I visit regularly, the number of adults now receiving anti-retroviral drugs is more than 120,000, so they have dramatically scaled up over the past five years; and it is not that those people are easy to reach, those are big, difficult programmes, often supported by PEPFAR,[3] the Global Fund and the Ministry of Health in Zambia, but, at the same time, women who come to a regular antenatal clinic are not always offered an HIV test, do not always receive anything to prevent infection of their infant; in fact the rates of services to prevent mother to child transmission for those women is still unacceptably low. My own perception is that that has been because there has been a focus issue, and I think that focus is now shifting back a bit. I think people are accepting the importance of prevention, which perhaps we had lost a little bit in the push to get people on to treatment, and I think perhaps we are becoming a bit more balanced, not least because, as more people are treated, many of those people have been treated through programmes that have been established in order to treat people and they are based within the health service; they, nonetheless, have their own reporting and recording systems often. There is a degree of disease-specific focus around that, and the obstacle to continuing to expand those programmes is the weak health infrastructure, and the weak health infrastructure in turn relates to why women may not want to go to the health service in the first place; it relates to the inefficiencies in the health service in delivering what should be a much more straightforward intervention. If one talks about the medical side of it, and I think it is very important that we move beyond just thinking of the medical part of preventing mother to child transmission, but if we think of the medical side alone, it is a much more straightforward intervention than the idea of starting someone on treatment and then keeping them on treatment for the rest of their lives because it is a time-limited intervention that is just for the period in the run up to labour, in labour and thereafter. It should be much more straightforward. So, I do not believe that it is because it is more difficult, I believe that it is because of the attention that has been placed upon it. Q180 Chairman: Can I ask the other witnesses. Is there anything specifically you think DFID could be doing to help address this shortfall? Ms Taylor: In fact, I would just like to go one step back before answering that question, if I may. My fellow witness here has alluded to this fact. Often HIV/AIDS, TB and malaria are seen as disease specific and activities involved in actually addressing those diseases are not integrated into their health system and so they often run as parallel systems, and I think that that is historical in that HIV/AIDS was almost taken out of reproductive health and placed over here and so we have actually had fragmentation of the issues. I think that that is playing out in the fact that often maternal health services and health systems in low income countries are poorly resourced, both financially and in terms of human resources, in relation to HIV programmes. So that is the context. In relation to what DFID could be doing, I think from the work it has been doing recently it is going in the right direction. It is working at a global and regional level with policy-makers to address this lack of integration and is highlighting the need for reproductive health services and family planning services as part of PMTCT[4] activities as well as looking at continuing care throughout pregnancy and after. For example, it recently funded the maternal and newborn health programme in Zimbabwe which actually linked very closely with the HIV/AIDS programme, and it was specifically designed to do that; so that they are, for example, at a policy level, talking with the major agencies and funding and then, at a country level, they are actually leading by example and funding programmes where there is linkage between maternal health and HIV/AIDS. What more could DFID do? I think definitely more of the same. There is a lot of lobbying and the new International Health Partnership that they introduced in the autumn, I think, is a very good step in that direction, looking much more at health as an integrated approach rather than in silos, as they are called. As I said, more of the same, lobbying at an international level, but also at a country level. We know that there has been a shift over the last few years towards budget support, and I believe that that has a lot of advantages in many areas, but when you are giving budget support there is also a need for very good technical knowledge at a country level so that you can enter into negotiations at a country level and be seen as credible in those negotiations with government, so that you can actually influence policy at a country level, so that the budget support is well spent, but also keeping up technical support for countries that do have budget support. In the more neglected or marginalised areas, such as youth, for example - I use youth as a marginalised area - we often think of neglected or marginalised groups in terms of commercial sex workers or males having sex with males, but youth are quite neglected and marginalised areas and often governments are quite reluctant to deal with those areas. Q181 Chairman: The Committee addressed that in our report on AIDS last year, but it is still relevant. Ms Taylor: I think there is still a need for a varied basket of aid instruments at a country level. Yes, budget support, because that has many advantages, but also not forgetting that there are other areas that are neglected which sometimes require integrated programmes to perhaps kick-start or help governments develop evidence in their own country which then they can act upon. Q182 Chairman: Professor Watts, the evidence we have had so far on the general issue of maternal health has been that the cost of accessing health services, particularly if they are of poor quality and a long way away, is high, and also women may not be able to get transport or even have their own money. Is this the same problem - that access to anti-retroviral drugs or even the knowledge that you have a problem is exacerbated by the fact that there is no infrastructure? Does it bring us all back to that same problem? Professor Watts: I agree, there are large issues around infrastructure, accessibility, weak health systems. I agree completely with my colleagues. The point that they have not touched on which I think is also important to consider is the gender issues about the barriers that women face in terms of actually getting HIV tested. You might have a woman coming to a facility but being too scared to find out her HIV status because the implications of knowing her status are very scary for her. She might fear violence if she does find out that she is HIV positive, and what we see from prevalence surveys in low and middle income countries are figures like one in three women are experiencing physical or sexual violence by their partner. This is a very common reality and, even if a woman is not in a violent relationship, that fear of violence is often very much there. Thinking about how we can strengthen health systems, a component is to try and think about how we can support health workers to start talking about these issues with women. There are some research studies talking about increased experiences of violence for women who test positive. Often this is a continuation of previous violence that is happening in their relationship. How can the health sector be involved in engaging with women around these issues? Q183 James Duddridge: Of the women that do go along to get tested, what percentage manage to do so without their partner or close community actually knowing? Professor Watts: I do not know the figures on that, but my sense (and my colleagues can correct me if I am wrong) is that if you are thinking about antenatal settings, women are getting tested on their own, they are not there with their partners, so there is quite an important opportunity there, and health workers are being trained in counselling around HIV; they could also be receiving training around gender, around violence, how to respond if a woman fears violence, what are the issues around how to disclose and think about the procedures around disclosing in a safe way to their family, to the community? In terms of how many women succeed in doing that, I do not think we have figures on that. Professor Godfrey-Fausett: No, but I think the point is well made. I think one of the advances, perhaps, that has been made in the HIV testing field is to encourage more family-based and couple-based counselling where both husband and wife might know their result together, because it allows one to negotiate and to think about it. The danger for a woman who finds out she is HIV positive, if she discloses that to her husband or to her sexual partner, is that he will often assume that she brought it into the relationship, whereas, of course, who knows what the real story is and how it came about. I would certainly agree with Charlotte that many women do not disclose their status. I think increasingly, to come back a little bit to the question - I am sorry, I cannot remember which of you posed it - of whether it is the difficulty in getting to the health centre, certainly that is part of the issue, but the fact is that technological advance has meant that the technology of HIV testing is extraordinarily straightforward now. You can have HIV tests that do not need to be stored in a fridge, that are accurate, reliable, work in 15 minutes on a spot of blood that is put on the filter paper, on the stick, and give a reliable test. So many women are passing into antenatal care - though by no means all - and of course we should be pushing rates of antenatal attendants and skilled attendants up, but many more women are having a skilled attendant in attendance at some stage during their pregnancy and yet many of those same women are not being offered an HIV test, which could dramatically reduce the chance of their infant being infected with HIV. HIV in children virtually does not exist in this country now. Children are not becoming infected because of a policy of routine screening of all women, whether they are thought to be at risk or not, and they will all have an HIV test, routinely, unless they specifically say, "You must not test me for HIV." The same policy is gradually being rolled out across most other countries, a provider initiated HIV test. Again, the traditional approach to HIV testing has been much more softly, softly, has been based very much on being really sure you want to know your HIV status because there are risks associated with that; whereas I think the system is changing now so that in many antenatal clinics the aim is that women should routinely be offered an HIV test unless they say they do not want to have an HIV test, and then, depending on the results of that test, a number of other actions follow. Can I add one extra thing that came out of this: the role of men. We talk about the prevention of mother to child transmission; in our Technical Review Panel at the Global Fund we like to try and think about parent to child transmission, because this business of involving the father or the sexual partner is extremely important in the whole process. The first aim, of course, is to prevent the mother from becoming infected with HIV, which also has a lot to do with the partner's behaviour. Specifically there are examples where sexual intercourse during pregnancy is seen as taboo or is not permissible in many cultures and, as a result, there is some pressure on the man to seek other sexual partners during pregnancy, and, of course, that puts the man at risk of acquiring HIV infection and we know that the period shortly after acquisition of HIV infection is the most infectious period. So a man who goes and acquires HIV infection because his wife is pregnant is particularly likely to infect her when they do have intercourse, and, if she is recently infected, similarly, studies show that she is particularly likely to pass it on to her infant, because she has a high viral load around the time of infection. One can see a sort of scenario where cultural norms enhance the possibility of transmitting HIV to both the mother and to her infant, and, therefore, we do need to be involving men in the situation. I am sure many of you have visited health centres or antenatal centres in developing countries. They are not at all male friendly. Men are very much kept out of maternity suites and so on because many women are in labour side by side, or whatever, and it is often not seen as appropriate for men to be there. Managing to create a more male-friendly environment is very important, I think. Q184 Hugh Bayley: You have begun to answer my question without prompting. Clearly the health environment is one of the factors that increases rates of mother to child transmission, but even when the woman knows her HIV status there are a number of simple, cheap, easy to use in developing countries, clinical interventions that can dramatically reduce the risk of transmission at birth. Why has the spread of that knowledge, the use of that knowledge, in developing countries been so slow and what can be done by DFID to speed it up? Ms Taylor: May I just make a quick point on another question before I answer yours. I think we sometimes fall into the trap of thinking about PMTCT as only the third of the four prongs. PMTCT is not just about pregnancy and HIV testing in pregnancy and the use of anti-retrovirals, et cetera. PMTCT starts in actually ensuring that women do not become HIV positive whether they are pregnant or not. That is the first issue. It also involves women making reproductive health choices: "Do I want to get pregnant? If I do not, how do I ensure that I have access to services so I can get contraceptives for dual protection purposes: both from pregnancy and from HIV?" Then we come to the question, as you mentioned, of services during pregnancy, but after that there are also services for making sure that the woman who is HIV positive remains healthy, and often women fall off the cliff, as it were, in the postnatal period when they then do not have access to anti-retrovirals, and of course the likelihood that she will die and then her child will die is increased. I just want to mention that when I talk about PMTCT I am not just talking about in pregnancy. To go to your question around PMTCT in low income countries, many low income countries have increased their services for PMTCT during pregnancy and they have introduced antenatal care testing facilities. Somewhere like South Africa, for example, I think probably about 90 % of their primary health care clinics would put their hands up and say, "We provide PMTCT services", but as my colleague said--- Q185 Hugh Bayley: But doing it in South Africa is hugely easier than doing it in Malawi or Zambia. It ought to be, it is a much richer country with a much stronger health infrastructure, more trained personnel, and so on. Ms Taylor: Yes, but still the rates there vary very dramatically. If you look at Cape Town, for example, over 70 % of the women who need it will have it. If you look at some rural areas, you are looking at an uptake of PMTCT as low as 24 %. Offering the service is one thing, but during that period there are a lot of things that can go wrong; so the service may be there but then the woman has to actually go to antenatal care, and over recent years - and I am making a link with maternal health here - the focus has gone away from antenatal care, because in maternal health we were thinking that really lives are saved at delivery and after, which is true, and then there was less focus put on antenatal care, I believe, for a number of years. So, you have a situation where the services for antenatal care are perhaps not as good as they should be because there has been lack of resources and there is not the quality, and then you are asking them to add another service, which is PMTCT. The woman has to agree to actually go to antenatal care (and this is an access issue), then she has to agree to have a test, then she has to have the results and there are rapid tests where she could have the results that day, but often services do not provide that, so she may have the test and then not go back. Q186 Hugh Bayley: By all means explain what the difficulties are, but the question is what can be done by DFID or other agencies to help to improve the state of provision? Ms Taylor: I think perhaps, if I may go back to this, the fact is that we always think about PMTCT as a point of contact, say, in the antenatal clinic or a VCT[5] testing centre. Perhaps one of the things that we could be doing is to look at how we can really expand opportunities for people to actually know their status for HIV. So, rather than thinking of it purely along the lines of those areas, examples would be family planning clinics: make sure they have VCT testing, make sure that ordinary primary healthcare clinics have the facilities for VCT testing and that they do not just have it in one room where people have to actually go to a room but that it is part of the general service. I think it has been a problem that often it is not seen as being an integral part of the health service but something separate. I would say increase opportunities for people to understand their status but at the same time, I think when we are looking at health services, as my colleague said, we forget the community aspects of that, and I think civil society and community groups have a huge role to play in reducing stigma and discrimination against people who are HIV and I think often that is a neglected area. So, it is funding health services to increase access but at the same time ensuring that resources are going to civil society and community groups to reduce stigma and discrimination. Q187 Hugh Bayley: Could I ask further about the balance between prevention and treatment? Are any of you able to give the Committee a ball park figure of the cost per HIV infection avoided for, on the one hand, prevention for women of child bearing age and, on the other, prevention of a mother to child transmission? Which is the more cost-effective? Professor Godfrey-Fausett: I thought they were both same. Q188 Hugh Bayley: Prevention of infection for a woman of child bearing age as against prevention of mother to child transmission at birth. Professor Godfrey-Fausett: I can give a ball park figure for the first. Q189 Hugh Bayley: Perhaps a general cost--- Professor Godfrey-Fausett: Charlotte has done some work around this. Around 250 dollars per HIV infection averted. Q190 Hugh Bayley: ---of general health education. Professor Godfrey-Fausett: There are a number of approaches, but somewhere around that sort of value. That was the value that came out of one of the trials. Q191 Hugh Bayley: The cost of preventing mother to child transmission. I understand it is not just giving anti-retrovirals at birth, it is providing a whole package. Professor Godfrey-Fausett: I am afraid I have not brought the data with me. Elliot Marseille has done work on this. Q192 Hugh Bayley: Behind the question is this. If I was a policy-maker, have we got the balance right between prevention and treatment of an HIV positive pregnant woman and her baby? Professor Watts: I find the comparison a bit hard. You are saying is it better, is it cheaper, is it more cost-effective to prevent an infection of a woman--- Q193 Hugh Bayley: These are always hard choices. Professor Watts: I know. ---or the subsequent transmission to her child, but if we prevent the infection of that woman we also prevent the subsequent transmission to her child. If we are talking about $250 to avert an infection amongst women, then we are actually averting two infections potentially, if she is likely to become pregnant over that period. Q194 Hugh Bayley: Or perhaps, given the birth rates in Africa, more than two? Professor Watts: Maybe that. We have a one in three transmission probability. Q195 Hugh Bayley: The question is: have we got the balance right between prevention and clinical interventions to deal with people who are HIV positive, but rather than just talking in general terms, we have to do as much as we can for both? Given resources is a huge constraint in sub-Saharan Africa, it would be helpful to know how many lives are saved or how many lives avoid infection by one emphasis over the other. Professor Godfrey-Fausett: I entirely appreciate Catharine's comments about not focusing just on the medical side, but I want just to focus on--- Q196 Hugh Bayley: I think it is very important. Professor Godfrey-Fausett: Nonetheless, since you raised the question of treating them, there is no doubt that finding that a mother is HIV positive and giving her and her infant a short course treatment with anti-retrovirals is certainly a very cost-effective way of ensuring that that infant is not infected. If we look at the Global Fund's programmes, for instance, I think that currently 130,000 HIV positive mothers have received such treatment through Global Fund programmes up-to-date, but I think it comes back to your earlier question about what DFID can do and how it is doing it, and it comes to the question of a country's own priorities. When one puts in budget support, then to a large extent the country is deciding what are its priorities, and there are many political pressures on that priority setting process in-country as well and it is not always clear, but the budget is often not supported to the extent that everything they would want to do is being done. Unfortunately, ministries of health and, indeed, ministries of education often get less out of the budget than might be anticipated and, as a result, it is not only that you find that peripheral clinics do not necessarily have the facilities to do HIV testing and offer a cheap way of preventing mother to child transmission, they often do not have antibiotics in the cupboard, they often do not have this or that, and that relates to procurement systems, it relates to delivery systems, it relates to the quality of the roads, it relates to the quality of the staff, it relates to development in fact. So, of course, as one wants to develop, one has to work out how to encourage countries to develop and then they will be much better at that. The alternative is to take a more targeted approach where you say that we think that this particular problem should not be allowed to go on but we can do something very concrete about it, and that tends to lead to more specific interventions around maternal and child health or around tuberculosis or around the delivery of anti-retroviral care. You ask: why are things different? The reason things are different for anti-retroviral care is that the international community made a very strong push and pushed, through the World Health Organisation, perhaps through its Three by Five initiative, and through PEPFAR, which is a very big programme from the American Government for putting large numbers of people on treatment. They were very focused on targets and they said, "This is what we want to achieve"; whereas the targets that were set up at UNGASS[6] to achieve 80 % reductions, and so on, they did not have an action plan to follow. They were aspirational targets and very different from, if you like, a PEPFAR target to say, "We are going to treat this many people with anti-retroviral drugs and prevent this many new infections and this is how we are going to do it." I think I would echo what you said, Catharine, but perhaps I am slightly further on one side than that. You mentioned in your comments the need for multi-modes of funding. My own view is that if you put all the money into budget support, many of these programmes simply will not happen, they will not work. We know that things are extremely difficult in the poorest countries of the world and that those governments have many competing priorities of which ensuring there is a rural clinic where the people do not have much political clout, ensuring that the women there have adequate care, maybe quite low on the political agenda and may not be something that is easily funded out of budgetary support. It is, of course (and I am arguing from the Global Fund standpoint), a good reason for support through a mechanism like the Global Fund that takes internationally recognised priority areas of HIV, TB and malaria, including reproductive health within the HIV focus, and says, "We are going to give money for what the country chooses." It is a demand driven process. The country has to say, "These are the things that we want to do." The Global Fund provides money, if they seem technically appropriate, but also ensures that they are doing what they said they were going to do. So, I strongly support this view that you cannot simply give budget support and say, "We have done our bit and we can encourage the country to go down that way." I think more targeted interventions are much more likely to have an impact on specific disease levels. Chairman: Can I give a time warning here, because we have quite a lot of questions and we are going to run out of time. Can I say to both sides, shorter questions and shorter answers and we will get through them. Q197 Hugh Bayley: How important is it to have a skilled birth attendant at the time of birth to reduce mother to child transmissions, which is extremely important, and do you think sufficient emphasis is given to training staff, paying whatever incentives you need to get them into rural areas, as against some of the other priorities of the Global Fund? I understand the political pressures from the West for universal medication. It is the sort of thing you have just been criticising me for, for looking at interventions and thinking that that alone will solve the problem, but the cost of a life-year gained through anti-retroviral drugs is usually higher than the cost of a life-year gained through preventing, avoiding mother to child transmission. Is it important to divert some of the Global Fund's resources into training of more qualified birth attendants and midwives? Ms Taylor: Yes. Q198 Hugh Bayley: Perhaps we should ask the Global Fund to comment. Professor Godfrey-Fausett: I would also say yes, but I would follow that by saying, and you may think that I am dodging the question, that the Global Fund is a financing mechanism. The Global Fund does not decide what countries should ask for. I would say that the Global Fund, certainly at our Technical Review Panel, are frustrated in the area of mother to child transmission in its broadest sense, that countries themselves frequently focus precisely on testing and giving Nevirapine. We cannot do anything about that, because our job is to recommend to the Board, yes, or, no, on the technical merits of a programme. The Global Fund does not tell countries, "That is what you should do." That is the role, if you like, of the technical partners, of the international NGOs, the people who work with the countries to encourage them as to what they should apply for. Q199 Hugh Bayley: Let me ask you this question. If you had a free hand, knowing what you know having been Chair of this Technical Panel for some time, would you say we ought to be giving advice about the shape of a cost-effective health intervention, a mother and child strategy for a developing country? You cannot control the whole thing, but do you think more emphasis should be placed on this? Professor Godfrey-Fausett: I think that we should be engaging countries in a conversation about what they see as their priorities. I think we should be working hard to build the public health capacity of the countries themselves so the countries do not feel that they are being, if you like, dictated to. It should be that they can enter that conversation in a less asymmetric way than they do at the moment. The more we can build up the ability within countries to have that conversation the better. I would be careful. I would not want to say we should say this is how it should look; one size will certainly not fit all in different situations. Certainly we should be laying out, "These are the possible benefits of things", and letting countries come and say, "Yes, that is what we want to do." Q200 Sir Robert Smith: We have been talking about integration. You have got a targeted fund at the Global Fund looking at specific diseases and then, obviously, the clear links with sexual and reproductive health. From what you are saying though, does the Fund actually take any practical steps to encourage that integration of maternal, sexual and reproductive health into the programme that it funds or are you very much reacting to what is coming in? Professor Godfrey-Fausett: We are a demand driven process. It does not encourage specific things, it says, "This is the area", but it catalyses discussion on those areas mainly through its technical partners. For instance, there was a recent meeting that the WHO (World Health Organisation) organised in conjunction with the Global Fund to which it invited countries and experts to discuss the ways in which countries could apply for money to strengthen their health systems. The Global Fund has always made it very clear that strengthening health systems in order to have some impact on HIV, TB and malaria is an entirely legitimate use of the Fund's money, but to date countries have not availed themselves of that resource as much as they might, maybe because they misinterpret, they say, "HIV, TB and malaria - that is what it is for", whereas actually I think the Fund would welcome a broader base to what countries ask for. In answer to your basic question, the Fund is not a technical agency. The Fund does not tell people, "This is what you should be doing." It says, "Apply to us with what you want to do and, providing it is in line with international best practice, then we will fund it." So I think it is more up to DFID, WHO, more technical agencies, to be encouraging countries with what they could apply for. Q201 Sir Robert Smith: Do you have any examples though of applications that have shown good integration that maybe you could give us? Perhaps not now. Professor Godfrey-Fausett: Yes, there is a number of different ways of integration of different parts. There are certainly programmes. In Malawi there has been a programme that is about healthcare workers at perhaps a more peripheral level; so precisely the point we were talking about earlier of having a more rural-based cadre, resurrecting a lower cadre of healthcare workers with support from the Global Fund to allow the reach of the health system to go further. There are numerous projects that aim to embed within reproductive health services at clinic level the ability to encourage prevention of HIV at that level and prevention of mother to child transmission. I have mentioned that about 130,000 women so far have been treated in such ways, and those are within a large number of programmes across all the regions. I can list a few of them if you would like me to. Q202 Sir Robert Smith: Perhaps you could send them to us? Professor Godfrey-Fausett: Yes. Q203 Sir Robert Smith: DFID is giving £359 million through to 2008 to the Fund? Professor Godfrey-Fausett: Yes. Q204 Sir Robert Smith: But your advice is if DFID wish to see that money go to more integrated delivery it has got to actually speak to the applicants? Professor Godfrey-Fausett: Yes, DFID is in a strong position because it has country programme staff as well, it has people who are engaging with ministries of health, ministries of finance and the technical people on the ground, and if it encourages those people to realise what they can apply for, then the money is sitting there and is largely available. I think that the Global Fund is happy to receive things. This is not a carte blanche. The Fund was set up to make an impact on HIV, TB and malaria, but I think it is very easy to make the argument that investing in improving integration of reproductive health services and HIV, investing in reproductive health services, is very likely to make a difference to HIV and tuberculosis, as we heard at the beginning, and, indeed, malaria. I think all of these, in fact, relate to maternal health in a big way. I think that the argument is very easily made and, providing that argument is made in the proposal and it is not seen that this is simply investing without the link, if the link is made I think it is entirely appropriate. Q205 Jim Sheridan: Can I perhaps address my question to Professor Watts. There is a clear inter-relation between sexual violence against women and HIV/AIDS. Is there any practical example that you can tell us about where you have intervened to try and perhaps stop this from happening? Professor Watts: A recent and quite high profile success was an intervention study that I was involved in in rural South Africa, and that was very much primary prevention. It was in part funded by DFID, where we basically empowered women, both economically and socially. It was working with a very strong micro-finance group and adding on to that micro-finance participatory activities around gender, violence and HIV. What we saw over two years, over a short pragmatic time-frame, was a 50 % reduction in women's experiences of partner violence. It has been a very exciting study and it illustrates the potential. I think looking at development opportunities - in that case we were looking at micro-finance - but adding on issues around gender, around power, and we saw a very synergistic effect that very much resulted in changed relationships, much stronger improved communication and reductions in HIV risk behaviours amongst participants and reductions in violence. Q206 Jim Sheridan: A 50 % reduction. Have you any plans to reduce that even further, or how best could you extend it into other areas? Professor Watts: It is a very good question. I was pretty pleased with a 50 % reduction. For that project it was a small scale thing, and what we are doing now is the micro-finance group is scaling up across the region and we are doing work with them to say, "How do we scale up the gender elements?", but also trying to learn from that about what are the implications for other development initiatives. Are there ways that we can take some of that learning and apply it in other settings? It is not something that is done very much though. There are these promising initiatives, and I would be very much encouraging DFID to be trying to learn from that in terms of their broader activities. Q207 Jim Sheridan: You said DFID part-funded it. Professor Watts: Yes. Q208 Jim Sheridan: Who else funded it? Professor Watts: Ford,[7] CEDAW,[8] a range of the more progressive donors essentially. Q209 John Bercow: Apologies, Chairman, to you and our witnesses for arriving late. Professor Watts, I am very interested in this field and, in particular, in the reference to the survey that you have just made. On the assumption that predominantly gender-based violence is inflicted by the existing male partner rather than by somebody else in the household or in the village or neighbouring area, was it the working assumption of that study that both partners should be involved so that the men, who are after all the culprits, have some purchase on the training, the therapy, the advice, the exhortation, whatever misogyny or different tactics are involved? Professor Watts: A good question. In that particular study we very much focused on women, but it was very context specific; so in this setting it was very much that men are quite migrant, they are going to Johannesburg to work in the mines and coming back. We started off wanting to work with both men and women, but men are much less accessible and so when we were talking to women, they were saying, "No, work with us and then we will take issues to the community." As part of that work there was a very strong emphasis on social mobilisation and part of the lower group activities, part of the micro-finance activities, led to those groups taking issues to local leaders, going out and talking to youth, to boys, and so it was working through women to reach men. There are other examples of programmes that focus exclusively on men that are also very promising in terms of promoting alternative models of masculinity, really engaging on: what does it mean to be a man? To me it is a challenging issue, but actually fundamentally it gets at what we need to be looking at around being a good father, about not coercing sex, about issues of HIV prevention, and where you do see evaluations of those projects they are quite promising and they lead to multiple benefits. Q210 John Bercow: Of course, from our visits to several different countries in Africa, we are well familiar with the phenomenon of substantial periods of separation between male and female partners, with the man typically going to work in one or other of the big cities a substantial way away. It would be of interest to me, and it may seem academic, but I think it would nevertheless be potentially relevant to know, whether the incidence of gender-based violence is that much greater, and therefore the problem is that much more acute, in those households where there are long periods of separation and, to put it very bluntly, Professor Watts, the male partner, the husband, comes back and then, if I can, as I say, put it very explicitly, thinks, "Well, I have got to make up on lost time." However intolerable culturally that is to us, it is a reality, is it not? Does that tend to have an impact? Professor Watts: It is a good question and one we have not looked at. When we looked at the level of violence in those populations, they were pretty similar to other areas in South Africa that have less mobility, but in a way you think it could be lower because the men are not around that much. I cannot say yes or no. Q211 John Bercow: On the whole question of the cultural norms which tend to influence behaviour, do you or others in programmes of this kind tend to accept male resistance to condom use as a given and feel you have just got to work round it or are you, where it is, frankly, prevalent, trying, at the risk of being accused of cultural imperialism, to say that this really will not do and there is a better way? Professor Watts: I think in the end, in terms of this project, if I think about this project, the focus has been on everything, so you want to reduce risk behaviour, you want to try and challenge the acceptability of men having multiple sexual partners, extra-marital relationships, you want to improve communication in the household, you want to empower women to be able to more openly discuss condom use or other health needs and you also need to be investing in alternative technologies. I think you need to be pushing on all fronts but recognising that those underlying issues around concepts of masculinity, around violence are something that you have to be quite explicit about and we have to engage with in a meaningful way. When you look at HIV messaging, my frustration is that there is this sort of implicit assumption that most sex is consensual, or that sex is consensual within loving relationships. That has become very distant from the reality of many people's lives and we have to start thinking about how do we deal programmatically with those uncomfortable realities that you are referring to. Q212 Richard Burden: John has covered many of the areas I was going to explore with you. Perhaps I could focus a little bit more on DFID's role both in relation to the South African project that you have been talking about and also some of the projects that have been done in relation to gender-based violence in Nepal. What lessons have you learnt from those in terms of how DFID itself could make a greater contribution, could scale up and apply any lessons elsewhere? Professor Watts: I think there is a number of different levels where DFID could be making an important contribution. At an international level, for example, in the recent UNAIDS[9] costing of resource needs for HIV, for the first time they included responses to gender-based violence and $2.2 billion was included in those projections. I think DFID has an important role at that international level pushing for there to be investment in that, and when you translate that into a national level, those resources are going in, explicitly addressing some of those links between violence and HIV. One of the main challenges in terms of what do we do is the limited evidence-base, and what I see is a number of very promising interventions that do show we can have quite large impacts over short periods of time but I can count the evaluation studies on one hand, and so we do need to build an evidence-base about what are the approaches that work with men, with women, what is the role of the economic components versus addressing issues around alcohol, fundamental attitudinal issues around the acceptability of violence. From the projects that we do know, where there is success, I think the core elements are that there is a meaningful engagement with communities, with men, with women, over time, and so in terms of programming, I think it is looking at what are opportunities of, say, working within the development sector or even within the health system; where an agency is having an on-going relationship with the community or interaction with men and women in that community, to say how can we explicitly bring issues around gender and HIV and violence into those programmes. Q213 James Duddridge: A few questions for Catharine Taylor. The first one is around the interaction between sexually transmitted diseases and HIV. In particular what can donors do to integrate the diagnosis and provision of treating the two conditions together, because that seems to be the thrust of what you were saying: a more integrated health system? Ms Taylor: Yes, as you were saying, there is a lot of evidence about the interrelationship between HIV and sexually transmitted diseases. I think, again, look at reproductive health in its broader sense. For example, you often find that STI[10] diagnosis and treatment is actually very poorly implemented at a clinic level and often is not really seen as part of the package. Again, from personal experience here, often in countries you go to the dermatologist if you think you have got one of those diseases, as it were, and so often health services are not fully equipped to deal with the diagnosis and treatment of STIs. So I think ensure that it is part of the package within the health service. Q214 James Duddridge: The donors' funding money in that direction though: is the message getting through to donors? Ms Taylor: Yes, I think the message is getting through to donors but I think often there is a disconnect between what the donors are saying at a policy level and the implementation of that on the ground. I think there needs to be not only a lot of emphasis on policy but also looking at integrating and implementing good services on the ground. I think there is still that disconnect. If you talked to anybody in the Ministry of Health they would agree with you that STI diagnosis and treatment is a very important aspect of care, but if you go to any clinic it is not happening. So it is really to ensure that the implementation is there as well as the policy. Q215 James Duddridge: Have we seen any benefits yet of the integration within the DFID team of the HIV/AIDS policy group and the reproductive and child health policy group, or is it too early to see the benefits? Ms Taylor: It has only happened quite recently and I think it is possibly too early to see a lot of the benefits, but I do see in my discourse with advisers, et cetera, a lot more discussion around the integration of reproductive health and HIV, certainly. The fact that the maternal health adviser is not in that group but, I think, in a separate group perhaps needs to be addressed so that she has the opportunities to interact with that group as often as possible. Q216 James Duddridge: Was that issue raised when the integration was talked about? I had not appreciated that the maternal health side still sat outside that group. That seems to be an anomaly. Ms Taylor: It is my understanding that that is the situation. I cannot say what the discussions were when the decisions were made. If I understand correctly, I think that she is in the Scaling up Services Team, so she is very much within the health systems aspect of it, but I think a lot of linkages need to be maintained. Q217 James Duddridge: We will make sure we go away and check the facts. Ms Taylor: Yes. James Duddridge: You said you are unsure, so we will go away and check. Thank you very much. Chairman: Thank you very much. The general theme of the evidence we have taken so far is a rather big one, which is that you can only tackle these problems if you have an integrated health service. We have enough trouble with the Health Service in this country. I am not going to ask you to answer the question now, but if you have any thoughts at the intermediate level, how you get from having a proper health service when there is none to ensuring that, nevertheless, there is practical access to essential services. That it what we are struggling with, because we are not getting anywhere near the MDG[11] on maternal health. It has been suggested to us that a lot of that is cultural, attitudinal and gender-based, in other words women's low status - I guess one is trying to fight for that - but if you pull it together and say it is all part of the general health of people of both sexes and all ages, you actually start to get it into a situation where it does not get that degree of discrimination. If you have any thoughts, having exchanged this evidence with us, that would help us in that direction to make some constructive recommendations, because we have got this big vision and a huge gap in practical terms in relation to which, certainly for me and other members of the committee as well, we are struggling to find something useful and constructive that can take us from where we are. May I thank all three of you. Q218 Hugh Bayley: Can I ask for one further bit of information after the event. To go back to the question about the relative cost of preventing mother to child transmission, you gave a figure for prevention, but if you could come back, if you could find a figure for mother to child transmission and also find a comparative figure of the cost per life-year gained through anti-retroviral therapy, I think it would be a very useful indicator of relative costs of interventions for the Committee. Professor Godfrey-Fausett: I would be happy to, and I will certainly try and find those costs, but I would like to preface that with a comment to be cautious in the interpretation of these data. I think we possibly met in Zambia on one occasion some time back. I lived in Zambia at the time before the anti-retroviral drugs became available; I have been visiting Zambia continuously. I lived there from 1992 to 1998 and have been visiting two or three times a year ever since. I have seen the emergence of what has happened. There is no doubt that the provision of anti-retroviral drugs has a far greater impact than simply those people who are being kept alive. You can imagine that to work in a clinic where, of the people who come to that clinic, 50, 60 sometimes 70 % of the adults are dying of HIV. If you do that in an era before anti-retroviral drugs, your morale is zero. You have nothing to offer people except the home-based care. You then transform the situation by saying: "Actually now this is how we can do something about it", and you can see the change in the way clinics are performing in Zambia now, not just in delivery of ARVs[12] but in terms of a feeling that actually we are delivering healthcare. For the healthcare workers' morale, esteem, situation in the community, it leads to cleaner clinics, so I think it is much more transformative and I think it can be dangerous only to consider the costs and immediate, medical benefits. Because anti-retroviral care is widely available now, in all districts in Zambia, for instance, and this would be true in many other countries - there is some access, people know about it - that in turn transforms attitudes to HIV itself. It means that people are much more able to name the beast because they think, "Actually I can get treated if it turns up." It alters things in ways that are every hard for an economist to put down on a sheet of paper and probably, although it is hard to prove, has a major impact indeed on prevention, because if, as a result of reducing stigmatisation around HIV because more treatment programmes are available, women feel more able to discuss it with their partner in a less frightening way, that may well have a beneficial impact. Whilst there are certainly figures out there, I would have considerable caution in using those to make policies. Of course they are part of the decision-making and the policy-setting agenda, but I do think they need to be taken quite carefully because there are many intangible benefits that are very hard to put down as a cost. Chairman: If you feel able to attach a couple of practical case studies to the figures, that might help. Thank you very much indeed.
Examination of Witnesses
Witnesses: Dr Gill Greer, Director-General, International Planned Parenthood Federation (IPPF), gave evidence. Q219 Chairman: Good morning, Dr Greer. Thank you very much for coming in for the second half of our session. Again, briefly for the record, would you introduce yourself? Dr Greer: Thank you very much indeed. I am delighted to be here and thank you for your time and interest. I am Gill Greer. I am the Director-General of the International Planned Parenthood Federation. We have 152 Member Associations affiliated with us and we work in 180 countries in delivering comprehensive sexual reproductive health services, providing education and information, including sex education, and also in advocacy with civil society, with governments, with ministries. Thank you very much indeed for this opportunity. As you can tell, I am a New Zealander, so let me know if there are any problems with translation. Q220 Chairman: Thank you very much. Those of us in Scotland will have no difficulty! The situation with MDG 5, the most off-track of the Millennium Development Goals, is that, as we move off track, we seem to increase the targets and we have actually added to it and embellished it and made it more difficult even though we are actually drifting away from it. DFID, I understand, has been involved in developing the new target in spite of the fact that we are not making progress on what the original target is. I think we have now incorporated into the target addressing the adolescent birth rate, antenatal care and the unmet need for family planning on top of the original targets. What do you think the barriers are both for achieving the original target and how much more difficult is that target going to be now we have extended it and expanded it, and what is your organisation, the International Planned Parenthood Federation, recommending about how we can actually take on that challenge? Adding new targets when you are not achieving the first ones does not in itself seem to change the situation. Dr Greer: Thank you very much indeed. It is our conviction that we will not achieve the first target or, indeed, MDG 5 or, indeed, any of the MDGs if we do not address the issues that are covered by the new target. We are very grateful, in fact, to the UK Government and DFID for supporting the call for this target. Originally, you may know, we called for a ninth Goal, because we believe that of all the important international meetings, declarations, conventions of the 1990s, the one that was left out when it came to the MDGs being finally framed, which is so essential for maternal health and for health and well-being generally in development, is that of universal access to reproductive health, which was the Cairo goal from 1994. I believe that if we really are to meet the goal and the targets (the target now has a contraceptive prevalence rate indicator), then we will make progress on the first, but, I agree, it does not seem to make logical sense when you first look at it. Q221 Chairman: I am not deploring the targets, it is the practicality, and that is really the point you are trying to press. For example, if you take the new targets, how are they going to be measured? How are we going to determine that we are reaching them? Is the information that exists and the method of collecting facts and figures in developing countries adequate enough? When we were having our preliminary discussion, I was pointing out that the figure for the number of women who die in childbirth is very precisely stated in a number of publications. In spite of the fact that we have had evidence that nobody actually knows what the figure is because there is no satisfactory method. The question really is: once you set a target, how do you actually define what the situation is in individual countries and how do you then determine how they are progressing towards meeting that target? Have you got any constructive recommendations? Dr Greer: I think there are some very interesting questions embedded in there. I do agree that trying to get really clear data is a major problem in itself. I am very interested in seeing in the IHP[13] Plus that there is going to be a component of data analysis at the very beginning. I think it is very important to try to build (and this is perhaps a role for DFID to consider) the in-country national competency in building statistical surveys and data collection so that it is sustainable. If it is always done by people coming in from the outside and, even though we do, as we can, encourage people to report against those MDG goals and other UN commitments, it is very difficult. I think, too, just from our own experience, we have recently put in place for all of our Member Associations reporting for a global indicator survey against 30 indicators, which include sexually transmitted infection, sexuality education, maternal health, HIV-SRH[14] integration, and so on. I know the difficulties that our Member Associations experience in trying to keep that data, but I am also seeing that it can be done. I launched a project in Kampala for HIV/AIDS and sex workers recently and, two months later, was able to get a very clear picture of the work that they are doing in broader primary care but also specifically related to maternal health and HIV. So I think there are some models there, and I know that the ideal is civil registration. When it comes particularly to maternal health, we are a long way from that in many places, but I think we can move towards it, and I know that there are some new models around too that the UN are considering as possible ways of measurement. I think it is difficult, particularly in areas to do with this area of health, because often it takes so long for the outcomes to become obvious. We can count inputs and outputs, but the outcome is much harder. Q222 Chairman: When we were recently in the highlands of Vietnam we were in a village where the norm was for girls to get married as young as 13 or 14 and very quickly have families. That is obviously one of the new areas, which is that girls are getting married and having children younger, when they are not fully developed, and that is a contributory factor. How can you change that if you have got an embedded cultural situation? How do you actually get across that you are putting your community and your people at risk for your cultural reasons that are actually not healthy? Dr Greer: I think encouraging governments to invest in girls' education and women's literacy is critical to that. We have enough data that shows the impact of that on later first birth, on child spacing, and so on. There have been some very interesting projects in Bangladesh and Nepal, where community groups work with parents to encourage parents to keep their girls at school. Also, when we look at the impact of free lunch schemes, which of course was one of Jeffrey Sachs' quick wins, we know that it actually works - the same with school uniforms - it encourages and motivates parents to keep their girls at school. We know that for every year that they are in school there is considerable impact on both the timing of their first child, and the number and the spacing of their children which will then impact, of course, on maternal health, plus their ability to understand nutrition, risks to themselves in pregnancy, have some sex education. Q223 Chairman: It is a chicken and egg situation, because if the girls are at home having babies they are not in school getting the education to tell them that is what they should be doing? Dr Greer: Indeed, one of the drivers of unsafe abortion is that in many countries a girl must leave school if she is pregnant, there is no way that she can continue her education, and in some cases that is likely to drive that issue, but I think there are laws and we need to encourage their implementation and enforcement. Nepal is an interesting example. Chairman: We might come to that later in more detail. Q224 Richard Burden: I would like to ask you one or two questions, if I may, about the unsafe abortion issue. It is obviously a very big question. One in eight of the 600,000 women who die from pregnancy-related complications somehow seem to have a link through to abortion-related complications. I want to ask you in a minute about the substance of that and maybe what we can learn from that and policy directions. But going back to the thing you were talking about before about the data itself, apparently the figures there have not particularly changed since 1990 and a question mark has been put to us particularly about the reliability of that data. Do you have anything to say about that and is there anything in relation to unsafe abortion where we can improve the evidence-base? Is it easier, is it more difficult or is there anything specific about the evidence-base there that we need to do to get more reliable information? Dr Greer: If I could go back and say that, if we start by recognising the fact that 200 million women cannot access modern, effective contraception and, therefore, we have high numbers of unplanned pregnancy, some 86 million; there are 40 million abortions a year, of which 20 million will be unsafe, it is not surprising 70,000 die as a result. Yes, we will not have exact figures and, as long as it remains illegal in so many countries, we will continue not to have exact figures, I believe, because very often it will be laid down to either the immediate cause of death, whether it is haemorrhage, anaemia, whatever it may be. It is going to be very difficult. It is hard enough to get figures for maternal deaths as it is let alone for those deaths which occur as a result of unsafe illegal abortion. I think that is enormously difficult. What can we do? At the moment, for example, we have just developed a tool which we are sending out to all countries and we are working also with FIGO[15] to get them to analyse exactly what the law is. One of the problems is that in many counties the law does allow abortion under very certain restricted circumstances, but in fact neither the providers nor the women themselves often know to what extent it is available and allowed or how to access it; so we have to have really clear data in relation to that and I think then build on that to get the kind of data that gives us a clearer picture. We do know in some countries like Uruguay around 46 % of maternal deaths are caused through unsafe abortion. Q225 Richard Burden: Obviously there is a real issue in countries where it is illegal, or near as damn it illegal, to get at that kind of data, and there are all sorts of issues around that, but are there any countries, even where it is illegal, where in terms of collecting data there is any best practice that could be applied, or pressure could be applied elsewhere? Dr Greer: There is no doubt that through menstrual regulation (for example, manual vacuum aspiration) there is much more done than people are aware of, but providers in those countries where it is illegal and where there are harsh penalties of imprisonment, both for the woman and the provider, to a point where sometimes providers will not even address issues of a possible ectopic pregnancy because they are worried about being accused of carrying out an illegal abortion, are not going to record in any way that could be publicly disclosed what the numbers are because of the risk to themselves and their clients. That is why I say we have to work in every way we can to advocate for law change. I want to congratulate the United Kingdom and DFID for the Safe Abortion Action Fund, which we manage and distribute. Out of the first year, I would just like to say, we have distributed to 45 organisations and 32 countries for two-year projects, and they cover a range of projects, and it is that kind of funding which enables us to work as advocates, not us but, in fact, civil society, and even sometimes ministries, to work together on these issues. Q226 Richard Burden: I think Jim will be asking in a minute specifically about the Fund. Could I perhaps ask more broadly as far as IPPF is concerned, as well as the use of that Fund, first of all, what are the areas that you are involved with in terms of reducing maternal deaths through unsafe abortion, and where do you think we should be going? Where should we be moving next on that? What are the kinds of things we need to be doing? Dr Greer: We need to upscale family planning, for a start, as part of a comprehensive sexual and reproductive health continuum of services and information. We have already talked about the unmet need of 200 million and I have read one figure that would suggest that maternal mortality could be reduced by 20 % simply by meeting that need. Another is to encourage, for example, a focus particularly on the young. We know that girls between 15 and 19 are twice as likely to die as those above 20 from pregnancy-related complications, and we have the biggest population of young people that the world has ever seen in the world's poorest countries right now, so we must focus on that, and that is part of the work that we are trying to do, integrating sexual and reproductive health and HIV and AIDS and trying to make sure (and this is again something that your Government and DFID can do) that civil society is at the table when planning and budget decisions are discussed and that these issues, which have been neglected tragically for so long, are now included at a time when there are so many competing priorities. When, for example, the Global Fund is being considered - whether it is SWAps,[16] PRSPs,[17] budget support - we are concerned, and every donor government I have spoken to so far continues to be concerned, that issues of sexual and reproductive health and maternal health will fall off the agenda if, indeed, to whatever extent they were on the agenda to start with. So, for us, advocacy with our Member Associations so they can convince others in the development community of why these issues are important to development as a whole and then, together, convince their governments so that they too, not just donor governments, play a part in recognising that they need to implement their commitments, they need to make sure that these are part of the discussions that they have with donors when, for example, they are developing national health plans, national AIDS and development plans, when they are developing infrastructure plans. This needs to be integrated into all of that. So, that is part of what we are doing, advocacy as well, and trying to get investment by local governments as well, but also working with sexuality education and trying to reach the poorest of the poor, the rural, the urban poor, the most marginalised - sex workers, men who have sex with men, young, gay, lesbian and bisexual people. If I can just comment, there was a question earlier about sexually transmitted infections. Can I say that that is a major part of our work, and I believe the stigma surrounding STIs is as great as that surrounding HIV/AIDS, and that impacts on maternal health and on HIV and AIDS obviously. Q227 Jim Sheridan: Can I just probe you on the Safe Abortion Action Fund and thank you for your kind words about the funding from UK taxpayers through DFID. Experience tells me that is usually a code for: "Leave my fund alone and go and look somewhere else if you want to make cuts." Against that background, can you give us any tangible evidence that the Fund that the taxpayer is paying for is going to the people it should be going to and can you justify the amount of money you are receiving just now or, indeed, an increase in it, but, most importantly, can you tell us exactly how this money has been spent and has it been targeted at the people that it should be targeted at? Dr Greer: To begin with, we were not sure how much the amount of the Fund would be because we had the original funding from the United Kingdom, who then worked (and we supported them) with other governments to encourage them to contribute. In terms of process, I think it has been rigorous. To begin with we advertised the Fund mostly through civil society networks, we did not go much beyond them. We had over 170 applications in that first round, and I think that sheer number in itself speaks for the fact that there is a real need for this. There was an extremely rigorous process of technical review to come up with those 45 final projects, and those were independent technical reviewers who did this on an entirely voluntary basis and then met and discussed this face to face. DFID itself and the other donor governments are represented on the panel and we believe that this helps to ensure good processes. Clear expectations are in place for monitoring and evaluation and, of course, we are only at the beginning of the projects now being implemented, but we are already noticing in terms of, for example, demand for supplies and other things coming through, that the progress is moving rapidly and we will get regular reports on that; but I have brought some further information on that for you as well. Q228 Jim Sheridan: When will you be in a position to give us clear evidence that the number of women who are dying from unsafe abortion is decreasing? Dr Greer: We will have the first reports back on the projects within a year after they started. To what extent that will demonstrate that, I cannot honestly say because, for example, if it is an advocacy campaign, that will have taken time to put into place, to implement, to see if there is any change in the law. If we think of Nepal, our association began advocating for law reform on abortion in 1971, and the law was finally changed in 2002, so outcomes are not as quick as you and I would want, but I am sure that these are good projects and I am sure that they will the give us results. Q229 Jim Sheridan: Is there an audit trail to ensure that the money is getting to the actual people it is meant to go to? Dr Greer: Absolutely; yes. Q230 Jim Sheridan: Is it evaluated? Dr Greer: There will be an audit trail. We do not allocate funds without a very clear audit trail on expenditure and very clear reporting dates and guidelines for that. Q231 John Bercow: Dr Greer, forgive me if I am being abnormally slow on the uptake, but as of this moment it is not clear to me what is the balance of your work as between advocacy of safer abortion in countries where it is already legal but often unsafe and advocacy for legal abortion in countries where it remains illegal, the latter being of notable significance when one considers, as we are advised, that no fewer than 69 countries, representing just over a quarter of the world's population, currently ban abortion? Dr Greer: Any organisation that is a member of IPPF works in some five priority areas, and they are expected to do something in all of them and the objectives are laid down. These are HIV and AIDS, access, which includes in particular maternal health and wider access to a range of services, adolescents, abortion and the last is advocacy. In the case of the Safe Abortion Action Fund and, indeed, our own Member Associations, they are expected to report back annually as to what they do in abortion-related services and advocacy in relation to abortion. So there are two components in that which they report on. Given the figures you have just given, more work is done in relation to advocacy, in particular making sure - and this is the reason for the new tool that we are sending out - what the law is, are providers absolutely aware of the law, are women aware of the law and, even in countries where it is legal, how accessible is abortion because of transport costs, service coverage, stigma, a whole range of issues, is a major part. We believe that there is not a country in the world, including this one, where our Member Associations cannot continue at least to work in advocacy. When it comes to services, many will give options counselling only, and it is because of that, of course, we do not receive US funding, as you will be aware. Many will refer and some will carry out abortions, either medical abortion or surgical abortion, depending on each country context and the capacity of the Member Association. So, it is hard to give an overall figure, but I can certainly send you the data for the percentages in terms of both service delivery and advocacy if that would be useful. Q232 John Bercow: The prohibition on American funding is not of very long standing, is it? It depends what you regard as long standing, but, for the avoidance of doubt, that prohibition on American funding was applied under President Bush but did not apply, presumably, under President Clinton. Dr Greer: No, it did not under President Clinton. Q233 Chairman: It does not apply to the Gates Foundation, just to the American Government. Dr Greer: No, American funding. Q234 Chairman: Any American funding? Dr Greer: Access to American Government funding, for example from USAID. Q235 Ann McKechin: You mentioned recent legalisation of abortion in certain Asian countries such as Nepal and Bangladesh. I wondered to what extent you are gathering statistics about the incidence of female foeticide because of gender-based abortions and whether or not this is becoming an increasing issue? Dr Greer: We are aware of the issue and of the concern about the issue. I suppose, for us, it is another sign of male preference and often of the invisibility of women which, I think, impacts on their lack of education, their lack of empowerment, the lack of maternal health. It is very difficult indeed to, again, get accurate figures. I must say that the expansion of medical abortion, which many would see as the greatest technological development in the area for many years, will make it even more difficult to be aware of the extent of this; if women really are eventually able to take absolute control of this with minimum input from health providers, although that might not necessarily be advisable, but that may be the way it is. There is no doubt that it will have an impact where you get a major imbalance, and I think China is recognising it, India is recognising it, but at the same time a woman who has been raped or has seven children is not necessarily going to want to have an eighth and the sex of that child will not be what is primarily in her mind, and I think we need to be aware of that and also aware of what it is that pressures a woman to undergo a sex-selective abortion. It is not a simple matter, and I think there is enormous pressure on women to do that, where that occurs. Again, I think it is very much about addressing issues to do in particular with male preference and instead valuing women in every aspect of life and making that value visible. Q236 Ann McKechin: We visited Vietnam recently and someone said to me that this incidence actually increases as people become wealthier; so it is not necessarily directly related to poverty or lack of economic power but becomes a question of status. We obviously talk about the interventions of providing health facilities, trained attendants, contraception, but do we actually do that at the expense of addressing some of the more difficult social and cultural issues which underlie some of these problems and which, if you do not address them, are likely to become the dominant factor as countries develop? Dr Greer: I have heard a similar statement. At the same time I have also seen presentations which have talked about rural peasant populations believing that it is only if they are buried by their sons that they can meet their ancestors. So I think we do see it at both ends of the social continuum. At the very core of our work is a Charter of Sexual Reproductive Rights which we developed 10 years ago which is translated into many languages, well over 30 anyway, and is used by all of our Member Associations, and we are currently updating that in a Bill of Sexual Rights, recognising that although sex precedes reproduction it is also often separate from reproduction and we need to be making sure that we are addressing that end of the continuum as well. Part of our work, whatever we do, is to make sure that services and information have a strong rights-based approach, that a gender equity perspective is in everything we do, and it includes addressing gender-based violence, domestic violence, violence during pregnancy, and that women's empowerment is seen not as the disempowerment of men but the opportunity for both to be equal, to strengthen families, to strengthen communities and be strong together, and so a lot of work with men, in particular, to help them recognise both the importance and the contribution of women and girls but, second, the impact of disempowerment and violence against women, and thirdly the importance of their own good health. Q237 Sir Robert Smith: You have already mentioned in your evidence that if the unmet need for contraception was satisfied maternal mortality would be dramatically reduced. What sort of effect have the current pressures for funding for HIV services over the last decade had on the availability of funding for family planning and other reproductive healthcare? Dr Greer: I think it is clear, if we look historically at funding levels, that funding for family planning has decreased in proportion as funding for HIV and AIDS has increased, but having said that, I do not see it as either/or. I can absolutely understand, when we see how relatively few still are able to be on ARVs, for example, that there is an absolute need, and the virus will mutate and it is always one step ahead of us. That is critical, but so is funding for family planning. It is when we hear, for example (and figures were quoted earlier), that less than 16 % of women who are pregnant have had voluntary counselling and testing for HIV. This is a major project of ours to push that out across the globe now. I am a woman. I walk into a clinic. I want to know how to manage my contraception. I want to space my children. I may also have an STI, unknowingly, and in many countries, as you and I know, the greatest risk of HIV is to be young and married for a woman. It is the greatest risk for HIV altogether. So I may also have HIV. I have to be treated as a whole person, and so, for example, we believe that the Global Fund needs to be far more proactive in ensuring that the broader continuum of sexual and reproductive health, including family planning, is included, and some of that is to do with the country mechanisms and what comes forward, of course, to the Global Fund, but we would like to see a greater proactive approach in that way. Q238 Sir Robert Smith: You think the Fund should actually be asking---. You heard from the earlier evidence maybe that the Fund was saying, "We sit here. We have got the money. It is up to the applicants to recognise they can unlock that connection." Should DFID be doing more to encourage applicants? Dr Greer: I absolutely believe that DFID should be doing everything it can to encourage the involvement of civil society and women's organisations, for example, at country level in the mechanisms that are related to any funding at all and, in particular, to make sure that sexual and reproductive health and HIV and AIDS are integrated. There are many women who will not go to an HIV and AIDS clinic in Vietnam - you have been there, some of you; you will understand that - for testing or to a sexual health clinic, but they have been for a long time to a family planning clinic or to a primary care provider. There is no stigma with going; it is acceptable to plan their family. They feel safe; they feel secure. They need to be able then to access voluntary counselling, testing, prevention of mother to child transmission, all of them, the full requirements. Q239 Sir Robert Smith: One of the other barriers you also touched on to accessing family planning is pressures from society, male dominance, and so on. What more can be done to relieve those pressures, to actually enable women to access family planning? Dr Greer: Again, I think, education, both of men and women, plays a major role. Once one generation of women is educated, then it becomes far more acceptable in the next generation of both boys and girls, men and women. Secondly, I think we have to invest more in outreach and outreach is expensive. We know, for example, from work that we are doing with displaced people, with refugees, we must reach out to those communities. There is no way they can ever find their way to a clinic - that is a static clinic. That is part of it. Secondly, we need to use the media more. We need to use interactive technologies. We have sitting in the room somebody who has done some fantastic work with our Ethiopian Association using film to demonstrate both safe birthing but also to help to build education around these issues. There is a whole range of ways in which we can move, we just need to scale them up, and we need to measure their effectiveness as we go. Q240 Ann McKechin: You mentioned how it took over 30 years to legalise abortion in Nepal. How was it eventually achieved and to what extent did civic society play a role in that? Dr Greer: As I said, they held their first workshop back in 1971. After Cairo in 1994, they held another series of workshops with parliamentarians, civil society and others and working with other partners. In 1997 they had the first draft Bill. In 1999, you may remember, there was a major outcry around the world about a 14-year old who was imprisoned after she had been raped by her uncle, reported by her father, and nothing happened to the uncle. There was a call by IPPF, together with donor governments, to have this life sentence reversed, and this was done. Not long after that it really gathered impetuous. She, in fact, now works for the Member Association which received, ironically, an award from the Government this year and they then worked again with a wide range of civil society and with people interested in the Government so that the draft Bill was passed into law in 2002. There are 165 providers. Our organisation has 13 clinics and is hoping to build another six, and they are working very closely with the Government to address the issue, but there are still a number of unsafe abortions being carried out. Q241 Ann McKechin: I was going to ask you that, because I noticed in your submission that you did not actually state what the actual reduction had been in maternal deaths? Dr Greer: There is a reduction in maternal deaths and it is a dramatic reduction, and it has been basically halved. About 48 % is the reduction. Q242 Ann McKechin: I have also noticed there has been a very dramatic reduction in the fertility rate over 10 years from 5.1 to 3.1. Is it because there now is open provision of family planning or are there any other issues, like marriage age, which have been altered? Dr Greer: I think that has certainly contributed to it, and there is a law against child marriage, although it is inconsistently applied and the sanctions are not as rigorous as one might hope for: because, without a doubt, child marriage is a driving factor in increasing rates of maternal mortality and particularly maternal morbidity, and I think that is what we must not forget. For every one of those half million who die, another 30 women are disabled or injured or ill as a result, and in Nepal in particular, as a result of early marriage, of child marriage, we see a lot of pro-uterine prolapse, which it is very difficult to get funding to address. We have tried a couple of times unsuccessfully. Q243 Ann McKechin: Which countries apart from Nepal have seen a drop in maternal deaths following legalisation of abortion? Has that been a universal consequence? Dr Greer: I think, yes. Q244 Ann McKechin: Are there other measures? Dr Greer: If you take, for example, Eastern Europe, Romania, which is the classic example because it has been backwards and forwards now several times, yes, we have seen a real demonstrable drop in countries where abortion has been legalised. Q245 Ann McKechin: Lastly, can I ask you how significant was DFID's role in reducing maternal mortality in Nepal? Was their particular intervention a catalyst for change and how easily could they actually replicate that approach in other countries in which they operate? Dr Greer: I think it has been a major success. I understand that at the beginning perhaps there were queries about who was accessing and whether it was the neediest who were accessing, and that has been addressed and I think, with those lessons learned, it can certainly be built on and replicated as, indeed, DFID projects in terms of increasing the number of health workers, trained birth attendants in countries like Uganda, Malawi, but I am really critical, and I do think one of the things we need to think about is very much the role of volunteers, of lower level health workers in maternal health in particular and the impact too, if I can add very quickly, of micro-credit. I am thinking of a scheme, for example, in India where women purchased a taxi. They make money from the taxi but when anyone needs emergency care because of problems during labour, they use the taxi, and they have also managed to get cell-phones so that they have a method of contacting each other to get a woman to care in time. Q246 Chairman: Can I ask you on this issue of family planning and abortion and maternal mortality how aggressive you feel you can be in promoting your case? These are sensitive issues, there are faith issues and there are moral issues. You put it starkly on the basis of the figure you gave before. What you are really saying is that more than 100,000 women a year are dying in childbirth because they have been denied access to contraception, yet you cannot get money from the United States and there are other organisations, churches and the like, who say we cannot do that. How aggressive do you feel you can be in saying, "Actually these organisations are condemning women to death by denying them access to these facilities? Dr Greer: It is similar to saying that condoms are not effective against HIV and AIDS when they are 98 % effective. It is denying people in that case information and a method to protect themselves. IPPF describes itself as a leading advocate on sexual and reproductive health and we believe that that is absolutely what we must do. We recognise that in those 152 Member Associations they are working in differing country contexts and there is no doubt that, unfortunately, morality and mortality become intertwined all too often, and so they need to choose their own strategy for working. Somebody said to me recently, they could understand that it was difficult for a particular association or particular country because it was a Muslim country, as was theirs, and I said, yes, as are most of the countries in which we work in in South Asia, many in South East Asia, many in Africa and, of course, in the Arab world, and those that are not will often have a very strong Roman Catholic tradition or sometimes a new fundamentalist religion, but if we do not call out and say that no-one should die as a result of sex, that pregnancy should be a cause for celebration and joy, not for despair, and that women should not die needlessly, if we are not brave enough to say that after 50 years, or 60 years, who is going to say it? So, we do expect our organisations to be brave and angry and effective and accountable. It is what Gloria Steinem used to call "intelligent rage". It is no good just getting in and shouting about it, although that has its part to play. It is about showing the data, telling the stories of those who die needlessly. I do not believe that anyone really wants to see women continue to die. We have seen changes, and we can make change. It will take time, but we can do it, with support. Q247 Chairman: Thank you very much for that. I am glad I asked you that question. Thank you for coming. Dr Greer: Thank you very much. [1] Department for International Development (DFID) [2] the United Nations Children's Fund (UNICEF) [3] the United States President's Emergency Plan for AIDS Relief (PEPFAR) [4] Prevention of Mother to Child Transmission (PMTCT) [5] Voluntary Counselling and Testing (VCT) [6] The UN General Assembly's 26th Special Session (UNGASS), meeting in 2001, issued a Declaration of Commitment on HIV/AIDS [7] The Ford Foundation [8] The United Nations Committee on the Elimination of Discrimination against Women (CEDAW) [9] the Joint United Nations Programme on HIV/AIDS [10] Sexually Transmitted Infection (STI) [11] Millennium Development Goal (MDG) [12] Anti-retroviral Drug (ARV) [13] International Health Partnership (IHP) [14] Sexual and Reproductive Health (SRH) [15] the International Federation of Gynecology and Obstetrics (FIGO) [16] Sector-Wide Approaches (SWAps) [17] Poverty Reduction Strategy Programmes (PRSPs) |