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CORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 66-iv House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE INTERNATIONAL DEVELOPMENT COMMITTEE
Tuesday 18 December 2007 BARONESS VADERA, DR STEWART TYSON and MR ANDREW ROGERSON Evidence heard in Public Questions 248 - 314
USE OF THE TRANSCRIPT
Oral Evidence Taken before the International Development Committee on Tuesday 18 December 2007 Members present Malcolm Bruce, in the Chair John Battle Hugh Bayley John Bercow Richard Burden James Duddridge Ann McKechin Jim Sheridan Sir Robert Smith ________________ Examination of Witnesses Witnesses: Baroness Vadera, a Member of the House of Lords, Parliamentary Under Secretary of State for International Development, Dr Stewart Tyson, Head of Profession for Health, Human Development Group and Mr Andrew Rogerson, Head of Human Development Group, Policy and Research Division, Department for International Development (DFID), gave evidence. Q248 Chairman: Good morning, Minister, welcome to the International Development Committee and your first appearance in front of us, but not your last, as we have already got your second appearance booked in. Thank you for coming in. As you know, this is the last evidence session on our report on maternal health, which is the MDG[1] which is most off-track and one which we are particularly concerned about. For the record, I wonder, first of all, if you could introduce your team - I know you have a change, which we have been notified of - and then we can proceed. Baroness Vadera: Yes, I am sorry, it is Christmas week. This is Dr Stewart Tyson, who is the Head of Profession for Health, and Andrew Rogerson, who is the Head of the Human Development Team. Q249 Chairman: Thank you very much indeed. I re-read last night the Department's submission for this inquiry and I have to say it is extremely robust, both in terms of the language and the commitment - that is not in question. I think we accept that DFID, both in its own terms and internationally, is seen to be a major driver of maternal health issues and progress towards MDG 5, but the problem is progress is poor. I suppose that is the first question. If DFID is so strongly committed to it - and that is not in question, that is clear and comes through very definitively - and is providing a leadership role, why are we doing so badly and what, particularly, do you think are the things that are holding us back? Baroness Vadera: I guess I would say the fact that there is no magic bullet here when it comes to maternal health. Maternal mortality is one of the trackers of health systems but you have to get a very comprehensive health system in place in order to ensure progress. There are some of the other MDGs where you can do certain things immediately, for example, with child mortality, and while health systems are very important you can get a great deal of immunisation coverage without. So it is the comprehensive nature of the solution, I guess, that is one of the main issues. The second is, obviously, the cultural and social issues, particularly around women's rights and the role of women in society and political leadership. I would say that political leadership is one of the big issues here which, in one sense, internationally, behoves us to do more but a lot of it has to come from the country. I think it is also a cross-sectoral issue because it links to girls' education, to access to treatment and poverty issues, in terms of remoteness and getting money to get to health care services, transport. So I think the fact that there is no silver bullet means that that attention is not as easy to get and the problem is more difficult to solve. Q250 Chairman: If you think back a few years, for example, maybe 20 years, there was a huge, international world obsession with population growth and huge campaigns for family planning, and these kind of issues, which seem to have gone off the radar. If there is no silver bullet - we accept that and we have obviously been taking evidence from a variety of quarters - are there particular obstacles that you feel are standing in the way? Baroness Vadera: I would say that health systems would be one of the first ones that we would like to see more focus on, and that is why DFID is focusing a lot more now on health systems, and on making sure that the health systems and the countries actually care about and track maternal health issues, whether that indicator is on maternal mortality or skilled attendants, or whatever it might be, and getting it universally available and getting it to remote areas. That would be one big area. The second would be around women's rights and girls' education because we do know there is quite a direct correlation here. Sometimes it is obviously very difficult for us to be advocating changes in legislation in-country, but when we do see a wedge we do try and go in there and work with the country to try and change the legislation and the rights, because, obviously, issues like access to safe abortion are very critical as well, as the third largest reason for maternal mortality. I would highlight those two. Chairman: The evidence has thrown up a number of issues which we will explore during the course of the morning. Q251 John Battle: In a sense, unlike dealing with malaria or HIV/AIDS, it is clearer where to go, but what has come across in this evidence is that it is quite a diffuse target, in a way. Therefore, there is a sense in my mind that sometimes people think, in all the agencies and the donors, that: "We will do what we can and we hope that the country shares the funds out into transport, into the clinics, into peripatetic workers, and health workers and hope that it somehow hits the target". I was really encouraged by DFID's lead, our Government's lead, to make MDG 5 a key target. It is miles behind all the others and I wonder whether we could not just catch up but really push it and champion it. Just to give an anecdotal account, as part of our evidence we did see the film Dead Mums Don't Cry, a Panorama programme, and I showed that film in my neighbourhood in inner-city Leeds and invited people to discuss development from the SureStarts, the Mums and Tots and groups that never go anywhere near development. They were shocked and enlightened and encouraged that DFID had championed it so far, but then wanted to know what more could DFID do to get a grip on this MDG nationally and internationally. They were actually saying: "Can we raise money to help? It connects to our agendas here. It is a campaign-championing issue." What more could DFID do and where do you see DFID going? Not for DFID to do all the work but with that leadership and campaigning and championing to get MDG 5 as well ahead as the others and as a kind of catalyser for the other MDGs as well? Baroness Vadera: I really agree with you on that. I think that we need to push harder in terms of international advocacy. We have got this call to action for the MDGs coming up in 2008 and the UN Secretary-General has agreed to a meeting at the UN General Assembly in September. What we would like to do, and I know that the Prime Minister is personally very interested in that, is to push on MDG 5, not just because it is the most neglected and it is the one that is most off-track but, also, it affects MDG 4[2] very significantly. It is the best tracker of overall health care and health systems. So one of the things we would like to do is up our own game, in terms of advocacy. Two things that we are trying to do are we have managed to persuade the Norwegians when they started on their initiative, which was just on child mortality, to include maternal health. So they have a big piece of advocacy work which we have been trying to assist them with and they have got these champions in Indonesia, Mozambique and Tanzania and other places. So we are trying to put some effort through that. The second is that we are talking to the Japanese, because they have the Presidency of the G8. In fact I was talking to the Sherpa yesterday, who is visiting, and I am going to be going to Japan in February of next year. It is really interesting because they were influenced by us - we sent them privately papers - and the Sherpa told me that he had read one of the Prime Minister's speeches - I could not quite figure out which one ---- Q252 Chairman: Which Prime Minister and which speech! Baroness Vadera: They had made a statement that they are going to make health one of the priorities, but really interestingly they are looking at maternal health and health systems. The foreign affairs minister made a speech actually saying that post-war Japanese experience showed that you have to do disease-specific things, like TB,[3] which they had in Japan, but you need the health systems and action on maternal mortality. He has made a speech about that which reflects some of the work we have input. So I think it will be quite an exciting year, and I do think that the whole issue of political leadership and advocacy is very, very central. However, we also need it in the country; it cannot just be us leading, but I think that is a much more difficult thing because sometimes (and I mean no disrespect) male politicians in Africa find it a bit uncomfortable. I think we need to find a way of getting champions. We are talking to the elders group - Mrs Michel and Mary Robinson and people - and we need voices and champions that will put it really centre-stage on the agenda. Q253 John Battle: That is an encouraging answer, and if others are looking to us to lead, what about not just in-country but the UN? We channel our money through the UN; are there enough champions in the UN in this area? Baroness Vadera: I thought you were going to ask me if there were too many champions in the UN! I think that there are now champions in the UN. I had the opportunity, while we were working on developing the International Health Partnership, to work very closely with Margaret Chan (WHO),[4] Anne Veneman (UNICEF)[5] and Thoraya Obaid (UNFPA)[6] and it is quite interesting that there is this group of women leaders now, and they have got a greater sense of this. In the IHP[7] we are going to put maternal mortality - I hope they will agree in the meeting that we are going to have in January - as one of the key indicators or one of the key outcomes in terms of how we evaluate success. I do think that the UN agencies have actually come together a bit more on this, and I think the women leaders are helping and the IHP is helping. Q254 Hugh Bayley: Your evidence reported the UK as the biggest donor to WHO, the second biggest to the UNICEF, and one of the largest donors to the UNFPA. What evidence is there that the UN is a good channel through which to place money which has a demonstrable impact on improving maternal health? Baroness Vadera: When it comes to the funding that we put in through the core funding, they obviously report back to their own boards, and we have pushed quite hard on improved evaluations at the board level of the core funding, and we have our own tracking system for impact, when we do give specific funds. We have also developed the multilateral development effectiveness indicators in which we monitor each of the agencies and their effectiveness. I am not going to deny that there is a lot more we could do or the UN could do in terms of impact and effectiveness. The point about the UN is that it is trusted on the ground by the countries and, particularly, on sensitive issues like this, it makes it more effective. Secondly, when it comes to conflict situations we, very often, have very little choice other than to work through the UN. Sometimes, obviously, we can use NGOs[8] but the UN remains the biggest and it leads the Health Cluster, for example, in many situations. We do have to use them. In my previous existence I spent quite a lot of time on the High Level Panel for UN Reform and looked at evaluation methods as well. I think some of them are showing some signs of improving, particularly UNICEF and UNFPA. Q255 Hugh Bayley: You anticipated my next question about too many champions. What impact does the fragmentation of the UN system have on the effectiveness of their work towards this particular Millennium Development Goal? Also, in your evidence, you talk about a pilot study in a number of countries - Tanzania, Mozambique, Rwanda and Vietnam and others - where the UN has agreed to bury its logos and operate around one lead agency. Is that working and when will that become the norm? Possibly, when will that become the norm in New York as well? Baroness Vadera: On the issue of the impact of fragmentation, I would say, historically, it has had an impact on this particular MDG, disproportionately, because this MDG is very dependent on health systems. If you really want to tackle systems then you really need co-ordination. There are some MDGs where a more vertical approach can work better. So I do think it has had an impact but it is one of the main reasons we launched the International Health Partnership, to actually bring them together. I was very encouraged by what I have seen, in fact, from the UN agencies and the WHO, in particular, championing this. On the International Health Partnership the problems we have seen around co-ordination have not been through the UN agencies; it has been a couple of the others, which has been interesting. On the issue of the One programme, which is one office, one budget, one leader, we were very much champions of that and directly funded that. I was in Rwanda recently, one of the pilot countries, where it seemed to me to be working very well. I was actually addressing the donors' conference, where co-ordination is the big issue. It seemed to be working very well. My sense is it is quite dependent on the UN leader. That is the impression I got, and it was a really good one, of Rwanda, but I hear that in a couple of countries there have been issues. I think the problems are being sorted. They have decided to roll it out on a kind of volunteer basis, and I think 32 countries have expressed an interest. They will be doing an evaluation a year from launch, and then trying to roll it out. We attempted at the time of the UN High Level Panel that I worked on, because Gordon Brown, then as Chancellor, was on it, to set a target but they felt it would be better coming from the country. It is interesting that countries have expressed an interest in doing this. Q256 Hugh Bayley: That means that during the coming year, 2008, it will roll out in 32 countries? Baroness Vadera: No, it will not roll out to 32 countries in the coming year. I would say, possibly, by 2010 it would have rolled out to significantly more countries, but they are going to evaluate it during the course of 2008; they are going to evaluate the current pilots during 2008, but there are seven or eight more that might be rolled out. Q257 Hugh Bayley: I am bound to say the clock is ticking. The MDG is a 2015 MDG, and if you do not start better co-ordinating the UN until 2010 what are the chances of meeting the Goals? Baroness Vadera: We continue to press very hard. At the first meeting we had with the UN Secretary General this was the issue that was raised. So we do press very hard. As I said, the reason I am hopeful is that it is coming from the countries that they want this, and I think that might push it further forward. The other thing we are attempting to do - there have been countries who wanted to join the IHP, so we are trying to find the countries that join the IHP to be the same as the countries who have the One programme, to bring them together. Currently, we have Mozambique but we will have Ethiopia and Rwanda who are both going to join the IHP, so we will start to get a sort of volume, I think. Q258 James Duddridge: In the maternal health sector, where is DFID's comparative advantage? Have they got a comparative advantage? Baroness Vadera: I think part of the fact that you are having this Committee shows that we have a broad understanding of this issue and a cross-party understanding of this issue, and the comparative advantage is in being able to do and say difficult things; that we are able to champion something that not many countries very easily champion. It is, basically, us, the Scandinavians and the Dutch, but in terms of scale we are able to come out and champion, for example, access to safe abortion, which they do as well but they do not have the same scale. The fact that we have this depth of understanding also means that we can focus on things that sometimes people think are slightly dull, like health systems, which are very important. I think the fact that we give predictable, long-term financing, which is very central to health systems, is also our comparative advantage. Q259 James Duddridge: Are you concerned that given the requirement to reduce headcount, despite our comparative advantage, other international players are unrealistic about what can be expected of DFID, because it is not just about money, you need individuals to help deliver the strategy. Baroness Vadera: Yes, I very strongly believe it is not just about money. One of the tests that I apply to any of the submissions that come up is that if it is just about the money we spend, then that is not good enough because we need to be adding value. DFID has had an 11% headcount reduction since 2004, and I do not think it has affected its performance. I guess, coming from the Treasury, you might say that I do not think efficiency affects performance. However, we also, in the Spending Review settlement, have agreed that two-thirds of the frontline offices will not be subject to headcount reduction and will be allowed a 1% increase in real terms. That is, really, where we need the health advisers. So we have got 53 health advisers, 39 of which are in countries. Q260 James Duddridge: To clarify that, that headcount reduction on the front line is not as aggressive ---- Baroness Vadera: There is not a reduction in the front line. Q261 James Duddridge: Is that matched by a more aggressive reduction in terms of back-office back in Palace Street? Baroness Vadera: We have the same requirement as all the other departments for the headquarters, which is 5%. In terms of the frontline programme we have this protection and indeed have allowed a 1% increase for two-thirds. Q262 James Duddridge: What will the overall reduction be, from a DFID viewpoint? Is there a specially negotiated settlement for DFID globally as well? Baroness Vadera: No, there is not an overall for DFID globally; it is the headquarters which has the 5%. It is the frontline which is separated out. Q263 James Duddridge: Returning to maternal health issues, what are DFID doing to make sure that they are more co-ordinated with other donors to make sure there is not duplication and that both DFID and other countries do what they are good at rather than simply duplicating or chasing the more high-profile tasks or countries? Baroness Vadera: This is obviously a very big issue so we launched the International Health Partnership in September this year. The principles around it are that the big eight agencies, health agencies, which were the UN, GAVI[9] and the Gates Foundation, would abide by three principles: that we would be led by country-owned plans and have a health plan, that we would be co-ordinated around that plan and that the plan needed to focus on the development of sustainable health systems. Those were the three principles. We have now got eight countries, the first wave of countries, and the point about that is to have the discussion, the dialogue, to ensure exactly what you are saying, which is that we are not duplicating - that everybody is doing a piece of it or, indeed, doing it through a single pool, which would be even better. Sometimes we are not able to do that with the vertical funds but with the bilateral donors we can. In terms of PEPFAR (US President's Emergency Fund for AIDS Relief), which is a very significant health funder now, in so many countries. They did not join the International Health Partnership but, in fact, have, in principle, signed up to the principles of it, and we are now working with them on how we operationalise that, so if they are funding nurses who are providing ARVs (anti-retroviral medicines against AIDS), then we are talking about whether we can provide the marginal additional costs for them to also provide the other services. I have a meeting in January, which the head of PEPFAR and I will be co-chairing, to talk about exactly how we operationalise these overlaps and how we ensure that we are funding something that is going to be sustainable and create something that is going to survive in the long term. Q264 James Duddridge: Are you happy that the co-ordination between DFID and the EU is effective? Baroness Vadera: On health care systems, I would say that they are. I am not going to comment on a couple of other areas that I have noticed in my travels, but maybe in one of the other committees we can pick up on that. I do think that on health I had not seen them as a major player in terms of the countries that we are working in. We have not had significant problems with them. I would say the problems have really been round PEPFAR and the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM) - some of the vertical funds. Q265 Chairman: Can I press you a little harder, Minister, on the staffing constraints? We have had evidence that suggests that your sanguine view about efficiency is not entirely shared. One specific piece of evidence from Immpact (the Initiative for Maternal Mortality Programme Assessment) says that DFID staff "are frequently overstretched by the volume and range of work they must undertake, so that their potential for providing leadership and influence cannot always be realised."[10] That is a general view. It has come up elsewhere in evidence, which I have not got to hand. There are suggestions that on this particular area of maternal health there are staffing constraints that are affecting the delivery of programmes. Baroness Vadera: I did read quite a lot of the evidence and I noticed that a lot of the NGOs talked about that but there was a specific comment on research as well. I do not think the numbers have reduced and I do not anticipate that in-country, in terms of health advisers, it will have a significant impact. I think everybody is always stretched and we are working in a field where the need is, in one sense, endless. So I do feel reasonably confident that we will be pushing on the maternal health agenda and we will ensure that we are sufficiently resourced to do that, both in terms of funding as well in terms of people. Mr Rogerson: Can I just add to that? We are trying to make the best use possible of our bilateral relationships, particularly with European Union members, such as the Netherlands. In some countries we have taken over their co-ordinating lead from them and in others they are offering to take it over from us. This is not a one-shot solution but it does help make the maximum use of the few people on the ground that the bilaterals can have. Q266 Chairman: As you will be aware from the debate we had in the House, the Committee at this stage has said they accept the constraints on the Department and the Department is adjusting its priorities within that framework, but we have expressed concerns that decisions might be taken sometimes which would be different if there were not those staffing constraints.[11] Baroness Vadera: I understand and I accept that and we will be vigilant, particularly in this area, if we are going to give it a big push in the New Year. Andrew is right to point out that we do work with others but we are not driven by the staffing constraints in working with others; we are driven by the Paris principles. So I think that on that we are very clear that actually the value we add is not just about our money but that we are influencing and effecting good health outcomes. Q267 John Bercow: Minister, at the Partnership for Maternal, Newborn and Child Health Board meeting in Addis Ababa earlier this month DFID resigned from the Board to be represented from now on by the Norwegians. Why? Baroness Vadera: I think, because they are leading on the MDG 4 and 5 initiative and we are co-ordinating behind them, that was considered, again, in terms of the spirit of the partnership, to be the most effective way forward. Q268 John Bercow: That raises the obvious question of whether ---- Dr Tyson: I would just come back and say that DFID has been very influential in creating quite a lot of these partnerships. There is the Maternal, Newborn and Child Health, the GAVI Alliance, the Global Fund, the Health Metrics Network, the Global Health Workforce Alliance. These were all global partnerships set up, initially, to address under-resourced areas and areas of under-focus. I think we agreed that we do not have the capacity to continue to serve on the management boards of all of these. For example, with the Global Alliance on Vaccines, we were there for the first three years, we rotated off and we came back three years on. Similarly with the Global Fund, where we have been on the board for, I think, the first three years, and we are in a constituency with other partners. This is very much the case with the Partnership for Maternal, Newborn and Child Health, and I think you will see, if you look across the various partnerships, that we will actively engage on the board for a period, we will try and work through others, perhaps we will come back to it and we will spread ourselves in a more rational way. Baroness Vadera: It is about us, I think, being good at the start-ups and ensuring that we move on. Q269 John Bercow: That is fine, as long as there is not a discontinuity resulting therefrom. In other words, from coming off and going back on again. If you are satisfied there is no discontinuity of policy or loss of effective action, so be it. This is not, in any sense, a joke question; it is a serious question: do you know, off the top of your head, on which boards of international initiatives DFID sits? It is relevant in the sense that where increasingly you are required with a rising budget to be accountable, both to a domestic audience and, perhaps, more widely, it is quite important to know exactly what you are on and what you are not on - where you are in a primary leadership role and where you are not. Baroness Vadera: On the whole, I would say that I am aware. The one that is fixating me the most, at the moment, is the Global Fund, where I am very pleased that we are on the board because we have given them a long-term commitment and there is no secret about the fact that we have some issues and, therefore, the board is important to us and we ensured that we maintained it. With GAVI we have less of an issue. For example, with the IHP there is not a board, it is a kind of working group and it is actually meant to be led by the health agencies but we ended up having observer status, which is quite unusual for a bilateral donor. Obviously, one of the other big agencies is the World Bank. So I think we do have an awareness of the fact that we need to influence these agencies, and I would say that one of the things that I am pleased by, but feel we could do more, is the whole influencing strategy; that DFID is influential; we have now become the largest donor for a lot of multilateral agencies and I know that we have a voice, but I think we could be more concerted in ensuring that we have objectives for what we are trying to influence them to do and we definitely did that, for example, for the Global Fund using our ability to raise issues, and in fact I had a long discussion with the Chairman about it yesterday. Dr Tyson: We are trying to take a pragmatic approach to these and we have worked in partnership with other European donors. An example would be Roll Back Malaria and Stop TB. These are very substantial partnerships. For a number of years we have sat on the Roll Back Malaria Board, and we have represented the Dutch and they have represented us on the Stop TB Board. Last year we exchanged board seats although the Dutch have recently requested a return to the former position because they felt that with changes in their own administration they have greater strength in TB. We have been happy to do that. Q270 John Bercow: I do not sniff at the significance of that but I am concerned about the question of leadership more widely, specifically amongst southern partners. Minister, I simply remind you that you yourself referred, briefly, much earlier in this session, to the imperative of securing safe abortion services. In a sense, the question I want to ask you gives you an opportunity to place beyond peradventure your position on the record. You were, I think, at one point, going to speak to Global Safe Abortion hosted by Marie Stopes International in October but had to pull out of that engagement - I am sure there were perfectly good reasons for that and I am not here to pick an argument over that - but I wonder if you could just take this opportunity to underline your support for the provision of such services to reduce maternal mortality and morbidity. Also, I wonder if I can inveigle you into something a little beyond that. If we are going to talk about leadership and changing the attitudes of southern partners I wonder whether you think that Britain, perhaps in concert with others, might start to be as robust in arguing for safe abortion services amongst developing country leaders as the United States is, sadly, robust in the wrong direction by taking the, dare I say it, evangelical view as far as contraception and abortion are concerned? I know there is always the danger of being accused of ultra-imperialism but if a judgment has to be made between maternal and child health on the one hand and bearing the scars of being attacked by others for one's cultural imperialism, presumably your shoulders are broad enough to bear the burden of the latter? Baroness Vadera: I am delighted to have the opportunity to restate very clearly our commitment to access to safe abortion if it is within the law. I would just like to be clear about the fact that my very first speech, before my maiden speech, ever, as a Minister, or as anything else, indeed, was on World Population Day for Marie Stopes and, I think it was, the APPG.[12] That was when I talked about access to safe abortion, contraception and to birth attendants as the three key things to do. That was my very first speech before I did anything else. The reason I was unable to go was because I went to New York to try and secure, which we have now secured, having the MDG day in September, which I hope will very much highlight maternal health and mortality. So, if anything, we feel, halfway through the MDGs, we have to up the game on this. I think the issue of leadership in southern countries is a lot more difficult. I do not think it is because of a fear of being controversial. Our position is very clear about what we say within the ICPD[13] but I think the issue is: will it work? If we were to just become evangelical about this and go to country I do not actually think it would end up with having an impact because I do not think that you can change people's minds, particularly on cultural issues like that. I do not think, even if we did manage to get anywhere because they felt dependent on us in any way, that they would be committed to rolling it out effectively. What we do better is if there is, as I said, some interest where we can go and provide evidence, fund NGOs and fund civil society. It is always better to give the voice to women in those countries directly for them to be the advocates than for us to be the advocates. I think that is more effective as we have seen. We have done that in Nepal, and we have been doing that in Sierra Leone where we are about to start a maternal health programme. I actually have had discussions privately, for example, when I was in Rwanda, and President Kagame is very committed and they are now thinking about using maternal mortality as an indicator of their health, and access to family planning, in particular. So there are ways in which we do this but becoming the public advocate could, in fact, make us less effective rather than more. Q271 John Bercow: Very briefly, if I may, Chairman, I want to wrap two into one. The DFID annual report for 2007 referring to financial year 2005-06 makes it clear that, excluding budget support, maternal health expenditure amounts only to £16 million out of a total health spend of £200 million. So it is a relatively small proportion. I just wonder whether that, alongside what has been a very sharp reduction in absolute dollar terms, in donor support for family planning since 1995, is in any sense a cause of concern for you, and if so whether you propose to do something about it. The related matter is whether you feel that in terms of improving health performance, there is something to be said for DFID in its advocacy role advocating the para-medicalisation of medical procedures so that suitably trained nurses as well as doctors can perform worthwhile procedures. Baroness Vadera: There are about three or four questions there. On the issue of our direct spend on maternal health, in fact, it has increased since then; it has doubled from that and will be doubling again. Q272 John Bercow: Doubled from what? Baroness Vadera: From before the £16 million figure. It went from £16 million to £23 million and is projected to go to over £50 million - about £53 or £54 million - by next year. That is very significant because our programmes in India and Pakistan on reproductive and maternal care, of which portions are directed to maternal health, will be coming through. We do have increasing specific targeted maternal health care programmes. We have also got Ghana, which is going to have a health SWAp[14] which will be focusing on MDGs 4 and 5, we have got Sierra Leone coming on-stream, so, in fact, we do have an increase very significantly. I do want to say that the issue of budget support is important. One of the things we found, and we have evidence of, in an early programme from, I think it was about 1995, in Malawi (in 1995 to 2000 we ran this programme) was that if you just do vertical programmes without ensuring that you are taking care of the rest of the system you cannot always sustain it, and we were not able to sustain it effectively. The most effective way to deal with maternal health care is to have health workers, skilled attendants and midwives and actually you need to have them in the budget line, and the best and most effective way to do that is to also be working on budget support and health sector support. We do need to be doing both. Another thing we need to be doing and will be doing - we have actually just been having that discussion recently - is that when we are doing budget support the big headline indicator for health has traditionally been on immunisation rates, which is easier to do because, as I said, you can get coverage more easily. Once it gets to beyond 85% coverage, you do need to move on. So we are talking about whether, when we are renewing budget support, we should be asking countries to move from immunisation to maternal care. Q273 John Bercow: I absolutely understand what you say about the budget line, and I am grateful for and have some enthusiasm for what you have just said about the significant increase in the figures from relatively low figures about which I was complaining, so that is a case of immediate gratification, if you like. I still feel, going back, to what you were saying earlier about relatively patriarchal societies - I do not think you used that word but that is the implication I drew from it - in which, frankly, men either do not want to talk about these things or, if they do, they have got pretty - how can I put it - atavistic views on these matters. In that sense, surely, that rather underlines the importance, from the other side of the equation, and underlines the need to have strong civil society programmes as well, so you are backing civil society organisations that are acting as advocates for women's health. In that sense, I am mildly concerned that the Civil Society Challenge Fund does not fund even the most successful advocacy programmes after the completion of the first round of funding. I think I can almost anticipate that an experienced Treasury hand is going to say: "Well, Mr Bercow, you cannot fund things forever", and I accept that, but is there not a danger that just as something is starting to bear fruit it is cut off at the stem - if that is not a mixed metaphor? I just wonder whether you can hold out some hope that projects which are of demonstrable value are not going to be subject to an arbitrary and capricious cut. Baroness Vadera: Going back to the first question, which is about patriarchal societies, it goes back to the point that I made at the start, which is that there is no magic bullet; you need the health systems and you need the workers in the budget line, because if you do not have the workers in the budget line we cannot actually support the outcome. However, in certain countries we do need to have, exactly as you said, the approach which targets maternal health because of some of the, perhaps, invisible, social-type barriers. So we do have that in Nepal, Bangladesh, India and Pakistan, so in the sub-continent where this is an issue. In post-conflict countries where there are specific problems - Burundi, Sierra Leone and even Ghana where we are actually, even though it is the most advanced in many senses, possibly, most likely to reach the MDGs in sub-Saharan Africa - we have this issue, and that is why we are focusing on it, in terms of the health sector programme on MDGs 4 and 5. I think it needs both approaches, and we have to make an assessment on the ground of how we do it. I think, also, helping in the budget support to get the indicator moved to maternal health would focus minds on this as well. I think, from reading the evidence, I have a sense of which specific organisation you are talking about. I would say that we do pride ourselves on giving predictable funding, and that is, in fact, one of our comparative advantages. When we make an assessment of applications for civil society we do have to look at the value added and we do have to make a comparison. So there are choices in that, and I do not think we can always please everybody but we do have partnership agreements with certain agencies that give them a core funding that ensures some predictability. I know that IPPF (the International Planned Parenthood Federation) has that and I know that Marie Stopes do not have that and they are not successful. I cannot really answer for every organisation. Q274 Sir Robert Smith: Earlier you mentioned how Japan is trying to prioritise health at the G8 Summit. Did their awareness of the maternal health issues come at their own initiative or was it prompted by DFID? Baroness Vadera: I would not want to start to attribute causality here. I could be being flattered by the Sherpa who came in yesterday. I had quite a long conversation about this issue because we were both at the replenishment of the Global Fund. Unfortunately, I think I probably accosted him on this and he went away and he read up about it and then his foreign affairs minister made the speech on 25 November. We have had discussions and sent them papers but they do, in this very interesting speech, refer specifically to their own post-war experience. It is difficult to say. The one thing they did pick up on that was specific to us was the fact that we said that the horizontal issues were not receiving attention and the health systems needed to, and they picked up on that because of their own experience and they picked up on the fact that maternal mortality is one of the best trackers of the effectiveness of health systems. They seem to have put something together but I would be flattering myself if I said it was entirely due to us. Q275 Sir Robert Smith: Do you think the other players at the G8 will be up for making it a priority? Baroness Vadera: The Germans made a piece of it a priority, obviously, this year in the commitments they made around HIV/AIDS which really focused on mother to child transmission and paediatric care. So I think if they see this as a continuation of what they did that would be possible - in one sense it is about making everybody feel ownership of it. The Americans could view this, again, as part of what they already do, in terms of PEPFAR, as long as they do not see it as a kind of attack on the vertical, in terms of their approach. There are ways of including other people. I think it always comes down to implementation. We can do a lot at the G8 but we have got to implement what we do, and that is always an issue. Q276 Ann McKechin: I think it struck us in our inquiry just how often women are invisible within their own society, even to the fact that their births and deaths are not registered in their own countries. A recent study by Médécins Sans Frontières in the DRC[15] found maternal death rates to be 10 times higher than the national reported average of 520 deaths per 100,000 of live births, which is a completely horrific figure. In these circumstances, and given that it is important that we have some degree of accurate information, what is DFID doing specifically to try and improve the routine availability of maternal health data? Baroness Vadera: We are the biggest funder of statistics but, of course, maternal health data has been notoriously difficult to get. We do fund a variety of programmes as the Health Metrics Network. Stewart works directly on that so he might want to say something about that. We are also going to be funding the census which is one of the best ways of doing this, and I know you have had evidence from Immpact about the work that they do to try to find easier and quicker ways of doing it, and Professor Graham is advising you and knows more about it than most people. So we are working to track this information, and it is very important because I think it is possibly one of the reasons that we have not been as effective as we could have been on maternal health; you are pitching to a minister of health for funding and you cannot track what the data is and what your results are going to be, and that actually makes it quite hard. So I do think it is quite an important element of the piece. Immpact is the most ambitious programme on maternal health that we have got so far. Q277 Ann McKechin: Should we make the priority maternal health data or should we just prioritise general health data? Which should have the biggest priority currently? Baroness Vadera: It is the most difficult to do, but we do think, as I say, that it tracks health systems very well and is sometimes used as a proxy for health systems. So in one sense it would be good to track a lot more than one thing. We should track as much as we can but it is about the effectiveness and the impact of what we are doing, and maternal health is one of the best indicators. Q278 Ann McKechin: So, from your point of view, this should be the priority? Baroness Vadera: I think it should be a very significant priority, yes. Dr Tyson: I would just add we do fund the Health Metrics Network with a group of other donors; it is another one of these global health partnerships addressing neglected areas, and that really is trying to put in place the building blocks of a comprehensive health system right from vital registrations - so registering births and deaths. Not many countries do that and it is a very big step. It is working in about 70 countries, it is developing situation analyses of what is there at the moment, where the gaps are and where the bottlenecks are - where there are opportunities to move forward. I think that sort of systematic approach is very useful and, at the same time, taking opportunities to get better data. The Immpact programme has developed a relatively low-cost method to assess maternal mortality and you have heard a lot about that and, also, other tools that have been around for many, many years but have not been as extensively used as we would hope; things like maternal death audits - on every woman who dies in a health facility - to try to look, in a non-threatening way, at why that happened in a non-threatening way, to try to learn lessons and to try to change practices. I think it is trying to do both approaches at the same time, really, to get the best possible data. Q279 Chairman: Can I reinforce that? In your evidence to the Committee you quote the figure that 529,000 women continue to die. The note says that this is actually the figure for 2000 and is based on estimates developed by WHO, UNICEF and UNFPA. Yet the evidence from Immpact and from Médécins Sans Frontières suggest that is rather a precise figure, given the method of recording is so poor, and that, if anything, the situation is substantially worse. If you are going to have targets you do need to have base information. Would you accept that we need to update that information and perhaps produce a range, which also shows that the upper limit might be a lot worse? Related to that, when you were talking to John Bercow about whether there is family planning or safe abortion - it was a point I made at the end of the last evidence session - essentially, if you have very high figures and you know what the percentage reduction is if you have access to safe abortion, you are basically saying to people: "If you don't pursue these policies on giving access to abortion or family planning you are condemning X-thousands, or tens of thousands or hundreds of thousands of women to death". I take the point about the culture, but those are pretty dramatic statistics. Do you not think we could do better to confront people with the horrors of this information? Baroness Vadera: This is like music to my ears because I have this issue about spurious precision. We have quite lively debates in DFID now about why numbers differ depending on the source. For me it is imperative. If you cannot show the results and you cannot show the numbers and you cannot show the impact of policy then we are not going to win the argument. So I very much agree with that. I would rather, in the interim period while we are trying to improve data systems use ranges, but we have to accept that in some countries it is going to be really difficult. I was in the DRC and the idea that we could actually be able to get very serious data out of the DRC in the foreseeable future is just not very realistic, or Afghanistan. Sharing data and having some common ground on which we can influence policy makers is really important, so I completely agree with you. Chairman: I hope our report might help on that. Q280 Richard Burden: In, I think, one of your first answers this morning you described the Global Fund as "fixating" you at the moment. I would like to ask you one or two things about that fixation. Whatever else it has done, and it has done a lot of good stuff, the Global Fund has not necessarily done a great deal to reverse the trend of separate policy and financing strategies for HIV, on one hand, and maternal, sexual and reproductive health on the other. Given the emphasis you have consistently put today on the importance of developing integrated health strategies and particularly strengthening health systems, how do you feel that we can move forward to get the Global Fund to contribute better to that? Baroness Vadera: I can see that I am going to get into trouble now with Michel Kazatchkine when he reads this transcript! I think we have a great opportunity with the Global Fund. It has a great chair now who is very businesslike and understands these issues and Michel Kazatchkine who is also aware of them. They have signed up to the International Health Partnership and we are using that to point out the areas where they are doing well and the areas they are not. It was the most fabulous sight: when they arrived to the first IHP meeting - Mozambique is one of the countries - the Mozambique Health Minister was pointing at him and in the end he had to agree to change quite a lot of the things they were doing in Mozambique. They have sent a special group to change that and so they are much more integrated into the overall Mozambique health plan. Now, we are talking to the Zambians and we are having the same issues there. Yesterday I raised that with the chairman and he immediately said that he would raise it and deal with it. I think there is a huge willingness, but I want to be clear that it is variable. It is not that they consistently do not do it; it is just very variable and it depends on the strength of the country in terms of their own ability to influence it. When I was in Ethiopia they were funding health extension workers alongside us; in Malawi they fund health workers, co-funded by DFID. It is the variableness we need to fix. We need to make sure it is consistent and systematic. Mr Bercow asked about the issue of the board and we are doing this mainly through the board but also in private discussions. In their evaluation, we are going to ask them - and they have agreed - to evaluate not just the immediate impact of what they do but the impact on the overall health systems of what they do and that is very important. Secondly, at the most recent board meeting they agreed - and this was based on discussions that I started in July with Michel Kazatchkine - to have a gender strategy which will ensure that it is linked more seriously into the maternal health piece. We are already starting to talk to them about what might be in that and the board has asked them to do that. There is a change and there is a willingness. They have their portfolio committee looking at giving guidance on how applications are made so that the applications can be more integrated and can fund health systems. I think this is an opportunity. There is also an opportunity with PEPFAR coming up: the current chairman is very willing and very aware of these issues and we are going to be talking about how we integrate them into health systems. This could be a big prize really. I am sorry; I am showing my fixation again. Q281 Richard Burden: That is interesting. From what you have just been saying, you seem to be suggesting that it is very much a function of the Global Fund itself to be able to push that kind of agenda. We may have misunderstood but we had evidence a week or two back from the representatives of the Global Fund, amongst one or two others, and there was an issue there about how far the Global Fund should be responsible for promoting integration between sexual and reproductive health, on the one hand, and work specifically on HIV/AIDS, on the other, and how much that should be the responsibility of donors themselves. When that issue came up, the representatives said that the Global Fund does not decide which country should ask for this or that but it is more up to DFID, to the World Health Organisation, to more technical agencies to be encouraging countries as to what they could apply for. What you have said today does not particularly agree with that. You have said that it is certainly up to those agencies but also it is a responsibility of the Global Fund itself. Baroness Vadera: This relates exactly to the issue of variability. It is not their responsibility, in one sense, to be working on maternal health, it is their responsibility to do HIV, but they cannot be an obstruction and they do have to work with others. They are willing to do that and they have shown serious signs of being willing to do that. Their portfolio committee was charged at the last board meeting to go away and look at the guidance that they give to countries about the applications they make and in terms of the flexibility they have. It is true that if the countries push hard they can get a lot further in terms of getting flexibilities from the Global Fund but I think we also need to be making it clear to countries that that is possible too. Q282 Richard Burden: My last question is in relation to DFID's own strategies for integrating HIV/AIDS work and maternal health work. You are amalgamating the HIV/AIDS policy team and the reproductive and child health policy team. How far is that contributing to the process? Baroness Vadera: It is slightly difficult for me to judge because I have only been there since July and they have been amalgamated since then, so I do not know how it operated before. Obviously we are in discussions now to develop our renewed HIV/AIDS strategy, which we are going to publish in the spring, and we are integrating the two elements in there. We are having the discussion and it is good to have a discussion with the same bunch of people really. I do think it will make a difference. Q283 Jim Sheridan: I understand that we are in the process of exploring setting up the Global Fund for Women's Health. What is the rationale behind that? I would not underestimate for a moment the horrific statistics in terms of the maternal mortality but would you not agree that men have a responsibility also for that mortality in terms of their sexual behaviour, infection, et cetera. I am wondering why you have to set up this committee, if I may call it that, mainly for women's health. My concern is that then allows the males to abdicate their responsibilities and to say that this is mainly a problem for women and therefore women have to deal with it. Basically, what is the rationale behind this decision? What do you hope to achieve? Baroness Vadera: It is not what we are advocating, in fact. There was a suggestion on the second day of the Women Deliver Conference that there should be a specific vertical fund. We would agree with you. We do not think that would necessarily help for a whole number of reasons. One of the reasons is the one you have mentioned, but one of our issues, as we have discussed earlier, was the duplication and proliferation issue and the fragmentation issue: to be adding to that would not necessarily help unless you take away things from others and you cannot take things away from others because it is important that they are integrated. This is a very hard area to start to fragment and we would accept the view that we do not think that a single new fund or agency would help. You do need to be effective in the mainstreaming. There is an issue here: if we say we cannot do this, we cannot fragment and therefore there has to be mainstreaming, then the mainstreaming does have to work and be effective and we need to be quite vigilant about that. That is why having specific indicators and specific focuses on maternal health is a more useful way than perhaps to set up a single fund. Q284 Jim Sheridan: If DFID is not supporting this committee ---- Baroness Vadera: It is a fund. It is not a committee. Q285 Jim Sheridan: I am sorry. If DFID is not supporting the fund, is it dead and buried? Is it finished? Baroness Vadera: Would you suggest that DIFD is overpoweringly influential? Perhaps it is not! Mr Rogerson: I think it is just an idea. Baroness Vadera: It was an idea that was floated. During the course of the conference it all came about through the whole issue of why there is not enough focus on the issue, rather than because people thought that operationally that was needed. I think it is better to do an advocacy campaign around lots of different things like the Japanese or the Elders or the G8 than to have a separate fund. Q286 Jim Sheridan: The only reason I mentioned a committee is because if you are going to set up a fund then it follows that you are going to set up a committee to look after the fund. Baroness Vadera: It is our view that it would be adding to the proliferation. Q287 John Battle: Perhaps I could go back to the International Health Partnership that Gordon Brown launched and which you have referred to and press you a little on the targeting, if you like, or the pilots. Seven were chosen. One of the people who gave evidence said: "It is important to learn from pilots but we need to make sure that all the 75 high burden countries move quickly to reach the assigned targets under the MDGs. It is not enough to take seven or eight countries to start with and assess them at the end of 2008."[16] When listening to your response to John Bercow's question on pilot schemes and funding things to get them off the ground, I was thinking that too often we light pilot lights and then snuff them out before the main oven is burning. In this area we cannot really wait for the pilots. What is DFID trying to do to ensure that the Partnership gets engaged with those 75 high burden countries, as they are called, and quickly? Baroness Vadera: There is always a trade off. We did have a very long debate about this while we were developing the IHP. It is eight now because Mali has joined: it was meant to join but was not ready and so it joined very soon after that. We picked the eight because they were in a wide range in relation to where they were in terms of the effectiveness of the health sector plan. We wanted to make sure that the eight agencies were working effectively regardless of the state of the plan or the effectiveness of a government in terms of the "ask". We know that if a plan is good and the government is very effective it is easier for donors to be coordinated. We have chosen a range and we are trying to find ways to change the practices of the agencies. That is the example I was giving Mr Burden of seeing the Global Fund doing really well in Ethiopia and not so well in Mozambique, and trying to make it systemic. If you roll it out to 72 countries, what are we going to change in the behaviour of the Global Fund unless we have targeted it, pointed it out and they have changed it systematically? That is a very important thing to do. Q288 John Battle: I can see that you do not go straight at the 75 countries, but are you engaged in that move from the seven or eight to the others? Have you bunched them into groupings? Baroness Vadera: We have had a lot of countries express interest in doing this. I suspect we will go with the ones which have expressed interest because it shows their willingness and ability to do this. One of the problems that we have in development is that it is all about implementation. It is boring and it takes time but it is all about implementation. I am really loath to go with something that is half-baked, where we have not sorted the systems issues out or figured out what all the problems are. The point about the IHP is not to say: "Here's the template; everybody is going to do this" because every country situation is different. We have to figure out how people work on the ground in varying circumstances and ensure their headquarters are aware of it and know about it. If we do not get that right and we roll it out then it is not going to be effective. Q289 John Battle: You are not hanging back waiting for the pilots to be reviewed in 2008; you are engaged to move down that track. Baroness Vadera: Yes. I have been lobbied by the Rwandans very heavily. We are telling our country teams on the ground and the other agencies' country teams on the ground, even if they are not an IHP country, "Here are the principles. You should already be starting to look at these principles." I just do not want to move until we have really figured it out. Q290 Ann McKechin: I wonder if we could move to the issue of maternal health in conflict settings. DFID currently funds a range of partner organisations, mainly NGOs and multilateral bodies, in most conflict areas. Particularly in countries like the DRC or Afghanistan, where we have large bilateral programmes, what can we do to ensure that reproductive and maternal health are suitably prioritised in a conflict setting? Baroness Vadera: I do not know what you would describe as conflict or post-conflict but we have certain countries where it is difficult to be active - and I am talking about Somalia or Sudan, where we have to fund through the UN system or through NGOs. In post-conflict situations we do try to talk to them as soon as we can. I was in the DRC earlier, as I mentioned, and I raised the issue directly with President Kabila. We are funding already a lot of the NGOs but I would really like to be able to move to funding something more systematic and not just the emergency relief. The DRC is still slightly divided: in the east you have this incredible violence against women which is leading to fistula and all sorts of other problems, and then the west is a little bit more stable. We are in discussions about trying to get it more systematised but, if you are going to do systems, you have to have capacity in government and that is really the fundamental issue. In Sierra Leone - if you classify that as post-conflict - we have been working with the government on a health plan, which they are about to finalise. Sierra Leone is absolutely the single worst country in terms of maternal health indicators. We are working to get them to focus. We do try to move as quickly as we can. In Afghanistan we fund health workers through the Reconstruction Fund and we have recently seen - but again it comes back to the problem with figures - a reduction in maternal health issues. Q291 Ann McKechin: You have talked about the weakness of the evidence base. To what extent do you think that the priorities should be for, firstly, DFID, but, secondly, for the multilateral organisations such as the UN in strengthening the evidence base and trying to use best practice from other post-conflict areas which can be replicated in other areas, so that we do not have to reinvent the wheel every time we come to a conflict area. Baroness Vadera: I think there is best practice, but you get into the problem which Mr Battle was questioning me on as to whether we are going to wait and then roll something out when people are in need. There is a lot of evidence base now. I think our biggest learning place was Nepal post-conflict. They had managed in this period to have an impact. Roll-out has been quite speedy and they have done some really interesting things including involving the non-state sector in a social/private contracting structure. We have given direct payments to women to access transport - rickshaws and so on. There are certain things that you learn and the DFID programme is something we could learn from and replicate, because it is really seen to be very successful. Q292 Ann McKechin: Are there still problems about coordination between bilateral donors, multilateral donors and the NGO sector? Is that still a problem when it comes to rolling out maternal health services in post-conflict areas? Baroness Vadera: Yes. It is always a problem, in post-conflict areas particularly, because people come in and you cannot work with the government, the government is not effective, so there is really nobody coordinating, so it tends to be more exaggerated than it is in other situations. To go back to the IHP: Nepal is an IHP country and we have tried to use that as a mechanism to get donors to coordinate. When we were in the DRC we seemed to spend quite a lot of time on the coordination issue, but it is inevitably a problem because there is not an effective state to interact with. Dr Tyson: Nepal has had 10 years of conflict and yet the programme worked all the way through that period. The focus of the maternal health programme was the Maoist area in the far west of Nepal. I was there last week. Throughout that time both sides valued the services that were being delivered and that enabled them to carry on. That has been a testament to good practice. I was told that there are between 20,000 and 35,000 NGOs working in Nepal that have come in through this period, so you can imagine the problems that governments have in the peaceful period in trying to bring them together. It is always one of the issues on which we are attacked - you know, "How do you get NGOs represented in the International Health Partnership?" What is an NGO? Who can represent the body of special interest? It is something we are struggling with in a number of those areas. Ann McKechin: Should we get a certification scheme in place, so that if you reach a certain level of coordination you will get a certificate? Q293 Chairman: NGOs may be a good thing but you can have too much of a good thing. Baroness Vadera: It is not just coordination. We are paying with it not being the most efficient way of doing things. Q294 Chairman: In Annex 2 to your evidence, you talk about the role of budget support in the context of maternal health and you make the point that it is quite difficult to follow through exactly how much of the budget support does deliver maternal health benefits. When we are visiting countries where budget support is a significant part of the UK contribution, the DFID team will tell us that one of the virtues of budget support is that it gets you a seat at the table; in other words, you are working in a kind of partnership with the government. If that is the case why is it not possible to get a little bit more direct handle, without putting conditions, on exactly how the budget support is being used specifically to deliver maternal health? You also say: "A process is underway to bring DFID's statistical monitoring systems in line with the OECD..."[17][18] I wonder if you could give us a bit of information as to what that means in the process. Baroness Vadera: The seat at the table is, in one sense, about influencing the decisions and the policy and the allocations of spend within the budget - and that is fairly critical. We can influence the amount that is allocated between sectors and into the health sector. It then becomes an issue of statistical systems and tracking - and we have had the discussion about tracking the indicators, et cetera. As I said before, I think it will be an important move for us. It will be good in terms of a change of mindset. There are certain headline indicators in budget support and it has traditionally been immunisation rates. If we could move that to maternal, because that is a better tracker of the effectiveness of the health system, then we will ensure that we have greater focus and we are going to try to start to do that. The tracking system that we are implementing is basically automating the tracking of our own funding. It is called ARIES.[19] It is being rolled out over the course of the year and means that we could then track quite a lot of sub-sectors and sub-indicators that we were not able to before. It was semi manual before. I think that will help. It is already in process at EU division and it is going to be rolled out in the course of the next 12 months. Q295 James Duddridge: Best practice seems to be around sharing information. Will ARIES be published on the web, or a distilled version? Baroness Vadera: I do not know. Mr Rogerson: It is primarily an internal management system but presumably we will continue to publish the statistical data that results from it in the normal annual reports and compilations. Q296 James Duddridge: Certainly, when we are talking to people, the more that can be shared the better the possibility for coordination. Mr Rogerson: Yes. Baroness Vadera: Were you talking about sharing the information that comes out of it or sharing the systems? Q297 James Duddridge: The information not the systems. Although, if our comparative advantage is being at the cutting edge in persuading people, why should DFID have a single management information system? Perhaps there needs to be coordination there as well. Baroness Vadera: I think it is meant to be a system for live management of the information. When we are asked to publish information, we will be using the ARIES system to provide also for whatever we do publish. You ask the system to provide certain tracking and then you can make that information available. Q298 James Duddridge: I suspect the Committee will be interested more broadly in that system and understanding a bit more about what value it could add. Baroness Vadera: Maybe we could send you a note. Q299 Chairman: Related to that is the role of civil society - not necessarily the 34,000 NGOs but some of the good ones to help in that process. In other words, if they know there is some commitment by the government of their country to improving maternal health then they can clearly be instrumental in monitoring it. You specifically also say in your evidence to us that the department seeks the support of the IDC[20] to work with parliamentarians in developing countries on this issue. That is something we as a Committee have an interest in. Hugh Bayley has left but he is with the Westminster Foundation for Democracy and also the Parliamentary Network of the World Bank which we understand is likely to be revamped - at least, that is what we were told. Do you have any means of proactively encouraging the development or the support for local NGOs as part of the process of helping to raise both awareness and monitoring performance on maternal health? Do you have any specific thoughts on how the Committee particularly might help in terms of the links in that area? Baroness Vadera: Because we think holding governments to account is better done by civil society than by us we have the Governance and Transparency Fund, which is going through its process of assessing applications. I am certainly hoping - and we have yet to see the applications, the assessment is coming out - to see a really strong focus on gender issues, women's groups, including maternal health. I think that is a very important area. You will know that women's gender issues are very much at the heart of poverty, so I expect a lot of that will come through the Governance and Transparency Fund. Once the allocations have been made and the applications have been assessed, perhaps we could advise you of that. For me, the role of parliamentarians is very important. I have in the past had discussions with Mr Bayley about this. I know we have used the parliamentary group for things like female genital mutilation. When it comes to really sensitive issues it is almost easier not to have it as part of a donor relationship but as a relationship between parliamentarians. I do not know what we specifically do in that area but perhaps we should think about that. Dr Tyson: Last week I was at a sector review in Nepal, looking at progress and where the programme is going. It was an unusual experience for me because most of my experience has been in Africa. In Nepal it is about government talking to donors with very few other parties in the mix, yet if you go back to Uganda and look at how they run it they would have parliamentarians, civil society, the press. To try to encourage those processes in other countries in Africa, we have encouraged or facilitated people from one country going to another: parliamentarians, civil society groups, and to learn from the positive experience and try to take that back. In Nepal, when we go back a year down the road, we will see that they took on the message about the need for a much more inclusive process that brought in all those other players. That is a very simple example but one that can move us forward. Q300 Chairman: We will come back to the parliamentary network when we are talking about the World Bank. They seem to be upgrading that. The Committee is planning to visit Nigeria and Ghana next year. We always try to seek out parliamentarians but it may be appropriate for us to look for parliamentarians who have a particular interest in this issue as part of it. It does say in your evidence that you want to work with the Committee but perhaps you might want to give some thought to how that would be. Baroness Vadera: Perhaps we should take the visits as a specific ask and give you some suggestions, to see what to do and what to push for. Particularly if we are having this focus on MDG 4 and 5 in the Ghana programme ---- Q301 Chairman: I was thinking of Ghana in this issue particularly. Mr Rogerson: Ghana would be a good example. The nature of the parliamentary scrutiny on the budget, for example, has been toughened up considerably and so you could ask questions of your peers about how they look at the balance of health spending. Q302 Chairman: I guess this is not the appropriate place to pursue that. We have had evidence that there was some discontinuity in the programme which raised some criticisms of DFID. The point is that is the opportunity to find out exactly what the perception on the ground is on these kinds of things. Baroness Vadera: Yes. Q303 Sir Robert Smith: We have already touched on the crucial role of human resources. Unless there are people to do the delivery then you are not going to tackle this goal. There is obviously the supply side but then there is the worry of a brain drain, in a sense. The Royal College of Obstetricians and Gynaecologists were saying to us that there ought to be a model that allowed professionals to come here for two years to get their training and then they would go back, rather than having them stay here. What sorts of joined up discussions are there in Whitehall to try to tackle this problem of skill shortages and avoiding sucking them away from where they live? Baroness Vadera: We have an inter-ministerial group. The NHS signed a code of conduct in terms of not poaching and not actively recruiting where there are skills shortages - which is about 150 countries, so that is quite a lot. There has been significant reduction in certain countries that we track of people migrating. It is not just active recruitment. When we were working on the emergency human resources programme in Malawi, it was interesting that there were more health workers and doctors and nurses who were in Malawi not in the health system but doing something else - because there was not sufficient pay and they could not guarantee a proper functioning system. We have ended up doing salary top-ups and golden hellos and innovative things to try to get them back in. So it is not just an issue of poaching. We have had a decline in the UK. Q304 Sir Robert Smith: Do you work with the private sector? Baroness Vadera: Yes. They signed up. We say that if the NHS is using a private provider then they should have signed up to this code. We encourage the private sector to sign up to this code as well. It is an important area. We are also working with the EU to try to get other countries involved. It is not just about us. Although English as the natural language is an important attraction, I think it is quite important that we ---- Q305 Sir Robert Smith: Do you still see a model whereby coming here for two years is a useful way of getting the skills to take back? Baroness Vadera: I think it is. I know there are already programmes in place. I think that works quite well at the high end - for very skilled doctors mainly. I think there is an issue about whether we should be assisting in sending trainers, because you get to know people and you get better sustainability than if you just have a group of people coming over here. In specialist areas they obviously do. The report talks about you could have better interaction between the NHS and health workers and the service here and developing countries, and we are going to be responding to that in the New Year. Q306 Sir Robert Smith: How are you looking at the pull within countries towards the cities? What strategies are there to persuade the health professional to stay in the rural community? Baroness Vadera: Using and training workers who are from the local community for certain things always works more effectively, and having a tiered system that ensures you have community health workers on the ground. In the case of maternal health, obviously those women would like to be given a training gap, but then being able to ensure that there is a system, if they recognise warning signals, for them to need to move on to the next stage. I think that works. We also do salary top-ups. We have a lot of schemes in Malawi. As I was saying, we have exactly that, salary top up and things, but it is one of the most difficult things. Maternal health is not just the best indicator of a health system, it is one of the best indicators of access and poverty too because you can see where the problem is. It is really inequitable. In rural areas in India the level of access is significantly lower than for women in urban areas. It is a very difficult issue, particularly for maternal health. Q307 Jim Sheridan: I wonder if you could expand what you have said. You say you spot recruit from people from other countries. In another life on another committee I visited Nigeria and met a very excited parliamentarian who was also a doctor who was extremely angry that he was not allowed to come to the UK. What practical steps do you take to stop people from Nigeria coming to this country? Baroness Vadera: There is obviously a new system now, a points-based system. I was in Nigeria earlier in the year, in August or September, and I had a very direct discussion with the Minister of Foreign Affairs about the immigration from Nigeria and doing a bilateral compact, which we have had before. We are going to review that, to look at that issue. As I say, we are trying to stop doctors from coming here but what you were witnessing was the other side of the equation. It is probable that he was not practising as a doctor. Q308 Jim Sheridan: He trained in Edinburgh. Baroness Vadera: This is the problem we are encountering. You train them but they are not working in the system. Q309 Jim Sheridan: Nepal has come up several times this morning, where perhaps the Nepal experience can be replicated and others where it is difficult to transfer from one situation to another. Specifically on the question of the experience of women advocating to improve maternal health, how far do you feel the Nepal experience can be replicated and how do we do that? Baroness Vadera: I could give you my view but there is an expert sitting next to me who has just come back. Dr Tyson: It is always very dangerous to try to replicate too much. Nepal was the first country I worked in 27 years ago for Save the Children, so I had some comparison there. We have tried to do two things in parallel. One was to invest through flexible, long-term predictable support to a reformist government that was trying to deal with all the difficult things - how does it recruit staff? How does it get money down to the system? How does it strengthen the information system? That was one arm. In doing that we were working very closely with the World Bank and European bilaterals. That was the longer-term agenda. At the same time, we were investing in frontline services. Doing both together - and we have done that in Bangladesh, Malawi and a number of other countries - I think is the right way to go. The nature of the frontline service is also comprehensive. It was not just dealing with one of the problems; it was dealing with family planning, safe abortion services, safe facilities for women to deliver in, investing in voice and accountability through civil society groups, working with local radio and working directly with the community, making sure that there were low-level community health workers from that community, trusted by that community who were there when needed. It was using innovative approaches that may or may not be transferable, using cash incentives or vouchers to attract them to come and deliver in a safe environment, but it was having to build up infrastructure and blood transfusion services and transport facilities. That takes us back to the beginning of the day: it is about building that system. The really encouraging thing was hearing the Nepali ministers using maternal health as their marker of progress - we have said it time and time again but they said it: if we can put in services at the district hospital level that enable us to deal with maternal health issues, then we can deal with surgery, other medical problems, road traffic accidents. Baroness Vadera: In terms of women's groups, there were specific elements of Nepal which I, travelling between countries, have found interesting, and one of them was the community health workers and particularly the fact that women felt more comfortable with them: they were local, they knew them, and therefore that works. The cash incentive is worth considering looking at because you need to have certain incentive structures. I have seen that incentive structure replicated. We have it in India now. In Nigeria they have a very interesting system that they are experimenting with. In India I found they were paying anybody, a neighbour or a friend, who had brought the women into a facility so that they could have skilled attendance. There was also the transport piece, the rickshaw service they had. They are two or three things that are replicable. It is much more difficult to look at replicating local women's groups and networks because they tend to be very individual to the country. You just tend to have a very individual cultural and social set of issues. That is much harder to do. Possibility on the sub-continent it might be easier and in Africa there might be quite different models in terms of accessing. Q310 Ann McKechin: We visited the project in Malawi last year and exactly those points were raised. There was no civic society organisations at all. They had to be started from scratch so it has taken much longer but I think they are doing very good work. I was very impressed by it. I think you are right: it is not one-size-fits-all that is going to work. Baroness Vadera: No, it is not. Once you create a women's group it becomes quite interesting because you can do micro-credit through it and childcare. There are lots of different elements you can do if you can create the women's group but in the main they do not tend to exist. That is the whole point about them being voiceless: they are voiceless in that they do not have immediate advocacy in any way. Q311 Richard Burden: When we were in Ethiopia earlier this year, we were all impressed by the work of the health extension workers there. In that particular context we were looking at water and sanitation. The impact of the contribution of women in not the most remote villages but relatively remote villages was phenomenal. It did seem that that kind of model could be taken up and used in a much broader way on perhaps some of the agendas we are talking about here. Baroness Vadera: It is very different but similar to the experience in Nepal. In one sense, it is finding women locally and training them and making them community health workers. It is a very important dimension and a lot of people describe them in slightly different ways, as low-level intervention, but it is very critical. So long as you can give them access to transport and training and supplies and everything else around them, it is one of the most effective ways of doing things in remote areas. Also, women prefer to stay in their local community. In Ghana we have funded giving motorbikes to health workers. In Pakistan we have a lady health workers scheme. It is something that is one of the common features. Q312 Chairman: You have already mentioned the problems of unsafe abortion and the fact that literally tens of thousands of women die as a result of that. Other evidence tells us that quite a lot of women find they are forced into sex, they have more children than they want, they have unwanted pregnancies because they do not have access to family planning or that they are married at a very young age. There is a picture in today's Metro I think of a 40-year old man and his 11-year old wife in Afghanistan. We know that young girls are more like to die in childbirth in that situation if they get pregnant and it would be better having a safe abortion. What can DFID do to ensure that at least where abortion is legal, women understand their rights and can get access to them. Many, we understand, either are not aware or fear they will in some way or other be punished or penalised, so they resort to unsafe abortions and many die or suffer severe disabilities? Baroness Vadera: This is one of the hardest areas because it is about getting into people's homes and how they interact and how they feel about it. There are things we can do. We do promote and fund certain agencies that can work to ensure that women, in particular, are aware of their ... I think "rights" is difficult, but the fact that there are services that are available. It has been very effective in Bangladesh, where there are centres. They are called Menstrual Regulation Centres - which is obviously just a terminology issue - but that has ensured that women are aware, feel safe, do not have stigma and can access safe abortion. That has led to a reduction in maternal mortality. There are things that can be done but I am not going to pretend this is the easiest area to work in. Q313 James Duddridge: This is the first time you have come to speak to us in roughly six months into a job. What have been the surprises, both welcome and unwelcome within the job? What are the strengths and weaknesses of the department? What are your first impressions of DFID? Baroness Vadera: If it was a surprise, the more I have done the more I have enormous respect for the people: how much they know, their integrity in doing the right thing. The more I travel, the more I am proud of the fact that DFID is the leading agency in the world. I sort of knew that but you have to be there to feel it and I am very proud of that. In terms of my areas of focus, I, the Secretary of State and others are very interested in ensuring that we look at issues around growth and not just around the social expenditure side because in one sense this is really the only thing that is going to make development sustainable and the expenditure we are talking about in social services sustainable. We are working on a growth strategy. I am delighted you have talked about data, evidence and numbers and tracking because it is something we raise very regularly and it is one of the areas I press on. At most meetings, I will say, "What is the impact? Where are the numbers?" being harder edged about that. It is there, it is not that it is not being done, but it is making sure that we are able to access it or communicate it. I and the Secretary of State would really like to make 2008 an opportunity to mark the hard work of the MDGs and make sure DFID is able to have that influential role. It plays a very important role. Maybe I am a little bit surprised about how influential it is. It boxes a little bit above its weight, even thought its weight is getting heavier all the time. Q314 Chairman: Could I thank you very much for your first evidence session in front of the Committee. The Committee regards itself as interested in what works. Our engagement with the department, whilst it does not mean that we do not criticise them, the criticism is always constructive, in as much as all these questions have to be asked and impact and effectiveness has to be monitored. That is what we are trying to do. The Committee would share the same view as DFID. We have travelled quite extensively and wherever we go, when we talk to other donors and recipients the image of the department is extremely high and its reach and influence is extremely far. The truth is, I guess, that all of us are proud of what is achieved, but we are also conscious of the fact that the budget is growing, the ambitions are growing and we have to be sure that we continue to deliver effectively. We see the role of this Committee as being to assist in that. This particular inquiry is clearly prompted by the fact that this Millennium Development Goal is furthest off track. That is why we decided to do it - and John Bercow, I know, was particularly keen that we should - but I think it would be fair to say that, whilst we knew that, having taken evidence the Committee has been frankly shocked at the status of women and the suffering that they undergo for something which in many, many cases is avoidable and where there is much that can be done to raise the status. We did realise that it was not that different in developed countries 100 years ago and we have to try somehow or other to help developing countries to travel 100 years in 10 rather than have to wait 100 years themselves to catch up. I hope our report will make a constructive contribution to that. This is the last evidence session we are taking. If there are any particular issues that have arisen that on reflection you would wish to add to or reinforce, we will be very happy to receive that. Baroness Vadera: I am really delighted that this subject was my first, because I do feel very strongly about it. I think this report will be very important and I would like it to feed into the attention that we need to give to advocacy and somehow also be able to be used in countries. It is not just about the international advocacy and what donors do but what happens in country. If we can find a way of using that, it would be absolutely fantastic. I have read a lot of the evidence that has been given and I have been as shocked as you. You do know it, but, when you start to realise, some of the things we know are very shocking and perhaps we do not pay enough attention to them, so I am really pleased you are doing this. I would like to use the report when it comes out. Chairman: We will produce the report very early into the New Year. Thank you very much
[1] Millennium Development Goal (MDG) [2] To reduce child mortality [3] Tuberculosis (TB) [4] the World Health Organization (WHO) [5] the United Nations Children's Fund (UNICEF) [6] the United Nations Population Fund (UNFPA) [7] the International Health Partnership (IHP) [8] Non-governmental Organisations (NGOs) [9] the Global Alliance for Vaccines and Immunisation (GAVI) [10] Ev 10 [11] HC Deb 15 November 2007, cols 869-928, debate on International Development [12] All Party Parliamentary Group (APPG) [13] International Conference on Population and Development (ICPD) [14] Sector Wide Approach (SWAp) [15] Democratic Republic of Congo (DRC) [16] Q 9 [Dr Songane] [17] Organisation for Economic Co-operation and Development (OECD) [18] Ev 23 [19] Activities Reporting Information E-System (ARIES). [20] International Development Committee (IDC) |