Examination of Witnesses (Questins 120-130)
MR RAY
HASAN, MS
LINDA DOULL
AND MR
LEO BRYANT
12 JUNE 2007
Q120 Sir Robert Smith: I suppose
though looking at the bigger picture you are still restricted
in the geography of which parts of the country the Fund can reach?
Ms Doull: Yes, but I think if
you look at Chin State's statistics, what few there are, in comparison
with other parts of the country it is grossly underserved and
an area that is extremely difficult to access physically in terms
of its geographical location, has quite significant levels of
malaria morbidity in particular and high proportions of the population
that have no access to health care at all, particularly in Chin
itself where over half the population do not have access to health
facilities, so in anybody's books if 50 per cent of the population
do not have access to health care, that is something that needs
to be addressed, so I do not think we are so off screen.
Q121 John Bercow: But it would be
fair to say, would it not, that the requirement for a Memorandum
of Understanding is of itself, by definition, a rather exclusivist
approach? Manifestly, if you require a memorandum and you are
at loggerheads with the SPDC and you do not reach an agreement
and there is not a memorandum, whole swathes of the population
lose out. I would have thought that that was self-evident really.
Ms Doull: Your point is fair but
I suppose you can argue exactly the same for Darfur, that we have
to get permission to work in particular areas of Darfur and therefore
by default there are some other populations there that do not
get access. The choice is do you not engage at all because you
think it is an unfair system or do you engage at a particular
level and use that as leverage for further advocacy?
Q122 John Bercow: Indeed, I suppose
really my point was not that one should not undertake that activity
or spend that money, it is simply that it would perhaps be wise
to recognise the inherent limitations of operating with one of
the most sadistic regimes in the world, and having to have their
agreement and to work with them is of itself manifestly a constraint,
is it not?
Ms Doull: We do that on a daily
basis in a number of countries.
Q123 John Battle: I am tempted to
add just as a side comment that in the evidence that we have received
and in some of the commentary there is a question about displaced
people and resettlement that we are not addressing. Why I say
that is I thought that Karenni people were a long way away and
hard to get to until I got back to my home own city where a newspaper
reported that I had visited sunny Thailand as part of my holiday
pilgrimages around the world and what on earth did I think I was
doing, and someone then pointed out that Karenni people who had
had been displaced had been moved by the Thai authorities to Yorkshire
and were a few streets away from the person who wrote the letter
to complain about my visit. So we had a little community meeting
including the Karenni and they raised the question in the neighbourhood
"Will Britain take more displaced persons?" I think
it is a conversation we have not had with the Thai authorities.
I simply point to refugees who have been 40 years on the anniversary
of Palestine and you mentioned the length of time in Darfur and
other parts of the world. How long will these refugees remain
in camps until the authorities locally decide that dispersal and
moving out is an issue? We could flag that up in the background
and maybe you could give your comments in the background in our
inquiry. More particularly, working with displaced people not
on the border, the idea is people will return but within Burma,
there seems to me a contradiction that you recently got a programme
agreed for primary health care for displaced persons in Burma.
Could you say anything about the response of the Burmese authorities
to your proposal to do a programme with displaced people. They
have recognised the concept of displaced persons and they are
quite comfortable with that, so how will your health care programmes
reach IDPs? Could you say a little bit about that for me please.
Ms Doull: Maybe to say first that
in Merlin's approach to supporting IDPs I think we are extremely
aware of the tensions and that while IDPs themselves have difficulty
in accessing health care, they are not necessarily alone and the
host population themselves, particularly in places we are working,
are if not as affected are similarly affected, so the approach
is to take a holistic view to strengthening primary health care
activities, whether that is at clinic level, but also then using
outreach to do further targeting of specific IDP populations,
so we are trying to take a relatively balanced but where necessary
focused view on IDP health care. I think in terms of the Ministry's
acceptance of what we are doing, maybe we present it too easily;
it is not easy at central level, there has to be months and months
of discussion and quite difficult argument, as I am sure you are
aware, but I think at local level—and it comes back to the
point of working in extremely difficult countries—you can
achieve much more at local and community level than perhaps is
necessarily talked about and therefore it is the approach that
is taken for delivery that we feel is important and it is the
issue of engagement, and I think you can take that back to what
is DFID's role in a country like this. I think if you back DFID's
current strategy on focusing on engagement in fragile states,
then you have to go in there being willing to have a level of
engagement without necessarily supporting a regime—I take
that point fully—but finding inventive ways to then work
with existing structures or support emerging structures, and a
lot of what we do is with civil society organisations, village
health committees or school committees, just working with people
in the community itself, and to date we have not experienced that
many problems. There have been occasions when we have been asked
to stop particular activities for short periods of time, like
folk theatre or whatever that we are doing, but two weeks later
we are allowed to do it again. It has never been to the extent
that we have felt it has negated the point of us being there.
I think that is just the challenge of being in-country. So for
us we put a lot of emphasis on working at community and local
health level with local health officials.
Q124 Chairman: Accompanied by the
SPDC.
Ms Doull: They are accompanied
but what we try to do as well in terms of training activities
is that while we are training community members, we train private
health providers (because 60 per cent of the population go to
private providers) but we also include Ministry of Health staff
in clinical training so the sense is that no-one is being left
out, there are opportunities there. Now that is something we have
to just balance on a daily basis and be sensitive to the situation
around about us.
Q125 Ann McKechin: If I could ask
Mr Bryant from Marie Stopes what are the major reproductive and
maternal health needs amongst vulnerable communities, including
for example in Chin State, which I understand your colleague has
been working in recently, and what is the type of work the donor
community or other NGOs are trying to provide in this area?
Mr Bryant: The leading cause of
death of women aged 15 to 49 is complications due to pregnancy
and child birth, and reliability of cost of contraception supplies
are a critical factor to ensure regularity of use. One of the
key difficulties is that even a small price increase can render
commodities unattainable for women in vulnerable communities.
So the major issue is really simple access to basic services,
to commodities and to information. The challenge is how to provide
access to services to a maximum number of people using the limited
funds available.
Q126 Ann McKechin: Have you made
any assessment of a difference between, for instance, the general
population and among people who we might classify as IDPs and
whether they are being served, or how do you manage to get to
IDPs within-country?
Mr Bryant: We use a system of
community-based distribution workers and so we have our main clinics
in urban centres but then around that we have satellite clinics,
and from satellite clinics we have a network of people who we
recruit from the communities we want to target, including vulnerable
groups, some of which come from mobile populations. These community-based
workers will be allocated settlement sites and villages that they
are responsible for and they will visit again and again every
month so that they build a relationship with the local people
there, and then they supply contraceptives, condoms, iron tablets,
and also offer a referral service back to the satellite or to
the main clinic. And I think through that mechanism you can literally
introduce basic and life-saving services to areas where there
is literally a total lack of services.
Q127 Ann McKechin: Are you witnessing
an improvement in maternal health in those areas to which you
have been able to provide services?
Mr Bryant: It makes a huge difference
giving a woman access to contraception where before she would
be consigned to, say, five pregnancies in six or seven years,
and it makes a huge difference to maternal mortality.
Q128 Chairman: What is the attitude
of the Burmese Government? This is a rigid, hierarchical, conservative
society and yet they have these problems. What are the drivers
of HIV/AIDS and how do they view what you are doing as a means
of trying to tackle it; are they indifferent, supportive, opposed?
Mr Bryant: It depends. There is
broadly in the country a pro-natalist attitude, but nevertheless,
there is a recognition that maternal mortality is something that
needs to be tackled, and the guidelines that are issued may be
implemented to varying degrees depending on where you are operating.
Q129 Chairman: If DFID has a comparative
advantage, which is debatable, is there more that they could do
to help in terms of in-country?
Mr Bryant: There are regions where
this community-based work has not yet reached, so there are areas
where there are no services and an increase in funding could be
used to expand the system and bring basic life-saving services
to groups who currently do not have it.
Q130 Chairman: You mentioned earlier
the problem of high mortality through unsafe abortion. Does the
Government accept that access to contraception as well as health
education and so forth is actually beneficial and therefore agencies
such as yours are deserving of support. And are they prepared
to engage to deliver that?
Mr Bryant: I am afraid I do not
think I could give a detailed answer on that at this stage but
I could follow that one up.
Chairman: Can I thank you for what you
have given on the record. What I was going to suggest now is that
we have a short private session for those witnesses who wish to
share more information. If I could say to the public if you would
not mind moving, we will have another evidence session in a few
minutes' time, so you are welcome to wait outside.
At this point the Committee went into private
session
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