Examination of Witnesses (Questions 1
- 19)
TUESDAY 16 OCTOBER 2007
MRS THORAYA
AHMED OBAID
AND DR
FRANCISCO SONGANE
Q1 Chairman: Good morning. It would
be helpful if you gave an introduction about who you are and your
background for the record. Thank you for being here. I appreciate
you are here for other reasons as well but it is fortunate for
us.
Mrs Obaid: Thank you for having
us here today. I am Thoraya Ahmed Obaid and I am the Executive
Director of the United Nations Population Fund. I have been in
this post since 2001, basically working on our areas of concern,
which are population and development, issues of data and statistics
and so on. A major part of that is promoting sexual and reproductive
health. We work in almost 140 countries where we have country
offices. Our staff doing this work are one-third international
and two-thirds national.
Dr Songane: I am Francisco Songane.
I am the Director of the Partnership for Maternal, Newborn and
Child Health. I am a medical doctor, an obstetrician and gynaecologist.
I started this job in February of last year. The Partnership for
Maternal, Newborn and Child Health is a new partnership which
was launched in September 2005 as a way of harmonising and co-ordinating
activities around maternity, newborn and child health. As you
may be aware, there were three partnerships addressing children:
the Child Survival Partnership, the Safe Motherhood and Newborn
Partnership and the Healthy Newborn Partnership. Of course all
these things are interrelated, particularly when we are on the
ground. We do all these things together. It was found useful to
merge these partnerships and form one. That is how we were created.
Before I became the Director of the Partnership last year, I was
the Minister of Health in Mozambique from January 2000 up to January
2005. Before that, I worked as an obstetrician in district and
provincial hospitals and in the central hospital co-ordinating
activities in maternal and child health.
Q2 Chairman: Thank you for that.
The Committee did make a very interesting visit to Mozambique
18 months ago and we saw some of the co-ordination that was going
on there, which was good, although we were not particularly looking
at aspects of health; it was more about general development. It
was an interesting and worthwhile visit. This is the first formal
evidence session that we are taking in this inquiry, which we
have undertaken fundamentally because of all the MDGs,[1]
this is the one that most often turns up and causes most concern
as to why that should be and why it is proving so difficult to
get it on to target, and indeed in some cases it appears to be
going backwards rather than forwards. I wonder if you can perhaps
give us a general feel, both of you, as to why you think that
is. We had an informal teach-in last week when we saw some of
the challenges and heard about them. What came out of it all the
time was that two things are needed: one is resources in a whole
variety of different ways; and the other is political will. I
have probably put those the wrong way round in the sense that
the resources are no use if they are not backed up by political
will. I wondered if you could give us your thoughts on that: which
is the greater and where you think the problems lie. Perhaps I
can push this a little bit further. If it is political will, whose
political will needs to be jacked up? By definition, as you have
already said, there are quite a lot of initiatives—our own
government has taken initiatives—but none of it seems to
make any difference. That may be political will on some kind of
round the world platform but it does not translate to realities
on the ground. I wondered if you could give us a flavour of what
you think. Is it political will or resources? Where is the problem?
What do you think might move us forward?
Mrs Obaid: Political will is certainly
a very important part. It is political will on both the national
governments as well as on the donor side. On the national governments,
basically—I think my colleague, Francisco, can testify as
a health minister—the investment from the national budget
into the health sector is not as it should be to meet all the
needs. From the donor side, we know that to deal with maternal
health, and particularly maternal death and maternal mortality,
there are three interventions: family planning, emergency obstetric
care and skilled birth attendance at birth. In terms of family
planning itself, I will give you some figures. We know that there
are 200 million women who would like to plan their families but
they have no access to contraceptives to be able to plan. If a
woman can plan the spacing and number of her children, then her
survival will be much greater. In terms of investment, in 1995
of population assistance as a whole, 55 % was going to family
planning and in 2004, the figure was 9%, so investment in family
planning including contraceptives has gone down, which means one
of the three interventions to save mothers is not there. That
is a political commitment issue, which is to invest in terms of
ensuring that contraceptives are available.
Q3 Chairman: If I could press you
on that, is that commitment or is there prejudice?
Mrs Obaid: From the donors' side
it is commitment but also competing demands; that is part of it.
It tends to shift from one area to another. That is why now that
there is the new initiative by DFID[2]
in terms of health sector reform and health sector support, we
need to ensure that this will go on, as they say in their strategy,
for 10 to 20 years, with consistent support for that. That is
one thing. The second, which is related to our work, is the whole
issue of gender. That is one of the MDGs, the issue that women
are of low status; they are not a priority politically; and the
whole issue of maternal health and gender empowerment is not yet
on the political agenda at the national level. There is that exclusion
also: denial of rights and not enough recognition of the human
rights of women, and certainly health is a human right. This is
the second challenge: political commitment on the health issue.
The third one is the capacity of the health system to deliver.
Here, as we are talking about health systems, we are talking at
the national level, but women die at the community level where
the poor are, and therefore the ability of the health system to
deliver primary health care and to create a package of reproductive
health that takes women throughout their reproductive age is a
very important component and there is not enough investment there.
Dr Songane: Thank you for that
good introduction by Mrs Obaid. This is an important occasion
and we welcome it profoundly, particularly now that you are marking
20 years of the Safe Motherhood Initiative this week here in London.
We have a conference with the title "Women Deliver"
exactly to address these concerns. A committee is trying to go
into the details. Political will is very important. We need this
political will at all levels: at the country level and internationally.
Things are happening but they are not happening fast enough and
not with the comprehensiveness we would like to see. As my colleague
has said, there are three important deprivations. There is no
doubt that access to family planning, skilled attendance at delivery
and prompt access to emergency obstetric care when needed are
crucial. If we do not put these things in place, there is no way
we can lower the high levels of maternal mortality. We can make
an assessment through the publication this week of the paper in
The Lancet on estimates of maternal mortality. Sadly, we
have not made progress. The figures we had in 1987 when the Safe
Motherhood Initiative was launched in Nairobi are exactly the
same today. Half a million women die every year, which is one
woman per minute every day. That is the picture. Why have things
not changed? It is partly because the political commitment which
was required to bring about this change was not at the level of
the challenge; secondly, it is because there has been too much
talking and concentration on activities which were regarded as
simple, cheap and easy to do. In particular, there was a push
to train traditional birth attendants only and no proper attention
given to the need to increase the number of skilled attendants
at delivery and the number of institutions providing the services
in order to allow women to be there and be taken care of by a
skilled attendant. You need a small maternity unit. The emergency
obstetric care was not there. I can judge by the experience I
went through in my own country. As I said, I am an obstetrician
by training; I worked in the district, provincial and central
hospitals. I remember well the long tedious discussions we had
with many funding institutions, including the World Bank, to convince
them in the Eighties that we needed to increase the number of
maternity units and the number of district hospitals offering
emergency obstetric care in order to provide better outcome.
Q4 Chairman: That is an important
point. What you are saying is that in the context of Mozambique,
for example, there was political will within the country but international
institutions did not respond appropriately.
Dr Songane: Exactly; it took a
long time for them to change and adopt a different approach and
agree that they should fund the kinds of interventions we were
advocating. It is important to know that. In terms of the overall
co-ordination internationally, if you wanted additional resources
to get the services improved, to train more staff in the procedures
of which they should have profound knowledge to take care of women,
you would have a hard time as compared to the resources to train
traditional birth attendants. It is not that the traditional birth
attendants are not needed; they are important but that has to
be put in context as part of a team where there is a continuum
from what they get at the house in the village and in the community
and they bring the woman to the nearest maternity unit or where
there is a station where she could have a midwife or a nurse.
This is the process. In terms of resources, the resources are
needed internally in countries and internationally to add to what
we are doing now. The issue of additional resources has not been
addressed properly. There has been resistance to putting resources
where they are needed. For instance, the WHO[3]
World Health Report of 2005, which addressed maternal, newborn
and child health, pointed out that we need an additional US$ 9
billion per year to address the basic services in maternal, newborn
and child health and we are not near that figure. Then The
Lancet issued a series on maternal health in October last
year. There was an exercise to assess how ODA (Official Development
Assistance) is doing in different countries. Sadly, we found that
only 2 % of ODA is going to maternal and child health. If you
break these figures down you get the staggering figure of only
half a billion that is going to maternal health and newborn health.
There is neglect in terms of maternal health. This is the situation
we have to change. There is a new momentum and Britain is part
of that. We should commend the UK on the initiative to try to
get things fixed. The International Health Partnership which was
launched here in London has to be seen within the context of the
whole effort which is made to address MDGs 4 and 5, relating to
child and maternal health. This is being done together. The honourable
Members of Parliament will know that this is about the UK, Norway,
Canada, the Gates Foundation and various countries, be they donors
or countries in need. The Partnership for Maternal and Child Health
provided a platform to reach out to a wider membership. These
are the things we have to build on. Last month there was an announcement
in New York at the launch of the Global Campaign for the Health
MDGs by the Prime Minister of Norway and the Prime Minister of
the Netherlands of US$ 1 billion over 10 years from now as
additional money from Norway and US$125 million for three years
as additional money from the Netherlands. We have to seize and
build on these things. I am sure that this week at the Women Deliver
Conference we will add to that and it will be the focus of conference.
We hope to get ministers of health and the ministers of planning
and other leaders worldwide to come to terms with the issue that
we have to remove this shame; we have to take a different stand
and address this as a human rights issue and say that it is not
permissible when we know what to do, when we have the resources
and when women are dying in the same number as in 1987.
Q5 Hugh Bayley: In relation to maternal
and child health, what are the respective responsibilities of
UNFPA, WHO, UNDP[4]
and UNICEF[5]?
Who is responsible for what?
Mrs Obaid: WHO did an exercise,
all of us together, to discuss where we are. They produced a nice
graph of the continuum of services, which we are all in the process
of agreeing upon. Each one of us agreed on where we can play the
role of a focal agency. For example, family planning is UNFPA;
antenatal care is UNICEF; skilled birth attendants, is UNFPA,
which includes midwives as well; emergency obstetric care is UNFPA
and UNICEF jointly (we work together on that); post-partum and
care of mothers, et cetera, is UNFPA; and management of newborns
is UNICEF. In a sense, UNICEF gets the children and we get the
mothers but there is an overlap when we are talking about emergency
obstetric care and we do that together. WHO is very much the normative;
WHO sets standards for us; they do the protocols and guidance
notes and we work with them on that. They provide technical assistance
to governments but in the field they are not as operational as
UNFPA and UNICEF and we consider them as our reference points
basically. Of course the World Bank deals with the whole area
of finance, strategic planning, poverty reduction strategies and
so on. We want to ensure that within these national processes
maternal health finds a place. We try to be at the table to be
able to advocate with the governments when these big funds are
being allocated that appropriate funds go to UNFPA. UNDP does
not necessarily deal with issues of maternal health. They deal
with issues of governance as a whole where systems are in place
to deliver. It is really the three organisations—WHO, UNFPA
and UNICEF—and we are working together. We already have
a coalition or a partnership among the three of us to continue
to work together with an agreement that whoever has the most resources
at the country level should be the lead agency. For example, in
family planning, we are a lead agency but that does not mean we
are doing it alone; it means we are supposed to catalyse whoever
is on the ground to work with us, whether they are NGOs,[6]
bilaterals or UN agencies, and of course to support governments
in that. That is how we are trying to function with one another.
Q6 Hugh Bayley: It seems to me that
the fragmentation is part of the problem. Why does not the UN
grasp the nettle and simply merge the three agencies? There needs
to be a clear strategic lead and it does not seem to me, despite
attempts at co-ordination, that that really exists.
Mrs Obaid: The way the UN is set
up, if you are not co-ordinating, including them will not solve
the problem. Already there are two important things happening
to address exactly what you are saying. One of them is that now
we have a group called the H8. All the agencies working in the
area of health have a commitment to work together and to hold
each other accountable for what we are committing. That includes
GAVI[7]
on vaccination; the Global Fund on HIV/AIDS, Malaria and Tuberculosis
because it is sexual reproductive health that is related to HIV;
the World Bank; the Gates Foundation; and of course UNICEF, WHO
and UNFPA. The main purpose of this coalition of the H8, the eight
agencies working on health, is to get together to do exactly that,
to ensure that at the country level co-ordination is taking place,
that there are comparative advantages in certain areas and therefore
we can deliver. DFID is very much involved in is delivering as
one and the eight pilots that are happening at country level.
Those are led by the resident co-ordinator; often that is UNDP.
Here Vietnam is an example where we have one programme with input
from everybody; both budgets are allocated together as is the
leadership in the different areas so that we are not doing fragmented
programmes but rather an integrated programme that looks at poverty.
When you look at poverty, you are also looking at population size,
at the bulk of young people who want jobs and healthy lives, and
also at sexual reproductive health needs that are not being addressed.
As you look at reproductive health, you are looking at issues
of gender, empowerment and violence against women. What is important
at the country level where that take place is the fact that we
can deliver as one. Now we have eight pilots for the `One UN'
Initiative. The General Assembly has taken a decision to study
the eight pilots to see what we have learnt from them before proceeding
further. Lots of the decisions are also Member State decisions
that are made in the General Assembly that impact on all of us.
Q7 Hugh Bayley: It seems to me that
politicians need to take a share of the blame because we set up
all these agencies. We have the benefit in the UK of having one
government development agency. We have mentioned already four
separate UN agencies plus the World Bank plus a global fund plus
GAVI. All are funded with governmental money. I suppose the Gates
Foundation is not. Is the problem that we get so little money
down to clinics in the field because we are supporting all the
dozen or so international bureaucracies full of officials, full
of policy planners, full of conference members? Should we not
be cutting away the bureaucracy to enable what limited money is
available—hopefully it could be more money—to actually
provide more emergency obstetric care?
Mrs Obaid: Actually, you are moving
that way. Many of the donors are going for budget support. There
is money flowing to governments. It is important to ensure that
the budget support itself includes maternal health. That is the
challenge for all of us. Part of our role in these countries is,
as I said, to ensure that sexual reproductive health does not
fall between the cracks. This issue is still sensitive—politically
sensitive, socially sensitive, culturally sensitive and religiously
sensitive—and often it does fall between the cracks. We
have made a great deal of effort even to buy a seat for example
in health sector reform where we pay into that so that we will
be at the table to ensure that the issues of sexual reproductive
health and maternal health are on the table. Governments have
an important role in this; donors have an important role; and
national governments also have an important role to play. Part
of this movement is to ensure health sector reform. When we talk
about health systems, we do not remain at the national level,
as I said before, but there is a push to go downwards. In terms
of size, and you have mentioned bureaucracy, I specifically indicated
where we are in terms of UNFPA; we are one-third international
with 210 staff members and the rest are national. The whole organisation
has one thousand staff members. Our numbers are not at six or
seven thousand like other organisations. The whole idea is to
move the dialogue to the national level where there are the skills
to do the work. There is emphasis now on the new aid modalities,
the Paris Declaration on aid effectiveness, to look at capacity-building
at the country level so that at some point they will not need
us. They need their own people to develop. If I can diverge a
little to return to what Dr Songane has said, the issue here is
not just money; it is the fact that some national capacity has
been lost; either people are not trained or they migrate if they
are well trained. In this whole area of human resources in the
health system, no matter how much money you pour in, you do need
the system in place and people who are not only trained but enjoying
good working conditions. Things are always greener outside. The
whole area of retaining them, training them and giving them incentives,
including social status to remain, is a big challenge. I believe
DFID is now experimenting in Malawi in the whole area of human
resources. That is something we should all look at, analyse and
learn from because we have to go that way. We should emphasise
national capacity.
Chairman: I do not want in any way to
constrain your replies because they are extremely helpful but
we do have a second evidence session. I ask colleagues to keep
their questions short. I do not want in any way to hold you back.
Q8 John Battle: I want to explore
the MDG targets. It is acknowledged that for the MDG 5 target
there has been no progress, deterioration and reversal. In 2006,
Kofi Annan announced that there would be a new reproductive health
target under MDG 5 "to achieve universal access to reproductive
health services by 2015". It is as if another target has
been tagged on to the original one. What is the status of that
and has it been formally agreed? How will it work? Are there timetables
and pathways now for implementation to get this MDG lifted from
being the lowest achiever to one of the highest?
Mrs Obaid: Thanks to DFID and
other donors as well as the co-operation and alliance with the
UN organisations especially UNFPA and the NGO Co-ordinate, the
target has now been approved. The report of the present Secretary
General has come out. It has been presented to the General Assembly
and now the target has been approved by the General Assembly.
We are working on the indicators. There are already proposed indicators
for it. We hope by March that the indicators will be finalised
and become officially part of what the national governments have
to report on. The struggle we had previously to get a target is
now practically finished. Importantly, it is politically finished.
Now we need agreement on the indicators and then to put it to
the national governments for reporting.
Q9 John Battle: Is there a plan to
get that target to catch up with the others. Is there a timetable
and a percentage to get it increased?
Mrs Obaid: The deadline is 2015.
We want to be able to decrease maternal mortality by 75 % by 2015.
Dr Songane: Part of your question
covers why MDG 5 is lagging behind. The issue is that not enough
attention has been paid to this aspect and it has not been done
comprehensively. We very much welcome the agreement of this target
in terms of health. We are looking to family planning as one important
intervention. We have to see family planning within the context
of the whole of reproductive health. If women do not have this
at the primary health care level, how can they access the Pill
and other means of contraception in order to avoid a multiplicity
of pregnancies? The more pregnancies you have, the more prone
you are to the risks. There is another important aspect that we
have to address within the context of an overall health plan.
As Mrs Obaid has said, it is important to make sure that maternal
and child health issues are put into the country plan. This brings
me to what Mrs Obaid said earlier, that things happen at the country
level. We need to gain acceptance that countries should lead the
process. The UK should be commended on the approach it is taking
with regard to giving this back to the countries so that they
can track the process. We need to exert pressure. Some institutions
in Britain have seats on the boards of these big institutions
and you could exert influence to change the way institutions behave,
particularly at the country level. Britain is part of the Global
Fund and part of GAVI. It donates money to the institutions. It
could exert pressure on those institutions to make sure that they
do not cause problems at the country level with various mechanisms,
ways of reporting and protocols to access the money. Let us all
take the country plan as our guiding document and all of us accept
that this should be the guiding document. If there are insufficiencies,
then the representatives of the different partners at the country
level should work together with the country to improve the situation
and facilitate the work of the country. If we could get that help
from Members of Parliament to change the situation, that would
really be wonderful. Members of Parliament may realise the neglect
to which this report has referred. One important thing it shows
is that where there is slight progress is amongst the countries
that are doing better. In the countries which are really doing
badly, there is no change at all; the situation is getting worse.
That means that the neglect is such that those countries are not
managing to get to the bottom of the problems. We need to move
quickly. The other plea is that within this International Health
Partnership framework which is being suggested we should take
as many countries as we can. 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. We have to learn from the process
already in place in many countries. Numerous countries have done
this but they did not go further because they did not get backing
or resources. Our drive is to take on this process. We should
not accept that these figures will only be improved by 2015. We
have to do what we know that we should be doing. We know the causes
of death and disability; we know the aggravations at work. It
is possible to deliver and to train people to do this. We can
do it.
Q10 Sir Robert Smith: You have emphasised
the need for skills and a lot of the written evidence has said
that skilled intervention at the time of birth and just after
birth can make a huge difference to survival rates and reaching
these goals. Has any estimate been made of the number of extra
trained health professionals needed to reach the millennium target?
Dr Songane: It is a huge number.
Last year the World Health Report was devoted to human resources.
It was estimated that an additional 300,000 nurses and midwives
will be needed as a minimum to address the issue of maternal health.
The other finding reported in the document I have referred to
is that the place where we have the highest burden is where resources
are lowest. The highest figures for mortality are in Africa. Africa
has 24 to 25 % of the burden of disease world-wide and less than
3 % of all the world-wide health workforce. In terms of resources,
with this burden Africa has less than 1 % of the overall resources
for health.
Q11 Sir Robert Smith: That is the
figure for midwives and nurses. Is there a figure for specialist
doctors?
Mrs Obaid: The figure from WHO
is 700,000 more midwives in 57 countries where there are critical
shortages. There is a global deficit of 2.4 million doctors, nurses
and midwives altogether.
Dr Songane: This is a critical
issue. We see this within the context of health systems. These
are critical interventions. If we do not have the people to run
the programmes, there is no way forward.
Q12 Sir Robert Smith: Is there any
strategy developed or in practice to try to encourage or increase
the number of midwives and obstetricians working in the developing
countries?
Mrs Obaid: We are certainly working
with the International Confederation of Midwives and there is
a strategy in place to train midwives in many of these countries.
We are also working with the International Federation of Gynaecology
and Obstetrics. It is a joint effort to do exactly that. As we
have said, part of the problem is that even if these people are
trained, if they do not have good working conditions and financial
incentives, they will migrate. They are wanted. That is why it
is very important to change the social status of midwives to ensure
that they have good financial compensation and good working conditions.
There is an experiment in Malawi by the UK and it is important
to look at that. Not only are they topping salaries and training
but they are bringing in volunteers to fill in while the midwives
are being trained. They are also building housing in some communities
to make it attractive to live in the rural areas. This is an integrated
and complex issue.
Dr Songane: May I add this to
the issue of training? We should not wait while we are training
doctors. There are ways of bringing the skills needed to people
who are not specialists, who are not doctors, and train them in
life-saving procedures, be they midwives, nurses or assistant
medical officers. That is being done in Mozambique, Tanzania,
Malawi, and Burkina Faso, to cite a few countries. There are publications
on this. This came out in the British Journal for Obstetrics
and Gynaecology and the WHO Bulletin and the Human
Resources Bulletin showing that they are as effective as specialists
in providing emergency obstetric care. Those nurses and assistant
medical officers can be trained to give those services. We build
as we go along: it is ideal to reach a certain level but we need
to find out how to deal with existing resources to make sure that
the care we are providing is safe and of quality.
Q13 Hugh Bayley: How many developing
countries have effective manpower, i.e. training plans, for health
workers that identify the numbers they will need in different
disciplines and match training to that? Is there a problem for
instance with the emphasis on universal medication for HIV/AIDS
that one agency will tip in a salary incentive to get people to
transfer from maternal and child health to AIDS work? How do you
overcome that problem of one international agency in effect poaching
staff from another international agency?
Dr Songane: That is a very good
question. It addresses the issue of how the different institutions
operate at the country level. If we accept co-ordination and know
that we are there not to raise the flag of HIV, malaria or tuberculosis
but to be part of the building of the health system and to address
that country's plan, then whatever resources we bring, we should
put those to the use of the country under the leadership of the
government. That is a major undertaking. If everyone agrees to
do that, saying that there are these resources and they will be
used only for HIV, then paying more to poach staff could be minimised.
I think that is the way to do it. It needs a change in attitude
in the various institutions and an acceptance that this should
be done under government leadership. If you want to address HIV/AIDS
without addressing the development and strengthening of the health
system, you are bound to fail. You cannot secure the person who
is under ARVs.[8]
That patient needs proper care, home care and social support.
If you do not build in all these things, you cannot be sure that
he or she will live a normal life and that person could die anyway,
even with ARVs. It is not with HIV alone; we do have other elements,
particularly the subject we are discussing today. In maternal
and child health we have more burden than HIV, Aids, tuberculosis
and malaria together but yet that is not recognised as an issue
in terms of the number of deaths and number of disabilities. It
is not recognised because it is not fashionable or a flag raising
matter to be seen as good to provide money for maternity and child
health. That is why we are quite pleased to be getting this hearing
and this commitment from Members of Parliament in the UK to help
us to raise the voice of those women and children. Countries have
plans. The issue of the long-term plan is that of predictability
of funding. We have a plan today; we are thinking about two or
three years. After those two or three years, we do not have the
resources we were counting on three years previously when we wrote
the plan and to know how to build on it. Let us revise this plan
and make a new one. The new way of doing business is to provide
the country with the possibility of predicting the money they
have and do their long-term planning. We should address the development
process of that country. Sustainability of resources is another
element to make sure that if they plan ahead for 10 years, they
know that they will have the money to get the workers they trained
today making progress in their careers. Progress in their career
is a very important element if we want to pay attention to the
status for the workers themselves. As Mrs Obaid has said, working
conditions and proper salaries form another element. I would put
that in this context.
Mrs Obaid: Can I add that the
traditional way of supporting governments is by vertical programmes,
and this is already happening. You support family planning alone
and you support HIV alone. Now we are moving towards linkages;
that has been adopted. It is within the UK strategy. All of us
have come together to integrate sexual reproductive health plans
with HIV because they are related. There is no way to look at
HIV and not at sexuality and reproduction. By integrating those,
you are increasing the workforce. If you train the family planning
people in HIV/AIDS and vice versa, you will then have increased
the human resources base that addresses communities and works
on that. That is one way of doing it. Family planning is a long
story that has been quite successful in the past. You build on
the institutions that already exist and go with them. The reason
we want to integrate is that there is mother-to-child transmission.
Often the child gets the treatment and survives but the mother
does not get the attention and she dies. We say that if you integrate
these, then you will catch the mother very early if she is HIV
positive and you start working with her and you do not wait for
delivery and for retrovirals. We were very pleased when we saw
in the UK strategy that it is talking about exactly what Dr Songane
has said. They are saying that investment in the health sector
should be long term, 10 to 20 years. There should be predictability
of resources and of course monitoring and ensuring accountability
over a longer period because this kind of change does take a long
time.
Q14 James Duddridge: Our principal
role as a select committee is to hold the Department for International
Development to account. On maternal health where our Department
for International Development works, if we could send our minister
away on two, two-day trips, one to a country and one to an international
donor, to learn best practice, which country and with which donor
would you suggest the minister spends time?
Dr Songane: That is a tricky one
because then we risk missing the countries that are doing well.
The committee has visited Mozambique. I do not say this because
I am Mozambican but the minister should definitely visit Mozambique.
I am just talking about what we have done there. Mozambique is
one of the countries. Another country is Tanzania. Uganda is another
country we could suggest if we are talking about Africa. If we
go to other places like Sri Lanka, the state of Kerala in India
or Vietnam, they are now coming up quite strongly and quickly.
Take Egypt and the Maghreb area: Egypt is moving quickly in terms
of improving the figures and addressing in a comprehensive manner,
although it is a Muslim country, maternal health and the figures
are coming down quickly. That is one of the leading examples.
Go to Latin America. Take Honduras or what Bolivia is doing with
insurance schemes to make sure that women are not dying in childbirth.
There are different examples we can list. In terms of institutions,
I would highlight the progress which we are seeing now at GAVI,
the Global Alliance for Vaccines and Immunization. There is now
a drive to make sure that the distortion the different funding
agencies cause is changed. I would plead with the Members of Parliament
to help us address the issue of other institutions. We know very
well the problems that are caused by the Global Fund to Fight
HIV/AIDS, Tuberculosis and Malaria in countries. It has been a
nightmare in some countries where they are putting in the largest
amount of money. Because of the power to influence the process
in countries through the amount of money they have, they are causing
many disturbances in the normal processes. The UK could play a
very important role there. Lastly, perhaps you could recommend
additional money for DFID to help us address this issue so that
women get support from DFID. I think we should see more being
done at country level. DFID is clear about the way the money should
be spent going to the countries; we need to get these resources
at a substantial level. It is good to do things in a different
way, to be co-coordinated and streamlined by doing one country
plan but additional money is needed. Even in my country, Mozambique,
we have progressed. We are almost reaching the Abuja target of
15 % of the budget allocated to health. Now it is around 12 to
13 % depending on the waves, but we need to do more and additional
money is needed. If whatever is started is not consolidated, then
there is risk of a breakdown and a return to square one because
the economies and the institutions are not strong. We need to
address this issue. It is like having an elephant in the room
when the discussion on health systems takes place; everyone moves
away because it is a huge subject, but this is basis. If we do
not address the health systems, there is no way we can move the
agenda in terms of health. Those countries which are successful
are addressing the issue of health systems. Money is needed. DFID
is well positioned to help this process through because they have
demonstrated that they do what they say they will do.
Mrs Obaid: May I add two quick
points? One is in terms of best practice. This is where DFID can
give support. We do have the H8 and GAVI is a member. GAVI has
decided to move into looking at the health system and not do a
vertical programme of just vaccination. All the H8s are talking
to each other about how to move together to be able to support
health systems and work within that. No money is needed there.
It is about us agreeing and moving forward. Because MDG 5 on maternal
health and MDG 4 have become so focused, there are many initiatives
coming up. The national governments are saying that they cannot
handle too many processes, that we should integrate the processes.
We cannot have a Canadian initiative and a Norwegian initiative.
There is the important International Health Partnership promoted
by Gordon Brown. There is no money there but it is a framework
that will get all of us to look at how these initiatives work
together and how they can support health systems. It is a co-ordinating
framework more than additional money. I think we need to emphasise
that. We cannot have so many different initiatives that the countries
themselves cannot deal with them. We have to integrate the initiatives
to help and feed into the national health plans, as Dr Songane
has said.
Q15 James Duddridge: So the recent
UK initiative is more than another initiative. It sounds to me
like an initiative that brings together initiatives, exactly the
opposite of what you are wanting.
Mrs Obaid: I am saying that it
is very important that these various initiatives that bring money
in are co-ordinated and support the national health plans. The
International Health Partnership promoted by the UK is really,
as you say, a framework to ensure that these are all co-ordinated
and that there is joint accountability in what we are doing.
Q16 Ann McKechin: We have been speaking
this morning about the danger of a plethora of international initiatives.
I think there is some concern that this new initiative announced
in September does not really make specific reference to maternal
health sufficiently. It speaks about global systems in the round,
and yet it will now have to co-ordinate with GAVI and with Dr
Songane's initiative and with a whole range of other multilateral
bodies. I wonder if we have got to the critical mass when we have
to say stop and we need to rationalise the number of initiatives
we actually have. In that context, I wonder whether you think
that there is a growing danger of maternal health not deliberately
but indirectly just beginning to be pushed back out. People will
look at things which are easier to define to donor communities.
It is easier to define vaccinations; it is easier to define antiretroviral
drugs, but it is much more difficult to define accurately reproductive
advice and facilities.
Mrs Obaid: Thank you very much
for raising this question because we are one of the co-signatories
to the initiative. We have been continually saying that there
has to be reference to reproductive health in the agreement. Finally,
it is there. I was at the launch of this initiative. In the discussion
I had to bring up sexual and reproductive health and say that
when you talk about mothers, there is sex somewhere in that. You
cannot talk about mothers out of the air. We need to push this
all the time and advocate it to ensure that whenever we are talking
about MDG 5, we talk about the bigger picture of reproductive
health before a woman becomes pregnant. Her health will impact
on the pregnancy and the child. This is about nutrition, education,
the complex way she lives, her access, customs and traditions,
et cetera. I agree with you that in this larger initiative there
always has to be voice and action to ensure that sexual reproductive
health is an integral part of these initiatives. It was mentioned
at the launch of the International Health Partnership agreement
and we would push for that.
Q17 Ann McKechin: Going a bit further,
you say it is in the agreement and it is in the text but is there
some agreement about what proportion of the funds raised under
this initiative will go to issues such as preventative health?
In our own health systems, prevention always gets cut away rather
than drugs or treatments. So are we going to say it is 10 % or
25 % that needs to be in health prevention?
Dr Songane: You have raised a
very important question. The Partnership for Maternal, Newborn
and Child Health provides the platform for development of this
process. We should see this in the context of a global campaign
for health MDGs. The whole campaign was built with various pillars.
One of the pillars was supposed to address the so-called global
health architecture: how we do business, how we liaise with countries,
how we avoid the disturbances we are causing. Another pillar was
to see what we do to address specific issues on maternal and child
health. When that was launched, the lead person was the Prime
Minister of Norway. Our campaign was launched at the same time
on 26 September called "Deliver now for women and children".
The campaign started in New York. We have to take this campaign
to the regions and to the countries to make sure that we do raise
the issue and ensure that the resources are put in. It is a very
important aspect and we must ensure that we are not distracted
by discussions about global health architecture which could cause
us not to put in the money, resources and drive where they should
be. "Deliver now for women and children" will be the
conduit through which we have to address this issue but we need
the whole context because the International Health Partnership
is supposed to provide the new drive for the global health architecture
and how we do business. Your question and another one earlier
are about countries receiving clarity. It is important to emphasise
that this is the first time that leadership at a high level has
addressed the issue of what are we doing in countries where we
are probably causing more harm than good. Together the Prime Minister
of the UK and the Prime Minister of Norway are saying that we
should reflect on this. It is the very first time this has been
dealt with at a high level of political leadership. I agree with
the caution of Members of Parliament. We should not build this
initiative as a big institution. We should not drive this in that
process. It is a platform for discussion and we have quickly to
get the different players really to change their attitudes and
show the countries that they are changing the way they do things.
If they admit that at country level different institutions are
going in and doing their own thing and so they are not doing any
good, that will be another addition to the partnership. You are
absolutely right: we have to address the countries' priorities
and have the country plans as the lead documents, and stop the
proliferation of different initiatives. All the resources should
go there. I would be glad to hear in the upcoming cycle of board
meetings of GAVI, the Global Fund and our own institution that
they are addressing the issue of what we have to change immediately
so that next year the countries will have a new picture of the
Global Fund and a new improved picture of GAVI—GAVI is doing
well, as I have said—and other institutions addressing what
the countries are asking for. Stop this proliferation and accept
that the country planners will deliver the documents. Work with
us so that the various groups do not function in a different manner.
Q18 Chairman: It is a big challenge.
Louis Machel said last week that in Tanzania there were 600 health
projects of under €1 million every year. He asked how the
Tanzanian Government can do that and why are those not co-coordinated.
It is a big challenge but I take your point.
Mrs Obaid: Can I raise one more
initiative of which the UK is a member and that is the G8? They
have committed themselves in 2007 to $1.5 billion of funding for
maternal and child health and voluntary family planning. Your
role, that of the Government of the UK, in this G8 initiative
would be to ensure exactly what Dr Songane has said, that funds
are pushed in the direction of the national roadmaps for maternal
health. We cannot say 10 % or 20 % because it depends on the country.
If we feed into the roadmaps of maternal health at the national
level, then the appropriate resources have to go to prevention
as well as treatment.
Q19 Richard Burden: Of the around
600,000 women who die each year from pregnancy-related causes,
about one in eight of those will die through issues related to
abortion-related complications. The concentration of those problems
tends to be in those countries that have the most restrictive
abortion laws. Obviously this has been in the news quite a lot
over the last few days. Given the fact that those countries count
for about 26 % of the world's population, how do agencies like
yours deal with that? The UN operates on the basis of building
consensus but there is this glaring issue there where a significant
number of countries have laws that apparently run completely counter
to trying to improve maternal health and women's health in the
way that you are trying to achieve. How do you deal with that?
Mrs Obaid: Actually as you have
said, death from unsafe abortion is the third cause of death in
Africa, for example. Also it is not only death, it is the issue
of disabilities that are associated. You have a larger number
of women then suffering, not only dying but having disabilities,
including infertility. For us as an intergovernmental multilateral
organisation we are mandated by our Member States to abide by
what was agreed upon in Cairo, which is paragraph 8.25 and we
have learned it by heart because we are asked about it all the
time. Basically our mandate is, one, to ensure that abortion is
not used as a family planning method; and that where it is legal,
which is all countries except four, all countries have some sort
of conditions under which abortion can be done; where it is legal
it should be done under good medical conditions. This means that
our role as the United Nationals Population Fund is basically,
one, to provide data, analysis and the numbers based on evidence
of what is happening in that area. Often they do not have the
numbers. One is to give evidence to the countries, so that they
have to understand the impact of unsafe abortion. That should
lead them to take correct decisions in terms of that issue. In
Cairo the consensus is that the decision on abortion is a national
decision—it is not imposed from outside—so you have
to work within that communication. The second one is when we strengthen
the health system capacity to prevent abortion, have family planning,
have planned pregnancies, you are decreasing the possibility of
abortion, but working with health systems to ensure that we are
developing the capacity to deal with the consequences of unsafe
abortion, as well as post-abortion care. We are the United Nations
Population Fund—this is what our Member States have told
us are our limits. However, there are NGOs; we have partner NGOs
who work in that area. As you know, the UK has established a fund
for safe abortion, which is managed by IPPF.[9]
We have our counterparts who have the ability to move in that
direction. Our role is limited to dealing with the complications
of unsafe abortion, providing data, developing the skills in the
health sector to deal with that and, of course, helping the governments
make the correct national decisions by providing evidence on the
impact of unsafe abortion.
1 Millenium Development Goal (MDG) Back
2
the Department for International Development (DFID) Back
3
World Health Organisation (WHO) Back
4
the United Nations Development Programme (UNDP) Back
5
the United Nations Children's Fund (UNICEF) Back
6
Non-governmental Organisation (NGO) Back
7
the Global Alliance for Vaccines and Immunisation (GAVI) Back
8
Antiretroviral (ARV) Back
9
the International Planned Parenthood Federation (IPPF) Back
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