Examination of Witnesses (Questions 80
- 94)
TUESDAY 13 NOVEMBER 2007
DR TIM
ENSOR, MR
ALEC CUMMING
AND DR
SAM ADJEI
Q80 Sir Robert Smith: Alec?
Mr Cumming: I just wanted to pick
up the associated point. One of our key findings is that even
if we were able to provide three pillars of a sound system to
address maternal health, that is family planning, skilled attendance
at delivery and access to emergency obstetric care, we have accumulated
a great deal of evidence that unless we identify in an individual
country's circumstances what it is that acts as a barrier to the
poorest women accessing these facilities the provision of the
facilities by themselves will not work. So we should not rule
out any means of achieving that, and Tim is identifying possible
means. Clearly the best means is if it can be system-wide support,
but the crucial thing is that unless we are able to ensure that
the poorest women can access facilities then we will not achieve
MDG 5. There are huge discrepancies between the maternal death
rates for the poorest women and the richest women in developing
countries. In Peru, for example, the level of maternal mortality
is eight times as high in the lowest income quintile as in the
highest. Generally speaking in the countries we are looking at
it is two and a half to three times. Unless the issue of addressing
access by poor women is tackled then we will not succeed in achieving
MDG 5. Vouchers, cash systems, supply-side provision, demand-side
subsidies, all need to be looked at depending on the individual
circumstances of the country, but what should drive it is ensuring
that the poorest women in society are enabled to access facilities.
Q81 Sir Robert Smith: The advantage
of cash over vouchers is that the person can be more flexible.
There are so many costs, whether it is drugs, blood or the transport,
that if they could maybe get a neighbour to help with the transport
then they have got some in reserve for other things.
Dr Ensor: Yes. There were real
doubts in Nepal when they introduced the cash a couple of years
ago whether facilities would simply have the ability to manage
cash because you have got to have the cash available when the
woman goes for the delivery. If you think of a remote area of
Nepal, perhaps at that time controlled by Maoists, there were
severe doubts that they would have the ability to secure cash
and I think those are very real problems. If you can get over
that it does offer a more flexible and simpler way of directing
resources.
Q82 John Bercow: Dr Ensor, in respect
of vouchers you highlight the problems of bureaucracy and cost.
I wonder if I can just ask you about two other issues and specifically
your view on them as between cash and vouchers. One is the question
of the scope for corruption. I do not know whether the scope is
greater with cash, as one might think, or with vouchers, but I
would be interested in the evidence based view or in any anecdotal
impressions you have got on that point. The second is the issue
of stigmatisation and what one might call transparency, but transparency
in a bad sense rather than a good sense. Ordinarily when one talks
in international development terms or public policy terms about
transparency it is normally magnified as an objective to be sought,
but in this context I mean more branding people. Although the
service to be accessed is a service for which it is perfectly
reasonable that people should get support, I wonder whether in
the context of the society it might contribute to labelling, abuse,
discrimination, dehumanisation or whatever. I do not know if you
have got a sense of that. Certainly in the very, very different
circumstances of our own society and in relation to a different
area of policy, namely the provision of support to certain categories
of asylum seeker for example, it is sometimes said by critics,
amongst whom I would number myself, that providing vouchers to
people is, frankly, a rather inequitable way in which to proceed.
Dr Ensor: There may well be good
evidence. I am not aware of good evidence one way or the other
on the ability to corrupt either a voucher or a cash system. I
think it is present in both systems. I am not sure which is more
or less likely to be corrupted. In terms of the stigmatisation,
I think that is an issue. It is a slightly tangential example,
but in Vietnam, certainly when they introduced insurance, which
was a kind of voucher for primary care for the poor in the 1990s,
many hospitals just refused to take it. They much preferred to
receive user charges where they could charge what they liked.
I think the other observation there is that if you target poor
areas rather than poor individuals then the problem of stigmatisation
is probably lessened. If you say there are vouchers for every
woman that lives in this area that happens to be poor then the
relative stigmatisation of individuals disappears a little.
Q83 John Bercow: Dr Ensor, you have
shown a prescience bordering upon a psychic quality which is greatly
to be admired because I was going to come on to the question of
insurance schemes. Are you arguing that intrinsically such insurance
schemes would fail to reach poor people or should donors, such
as DFID, in a sense refine and improve the model to ensure the
community insurance schemes for maternal healthcare hit their
target?
Dr Ensor: I think it is possible
for community insurance schemes to hit their target. I do not
think you can expect community insurance schemes to be sustainable
in that you expect people that contribute to cross-subsidise those
that do not contribute. The overwhelming evidence is that that
does not work. If you are paying into a voluntary scheme then
individuals are reluctant to make that much of a subsidy to the
costs of other people's care. If you want it to work then you
have got to be prepared to fully fund the same kind of coverage
for the poor as is funded by individuals that are not poor. There
is a colossal amount of evidence on community insurance and each
scheme varies. Most community schemes do not cover normal deliveries
because it is a predictable event. There is a problem with predictable
events. Many also do not cover complex obstetric care because
it is so expensive and community schemes tend to have small reserves
so there is a problem there. That is not to say you cannot do
it through community insurance, but it may not be the best vehicle
to provide for the sort of very complex demands of obstetric care.
Mr Cumming: The stage that Immpact
has now moved to— and it is in the final year of its activity—
is in fact to work with governments in the three countries in
particular that we have worked with to assess the most appropriate
strategy to ensure that maternal mortality is reduced. We have
the example of an insurance based scheme in Ghana, in Indonesia
different sorts of insurance based schemes, and in Burkina Faso
a rather different approach. We intend to go back. As both Dr
Ensor and I have said, there is no single answer to this. It will
very much depend on the social, cultural and governance status
of individual countries, but our intention is to work with governments
to identify those strategies which are going to be effective and
then we hope to publicise universal messages from that work.
Q84 John Battle: I want to return
to a point that was made earlier on about the budgets and monitoring
the budgets. What is a maternal health budget? How does it get
there? Why I am haunted by that question is that it seems to me
budgets to improve maternal health may have to fund hospitals
in an integrated way and even transport. The reason MDG 5 seems
to be so far behind other MDGs is you can clearly identify provision
of anti-retroviral drugs or mosquito nets, but in this area the
budget seems so diffuse. How do we know it is ever going to get
there? I was at a conference of the Voluntary Service Overseas
and they were having a conversation north and south and it was
suggested that rather than sending doctors and teachers, what
were really needed were good lawyers, IT specialists and accountants
to track and monitor the money. I want to ask you about that tracking
and monitoring of the money. What can be done in-country by civil
society to track the money effectively to make sure it reaches
the parts that need to be reached? What could DFID do more of
to ensure that that was a priority?
Dr Ensor: There are some very
good regular public expenditure reviews accompanied by those less
regular public expenditure tracking studies which summarise how
money is spent in the public sector and even in the non-public
sector and then look at whether the money actually reaches the
facilities. Those tools are well publicised by DFID in some countries.
What extra could be done is regularising those tools. There are
a few examples where governments themselves or Ministries of Health
themselves undertake annual public expenditure reviews, but there
are not many of them. Usually it is something that is enforced
from outside, often by the World Bank but also other agencies.
Encouraging a home grown public expenditure review is a very useful
tool. The second part relates to the second part of your question
and that is the role of civil society. Unfortunately civil society
has not been involved very much in using those tools, at least
in my experience and the countries I have worked in. The public
expenditure tracking studies, for example, are often extremely
sensitive. They are often done reluctantly by governments because
donors want them carried out. The one that was done in health
and education in Bangladesh, for example, took several years to
really see the light of day and to be properly disseminated because
it raises sensitive issues. I believe there are now some examples
in India where civil society is actually involved in training
people to undertake these studies and civil society are involved
in those processes. I agree with you that that is one area where
DFID could pursue more— I believe they are already—
in pushing the role of civil society in the use of those tools.
Mr Cumming: I am slightly concerned
at the first bit of your question, lawyers and accountants rather
than health professionals. Tim is entirely right, we need good
systems for tracking, but there is a gross deficiency of health
professionals in many countries.
John Battle: I am not trying to set one
against the other. I am just trying to raise the status of lawyers
and accountants!
Q85 Chairman: Were we not told in
Chad that 1 % of the budget reaches the end result?
Dr Ensor: There is a lot of evidence
on that now in different countries.
John Battle: Even the theme is becoming
a little bit of an `in' word, a bit trendy. You have got participatory
budgeting and civil society monitoring and budgeting even in the
north is only beginning to happen. Perhaps I could just ask if
there is information about the Indian example that would be helpful
and maybe we will encourage DFID as well as the government in-house
to encourage the civil society monitoring as well and look to
see how they can develop instruments and we could do a bit more
here as well.
Q86 Chairman: If there is any information
on that it would be helpful.
Dr Adjei: In Ghana what we do
is at the beginning of the budget year we all have targets set
around expenditures, for example that 42 % of expenditure would
be at a district level for different programmes and then at a
regional and then at a national level. At the end of the year
when the audit is done we can track and see if we are achieving
these budgets. Then you can do costing studies within the various
levels to look at where the money is spent in each area so that
you can know exactly how the funds that went, for example, to
the districts were spent because they will keep records of everything
within the system. The support for that kind of expenditure to
be done by the institutions themselves has always been the way
to assess whether donor funds have been used appropriately. In
addition we have independent audit systems which we agree with
the donors and they will bring together independent auditors and
they will go through the books and make sure that the funds are
reaching where they should be, and then the public accounts systems
bring to the public how funds that have been allocated to the
governance sector have been spent and on what. It is a system
that has been growing very slowly but importantly in ensuring
accountability and the proper use of funding that comes into the
system.
Q87 Hugh Bayley: I have been provoked
by your comment to ask about nutrition. Do you have any idea about
the cost-effectiveness in terms of maternal and child lives saved
per dollar spent by putting money into better nutrition as opposed
to into health? I am old enough to remember queuing up with my
ration book for welfare support in this country. If you were to
introduce food interventions, perhaps not so much in Ghana but
in parts of Africa that have suffered severe food shortages in
recent years, what sort of food interventions would you put resources
into?
Mr Cumming: That is not something
that our project has looked at. We have made the point about the
link between poverty and maternal health and clearly nutrition
is one of the factors that lead to the very, very heavy levels
of maternal mortality in the poor, but I cannot answer that question.
Dr Adjei: At the moment the bigger
problem area has got to do with anaemia in pregnant women. Much
of the emphasis has been on more nutritional supplements, iron
tablets and folic acid tablets to address anaemia because that
is the greatest risk. If the anaemia is very bad and the woman
has a small bleed then they can go into shock very quickly. The
emphasis has been on nutritional supplements for pregnant women
who come to us. Then there are associated factors like malaria
in pregnancy which also causes severe anaemia very quickly. Making
sure that you prevent malaria in pregnant women by treatment is
one of the ways to address the problem. The government has started
work in the whole area of nutritional messages called regenerative
health. It is a new programme that is targeting pregnant women
and what they must eat and the locally available foods that have
been studied and are rich in nutrients for pregnant women to keep
them well. That has also been promoted of late.
Q88 Sir Robert Smith: Just thinking
about previous evidence sessions and some of the briefings we
have had. Is not the reality that in relation to the survival
rate for mothers in childbirth it is actually being able to intervene
at the time of the birth that makes the dramatic difference? Dr
Ensor: Yes. I am not sure I can offer very much on the
nutrition angle. I do not think you would pitch the two together
in an analysis of cost-effectiveness because both are needed and
as you say, many of the deaths are because you cannot deal with
the emergency as it occurs. Better nutrition certainly helps the
final outcome, but the infrastructure for that emergency care
is also important.
Q89 Hugh Bayley: Maybe it would have
a bigger impact in terms of years of life gained with children
rather than with the mothers.
Dr Ensor: Yes.
Mr Cumming: The main causes of
maternal death are not directly nutrition related.
Dr Adjei: It is the haemorrhage
which is the problem because if it is bleeding you have to intervene
with the bleeding, but to the person who is anaemic and who loses
a small amount of blood very quickly, that is where the link with
nutrition comes in. You have better haemoglobin levels during
pregnancy.
Q90 Hugh Bayley: Iron tablets rather
than food rations?
Dr Adjei: Yes. Basically, that
has been the approach but also malaria is a major cause of anaemia
in pregnant women so that is also another one to deal with.
Q91 John Bercow: How widespread has
the uptake been of Immpact's new tools for measuring maternal
mortality such as the Sampling at Service Sites methodology?
Mr Cumming: They are only now
being publicised so the uptake at the moment has been internal
within the project. The aim now is that we are offering them as
a public good. We published a revised version of the Immpact toolkit
to coincide with the major conference, which I think you are aware
of, that happened last month, Women Deliver. Subsequent to that
there was a huge amount of interest in these tools and we are
arranging for a series of training courses in the use of the tools
with colleagues in developing countries. We expect to see these
tools used widely. So far though they have strictly developed
within the project. Given the huge cost benefit— for example,
in the Sampling at Service Sites technique— compared with
the population— wide surveys and given the very dubious
nature of the evidence just now on maternal death, it is really
important that these methods are publicised and made widely available.
That is the aim.
Q92 Chairman: The effect of these
methods is that you are identifying a worse situation.
Mr Cumming: It varies a little
but generally speaking we are finding that levels of maternal
mortality are higher than those that are officially recorded.
Q93 Chairman: You talked about the
project being in its final year. What is its current situation?
You have done the work. You are presumably now putting forward
recommendations. What is DFID's engagement? Is there an absolute
timescale? In other words, is it all going to come to a definite
end?
Mr Cumming: The project was funded
for a specific purpose, to identify evidence of what is effective
at reducing maternal mortality. We have done the work. The last
stage of what we are doing should be to prove that it works by
going back to individual countries to work with them in developing
strategies. The funding that we have from DFID, the Gates Foundation,
USAID and the EC[4]
will be fully exhausted by the end of August of next year. We
do think a project should have a beginning, a middle and an end
and it will come to an end at the end of August. There is a need
to continue with research into maternal health, both in terms
of measurement and in terms of effectiveness, but that would represent
a new phase and we are in discussion with DFID about that. DFID
are very positive about supporting the work that we do in making
sure that our findings are implemented and they have said that
if we come back with proposals for further research then they
and others will be interested in that, but that is for us, to
go back to them and make the case for further work.
Q94 Chairman: Will you be producing
a final report on the project and, if so, is there a time frame?
Mr Cumming: Yes. We are working
on that right now. The emphasis of that report is on freeing the
poorest women in society from barriers which stop them attaining
care. We expect to produce a draft of that by about the end of
the year and to publish it in the spring of next year.
Chairman: I think that will be extremely
helpful. Those of us on the Committee who have embarked on this
report, to be honest, have been absolutely shocked to the core
about both the figures and the appalling suffering and indeed
major social consequences in terms of orphaned children and fragmented
societies and indeed the interesting point that it can contribute
to conflict and social breakdown. In other words, it is a fundamental
contributor to poverty. Anything that helps focus on practical
measures that can address this is much more significant than just
isolating it as a single factor. Yes, it is terrible for women.
Yes, it is terrible but it has much wider repercussions than people
think. I am sure that your work is extremely helpful in understanding
the problem and perhaps coming up with solutions and I hope our
report may help contribute to that as well. Can I thank you all
for coming in and helping us with our inquiry.
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