Examination of Witnesses (Questions 95
- 99)
TUESDAY 13 NOVEMBER 2007
DR TONY
FALCONER, DR
MONIR ISLAM
AND DR
NYNKE VAN
DEN BROEK
Q95 Chairman: Can I welcome the three
of you. You have obviously been here for our previous evidence
and have heard what issues we are exploring. We are grateful to
you for coming in and giving us your expert advice. Just reading
the background brief, it is clear that your organisation effectively
sprang from these problems in the now developed world. Obviously
we are interested in the extent to which what we might call the
crisis or the shame of the developing world can be addressed.
Could you introduce yourselves and say who you are and what your
qualifications are for our record?
Dr Falconer: I am Tony Falconer.
I am basically a practising clinician, obstetrician and gynaecologist
in Plymouth. I have recently taken over the responsibilities of
senior vice-president of the Royal College of Obstetricians and
Gynaecologists. The principal brief of that job is international
affairs. Our Royal College, as you said quite rightly, was instigated
77 years ago in response to the magnitude of maternal death in
the United Kingdom. We are an international organisation. About
50 % of our members and fellows come from overseas, principally
in the developing world, so we have a massive training, teaching
and supervisory responsibility for that part of the world. Recently
the International Office has also developed very close relationships
with Liverpool and that has enabled us to become, I suppose rather
late in the day, rather more adventurous about some of these very
major issues that your inquiry is highlighting.
Dr van den Broek: My name is Nynke
and I am a trained obstetrician and gynaecologist. I am a Fellow
of the College of Obstetricians and Gynaecologists, trained in
this country. I have spent most of my working life working with
resources projects, mainly in sub-Saharan Africa but also in Asia.
In 2001 I joined the Liverpool School of Tropical Medicine as
a senior clinical lecturer and my work combines improving delivery
of clinical services research with evaluation and management of
programmes. I lead a small team in the School and, as you all
know, the Liverpool School of Tropical Medicine is the oldest
school of tropical medicine in the UK.
Dr Islam: I am Monir Islam. I
am the director of Making Pregnancy Safer, a department in the
World Health Organisation in Geneva. I am also a member of the
executive board of the Royal College and that is our collaboration.
We are responsible from our department with global responsibility
of maternal health.
Q96 Chairman: Thank you for that.
It is extremely helpful just to have that brief introduction to
your own backgrounds. As you can see, what we are looking into
is, in practical terms, how DIFD and donors like DFID can be more
effective in helping developing countries to deliver improved
maternal services. What do you think that an organisation like
DFID could do that would help strengthen health systems in ways
that would deliver results? In other words, are we talking about
developing the infrastructure network, developing the expertise,
the human resources, providing the drugs or the monitoring of
all of that to make sure it happens, because we have evidence
of resources being put in but not actually getting to the people
who need them. We have had anecdotal and specific evidence for
example in Chad of essential drugs simply not being available
in the country. Could you give us a flavour of where you think
the priorities are? They are probably everywhere but have you
some thoughts as to how they can be channelled down and focused
effectively by the intervention or support of an organisation
like DFID?
Dr Falconer: Your question is
very penetrating but I guess, from the position I am coming from—
we will have different positions— it would be human resources.
The bottom line of what I have heard in the previous hour is that
the thing that really is missing in most of the provision of health
care to labour in women overseas is people with the skills. The
position that we are coming from I think is a multidisciplinary
one to training. Our principal responsibility in the Royal College
has always been training. Over the years we have been active in
training doctors. We have a huge membership overseas, organised
in networks. For instance, if you look at an old fashioned map,
most of the countries that are pink on that map will have representative
committees and large numbers of members and fellows, so there
is a certain standard and quality for provision of care with the
doctors in those countries. I think now we need to be more adventurous
in this because the evidence is that SBAs[5]
are the critical, key player in terms of provision of primary
health care to women. New models need to be looked at for how
you train other health care professionals. That is the position
I come from. The issue you raise about drugs I guess perplexes
most of us because the major obstetric drugs— be it oxytocin,
although that has a problem because that has to be kept in the
fridge— but, if you look at magnesium sulphate, it is dirt
cheap. There is no provision in terms of care and how you manage
that and it just bewilders me why provisions for that are so problematic.
People who have spent much more time overseas will be able to
answer those questions, but that should not be a major difficulty.
The last point that you made I think is incredibly important,
which is quality assurance and having some audit on what is going
on. Nowadays we need to get into the situation where, whatever
interventions we do, whether they are training or whatever, there
is an audit trail on those so that we have evidence of good practice.
Nynke, I am sure, will talk about some of the courses that we
have delivered overseas in terms of training people.
Dr van den Broek: That is right
and I think I agree with the previous evidence that you need to
have a functioning, good health system to be able to have equitably
distributed maternal health services. I am encouraged that there
is increased advocacy for this because that is needed. MDG 4 and
5 have not been highlighted. Malaria, HIV and TB have been much
more prominent. Perhaps it may be easier to solve them. It is
quite clear that there are insufficient good quality services
available worldwide for women who are about to deliver or who
have complications of pregnancy delivery. You cannot really develop
one without the other. If you can use the development of a good
system and that is management, governance, finance, all the things
that we know you need in a health system, the infrastructure,
the drugs but also the governance and focus on making sure that
at least a minimum number of health services are available for
maternal health, then you can see how one influences the other.
You will make a real difference and there is evidence for that.
It is very clear that the two key health services, if you like,
that are needed are skilled birth attendants and essential or
emergency obstetric care and they are very well defined. That
is what I would go for and unfortunately that is more complicated
than saying "we are only going for drugs". You need
to address the spectrum.
Q97 Chairman: I kind of expected
you would say that. It is really trying to see how these things
fit together from your point of view as professionals.
Dr Islam: We discussed this morning
whether DFID should provide budget funding or vertical funding.
It would be good to provide budget funding but with some indicators
to ensure this funding is being utilised for priority activities.
There has to be a monitoring system because if you are providing
only the budget funding without any indicators or control then
the money can go anywhere. How then will you ensure that money
is going to be spent on the health system? The maternal mortality
rate is one of the indicators for a functioning health system.
I would like to see improvement of maternal health become an indicator
to assess how countries are using the funds. If you add those
indicators, then budget funding would be a good thing. To give
an example, when DFID funded a project in Nepal on maternal health,
they had improved the system making surgical procedures and blood
transfusions available. This improved system not only helped maternal
health but also other programmes. In road accidents blood transfusion
is necessary, surgical expertise is necessary, the system could
be used. The health workers with surgical training were there
to provide services in those cases. So I would suggest incorporating
some indicators in budget funding. Then, also some vertical funding
needs to be available. Last week I was in Zimbabwe and I visited
one of the midwifery training schools. The school did not have
the necessary books. They have only one midwifery book and 120
students are using the same book. One book costs nowadays $29
million Zimbabwean which is nearly $29 US. It is now $950,000
Zimbabwean for $1 US. We changed in one day from $800,000 to $950,000
Zimbabwean for $1 US. You can understand what is really happening.
The books are not there. The number of faculty members has gone
down. There are supposed to be seven or eight faculty members
in that training school. They have only three. They do not have
the right number of trainers. They do not have books or dummies
and the charts are old because the funds are not there. I was
so surprised to see that the students are really willing to learn
and to contribute to the nation, but those necessary supplies
are not there. We need to look at how we can improve the training
facilities and providing the training. Then look at part of the
supply side of it, particularly in maternal health. Oxytocin,
magnesium sulphate and antibiotics are the most needed supplies.
These are a few things which are necessary for maternal health.
More importantly, DFID and particularly the parliamentarian group
can also look at investment issues in developing countries like
Malawi, Zimbabwe or Chad. The developing countries should not
only be looking at what money they are getting from DFID but need
to look at what they themselves are investing to improve maternal
health. The countries need to also look at how the national budget
is being allocated. What are the priority areas? This year with
the UK Parliamentarians in Westminster, we got the parliamentarians
from 15 developing countries and discussed how parliamentarians
can raise that issue in their own parliament to increase their
investment on maternal health and in other social sectors. That
also needs to be there. The last issue that I would mention for
DFID's support is the monitoring system because today if you ask
the polio programme they will be able to tell you exactly where
polio is coming from, where the outbreak has happened, but for
maternal health the monitoring system is still very weak. We need
to really invest more on the monitoring system and see how at
the district level they can use the monitoring system data for
planning, not only to send it to the national headquarters for
a report to come out after four years and it has not been used.
They can improve how districts use data for their own planning
purposes. In those areas, I think DFID has done good work and
DFID's support for maternal health is really tremendous. We need
to look at all those things and decide how we can provide funding
support.
Q98 Hugh Bayley: I just wonder what
role there is for the private sector to make a contribution to
reducing maternal deaths in developing countries?
Dr van den Broek: Many countries
are addressing this issue because it is recognised that in a number
of countries the private sector is, if you like, going up, which
generally means that people with more money have better access
to care. The report we compiled brings that out a little bit from
people working in various countries, looking at different mechanisms
with which you can make use of the skills and expertise, which
are more available in the private sector, and distribute them
more equitably. There are small scale projects where this is happening,
where members of staff are doing both, some private and some more
public orientated. There are bigger projects in districts where
private hospitals adopt smaller hospitals and make a very close
link. There are also other problems with the private sector in
that they might not be helping. I think they should be regulated,
especially with regard to for example Caesarean section rates
or quality of care that is being given, so not perhaps for evidence
based care but for financial incentives. There needs to be better
international regulation of such institutes who will want to be
highly accredited and seen to be doing the right thing. This has
recently been approved for example in Sri Lanka, where at the
moment less than 7 % of deliveries are happening in private facilities.
They are looking for regulation but there is no international
guideline either from the UN bodies or from us, so there are opportunities
and I think the time is right to address this. It is too simple
to give one simple answer but it is no longer okay to ignore that
the private sector is growing, including for maternal health.
Dr Falconer: It is a very interesting
question and an analogy with our own system. There is an inherent
conflict here. If you look at where medical personnel are in many
of these under-resourced countries, they will be in the major
conurbations and they will be doing some private sector work.
You cannot maintain these staff in the rural locations. One of
those conflicts is that they get paid so poorly in their basic
hospital salary that they have to do private practice. Certainly
my experience of visiting many of these people is that they have
to work in the evenings and through the night to make their money.
In terms of what impact that makes in the totality of health care,
I would think it is probably relatively small in those countries.
Q99 Chairman: It does not have a
political fall-out? Some of the statistics we have seen are that
in quite a lot of these developing countries what you might call
the elite, the better off, do not suffer all these dreadful maternal
deaths and problems so they do not perhaps see the need to fight
for those who do.
Dr Falconer: This is again going
back to the training issue in terms of who should you train. If
you train people who do a Caesarean section who are not doctors,
then they will not be attracted because they cannot charge that
fee. Again, in terms of where you put your resource, you may be
better not to train people like me.
Dr Islam: We need to also look
at the issues of the private sector. Of course the private sector
has to play a bigger role but there are issues coming out that
we need to look at while considering the private sector. Because
out of pocket expenditure is high and going up why not invest
in the private sector? Then we need to look at the out of pocket
expenditure. A poor man: is he buying health or remedies? If somebody
has had a cough, a poor man, he does not go to check whether he
has TB but he goes to buy a cough mixture, just for the remedy.
If this poor man has got a high temperature, he does not go and
check whether he has malaria or pneumonia. He goes for Paracetamol.
They are buying, spending their own money, just for temporary
remedies but they are not buying health. This is out of pocket
expenditure. Looking at only the amount of out of pocket expenditure
and then saying, "Okay, out of pocket expenditure is so high,
like in India 60 % of total health expenditure is out of pocket
expenditure, therefore we should go to a private sector."
That should not be the argument. We need to look at the private
sector which needs to play its role but at the same time we should
not be avoiding investing in the public sector. The public sector
has provided support for a long time and we need to look at why
the quality of services is going down. Private sector salaries
and NGO sector salaries are higher than public sector salaries.
So we need to look at the other issues, at why the public sector
is not functioning before we say forget about the public sector.
5 Skilled Birth Attendants (SBAs) Back
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