Examination of Witnesses (Questions 120
- 139)
THURSDAY 22 NOVEMBER 2007
MR RICHARD
HORTON AND
MS BRIGID
MCCONVILLE
Q120 Chairman: Can I bid you good
afternoon and thank you for coming in on this inquiry into maternal
health that the Committee is carrying out. We have had a considerable
amount of evidence. We have already taken some formal evidence,
and I would not say the Committee is yet expert, but we are beginning
to get to grips with the issues of what is an extremely demanding
international ambition which we are falling a long way short of
achieving. I wonder if, for the record, you could briefly introduce
yourselves and then we can perhaps proceed with some questions.
Ms McConville: I am Brigid McConville.
I am a journalist. I was elected to the Board of the White Ribbon
Alliance for Safe Motherhood in 2005. The White Ribbon Alliance
is a unique international grass roots advocacy organisation based
in developing countries. We have got 14 country alliances; we
have got members in 91 countries. Our basic approach is that this
is a social and political issue and that advocacy is the key to
moving the whole issue forward, and the main problems are rooted
in the low status of women and that the voices of the poor, especially
poor women, are not being heard.
Mr Horton: My name is Richard
Horton. A long time ago I used to be a practising doctor, but
no longer. I edit a medical journal, The Lancet. We have
a particular interest in international health issues, very broadly,
and what we have tried to do over the last three years or so is
bring together teams of international scientists to focus on neglected
issues, of which maternal health and sexual reproductive health
are two very important domains, to try and generate new evidence
to inform the global and country debate around solutions to these
challenges.
Q121 Chairman: Thank you very much
for that. One of the things that have been said to us is that
the ideal solution to the problems of maternal mortality is an
established health service infrastructure on the ground that women
can access, but that is a long way from where many developing
countries are. There seems to be a debate about whether the emphasis
should be on providing the services or actually helping with what
their rights are and supporting their demand for the services.
I wondered if you could comment on whether you think that the
DFID[1]
approach has got that balance right or whether there is a need
for reassessment of where the emphasis should lie and whether
or not you accept what we have been advised, that DFID's record
on this is, generally speaking, good, but feel free to make any
comments that you think appropriate about your judgment of DFID?
Ms McConville: We feel that DFID
has done an excellent job in many ways, especially in funding
governments, and also DFID has supported the White Ribbon Alliances
to some extent. Our point of view would be that, unless there
is demand for services in communities, women will not have access
to them. For instance, I do not know if you have heard the expression
"the three delays"; that is one way of describing the
difficulties that a women will face. For instance, if she goes
into labour in Burkina Faso and she starts bleeding, that is a
medical emergency, but there will be a great delay for her seeking
help because she will perhaps think, for a start, that it is a
matter of witchcraft, and after that, when they finally get round
to moving her to a health facility, it could be a 30, 40 kilometre
journey to the health facility. If she does not have any money
to pay for the care that she will need when she is there, she
will not be able to go. If she does not have her husband's permission,
or in some countries her mother-in-law's permission, all those
delays will prevent a woman in the community from seeking care
and, unless we address those delays, even if the best services
are there, she is not going to get to them. So, one is no good
without the other would be our view.
Mr Horton: I think you point out
actually a dilemma that has in many ways split the maternal health
community in an extremely damaging way, because it has caused
confusion about advocacy. Should one take the line, as many would
say is the ideal solution, of a facility-based intrapartum care
solution or (but maybe it is an and) have community based solutions?
In terms of DFID's role, when you look across the array of donors
out there, I would say that DFID has played an outstanding role
in trying to get the balance right between those. It is a very
hard balance, because you always end up upsetting one group or
other, and they do, unfortunately, divide into groups rather clearly.
The DFID approach, as far as I see it, has been to support very
strongly the policy of facility-based intrapartum care but also
to support very valuable research based in the United Kingdom
into the efficacy, the impact, of community-based solutions; and
over the last three years there has been a gradually accumulating
evidence-base to show that women's groups in communities can be
extraordinarily powerful in reducing maternal mortality, newborn
mortality where you do not actually require facility-based intrapartum
care.
Q122 Chairman: Is that by providing
support in the community for the mother?
Mr Horton: Exactly right. It is
about building up knowledge and social capital awareness and a
demand from women in communities for maternal health services
and local knowledge about very simple things related to hygiene.
DFID has pursued this dual approach to try and accumulate knowledge,
on the one hand, about community-based solutions that pursue a
more political target of a policy of intrapartum care.
Q123 Chairman: So you say that DFID
is good at identifying and, indeed, even encouraging the local
communities and the women in the communities especially to express
themselves. I do not know if that is Brigid's area, but that is
the real key. You have kind of sat on the fence and said they
do it, but I just wondered: are they proactively doing it?
Mr Horton: There is a divide between
DFID's role in countries and DFID's role at the centre. I am talking
about DFID's role at the centre in supporting the creation of
a strong and robust evidence-base that can then lead advocacy
for community-based solutions.
Ms McConville: I would say that
DFID has supported some excellent projects. This is one that I
received from DFID. It is a short participatory film project.
I will give you copies later.[2]
You will see here there is a community of mothers and midwives
making their own film. This film was then shown in the communities
outside the local hospitals. That raised the profile of the issue
and of the women involved in those communities. It then went to
the capital, Dar es Salaam, where it was shown in the Parliament
building. The Minister of Health was there; all the leading figures
were there. That raised its profile again. It then became a film
that was shown on TV. The White Ribbon Alliance rang around all
of the parliamentarians and said, "Watch this film and ask
questions of the Minister tomorrow", and they did that in
Parliament and that was a tremendous amount of pressure to improve
human resources for maternal health. That is an example of a very
successful project, but it has not been sustained. I think the
other point I would like to make is that DFID is funding governments,
which we welcome. However, governments do not hold themselves
to account. Who is going to hold those governments to account?
As MPs, you know how that works. You do need civil society to
ask the questions. I can tell you that White Ribbon Alliance members
in many countries are going out to the facilities and finding
out who is there, and they might find that the Government has
said there should be two or three midwives and, in fact, there
is only a caretaker. They are bringing back the statistics and
raising the pressure on governments to fulfil their duties and
they are also then working with governments on policies and plans
for the future. So I would like DFID to support that.
Q124 Chairman: Do you think that
it could do more on that front?
Mr Horton: It could do more on
supporting civil society, yes.
Q125 Jim Sheridan: Just on the community-based
service facilities or, indeed, qualified staff, particularly in
rural areas, and I have extremely limited experience: it is extremely
difficult to get facilities or services or, indeed, qualified
staff to move out of the city centres, if we can call them that,
into the rural areas because most of the qualified people either
want to emigrate to some other country or they want to stay where
they are. The main reason for that, particularly if they have
a family, is there are no education facilities for their children,
and that is the reason why they do not move to the rural area.
Is there anything that DFID can do to incentivise qualified people
to move from the urban areas to the rural areas in order to deliver
maternal services?
Ms McConville: You are absolutely
right that that is a major barrier. Of course people who have
qualified and worked very hard to get there are then reluctant
to go off into remote and possibly insecure districts. I think
that DFID can certainly help civil society and lobby government
for perhaps better salaries and better incentives to work in those
rural areas. Certainly in Tanzania they have been very successful.
There has been a five-year advocacy campaign to persuade the Government
to employ and deploy more skilled birth attendants to the rural
areas, and I can provide you with those figures, if you would
like.[3]
They are quite stunning. That steady pressure has been very successful
and, in some health facilities where no women were going to give
birth, there are now 30 in a short space of time, and in places
where there were two healthcare workers there are now four or
six. So that steady pressure on government, if DFID can back civil
society to help bring that pressure to bear on governments, I
think is the way forward.
Q126 Chairman: That is a slight difficulty
for DFID— I do not mean it is one that they cannot take
on board— as to what extent are you responding to community
needs or stirring them up or trying to manage them. In terms of
the practicalities, how can DFID do that in a way that is ensuring
that they are genuinely getting the response of the community
rather than, even if unintentionally, manipulating or directing
it?
Ms McConville: I was part of the
Women Deliver team planning the conference that was on recently;
there were some advocacy people in New York saying, "We need
to start a global movement." There is a global movement.
All over the developing world there are people who are the people
with the ideas, with the experience, with the energy. They are
the people who know the problems. They are the people who know
the solutions. They are the social entrepreneurs of their generation.
They are often midwives who have had the tragedy of working with
women who have died in childbirth, and that never leaves you.
They are already working very, very hard, and this has not started
with DFID, it started in those countries with those local people.
In India, where the White Ribbon Alliance has been tremendously
successful, for instance, there was a march to the Taj Mahal,
I think in 2000 or 2002, and thousands of people attended that
march. It grew and grew— parliamentarians, media and film
stars were involved. That made such a big impact on government
that they then invited the White Ribbon Alliance to work with
them on planning and policy changes, and there was a tremendous
shift there in that the staff, and even the auxiliary nurse midwives
who were previously not allowed to perform certain life-saving
skills, were then licensed to do so; that work is continuing and
the White Ribbon Alliance is now working with government in six
states. There are six state alliances as well as the national
one. So, I would say that is not a matter of DFID stirring things
up; there is already a tremendous amount of energy and activity
that needs to be supported.
Mr Horton: Yes, I think that is
right. I will try and place it in a broader context, because there
is a danger of having a series of vertical programmes here. One
of the things that DFID is doing very well and is being encouraged
to do even more is to help persuade governments to support the
health system more generally. It is not just about maternal health
here. There is a whole series of issues for which the health system
has to be strong in financing human resources stewardship in order
to cover, including maternal health but also many other areas,
so I would be careful about singling out one exclusively. If you
go to a health facility in Northern Ghana, there will be a doctor
there who is trying to cover surgery, paediatrics, maternal health,
a whole range of things— just one person covering a huge
area. It is that broad-based general budget support for the health
system that has to be the focus, and that is, indeed, what DFID
has been pushing strongly.
Q127 Sir Robert Smith: You have already
touched on the balance between facility-based and community intervention.
In September 2006 you carried an article by Anthony Costello and
others that in the long run the ideal solution is the facilities
based but in the short run medium term community interventions
can make a difference. I think you said in an earlier answer that
DFID were already funding research that was showing that community
interventions could make a difference.
Mr Horton: They funded Anthony
Costello's work.
Q128 Sir Robert Smith: Is this the
only research, or is there other research that you could point
us to that shows, in the short term, that having that community-based
intervention would make a difference?
Mr Horton: This is one of the
problems. There has been a lack of evidence about the community-based
support. There are vitamin A trials going on, community-based
interventions, women's group interventions; there are something
like four clinical trials that are currently in progress in Asia
and Africa, some of which are being done by Anthony Costello,
many of which are being supported by DFID. So we are accumulating
knowledge right now as we are meeting to try and answer this question,
but to my mind this dichotomy that is being created is a false
dichotomy. You need dual approaches. You are not going to solve
this by a purely top-down building clinics and facilities. You
have got to mobilise the grass-root support in villages if you
are really going to tackle this as well, and I think that that
policy message has not been strong enough out of UN agencies.
I think there is a real problem in UN agencies over this. We have
a UN system that, frankly, does not work very well. There is no
single technical agency that leads on maternal health; it is divided
amongst many. There is a paralysed partnership on maternal, new
born and child health right now, and so we have a problem there
in terms of global leadership, and I think DFID can play a vital
role, an increasing role, in trying to mobilise that global leadership
which is absent right now.
Q129 Sir Robert Smith: In mobilising
the community to demand so that there is better delivery, is there
an ethical dilemma in maybe raising the expectation of the community
that that is what they need and, in a sense, creating a demand
so far ahead of any supply that you are actually----. Is there
an ethical dilemma there?
Mr Horton: I think if you go to
villages and you just sit with village elders, with women and
talk about the predicament they face, those kinds of dichotomies
I personally have not seen; maybe others have. What you see is
just a desire to take control of decisions about their health,
to get access to services to which they do not have access and
to find the best way to do the best they can for their families,
their children and their community. These nuances that we talk
about are really not very strongly evident in the villages that
I have visited, which is why I think we need to be ruthlessly
pragmatic about what we can do and not let ourselves fall into
what are sometimes ideological traps: we must only follow this
course because that is the ideal, that is the rights-based approach
that says you must have this and nothing less will do. We need
to be a little more, as I say, pragmatic about solutions.
Ms McConville: I would back Richard
up on that. What comes to mind for me is that, when you go to
villages and you listen and talk with the people about what is
going on, you will get a sense of how incredibly hard people will
try to save mothers' lives, how difficult it is, the dangers and
the perils that they face— long journeys through the night,
down rough roads where there are security problems, sometimes
carrying women on wheelbarrows or on stretchers, sometimes for
days on end, a woman who is in agony, who is bleeding and dying.
Often men get blamed for not giving enough support, but the number
of husbands who have contributed to our Stories of Mothers' Lost
exhibition and talked about their terrible grief at losing wives,
fathers who have lost daughters. It is a whole community thing,
and I think really that we have to all work together to support
the people in communities, who are very intelligent and determined
people, who are tremendously resourceful up against barriers that
we can hardly imagine and they will do anything that they can
to save the lives of their mothers, and we are letting them down,
frankly, by not providing the health system that they need to
make that possible. Why is it that there is no road for them?
Why is it that there is no form of transport? Why is it that there
no magnesium sulphate in the first health centre that they get
to? It is as cheap as table salt. In an age where we have had
astronauts on the moon for decades, it is a disgrace. We need
to work together to make sure that we back the energy of those
communities with an equal commitment to make sure that those lives
can be saved.
Q130 Sir Robert Smith: Magnesium
sulphate came up last time we took evidence. No-one could quite
understand why something so basic—. It is not particularly
rocket science.
Mr Horton: No.
Ms McConville: I can give you
a view on that. It is that women are not valued around the world.
A woman's life is of very little consequence, unfortunately, in
many, many cultures, and that is the bottom line of all this and
this is why this is a political issue. For a very long time it
has been seen primarily as a health and a technical issue, and
of course that is true, and we do need the health solutions, we
do need the health systems, but the key to this is the advocacy
to make that link, to convince the people who have power in communities
(and that is usually men) and in governments to value the girl
child, to value women. Girls do not get fed in the same way that
the boys get fed around the world. Girls do not survive. They
do not get educated. They do not get employment. They do not get
health services. That is the level, and we can take the lead on
that, I think, internationally.
Q131 Ann McKechin: Brigid, you spoke
about a network of groups within developing countries who are
advocating for change, but on the other hand Richard was speaking
about the failures of, for example, the UN system at a global
level. What do you consider should be the priority of advocacy
currently for maternal health? Should it be based on developing
governments or should it be focused at a global level? How much
priority do you give to each?
Ms McConville: I think we have
had quite a lot of international advocacy over the years. There
are many UN departments with their own communications people who
have run campaigns and so on. What we have not had is sustained
and long-term support for the advocacy needs of developing countries,
and that, I think, is where we need to focus now. For instance,
White Ribbon Alliance has an alliance in Orissa, in India, one
of the poorest states. I heard recently that they had managed
to gather a petition of 35,000 people: many of those will have
been thumbprints. That is a massive petition by any standards.
I said, "Have you got a photograph of that so we can use
it on the website and publicise it?" They did not have a
camera. They were asking us, "Please can you help us with
our advocacy needs?" Here we are: "A 1999 World Bank
survey asked 60,000 people living on less than a dollar a day
to identify the biggest hurdles to their advancement. It was not
food, shelter or healthcare, it was access to a voice." People
are always asking us, there is a great demand, for more and more
alliances all the time. Advocacy is what we see as the key, and
this is what will unlock the process in moving forward. So, yes,
we would ask DFID to focus more on civil society organisations.
Q132 Ann McKechin: Richard, where
do you think the priorities should be based?
Mr Horton: I am not going to disagree
with Brigid, of course there needs to be a civil society approach,
but there is a huge space that needs to be filled on the global
side. We must not pitch one programme against another programme—
it is very important not to do that, so do not get what I am about
to say wrong. It is about increasing the envelope of funding,
but if you look at the attention that is given to HIV/AIDS in
the world today through incredibly successful advocacy and then
you look at the place of women and maternal health, there is a
disparity. I am not arguing against HIV/AIDS, but I am saying
that we have to get the balance slightly different to where it
is right now.
Q133 Ann McKechin: This would seem
to follow on from Brigid's argument about the position of women
and the lack of power that they have.
Mr Horton: Right, but if you had
the G8 focusing on women in Japan next year---. The Foreign Minister
of Japan is making a speech on Sunday at a conference where he
is going to start laying out his strategy in the run up to G8
next year. Japan is desperate to engage the world to help it shape
its position for G8 next year, particularly on health, and you
have got the Foreign Minister talking about health, so there is
an opportunity for DFID to help shape the G8 agenda and get women
as a much higher priority.
Ms McConville: You are all parliamentarians.
You all know how important it is when the NHS comes up at election
time when there is something wrong with your local hospital or
there is something wrong with the ambulance service. As far as
I know, there has never been an African election in which health
is a major issue. That is a telling point, is it not?
Q134 Ann McKechin: I think that shows
in the share of the budget that is sometimes allocated. Can I
ask you briefly about the Women Deliver Conference in October
2007 and whether or not you think it was effective in responding
to the issues raised by women and health professionals in developing
countries, including midwives, about the priorities that need
to be set over the next few years?
Ms McConville: I would welcome
the approach of the Women Deliver Conference. It framed the issue
in terms of a political meeting. I think that was a very wise
and a very good move. From our point of view, it would have been
better if more voices from developing countries were involved
in the planning and perhaps there could have been better listening
to those voices during the meeting itself. There was a sense that
it was rather the same old same old, but lets move on in a positive
way.
Mr Horton: I think Women Deliver
was an opportunity for the maternal health community to regroup.
It was a very important moment. Twenty years of Safe Motherhood
had not worked, and the whole issue had to be reframed, and the
beauty of Women Deliver, in the very title Women Deliver, it was
about reframing the whole question of maternal health in the context
of women, not motherhood, and that opens up so many more opportunities
for progress on advocacy and technical solutions and so on. It
gives you an entry into the women's movement which, if you just
focus on Safe Motherhood, there was dissociation between the two.
It allows you to think of women as political and economic citizens,
not just about people who produce babies. I think Women Deliver
gave us an opportunity to create a different frame of reference
for maternal health which now is our responsibility to work from.
It did not come up with a magic solution, but it was a very important
step-change in our thinking.
Q135 John Bercow: What role should
scientists and scientific journals play in advocacy for maternal
health? I am possibly playing devil's advocate and possibly not.
Is there any possible conflict of interest, in a sense, with primacy
of scientific principles of independence and impartiality?
Ms McConville: I would say that
as the White Ribbon Alliance we are a coalition, so we welcome
what everybody has to bring to the table from whatever sector
they come, whether it be faith-based, individual, media, government,
UN agency or academics and scientists. Over to you.
Mr Horton: Science is political.
How a democracy chooses to spend its money and which areas it
chooses to spend its money on are political decisions, not just
scientific decisions. So the idea that science is somehow immune
from politics would be a fundamental mistake, I think. The responsibility,
therefore, is on scientists to try and select what areas they
are going to study and journals to do the same, to look for gaps
in the evidence, to look at what the priorities might be, should
be, in the world and bring those scientists together to focus
on generating the best evidence so that it can be used as a platform
for advocacy. Advocacy, without some kind of reliable, robust
knowledge-base underpinning it, is empty advocacy. I see our role,
one of many thousands of journals, as trying to bring those scientists
together to create that foundation of knowledge on which advocacy
can be built. I would say the one additional thing is that if
you sit down with these scientists who have dedicated their careers
to this, they are fantastic advocates but they do not see themselves
as advocates particularly, but you get some of these people out
on the stage talking with ministers— I have sat in rooms
where you have the Minister of Health from Mozambique or Nigeria
sitting right next to a scientist who has done work in their country—that
interplay is fantastic. You can see how ministers will imbibe
the science. They demand the science, they need the science to
formulate strong policies; so it is a question of bringing them
together, and I think what journals can do is to help create the
climate for those kinds of interchanges to be made. I think science
has been far too removed from the policy process before. It is
part of democratic accountability.
Q136 John Bercow: To what extent
then is policy, in practice, either of developing countries or,
indeed, of our own, genuinely evidence-based? Can I pick up on
the metaphor that you used as you viewed, I think you meant in
developing countries, ministers imbibing the science, so to speak,
the informed outpourings of the scientists? To what extent, having
undertaken their imbibing, has that influenced their future choice
of menus when implementing policy? In other words, do they actually
take note? It is one thing to be inspired there and then, but
do they take note to such an extent as to change policy?
Mr Horton: I can give you one
set of examples related to maternal health but focused on child
survival. A few years ago we were involved in producing a similar
series to the one that we sent you on child and newborn survival.
There is no question that bringing that knowledge-base together
helps inform ministries of health in continents like Africa. The
problem is that ministries of health on their own are quite weak,
of course; so we cannot do it all. What you are trying to do is
provide the ministries of health with that knowledge but then
also trying to influence presidents and prime ministers. Building
that social, that political movement you have to include both
groups, and I think conferences like Women Deliver can be valuable
because it brings the finance ministers, ministers of interior,
presidents and prime ministers together with ministries of health
to change their culture. On our own, of course we cannot do it.
Q137 John Bercow: Thank you for that,
Mr Horton. May I follow up on one of the initial observations
that Brigid made when this question began or in response to earlier
questions, namely the importance or lack of importance attached
to women within society, particularly in the developing world?
I do not know whether you think, because some reference was made
to welcoming evidence from scientists and contributions from a
whole variety of actors on the stage, including faith groups,
that the presence in a room, or the delivery of a very effective
scientific paper by an expert scientist to a minister in a developing
country government can in any way match or counteract the sort
of cultural or even religious influences under which that minister
would normally act. To put it very simply, if there is a natural
lack of interest in these matters or, dare I say it, even an attachment
to what we would consider very outdated ideas of women's importance
or lack of it, can that attitude be atoned for when distinguished
science is presented?
Ms McConville: I think distinguished
science can form the foundation, the bedrock, for the work that
will follow. I think those maternal mortality figures, in particular,
the data is very important. We hear over and over again, a woman
has been buried in the garden and not even counted, and that has
been one of the problems when work has begun on so-called Safe
Motherhood. One of the first things that happens is the counting
starts and then the figures look bad, they look work worse, and
it does not look like a good return on the investment, but once
those figures are in place, things can move. Jeremy Shiffman,
who has done some leading work on advocacy, has worked out some
of the key issues in how advocacy has changed issues around the
world. For instance, in Guatemala a reproductive age mortality
survey was one of the major factors in moving things forward in
that country, so I think data can be tremendously important. I
will give you a slightly different perspective. One of our leading
advocates in Africa, working within her own country, a senior
figure in the government said to her, "What is all this fuss
about? Here we have one woman crying. A few women are dying and
one woman is making a fuss." That is the response she got
at her own government level. Women are up against that all the
time. I have worked as a journalist in developing countries. It
is very hard sometimes to find a space in which women can make
themselves heard. You find yourselves crowded out by men, very
often. Women face a lot of barriers and they may not feel safe
to express themselves. If you have a leading figure in a movement
like the White Ribbon Alliance who is seen on TV, as our co-ordinator
from India, Aparajita Gogoi— she was on the stage at the
Clinton Global Initiative— that is an amazing role model
for other women in India. I think there is a matter of solidarity
there and a matter of leadership that can inspire and give courage
to other women, but we need these things together. It is not either/or.
Mr Horton: May I be allowed to
add one very brief codicil. I want to be very clear what we mean
by science. By science I do not mean stuff that goes on in the
lab or even clinical trials. Monitoring and evaluation of what
governments are doing, creating league tables. Are governments
investing in health? Are they meeting the Abuja Declaration? What
are the financial flows? How are they using that? That is the
sort of science I mean.
Q138 John Bercow: It is output driven.
Mr Horton: Yes, and that is the
kind of accountability mechanism that the scientific community
can provide. There is nothing more worrying to a minister than
being held up as not meeting some international norm. I do not
say it is about shaming, but it is about naming, and in a very
public sense, and that can make a difference.
Q139 Chairman: Is The Lancet
a campaigning scientific journal?
Mr Horton: I jolly well hope so.
It was founded in 1823 by somebody who was a campaigning doctor
at the time and he became a Member of Parliament in the end and
fought for the coroners' courts in the UK and for public health
and sanitation law. I think what The Lancet is trying to
do now is reinvent itself in a global setting.
1 Department for International Development (DFID) Back
2
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