Examination of Witnesses (Questions 140
- 155)
THURSDAY 22 NOVEMBER 2007
MR RICHARD
HORTON AND
MS BRIGID
MCCONVILLE
Q140 Jim Sheridan: I am delighted
that the scientific profession are acting in the pragmatic way
in which you are suggesting, but picking up the point that Mr
Bercow made about faith groups and various religions, is there
the same potential conflict there amongst faith or religious groups,
particularly when we talk about birth control and maternal services?
Mr Horton: That is a really tough
one, is it not? The Catholic Church, for example, provides a huge
amount of the care services for people living with HIV in Africa,
and if you took a completely negative view of faith-based care
services, you would pull the rug out from the care of millions
of people on the continent, so one has to be very careful about
how one frames this point. My experience is that we sometimes
put faith groups in little boxes and stereotype them. I know a
lot of people who are from faith communities, who work in science,
for example, who might have a personal view about abortion but
will be part of a movement that will argue very strongly for harm
reduction, which means providing safe abortion services; so I
would be quite cautious about accepting any stereotypes. I find,
again, that when it come to issues like this people are actually
very pragmatic.
Chairman: There is an interesting poll
in today's papers, Catholics For Free Choice, which is
identifying that the Catholic Church is rather divided on that
issue.
Q141 Mr Crabb: Mr Horton, in your
Healthy Motherhood piece as part of the maternal survival
series last year you issued a call for the professionalisation
of maternity care to be made an absolute priority. To whom were
you laying down that challenge? Who was the relevant audience?
Mr Horton: Policy-makers. There
is no question about that. I think one of the problems within
the medical community---. First of all, I think the medical community
can be an extremely damaging obstruction to some of these issues,
because we as doctors sometimes think that it is only doctors
who can provide solutions, and it is not, there is a whole set
of community health workers out there who are much more likely
to be offering solutions than doctors are, but the professionalisation,
the improvement in skills, that message still has not been more
forcefully made to policy-makers and I think the medical community
can be an extraordinarily important lever in making that message
heard more loudly. The medical community is an advocacy community
in its own right, and I think it can mobilise itself more effectively
to make those messages.
Q142 Mr Crabb: Can you give us some
thoughts on why professional attendance at birth has remained
so stagnant in Sub-Saharan Africa and South Asia over the last
15 years?
Mr Horton: I think that comes
down to Brigid's point again about the failure of advocacy. You
do not need more research to prove this, these are messages that
are well known, but we have not been able to make the case strongly
enough that professionalisation of care, skilled birth attendants,
emergency obstetric care, facility-based care, is an absolute
priority.
Ms McConville: I think that is
somewhere that we can really show that we have been very successful
in working with communities. For instance, in countries like Tanzania
only just over half of women give birth with any kind of skilled
attendant, and that mirrors the figure for the whole world. It
is just extraordinary in this day and age. Fifty per cent of women
all around the world are still giving birth, probably at home,
alone or with a mother-in-law or a neighbour, with no skilled
person at all to help her if she gets into difficulties; but the
journey from there to skilled care is a long and social one. The
roots of her getting from A to B lie in the community, in her
own empowerment, in her own education, in the amount of information
she has, in the power she has to make decisions for herself about
her own healthcare. Those are social issues and it is only community
mobilisation that can bridge that gap up to the health centre.
There has been this debate for many years about traditional birth
attendants versus skilled birth care, and the evidence is overwhelming
that skilled birth attendants are the answer to this issue. However,
we can work with traditional birth attendants to encourage them
to come with women to the health facility. It is not a question
of excluding the community, excluding and blaming those people
who do not have those skills. We can work with them to bring women
to health facilities.
Mr Horton: It is making connections
outside of the health sector. This is not just a health solution
we are looking at. Work done in Bangladesh, for example, shows
that reductions in maternal mortality are tightly linked to improving
educational status for women. In the educational sector, MDG 2,
on education, there are vital links that are made. Again, we must
not pigeon-hole health, we must look across the multiple sectors.
Q143 James Duddridge: What is the
most effective contribution civil society and grass roots organisations
can have for advocacy on maternal health? You mentioned a number,
but what are the most effective levers?
Ms McConville: The most effective
levers in terms of?
Q144 James Duddridge: In terms of
their advocacy work. Who are the most effective people to target
and with what methods? Rather than simply talking about advocacy
overall, who do they target and how?
Ms McConville: I think there are
various levels and, as Richard is saying, we cannot have one against
the other. We cannot divide them up; we have to look at the issue
in the whole. We have to have community-based advocacy; we have
to work very closely with families. We have to have men on board;
we have to have husbands and mothers in law. One of the things
that we do in India, for instance, is Safe Motherhood classes
for young couples and, at the end of it, the husband, if he graduates,
will tie a white ribbon in the hair of his new bride to show so
he has made that pledge to care for her in the future. We can
also then have representatives on local health committees; so
that district level is often very, very important; that is where
a lot of decisions are made about healthcare. So we have White
Ribbon Alliance members represented and asking questions on those
committees, and then, at national level as well, we need to be
pursuing the policy-makers in government. By the way, health ministers
often welcome that pressure, because they need to advocate within
their own governments for more funds for maternal health. In Burkina
Faso, for instance, the White Ribbon Alliance there persuaded
the Government to hand over a further 10 % of the health budget
to maternal health, which was then spent on facilities, training,
community awareness raising and sensitisation, and so on. I would
not prioritise one against the other; I think we have to work
right across the spectrum.
Q145 James Duddridge: Presumably
with a limited budget, White Ribbon individually, or globally
with a limited budget for advocacy or maternal health services,
choices have to be made. Perhaps another way of expressing the
question is: of the White Ribbon budget, the advocacy budget,
where do you spend that? What of it is the grass roots? For example
these classes for fathers and families: what percentage, broadly
speaking, is for the advocacy at an international level and at
a country level?
Ms McConville: When you talk about
the White Ribbon Alliance budget, a lot of our people are actually
volunteers. Many of our co-ordinators are not paid. We often work
within other organisations, we are given a home within another
organisation, and then we survive on projects, but many of our
co-ordinators knock on doors for several years before they get
any pay at all. The other point to make, I think, is that different
countries and even different regions within countries will have
very different priorities, so our alliances will decide within
those countries what they should work on in an autonomous way.
In India, for instance, I have told you about the new laws that
were steered through to enable nurse midwives to perform. In Tanzania
the priority was human resources. There was a tremendous shortage
of skilled birth attendants. There was also an unemployment issue
in Tanzania, so the focus there was on persuading the Government
to hire staff immediately. The step forward has been made in that
the Government now immediately employs graduates from the medical
and midwifery schools, so they go straight to work, whereas before
they were waiting around for interviews and then disappearing.
So that was their target. In Indonesia the issue was to alert
villages. Communities raised awareness so that families would
know the danger signs in pregnancy and plan ahead, and they would
have some funds ready for transport. A similar thing happened
in Malawi, where White Ribbon Alliance members joined forces with
the police service. The roads there are often atrocious and there
is very little transport, so you would often find women giving
birth on the road or walking to a facility many, many kilometres.
They worked together with the police to set up a small fund so
they could use the police transport to get to a health facility
and beyond. For us it really depends on what the issue is in that
particular country and the decisions that are made within that
country.
Q146 James Duddridge: Earlier you
gave quite a powerful example of being asked by some Indian ladies
(there was a petition of 35,000) for a camera, something as basic
as being able to capture the moment. How are local groups best
supported by international organisations such as yours, or is
it really, as you are saying, driven on a country by country demand-led
basis? Is there a model perhaps for what other international networks
can be doing to assist local groups?
Ms McConville: I think we are
a unique organisation in that we have got going within the last
nine years and we have absolutely mushroomed, and the demand for
the Alliance is growing all the time. We do not have any sustained
or core funding, except for a small team that runs a kind of hub,
a secretariat. If you like we are almost the inverse of a UN organisation
where we are very, very big and extensive at grass roots but we
do not have any sustained or steady funding sources, and certainly
that is where we could do with some help.
James Duddridge: Message received!
Chairman: A straight answer to a straight
question.
Q147 John Battle: I rather liked
Richard's broader definition of science. I am interested in what
might be in your term "the science of civil society"?
I think we have massive questions to ask, not only developing
countries but also here, about representation, role and voice,
not least to ensure that the poor are heard rather than spoken
for. I wonder if I could ask you: how do we turn positive anecdotes,
personal community stories, into analytical evidence that can
be used to drive the argument and the advocacy forward? Bridgid,
you gave us some examples: I think a film that was taken in Tanzania,
Burkina Faso, the health budget; you mentioned Indonesia and Malaysia;
but can those success stories of community mobilisation be turned
into a source of analytical evidence to push the arguments further
forward? Where would we go to get them and who could put them
together?
Ms McConville: Jeremy Shiffman.
I have got a summary of a piece that he did in Insight Magazine.
He is a leading researcher from the USA and he is saying that
advocacy is the key, and he has done an awful lot of work on this,
and he says that the degree to which political leaders actively
pay attention and allocate resources to this issue varies according
to the amount of pressure that is put upon them within developing
countries by advocates, and he has got chapter and verse about
how that works. He says, "National advocates have achieved
varying degrees of success in promoting the cause and they were
most successful when they" (and he has given one example)
"organised focusing events such as national forums to promote
the cause, including a march to the Taj Mahal in 2000 organised
by the White Ribbon Alliance of India", and a couple of other
examples there, and he is saying, "Advocates must develop
political not just technical strategies".[4]
So the research is there. There is also Wim Van Lerberghe at the
WHO[5]
has published papers about how that worked in Europe. We have
got where we have got because of sustained political pressure
and advocacy over the years.
Q148 John Battle: I am tempted to
say that, in terms of poverty in the UK, Europe and America, we
are not there yet.
Ms McConville: No, I think there
is a very important point there, which is that in every society
there is a marginalised group and it is those groups that we need
to reach, and we have that same problem. The maternal mortality
rate in America is shockingly high. Those are usually the black
and Hispanic communities. It is the same pattern.
Q149 John Battle: I think in my neighbourhood
in the inner city I kind of jib at the notion of the hard to reach
people because they are there all right, it is that others talk
about them as the hard to reach; but what I am saying about that,
Brigid, is to push this idea. Can we get the analysis from the
local to the centre? Can we really tune in? Let me ask a particular
example. DFID is funding, I think, research in Nepal, for example.
Can we get from that research, just in the same way—I do
not know the two people you have referred to, and that is very
helpful, but the Alinsky Institute, for example, in Chicago and
all the work they did on community campaigning to push civil society
in the west, has that research in Nepal given us the kind of evidence
to say that community mobilisation has brought tangible improvements
in maternal health and we can document it, list it and tabulate
it so that we are in Richard's domain of science, not to play
that off against you, and the science is fused with the advocacy
to become an unstoppable argument in terms of demanding justice
for the poor, not least women, who pay the highest price of all
everywhere?
Mr Horton: The answer is absolutely,
unequivocally, yes, and DFID has funded this research. It is back
to Anthony Costello again. Let me just give you an example of
his work. What has he done? He has done a randomised trial to
show that women's groups can reduce maternal mortality, newborn
mortality. He goes on to show that that is a cost-effective intervention
being afforded by the health system, and then he has done, effectively,
anthropology, looking at the care-seeking behaviour of women,
reporting that in a very conventional, rather boring way in a
boring medical journal like The Lancet that can be used
by Brigid and her colleagues as the mechanism for advocacy, doing
exactly what you say. That is science for civil society, so that
it can be recognised as robust evidence at a ministerial level
but it has that texture, that quality, that means something and
is not just numbers in an abstract sense.
Ms McConville: The whole function
of an Alliance is to bring everybody together with those complementary
perspectives that we can build on and move forward together.
Q150 John Battle: And build the commonsense
for change.
Ms McConville: Exactly.
Q151 Chairman: Thank you for that.
You have already mentioned, Brigid, your Stories of Mothers Lost.
You made reference to it and gave one or two points from it. First
of all, is that still on its travels?
Ms McConville: Yes, indeed.
Q152 Chairman: What are the sort
of key points? In a sense one can judge what it is, but can you
just tell us a little bit more about what is in it and how it
is focused to get these results?
Ms McConville: Yes, by all means.
In fact I have brought you all a folder that you can take away
with you.[6]
The exhibition is a collection of fabric panels. We put the word
out to our members in all our countries and asked them each to
submit a number of stories from those communities, the story of
a mother who has died in pregnancy or birth, and the result was
absolutely stunning. We expected 50. We had some funding from
the UNFPA[7]
for that. We got over 120 in the space of a few months. I am glad
to be able to say that our partner in the UK has been the Royal
College of Obstetricians and Gynaecologists International Office,
and they very generously lent us their premises for setting up
the exhibition. We launched that— you were all invited actually—
in October and we had a tremendous audience, over 250 people,
and this is where we can do things differently in the Alliance.
We had not only the medical and health community and the development
community, but we had media people, theatre people, music people,
ordinary citizens— the whole spectrum came to that event.
We had asked Mrs Sarah Brown if she would open that event for
us, and she said that she could not do that but instead she would
invite us to a reception at Number 10 Downing Street. So, two
days later, we took 20 of the panels, the stories, into Number
10 and we invited, again, a very broad range of people, and our
advocates included such women as Judi Dench and Diana Quick and
we had some top media people as well, executive editors of our
national papers, we had some top music people and some people
from the business and corporate communities. We also had Douglas
Alexander, and we had our singer Stara Thomas, the pop star. I
think what was wonderful about that was that we were able to bring
stories of women who have died. Normally those stories are never
heard— that woman has gone— her story is not heard.
The community told her story. These are the poorest of the poor.
Those stories were brought right into that hub of power and influence
and I am tremendously proud of that, and most of our co-ordinators
from Africa and India, many of them, were there, and I think that
was a tremendous accolade and a tremendous boost to their morale.
We are following up all of those leads and all those connections
that we made at that time. We also are very pleased to announce
that we now have funding from the Bill & Melinda Gates Foundation
to take the Stories of Mothers Lost on an international tour.
So that is going to be the focus of an international advocacy
campaign. Our next port of call is Washington DC in April, which
is the World Bank and IMF[8]
meeting, so we want to influence policy-makers there, after that
we go to Japan for the G8, and we hope again to make sure those
voices are heard in the highest places, and after that we go to
South Africa, which I believe is the World Economic Forum. So
we have got three major political meetings to which we will be
taking the panels as evidence.
Q153 John Battle: Just a suggestion,
as well as the excellent work there. In this room we saw the Panorama
film which was in the early sessions of our inquiry. I showed
that film in my own neighbourhood and Sure Start Group in an area
which has some of the worst records of maternal health in Britain.
The response was fantastic. I would like to suggest, if it was
possible, for the international exhibition as well as aiming at
the world economic fund, the policy makers, also to be used to
build support on the ground floor level to push the policy makers
from solidarity from the base as well.
Ms McConville: Absolutely. Obviously
we cannot take the panels to every place but we are making a film
about the exhibition. Some of the footage was taken by the communities
as they put their pieces together and I should tell you also that
there was a tremendous amount of advocacy in the putting together
of those panels. For instance, in some communities in Pakistan,
young people got together in the making of the panels and pledged
a commitment to Safe Motherhood and signed pledges. In one other
area there were 25 media articles alone around one particular
story. In Uganda there was a TV programme. Parents were filmed
by the graveside of their daughter, talking about her death and
that film was on television, so already those panels have had
a tremendous advocacy effect in the communities. The panels, by
the way, will go back to those communities at the end of their
job. To build that connection in the UK we are also very keen
to do that.
Q154 John Battle: Perhaps the department
that is in charge of the Sure Start programme should be alerted
to your campaign and push it through Sure Start.
Ms McConville: That would be wonderful.
Q155 Chairman: Thank you very much.
When we embarked on this inquiry, obviously the first thing we
did was to get a briefing on the context. The context is appalling.
It is the most off track MDG. The figures are variable but there
are more than half a million women dying in childbirth and many,
many more millions of people are affected by the consequences
of that and the very poor progress towards dealing with that.
That is part of the reason we are doing the inquiry to see whether
or not we can focus on this. Your evidence has been extremely
helpful. You have given us some very powerful evidence in terms
of what you feel works and what you feel is the right approach.
It is a very subjective thing but how optimistic are you? It is
not a question of physically doing it. Both of you say of course
we can do it. We can mobilise world opinion and the people who
need to make those decisions including in the developing countries.
We need to do it. How optimistic are you?
Ms McConville: My view would be
that this is a really important time in history. We have had 20
years of the Safe Motherhood initiative with shamefully little
progress. However, at the moment there is a tremendous amount
of pressure from the governments of the UK and Norway. There is
also a building global movement at grass roots level. We are getting
closer to the target date of the Millennium Development Goal.
If we can bring those together now, if we can bring top and bottom
levels together, we have a tremendous opportunity, but we can
only do that if we really respect and listen to the voices of
the people in the countries where those issues are problematic.
Mr Horton: I am extremely optimistic.
In the past five years we have scaled up advocacy, resources and
political commitment to child survival. I think we can do the
same over the next five years for maternal health more broadly.
We have a lot of the knowledge in place. We have a lot of the
leadership in place. It is a question of making connections between
those two, between the politics and the knowledge. If we get that
equation right, we can make incredible progress at country level.
Chairman: That is a very positive note
on which to end your evidence. Thank you very much indeed. It
has all been very clear and helpful.
4 Jeremy Shiffman, Generating political priority to
reduce maternal mortality, id21 insights, vol 11 (2007),
p 5 Back
5
World Helath Organization (WHO) Back
6
Ev Back
7
United Nations Population Fund (UNFPA) Back
8
International Monetary Fund (IMF) Back
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