Examination of Witnesses (Questions 156
- 159)
THURSDAY 22 NOVEMBER 2007
MS AASHA
PAI AND
MR GIORGIO
COMETTO
Q156 Chairman: Thank you both very
much for coming to give evidence to us. You obviously have heard
the evidence we have just had. You are particularly focusing on
conflict situations in fragile states but I wonder, for the record,
if you could please introduce yourselves?
Ms Pai: I am Aasha Pai. I am Acting
Regional Director for Africa and Latin America for Marie Stopes
International. MSI is one of the leading sexual and reproductive
health organisations working globally in 38 countries. Last year
we served five million clients and particularly in terms of humanitarian
work we have an initiative working with Columbia University called
RAISE[9]
which is really looking at trying to be a catalyst to change the
way that reproductive health is seen in crisis situations. This
goes from a very practical level in terms of integrating reproductive
health with the work of health care NGOs[10]
and other humanitarian NGOs, also to making a more enabling environment
for funding and for policy change on the issue.
Mr Cometto: My name is Giorgio
Cometto. I am a physician. I have worked in the last few years
in east Africa and the whole of Africa in managerial, policy and
advisory positions with international NGOs, a bilateral donor
in the World Health Organisation and very recently I joined Save
the Children UK as a health advisor based here in London. Save
the Children UK, as you might know, is a leading global NGO working
for the protection of the rights of children and their carers
and it has operations in over 30 countries, in Latin America,
Africa, Europe and Asia.
Q157 Chairman: Last year the Committee
did a report on conflict and post-conflict reconstruction. We
are not expert on anything in this Committee but we do try to
inform ourselves and focus on certain issues. Obviously we have
seen some of the devastating effects that conflict has in general
terms on women and children in particular. I wonder if you could
give us a little bit more insight into why, in that situation,
maternal health is particularly badly affected by conflict as
opposed to the destruction of a health service or the lack of
it or inability to get about. It means that all health issues
are a problem but why and in what ways is maternal health particularly
badly affected by conflict and post-conflict situations?
Ms Pai: Very particularly in conflict
situations you have quite a lot of gender based violence so we
are looking at rape being used as a weapon of war. We are also
looking at domestic violence. Refugees may be coming from areas
where you have high levels anyway but in those high stress situations
we see an increase of domestic violence. You have these situations
where women are being raped, being raped systematically, being
raped simply when they want to walk to get water, to get fire
wood for their survival needs; but also an increased level of
violence in their own relationships coupled with being forced
to sell sex in many situations in order to just get their basic
needs met. In these ways you see that the reproductive health
needs you have anyway are far more acute in terms of the depth
but also in terms of the scale because, in many refugee and displaced
people camps, the majority of the people who are there are women
and children. When you have maternal mortality and maternal morbidity,
you see that affecting straight away most of the people that you
have there in the population and children being affected when
their mothers are dying or suffering from disabilities as a consequence
of poor maternal health.
Q158 Chairman: I would just comment
in passing on our conflict report. In reality, we saw in the Panzi
Hospital in the eastern Congo the victims of systematic and abusive
rape. We have seen in the camps in northern Uganda the whole issue
of poor support. Just having come back from Afghanistan, we were
told that 80 % of women are subject to domestic violence within
their relationships. So there are just three examples of countries
which the Committee has visited which have come out of conflict
where those facts have been brought to our attention. It does
reinforce what you have said.
Mr Cometto: That is the case also
in other settings. In Liberia for instance it has been estimated
that between 60 and 75 % of women of child bearing age have been
forced into sex at some time or other during the period of conflict.
Gender based violence is a big part of the reasons. It should
be emphasised that conflict and immediate post-conflict situations
usually are characterised by a near total collapse of health systems.
Maternal mortality relates very directly to the status of health
systems and the capacity of women to access health services. This
relates both to the supply side and the demand side. In many cases
access can be constrained by security problems. A generally intimidating
climate can suppress demand from the women so there are multiple
dimensions in conflict that directly pose an increase in maternal
mortality. Considering the groups of fragile states and other
low income countries with a more stable political environment,
the maternal mortality ratio is up to 2.5 times higher in fragile
states or else it is equal, so there are really significant elements
that determine higher maternal mortality in fragile states.
Q159 Sir Robert Smith: Given that
challenge, what do you think donors such as DFID can do to ensure
that issues like maternal health, reproductive health and gender
issues are dealt with systematically at that time of conflict
affecting countries and these fragile states? Is there any specific
strategy?
Ms Pai: DFID has been a leading
donor in terms of humanitarian issues. DFID has also been a leading
donor in terms of gender and reproductive health but where I think
more can be done is to bring those two together. When you look
at a crisis situation from the outset, you should be looking at
the needs of reproductive health and consider them to be as essential
as any other health issue. If you look at all of the things we
just talked about in terms of maternal mortality and morbidity
from the onset of the emergency we have to put the systems in
place so that you have basic emergency obstetric care, for example,
so that you can deal with these situations from the beginning.
Also, we need to look at the complexity of programming that is
required. If you are talking about different groups of people
from different places, you have a lot of socio-cultural issues
as well and if you are talking about places like Afghanistan,
as you would have seen on your visit, it is so important for example
to have women doctors providing care for women, for them to access
service. All these things are incredibly sensitive and require
slow funding that trickles over time, that is constant over a
long term. You need to have a concerted effort over time to be
able to transform situations and make a difference. At the programming
level DFID could do more to bring that together also through specific
mechanisms, such as through CHASE.[11]
Now there is language that has been added to include reproductive
health and to encourage NGOs to apply for funding through that
mechanism, but more could be done to make sure that their programming
does include reproductive health and that there are some tracking
mechanisms to see that the money that is being allocated for these
NGOs is increasing over time.
Mr Cometto: I would like to emphasise
that post-conflict reconstruction programmes are long term endeavours.
It is quite frequent to witness a pattern in terms of aid disbursement
into post-conflict settings. In the immediate post-conflict period,
there is a gap between the time emergency funding is scaled down
before recovery and development mechanisms pick up. This has been
documented in several countries all over the world. DFID acknowledges
this. For instance in a country like South Sudan, they set up
a basic services fund, acting as a bridging gap measure for this
period. This, in my opinion, is best practice that other donors
should look at. What specific strategies and answers are to be
put in place? It probably depends from country to country. What
can be realised is that these are long term endeavours. The answer
lies in strengthening health systems as a whole and also recognising
the important role that civil society has to play in particular
in settings like fragile states and in an area like maternal health
and reproductive health. We broadly concur with the strategy of
prioritising the strengthening of government structures and the
adoption of government mechanisms for disbursement and for building
up health systems. Having said that, it should be acknowledged
that in certain countries government structures are not in place
and governments may not be able or, sometimes, willing to provide
what is needed. In these cases, probably civil society has a role
to play also in terms of service delivery. Even when that is not
the case, even when a government is effective in providing service,
there is anyway a residual role for civil society in terms of
advocacy, capacity building and piloting different approaches
that can fit into the general policy at country level.
9 Reproductive Health Access, Information and Services
in Emergencies (RAISE) Back
10
Non-governmental Organizations (NGOs) Back
11
Conflict, Humanitarian and Security Department (CHASE) Back
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