Examination of Witnesses (Questions 160
- 176)
THURSDAY 22 NOVEMBER 2007
MS AASHA
PAI AND
MR GIORGIO
COMETTO
Q160 Sir Robert Smith: In the emergency
funding phase, how are things at the moment?
Mr Cometto: You refer specifically
to the case of southern Sudan?
Q161 Sir Robert Smith: No. In the
emergency funding phase post-conflict, how does maternal health
cope at the moment?
Mr Cometto: My experience, which
is limited to two or three countries post-conflict, I would say
that it is quite fragmented. Multiple partners intervene sometimes
with overlapping mandates. A lot of the funding is still structured
according to vertical lines in vertical structures. It is something
that usually comes during the recovery and development stage,
but typically the emergency relief phase is characterised by severe
inefficiencies.
Q162 John Battle: I wonder whether
funding, a trickle over time, to develop a health system is not
irreconcilable with a fragile state. There seems to be a complete
incompatibility. Do you think you could identify at what point
in a post-conflict situation donor attention should move from
emergency support to strengthening health systems. Sierra Leone
was one of the places I visited with the Committee.
Mr Cometto: We would recommend
pursuing a twin track approach. It is very difficult to recommend
a specific point in time, whether country specific or when emergency
funding should be scaled down. Something that has happened a number
of times and has been documented for instance in Liberia or in
the mountain region of Sudan is a severe contraction of service
delivery right after the conclusion of the hostilities. Probably
the wisest approach in my opinion would be to scale down emergency
relief once something else is available. That usually takes a
minimum of two or three years before something is put in place.
Q163 John Battle: To follow the scientific
approach of the previous conversation, are there types of information
or data that can be collected to inform policy makers and monitor
progress in that context so that you maybe cannot identify a moment
on 26 April at 4.30 but rather can we identify some key indicators
and data that we can work from to say to donors, "Look, there
is an area here now where we could give more support to health
systems and move away from emergency funding as a result of a
crisis or conflict"?
Mr Cometto: I believe that a lot
of information has been published, in particular from countries
that have shown better results than others. For instance, Afghanistan
features quite prominently in the literature in the light of its
faster than usual results in delivering improvements in outcomes.
I am not familiar with a particular person or a particular set
of publications that looks specifically at these points. Usually,
a lot of the evidence is published at country level and rarely
does it fit into global debates, but there are units, for instance
the World Health Organisation, and other departments that look
specifically at conflict or post-conflict situations. Another
example is the London School of Hygiene and Tropical Medicine.
They are an important source of information and they are a leading
global partner in determining, publishing and assimilating evidence
on this.
Q164 John Battle: I was incredibly
encouraged by the positive responses to the Chairman's questions
about the hope for the future in the last session. I wonder if
we could look at health care in a positive way. I once went to
Kosovo right at the end of the conflict. I observed and was part
of a deal where an Albanian and a Serb started to work together
as two electrical engineers repairing a power station. They were
discussing politics and theology when they did it but it got it
up and running. It was a moment when repairing a power station
was a catalyst for peace in the neighbourhood. Could provision
of basic health services act as a tool or a catalyst for promoting
peace and stability in fragile states? Could we look at it in
that context?
Mr Cometto: I suppose it is possible
to look at it that way. As a matter of fact, the association between
the provision of social services and peace and stability or conflict
on the other side has been made in several settings. Establishing
a causal link between the two might be harder than a general type
of association but it is probably an area which further research
and better evidence could help.
Ms Pai: Any kind of investment
to any social services could very potentially have that effect.
You also see that in fragile states, if you can focus on working
with NGOs, that is one thing. Maybe you are going to have a stop
gap service that can be provided. Going back to what was said
before about also working on the capacity building and advocacy
issues at the same time, it is an investment not just around immediate
needs but around avoiding potential conflicts in future because
you are addressing the needs that people have. Again, it is about
not putting health in a particular box but looking at overall
development.
Q165 Chairman: Is it not extraordinary
in the situation with DRC?[12]
Everybody happily—I say "happily" using a very
ironic term—talks of it being the worst conflict worldwide
since the Second World War in terms of the numbers of deaths.
A figure of four million was quoted, but when you ask how did
these people die most of them were not killed in conflict. They
died of disease and lack of access to health care and so on. From
your engagement in other conflict states, is there something wrong
with the international community that it does not understand that
what is needed in a post-conflict situation is prioritising the
delivery of those kinds of services? The specific issue we had
as a Committee was engaging with ECHO,[13]
who were proposing at the time to withdraw funding from the Panzi
Hospital on the grounds that the conflict was over. The Panzi
Hospital was full of people who were coming in every week, women
who had been mutilated and savaged and yet somehow the international
community said, "Well, there is no conflict so there is no
need for further funding." The point I am making is, from
your perspective, should the international community respond better
and to what extent do you argue that case?
Ms Pai: Absolutely. If you look
at reproductive health specifically and ask the questions about
how or why is it different in emergency situations, of course
we have a lot of evidence to show that. The point is that reproductive
health is a fundamental right anyway, whether you are in a crisis
situation or not and of course the needs are more acute when you
are in crisis situations. We make a lot of unhelpful distinctions
around what is conflict, what is post-conflict, what is development,
what is not, what is crisis and what is not when in fact these
are basic human needs and basic rights that we as an international
community are ignoring, whether it is a crisis situation or whether
it is not. We need approaches where we can look at working with
NGOs and funding NGOs, look at making the work of NGOs less fragmented
by funding larger NGOs and funding smaller NGOs who can come together
and have more of an impact at the same time that we fund governments
and civil society to influence policy change. We simply have to
work on all fronts. I just do not see it any other way.
Q166 James Duddridge: This Committee
recently returned from Afghanistan and you have touched on Afghanistan
and the need for women doctors in particular in Afghanistan. That
might be one of the challenges but what are the other challenges
particularly in Afghanistan in relation to maternal health? From
both your organisations' perspectives, how well are DFID doing
in addressing some of the challenges and what more should they
be doing going forward?
Ms Pai: In Afghanistan particularly,
apart from the women health care providers, you have the same
kind of security issues that you have anywhere else. The cost
of being able to provide services and at the same time have security
for your staff is incredibly high. Then you have all the other
issues that you have already when you have damaged infrastructure
and poverty. The costs are incredibly high and donors are not
always willing to go as far as they need to go in order to address
all the issues. DFID can play a really strong role in terms of
influencing other donors as well. The interesting thing about
Afghanistan, I understand, is that if you look district by district,
because you are having to work through NGOs as well as doing some
work through government, you can see big differences district
to district, depending on the donor who is there and depending
on donor policy. For example, where you have USAID working, you
do not have the same attention to reproductive health issues and
you can see the gaps in services. Where you have other donors,
you see that there is that influence. With DFID's influence in
terms of reproductive health, not just in Afghanistan but in other
places, it can show what can be done if you put that attention
onto the issue, funding NGOs, getting the money in but also influencing
other donors in order to do the same thing so that you do not
end up having these very fragmented situations where you are not
addressing the issue.
Q167 James Duddridge: In provinces
in Afghanistan where the Americans control, will they provide
cover and allow people to come in from international organisations
looking at reproductive health? Will the American military facilitate
that?
Ms Pai: I am not sure about that
actual access issue in terms of those districts but what I do
understand is that, whatever is happening, the result is that
you do not have the services. It may just be a question of funding
and not access. The way I understand it is that certain donors
are funding certain districts, so it could just be that there
are not other donors present and that is why you do not have that
reflected.
Mr Cometto: I was one of the NGOs
that were subcontracted out to run health care services in one
of the provinces in Afghanistan. I do not know if you are familiar
with the aid architecture in health in Afghanistan but basically
it was decided that a basic package of health services would be
subcontracted according to geographical regions. The three main
financiers would be the World Bank, USAID and the EC.[14]
The Save the Children province was in USAID and to a certain extent
it is correct that the different donors have placed different
emphasis on certain components. The issue of reproductive health
being less of a priority for USAID as compared to other donors
is a factor, although there was an attempt at national level from
the point of view of the Ministry of Health to achieve a standardisation
of the service that would apply across all the regions. As far
as I know, there is not a problem of access to areas that are
directly controlled by the Americans.
Q168 Sir Robert Smith: We visited
a hospital in Lashkagar in Helmand where British money had built
an accommodation block for trainee midwives to live in while they
were being trained. Because they thought USAID were going to provide
money to train the midwives, the block was empty while we were
there because at the time USAID had run out of money. Because
the block was there it looked like USAID were going to deliver
the money. Presumably, that highlights the coordination. There
are a lot of players there and maybe greater coordination is needed.
Mr Cometto: To be fair, in the
hospital that Save the Children UK managed, which was funded by
USAID, we did not do training of midwives so perhaps that was
a localised problem.
Ms Pai: Undoubtedly where you
have that better coordination you have much better results. Now
that you have some moves for example with the WHO to be a coordinator
amongst humanitarian organisations in terms of health, the key
there is making sure that what you see is part of the basic package
of health services with reproductive health, particularly emergency
obstetrics.
Q169 Ann McKechin: I wonder if I
could ask for your comments about how effective you think the
UN cluster system has been. The Committee visited Pakistan last
year where we obviously had a chance to talk to people about the
cluster approach after the earthquake. I wonder how you think
DFID could best support humanitarian actors, especially in an
emergency, and whether the cluster system has any benefits.
Ms Pai: I certainly think it has
benefits because in so many other places what you have is a complete
lack of coordination. In the UN agencies you have lots of different
NGOs, everybody doing their own thing to the extent of carving
up districts and doing very different things in different places.
Absolutely from a principle point of view that would make sense.
Further to that, DFID again could use influence there to stress
the needs of maternal health and reproductive health in those
situations and even beyond having a health cluster that is coordinated,
but specifically within that have something that is for reproductive
health which is also a coordinated mechanism.
Mr Cometto: I agree with this
perspective. In many ways DFID is to be commended for its commitment
and for putting in place policies that most technical people would
largely agree with. If something can be suggested to do more,
it would be to strengthen the role that DFID plays at country
level. Sometimes there is a sort of hands off approach operating
mainly from multilateral agencies or NGOs, whereas perhaps DFID
could play a stronger role in terms of leadership and engagement
with other partners.
Q170 Ann McKechin: I wonder if either
of you or both of you perhaps could give us some examples of success
stories in providing effective health services. You have talked
about best practice. What do you think are the key factors in
that success?
Mr Cometto: If we talk about fragile
states in particular, in my experience the list of success stories
is not very long unfortunately. Afghanistan usually comes up as
one of the best examples of quick improvement in health outcomes.
To a certain extent, this can be ascribed to a bold decision that
was taken by the Ministry of Health early in the reconstruction
process of sticking to a more limited role in terms of coordination
and oversight of the health system but subcontracting the provision
of health services to non-state providers. This translated into
massive improvement in terms of health service utilisation indicators
and child mortality saw a dramatic improvement. It was reduced
from 257 per 1,000 to a little more than 190 per 1,000 in the
space of five years. Likewise, there has been an improvement in
skilled birth attendants and antenatal care attendants. In terms
of maternal mortality it has not yet been possible to document
such a dramatic improvement. Whether this is an example that can
be adopted successfully in other countries in other contexts remains
to be seen. Despite the obvious appeal of the approach, there
are also setbacks that have been identified, such as a hypothetical
lack of sustainability with such a strategy and, to a certain
extent, conflicts of dynamics between non-state providers and
the government itself, especially at provincial level. A similar
approach has been adopted for instance in southern Sudan as well
with still to be documented results, but in other countries that
have successfully moved from a conflict situation to a more stable
type of environment the time frame typically has been much, much
longer. For instance, in Mozambique, it took 10 years before significant
improvements could be documented. It should probably be acknowledged
that these processes take time. Sustained effort, sustained commitment
and prioritisation of maternal reproductive health can achieve
results.
Ms Pai: I agree with the point
about when you go to an emergency at the beginning and the way
that you view what is considered to be an essential or a basic
health package, how important that is. If you say that from the
beginning emergency obstetrics, post abortion care and family
planning are all fundamental parts of that package, then you can
go a long way with that. In terms of more specific examples of
success stories, in northern Uganda where we have been working
for many years we have seen great success in terms of the demand
and supply side when it comes to these reproductive health issues.
We are working in a few clinics in the areas where we have a whole
lot of displaced people's camps and we are doing a lot of outreach.
There are many organisations working there. Part of this RAISE
initiative is to work with these other organisations that were
not ever doing reproductive health. We are training them in reproductive
health areas so that their health providers can do counselling
and also provide services in these areas. We have seen thousands
of clients coming in and demanding family planning which has been
quite an amazing thing to see. Even in these conflict situations,
often people say that women have perhaps lost children so they
are not interested in using family planning because they are quite
desperate to have more children. Of course, that is going to be
true for some women but for a lot of people they are in situations
in displaced people's camps in northern Uganda for years and years.
That becomes their life. They also see that having too many children
too close together results in all kinds of problems as well, so
there is a very high demand not just for limiting the number of
children but also spacing births. We have seen through our outreach
people coming and also changing people's ideas. This is where
the advocacy comes in. DFID has been funding through the Civil
Society Challenge Fund for us to work with the police and the
local military and work at the district level, so that at the
same time while you work at a national level and you try to make
sure that the policies are there— often the policies are
already written there— it is about getting people to put
money behind those policies and get that to happen at a district
level. We also work through committees whereby our staff will
go to the district health meetings and say, "We understand
that there has been an allocation for reproductive health. We
do not see it here in your district. Where is it? Why is it not
here? Why is it, when I go to my local public facility, there
is nobody there providing the service?" We are trying to
work to help that through this advocacy but also by providing
services in the meantime, taking our teams and going to work in
the public facilities. This is where I think it is really important
to look at the public/private initiatives of NGOs working together
with government and the demonstration effect that has. We have
our own clinics. That is fine and good but they are only in certain
areas. If we can go and work where there are already government
facilities, perhaps not well staffed, without supplies etc., if
we can bring our teams there, we can work with the one nurse who
is there, who is completely demotivated and does not have anything
to work with. That is also building up her skills and that is
providing many more points of service delivery for people.
Q171 Chairman: You have partly answered
the question I was going to ask. If you look at the European experience
in the Second World War, it tells you that people do tend to postpone
children at a time of crisis. This is why we had a low birth rate
during the war followed by a boom afterwards. The first question
which you partly answered was the role of family planning, not
least because in the wider context of maternal health it has been
pointed out that if women are under pressure they do not necessarily
want to have children but do not have an option and if there is
difficulty feeding the family they have so they are underfed and
under-nourished, vulnerable and not easily accessible to services,
how important is family planning? That seems to be a classic case
where you need to be alongside women and say, "I want it."
Somebody has to be there to fight for it. I was interested in
what you said about Uganda because, having been twice to northern
Uganda last year—it may be my fault or the view that we
took—what disappointed me about the camps was the total
lack of any visible facilities for almost anything. You said you
were working there successfully, so how are you delivering those
services when there does not seem to be much in the way of clinics
or any other kind of facilities, in spite of the fact that sometimes
tens of thousands of people were living in a camp and you would
have thought it would be easy.
Ms Pai: Absolutely. Our particular
model has been an outreach model. We have clinics that are located
just outside of where the camps are. Our medical teams use those
as a basis and move in and out of the camps. We have to work with
the other NGOs that are there. This is a good collaboration with
other NGOs who are there, who are not particularly providing reproductive
health, also going to the public facilities which are already
there. In some cases they are in an absolutely shoddy condition
and it does not look like a place where you would want to provide
any services. This is how we work in other countries as well.
If you bring in a medical team and you can provide a sterile environment,
it can just be a small room and you can provide family planning;
you can provide post-abortion care for women who are suffering
from the consequences of unsafe abortion. There is a whole lot
of things you can do. Going back to your question about family
planning, it is absolutely critical but again in emergencies it
is always seen as something that is second or third tier because
the immediate benefits are intangible. There are a lot of studies
that show, if you spend one pound on family planning, you will
lose so many problems; you will save £10 on other services.
Apart from the fact that women want to limit births, also looking
at what happens when women do not have access to family planning
and they are faced with unwanted pregnancies, we know that women
all over the world, in conflict situations or not, do extraordinary
things to end an unwanted pregnancy. The consequences of that
in terms of maternal mortality are staggering. If it is 25 or
30 % outside of crisis situations, the stats go up to 50 % if
you are talking about emergency situations. You also have to look
at emergency contraception, at post-abortion care for when women
take matters into their own hands and at safe abortion, where
it is legal and you are able to provide it.
Q172 Chairman: How do you coordinate?
Marie Stopes is almost a world leader in this and people would
know what your sphere is but Save the Children has a broader remit.
Your own survey said that coordination was not right and the skills
were not always there. What should be done to try and ensure that
in these conflict situations NGOs can cooperate and the sexual
reproductive health element can be built into that? Does it require
an agreement to give some leadership to certain ones? How does
it work? Otherwise, if you are all doing your own thing in your
own boxes, you could get in each other's way.
Mr Cometto: In my opinion, the
issue of positive reconstructive leadership is key. The government
plays a very important role in these issues and therefore it is
important to exercise sufficient advocacy at a higher level in
government to ensure that reproductive health and maternal health
becomes a political priority for the country; that comes before
the coordination of operational activities at country level. That
is something that in many countries, in my experience, is lacking,
the perception of the needs at political level and the perception
that these represent a priority for the population. As other speakers
have said, in certain areas advocacy is really key to the development
of successful solutions to problems at the local level. In terms
of coordination of activities, again the role of government is
essential. It is only the government that has sufficient clout
and political weight to mandate how coordination should work.
One reason why Afghanistan is considered in international aid
circles a successful example in terms of health is that the government
gave very strong directions and indications, demanding that the
contracting of health services for instance happened on a geographical
basis. An organisation now for instance is responsible for a whole
area and that means at the hospital level, the primary health
care facility level, the community level, everything; whereas
in many other contexts you have multiple actors operating, frequently
stepping on each other's toes in the same area and that obviously
leads to duplication and inefficiency.
Q173 Chairman: What do you think
DFID could usefully do in terms of relating to NGOs in helping
to deliver better priority towards sexual and reproductive health
generally but obviously in post-conflict situations? Do either
of you feel there is more they could do, whether in terms of their
country programmes, resource or overall policy or whatever you
think is appropriate? What do you think DFID could do differently
or better that might help deliver your objectives in this field?
Mr Cometto: Building on what I
was saying before, we do believe that NGOs have a strong role
to play in this area of maternal health, in particular in conflict
or post-conflict settings. This relates not only to service delivery
but also to other areas, advocacy, capacity building etc. That
requires resources and to a certain extent sometimes the balance
which is struck between strengthening government structures and
keeping a lively civil society sector to exercise a watchdog function
or to fill some of the gaps that the government is unable to fill,
in terms of resource allocation, is in our opinion struck too
much to the side of the government. That is something that could
be considered.
Q174 Chairman: To acknowledge your
role, in other words, a little bit more?
Mr Cometto: Definitely. If you
want NGOs to do something, you also have to back that up.
Ms Pai: I absolutely agree with
that. Again, I really think it should not be seen as an either/or.
If you fund NGOs, it does not mean you cannot fund government
and vice versa. Also, to look at the ways where NGOs work
with government, where NGOs are able to enter into agreements
where we work in public facilities and help bring up the skills
of providers there, where we are able to build the capacity of
government providers through more formal training. Also, through
advocacy. That is absolutely key. Where DFID has in certain countries—whether
in crisis situations or not—decided that reproductive health
is a priority, it becomes a priority at every level. I also think
that what has been great to see with the Civil Society Challenge
Fund is the recognition that it is not just advocacy that should
be funded but also the service delivery. This speaks to the question
that was raised earlier: are you creating demand where there are
no services? Is that not fair and unethical to do that, to work
only on that front? I would say to continue that funding, becoming
more of a leader in terms of combining. DFID is a leader on one
side and on the other but to bring together humanitarian funding
and the reproductive health funding is most critical.
Q175 Chairman: Does it matter to
you whether they do it as a partnership with the government of
a country? In other words, saying let us bring in these NGOs as
part of your service delivery programme, or would you prefer DFID
to say, "That is providing support but we will provide direct
support." Does it matter to you which way it is done?
Ms Pai: Certainly, practically,
the direct support to NGOs makes a big difference. If you say
the money is going to go to direct budget support, we say that
some of that should go to NGOs and there should be encouragement
or policy around work with NGOs and government, the mechanisms
are of course very difficult. If it comes down to the government
saying, "Fine, okay, we will subcontract NGOs to do various
things", if all your money is going through there, at the
end of the day, not all your money is going to come out the other
direction for the NGOs. NGOs are going to spend a lot of time
just trying to get paid for the services that they are providing
and that they are willing to provide. I think that as much as
DFID wants to support sector wide approaches, direct budget support
and all of that, you have to work at the same time on both fronts
and at the interface between NGOs and government.
Q176 John Bercow: It may be that
I am being quite obtuse about it but just for purposes of clarification,
when you say that if and where DFID decides that reproductive
health care shall become a priority it does, do you mean that
that is so because of DFID's stated expenditure intentions or
because it is able to exert some other influence?
Ms Pai: I think it is both. The
two go hand in hand. Other donors will look to DFID. Because DFID
is spending the levels of funding that it is spending on humanitarian
issues but also reproductive health separately, if in a particular
country DFID says, "In this emergency situation, we see that
reproductive health is essential and we are going to fund it through
all the means we just talked about in terms of capacity building,
advocacy, service delivery, both governmental and non-governmental",
then it does have an impact. There is influence that can be used
with other donors and governments also change their policies.
Chairman: Thank you both very much indeed.
It has been an interesting afternoon for us in what is a really
challenging environment. Both you and the previous witnesses have
given us something positive as well as a challenge. We will take
some more evidence. At some point we have to put this all together
and come up with some recommendations. This goes for our previous
witnesses as well: if anything occurs to you on reflection, after
this evidence session, that you feel you want to stress or bring
to our attention, I hope you feel completely free to contact our
Committee staff and feed that in because we are anxious to get
the most up to date and the most relevant input. Thank you very
much.
12 The Democratic Republic of Congo (DRC) Back
13
The European Commission's Humanitarian Aid department (ECHO) Back
14
the European Commission (EC) Back
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