Examination of Witnesses (Questions 200
- 218)
WEDNESDAY 5 DECEMBER 2007
PROFESSOR PETER
GODFREY-FAUSSETT,
PROFESSOR CHARLOTTE
WATTS AND
MS CATHARINE
TAYLOR
Q200 Sir Robert Smith: We have been
talking about integration. You have got a targeted fund at the
Global Fund looking at specific diseases and then, obviously,
the clear links with sexual and reproductive health. From what
you are saying though, does the Fund actually take any practical
steps to encourage that integration of maternal, sexual and reproductive
health into the programme that it funds or are you very much reacting
to what is coming in?
Professor Godfrey-Fausett: We
are a demand driven process. It does not encourage specific things,
it says, "This is the area", but it catalyses discussion
on those areas mainly through its technical partners. For instance,
there was a recent meeting that the WHO (World Health Organisation)
organised in conjunction with the Global Fund to which it invited
countries and experts to discuss the ways in which countries could
apply for money to strengthen their health systems. The Global
Fund has always made it very clear that strengthening health systems
in order to have some impact on HIV, TB and malaria is an entirely
legitimate use of the Fund's money, but to date countries have
not availed themselves of that resource as much as they might,
maybe because they misinterpret, they say, "HIV, TB and malaria—
that is what it is for", whereas actually I think the Fund
would welcome a broader base to what countries ask for. In answer
to your basic question, the Fund is not a technical agency. The
Fund does not tell people, "This is what you should be doing."
It says, "Apply to us with what you want to do and, providing
it is in line with international best practice, then we will fund
it." So I think it is more up to DFID, WHO, more technical
agencies, to be encouraging countries with what they could apply
for.
Q201 Sir Robert Smith: Do you have
any examples though of applications that have shown good integration
that maybe you could give us? Perhaps not now.
Professor Godfrey-Fausett: Yes,
there is a number of different ways of integration of different
parts. There are certainly programmes. In Malawi there has been
a programme that is about healthcare workers at perhaps a more
peripheral level; so precisely the point we were talking about
earlier of having a more rural-based cadre, resurrecting a lower
cadre of healthcare workers with support from the Global Fund
to allow the reach of the health system to go further. There are
numerous projects that aim to embed within reproductive health
services at clinic level the ability to encourage prevention of
HIV at that level and prevention of mother to child transmission.
I have mentioned that about 130,000 women so far have been treated
in such ways, and those are within a large number of programmes
across all the regions. I can list a few of them if you would
like me to.
Q202 Sir Robert Smith: Perhaps you
could send them to us?
Professor Godfrey-Fausett: Yes.
Q203 Sir Robert Smith: DFID is giving
£359 million through to 2008 to the Fund?
Professor Godfrey-Fausett: Yes.
Q204 Sir Robert Smith: But your advice
is if DFID wish to see that money go to more integrated delivery
it has got to actually speak to the applicants?
Professor Godfrey-Fausett: Yes,
DFID is in a strong position because it has country programme
staff as well, it has people who are engaging with ministries
of health, ministries of finance and the technical people on the
ground, and if it encourages those people to realise what they
can apply for, then the money is sitting there and is largely
available. I think that the Global Fund is happy to receive things.
This is not a carte blanche. The Fund was set up to make an impact
on HIV, TB and malaria, but I think it is very easy to make the
argument that investing in improving integration of reproductive
health services and HIV, investing in reproductive health services,
is very likely to make a difference to HIV and tuberculosis, as
we heard at the beginning, and, indeed, malaria. I think all of
these, in fact, relate to maternal health in a big way. I think
that the argument is very easily made and, providing that argument
is made in the proposal and it is not seen that this is simply
investing without the link, if the link is made I think it is
entirely appropriate.
Q205 Jim Sheridan: Can I perhaps
address my question to Professor Watts. There is a clear inter-relation
between sexual violence against women and HIV/AIDS. Is there any
practical example that you can tell us about where you have intervened
to try and perhaps stop this from happening?
Professor Watts: A recent and
quite high profile success was an intervention study that I was
involved in in rural South Africa, and that was very much primary
prevention. It was in part funded by DFID, where we basically
empowered women, both economically and socially. It was working
with a very strong micro-finance group and adding on to that micro-finance
participatory activities around gender, violence and HIV. What
we saw over two years, over a short pragmatic time-frame, was
a 50 % reduction in women's experiences of partner violence. It
has been a very exciting study and it illustrates the potential.
I think looking at development opportunities— in that case
we were looking at micro-finance— but adding on issues around
gender, around power, and we saw a very synergistic effect that
very much resulted in changed relationships, much stronger improved
communication and reductions in HIV risk behaviours amongst participants
and reductions in violence.
Q206 Jim Sheridan: A 50 % reduction.
Have you any plans to reduce that even further, or how best could
you extend it into other areas?
Professor Watts: It is a very
good question. I was pretty pleased with a 50 % reduction. For
that project it was a small scale thing, and what we are doing
now is the micro-finance group is scaling up across the region
and we are doing work with them to say, "How do we scale
up the gender elements?", but also trying to learn from that
about what are the implications for other development initiatives.
Are there ways that we can take some of that learning and apply
it in other settings? It is not something that is done very much
though. There are these promising initiatives, and I would be
very much encouraging DFID to be trying to learn from that in
terms of their broader activities.
Q207 Jim Sheridan: You said DFID
part-funded it.
Professor Watts: Yes.
Q208 Jim Sheridan: Who else funded
it?
Professor Watts: Ford,[7]
CEDAW,[8]
a range of the more progressive donors essentially.
Q209 John Bercow: Apologies, Chairman,
to you and our witnesses for arriving late. Professor Watts, I
am very interested in this field and, in particular, in the reference
to the survey that you have just made. On the assumption that
predominantly gender-based violence is inflicted by the existing
male partner rather than by somebody else in the household or
in the village or neighbouring area, was it the working assumption
of that study that both partners should be involved so that the
men, who are after all the culprits, have some purchase on the
training, the therapy, the advice, the exhortation, whatever misogyny
or different tactics are involved?
Professor Watts: A good question.
In that particular study we very much focused on women, but it
was very context specific; so in this setting it was very much
that men are quite migrant, they are going to Johannesburg to
work in the mines and coming back. We started off wanting to work
with both men and women, but men are much less accessible and
so when we were talking to women, they were saying, "No,
work with us and then we will take issues to the community."
As part of that work there was a very strong emphasis on social
mobilisation and part of the lower group activities, part of the
micro-finance activities, led to those groups taking issues to
local leaders, going out and talking to youth, to boys, and so
it was working through women to reach men. There are other examples
of programmes that focus exclusively on men that are also very
promising in terms of promoting alternative models of masculinity,
really engaging on: what does it mean to be a man? To me it is
a challenging issue, but actually fundamentally it gets at what
we need to be looking at around being a good father, about not
coercing sex, about issues of HIV prevention, and where you do
see evaluations of those projects they are quite promising and
they lead to multiple benefits.
Q210 John Bercow: Of course, from
our visits to several different countries in Africa, we are well
familiar with the phenomenon of substantial periods of separation
between male and female partners, with the man typically going
to work in one or other of the big cities a substantial way away.
It would be of interest to me, and it may seem academic, but I
think it would nevertheless be potentially relevant to know, whether
the incidence of gender-based violence is that much greater, and
therefore the problem is that much more acute, in those households
where there are long periods of separation and, to put it very
bluntly, Professor Watts, the male partner, the husband, comes
back and then, if I can, as I say, put it very explicitly, thinks,
"Well, I have got to make up on lost time." However
intolerable culturally that is to us, it is a reality, is it not?
Does that tend to have an impact?
Professor Watts: It is a good
question and one we have not looked at. When we looked at the
level of violence in those populations, they were pretty similar
to other areas in South Africa that have less mobility, but in
a way you think it could be lower because the men are not around
that much. I cannot say yes or no.
Q211 John Bercow: On the whole question
of the cultural norms which tend to influence behaviour, do you
or others in programmes of this kind tend to accept male resistance
to condom use as a given and feel you have just got to work round
it or are you, where it is, frankly, prevalent, trying, at the
risk of being accused of cultural imperialism, to say that this
really will not do and there is a better way?
Professor Watts: I think in the
end, in terms of this project, if I think about this project,
the focus has been on everything, so you want to reduce risk behaviour,
you want to try and challenge the acceptability of men having
multiple sexual partners, extra-marital relationships, you want
to improve communication in the household, you want to empower
women to be able to more openly discuss condom use or other health
needs and you also need to be investing in alternative technologies.
I think you need to be pushing on all fronts but recognising that
those underlying issues around concepts of masculinity, around
violence are something that you have to be quite explicit about
and we have to engage with in a meaningful way. When you look
at HIV messaging, my frustration is that there is this sort of
implicit assumption that most sex is consensual, or that sex is
consensual within loving relationships. That has become very distant
from the reality of many people's lives and we have to start thinking
about how do we deal programmatically with those uncomfortable
realities that you are referring to.
Q212 Richard Burden: John has covered
many of the areas I was going to explore with you. Perhaps I could
focus a little bit more on DFID's role both in relation to the
South African project that you have been talking about and also
some of the projects that have been done in relation to gender-based
violence in Nepal. What lessons have you learnt from those in
terms of how DFID itself could make a greater contribution, could
scale up and apply any lessons elsewhere?
Professor Watts: I think there
is a number of different levels where DFID could be making an
important contribution. At an international level, for example,
in the recent UNAIDS[9]
costing of resource needs for HIV, for the first time they included
responses to gender-based violence and $2.2 billion was included
in those projections. I think DFID has an important role at that
international level pushing for there to be investment in that,
and when you translate that into a national level, those resources
are going in, explicitly addressing some of those links between
violence and HIV. One of the main challenges in terms of what
do we do is the limited evidence-base, and what I see is a number
of very promising interventions that do show we can have quite
large impacts over short periods of time but I can count the evaluation
studies on one hand, and so we do need to build an evidence-base
about what are the approaches that work with men, with women,
what is the role of the economic components versus addressing
issues around alcohol, fundamental attitudinal issues around the
acceptability of violence. From the projects that we do know,
where there is success, I think the core elements are that there
is a meaningful engagement with communities, with men, with women,
over time, and so in terms of programming, I think it is looking
at what are opportunities of, say, working within the development
sector or even within the health system; where an agency is having
an on-going relationship with the community or interaction with
men and women in that community, to say how can we explicitly
bring issues around gender and HIV and violence into those programmes.
Q213 James Duddridge: A few questions
for Catharine Taylor. The first one is around the interaction
between sexually transmitted diseases and HIV. In particular what
can donors do to integrate the diagnosis and provision of treating
the two conditions together, because that seems to be the thrust
of what you were saying: a more integrated health system?
Ms Taylor: Yes, as you were saying,
there is a lot of evidence about the interrelationship between
HIV and sexually transmitted diseases. I think, again, look at
reproductive health in its broader sense. For example, you often
find that STI[10]
diagnosis and treatment is actually very poorly implemented at
a clinic level and often is not really seen as part of the package.
Again, from personal experience here, often in countries you go
to the dermatologist if you think you have got one of those diseases,
as it were, and so often health services are not fully equipped
to deal with the diagnosis and treatment of STIs. So I think ensure
that it is part of the package within the health service.
Q214 James Duddridge: The donors'
funding money in that direction though: is the message getting
through to donors?
Ms Taylor: Yes, I think the message
is getting through to donors but I think often there is a disconnect
between what the donors are saying at a policy level and the implementation
of that on the ground. I think there needs to be not only a lot
of emphasis on policy but also looking at integrating and implementing
good services on the ground. I think there is still that disconnect.
If you talked to anybody in the Ministry of Health they would
agree with you that STI diagnosis and treatment is a very important
aspect of care, but if you go to any clinic it is not happening.
So it is really to ensure that the implementation is there as
well as the policy.
Q215 James Duddridge: Have we seen
any benefits yet of the integration within the DFID team of the
HIV/AIDS policy group and the reproductive and child health policy
group, or is it too early to see the benefits?
Ms Taylor: It has only happened
quite recently and I think it is possibly too early to see a lot
of the benefits, but I do see in my discourse with advisers, et
cetera, a lot more discussion around the integration of reproductive
health and HIV, certainly. The fact that the maternal health adviser
is not in that group but, I think, in a separate group perhaps
needs to be addressed so that she has the opportunities to interact
with that group as often as possible.
Q216 James Duddridge: Was that issue
raised when the integration was talked about? I had not appreciated
that the maternal health side still sat outside that group. That
seems to be an anomaly.
Ms Taylor: It is my understanding
that that is the situation. I cannot say what the discussions
were when the decisions were made. If I understand correctly,
I think that she is in the Scaling up Services Team, so she is
very much within the health systems aspect of it, but I think
a lot of linkages need to be maintained.
Q217 James Duddridge: We will make
sure we go away and check the facts.
Ms Taylor: Yes.
James Duddridge: You said you are unsure,
so we will go away and check. Thank you very much.
Chairman: Thank you very much. The general
theme of the evidence we have taken so far is a rather big one,
which is that you can only tackle these problems if you have an
integrated health service. We have enough trouble with the Health
Service in this country. I am not going to ask you to answer the
question now, but if you have any thoughts at the intermediate
level, how you get from having a proper health service when there
is none to ensuring that, nevertheless, there is practical access
to essential services. That it what we are struggling with, because
we are not getting anywhere near the MDG[11]
on maternal health. It has been suggested to us that a lot of
that is cultural, attitudinal and gender-based, in other words
women's low status— I guess one is trying to fight for that—
but if you pull it together and say it is all part of the general
health of people of both sexes and all ages, you actually start
to get it into a situation where it does not get that degree of
discrimination. If you have any thoughts, having exchanged this
evidence with us, that would help us in that direction to make
some constructive recommendations, because we have got this big
vision and a huge gap in practical terms in relation to which,
certainly for me and other members of the committee as well, we
are struggling to find something useful and constructive that
can take us from where we are. May I thank all three of you.
Q218 Hugh Bayley: Can I ask for one
further bit of information after the event. To go back to the
question about the relative cost of preventing mother to child
transmission, you gave a figure for prevention, but if you could
come back, if you could find a figure for mother to child transmission
and also find a comparative figure of the cost per life-year gained
through anti-retroviral therapy, I think it would be a very useful
indicator of relative costs of interventions for the Committee.
Professor Godfrey-Fausett: I would
be happy to, and I will certainly try and find those costs, but
I would like to preface that with a comment to be cautious in
the interpretation of these data. I think we possibly met in Zambia
on one occasion some time back. I lived in Zambia at the time
before the anti-retroviral drugs became available; I have been
visiting Zambia continuously. I lived there from 1992 to 1998
and have been visiting two or three times a year ever since. I
have seen the emergence of what has happened. There is no doubt
that the provision of anti-retroviral drugs has a far greater
impact than simply those people who are being kept alive. You
can imagine that to work in a clinic where, of the people who
come to that clinic, 50, 60 sometimes 70 % of the adults are dying
of HIV. If you do that in an era before anti-retroviral drugs,
your morale is zero. You have nothing to offer people except the
home-based care. You then transform the situation by saying: "Actually
now this is how we can do something about it", and you can
see the change in the way clinics are performing in Zambia now,
not just in delivery of ARVs[12]
but in terms of a feeling that actually we are delivering healthcare.
For the healthcare workers' morale, esteem, situation in the community,
it leads to cleaner clinics, so I think it is much more transformative
and I think it can be dangerous only to consider the costs and
immediate, medical benefits. Because anti-retroviral care is widely
available now, in all districts in Zambia, for instance, and this
would be true in many other countries— there is some access,
people know about it— that in turn transforms attitudes
to HIV itself. It means that people are much more able to name
the beast because they think, "Actually I can get treated
if it turns up." It alters things in ways that are every
hard for an economist to put down on a sheet of paper and probably,
although it is hard to prove, has a major impact indeed on prevention,
because if, as a result of reducing stigmatisation around HIV
because more treatment programmes are available, women feel more
able to discuss it with their partner in a less frightening way,
that may well have a beneficial impact. Whilst there are certainly
figures out there, I would have considerable caution in using
those to make policies. Of course they are part of the decision-making
and the policy-setting agenda, but I do think they need to be
taken quite carefully because there are many intangible benefits
that are very hard to put down as a cost.
Chairman: If you feel able to attach
a couple of practical case studies to the figures, that might
help. Thank you very much indeed.
7 The Ford Foundation Back
8
The United Nations Committee on the Elimination of Discrimination
against Women (CEDAW) Back
9
The Joint United Nations Programme on HIV/AIDS Back
10
Sexually Transmitted Infection (STI) Back
11
Millennium Development Goal (MDG) Back
12
Anti-retroviral Drug (ARV) Back
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