Examination of Witnesses (Questions 219
- 239)
WEDNESDAY 5 DECEMBER 2007
DR GILL
GREER
Q219 Chairman: Good morning, Dr Greer.
Thank you very much for coming in for the second half of our session.
Again, briefly for the record, would you introduce yourself?
Dr Greer: Thank you very much
indeed. I am delighted to be here and thank you for your time
and interest. I am Gill Greer. I am the Director-General of the
International Planned Parenthood Federation. We have 152 Member
Associations affiliated with us and we work in 180 countries in
delivering comprehensive sexual reproductive health services,
providing education and information, including sex education,
and also in advocacy with civil society, with governments, with
ministries. Thank you very much indeed for this opportunity. As
you can tell, I am a New Zealander, so let me know if there are
any problems with translation.
Q220 Chairman: Thank you very much.
Those of us in Scotland will have no difficulty! The situation
with MDG 5, the most off-track of the Millennium Development Goals,
is that, as we move off track, we seem to increase the targets
and we have actually added to it and embellished it and made it
more difficult even though we are actually drifting away from
it. DFID, I understand, has been involved in developing the new
target in spite of the fact that we are not making progress on
what the original target is. I think we have now incorporated
into the target addressing the adolescent birth rate, antenatal
care and the unmet need for family planning on top of the original
targets. What do you think the barriers are both for achieving
the original target and how much more difficult is that target
going to be now we have extended it and expanded it, and what
is your organisation, the International Planned Parenthood Federation,
recommending about how we can actually take on that challenge?
Adding new targets when you are not achieving the first ones does
not in itself seem to change the situation.
Dr Greer: Thank you very much
indeed. It is our conviction that we will not achieve the first
target or, indeed, MDG 5 or, indeed, any of the MDGs if we do
not address the issues that are covered by the new target. We
are very grateful, in fact, to the UK Government and DFID for
supporting the call for this target. Originally, you may know,
we called for a ninth Goal, because we believe that of all the
important international meetings, declarations, conventions of
the 1990s, the one that was left out when it came to the MDGs
being finally framed, which is so essential for maternal health
and for health and well-being generally in development, is that
of universal access to reproductive health, which was the Cairo
goal from 1994. I believe that if we really are to meet the goal
and the targets (the target now has a contraceptive prevalence
rate indicator), then we will make progress on the first, but,
I agree, it does not seem to make logical sense when you first
look at it.
Q221 Chairman: I am not deploring
the targets, it is the practicality, and that is really the point
you are trying to press. For example, if you take the new targets,
how are they going to be measured? How are we going to determine
that we are reaching them? Is the information that exists and
the method of collecting facts and figures in developing countries
adequate enough? When we were having our preliminary discussion,
I was pointing out that the figure for the number of women who
die in childbirth is very precisely stated in a number of publications.
In spite of the fact that we have had evidence that nobody actually
knows what the figure is because there is no satisfactory method.
The question really is: once you set a target, how do you actually
define what the situation is in individual countries and how do
you then determine how they are progressing towards meeting that
target? Have you got any constructive recommendations?
Dr Greer: I think there are some
very interesting questions embedded in there. I do agree that
trying to get really clear data is a major problem in itself.
I am very interested in seeing in the IHP[13]
Plus that there is going to be a component of data analysis at
the very beginning. I think it is very important to try to build
(and this is perhaps a role for DFID to consider) the in-country
national competency in building statistical surveys and data collection
so that it is sustainable. If it is always done by people coming
in from the outside and, even though we do, as we can, encourage
people to report against those MDG goals and other UN commitments,
it is very difficult. I think, too, just from our own experience,
we have recently put in place for all of our Member Associations
reporting for a global indicator survey against 30 indicators,
which include sexually transmitted infections, sexuality education,
maternal health, HIV-SRH[14]
integration, and so on. I know the difficulties that our Member
Associations experience in trying to keep that data, but I am
also seeing that it can be done. I launched a project in Kampala
for HIV/AIDS and sex workers recently and, two months later, was
able to get a very clear picture of the work that they are doing
in broader primary care but also specifically related to maternal
health and HIV. So I think there are some models there, and I
know that the ideal is civil registration. When it comes particularly
to maternal health, we are a long way from that in many places,
but I think we can move towards it, and I know that there are
some new models around too that the UN are considering as possible
ways of measurement. I think it is difficult, particularly in
areas to do with this area of health, because often it takes so
long for the outcomes to become obvious. We can count inputs and
outputs, but the outcome is much harder.
Q222 Chairman: When we were recently
in the highlands of Vietnam we were in a village where the norm
was for girls to get married as young as 13 or 14 and very quickly
have families. That is obviously one of the new areas, which is
that girls are getting married and having children younger, when
they are not fully developed, and that is a contributory factor.
How can you change that if you have got an embedded cultural situation?
How do you actually get across that you are putting your community
and your people at risk for your cultural reasons that are actually
not healthy?
Dr Greer: I think encouraging
governments to invest in girls' education and women's literacy
is critical to that. We have enough data that shows the impact
of that on later first birth, on child spacing, and so on. There
have been some very interesting projects in Bangladesh and Nepal,
where community groups work with parents to encourage parents
to keep their girls at school. Also, when we look at the impact
of free lunch schemes, which of course was one of Jeffrey Sachs'
quick wins, we know that it actually works— the same with
school uniforms— it encourages and motivates parents to
keep their girls at school. We know that for every year that they
are in school there is considerable impact on both the timing
of their first child, and the number and the spacing of their
children which will then impact, of course, on maternal health,
plus their ability to understand nutrition, risks to themselves
in pregnancy, have some sex education.
Q223 Chairman: It is a chicken and
egg situation, because if the girls are at home having babies
they are not in school getting the education to tell them that
is what they should be doing?
Dr Greer: Indeed, one of the drivers
of unsafe abortion is that in many countries a girl must leave
school if she is pregnant, there is no way that she can continue
her education, and in some cases that is likely to drive that
issue, but I think there are laws and we need to encourage their
implementation and enforcement. Nepal is an interesting example.
Chairman: We might come to that later
in more detail.
Q224 Richard Burden: I would like
to ask you one or two questions, if I may, about the unsafe abortion
issue. It is obviously a very big question. One in eight of the
600,000 women who die from pregnancy-related complications somehow
seem to have a link through to abortion-related complications.
I want to ask you in a minute about the substance of that and
maybe what we can learn from that and policy directions. But going
back to the thing you were talking about before about the data
itself, apparently the figures there have not particularly changed
since 1990 and a question mark has been put to us particularly
about the reliability of that data. Do you have anything to say
about that and is there anything in relation to unsafe abortion
where we can improve the evidence-base? Is it easier, is it more
difficult or is there anything specific about the evidence-base
there that we need to do to get more reliable information?
Dr Greer: If I could go back and
say that, if we start by recognising the fact that 200 million
women cannot access modern, effective contraception and, therefore,
we have high numbers of unplanned pregnancy, some 86 million;
there are 40 million abortions a year, of which 20 million will
be unsafe, it is not surprising 70,000 die as a result. Yes, we
will not have exact figures and, as long as it remains illegal
in so many countries, we will continue not to have exact figures,
I believe, because very often it will be laid down to either the
immediate cause of death, whether it is haemorrhage, anaemia,
whatever it may be. It is going to be very difficult. It is hard
enough to get figures for maternal deaths as it is let alone for
those deaths which occur as a result of unsafe illegal abortion.
I think that is enormously difficult. What can we do? At the moment,
for example, we have just developed a tool which we are sending
out to all countries and we are working also with FIGO[15]
to get them to analyse exactly what the law is. One of the problems
is that in many counties the law does allow abortion under very
certain restricted circumstances, but in fact neither the providers
nor the women themselves often know to what extent it is available
and allowed or how to access it; so we have to have really clear
data in relation to that and I think then build on that to get
the kind of data that gives us a clearer picture. We do know in
some countries like Uruguay around 46 % of maternal deaths are
caused through unsafe abortion.
Q225 Richard Burden: Obviously there
is a real issue in countries where it is illegal, or near as damn
it illegal, to get at that kind of data, and there are all sorts
of issues around that, but are there any countries, even where
it is illegal, where in terms of collecting data there is any
best practice that could be applied, or pressure could be applied
elsewhere?
Dr Greer: There is no doubt that
through menstrual regulation (for example, manual vacuum aspiration),
there is much more done than people are aware of, but providers
in those countries where it is illegal and where there are harsh
penalties of imprisonment, both for the woman and the provider,
to a point where sometimes providers will not even address issues
of a possible ectopic pregnancy because they are worried about
being accused of carrying out an illegal abortion, are not going
to record in any way that could be publicly disclosed what the
numbers are because of the risk to themselves and their clients.
That is why I say we have to work in every way we can to advocate
for law change. I want to congratulate the United Kingdom and
DFID for the Safe Abortion Action Fund, which we manage and distribute.
Out of the first year, I would just like to say, we have distributed
to 45 organisations and 32 countries for two-year projects, and
they cover a range of projects, and it is that kind of funding
which enables us to work as advocates, not us but, in fact, civil
society, and even sometimes ministries, to work together on these
issues.
Q226 Richard Burden: I think Jim
will be asking in a minute specifically about the Fund. Could
I perhaps ask more broadly as far as IPPF is concerned, as well
as the use of that Fund, first of all, what are the areas that
you are involved with in terms of reducing maternal deaths through
unsafe abortion, and where do you think we should be going? Where
should we be moving next on that? What are the kinds of things
we need to be doing?
Dr Greer: We need to upscale family
planning, for a start, as part of a comprehensive sexual and reproductive
health continuum of services and information. We have already
talked about the unmet need of 200 million and I have read one
figure that would suggest that maternal mortality could be reduced
by 20 % simply by meeting that need. Another is to encourage,
for example, a focus particularly on the young. We know that girls
between 15 and 19 are twice as likely to die as those above 20
from pregnancy-related complications, and we have the biggest
population of young people that the world has ever seen in the
world's poorest countries right now, so we must focus on that,
and that is part of the work that we are trying to do, integrating
sexual and reproductive health and HIV and AIDS and trying to
make sure (and this is again something that your Government and
DFID can do) that civil society is at the table when planning
and budget decisions are discussed and that these issues, which
have been neglected tragically for so long, are now included at
a time when there are so many competing priorities. When, for
example, the Global Fund is being considered— whether it
is SWAps,[16]
PRSPs,[17]
budget support— we are concerned, and every donor government
I have spoken to so far continues to be concerned, that issues
of sexual and reproductive health and maternal health will fall
off the agenda if, indeed, to whatever extent they were on the
agenda to start with. So, for us, advocacy with our Member Associations
so they can convince others in the development community of why
these issues are important to development as a whole and then,
together, convince their governments so that they too, not just
donor governments, play a part in recognising that they need to
implement their commitments, they need to make sure that these
are part of the discussions that they have with donors when, for
example, they are developing national health plans, national AIDS
and development plans, when they are developing infrastructure
plans. This needs to be integrated into all of that. So, that
is part of what we are doing, advocacy as well, and trying to
get investment by local governments as well, but also working
with sexuality education and trying to reach the poorest of the
poor, the rural, the urban poor, the most marginalised—
sex workers, men who have sex with men, young, gay, lesbian and
bisexual people. If I can just comment, there was a question earlier
about sexually transmitted infections. Can I say that that is
a major part of our work, and I believe the stigma surrounding
STIs is as great as that surrounding HIV/AIDS, and that impacts
on maternal health and on HIV and AIDS obviously.
Q227 Jim Sheridan: Can I just probe
you on the Safe Abortion Action Fund and thank you for your kind
words about the funding from UK taxpayers through DFID. Experience
tells me that is usually a code for: "Leave my fund alone
and go and look somewhere else if you want to make cuts."
Against that background, can you give us any tangible evidence
that the Fund that the taxpayer is paying for is going to the
people it should be going to and can you justify the amount of
money you are receiving just now or, indeed, an increase in it,
but, most importantly, can you tell us exactly how this money
has been spent and has it been targeted at the people that it
should be targeted at?
Dr Greer: To begin with, we were
not sure how much the amount of the Fund would be because we had
the original funding from the United Kingdom, who then worked
(and we supported them) with other governments to encourage them
to contribute. In terms of process, I think it has been rigorous.
To begin with we advertised the Fund mostly through civil society
networks, we did not go much beyond them. We had over 170 applications
in that first round, and I think that sheer number in itself speaks
for the fact that there is a real need for this. There was an
extremely rigorous process of technical review to come up with
those 45 final projects, and those were independent technical
reviewers who did this on an entirely voluntary basis and then
met and discussed this face to face. DFID itself and the other
donor governments are represented on the panel and we believe
that this helps to ensure good processes. Clear expectations are
in place for monitoring and evaluation and, of course, we are
only at the beginning of the projects now being implemented, but
we are already noticing in terms of, for example, demand for supplies
and other things coming through, that the progress is moving rapidly
and we will get regular reports on that; but I have brought some
further information on that for you as well.
Q228 Jim Sheridan: When will you
be in a position to give us clear evidence that the number of
women who are dying from unsafe abortion is decreasing?
Dr Greer: We will have the first
reports back on the projects within a year after they started.
To what extent that will demonstrate that, I cannot honestly say
because, for example, if it is an advocacy campaign, that will
have taken time to put into place, to implement, to see if there
is any change in the law. If we think of Nepal, our association
began advocating for law reform on abortion in 1971, and the law
was finally changed in 2002, so outcomes are not as quick as you
and I would want, but I am sure that these are good projects and
I am sure that they will the give us results.
Q229 Jim Sheridan: Is there an audit
trail to ensure that the money is getting to the actual people
it is meant to go to?
Dr Greer: Absolutely; yes.
Q230 Jim Sheridan: Is it evaluated?
Dr Greer: There will be an audit
trail. We do not allocate funds without a very clear audit trail
on expenditure and very clear reporting dates and guidelines for
that.
Q231 John Bercow: Dr Greer, forgive
me if I am being abnormally slow on the uptake, but as of this
moment it is not clear to me what is the balance of your work
as between advocacy of safer abortion in countries where it is
already legal but often unsafe and advocacy for legal abortion
in countries where it remains illegal, the latter being of notable
significance when one considers, as we are advised, that no fewer
than 69 countries, representing just over a quarter of the world's
population, currently ban abortion?
Dr Greer: Any organisation that
is a member of IPPF works in five priority areas, and they are
expected to do something in all of them and the objectives are
laid down. These are HIV and AIDS, access, which includes in particular
maternal health and wider access to a range of services, adolescents,
abortion and the last is advocacy. In the case of the Safe Abortion
Action Fund and, indeed, our own Member Associations, they are
expected to report back annually as to what they do in abortion-related
services and advocacy in relation to abortion. So there are two
components in that which they report on. Given the figures you
have just given, more work is done in relation to advocacy, in
particular making sure— and this is the reason for the new
tool that we are sending out— what the law is, are providers
absolutely aware of the law, are women aware of the law and, even
in countries where it is legal, how accessible is abortion because
of transport costs, service coverage, stigma, a whole range of
issues, is a major part. We believe that there is not a country
in the world, including this one, where our Member Associations
cannot continue at least to work in advocacy. When it comes to
services, many will give options counselling only, and it is because
of that, of course, we do not receive US funding, as you will
be aware. Many will refer and some will carry out abortions, either
medical abortion or surgical abortion, depending on each country
context and the capacity of the Member Association. So, it is
hard to give an overall figure, but I can certainly send you the
data for the percentages in terms of both service delivery and
advocacy if that would be useful.
Q232 John Bercow: The prohibition
on American funding is not of very long standing, is it? It depends
what you regard as long standing, but, for the avoidance of doubt,
that prohibition on American funding was applied under President
Bush but did not apply, presumably, under President Clinton.
Dr Greer: No, it did not under
President Clinton.
Q233 Chairman: It does not apply
to the Gates Foundation, just to the American Government.
Dr Greer: No, American funding.
Q234 Chairman: Any American funding?
Dr Greer: Access to American Government
funding, for example from USAID.
Q235 Ann McKechin: You mentioned
recent legalisation of abortion in certain Asian countries such
as Nepal and Bangladesh. I wondered to what extent you are gathering
statistics about the incidence of female foeticide because of
gender-based abortions and whether or not this is becoming an
increasing issue?
Dr Greer: We are aware of the
issue and of the concern about the issue. I suppose, for us, it
is another sign of male preference and often of the invisibility
of women which, I think, impacts on their lack of education, their
lack of empowerment, the lack of maternal health. It is very difficult
indeed to, again, get accurate figures. I must say that the expansion
of medical abortion, which many would see as the greatest technological
development in the area for many years, will make it even more
difficult to be aware at the extent of this; if women really are
eventually able to take absolute control of this with minimum
input from health providers, although that might not necessarily
be advisable, but that may be the way it is. There is no doubt
that it will have an impact where you get a major imbalance, and
I think China is recognising it, India is recognising it, but
at the same time a woman who has been raped or has seven children
is not necessarily going to want to have an eighth and the sex
of that child will not be what is primarily in her mind, and I
think we need to be aware of that and also aware of what it is
that pressures a woman to undergo a sex-selective abortion. It
is not a simple matter, and I think there is enormous pressure
on women to do that, where that occurs. Again, I think it is very
much about addressing issues to do in particular with male preference
and instead valuing women in every aspect of life and making that
value visible.
Q236 Ann McKechin: We visited Vietnam
recently and someone said to me that this incidence actually increases
as people become wealthier; so it is not necessarily directly
related to poverty or lack of economic power but becomes a question
of status. We obviously talk about the interventions of providing
health facilities, trained attendants, contraception, but do we
actually do that at the expense of addressing some of the more
difficult social and cultural issues which underlie some of these
problems and which, if you do not address them, are likely to
become the dominant factor as countries develop?
Dr Greer: I have heard a similar
statement. At the same time I have also seen presentations which
have talked about rural peasant populations believing that it
is only if they are buried by their sons that they can meet their
ancestors. So I think we do see it at both ends of the social
continuum. At the very core of our work is a Charter of Sexual
Reproductive Rights which we developed 10 years ago which is translated
into many languages, well over 30 anyway, and is used by all of
our Member Associations, and we are currently updating that in
a Bill of Sexual Rights, recognising that although sex precedes
reproduction it is also often separate from reproduction and we
need to be making sure that we are addressing that end of the
continuum as well. Part of our work, whatever we do, is to make
sure that services and information have a strong rights-based
approach, that a gender equity perspective is in everything we
do, and it includes addressing gender-based violence, domestic
violence, violence during pregnancy, and that women's empowerment
is seen not as the disempowerment of men but the opportunity for
both to be equal, to strengthen families, to strengthen communities
and be strong together, and so a lot of work with men, in particular,
to help them recognise both the importance and the contribution
of women and girls but, second, the impact of disempowerment and
violence against women, and thirdly the importance of their own
good health.
Q237 Sir Robert Smith: You have already
mentioned in your evidence that if the unmet need for contraception
was satisfied maternal mortality would be dramatically reduced.
What sort of effect have the current pressures for funding for
HIV services over the last decade had on the availability of funding
for family planning and other reproductive healthcare?
Dr Greer: I think it is clear,
if we look historically at funding levels, that funding for family
planning has decreased in proportion as funding for HIV and AIDS
has increased, but having said that, I do not see it as either/or.
I can absolutely understand, when we see how relatively few still
are able to be on ARVs, for example, that there is an absolute
need, and the virus will mutate and it is always one step ahead
of us. That is critical, but so is funding for family planning.
It is when we hear, for example (and figures were quoted earlier),
that less than 16 % of women who are pregnant have had voluntary
counselling and testing for HIV. This is a major project of ours
to push that out across the globe now. I am a woman. I walk into
a clinic. I want to know how to manage my contraception. I want
to space my children. I may also have an STI, unknowingly, and
in many countries, as you and I know, the greatest risk of HIV
is to be young and married for a woman. It is the greatest risk
for HIV altogether. So I may also have HIV. I have to be treated
as a whole person, and so, for example, we believe that the Global
Fund needs to be far more proactive in ensuring that the broader
continuum of sexual and reproductive health, including family
planning, is included, and some of that is to do with the country
mechanisms and what comes forward, of course, to the Global Fund,
but we would like to see a greater proactive approach in that
way.
Q238 Sir Robert Smith: You think
the Fund should actually be asking---. You heard from the earlier
evidence maybe that the Fund was saying, "We sit here. We
have got the money. It is up to the applicants to recognise they
can unlock that connection." Should DFID be doing more to
encourage applicants?
Dr Greer: I absolutely believe
that DFID should be doing everything it can to encourage the involvement
of civil society and women's organisations, for example, at country
level in the mechanisms that are related to any funding at all
and, in particular, to make sure that sexual and reproductive
health and HIV and AIDS are integrated. There are many women who
will not go to an HIV and AIDS clinic in Vietnam— you have
been there, some of you; you will understand that— for testing
or to a sexual health clinic, but they have been for a long time
to a family planning clinic or to a primary care provider. There
is no stigma with going; it is acceptable to plan their family.
They feel safe; they feel secure. They need to be able then to
access voluntary counselling, testing, prevention of mother to
child transmission, all of them, the full requirements.
Q239 Sir Robert Smith: One of the
other barriers you also touched on to accessing family planning
is pressures from society, male dominance, and so on. What more
can be done to relieve those pressures, to actually enable women
to access family planning?
Dr Greer: Again, I think, education,
both of men and women, plays a major role. Once one generation
of women is educated, then it becomes far more acceptable in the
next generation of both boys and girls, men and women. Secondly,
I think we have to invest more in outreach and outreach is expensive.
We know, for example, from work that we are doing with displaced
people, with refugees, we must reach out to those communities.
There is no way they can ever find their way to a clinic—
that is a static clinic. That is part of it. Secondly, we need
to use the media more. We need to use interactive technologies.
We have sitting in the room somebody who has done some fantastic
work with our Ethiopian Member Association using film to demonstrate
both safe birthing but also to help to build education around
these issues. There is a whole range of ways in which we can move,
we just need to scale them up, and we need to measure their effectiveness
as we go.
13 International Health Partnership (IHP) Back
14
Sexual and Reproductive Health (SRH). Back
15
the International Federation of Gynecology and Obstetrics (FIGO) Back
16
Sector-Wide Approaches (SWAps) Back
17
Poverty Reduction Strategy Programmes (PRSPs) Back
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