Examination of Witnesses (Questions 248
- 259)
TUESDAY 18 DECEMBER 2007
BARONESS VADERA,
DR STEWART
TYSON AND
MR ANDREW
ROGERSON
Q248 Chairman: Good morning, Minister,
welcome to the International Development Committee and your first
appearance in front of us, but not your last, as we have already
got your second appearance booked in. Thank you for coming in.
As you know, this is the last evidence session on our report on
maternal health, which is the MDG[1]
which is most off-track and one which we are particularly concerned
about. For the record, I wonder, first of all, if you could introduce
your team— I know you have a change, which we have been
notified of— and then we can proceed.
Baroness Vadera: Yes, I am sorry,
it is Christmas week. This is Dr Stewart Tyson, who is the Head
of Profession for Health, and Andrew Rogerson, who is the Head
of the Human Development Team.
Q249 Chairman: Thank you very much
indeed. I re-read last night the Department's submission for this
inquiry and I have to say it is extremely robust, both in terms
of the language and the commitment— that is not in question.
I think we accept that DFID, both in its own terms and internationally,
is seen to be a major driver of maternal health issues and progress
towards MDG 5, but the problem is progress is poor. I suppose
that is the first question. If DFID is so strongly committed to
it— and that is not in question, that is clear and comes
through very definitively— and is providing a leadership
role, why are we doing so badly and what, particularly, do you
think are the things that are holding us back?
Baroness Vadera: I guess I would
say the fact that there is no magic bullet here when it comes
to maternal health. Maternal mortality is one of the trackers
of health systems but you have to get a very comprehensive health
system in place in order to ensure progress. There are some of
the other MDGs where you can do certain things immediately, for
example, with child mortality, and while health systems are very
important you can get a great deal of immunisation coverage without.
So it is the comprehensive nature of the solution, I guess, that
is one of the main issues. The second is, obviously, the cultural
and social issues, particularly around women's rights and the
role of women in society and political leadership. I would say
that political leadership is one of the big issues here which,
in one sense, internationally, behoves us to do more but a lot
of it has to come from the country. I think it is also a cross-sectoral
issue because it links to girls' education, to access to treatment
and poverty issues, in terms of remoteness and getting money to
get to health care services, transport. So I think the fact that
there is no silver bullet means that that attention is not as
easy to get and the problem is more difficult to solve.
Q250 Chairman: If you think back
a few years, for example, maybe 20 years, there was a huge, international
world obsession with population growth and huge campaigns for
family planning, and these kind of issues, which seem to have
gone off the radar. If there is no silver bullet— we accept
that and we have obviously been taking evidence from a variety
of quarters— are there particular obstacles that you feel
are standing in the way?
Baroness Vadera: I would say that
health systems would be one of the first ones that we would like
to see more focus on, and that is why DFID is focusing a lot more
now on health systems, and on making sure that the health systems
and the countries actually care about and track maternal health
issues, whether that indicator is on maternal mortality or skilled
attendants, or whatever it might be, and getting it universally
available and getting it to remote areas. That would be one big
area. The second would be around women's rights and girls' education
because we do know there is quite a direct correlation here. Sometimes
it is obviously very difficult for us to be advocating changes
in legislation in-country, but when we do see a wedge we do try
and go in there and work with the country to try and change the
legislation and the rights, because, obviously, issues like access
to safe abortion are very critical as well, as the third largest
reason for maternal mortality. I would highlight those two.
Chairman: The evidence has thrown up
a number of issues which we will explore during the course of
the morning.
Q251 John Battle: In a sense, unlike
dealing with malaria or HIV/AIDS, it is clearer where to go, but
what has come across in this evidence is that it is quite a diffuse
target, in a way. Therefore, there is a sense in my mind that
sometimes people think, in all the agencies and the donors, that:
"We will do what we can and we hope that the country shares
the funds out into transport, into the clinics, into peripatetic
workers, and health workers and hope that it somehow hits the
target". I was really encouraged by DFID's lead, our Government's
lead, to make MDG 5 a key target. It is miles behind all the others
and I wonder whether we could not just catch up but really push
it and champion it. Just to give an anecdotal account, as part
of our evidence we did see the film Dead Mums Don't Cry,
a Panorama programme, and I showed that film in my neighbourhood
in inner-city Leeds and invited people to discuss development
from the SureStarts, the Mums and Tots and groups that never go
anywhere near development. They were shocked and enlightened and
encouraged that DFID had championed it so far, but then wanted
to know what more could DFID do to get a grip on this MDG nationally
and internationally. They were actually saying: "Can we raise
money to help? It connects to our agendas here. It is a campaign-championing
issue." What more could DFID do and where do you see DFID
going? Not for DFID to do all the work but with that leadership
and campaigning and championing to get MDG 5 as well ahead as
the others and as a kind of catalyser for the other MDGs as well?
Baroness Vadera: I really agree
with you on that. I think that we need to push harder in terms
of international advocacy. We have got this call to action for
the MDGs coming up in 2008 and the UN Secretary-General has agreed
to a meeting at the UN General Assembly in September. What we
would like to do, and I know that the Prime Minister is personally
very interested in that, is to push on MDG 5, not just because
it is the most neglected and it is the one that is most off-track
but, also, it affects MDG [2]
very significantly. It is the best tracker of overall health care
and health systems. So one of the things we would like to do is
up our own game, in terms of advocacy. Two things that we are
trying to do are we have managed to persuade the Norwegians when
they started on their initiative, which was just on child mortality,
to include maternal health. So they have a big piece of advocacy
work which we have been trying to assist them with and they have
got these champions in Indonesia, Mozambique and Tanzania and
other places. So we are trying to put some effort through that.
The second is that we are talking to the Japanese, because they
have the Presidency of the G8. In fact I was talking to the Sherpa
yesterday, who is visiting, and I am going to be going to Japan
in February of next year. It is really interesting because they
were influenced by us— we sent them privately papers—
and the Sherpa told me that he had read one of the Prime Minister's
speeches— I could not quite figure out which one—
Q252 Chairman: Which Prime Minister
and which speech!
Baroness Vadera: They had made
a statement that they are going to make health one of the priorities,
but really interestingly they are looking at maternal health and
health systems. The foreign affairs minister made a speech actually
saying that post-war Japanese experience showed that you have
to do disease-specific things, like TB,[3]
which they had in Japan, but you need the health systems and action
on maternal mortality. He has made a speech about that which reflects
some of the work we have input. So I think it will be quite an
exciting year, and I do think that the whole issue of political
leadership and advocacy is very, very central. However, we also
need it in the country; it cannot just be us leading, but I think
that is a much more difficult thing because sometimes (and I mean
no disrespect) male politicians in Africa find it a bit uncomfortable.
I think we need to find a way of getting champions. We are talking
to the elders group— Mrs Michel and Mary Robinson and people—
and we need voices and champions that will put it really centre-stage
on the agenda.
Q253 John Battle: That is an encouraging
answer, and if others are looking to us to lead, what about not
just in-country but the UN? We channel our money through the UN;
are there enough champions in the UN in this area?
Baroness Vadera: I thought you
were going to ask me if there were too many champions in the UN!
I think that there are now champions in the UN. I had the opportunity,
while we were working on developing the International Health Partnership,
to work very closely with Margaret Chan (WHO),[4]
Anne Veneman (UNICEF)[5]
and Thoraya Obaid (UNFPA)[6]
and it is quite interesting that there is this group of women
leaders now, and they have got a greater sense of this. In the
IHP[7]
we are going to put maternal mortality— I hope they will
agree in the meeting that we are going to have in January—
as one of the key indicators or one of the key outcomes in terms
of how we evaluate success. I do think that the UN agencies have
actually come together a bit more on this, and I think the women
leaders are helping and the IHP is helping.
Q254 Hugh Bayley: Your evidence reported
the UK as the biggest donor to WHO, the second biggest to the
UNICEF, and one of the largest donors to the UNFPA. What evidence
is there that the UN is a good channel through which to place
money which has a demonstrable impact on improving maternal health?
Baroness Vadera: When it comes
to the funding that we put in through the core funding, they obviously
report back to their own boards, and we have pushed quite hard
on improved evaluations at the board level of the core funding,
and we have our own tracking system for impact, when we do give
specific funds. We have also developed the multilateral development
effectiveness indicators in which we monitor each of the agencies
and their effectiveness. I am not going to deny that there is
a lot more we could do or the UN could do in terms of impact and
effectiveness. The point about the UN is that it is trusted on
the ground by the countries and, particularly, on sensitive issues
like this, it makes it more effective. Secondly, when it comes
to conflict situations we, very often, have very little choice
other than to work through the UN. Sometimes, obviously, we can
use NGOs[8]
but the UN remains the biggest and it leads the Health Cluster,
for example, in many situations. We do have to use them. In my
previous existence I spent quite a lot of time on the High Level
Panel for UN Reform and looked at evaluation methods as well.
I think some of them are showing some signs of improving, particularly
UNICEF and UNFPA.
Q255 Hugh Bayley: You anticipated
my next question about too many champions. What impact does the
fragmentation of the UN system have on the effectiveness of their
work towards this particular Millennium Development Goal? Also,
in your evidence, you talk about a pilot study in a number of
countries— Tanzania, Mozambique, Rwanda and Vietnam and
others— where the UN has agreed to bury its logos and operate
around one lead agency. Is that working and when will that become
the norm? Possibly, when will that become the norm in New York
as well?
Baroness Vadera: On the issue
of the impact of fragmentation, I would say, historically, it
has had an impact on this particular MDG, disproportionately,
because this MDG is very dependent on health systems. If you really
want to tackle systems then you really need co-ordination. There
are some MDGs where a more vertical approach can work better.
So I do think it has had an impact but it is one of the main reasons
we launched the International Health Partnership, to actually
bring them together. I was very encouraged by what I have seen,
in fact, from the UN agencies and the WHO, in particular, championing
this. On the International Health Partnership the problems we
have seen around co-ordination have not been through the UN agencies;
it has been a couple of the others, which has been interesting.
On the issue of the One programme, which is one office, one budget,
one leader, we were very much champions of that and directly funded
that. I was in Rwanda recently, one of the pilot countries, where
it seemed to me to be working very well. I was actually addressing
the donors' conference, where co-ordination is the big issue.
It seemed to be working very well. My sense is it is quite dependent
on the UN leader. That is the impression I got, and it was a really
good one, of Rwanda, but I hear that in a couple of countries
there have been issues. I think the problems are being sorted.
They have decided to roll it out on a kind of volunteer basis,
and I think 32 countries have expressed an interest. They will
be doing an evaluation a year from launch, and then trying to
roll it out. We attempted at the time of the UN High Level Panel
that I worked on, because Gordon Brown, then as Chancellor, was
on it, to set a target but they felt it would be better coming
from the country. It is interesting that countries have expressed
an interest in doing this.
Q256 Hugh Bayley: That means that
during the coming year, 2008, it will roll out in 32 countries?
Baroness Vadera: No, it will not
roll out to 32 countries in the coming year. I would say, possibly,
by 2010 it would have rolled out to significantly more countries,
but they are going to evaluate it during the course of 2008; they
are going to evaluate the current pilots during 2008, but there
are seven or eight more that might be rolled out.
Q257 Hugh Bayley: I am bound to say
the clock is ticking. The MDG is a 2015 MDG, and if you do not
start better co-ordinating the UN until 2010 what are the chances
of meeting the Goals?
Baroness Vadera: We continue to
press very hard. At the first meeting we had with the UN Secretary
General this was the issue that was raised. So we do press very
hard. As I said, the reason I am hopeful is that it is coming
from the countries that they want this, and I think that might
push it further forward. The other thing we are attempting to
do— there have been countries who wanted to join the IHP,
so we are trying to find the countries that join the IHP to be
the same as the countries who have the One programme, to bring
them together. Currently, we have Mozambique but we will have
Ethiopia and Rwanda who are both going to join the IHP, so we
will start to get a sort of volume, I think.
Q258 James Duddridge: In the maternal
health sector, where is DFID's comparative advantage? Have they
got a comparative advantage?
Baroness Vadera: I think part
of the fact that you are having this Committee shows that we have
a broad understanding of this issue and a cross-party understanding
of this issue, and the comparative advantage is in being able
to do and say difficult things; that we are able to champion something
that not many countries very easily champion. It is, basically,
us, the Scandinavians and the Dutch, but in terms of scale we
are able to come out and champion, for example, access to safe
abortion, which they do as well but they do not have the same
scale. The fact that we have this depth of understanding also
means that we can focus on things that sometimes people think
are slightly dull, like health systems, which are very important.
I think the fact that we give predictable, long-term financing,
which is very central to health systems, is also our comparative
advantage.
Q259 James Duddridge: Are you concerned
that given the requirement to reduce headcount, despite our comparative
advantage, other international players are unrealistic about what
can be expected of DFID, because it is not just about money, you
need individuals to help deliver the strategy.
Baroness Vadera: Yes, I very strongly
believe it is not just about money. One of the tests that I apply
to any of the submissions that come up is that if it is just about
the money we spend, then that is not good enough because we need
to be adding value. DFID has had an 11% headcount reduction since
2004, and I do not think it has affected its performance. I guess,
coming from the Treasury, you might say that I do not think efficiency
affects performance. However, we also, in the Spending Review
settlement, have agreed that two-thirds of the frontline offices
will not be subject to headcount reduction and will be allowed
a 1% increase in real terms. That is, really, where we need the
health advisers. So we have got 53 health advisers, 39 of which
are in countries.
1 Millennium Development Goal (MDG) Back
2
To reduce child mortality Back
3
Tuberculosis (TB) Back
4
ixThe World Health Organization (WHO) Back
5
The United Nations Children's Fund (UNICEF) Back
6
The United Nations Population Fund (UNFPA) Back
7
The International Health Partnership (IHP) Back
8
Non-governmental Organisations (NGOs) Back
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