Examination of Witnesses (Questions 260
- 279)
TUESDAY 18 DECEMBER 2007
BARONESS VADERA,
DR STEWART
TYSON AND
MR ANDREW
ROGERSON
Q260 James Duddridge: To clarify
that, that headcount reduction on the front line is not as aggressive—
Baroness Vadera: There is not
a reduction in the front line.
Q261 James Duddridge: Is that matched
by a more aggressive reduction in terms of back-office back in
Palace Street?
Baroness Vadera: We have the same
requirement as all the other departments for the headquarters,
which is 5%. In terms of the frontline programme we have this
protection and indeed have allowed a 1% increase for two-thirds.
Q262 James Duddridge: What will the
overall reduction be, from a DFID viewpoint? Is there a specially
negotiated settlement for DFID globally as well?
Baroness Vadera: No, there is
not an overall for DFID globally; it is the headquarters which
has the 5%. It is the frontline which is separated out.
Q263 James Duddridge: Returning to
maternal health issues, what are DFID doing to make sure that
they are more co-ordinated with other donors to make sure there
is not duplication and that both DFID and other countries do what
they are good at rather than simply duplicating or chasing the
more high-profile tasks or countries?
Baroness Vadera: This is obviously
a very big issue so we launched the International Health Partnership
in September this year. The principles around it are that the
big eight agencies, health agencies, which were the UN, GAVI[9]
and the Gates Foundation, would abide by three principles: that
we would be led by country-owned plans and have a health plan,
that we would be co-ordinated around that plan and that the plan
needed to focus on the development of sustainable health systems.
Those were the three principles. We have now got eight countries,
the first wave of countries, and the point about that is to have
the discussion, the dialogue, to ensure exactly what you are saying,
which is that we are not duplicating— that everybody is
doing a piece of it or, indeed, doing it through a single pool,
which would be even better. Sometimes we are not able to do that
with the vertical funds but with the bilateral donors we can.
In terms of PEPFAR (US President's Emergency Fund for AIDS Relief),
which is a very significant health funder now, in so many countries.
They did not join the International Health Partnership but, in
fact, have, in principle, signed up to the principles of it, and
we are now working with them on how we operationalise that, so
if they are funding nurses who are providing ARVs (anti-retroviral
medicines against AIDS), then we are talking about whether we
can provide the marginal additional costs for them to also provide
the other services. I have a meeting in January, which the head
of PEPFAR and I will be co-chairing, to talk about exactly how
we operationalise these overlaps and how we ensure that we are
funding something that is going to be sustainable and create something
that is going to survive in the long term.
Q264 James Duddridge: Are you happy
that the co-ordination between DFID and the EU is effective?
Baroness Vadera: On health care
systems, I would say that they are. I am not going to comment
on a couple of other areas that I have noticed in my travels,
but maybe in one of the other committees we can pick up on that.
I do think that on health I had not seen them as a major player
in terms of the countries that we are working in. We have not
had significant problems with them. I would say the problems have
really been round PEPFAR and the Global Fund to fight AIDS, Tuberculosis
and Malaria (GFATM)— some of the vertical funds.
Q265 Chairman: Can I press you a
little harder, Minister, on the staffing constraints? We have
had evidence that suggests that your sanguine view about efficiency
is not entirely shared. One specific piece of evidence from Immpact
(the Initiative for Maternal Mortality Programme Assessment) says
that DFID staff "are frequently overstretched by the volume
and range of work they must undertake, so that their potential
for providing leadership and influence cannot always be realised."[10]
That is a general view. It has come up elsewhere in evidence,
which I have not got to hand. There are suggestions that on this
particular area of maternal health there are staffing constraints
that are affecting the delivery of programmes.
Baroness Vadera: I did read quite
a lot of the evidence and I noticed that a lot of the NGOs talked
about that but there was a specific comment on research as well.
I do not think the numbers have reduced and I do not anticipate
that in-country, in terms of health advisers, it will have a significant
impact. I think everybody is always stretched and we are working
in a field where the need is, in one sense, endless. So I do feel
reasonably confident that we will be pushing on the maternal health
agenda and we will ensure that we are sufficiently resourced to
do that, both in terms of funding as well in terms of people.
Mr Rogerson: Can I just add to
that? We are trying to make the best use possible of our bilateral
relationships, particularly with European Union members, such
as the Netherlands. In some countries we have taken over their
co-ordinating lead from them and in others they are offering to
take it over from us. This is not a one-shot solution but it does
help make the maximum use of the few people on the ground that
the bilaterals can have.
Q266 Chairman: As you will be aware
from the debate we had in the House, the Committee at this stage
has said they accept the constraints on the Department and the
Department is adjusting its priorities within that framework,
but we have expressed concerns that decisions might be taken sometimes
which would be different if there were not those staffing constraints.[11]
Baroness Vadera: I understand
and I accept that and we will be vigilant, particularly in this
area, if we are going to give it a big push in the New Year. Andrew
is right to point out that we do work with others but we are not
driven by the staffing constraints in working with others; we
are driven by the Paris principles. So I think that on that we
are very clear that actually the value we add is not just about
our money but that we are influencing and effecting good health
outcomes.
Q267 John Bercow: Minister, at the
Partnership for Maternal, Newborn and Child Health Board meeting
in Addis Ababa earlier this month DFID resigned from the Board
to be represented from now on by the Norwegians. Why?
Baroness Vadera: I think, because
they are leading on the MDG 4 and 5 initiative and we are co-ordinating
behind them, that was considered, again, in terms of the spirit
of the partnership, to be the most effective way forward.
Q268 John Bercow: That raises the
obvious question of whether—
Dr Tyson: I would just come back
and say that DFID has been very influential in creating quite
a lot of these partnerships. There is the Maternal, Newborn and
Child Health, the GAVI Alliance, the Global Fund, the Health Metrics
Network, the Global Health Workforce Alliance. These were all
global partnerships set up, initially, to address under-resourced
areas and areas of under-focus. I think we agreed that we do not
have the capacity to continue to serve on the management boards
of all of these. For example, with the Global Alliance on Vaccines,
we were there for the first three years, we rotated off and we
came back three years on. Similarly with the Global Fund, where
we have been on the board for, I think, the first three years,
and we are in a constituency with other partners. This is very
much the case with the Partnership for Maternal, Newborn and Child
Health, and I think you will see, if you look across the various
partnerships, that we will actively engage on the board for a
period, we will try and work through others, perhaps we will come
back to it and we will spread ourselves in a more rational way.
Baroness Vadera: It is about us,
I think, being good at the start-ups and ensuring that we move
on.
Q269 John Bercow: That is fine, as
long as there is not a discontinuity resulting therefrom. In other
words, from coming off and going back on again. If you are satisfied
there is no discontinuity of policy or loss of effective action,
so be it. This is not, in any sense, a joke question; it is a
serious question: do you know, off the top of your head, on which
boards of international initiatives DFID sits? It is relevant
in the sense that where increasingly you are required with a rising
budget to be accountable, both to a domestic audience and, perhaps,
more widely, it is quite important to know exactly what you are
on and what you are not on— where you are in a primary leadership
role and where you are not.
Baroness Vadera: On the whole,
I would say that I am aware. The one that is fixating me the most,
at the moment, is the Global Fund, where I am very pleased that
we are on the board because we have given them a long-term commitment
and there is no secret about the fact that we have some issues
and, therefore, the board is important to us and we ensured that
we maintained it. With GAVI we have less of an issue. For example,
with the IHP there is not a board, it is a kind of working group
and it is actually meant to be led by the health agencies but
we ended up having observer status, which is quite unusual for
a bilateral donor. Obviously, one of the other big agencies is
the World Bank. So I think we do have an awareness of the fact
that we need to influence these agencies, and I would say that
one of the things that I am pleased by, but feel we could do more,
is the whole influencing strategy; that DFID is influential; we
have now become the largest donor for a lot of multilateral agencies
and I know that we have a voice, but I think we could be more
concerted in ensuring that we have objectives for what we are
trying to influence them to do and we definitely did that, for
example, for the Global Fund using our ability to raise issues,
and in fact I had a long discussion with the Chairman about it
yesterday.
Dr Tyson: We are trying to take
a pragmatic approach to these and we have worked in partnership
with other European donors. An example would be Roll Back Malaria
and Stop TB. These are very substantial partnerships. For a number
of years we have sat on the Roll Back Malaria Board, and we have
represented the Dutch and they have represented us on the Stop
TB Board. Last year we exchanged board seats although the Dutch
have recently requested a return to the former position because
they felt that with changes in their own administration they have
greater strength in TB. We have been happy to do that.
Q270 John Bercow: I do not sniff
at the significance of that but I am concerned about the question
of leadership more widely, specifically amongst southern partners.
Minister, I simply remind you that you yourself referred, briefly,
much earlier in this session, to the imperative of securing safe
abortion services. In a sense, the question I want to ask you
gives you an opportunity to place beyond peradventure your position
on the record. You were, I think, at one point, going to speak
to Global Safe Abortion hosted by Marie Stopes International in
October but had to pull out of that engagement— I am sure
there were perfectly good reasons for that and I am not here to
pick an argument over that— but I wonder if you could just
take this opportunity to underline your support for the provision
of such services to reduce maternal mortality and morbidity. Also,
I wonder if I can inveigle you into something a little beyond
that. If we are going to talk about leadership and changing the
attitudes of southern partners I wonder whether you think that
Britain, perhaps in concert with others, might start to be as
robust in arguing for safe abortion services amongst developing
country leaders as the United States is, sadly, robust in the
wrong direction by taking the, dare I say it, evangelical view
as far as contraception and abortion are concerned? I know there
is always the danger of being accused of ultra-imperialism but
if a judgment has to be made between maternal and child health
on the one hand and bearing the scars of being attacked by others
for one's cultural imperialism, presumably your shoulders are
broad enough to bear the burden of the latter?
Baroness Vadera: I am delighted
to have the opportunity to restate very clearly our commitment
to access to safe abortion if it is within the law. I would just
like to be clear about the fact that my very first speech, before
my maiden speech, ever, as a Minister, or as anything else, indeed,
was on World Population Day for Marie Stopes and, I think it was,
the APPG.[12]
That was when I talked about access to safe abortion, contraception
and to birth attendants as the three key things to do. That was
my very first speech before I did anything else. The reason I
was unable to go was because I went to New York to try and secure,
which we have now secured, having the MDG day in September, which
I hope will very much highlight maternal health and mortality.
So, if anything, we feel, halfway through the MDGs, we have to
up the game on this. I think the issue of leadership in southern
countries is a lot more difficult. I do not think it is because
of a fear of being controversial. Our position is very clear about
what we say within the ICPD[13]
but I think the issue is: will it work? If we were to just become
evangelical about this and go to country I do not actually think
it would end up with having an impact because I do not think that
you can change people's minds, particularly on cultural issues
like that. I do not think, even if we did manage to get anywhere
because they felt dependent on us in any way, that they would
be committed to rolling it out effectively. What we do better
is if there is, as I said, some interest where we can go and provide
evidence, fund NGOs and fund civil society. It is always better
to give the voice to women in those countries directly for them
to be the advocates than for us to be the advocates. I think that
is more effective as we have seen. We have done that in Nepal,
and we have been doing that in Sierra Leone where we are about
to start a maternal health programme. I actually have had discussions
privately, for example, when I was in Rwanda, and President Kagame
is very committed and they are now thinking about using maternal
mortality as an indicator of their health, and access to family
planning, in particular. So there are ways in which we do this
but becoming the public advocate could, in fact, make us less
effective rather than more.
Q271 John Bercow: Very briefly, if
I may, Chairman, I want to wrap two into one. The DFID annual
report for 2007 referring to financial year 2005-06 makes it clear
that, excluding budget support, maternal health expenditure amounts
only to £16 million out of a total health spend of £200
million. So it is a relatively small proportion. I just wonder
whether that, alongside what has been a very sharp reduction in
absolute dollar terms, in donor support for family planning since
1995, is in any sense a cause of concern for you, and if so whether
you propose to do something about it. The related matter is whether
you feel that in terms of improving health performance, there
is something to be said for DFID in its advocacy role advocating
the para-medicalisation of medical procedures so that suitably
trained nurses as well as doctors can perform worthwhile procedures.
Baroness Vadera: There are about
three or four questions there. On the issue of our direct spend
on maternal health, in fact, it has increased since then; it has
doubled from that and will be doubling again.
Q272 John Bercow: Doubled from what?
Baroness Vadera: From before the
£16 million figure. It went from £16 million to £23
million and is projected to go to over £50 million—
about £53 or £54 million— by next year. That is
very significant because our programmes in India and Pakistan
on reproductive and maternal care, of which portions are directed
to maternal health, will be coming through. We do have increasing
specific targeted maternal health care programmes. We have also
got Ghana, which is going to have a health SWAp[14]
which will be focusing on MDGs 4 and 5, we have got Sierra Leone
coming on-stream, so, in fact, we do have an increase very significantly.
I do want to say that the issue of budget support is important.
One of the things we found, and we have evidence of, in an early
programme from, I think it was about 1995, in Malawi (in 1995
to 2000 we ran this programme) was that if you just do vertical
programmes without ensuring that you are taking care of the rest
of the system you cannot always sustain it, and we were not able
to sustain it effectively. The most effective way to deal with
maternal health care is to have health workers, skilled attendants
and midwives and actually you need to have them in the budget
line, and the best and most effective way to do that is to also
be working on budget support and health sector support. We do
need to be doing both. Another thing we need to be doing and will
be doing— we have actually just been having that discussion
recently— is that when we are doing budget support the big
headline indicator for health has traditionally been on immunisation
rates, which is easier to do because, as I said, you can get coverage
more easily. Once it gets to beyond 85% coverage, you do need
to move on. So we are talking about whether, when we are renewing
budget support, we should be asking countries to move from immunisation
to maternal care.
Q273 John Bercow: I absolutely understand
what you say about the budget line, and I am grateful for and
have some enthusiasm for what you have just said about the significant
increase in the figures from relatively low figures about which
I was complaining, so that is a case of immediate gratification,
if you like. I still feel, going back, to what you were saying
earlier about relatively patriarchal societies— I do not
think you used that word but that is the implication I drew from
it— in which, frankly, men either do not want to talk about
these things or, if they do, they have got pretty— how can
I put it— atavistic views on these matters. In that sense,
surely, that rather underlines the importance, from the other
side of the equation, and underlines the need to have strong civil
society programmes as well, so you are backing civil society organisations
that are acting as advocates for women's health. In that sense,
I am mildly concerned that the Civil Society Challenge Fund does
not fund even the most successful advocacy programmes after the
completion of the first round of funding. I think I can almost
anticipate that an experienced Treasury hand is going to say:
"Well, Mr Bercow, you cannot fund things forever", and
I accept that, but is there not a danger that just as something
is starting to bear fruit it is cut off at the stem— if
that is not a mixed metaphor? I just wonder whether you can hold
out some hope that projects which are of demonstrable value are
not going to be subject to an arbitrary and capricious cut.
Baroness Vadera: Going back to
the first question, which is about patriarchal societies, it goes
back to the point that I made at the start, which is that there
is no magic bullet; you need the health systems and you need the
workers in the budget line, because if you do not have the workers
in the budget line we cannot actually support the outcome. However,
in certain countries we do need to have, exactly as you said,
the approach which targets maternal health because of some of
the, perhaps, invisible, social-type barriers. So we do have that
in Nepal, Bangladesh, India and Pakistan, so in the sub-continent
where this is an issue. In post-conflict countries where there
are specific problems— Burundi, Sierra Leone and even Ghana
where we are actually, even though it is the most advanced in
many senses, possibly, most likely to reach the MDGs in sub-Saharan
Africa— we have this issue, and that is why we are focusing
on it, in terms of the health sector programme on MDGs 4 and 5.
I think it needs both approaches, and we have to make an assessment
on the ground of how we do it. I think, also, helping in the budget
support to get the indicator moved to maternal health would focus
minds on this as well. I think, from reading the evidence, I have
a sense of which specific organisation you are talking about.
I would say that we do pride ourselves on giving predictable funding,
and that is, in fact, one of our comparative advantages. When
we make an assessment of applications for civil society we do
have to look at the value added and we do have to make a comparison.
So there are choices in that, and I do not think we can always
please everybody but we do have partnership agreements with certain
agencies that give them a core funding that ensures some predictability.
I know that IPPF (the International Planned Parenthood Federation)
has that and I know that Marie Stopes do not have that and they
are not successful. I cannot really answer for every organisation.
Q274 Sir Robert Smith: Earlier you
mentioned how Japan is trying to prioritise health at the G8 Summit.
Did their awareness of the maternal health issues come at their
own initiative or was it prompted by DFID?
Baroness Vadera: I would not want
to start to attribute causality here. I could be being flattered
by the Sherpa who came in yesterday. I had quite a long conversation
about this issue because we were both at the replenishment of
the Global Fund. Unfortunately, I think I probably accosted him
on this and he went away and he read up about it and then his
foreign affairs minister made the speech on 25 November. We have
had discussions and sent them papers but they do, in this very
interesting speech, refer specifically to their own post-war experience.
It is difficult to say. The one thing they did pick up on that
was specific to us was the fact that we said that the horizontal
issues were not receiving attention and the health systems needed
to, and they picked up on that because of their own experience
and they picked up on the fact that maternal mortality is one
of the best trackers of the effectiveness of health systems. They
seem to have put something together but I would be flattering
myself if I said it was entirely due to us.
Q275 Sir Robert Smith: Do you think
the other players at the G8 will be up for making it a priority?
Baroness Vadera: The Germans made
a piece of it a priority, obviously, this year in the commitments
they made around HIV/AIDS which really focused on mother to child
transmission and paediatric care. So I think if they see this
as a continuation of what they did that would be possible—
in one sense it is about making everybody feel ownership of it.
The Americans could view this, again, as part of what they already
do, in terms of PEPFAR, as long as they do not see it as a kind
of attack on the vertical, in terms of their approach. There are
ways of including other people. I think it always comes down to
implementation. We can do a lot at the G8 but we have got to implement
what we do, and that is always an issue.
Q276 Ann McKechin: I think it struck
us in our inquiry just how often women are invisible within their
own society, even to the fact that their births and deaths are
not registered in their own countries. A recent study by Médécins
Sans Frontie"res in the DRC[15]
found maternal death rates to be 10 times higher than the national
reported average of 520 deaths per 100,000 of live births, which
is a completely horrific figure. In these circumstances, and given
that it is important that we have some degree of accurate information,
what is DFID doing specifically to try and improve the routine
availability of maternal health data?
Baroness Vadera: We are the biggest
funder of statistics but, of course, maternal health data has
been notoriously difficult to get. We do fund a variety of programmes
as the Health Metrics Network. Stewart works directly on that
so he might want to say something about that. We are also going
to be funding the census which is one of the best ways of doing
this, and I know you have had evidence from Immpact about the
work that they do to try to find easier and quicker ways of doing
it, and Professor Graham is advising you and knows more about
it than most people. So we are working to track this information,
and it is very important because I think it is possibly one of
the reasons that we have not been as effective as we could have
been on maternal health; you are pitching to a minister of health
for funding and you cannot track what the data is and what your
results are going to be, and that actually makes it quite hard.
So I do think it is quite an important element of the piece. Immpact
is the most ambitious programme on maternal health that we have
got so far.
Q277 Ann McKechin: Should we make
the priority maternal health data or should we just prioritise
general health data? Which should have the biggest priority currently?
Baroness Vadera: It is the most
difficult to do, but we do think, as I say, that it tracks health
systems very well and is sometimes used as a proxy for health
systems. So in one sense it would be good to track a lot more
than one thing. We should track as much as we can but it is about
the effectiveness and the impact of what we are doing, and maternal
health is one of the best indicators.
Q278 Ann McKechin: So, from your
point of view, this should be the priority?
Baroness Vadera: I think it should
be a very significant priority, yes.
Dr Tyson: I would just add we
do fund the Health Metrics Network with a group of other donors;
it is another one of these global health partnerships addressing
neglected areas, and that really is trying to put in place the
building blocks of a comprehensive health system right from vital
registrations— so registering births and deaths. Not many
countries do that and it is a very big step. It is working in
about 70 countries, it is developing situation analyses of what
is there at the moment, where the gaps are and where the bottlenecks
are— where there are opportunities to move forward. I think
that sort of systematic approach is very useful and, at the same
time, taking opportunities to get better data. The Immpact programme
has developed a relatively low-cost method to assess maternal
mortality and you have heard a lot about that and, also, other
tools that have been around for many, many years but have not
been as extensively used as we would hope; things like maternal
death audits—on every woman who dies in a health facility—
to try to look, in a non-threatening way, at why that happened
in a non-threatening way, to try to learn lessons and to try to
change practices. I think it is trying to do both approaches at
the same time, really, to get the best possible data.
Q279 Chairman: Can I reinforce that?
In your evidence to the Committee you quote the figure that 529,000
women continue to die. The note says that this is actually the
figure for 2000 and is based on estimates developed by WHO, UNICEF
and UNFPA. Yet the evidence from Immpact and from Médécins
Sans Frontie"res suggest that is rather a precise figure,
given the method of recording is so poor, and that, if anything,
the situation is substantially worse. If you are going to have
targets you do need to have base information. Would you accept
that we need to update that information and perhaps produce a
range, which also shows that the upper limit might be a lot worse?
Related to that, when you were talking to John Bercow about whether
there is family planning or safe abortion— it was a point
I made at the end of the last evidence session— essentially,
if you have very high figures and you know what the percentage
reduction is if you have access to safe abortion, you are basically
saying to people: "If you don't pursue these policies on
giving access to abortion or family planning you are condemning
X-thousands, or tens of thousands or hundreds of thousands of
women to death". I take the point about the culture, but
those are pretty dramatic statistics. Do you not think we could
do better to confront people with the horrors of this information?
Baroness Vadera: This is like
music to my ears because I have this issue about spurious precision.
We have quite lively debates in DFID now about why numbers differ
depending on the source. For me it is imperative. If you cannot
show the results and you cannot show the numbers and you cannot
show the impact of policy then we are not going to win the argument.
So I very much agree with that. I would rather, in the interim
period while we are trying to improve data systems use ranges,
but we have to accept that in some countries it is going to be
really difficult. I was in the DRC and the idea that we could
actually be able to get very serious data out of the DRC in the
foreseeable future is just not very realistic, or Afghanistan.
Sharing data and having some common ground on which we can influence
policy makers is really important, so I completely agree with
you.
Chairman: I hope our report might help
on that.
9 The Global Alliance for Vaccines and Immunisation
(GAVI) Back
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Ev 10 Back
11
HC Deb 15 November 2007, cols 869-928, debate on International
Development Back
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All Party Parliamentary Group (APPG) Back
13
International Conference on Population and Development (ICPD) Back
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Sector Wide Approach (SWAp) Back
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Democratic Republic of Congo (DRC) Back
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