Examination of Witnesses (Questions 280
- 299)
TUESDAY 18 DECEMBER 2007
BARONESS VADERA,
DR STEWART
TYSON AND
MR ANDREW
ROGERSON
Q280 Richard Burden: In, I think,
one of your first answers this morning you described the Global
Fund as "fixating" you at the moment. I would like to
ask you one or two things about that fixation. Whatever else it
has done, and it has done a lot of good stuff, the Global Fund
has not necessarily done a great deal to reverse the trend of
separate policy and financing strategies for HIV, on one hand,
and maternal, sexual and reproductive health on the other. Given
the emphasis you have consistently put today on the importance
of developing integrated health strategies and particularly strengthening
health systems, how do you feel that we can move forward to get
the Global Fund to contribute better to that?
Baroness Vadera: I can see that
I am going to get into trouble now with Michel Kazatchkine when
he reads this transcript! I think we have a great opportunity
with the Global Fund. It has a great chair now who is very businesslike
and understands these issues and Michel Kazatchkine who is also
aware of them. They have signed up to the International Health
Partnership and we are using that to point out the areas where
they are doing well and the areas they are not. It was the most
fabulous sight: when they arrived to the first IHP meeting—
Mozambique is one of the countries— the Mozambique Health
Minister was pointing at him and in the end he had to agree to
change quite a lot of the things they were doing in Mozambique.
They have sent a special group to change that and so they are
much more integrated into the overall Mozambique health plan.
Now, we are talking to the Zambians and we are having the same
issues there. Yesterday I raised that with the chairman and he
immediately said that he would raise it and deal with it. I think
there is a huge willingness, but I want to be clear that it is
variable. It is not that they consistently do not do it; it is
just very variable and it depends on the strength of the country
in terms of their own ability to influence it. When I was in Ethiopia
they were funding health extension workers alongside us; in Malawi
they fund health workers, co-funded by DFID. It is the variableness
we need to fix. We need to make sure it is consistent and systematic.
Mr Bercow asked about the issue of the board and we are doing
this mainly through the board but also in private discussions.
In their evaluation, we are going to ask them— and they
have agreed— to evaluate not just the immediate impact of
what they do but the impact on the overall health systems of what
they do and that is very important. Secondly, at the most recent
board meeting they agreed— and this was based on discussions
that I started in July with Michel Kazatchkine— to have
a gender strategy which will ensure that it is linked more seriously
into the maternal health piece. We are already starting to talk
to them about what might be in that and the board has asked them
to do that. There is a change and there is a willingness. They
have their portfolio committee looking at giving guidance on how
applications are made so that the applications can be more integrated
and can fund health systems. I think this is an opportunity. There
is also an opportunity with PEPFAR coming up: the current chairman
is very willing and very aware of these issues and we are going
to be talking about how we integrate them into health systems.
This could be a big prize really. I am sorry; I am showing my
fixation again.
Q281 Richard Burden: That is interesting.
From what you have just been saying, you seem to be suggesting
that it is very much a function of the Global Fund itself to be
able to push that kind of agenda. We may have misunderstood but
we had evidence a week or two back from the representatives of
the Global Fund, amongst one or two others, and there was an issue
there about how far the Global Fund should be responsible for
promoting integration between sexual and reproductive health,
on the one hand, and work specifically on HIV/AIDS, on the other,
and how much that should be the responsibility of donors themselves.
When that issue came up, the representatives said that the Global
Fund does not decide which country should ask for this or that
but it is more up to DFID, to the World Health Organisation, to
more technical agencies to be encouraging countries as to what
they could apply for. What you have said today does not particularly
agree with that. You have said that it is certainly up to those
agencies but also it is a responsibility of the Global Fund itself.
Baroness Vadera: This relates
exactly to the issue of variability. It is not their responsibility,
in one sense, to be working on maternal health, it is their responsibility
to do HIV, but they cannot be an obstruction and they do have
to work with others. They are willing to do that and they have
shown serious signs of being willing to do that. Their portfolio
committee was charged at the last board meeting to go away and
look at the guidance that they give to countries about the applications
they make and in terms of the flexibility they have. It is true
that if the countries push hard they can get a lot further in
terms of getting flexibilities from the Global Fund but I think
we also need to be making it clear to countries that that is possible
too.
Q282 Richard Burden: My last question
is in relation to DFID's own strategies for integrating HIV/AIDS
work and maternal health work. You are amalgamating the HIV/AIDS
policy team and the reproductive and child health policy team.
How far is that contributing to the process?
Baroness Vadera: It is slightly
difficult for me to judge because I have only been there since
July and they have been amalgamated since then, so I do not know
how it operated before. Obviously we are in discussions now to
develop our renewed HIV/AIDS strategy, which we are going to publish
in the spring, and we are integrating the two elements in there.
We are having the discussion and it is good to have a discussion
with the same bunch of people really. I do think it will make
a difference.
Q283 Jim Sheridan: I understand that
we are in the process of exploring setting up the Global Fund
for Women's Health. What is the rationale behind that? I would
not underestimate for a moment the horrific statistics in terms
of the maternal mortality but would you not agree that men have
a responsibility also for that mortality in terms of their sexual
behaviour, infection, et cetera. I am wondering why you have to
set up this committee, if I may call it that, mainly for women's
health. My concern is that then allows the males to abdicate their
responsibilities and to say that this is mainly a problem for
women and therefore women have to deal with it. Basically, what
is the rationale behind this decision? What do you hope to achieve?
Baroness Vadera: It is not what
we are advocating, in fact. There was a suggestion on the second
day of the Women Deliver Conference that there should be a specific
vertical fund. We would agree with you. We do not think that would
necessarily help for a whole number of reasons. One of the reasons
is the one you have mentioned, but one of our issues, as we have
discussed earlier, was the duplication and proliferation issue
and the fragmentation issue: to be adding to that would not necessarily
help unless you take away things from others and you cannot take
things away from others because it is important that they are
integrated. This is a very hard area to start to fragment and
we would accept the view that we do not think that a single new
fund or agency would help. You do need to be effective in the
mainstreaming. There is an issue here: if we say we cannot do
this, we cannot fragment and therefore there has to be mainstreaming,
then the mainstreaming does have to work and be effective and
we need to be quite vigilant about that. That is why having specific
indicators and specific focuses on maternal health is a more useful
way than perhaps to set up a single fund.
Q284 Jim Sheridan: If DFID is not
supporting this committee—
Baroness Vadera: It is a fund.
It is not a committee.
Q285 Jim Sheridan: I am sorry. If
DFID is not supporting the fund, is it dead and buried? Is it
finished?
Baroness Vadera: Would you suggest
that DIFD is overpoweringly influential? Perhaps it is not!
Mr Rogerson: I think it is just
an idea.
Baroness Vadera: It was an idea
that was floated. During the course of the conference it all came
about through the whole issue of why there is not enough focus
on the issue, rather than because people thought that operationally
that was needed. I think it is better to do an advocacy campaign
around lots of different things like the Japanese or the Elders
or the G8 than to have a separate fund.
Q286 Jim Sheridan: The only reason
I mentioned a committee is because if you are going to set up
a fund then it follows that you are going to set up a committee
to look after the fund.
Baroness Vadera: It is our view
that it would be adding to the proliferation.
Q287 John Battle: Perhaps I could
go back to the International Health Partnership that Gordon Brown
launched and which you have referred to and press you a little
on the targeting, if you like, or the pilots. Seven were chosen.
One of the people who gave evidence said: "It is important
to learn from pilots but we need to make sure that all the 75
high burden countries move quickly to reach the assigned targets
under the MDGs. It is not enough to take seven or eight countries
to start with and assess them at the end of 2008."[16]
When listening to your response to John Bercow's question on pilot
schemes and funding things to get them off the ground, I was thinking
that too often we light pilot lights and then snuff them out before
the main oven is burning. In this area we cannot really wait for
the pilots. What is DFID trying to do to ensure that the Partnership
gets engaged with those 75 high burden countries, as they are
called, and quickly?
Baroness Vadera: There is always
a trade off. We did have a very long debate about this while we
were developing the IHP. It is eight now because Mali has joined:
it was meant to join but was not ready and so it joined very soon
after that. We picked the eight because they were in a wide range
in relation to where they were in terms of the effectiveness of
the health sector plan. We wanted to make sure that the eight
agencies were working effectively regardless of the state of the
plan or the effectiveness of a government in terms of the "ask".
We know that if a plan is good and the government is very effective
it is easier for donors to be coordinated. We have chosen a range
and we are trying to find ways to change the practices of the
agencies. That is the example I was giving Mr Burden of seeing
the Global Fund doing really well in Ethiopia and not so well
in Mozambique, and trying to make it systemic. If you roll it
out to 72 countries, what are we going to change in the behaviour
of the Global Fund unless we have targeted it, pointed it out
and they have changed it systematically? That is a very important
thing to do.
Q288 John Battle: I can see that
you do not go straight at the 75 countries, but are you engaged
in that move from the seven or eight to the others? Have you bunched
them into groupings?
Baroness Vadera: We have had a
lot of countries express interest in doing this. I suspect we
will go with the ones which have expressed interest because it
shows their willingness and ability to do this. One of the problems
that we have in development is that it is all about implementation.
It is boring and it takes time but it is all about implementation.
I am really loath to go with something that is half-baked, where
we have not sorted the systems issues out or figured out what
all the problems are. The point about the IHP is not to say: "Here's
the template; everybody is going to do this" because every
country situation is different. We have to figure out how people
work on the ground in varying circumstances and ensure their headquarters
are aware of it and know about it. If we do not get that right
and we roll it out then it is not going to be effective.
Q289 John Battle: You are not hanging
back waiting for the pilots to be reviewed in 2008; you are engaged
to move down that track.
Baroness Vadera: Yes. I have been
lobbied by the Rwandans very heavily. We are telling our country
teams on the ground and the other agencies' country teams on the
ground, even if they are not an IHP country, "Here are the
principles. You should already be starting to look at these principles."
I just do not want to move until we have really figured it out.
Q290 Ann McKechin: I wonder if we
could move to the issue of maternal health in conflict settings.
DFID currently funds a range of partner organisations, mainly
NGOs and multilateral bodies, in most conflict areas. Particularly
in countries like the DRC or Afghanistan, where we have large
bilateral programmes, what can we do to ensure that reproductive
and maternal health are suitably prioritised in a conflict setting?
Baroness Vadera: I do not know
what you would describe as conflict or post-conflict but we have
certain countries where it is difficult to be active— and
I am talking about Somalia or Sudan, where we have to fund through
the UN system or through NGOs. In post-conflict situations we
do try to talk to them as soon as we can. I was in the DRC earlier,
as I mentioned, and I raised the issue directly with President
Kabila. We are funding already a lot of the NGOs but I would really
like to be able to move to funding something more systematic and
not just the emergency relief. The DRC is still slightly divided:
in the east you have this incredible violence against women which
is leading to fistula and all sorts of other problems, and then
the west is a little bit more stable. We are in discussions about
trying to get it more systematised but, if you are going to do
systems, you have to have capacity in government and that is really
the fundamental issue. In Sierra Leone— if you classify
that as post-conflict— we have been working with the government
on a health plan, which they are about to finalise. Sierra Leone
is absolutely the single worst country in terms of maternal health
indicators. We are working to get them to focus. We do try to
move as quickly as we can. In Afghanistan we fund health workers
through the Reconstruction Fund and we have recently seen—
but again it comes back to the problem with figures— a reduction
in maternal health issues.
Q291 Ann McKechin: You have talked
about the weakness of the evidence base. To what extent do you
think that the priorities should be for, firstly, DFID, but, secondly,
for the multilateral organisations such as the UN in strengthening
the evidence base and trying to use best practice from other post-conflict
areas which can be replicated in other areas, so that we do not
have to reinvent the wheel every time we come to a conflict area.
Baroness Vadera: I think there
is best practice, but you get into the problem which Mr Battle
was questioning me on as to whether we are going to wait and then
roll something out when people are in need. There is a lot of
evidence base now. I think our biggest learning place was Nepal
post-conflict. They had managed in this period to have an impact.
Roll-out has been quite speedy and they have done some really
interesting things including involving the non-state sector in
a social/private contracting structure. We have given direct payments
to women to access transport— rickshaws and so on. There
are certain things that you learn and the DFID programme is something
we could learn from and replicate, because it is really seen to
be very successful.
Q292 Ann McKechin: Are there still
problems about coordination between bilateral donors, multilateral
donors and the NGO sector? Is that still a problem when it comes
to rolling out maternal health services in post-conflict areas?
Baroness Vadera: Yes. It is always
a problem, in post-conflict areas particularly, because people
come in and you cannot work with the government, the government
is not effective, so there is really nobody coordinating, so it
tends to be more exaggerated than it is in other situations. To
go back to the IHP: Nepal is an IHP country and we have tried
to use that as a mechanism to get donors to coordinate. When we
were in the DRC we seemed to spend quite a lot of time on the
coordination issue, but it is inevitably a problem because there
is not an effective state to interact with.
Dr Tyson: Nepal has had 10 years
of conflict and yet the programme worked all the way through that
period. The focus of the maternal health programme was the Maoist
area in the far west of Nepal. I was there last week. Throughout
that time both sides valued the services that were being delivered
and that enabled them to carry on. That has been a testament to
good practice. I was told that there are between 20,000 and 35,000
NGOs working in Nepal that have come in through this period, so
you can imagine the problems that governments have in the peaceful
period in trying to bring them together. It is always one of the
issues on which we are attacked— you know, "How do
you get NGOs represented in the International Health Partnership?"
What is an NGO? Who can represent the body of special interest?
It is something we are struggling with in a number of those areas.
Ann McKechin: Should we get a certification
scheme in place, so that if you reach a certain level of coordination
you will get a certificate?
Q293 Chairman: NGOs may be a good
thing but you can have too much of a good thing.
Baroness Vadera: It is not just
coordination. We are paying with it not being the most efficient
way of doing things.
Q294 Chairman: In Annex 2 to your
evidence, you talk about the role of budget support in the context
of maternal health and you make the point that it is quite difficult
to follow through exactly how much of the budget support does
deliver maternal health benefits. When we are visiting countries
where budget support is a significant part of the UK contribution,
the DFID team will tell us that one of the virtues of budget support
is that it gets you a seat at the table; in other words, you are
working in a kind of partnership with the government. If that
is the case why is it not possible to get a little bit more direct
handle, without putting conditions, on exactly how the budget
support is being used specifically to deliver maternal health?
You also say: "A process is underway to bring DFID's statistical
monitoring systems in line with the OECD..."17, [17][18]
I wonder if you could give us a bit of information as to what
that means in the process.
Baroness Vadera: The seat at the
table is, in one sense, about influencing the decisions and the
policy and the allocations of spend within the budget— and
that is fairly critical. We can influence the amount that is allocated
between sectors and into the health sector. It then becomes an
issue of statistical systems and tracking— and we have had
the discussion about tracking the indicators, et cetera. As I
said before, I think it will be an important move for us. It will
be good in terms of a change of mindset. There are certain headline
indicators in budget support and it has traditionally been immunisation
rates. If we could move that to maternal, because that is a better
tracker of the effectiveness of the health system, then we will
ensure that we have greater focus and we are going to try to start
to do that. The tracking system that we are implementing is basically
automating the tracking of our own funding. It is called ARIES.[19]
It is being rolled out over the course of the year and means that
we could then track quite a lot of sub-sectors and sub-indicators
that we were not able to before. It was semi manual before. I
think that will help. It is already in process at EU division
and it is going to be rolled out in the course of the next 12
months.
Q295 James Duddridge: Best practice
seems to be around sharing information. Will ARIES be published
on the web, or a distilled version?
Baroness Vadera: I do not know.
Mr Rogerson: It is primarily an
internal management system but presumably we will continue to
publish the statistical data that results from it in the normal
annual reports and compilations.
Q296 James Duddridge: Certainly,
when we are talking to people, the more that can be shared the
better the possibility for coordination.
Mr Rogerson: Yes.
Baroness Vadera: Were you talking
about sharing the information that comes out of it or sharing
the systems?
Q297 James Duddridge: The information
not the systems. Although, if our comparative advantage is being
at the cutting edge in persuading people, why should DFID have
a single management information system? Perhaps there needs to
be coordination there as well.
Baroness Vadera: I think it is
meant to be a system for live management of the information. When
we are asked to publish information, we will be using the ARIES
system to provide also for whatever we do publish. You ask the
system to provide certain tracking and then you can make that
information available.
Q298 James Duddridge: I suspect the
Committee will be interested more broadly in that system and understanding
a bit more about what value it could add.
Baroness Vadera: Maybe we could
send you a note.
Q299 Chairman: Related to that is
the role of civil society— not necessarily the 34,000 NGOs
but some of the good ones to help in that process. In other words,
if they know there is some commitment by the government of their
country to improving maternal health then they can clearly be
instrumental in monitoring it. You specifically also say in your
evidence to us that the department seeks the support of the IDC[20]
to work with parliamentarians in developing countries on this
issue. That is something we as a Committee have an interest in.
Hugh Bayley has left but he is with the Westminster Foundation
for Democracy and also the Parliamentary Network of the World
Bank which we understand is likely to be revamped— at least,
that is what we were told. Do you have any means of proactively
encouraging the development or the support for local NGOs as part
of the process of helping to raise both awareness and monitoring
performance on maternal health? Do you have any specific thoughts
on how the Committee particularly might help in terms of the links
in that area?
Baroness Vadera: Because we think
holding governments to account is better done by civil society
than by us we have the Governance and Transparency Fund, which
is going through its process of assessing applications. I am certainly
hoping— and we have yet to see the applications, the assessment
is coming out— to see a really strong focus on gender issues,
women's groups, including maternal health. I think that is a very
important area. You will know that women's gender issues are very
much at the heart of poverty, so I expect a lot of that will come
through the Governance and Transparency Fund. Once the allocations
have been made and the applications have been assessed, perhaps
we could advise you of that. For me, the role of parliamentarians
is very important. I have in the past had discussions with Mr
Bayley about this. I know we have used the parliamentary group
for things like female genital mutilation. When it comes to really
sensitive issues it is almost easier not to have it as part of
a donor relationship but as a relationship between parliamentarians.
I do not know what we specifically do in that area but perhaps
we should think about that.
Dr Tyson: Last week I was at a
sector review in Nepal, looking at progress and where the programme
is going. It was an unusual experience for me because most of
my experience has been in Africa. In Nepal it is about government
talking to donors with very few other parties in the mix, yet
if you go back to Uganda and look at how they run it they would
have parliamentarians, civil society, the press. To try to encourage
those processes in other countries in Africa, we have encouraged
or facilitated people from one country going to another: parliamentarians,
civil society groups, and to learn from the positive experience
and try to take that back. In Nepal, when we go back a year down
the road, we will see that they took on the message about the
need for a much more inclusive process that brought in all those
other players. That is a very simple example but one that can
move us forward.
16 Q 9 [Dr Songane] Back
17
Organisation for Economic Co-operation and Development (OECD) Back
18
Ev 23 Back
19
Activities Reporting Information E-System (ARIES) Back
20
International Development Committee (IDC) Back
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