Examination of Witnesses (Questions 300
- 314)
TUESDAY 18 DECEMBER 2007
BARONESS VADERA,
DR STEWART
TYSON AND
MR ANDREW
ROGERSON
Q300 Chairman: We will come back
to the parliamentary network when we are talking about the World
Bank. They seem to be upgrading that. The Committee is planning
to visit Nigeria and Ghana next year. We always try to seek out
parliamentarians but it may be appropriate for us to look for
parliamentarians who have a particular interest in this issue
as part of it. It does say in your evidence that you want to work
with the Committee but perhaps you might want to give some thought
to how that would be.
Baroness Vadera: Perhaps we should
take the visits as a specific ask and give you some suggestions,
to see what to do and what to push for. Particularly if we are
having this focus on MDG 4 and 5 in the Ghana programme—
Q301 Chairman: I was thinking of
Ghana in this issue particularly.
Mr Rogerson: Ghana would be a
good example. The nature of the parliamentary scrutiny on the
budget, for example, has been toughened up considerably and so
you could ask questions of your peers about how they look at the
balance of health spending.
Q302 Chairman: I guess this is not
the appropriate place to pursue that. We have had evidence that
there was some discontinuity in the programme which raised some
criticisms of DFID. The point is that is the opportunity to find
out exactly what the perception on the ground is on these kinds
of things.
Baroness Vadera: Yes.
Q303 Sir Robert Smith: We have already
touched on the crucial role of human resources. Unless there are
people to do the delivery then you are not going to tackle this
goal. There is obviously the supply side but then there is the
worry of a brain drain, in a sense. The Royal College of Obstetricians
and Gynaecologists were saying to us that there ought to be a
model that allowed professionals to come here for two years to
get their training and then they would go back, rather than having
them stay here. What sorts of joined up discussions are there
in Whitehall to try to tackle this problem of skill shortages
and avoiding sucking them away from where they live?
Baroness Vadera: We have an inter-ministerial
group. The NHS signed a code of conduct in terms of not poaching
and not actively recruiting where there are skills shortages—
which is about 150 countries, so that is quite a lot. There has
been significant reduction in certain countries that we track
of people migrating. It is not just active recruitment. When we
were working on the emergency human resources programme in Malawi,
it was interesting that there were more health workers and doctors
and nurses who were in Malawi not in the health system but doing
something else— because there was not sufficient pay and
they could not guarantee a proper functioning system. We have
ended up doing salary top-ups and golden hellos and innovative
things to try to get them back in. So it is not just an issue
of poaching. We have had a decline in the UK.
Q304 Sir Robert Smith: Do you work
with the private sector?
Baroness Vadera: Yes. They signed
up. We say that if the NHS is using a private provider then they
should have signed up to this code. We encourage the private sector
to sign up to this code as well. It is an important area. We are
also working with the EU to try to get other countries involved.
It is not just about us. Although English as the natural language
is an important attraction, I think it is quite important that
we—
Q305 Sir Robert Smith: Do you still
see a model whereby coming here for two years is a useful way
of getting the skills to take back?
Baroness Vadera: I think it is.
I know there are already programmes in place. I think that works
quite well at the high end— for very skilled doctors mainly.
I think there is an issue about whether we should be assisting
in sending trainers, because you get to know people and you get
better sustainability than if you just have a group of people
coming over here. In specialist areas they obviously do. The report
talks about you could have better interaction between the NHS
and health workers and the service here and developing countries,
and we are going to be responding to that in the New Year.
Q306 Sir Robert Smith: How are you
looking at the pull within countries towards the cities? What
strategies are there to persuade the health professional to stay
in the rural community?
Baroness Vadera: Using and training
workers who are from the local community for certain things always
works more effectively, and having a tiered system that ensures
you have community health workers on the ground. In the case of
maternal health, obviously those women would like to be given
a training gap, but then being able to ensure that there is a
system, if they recognise warning signals, for them to need to
move on to the next stage. I think that works. We also do salary
top-ups. We have a lot of schemes in Malawi. As I was saying,
we have exactly that, salary top up and things, but it is one
of the most difficult things. Maternal health is not just the
best indicator of a health system, it is one of the best indicators
of access and poverty too because you can see where the problem
is. It is really inequitable. In rural areas in India the level
of access is significantly lower than for women in urban areas.
It is a very difficult issue, particularly for maternal health.
Q307 Jim Sheridan: I wonder if you
could expand what you have said. You say you spot recruit from
people from other countries. In another life on another committee
I visited Nigeria and met a very excited parliamentarian who was
also a doctor who was extremely angry that he was not allowed
to come to the UK. What practical steps do you take to stop people
from Nigeria coming to this country?
Baroness Vadera: There is obviously
a new system now, a points-based system. I was in Nigeria earlier
in the year, in August or September, and I had a very direct discussion
with the Minister of Foreign Affairs about the immigration from
Nigeria and doing a bilateral compact, which we have had before.
We are going to review that, to look at that issue. As I say,
we are trying to stop doctors from coming here but what you were
witnessing was the other side of the equation. It is probable
that he was not practising as a doctor.
Q308 Jim Sheridan: He trained in
Edinburgh.
Baroness Vadera: This is the problem
we are encountering. You train them but they are not working in
the system.
Q309 Jim Sheridan: Nepal has come
up several times this morning, where perhaps the Nepal experience
can be replicated and others where it is difficult to transfer
from one situation to another. Specifically on the question of
the experience of women advocating to improve maternal health,
how far do you feel the Nepal experience can be replicated and
how do we do that?
Baroness Vadera: I could give
you my view but there is an expert sitting next to me who has
just come back.
Dr Tyson: It is always very dangerous
to try to replicate too much. Nepal was the first country I worked
in 27 years ago for Save the Children, so I had some comparison
there. We have tried to do two things in parallel. One was to
invest through flexible, long-term predictable support to a reformist
government that was trying to deal with all the difficult things—
how does it recruit staff? How does it get money down to the system?
How does it strengthen the information system? That was one arm.
In doing that we were working very closely with the World Bank
and European bilaterals. That was the longer-term agenda. At the
same time, we were investing in frontline services. Doing both
together— and we have done that in Bangladesh, Malawi and
a number of other countries— I think is the right way to
go. The nature of the frontline service is also comprehensive.
It was not just dealing with one of the problems; it was dealing
with family planning, safe abortion services, safe facilities
for women to deliver in, investing in voice and accountability
through civil society groups, working with local radio and working
directly with the community, making sure that there were low-level
community health workers from that community, trusted by that
community who were there when needed. It was using innovative
approaches that may or may not be transferable, using cash incentives
or vouchers to attract them to come and deliver in a safe environment,
but it was having to build up infrastructure and blood transfusion
services and transport facilities. That takes us back to the beginning
of the day: it is about building that system. The really encouraging
thing was hearing the Nepali ministers using maternal health as
their marker of progress— we have said it time and time
again but they said it: if we can put in services at the district
hospital level that enable us to deal with maternal health issues,
then we can deal with surgery, other medical problems, road traffic
accidents.
Baroness Vadera: In terms of women's
groups, there were specific elements of Nepal which I, travelling
between countries, have found interesting, and one of them was
the community health workers and particularly the fact that women
felt more comfortable with them: they were local, they knew them,
and therefore that works. The cash incentive is worth considering
looking at because you need to have certain incentive structures.
I have seen that incentive structure replicated. We have it in
India now. In Nigeria they have a very interesting system that
they are experimenting with. In India I found they were paying
anybody, a neighbour or a friend, who had brought the women into
a facility so that they could have skilled attendance. There was
also the transport piece, the rickshaw service they had. They
are two or three things that are replicable. It is much more difficult
to look at replicating local women's groups and networks because
they tend to be very individual to the country. You just tend
to have a very individual cultural and social set of issues. That
is much harder to do. Possibility on the sub-continent it might
be easier and in Africa there might be quite different models
in terms of accessing.
Q310 Ann McKechin: We visited the
project in Malawi last year and exactly those points were raised.
There was no civic society organisations at all. They had to be
started from scratch so it has taken much longer but I think they
are doing very good work. I was very impressed by it. I think
you are right: it is not one-size-fits-all that is going to work.
Baroness Vadera: No, it is not.
Once you create a women's group it becomes quite interesting because
you can do micro-credit through it and childcare. There are lots
of different elements you can do if you can create the women's
group but in the main they do not tend to exist. That is the whole
point about them being voiceless: they are voiceless in that they
do not have immediate advocacy in any way.
Q311 Richard Burden: When we were
in Ethiopia earlier this year, we were all impressed by the work
of the health extension workers there. In that particular context
we were looking at water and sanitation. The impact of the contribution
of women in not the most remote villages but relatively remote
villages was phenomenal. It did seem that that kind of model could
be taken up and used in a much broader way on perhaps some of
the agendas we are talking about here.
Baroness Vadera: It is very different
but similar to the experience in Nepal. In one sense, it is finding
women locally and training them and making them community health
workers. It is a very important dimension and a lot of people
describe them in slightly different ways, as low-level intervention,
but it is very critical. So long as you can give them access to
transport and training and supplies and everything else around
them, it is one of the most effective ways of doing things in
remote areas. Also, women prefer to stay in their local community.
In Ghana we have funded giving motorbikes to health workers. In
Pakistan we have a lady health workers scheme. It is something
that is one of the common features.
Q312 Chairman: You have already mentioned
the problems of unsafe abortion and the fact that literally tens
of thousands of women die as a result of that. Other evidence
tells us that quite a lot of women find they are forced into sex,
they have more children than they want, they have unwanted pregnancies
because they do not have access to family planning or that they
are married at a very young age. There is a picture in today's
Metro I think of a 40-year old man and his 11-year old
wife in Afghanistan. We know that young girls are more like to
die in childbirth in that situation if they get pregnant and it
would be better having a safe abortion. What can DFID do to ensure
that at least where abortion is legal, women understand their
rights and can get access to them. Many, we understand, either
are not aware or fear they will in some way or other be punished
or penalised, so they resort to unsafe abortions and many die
or suffer severe disabilities?
Baroness Vadera: This is one of
the hardest areas because it is about getting into people's homes
and how they interact and how they feel about it. There are things
we can do. We do promote and fund certain agencies that can work
to ensure that women, in particular, are aware of their ... I
think "rights" is difficult, but the fact that there
are services that are available. It has been very effective in
Bangladesh, where there are centres. They are called Menstrual
Regulation Centres— which is obviously just a terminology
issue— but that has ensured that women are aware, feel safe,
do not have stigma and can access safe abortion. That has led
to a reduction in maternal mortality. There are things that can
be done but I am not going to pretend this is the easiest area
to work in.
Q313 James Duddridge: This is the
first time you have come to speak to us in roughly six months
into a job. What have been the surprises, both welcome and unwelcome
within the job? What are the strengths and weaknesses of the department?
What are your first impressions of DFID?
Baroness Vadera: If it was a surprise,
the more I have done the more I have enormous respect for the
people: how much they know, their integrity in doing the right
thing. The more I travel, the more I am proud of the fact that
DFID is the leading agency in the world. I sort of knew that but
you have to be there to feel it and I am very proud of that. In
terms of my areas of focus, I, the Secretary of State and others
are very interested in ensuring that we look at issues around
growth and not just around the social expenditure side because
in one sense this is really the only thing that is going to make
development sustainable and the expenditure we are talking about
in social services sustainable. We are working on a growth strategy.
I am delighted you have talked about data, evidence and numbers
and tracking because it is something we raise very regularly and
it is one of the areas I press on. At most meetings, I will say,
"What is the impact? Where are the numbers?" being harder
edged about that. It is there, it is not that it is not being
done, but it is making sure that we are able to access it or communicate
it. I and the Secretary of State would really like to make 2008
an opportunity to mark the hard work of the MDGs and make sure
DFID is able to have that influential role. It plays a very important
role. Maybe I am a little bit surprised about how influential
it is. It boxes a little bit above its weight, even thought its
weight is getting heavier all the time.
Q314 Chairman: Could I thank you
very much for your first evidence session in front of the Committee.
The Committee regards itself as interested in what works. Our
engagement with the department, whilst it does not mean that we
do not criticise them, the criticism is always constructive, in
as much as all these questions have to be asked and impact and
effectiveness has to be monitored. That is what we are trying
to do. The Committee would share the same view as DFID. We have
travelled quite extensively and wherever we go, when we talk to
other donors and recipients the image of the department is extremely
high and its reach and influence is extremely far. The truth is,
I guess, that all of us are proud of what is achieved, but we
are also conscious of the fact that the budget is growing, the
ambitions are growing and we have to be sure that we continue
to deliver effectively. We see the role of this Committee as being
to assist in that. This particular inquiry is clearly prompted
by the fact that this Millennium Development Goal is furthest
off track. That is why we decided to do it— and John Bercow,
I know, was particularly keen that we should— but I think
it would be fair to say that, whilst we knew that, having taken
evidence the Committee has been frankly shocked at the status
of women and the suffering that they undergo for something which
in many, many cases is avoidable and where there is much that
can be done to raise the status. We did realise that it was not
that different in developed countries 100 years ago and we have
to try somehow or other to help developing countries to travel
100 years in 10 rather than have to wait 100 years themselves
to catch up. I hope our report will make a constructive contribution
to that. This is the last evidence session we are taking. If there
are any particular issues that have arisen that on reflection
you would wish to add to or reinforce, we will be very happy to
receive that.
Baroness Vadera: I am really delighted
that this subject was my first, because I do feel very strongly
about it. I think this report will be very important and I would
like it to feed into the attention that we need to give to advocacy
and somehow also be able to be used in countries. It is not just
about the international advocacy and what donors do but what happens
in country. If we can find a way of using that, it would be absolutely
fantastic. I have read a lot of the evidence that has been given
and I have been as shocked as you. You do know it, but, when you
start to realise, some of the things we know are very shocking
and perhaps we do not pay enough attention to them, so I am really
pleased you are doing this. I would like to use the report when
it comes out.
Chairman: We will produce the report
very early into the New Year. Thank you very much
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