Examination of Witnesses (Questions 120
- 139)
THURSDAY 16 JULY 2009
MR GARETH
THOMAS MP, MR
EAMON CASSIDY
AND MS
BEVERLEY WARMINGTON
Q120 Hugh Bayley: In 2001 the Abuja
Declaration committed Nigeria to spending 15% of government revenues
on health. Currently they spend about a third of that, 4 or 5%.
Why has there not been more progress in increasing state spending
on health care and what can your department do to encourage and
help the government of Nigeria and governments locally in Nigeria
to increase spending?
Mr Thomas: It is not just health
care where all of us interested in the MDGs[2]
would want to see more progress. I think it is across the piece
in terms of the poverty reduction agenda. There is a series of
challenges for governments, some of which we have touched on in
terms of the basics and in terms of public financial management.
There undoubtedly is a very significant corruption challenge and
frankly the ability of Parliament and grass roots organisations
to hold government in terms of politicians and officials to account
for whether money is being spent properly and whether sufficient
money is being put into particular services is nothing like as
effective as I think any of us would want it to be. What can we
do about that? We can try and strengthen the ability of the National
Assembly to hold the Federal Government to account. We can try
to replicate that work at state level. We can help to try and
build up demand from grass roots level by working with civil society
organisations and the media so they are sufficiently knowledgeable
to ask the challenging questions of politicians and officials.
We have various mechanisms of support for doing exactly that.
Q121 Hugh Bayley: The prime argument
for that enormous debt write-off which the Paris Club did and
which we were a very large contributor to a few years ago was
that, if the government of Nigeria was paying less in interest
on historic and odious debt it would have more resources available
for basic human needs, including health. I really think we, as
one of the architects of that debt write-off, ought to be making
the case that more should be seen in terms of health spending
from the Federal Government. I hope very much that is one of the
issues you will put to the government when you visit Nigeria.
I wonder if you or one of your civil servants could spell out
some of the things that you think could constructively be put
to the government, because until the resource is there Nigeria
will not make progress on the health related MDGs.
Mr Thomas: I think that is true.
If that is one of the recommendations of the Committee, then of
course I will consider doing that.
Q122 Hugh Bayley: You may have gone
before we write our report.
Mr Thomas: I will take that away,
certainly. There are a series of things that we have done which
will have a benefit in terms of spending on the MDGs in terms
of health care related to the debt relief deal, some of them securing
some of the macroeconomic reforms which are both necessary to
secure the debt relief but which have significance in terms of
economic growth and foreign direct investment anyway. We have
also funded government offices so that they can monitor how the
savings from the debt relief deal are being spent and coalitions
of NGOs similarly to do the same. Some of the debt relief money
is helping to incentivise the states to put money into MDG related
projects. Essentially, some of that debt relief money is helping
to fund matching funding from a federal level to be invested in
MDG related projects. There has been a direct benefit in terms
of health care, but I would accept maternal mortality for example
as being one classic example where much more clearly needs to
be done in terms of health care in Nigeria.
Q123 Hugh Bayley: We had the benefit
of a meeting with the head of the President's monitoring unit
on the gains that came from debt relief. Some useful analytical
work is being done but it should not divert our attention from
the need for the people of Nigeria, those who are in a position
to contribute to the state, to build up their own resources for
health care and the need for the Nigerian people to contribute,
for the government to raise revenue and to apply it to health
care. The Health Minister told us about his plans to develop a
health insurance scheme. I wonder what potential this has to make
a difference in health care provision in Nigeria, particularly
for poor people who will not of course by definition be making
contributions. How is DFID assisting with this?
Mr Cassidy: At the moment there
has only been one experiment with this at the state level and
that has been in Kwara state. That has been quite an interesting
experience. It is early days yet. This is something which is fairly
new to Nigeria. Over the last couple of years there has been an
increase in the number of private companies that are offering
health insurance, so I think you have seen quite a lot of urban
people taking that up. We are probably quite some way from a functioning
health insurance scheme for poorer people. We do not have a basic
income tax system for example yet and I think we need to build
up that sort of tax base before you can do anything and I think
that is a bit more difficult to manage. There is potential there
for that to happen.
Q124 Andrew Stunell: Another aspect
of health is the maternal mortality rates for Nigeria which are
absolutely dire and probably even worse in the north than they
are in the south. We saw some of the evidence. We saw some of
the work that is going on and clearly one of the issues is the
lack of skilled birth attendants to assist mothers. We also saw
some evidence of two different plans. Plan A is to have doctors
and midwives and plan B is to skill up the traditional birth attendants.
I wondered if you could say something about which of those DFID
thinks it should be following, bearing in mind that I certainly
heard evidence while we were there that there were people on both
sides of that argument who seemed to be engaged on our projects.
Mr Cassidy: There are some differences
of opinion on this. The use of birth attendants is not a particularly
widely spread tradition in the north of Nigeria. To a large extent,
women tend to give birth on their own. The real reason behind
the extremely high levels of deaths is the absence of health services.
It is not, I think, necessarily that there are not birth attendants
there. When things go wrong, there is nowhere to which the woman
can be referred, so it is really an issue of lack of health services
rather than the birth attendants necessarily. There is a group
of people called CHEWs, Community Health Extension Workers, and
they are now being upskilled also to be able to give, if you like,
reactive help. I am not sure that bringing in a model from elsewhere
and the use of TBAs (Traditional Birth Attendants) would necessarily
help. I think there is a need in one or two areas to maybe think
about that, but again it is the access to basic referral services
that seems to me to be the basic problem.
Q125 Andrew Stunell: There is clearly
a net shortage. The evidence we took from some of the people working
on the project was that in fact, when a problem is not detected,
the basic monitoring that might be provided by a birth attendant
or a post-birth attendant is not available. I also heard different
evidence about what the right way of correcting that was. I am
just wondering whether you could just explore that point for us.
Mr Thomas: I think we would accept
that there is not enough support to monitor when women get into
difficulties. Not only that; there often is not good enough access
to health care and doctors to deal with those problems once they
have been spotted. As Eamon was alluding to, the community health
extension workers are beginning to be trained in the life saving
skills that are necessary and other parts of our programme are
trying to fund and support the expansion of access to obstetric
care so that you can begin to deal with the broader issues around
maternal mortality.
Andrew Stunell: A lot of those women's
mortality at birth issues are about detecting a problem in the
first hour, not whether or not they can be referred to a clinic
or a hospital further away.
Q126 Chairman: Or even before they
go into labour.
Mr Cassidy: Part of the problem
is that there is not regular monitoring during the pregnancy.
It is not necessarily that you suddenly get a problem during the
birth. I think there are problems that are not being picked up
during the nine months and that is again because of the lack of
access to basic medical services.
Q127 Andrew Stunell: Since we visited,
we have taken some evidence from Save the Children about the project
in Gambia which seemed to rely on non-medical female village leaders,
for want of a better word, to be operating some kind of early
warning service at a level of discussion, if you like, rather
than medical intervention. Is that something that you would consider
looking at in relation to northern Nigeria?
Mr Cassidy: Yes, absolutely. That
was very interesting evidence and we will certainly look at that.
Q128 Andrew Stunell: You have mentioned
the fact that there is a problem with women giving birth alone
and that obviously brings up a whole range of cultural, religious
and other difficulties. Underpinning that is the status of women
in society and their lack of power over events. To what extent
can DFID play a part in developing those cultural approaches to
reduce maternal mortality?
Mr Thomas: In most of the areas
where we work in terms of maternal mortality, there is a process
of talking to key leaders in local communities. It has certainly
been part of our work for example on polio elsewhere and in terms
of maternal mortality you have to have a conversation that does
on occasion begin to challenge some of the gender stereotypes
in order to get support for better access to services. I think
through the broader programmes we can do some of that general
work, but the question of the position of women, as you will recognise,
is far more complex and the response needs to be much more broad
ranging than just around tackling health issues specifically.
Q129 Chairman: Gender issues will
also raise themselves in education but before getting to that
we were looking at basic statistics in the brief you supplied
to us. Nigeria has the most primary school children out of school,
eight million estimated and an enrolment of around 63% of school
age population which has not changed much in the last decade.
Its performance in terms of the basic MDG of getting primary children
into school is poor and they are not making a lot of progress.
The indications are that the quality of what is being provided
is also not very high both in terms of buildings and in terms
of quality of teachers and so forth. We saw the Education Sector
Support Programme (ESSPIN) which has been sponsored by DFID. I
appreciate that that is really designed to try and address this
but first of all can I test what proportion of children in Nigeria
do attend state schools, given we also realise a lot of them are
in non-state schools, whether they are religious or otherwise,
and being provided with free education. Do we have statistics
for that?
Mr Cassidy: I do not have an exact
figure on that.
Mr Thomas: We will try and provide
it.
Q130 Chairman: Is that partly because
they do not keep them?
Mr Cassidy: I think it is partly
that. Data are extremely poor.
Q131 Chairman: Education may be provided
but there is a strong school uniform culture. There is inadequacy
in terms of books and materials. In a sense, there is a whole
load of not immediately visible obstacles. Is there a role for
DFID in perhaps plugging that gap, so where a school place is
being offered, whether it is means tested or whether there is
a mechanism for providing for poorer children and some assistance
in the essential equipment, has that been considered? Indeed,
is that part of the ESSPIN programme?
Mr Thomas: I think there are two
answers to that. The challenge for us in terms of education as
well as for the other MDGs is how can you use the money and the
people you have available to you to make most impact. There I
think our interventions have to be as strategic as possible as
opposed to being very specific in terms of providing help to a
particular individual to get to school. Having said that, we work
very directly with UNICEF, particularly in terms of trying to
deal with some of the issues around education for girls. We have
had success there in dealing with some of the reasons why families
have been reluctant to send their girls to school for example.
We have seen, we estimate, a 15% increase in girls attending education
to date. I would not want to make grand suggestions to you in
terms of the quality of educational experience that we have yet
seen. It is relatively early days in terms of our education sector
programme. In terms of attendance, we are beginning to see an
increase.
Mr Cassidy: There is a whole host
of fairly complicated reasons why it is that boys and girls do
not go to school, particularly girls. Part of it I think is to
do with infrastructure. Part of it is distance. Part of it has
to do with cultural reasons. Part of it has to do with simple
value for money. Parents do not think they will actually learn
anything and may be put at risk as a result of leaving home. We
try through the ESSPIN programme and also through the Girls' Education
programme to come at this from a range of angles. I suppose firstly
through ESSPIN what we are trying to do is to recognise that the
state has to be responsible for education, not DFID. We are trying
to help them to build a system, to plan, to manage, to budget
and to monitor, also looking at issues like for example teacher
distribution and teacher quality. As part of that we are also
working with the government on issues like infrastructure, water
and sanitation. We are helping to do some piloting there. We are
also piloting through ESSPIN a programme of grants to individual
schools. I think the school that you saw when you went to Kano
will be one of those which will benefit from this pilot scheme
of giving grants so that the management board can decide what
the best thing is they can do to try to increase the level of
enrolment. Also through the UNICEF programme we fund the GEP programme,
the Girls' Education Programme. We are now doing some interesting
piloting as well in one of the states—I think it is the
Niger state—where they are bringing girls in from the rural
areas basically to train them to be teachers so they can go back
to the rural areas. One of the big blockages also is that parents
do not want their girls to go to school if they have male teachers.
Female teachers are also a major part of the answer. That is an
interesting experiment that we want to monitor very carefully.
Q132 Chairman: Coincidentally, when
we were visiting the health clinic, if you recall, part of the
difficulty this Committee had with having no women on the Committee
was that Members of the Committee were not allowed to go into
the house to see the bed net that had been installed. It was left
to our clerk and other DFID female officials to do that. We had
to stand outside. In the process of the conversation, it was pointed
out that the covered area we were standing beside was actually
a school for 30 or so girls. In a conversation with one of the
local elders I said, "What are they learning?" He said,
"They are just learning the Koran by heart." I said,
"What else are they learning?" He said, "Nothing
else. They do not need to learn anything else. They will be married
off by the time they are 13. That is all they need to know."
I did have a further discussion with him where he acknowledged
that maybe Islam had had higher aspirations in the past. When
we went to the Islamiyya School, the formal school, which of course
is in a town as opposed to a rural area, the genders were 60%
boys, 40% girls, but still a high proportion of it was Koran teaching
with an increasing secular element. Interestingly enough, when
asking the girls what it is they liked most, their answer was
learning the Koran. It was difficult to get at whether that was
what they really meant or what they thought they ought to be saying.
Clearly there was pressure from parents to say, "We want
our girls to learn more maths, English, social studies" and
so forth, more than the states were prepared to provide. That
was basically the dilemma. How can DFID engage with the states
if the objective is to get the state to deliver? What can DFID
do to try and push that in a more positive direction? What you
just said about training young girls to become teachers to go
back to their villages is clearly a positive step in that direction.
Mr Thomas: We are working very
directly with the Kano state on an Islamic education strategy
to encourage more of the Islamic schools to take on more of the
core curriculum. I hope over time, from the experience you had
with the specific school, if you go back in two or three years'
time, you will be able to see a marked change in that way. We
need to recognise that the Islamic schools do enjoy significant
parental support. Our strategy to try and work with the state
and with both types of schools, government schools as well as
the Islamic schools, is the way in which we are likely to make
most progress in terms of raising educational standards and getting
people into school in the short term.
Q133 Chairman: I think it would be
fair to put on the record that it was the head of the governors
who was himself a teacher who quite explicitly stated that they
did not wish the state to take over the school. They wanted to
maintain their independence and it would therefore be the Islamiyya
School. What they did want was for the state to provide more secular
education within the school. I take the point that that is a balance
that has to be struck. If the state pushes too hard, then I guess
the school will back off. The pressure seemed to be coming in
that sense from the school and from the parents, or at least from
some of them. It is difficult to know how representative they
were. How many schools does the DFID programme engage with? We
saw the one and obviously that was just a sample school but how
many schools are involved?
Mr Cassidy: We are working in
three of the education districts, the local government areas.
I cannot remember off the top of my head how many schools that
involves but we are looking this year for example, with the grant
scheme, at 315 schools particularly on that pilot scheme.
Q134 Chairman: It seems to me that
it very quickly becomes apparent within the north of Nigeria that
the status of women and girls is critical to develop. Until you
address that issue, you are not going to get the economic activity.
You are not going to get the improvement in health and education
that is needed.
Mr Thomas: With respect, I think
that is true worldwide.
Q135 Chairman: It is especially true
here.
Mr Thomas: I accept it is particularly
true in northern Nigeria.
Chairman: I think it is an exceptionally
obvious difference.
Q136 John Battle: I would like to
ask about employment opportunities and job creation. In the DFID
evidence on page nine there is a challenging figure. Less than
10% of the 6 million new entrants into the labour market have
any chance of getting a formal job. It seems to me that providing
jobs is a massive challenge sometimes said to be underplayed in
the Millennium Development Goals. I just wonder if you could say
what you think are the main obstacles to job generation rather
than job creation, because lots of people in Nigeria seem to think
the state should provide them with a job. What about development
of the private sector, the skills gap, the business environment?
You mentioned infrastructure and electricity but perhaps wider
than that what is your general view on employment prospects?
Mr Thomas: I think there has been
a mindset issue until very recently in the sense that getting
access to oil revenues was the prime source of ambition for many
in Nigeria, both n terms of power but also in terms of employment.
That has begun to change in quite a significant way. There is
a series of opportunities in our view opening up to work with
a number of states, as well as to work with the Federal Government
to try and look at some of the issues around the business environment,
so questions around access to land, taxation issues, access to
finance and the quality or not of regulation. There are of course
then the infrastructure challenges that we touched on with Mr
Sharma, power and transport more generally. We are working on
and are close to finalising a new programme on employment through
growth in a number of states, which would seek to do further work
on the business environment in a number of states, but also would
seek to work in particular value chains. For example, meat, leather
and, secondly, construction, looking at the particular obstacles
in those industries for further employment. We have done some
estimates of the potential new jobs that could be created in some
of those areas which we would be happy to share with the Committee.
The intention of that new programme is to focus our work on four
states, Kano, Kaduna, Lagos and Cross River. It is a programme
that will work with the World Bank and we are hoping as ministers
to complete the approval programme for that work so we can get
cracking very soon.
Q137 John Battle: In the White Paper
that was published just recently there were again very encouraging
and ambitious targets to create 7.5 million jobs in five fragile
states and one of them is Nigeria. Encouraged by that figure,
it tempts me to ask you to break it down and say how many will
be in Nigeria. If we were to put the template of that ambition
in the White Paper, is that job creation programme the same as
the Growth and Employment in States programme with the World Bank
that you would be funding? Is it part of that programme? Is it
ancillary to it? Is it extra money that is coming in, in the White
Paper, to the money that you already planned, or will there be
a different pot of money to supplement what you are doing already
with the World Bank? How do you relate that passage in the World
Bank to the ambition that is there in the Growth and Employment
in States programme with the World Bank?
Mr Thomas: As we were drafting
the White Paper, we were thinking about the work that was underway
to prepare the Growth and Employment in States (GEMS) programme.
Our estimate is that we can potentially create 100,000 direct
jobs through the GEMS programme and potentially more generally
improve about 600,000 livelihoods. There is very significant potential
through that work programme. Just to reassure you, we are relatively
joined up in the department. The GEMS programme was very much
in our mind as we were drafting the White Paper.
Q138 John Battle: You would be able
to stand up those jobs in terms of sector? I am not wanting you
to name everybody who has a job and where. It seems to me that
some good work has been done in that analysis. To give that kind
of projection is very encouraging and it could apply in a lot
of other places as well. Some of it is in those five countries
but in Nigeria you have really drilled down to say where those
jobs will come from.
Mr Thomas: A considerable amount
of thought and effort has gone into preparing the programme, working
with the World Bank and thinking through particular value chain
sectors, to use the jargon, where we might have most impact most
quickly and be able to quantify the impact of our work.
Q139 John Battle: Could you say how
many jobs by 2013 or 2015 and what sectors they were in? That
projection could be laid out for us if we were to ask for it?
Mr Thomas: We would be happy to
provide you with the further analysis that underpins the thinking
behind the sorts of figures I have given you. Whether we want
to say exactly how many of the 100,000 are in a particular sector
or not I would want to reflect on before I rush to give you that
level of detail of our estimates. We have tried to be as conservative
as possible in the estimates that we have worked up, precisely
because you do not want to create expectations that you cannot
fulfil.
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