Examination of Witnesses (Question Numbers
34-39)
PROFESSOR ANTHONY
COSTELLO, MS
LINDA DOULL
AND MR
SIMON BROWN
12 JANUARY 2010
Q34 Chairman: Good morning. Thank you
very much for coming in to help complete our evidence on our report
on Nepal. Can I thank all of you for coming and, for the record,
could you introduce yourselves, please?
Professor Costello:
I am Anthony Costello. I am Director at the UCL Institute for
Global Health. I lived in Nepal in the 1980s and I have been working
with Nepali groups for the last 25 years.
Ms Doull: I am Linda Doull. I
am the Director of Health and Policy with the UK NGO Merlin and
we have had a programme in Nepal since 2006.
Mr Brown: I am Simon Brown. I
was a VSO volunteer in Nepal and recently the Assistant Country
Director for VSO in Nepal.
Q35 Chairman: Thank you. As you know,
the Committee visited Nepal at the end of last year and had a
look at quite a lot of different aspects. The Committee split
into two groups and went to different parts of western Nepal.
That will inform some of our questions. If we start off looking
at health where, in one sense, DFID are able to point to quite
good indicators of improvements in health but, nevertheless, both
the groups of the Committee visited hospitals and were made aware
of the things that were problematic. I wonder if I could start
on that. Which do you think are the groups that are least likely
to be able to access healthcare and have the most problems? The
thing we obviously appreciated is you do not have to travel very
far in Nepal to realise people are living away from roads, there
is very mountainous terrain, so access is difficult, plus the
cost of travelling, and also in the hospitals we went to, whilst
the people we saw were extremely good and committed, there were
not enough of them to do what was expected. Which are the groups
that we probably did not even see that are not getting the benefits
or are suffering from the least access to healthcare provision
at the moment?
Ms Doull: From Merlin's experience,
I would just say that our programmes are based in Pyuthan and
Rolpa districts, which are in the Mid-Western region, which are
already very remote and mountainous, so de facto geographically
there is a physical access barrier for many people who live there.
Within that, there are the usual cultural exclusions that you
experience throughout Nepal, particularly for the women, which
obviously has an impact on reproductive health, and then on a
caste basis. From our own information the Dalits still have a
problem accessing healthcare. To that end, free health services
have been introduced for reproductive health, which is a very
positive move from our side, and DFID are very supportive of that.
Q36 Chairman: Is that only for reproductive
health? I thought it was more general than that.
Ms Doull: For reproductive health
services. This is positive from our side but it is too early yet,
we need to indicate to what extent that has made a difference.
Free services alone are not the only issues that people take into
consideration about decision-making, about accessing healthcare,
and for women a lot of those issues are still related to their
power within households, their own ability to decision-make or
not. The difference that free health services make for reproductive
health needs to be tracked quite closely. Certainly we have insufficient
evidence to say whether that is working or not. That said, more
women are delivering at health facilities. Whether that is purely
down to free care or is a wider cultural change that has occurred
through awareness raising activities that we have been doing particularly
with women's groups, trying to create greater demand for services,
we have yet to see.
Q37 Chairman: You have talked about
empowerment and I suppose what you are saying is that men are
reluctant to allow their women to go to clinics or wherever they
can get safe delivery. If so, is that for reasons of cost or power
or control? How do you get through that? Clearly, from the men's
point of view one would like to think that they would not like
to see their wives suffering possibly a disability as a result
of poor delivery, or children being sick. It affects the men as
well as the women, so it is not rationally in the interests of
men to deny it. What is the root of that problem?
Ms Doull: It is fair to say men
have an impact on the decision-making, but we also know that in
places like Nepal and elsewhere in South East Asia actually it
is mothers-in-law particularly. When a woman marries into a new
household it is the mother-in-law who has a very strong control
over her decision-making power as well. We have evidence or experience
where people recognise the need, whether those are men or women,
for women to seek care but then it does come down to an issue
of poverty and whether they can actually afford that, which is
why we are very supportive of DFID's strategy of free health services.
Even if there is free healthcare you then have to get from A to
B, so the care may be free when you get to the clinic but you
still have to travel and that remains a barrier for many people.
Professor Costello: I think it
is a rational decision for many of them to stay at home because
their nearest health facility would be a sub-health post that
does not offer delivery. Health posts generally have very low
quality or absent access to delivery care, so if they are going
to go they have got to go usually to a primary healthcare centre
or a district hospital which, for the great majority of people,
is a long way away. The really interesting thing about Nepal is
why it has seen such improvement in its health indicators as it
has. It is on target to achieve both Millennium Development Goals
4 and 5 and yet access to health services remains really quite
poor. We are getting up towards an overall figure of about 19%
delivering in hospital but that is distorted a lot by the urban
figures—in many of the rural populations less than 5% or
8% will actually go—yet we are seeing this decline in maternal
as well as child mortality rates. Under-5 mortality rates are
now down to about 60. The latest figures from this, I think as
yet unpublished, report from Options is a maternal mortality figure
of around 230 for the country with, of course, variation. Generally,
the further west you go in Nepal the indicators are worse than
the east, as you will have discovered from your trip. It does
raise the issue of why that is the case. One factor that I have
noticed was when I lived in a district called Baglung in the 1980s—
Q38 Chairman: We visited there.
Professor Costello: That is an
interesting place because when I was there it was a two day walk
to get there, but now there is a road and it has quadrupled in
size. In those days, if you went out to the health posts very
few of them had regular supplies of drugs and that was the only
option for people. In the 1980s and 1990s the government trained
up a great number of people called community medical auxiliaries—CMAs—and
they were not taken into the government system and a very large
number of those—there are thousands and thousands of them—set
up their own pharmacies and diagnostic facilities. To a large
extent that private sector care does deliver a lot of the care
to households in the more remote, mountainous areas. It is not
just about the government facilities providing, say, access to
antibiotics. I think that is one of the reasons why maternal mortality
rates have come down, that even the poorest people in remote areas
can get access to some lifesaving drugs even if they cannot get
access to skilled birth attendants or a hospital delivery. The
other thing to say is the quality of care at health facilities
often remains very poor. Although DFID has done a lot to improve
maternity care at some of the major hospitals, very often they
are treated badly so, therefore, there is a big incentive for
them to stay at home.
Chairman: The problem we saw in Baglung
was that the place we visited was supposed to have seven doctors
and it had two. They were very good doctors and we had a very
good presentation but clearly they had an awful lot of work.
Q39 Hugh Bayley: My question would
be what should donors be doing to try and strengthen the health
delivery systems locally?
Professor Costello: That is a
big question. Personally, I think the biggest gap in Nepal, and
this has got a political undertone, is the weakness of local government.
After the democracy movement in the early 1990s when you had a
return to democracy, in the mid and late 1990s local government
really began to take off and my experience of working in districts
then was finally you had some very committed people trying to
make changes and it was quite successful. Effectively, for the
last seven or eight years local government has been virtually
dead in Nepal. The constitution has not really resuscitated elected
government. You have only got civil servants there and I think
that is absolutely crucial because with accountable local politicians
and better systems, that is going to be the most sustainable way
to maintain the quality of local services.
Ms Doull: I would concur on some
of that. From Merlin's perspective, while there are very good
policies and strategies in place in terms of health system strengthening,
and reproductive health in particular, to what extent those are
applied effectively at local level is the challenge. What we see
are gaps in relation to that in having a proper skilled workforce
in place. In the districts where we worked previously, during
the conflict a lot of health staff fled and, although there have
been significant improvements, probably 85% of the staff are in
the facilities where they should be on a relatively permanent
basis, there is still that 15% gap to fill. Also, the incentives
that have been introduced to retain staff in the remote areas
do not necessarily filter through as they should do, there is
a lack of transparency around that. There needs to be much more
accountability and monitoring that these initiatives are actually
happening and being used for the correct purpose. I would agree
with what was said earlier about staff at community level, non-government
staff, and the emphasis on building up the cadre of community
workers and creating a connection between them and the formal
health system to create that stronger compact between the communities
which are using the services and those who are providing them,
so again there is greater accountability and awareness of what
services should be available to people. From our perspective of
where DFID is, some of the other donors in Nepal are much more
engaged at the regional and district level with health services
whereas our perception is DFID is slightly more Kathmandu centrally
based. There are perhaps ways that we can strengthen that regional
engagement that may be quite useful to add some sort of pressure
on local government and accountability mechanisms.
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