Examination of Witnesses (Question Numbers
40-59)
PROFESSOR ANTHONY
COSTELLO, MS
LINDA DOULL
AND MR
SIMON BROWN
12 JANUARY 2010
Q40 Hugh Bayley: Is it a wish list
or a policy? If there were active, strong effective local government
I quite understand that would provide the framework for promoting
and holding accountable health services, but at the moment there
is not, and if we were to say, "Well, donors, you would be
strengthening local government", it could be a long time
before you would have the delivery systems and you could be five
health emergencies down the track. What could be done without
resuscitating local government to create local accountability
structures of the kind that you think are needed to improve delivery?
Ms Doull: There is a very robust
civil society movement throughout Nepal, even in the most remote
areas, but there is insufficient engagement with those groups.
There are fora but, again, they are fairly centrally focused,
so if there are ways in which those fora could be encouraged for
those discussions to take place, because unless you create that
dialogue you do not create demand for accountability, it could
almost come from a bottom-up approach. That is where organisations
like ourselves can facilitate civil society to take that step
and work, because we work with the district health authorities,
to encourage those agencies or groups to come together. I think
it is important that there is donor engagement in that as well.
It does not have to be particularly often but at least so there
is some sort of tripartite dialogue going on. I think there is
a potential mechanism there but it is not being as encouraged
as it should be.
Mr Brown: Coming back on to local
government, it is right that there has to be a very strong Ministry
of Health and health programme and there has to be a very strong
local government. We need to recognise that those things are beginning
to happen as well, there is an active DFID and other organisations'
sponsored programme to resuscitate local government and get it
moving, and that will take time, but in the interim there still
needs to be an improvement of health services. There is, and has
been, a very strong national health sector programme. The first
five year strategy is now ending and finishing this year, the
next one is just being created. We need to recognise there are
things that are very positive that can be built on. The Ministry
of Health, particularly, are recognising that women are disadvantaged
in access to healthcare and there are very specific parts of maternal
healthcare that need to be addressed with more vigour—for
example, there is a huge problem of prolapsed uterus in Nepal—and
there are other groups that need specific support, such as mental
health. We need to recognise that DFID sponsored programmes that
are happening already are doing quite a decent job and need to
be encouraged to do even more. There is good work going on there.
Q41 Mr Sharma: Very briefly, and
you have touched on it, there are the village doctors as I would
call them, those who go into the remote villages but are not qualified
under the present system. How much recognition do they have or
any working relationship between the official health state and
those people who traditionally have given the service and maybe
have closer links with the communities? What is the link there,
if there is any?
Professor Costello: I would want
to go and look at some of the evidence on this from latest surveys,
which I do not have. Compared with, say, Bangladesh, where a lot
of the village doctors are self-appointed and untrained, the difference
in Nepal is a lot of these people running pharmacies did receive
quite good training. A community medical auxiliary would have
two years of training. They understand the basic conditions and
are probably as good as a lot of the auxiliary workers in the
health posts and have got access to drugs. I suspect the quality
of care issues there are not too much of a problem, but there
will be variation and in the remote areas you will probably find
them the least qualified. There will be quacks. Unquestionably
there will be quacks in many parts of the country.
Q42 Mr Sharma: What impact has the
Safe Delivery Incentive Programme had on the numbers of women
giving birth in health clinics and attended by skilled health
workers? What we are looking at is what the main weaknesses in
this area are. For example, has it reached the poorest women in
the more remote areas? Are there sufficient numbers of trained
health staff available to meet increased demand created by this
scheme?
Professor Costello: The incentive
scheme was introduced in 2005. It was after a report prepared
by one of our researchers, Jo Borghi, for the DFID programme which
had shown that there were quite substantial costs for any woman
even having a normal delivery at home, but certainly if they went
to hospitals. At that time, which was during King Gyanendra's
time in charge, one of the royalist ministers said, "Right,
we're going to roll an incentive scheme out across the whole country",
when the proposal at the time was to evaluate this in a number
of different districts to see how it would work, but they said,
"No, across the country". I think DFID were slightly
wrong-footed by this, but agreed to stump up the cash for a lot
of this programme. We were asked if we would evaluate the maternity
incentive scheme and we got Tim Powell-Jackson, who is a health
economist from the London School of Economics, to get involved.
Then DFID ran into financial problems because they had spent too
much on the tsunami and the money was cut for that evaluation,
but we were extremely keen that should go ahead and, fortunately,
Tim managed to get an ESRC scholarship, so we carried on doing
that evaluation with the DFID funded Safe Motherhood Programme
and also looking at one of the sites where we have been doing
continuous surveillance of maternity outcomes in a large population
for about 10 years. What was interesting about that was the figures
that Tim came up with were that the economic cost for a normal
delivery to any household, out of pocket payments, was $63 and
if you had a caesarean section it went up to $350. That would
account for almost 20% of your entire household income for a year.
The incentive scheme in the Middle Hills was 1,000 rupees, which
is about $15, in the Terai it was 500 rupees and in the high Himalayas
it went up to 1,500 rupees, but there was no targeting of the
poor. When this programme was rolled out they did an evaluation
of what happened. There was not very high awareness of the scheme
and when they reviewed this a couple of years ago only about 30%
of women knew about it and only about 30% of women who went to
facilities where the scheme was supposed to be implemented actually
received the incentive. We looked from our household data in Makwanpur
at what happened to delivery rates before the introduction of
the incentive and then immediately afterwards to see if there
was a time series effect. The effect was about a 6% increase in
institutional deliveries, but when we broke it down by socioeconomic
quintile, richest 20%, poorest 20% and the rest, we found that
almost all of the incentive was taken up by the wealthier quintile
groups. That was not surprising because most of those who lived
close to hospitals were in towns and better off so they went to
receive the incentive. The conclusion overall was it is having
some impact but there is not sufficient targeting and it remains
open to question how you should continue. Obviously things have
changed a little bit in the last year because now services are
offered free and, therefore, that changes a little bit of the
economic equation but, unlike the Latin American example of conditional
cash transfers where there was a lot of targeting towards poorer
groups, that has not happened so far in Nepal.
Ms Doull: We do not have as detailed
information as that to provide because we have not done a study.
As I said before, while there has been an increase in the number
of women delivering at health facilities, it is only about 16%
overall in the areas in which we worked, which is still quite
low, which indicates there are other factors beyond the incentive
as to whether people choose to go to the facility. Of course,
the challenge then is to provide the quality of care once women
have reached that centre, hence a lot of the focus of the work
we have been doing is trying to ensure that there are 24-hour
services available. Similarly, with the health worker incentives
we know there are issues that when people get to the clinic the
incentive is not necessarily disbursed.
Professor Costello: There was
some evidence also that providers were charging more to women
who were receiving the incentive. So you would go in, you would
receive the incentive but then the cost would go up. That may
have changed now. I do not know enough about the actual implementation
of this free at the point of delivery scheme that the Maoist government
introduced a year ago and do not know how far that has been rolled
out. It highlights the importance of whenever you do these policy
interventions, and DFID has spent a lot of money doing this, it
is really important to evaluate them. Something similar is also
happening with DFID support in India in Orissa and informally
I was told in India last month that has had a much better effect
on institutional deliveries. I asked for the figures but they
did not give them to me. Anecdotally I have heard that it has
been much more successful. It would be interesting to compare
and contrast those two policy initiatives.
Mr Sharma: The Safe Delivery Incentive
Programme is only one element in the Support for Safe Motherhood
Programme in Nepal which DFID has supported and which we praised
in our 2008 report on maternal health. What other elements of
the SSMP have made it such an effective intervention? What other
strategies should donors pursue to support Nepal towards achieving
the MDG of reducing maternal mortality? Long question, long answer!
Q43 Chairman: When we were doing
the maternal health report, DFID was highlighting how much they
had achieved in Nepal and it was one of the things we were particularly
interested to follow up when we visited.
Professor Costello: I think they
have done a great job in strengthening central ministry capacity.
Their scheme meant that very good quality people kept a presence
in the Ministry of Health, whereas if they had not been there
I think they would have left. Some of them were being paid at
different levels from civil servants but, nonetheless, it kept
an integral Safe Motherhood group together over an extended period
of 10 years when otherwise I think things would have fallen apart.
There has been a high emphasis on maternal healthcare in Nepal.
Also, through this scheme they have done a lot to improve quality
of care at district hospitals. Curiously, I would contest the
idea that all of this necessarily has been the main reason why
maternal mortality rates have come down; I think that might be
explained by other factors. Nonetheless, generally I would give
good marks to DFID for having sustained this investment and, indeed,
having gone with this conditional cash transfer scheme. Although
I have been a little bit critical in evaluating it, I think it
was a very courageous decision to do this, it is a very important
policy initiative for developing countries and we can learn the
lessons from it to make it more effective.
Ms Doull: In addition to that,
the one thing I would add within the strategy is the emphasis
on having skilled birth attendants at different cadres. We all
know that human resources in a health gap is a major issue, not
just in Nepal but in many other countries, and without that sustained
focus I think there would have been less advances made. As I said
earlier, one of the issues was where those skilled birth attendants
are located and deployed and there has to be consistent monitoring
of ensuring that skilled birth attendants are put as far out into
remote areas as possible, and if you are going to deploy them
to remote areas how do you ensure that they stay there. That will
demand incentives of some kind, not always financial, perhaps
housing or whatever. Without that I think you will see quite a
high attrition rate. We are relatively pleased about the degree
of retention in the areas where we are working, but it is still
quite a fragile base and it would not take much for people to
be attracted back to the main urban areas.
Q44 Mr Evans: Can you tell us something
about the HIV/AIDS problem in Nepal?
Professor Costello: There are
about 75,000 people estimated to have HIV in Nepal. Personally,
I have not worked a great deal in this area. I know a little bit
about some of the people working in this area and there has been
quite a strong HIV/AIDS group within the Ministry and a lot of
civil society groups particularly looking at the high risk groups,
the trucking routes, the commercial sex workers, some men who
have sex with men and, I think, the growing problem of intravenous
drug use. It is still a relatively small problem and I would not
like to say any more about the efficiency and effectiveness of
the interventions that have happened to try and ameliorate the
problem.
Mr Brown: VSO do have a programme
in HIV/AIDS in Nepal. You are right, it is a concentrated epidemic
with about 0.49% of the population living with HIV/AIDS. It has
been estimated by organisations like UNAIDS that it is around
about 70,000 people. Official registration is now between 14,000
and 15,000. Historically, the most at risk parts of the population
have been female sex workers, men having sex with men, injecting
drug users and migrant labour. Recent surveys suggest, and it
is still very much a suggestion although there has been a Family
Health International survey run through the Ministry recently,
that the prevalence amongst female sex workers, men having sex
with men, and injecting drug users is actually falling, which
is very good news, and hopefully it will be reinforced by other
surveys. It is very good news that the programmes that have been
there, mainly run through civil society, have been the most effective
advocacy and awareness programmes and provision of testing and
counselling and do seem to be having a good impact. However, the
most at risk population then shifts quite alarmingly towards migrant
labour and particularly the wives of migrant labourers having
sex with their husbands who have returned from places like India
where they have had unprotected sex. Overall, it is very good
news on the effectiveness of civil society's awareness and advocacy,
but concerning news that prevalence amongst migrant labourers,
and the wives of migrant labourers, seems to be increasing.
Professor Costello: One of the
issues that I have always wondered about, and I do not know any
figures and do not know how reliable they would be anyway, is
the scale of the problem of trafficking of women from the traditionally
trafficked groups with the Tamang women from around the Kathmandu
Valley, many of them being told they were going to go to carpet
jobs or service jobs in India and then being taken to the red-light
districts of Calcutta or Mumbai. I have seen all kinds of figures
bandied around. Some people talk about 200,000 and others talk
about much smaller numbers. It certainly goes on and it is difficult
to know how many of those women come back and how many of them
are infected.
Q45 Mr Evans: It is a hugely religious
society, is it not? Do you believe there is a big stigma attached
to HIV/AIDS in Nepal?
Professor Costello: Definitely.
Q46 Mr Evans: How do you tackle that
stigma? Do you think the government can help or do you think it
just ignores what is going on?
Mr Brown: Gosh, that is a huge
question. Yes, there is a huge amount of stigma and discrimination.
There are a lot of programmes that are funded to try and encourage
people who feel they have been exposed to HIV to test, to go to
clinics. Within the family, within the religion, there is a massive
amount of stigma and discrimination of people who have disclosed
their positive HIV status. How do you tackle it? I guess you continue
to try and break those things down. There are programmes that
are trying to make people more aware of HIV/AIDS, that it exists,
and of the risks of contracting HIV/AIDS, and you continue to
try to support those programmes that try to make people more aware,
particularly amongst youth. Both the Ministry and a lot of other
agencies are recognising that particularly youth sexual and reproductive
healthcare is an area that needs a lot of attention and part of
that is making youth more aware of the risks, making them more
willing to talk about the risks, and avoiding, hopefully, what
could be very disastrous.
Professor Costello: I think things
are changing. People are talking more openly now. Certainly in
Kathmandu young people talk more openly about sexual behaviour.
The world is changing and you are moving towards nuclear families
now. The other big factor, of course, is the availability of anti-retrovirals.
In Africa that has transformed the situation because you have
now got opportunities for treatment whereas that was not the case
maybe half a dozen years ago. Things are changing a bit, but the
worry is that the donors are losing interest in HIV and whether
that will affect the funding of programmes for HIV will be interesting
to see.
Q47 Mr Evans: Is the government proactive
on this? What do they do about educating people to the dangers?
Mr Brown: It is mainly a civil
society activity at the moment. It is in the national health sector
plan for the next few years, and it does have some very important
indicators on the awareness of youth of HIV/AIDS and sexually
transmitted infections, but so far it has been very much a civil
society activity.
Q48 Mr Evans: Can you say something
about the health provision that is made available for those who
are tested if they test positive? Can anybody get access to anti-retrovirals?
Ms Doull: In the districts where
we work there is very limited provision, if at all. Basically
it is awareness raising activities, prevention, but there is no
access, there is no voluntary counselling and testing—VCT—in
many of the facilities and there is certainly no access to anti-retrovirals.
Q49 Mr Evans: There is no access?
Ms Doull: In the areas where we
work there is not. My understanding is that around the Kathmandu
area there is.
Q50 Mr Evans: If you can get tested,
it is a death sentence?
Ms Doull: You cannot get VCT or
you would have to travel and that has a cost.
Professor Costello: The rates
of positivity are very low in those areas. A lot of the HIV is
focused in the Kathmandu area and the trafficking routes, the
bigger towns, and certainly there you can get access to anti-retrovirals.
There is quite a good scheme run by the Teku Infectious Disease
Hospital in Kathmandu and all the major hospitals in the Valley
would be able to provide that as well.
Q51 Mr Evans: You mentioned something
about the donors. Could you say something about the funding? Do
you think there is sufficient funding for the needs of Nepal on
HIV/AIDS?
Professor Costello: I was talking
more about a worldwide thing. I was talking to Mark Dybul, who
was the Director of PEPFAR[1],
who was saying that interest in HIV/AIDS in the Senate and in
America had plummeted in the last couple of years. I do not know
how that will relate to Nepal.
Q52 Mr Evans: You are not aware of DFID's
involvement in this particular sector?
Professor Costello: No.
Mr Brown: DFID has been leading
the work across the sector in HIV/AIDS. It will be replaced by
the World Bank, which was supposed to happen this year but is
probably going to happen a year late so DFID will continue to
lead. Is it enough? It is very difficult to say. It is an epidemic,
it is 0.49% of the population, but probably more people die from
other, waterborne diseases at the moment so it is very difficult
to say it is enough. Clearly the Ministry have recognised that
their ability to provide services is not good enough and it wants
to do more. The money that has been spent on advocacy and awareness
has been well used. Clearly with some most at-risk groups showing
a decline in prevalence it is working. Civil society groups are
being included in policy by government. The government has recognised
that their service delivery is inadequate, so to improve it they
recognise they will have to spend more money on it and where that
money comes from, whether it is donors or other sources within
the country, is something they will have to work on. On the awareness,
and rights awareness, it is going very well; on service delivery
clearly not enough is being spent.
Q53 Mr Evans: Do you have a view
about the World Bank taking over lead responsibility for this?
Mr Brown: In what way?
Q54 Mr Evans: Do you think it will
be a good thing?
Mr Brown: I do not necessarily
think it should be a bad thing. Within the bilateral and multilateral
donors they have come to the conclusion that the World Bank is
probably best placed to do it.
Q55 Mr Evans: If you get it and prove
positive, do you lose your job? How bad is the stigma there?
Professor Costello: I would not
have thought so, but you may be able to find anecdotes of that
happening. These days if you are positive and on treatment most
people are not going to know, you are going to look pretty well
unless you get lipodystrophy or something.
Mr Brown: If people do find out
you will probably lose your job.
Professor Costello: Really?
Mr Brown: Yes.
Q56 Mr Evans: Can testing be done
confidentially so that people will not know that you are being
tested for it?
Mr Brown: There are discreet testing
facilities, but how discreet they are I do not know. They are
places you go into that do HIV/AIDS testing so if you are seen
going in there is probably going to be some suspicion that you
are going in to be tested, which naturally starts rumour. There
are places where you can be tested and they are readily available
for people just to walk in when they feel comfortable.
Q57 Mr Hendrick: DFID's evidence
tells us that Nepal is on track to meet its Millennium Development
Goals for universal access to primary education and gender equality
in education. We are told that the enrolment of Dalit children
is up to nearly a million and we are getting gender parity now.
Certainly on our visit to one of the schools we looked at there
seemed to be a lot more girls than boys and I was told that a
lot of the boys work out in the fields with their fathers. Leaving
that aside, can you tell us how you feel that social exclusion
and inequality are affecting access to education? Do you feel
that multi-donor support for the government's education programme
is addressing these issues effectively? What about the quality
of education? Do you feel that the children are getting a decent
quality of education?
Mr Brown: I am surprised DFID
say that Nepal is on target because the target is 100% and I cannot
see that they will get to 100% by 2015. The Education for All
Programme has clearly done some really good things in increasing
enrolment. The not so recent Millennium Development Goal assessment
by the government with UNDP suggested that they would not hit
it, but that is quite old, that is a 2005 review. I would not
say to get to 100% is impossible, but it is really challenging.
To get to 100% of children enrolled in primary school and 100%
of literacy in youth with complete gender parity is going to be
really difficult. The current School Sector Reform Programme recognises
that and that it has done some good work in Education for All,
but recognises that it is not going to get close to the Millennium
Development Goals without another programme, another initiative.
Even that does not target the 100%, it only gets to 98% of enrolment
in class one. The government's programme is less than the Millennium
Development Goal. It is very close—98% of 100%—but
it is not the Millennium Development Goal, which is why I say
it is surprising.
Q58 Mr Hendrick: Can you just back
that up a little. DFID is saying through its Community Support
Programme that it has contributed to the construction of 2,500
schools and also that 8% of children remain out of school in the
primary age group, which is down from 16% in 2004, which is effectively
half. There seems to have been some great progress.
Mr Brown: That is what I am saying,
there has been fantastic progress through the Education for All
Programme. It is very important to have the schools but it is
a lot more than building the schools, it is about getting the
community involved and making them aware of the specific availability
of subsidies and grants to help children get into school, but
it is not going to be 100% enrolment by the government's own target.
They are targeting 98%, which is still quite close, to be fair.
The government through its own analysis recognises that it is
still quite a long way short of that. To get from that, if you
take the 92%, from 92% to 98% is going to be a stretch. Even that
92% figure comes through the Education Management Information
System which, again, is a government statistic, a government database
of enrolment and retention. The UNDP have questioned the accuracy
of that data, that there may be some double counting.
Q59 Mr Hendrick: Do they know how
many Dalit children there are enrolled, for example?
Mr Brown: Yes. In EMIS[2]
the number of Dalit children is quite considerable and in certain
districts exceeds the population projection from the 2001 Census,
so you have got more Dalits in school than the population projection
was saying would be eligible to go to school. Again, we should
be congratulating Nepal and the education system, the government,
DFID and all the others for getting this data going but there
is a lot of cleaning to be done in the data still, it is not necessarily
100% accurate, and UNDP through the Millennium Development Goal
report certainly questioned that maybe it is not quite as high
as we think. Yes, Dalits and girls still have less access than
others and it is not uniform across the country. If we look at
the top 25% of districts in terms of primary school enrolment
there is very good gender parity, almost 100% gender parity, but
if we look at the worst then it goes down to between 0.6 and 0.7
in terms of gender parity. It is not geographically equally dispersed
and neither is it equally dispersed across caste groups.
Professor Costello: My impression,
and this is just having been there and visited, is that there
is huge demand for education, and I am sure the supply has met
some of that demand, but there is a huge issue around the quality
of what goes on in schools—class sizes, availability of
teaching materials, motivation, supervision of teachers—and
I think that is a massive issue, but I do not have the statistics
to hand about it or to what extent there have been quality evaluations.
1 US President's emergeny Plan for AIDS Relief Back
2
Educational Management Information System Back
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