Examination of Witnesses (Questions 46
- 59)
TUESDAY 20 OCTOBER 2009
PROFESSOR ANTHONY
COSTELLO, MS
SANDRA KABIR
AND MR
BEN HOBBS
Q46 Chairman: Good morning and welcome
to you. You have obviously been sitting through the last session
so you are aware of where we are coming from. Again, I wonder
for the record if you could introduce yourselves.
Ms Kabir: I am Sandra Kabir, the
Executive Director of BRAC UK. However, today I am representing
Women and Children First and the Diabetic Association of Bangladesh.
Professor Costello: I am Anthony
Costello. I sit on the Board of Women and Children First but my
day job is that I am Director of the Institute for Global Health
at UCL, and I run a DFID-funded research programme consortium
on maternal and infant health with the London School of Hygiene.
I was recently Chair of the UCL Lancet Commission on managing
the health effects of climate change.
Mr Hobbs: I am Ben Hobbs. I am
the Senior Policy Officer at Christian Aid in the Asia/Middle
East division.
Q47 Chairman: Thank you very much
and for your written evidence as well, which has obviously helped
us. I am looking at the achievements of progress on MDG4 and 5.
There clearly has been progress, although there is still some
way to go in terms of the overall target. Can you give us a flavour
of how you feel things are progressing? Will these targets be
met, and, if so, when and how? Do you think Bangladesh is doing
better or worse than its neighbours in the region?
Professor Costello: I work on
programmes in India, in Mumbai and Jharkand and also in Nepal,
Bangladesh and Malawi. One of the things that always strikes me
about Bangladesh is how well it is doing when you compare it with
Pakistan, with the deprived north-eastern states of India and
parts of Nepal. It is doing very well and it is going to achieve
probably MDG4, which is the child survival one. It is down to
an under-five mortality of 62, although one of our concerns is
that the newborn component of that remains high. In other words,
as your under-five mortality rate comes down in countries, you
tend to find a greater proportion of those deaths are now focused
on the newborn period. That is certainly true in Bangladesh where
nearly 60% of all under-five deaths are in the first month of
life. That is obviously linked to maternal care. The other observation
about MDG5 in Bangladesh is that maternal mortality has fallen
and probably halved over the past twenty years. This is of great
interest and has led me to rethink and challenge some of the accepted
wisdom about why maternal mortality rates have fallen, because
the WHO line, and to a certain extent the DFID line, has been
that this could only be brought about by increasing access to
facility care and midwifery services. That is clearly not the
case in Bangladesh. If you look at skilled attendants at delivery
the figures for Bangladesh overall are about 15%, but if you look
at it broken down by wealth quintile—the poorest 40% of
households—it is around 5%. Clearly, MMR has come down despite
the fact that the great majority of women are not getting access
to skilled birth attendants and to a caesarean section in times
of need, because almost all the increase in caesarean sections
has been in the wealthiest 20%. So why has it come down? I think
that the community component of this has been greatly underplayed.
I think that first of all community mobilisation through NGOs
has been important. I think nutritional change as a result of
economic improvement may have contributed. Personally, I think
one of the biggest factors is access to life-saving drugs. In
the 1930s in this country our maternal mortality rate was 500
and it went over a cliff in 1936, and over six years it almost
halved. That was because of the introduction, in my view, of sulfonamide
drugs in the mid 1930s. In Bangladesh, unlike, for example, the
country I work in, Malawi, where MMR is still sky-high despite
half the population getting access to skilled delivery, in Bangladesh
we sort of joke that it is almost impossible to walk more than
400 yards without a man trying to sell you an antibiotic. Actually,
the private sector distribution of drugs in Bangladesh has been
very effective and has increased three-fold over the past 25 years
or so. In a sense, we can learn lessons from Bangladesh, but you
are right to say that there is still quite a long way to go.
Q48 Chairman: On the evidence we
have the regional variations which coincide with the poverty patterns
as well still suggest that in the poorest regions the figures
are much higher. So the obvious question arises: what could donors
do to try and narrow that gap?
Ms Kabir: With regard to the regional
variations, there are several inputs required. One is at the political
level. If you look at the Chittagong Hill Tracts, for decades
there has been this ongoing battle—I use the word "battle"
but it is not necessarily actual warfare—about the rights
of minority groups. They are treated as minorities and not full
citizens of Bangladesh. They are seen as different. They speak
a different language and their religion and culture are different.
At the political level it is really important that the ethnic
minorities in Bangladesh are more accepted and have more say in
what happens in their lives, be it by being elected at the local
level, at the parliamentary level, or in terms of employment in
the civil service or in terms of getting loans from banks, education
and everything else. That is at one level. The other level is
ethnic minorities anywhere in the world tend to want to clump
together and live together, as British Bangladeshis here in the
UK live in a very similar way. It is necessary to try and encourage
ethnic minorities to come out of the areas where they have traditionally
lived over centuries into greater Bangladesh, although Bangladesh
is not a very big country, it is quite a small country. I would
not use the word "integration" because I do not believe
in integration, I believe in cohesion, but somehow to become more
involved in the mainstream activities of the country. Also, there
is less investment in ethnic minority areas by the governments
and NGOs could not work in the Chittagong Hill Tracts because
the government did not allow them to work. It was a restricted
area for security reasons because there was an uprising of people
coming from India into the Chittagong Hill Tracts and there were
battles going on and, therefore, NGOs could not work there. That
has had a big impact because NGOs normally work with groups that
are the most disadvantaged, but they were not allowed to by the
government.
Q49 Chairman: The implication in
that is that is more for the government or the political system
of Bangladesh to deliver. Is there a role for DFID in that context,
or are they restricted because of those constraints?
Ms Kabir: No, I think DFID should
just jump in. It is a matter of human rights. Here in the UK we
believe very strongly in people's human rights, so if we do believe
in it then we should do what we believe in, and I think DFID should
be in discussion with the Bangladesh Government about these issues;
it should not be shy about this.
Chairman: That is probably a useful line
of inquiry.
Q50 Mr Sharma: When there is an economic
downturn, priorities change. What evidence is there to suggest
that donor funding for maternal and newborn healthcare has or
might decrease? DFID spends approximately 7% of its bilateral
assistance to Bangladesh on health. How much should it spend?
If it is more, then which other areas should be cut down?
Professor Costello: MDG5 and the
neonatal component of MDG4 are the two that are most faltering
at the moment. If we took it more globally, in sub-Saharan Africa
there has been no change in MDG5 since 1990, by and large, from
the latest figures we have. In South Asia it has not been that
much better if you take out the China effect. So the argument
should be you should spend much more. The work done at the London
School of Hygiene by Giulia Greco and colleagues on the
amount of donor spend that goes to maternal and newborn health
programmes currently shows a figure of $1.2 billion worldwide
by all rich countries into all maternal and newborn health programmes
annually. That is about 7% of Goldman Sachs's bonus pool! It is
about 1% more than the Northern Rock bail-out! That is the levels
we are talking about. DFID, to its credit, has been one of the
major advocates for spending on maternal and newborn health, but
when anybody talks about MDGs for health, it all goes to HIV,
malaria and TB, or when children are mentioned it is always vaccination
even though we reached 80% vaccination levels 25 years ago. Vaccination
in Bangladesh is much better than where I live in Brent, much
better. We are having measles outbreaks in London because of that.
Anyway, back to your question: clearly there needs to be more
spend on this if we want to achieve Millennium Development Goals.
If you do not invest, then you tend not to get a return. What
other priorities should be cut I would leave others to decide
because I do not know enough about what is spent elsewhere in
Bangladesh. However, I think there is a strong argument for getting
a return. What to do, to get back to your first question, there
is a whole menu of evidence-based interventions, starting with
community mobilisation, perhaps conditional cash transfers. Something
that I think should be invested in a lot is regulation of quality
of care down at district level and below, all the way up to improving
quality of care and investment of hospitals, which is what DFID
is spending some money on at the moment.
Q51 Mr Singh: I am going to ask a
few questions around the role of the Skilled Birth Attendant Scheme
which Professor Costello earlier said in the context of MMR had
no effect. Let us focus on how successful this training scheme
has been, what the particular success is and what the figures
and statistics can point to in terms of addressing this programme?
Ms Kabir: I can tell you about
the BRAC experience. BRAC has trained women to be skilled birth
attendants, and along with that has set up committees at the local
level that are focusing on maternal mortality and maternal morbidity.
These committees are made up of local people. Having done that,
over the past few years there has definitely been a decrease in
maternal mortality, so it does work, but it is not happening enough
in Bangladesh. That is one of the areas that both Anthony and
I agree on very strongly, that much more investment needs to be
made in community organisation, women's groups, so that things
do happen at the local level. There is also a degree of accountability
for both governments and NGOs because NGOs also need to be accountable.
Q52 Mr Singh: I will just pursue
that a little bit. Can I just clarify something? My briefing says
this is a government programme. Is it a government programme or
a BRAC programme, or a government programme leading on from BRAC?
Ms Kabir: It is a combination.
The government is doing it and BRAC is doing it, and I am sure
other NGOs are also doing it. Women and Children First are also
doing it. When we speak about Bangladesh and services, you think
about a conglomeration of government services, NGO services as
well as the private sector. Do not forget that the private sector
is also there. The private sector can be good as well as bad,
because the private sector is your local untrained indigenous
provider of medical services or it could be the local person who
supposedly has spiritual powers that can heal you of all sorts
of diseases. The private sector can be both good and bad.
Q53 Mr Singh: In terms of the issues
surrounding skilled birth attendants, are there issues about numbers?
Are there enough of them? Is there an issue about women having
problems in accessing skilled birth attendants, and where do we
go from here in the sense of what DFID needs to do particularly?
Ms Kabir: We certainly need many
more skilled birth attendants. We only have in Bangladesh one
third of the total number that we really need to make a significant
change. But that is only one side of the issue. The other side
of the issue is how you get women to use a skilled birth attendant,
either for the attendant to come to the home or if the woman goes
to a clinic or a hospital. Where the status of women is so low,
and women do not make a decision about where they are going to
have their baby and who is going to deliver it, most of the time
women are delivering their babies at home. Most of the time the
babies are delivered by relatives. If she is lucky she may get
a skilled birth attendant. It is only a tiny percentage of the
total population of women who go to a facility where there are
trained providers. We have to change the way people value women's
lives, and that has to be done in many different ways, whether
education of girls in primary, secondary and vocational schools
or it is exposing men and other decision-makers within the family
to the value of women. If you have educated girls and women then
they can also bring in an income, and that is happening among
the middle classes of Bangladesh. You find now that when marriages
are being arranged between families, families are looking at whether
the woman can bring in an income to the family. That is only happening
among a tiny, tiny proportion of people. If people think more
about valuing women, that is really important. Unless that happens,
you might have the most fantastic services available in the whole
world but you will not have any women going there.
Q54 Mr Singh: You are saying that
more women would use the service if there were no cultural and
perceptual barriers. The service is available but it is under-used,
is that what you are saying?
Ms Kabir: The service is not available
as much as it should be. As I say, we do not have enough skilled
birth attendants, but it is a matter of how the community, the
family, perceives the value of the woman, whether it is worth
taking a woman to a facility. First and foremost, studies have
shown that it takes forever for a family to decide that there
is a medical emergency and the woman needs to go to a hospital
to have a caesarean, or whatever it may be. Sometimes the decision
takes so long and never happens that the woman dies. That is your
first problem. The second problem is transportation: how do you
get the woman from the home to the facility where she needs to
go for the service? Transport is not easily available, or it is
expensive, so it is difficult for the most disadvantaged to use
that. Then, when they do get to the facility, what are the costs
involved? It might seem that the government services are free
or whatever, but they are actually not; you have to pay for medicines;
you have to pay the doctor for services; there are bribes and
all the rest of it. Unless the value of the woman is there, nobody
is going to make that investment.
Q55 Mr Singh: In terms of recruits
coming forward for this training, are there any problems? Is this
a job that women want to go into?
Professor Costello: I do not think
there has been a problem. Clearly, getting more skilled birth
attendants is a long-term strategy and it seems like a very good
idea and should be invested in but there are potential problems
though. Firstly, you want to get good-quality people to be trained,
but then there is an issue, will they go out to the areas where
they are most needed or will they tend to congregate in urban
centres? That is a big question mark that remains. There is also
the problem that most poor people are very rational. They know
they live a long way away and they know it will cost them money,
and often when they get to a facility it may be poor quality.
There was a very interesting study done recently by Dr Iqbal Anwar,
who is associated with our research programme. He reviewed quality
of care in 12 districts, and went round and looked at various
functions around obstetrics and care for women and newborns. By
and large, the district hospitals, which often cater for four
to six million, were not too bad, and the NGO facilities were
not too bad, they did reasonably well. Once you got below that,
to union level, and remember a union still covers 25,000 people,
the services were of extremely low quality, and even worse was
the private sector at that level. A lot of very bad things were
being done. There is an issue around regulation here. Where the
skilled birth attendant would fit in is still not clear to me,
and how much they would be used, would they be attached to the
union complexes or whatever? As an aside, you could say, should
I not know that! There is still an observation, which we often
raise with DFID and a lot of people in DFID say is an issue. The
research programme consortia which are well funded by DFID in
many parts of the world, and country programmes, have a very weak
relationship. It is often informal and it is often social. I think
they are missing a trick—and I think DFID realises this—to
link up many skilled people in evaluation from all kinds of backgrounds—economic,
health, education—who are in the research programme consortia
that could help with the country programmes. Your question is
an extremely important one, and it does not just apply to Bangladesh,
it applies to India, Nepal and many other countries.
Q56 Mr Singh: Is there any kind of
health visitor service as we have here where health visitors or
community health workers go out and visit when you are pregnant,
and maybe identify to some extent whether they are going to need
treatment that the skilled birth attendant could link into? Is
that kind of work going on?
Ms Kabir: The government did have
a system before where they trained women to be family welfare
assistants but a few years ago that was withdrawn because the
argument given was that women are becoming dependent on these
women going to their doorstep instead of women coming out. I think
that was a big mistake and it was withdrawn very, very abruptly.
I think the real reason was just money basically. Many, many NGOs
in Bangladesh that work in maternal health do have outreach workers
who go to the home and visit women and try to do the very basic
antenatal care: immunisations like tetanus toxoid for the mother.
They talk about the importance of breast-feeding for the first
six months, immunisation for children and all the rest of it.
It is there, but it is not there enough. One of the other things
we need to look at in Bangladesh is there needs to be much greater
coordination on who is doing what. I do not think there is duplication
per se but there is not enough coordination. For instance,
if an organisation is providing certain services but the family
needs something in addition to that, does that organisation refer
that family to whatever service that may be? I do not think that
is happening as effectively as it should.
Q57 Mr Lancaster: You mentioned in
passing women's groups and in light of the particular isolation
in Bangladesh can you expand on the role of women's groups, their
importance and how they contribute to maternal health?
Professor Costello: We have been
doing formal research programmes on women's groups. In Nepal and
India, the two studies come to mind, we have done cluster randomised
control trials of women's groups focusing specifically on maternal
and newborn care. We did this in a very large area of a remote
part of Nepal, which we published in the Lancet 2004. To
my surprise, it showed a 30% reduction in newborn deaths even
in communities where access to health services was extremely low.
There was something about the group mobilisation process, raising
awareness about hygiene and care that was having an impact. A
lot of people did not believe us and said, "You ought to
replicate that". We have got six other trials. One which
will be published soon, in the next couple of months, in the Lancet,
from India, has shown a bigger effect, a 45% reduction in newborn
mortality in poor tribal areas where baseline newborn mortality
rates are high, and where there has been absolutely no change
in the use of antenatal care delivery and postnatal care services.
So, of themselves, that is quite a valuable thing. What the actual
impact is on maternal mortality, we did show in Nepal a statistically
significant effect but it was small numbers. There are anecdotal
reasons why the delays of seeking care may be improved by women
having been mobilised in their communities. This is an important
thing, but that is the demand side; you have also got to link
it up with the supply side.
Q58 Mr Lancaster: On the supply side,
how can donors help without moving away from the community-based,
bottom-up approach? You have dealt with demand; what are you doing
about supply?
Professor Costello: It is a good
question. One attempt that has been tried by DFID and is gaining
importance is the idea of the conditional cash transfer, which
is to encourage the poorest women to go to facilities by paying
an incentive. This scheme was introduced four years ago in Nepal,
and we helped to evaluate that with the country programme there.
I believe there is a maternal voucher scheme in Bangladesh, but
I do not know much about that. The problem is that even when you
do that it tends to be the better-off quintile groups that access
the hospital and get the incentive, so you tend to find yourself
investing in something that will tend to benefit the better-off
already. That is a problem always with the supply side. I come
back to what I think is the most important thing you can do on
the supply side. You can probably look at what is already there,
because there is a lot going on, and try and regulate it better
and look at indicators of quality of care from district level
downwards.
Mr Hobbs: I am not really a specialist
on health per se, my area of specialism is more climate
change, particularly UK funding for climate change in Bangladesh.
Coming back to the Chairman's earlier question about some of the
barriers to achieving the MDG on gender equality, building on
something that was said by Ms Kabir we need to look as well at
the value system in the country. There has, of course, been a
lot of progress in the development indicators for women over the
last couple of decades, but then, as has been pointed out, a lot
of the indicators are still stubbornly high, including the maternal
mortality rate. That is off-track at the moment for 2015. There
are also issues like completion rates in education and low employment
rates outside the agricultural sector for women. In regard to
value systems, we feel that DFID should focus not only on health,
although that is of course an important issue, but looking at
the economic and political empowerment of women in Bangladesh,
because one of the fundamental problems is that women lack control
over income and expenditure decisions at the household level and
are also limited in their participation in decision-making, both
at the family level and in society. In regard to the issue of
quotas in different levels of government and also the national
parliament, there has been a quota system in the national parliament,
for example, that has basically allocated a number of reserved
seats for women as opposed to the general seats, but those 45
reserved seats have not actually been contested seats, the female
MPs get indirectly elected by their peers, by the other MPs. Although
in the 2008 election there were some female candidates for the
general seats, which are the contested ones, 19 got elected in
that way, so we have now got 64 female MPs in the parliament,
the point is that there you can see a segregation of women in
these political power structures, so even when the quota system
is introduced it still leads to a form of segregation and a marginalising
of women within these decision-making structures. This is an important
point. We also made certain recommendations in our submission
about how DFID could improve the way it disaggregates data.
Q59 Mr Sharma: You have picked up
the question I was going to ask. What are the main factors which
account for women's lack of empowerment in Bangladesh? How do
you explain the paradox of having strong female political leaders,
including the current Prime Minister, and Bangladesh's low score
on the UNDP gender empowerment index?
Professor Costello: This is quite
complex. Clearly, there are regional variations in Bangladesh.
There are traditional conservative areas. We work, for example,
in Moulvibazar which is a much more conservative area adjacent
to Sylhet. Other parts of the country are more progressive. You
could say Bangladesh has done very well on its female education
rates and, by contrast, it has got much better indicators on that
compared to, say, Pakistan, starting from a lower base of independence.
The other thing in my experience is that the idea that all women
are lacking in power is simply not true, it depends on your life
cycle in many parts of these countries. When you are newly married
and you move to your husband's house you have very little power
and come under the control of your mother-in-law, but as you produce
children and become older, mothers-in-law are quite powerful in
households in decision-making. It is a complex business.
Ms Kabir: I think that having
a woman prime minister does not have any impact at all on status
of women in the country, as you have seen here in the UK also.
The gender issue touches everyone's life everywhere in the world,
but even more so in Bangladesh. If you look at the laws in Bangladesh,
we have not got sufficient laws that are gender-sensitive, and
the laws we do have that support women are not implemented. In
fact, in Bangladesh we have absolutely fantastic laws, but most
of the time they are not implemented in any shape or form. Then
if you come to the policy level, policy formulation is not gender
sensitive. The same goes for the implementation of policy. At
the programme level you have the same issue; the programmes are
not designed or implemented in a way that is particularly gender
sensitive. As my colleague said, if you look at monitoring and
evaluation, you do not have disaggregated figures available to
tell us about the impact of the health and family welfare government
programme. One of the difficulties we have in Bangladesh is that
there is a Directorate of Health and a Directorate of Family Welfare,
which is family planning, and they all come under the Ministry
of Health and Family Welfare, but the two directorates have their
own staff and their own resources, and they do not talk to each
other, they do not like each other. Donors for, I would say, twenty
years now have tried to convince the Government of Bangladesh
to amalgamate the two directorates and just have one, but that
has not been possible for political reasons because employees
feel they are going to lose their jobs or their seniority and
all the rest of it. Resourcing of programmes is also not particularly
gender sensitive.
|
