Examination of Witnesses (Questions 58-103)
Q58 Chair:
Good morning, and welcome to the Committee. Sorry for keeping
you waiting. Perhaps, just for the record, you could just introduce
yourselves before we start.
Professor Chambers:
My name is Robert Chambers. I am a research associate at the
Institute of Development Studies in Sussex. Research associate
means that you have retired and they have not yet figured out
how to get rid of you. Here is the man who is guilty of not having
found a way of getting rid of me. It is a wonderful condition
to be in, and I do recommend retirement to you all, if I may.
I am an undisciplined social scientist—failed biologist,
failed manager and various other things.
Professor Haddad:
I do not know whether to jump in or not.
Q59 Richard Harrington:
Why not stand for Parliament? You would be ideal.
Professor Haddad:
I am Lawrence Haddad, the director of the Institute. I am looking
for ways to retire, but they will not let me.
Hugh Bayley: A failed
retiree.
Q60 Chair:
Can I say two things? One is that, obviously, we are looking
into DFID's role in India. Part of the prediscussion is:
should we have a role at all? If so, what value can we add, and
why can't the Indian Government do it without us? What is the
benefit of our being there? That is the subtext, but we clearly
need to focus on what DFID is doing, how effective it is, what
it is not doing, and whether it should be. I hope you will feel
free to give your views on that. Can I also say, given that we
are starting a little bit late, and I know that one or two colleagues
have other constraints, I do not want to restrict you, but if
we can try to keep it crisp, that will help us to get through
things fairly quickly?
If we look at health first of all, it has been argued,
in The Lancet for example, that the failing health system
is perhaps one of India's biggest problems or predicaments—although
there are other areas where India is failing, and others where
it is succeeding. First of all, do you agree with that? The
more blunt argument is that India is a rapidly growing economy,
with a rapidly expanding middle class. Can they deliver it by
possibly transferring some of the wealth of the middle class and
putting it into developing a health service, which currently does
not meet the needs of the majority of the Indian people?
Professor Haddad:
Let me kick off on this, Robert, if you don't mind. I am not
a health systems expert for India. However, obviously I knew
that this Committee was interested in these issues, so I have
pulled out a couple of brief papers for you, which may be of interest
to the Committee. One was published in The Lancet, last
month. It is a call to arms from a leading Indian health expert,
Srinath Reddy, with whom we have worked at IDS, interestingly
enough in a DFIDfunded consortium on nutrition. He is leading
a group of highlevel academics, who are also policy advisers,
in saying, "India really should have an integrated national
health service." If you give me a minute, I will run through
the arguments. The first point is that the WHO in 2000 did a
ranking of health systems worldwide. It was quite controversial,
but nevertheless it ranked different countries' health systems.
India came out at 112.
Q61 Chair:
The United States, for example, where did they come?
Professor Haddad:
They were 37. They were quite annoyed by that.
Q62 Alison McGovern:
The UK?
Professor Haddad:
The UK was 18. Just to give you some comparators from the region,
Sri Lanka was 76, Bangladesh was 88, India was 112, Pakistan was
122 and Nepal was 150, which was interesting. That score is an
aggregate of a number of different components, and the Indian
system, in that 2000 ranking, came out very badly in terms of
the distribution of available services. It came out quite well
in terms of the fairness of financial contribution. The WHO defined
fairness of financial contribution as: "If you are sick,
are you the one paying?" You can define fairness in lots
of different ways, but because the health system in India is 80%
out-of-pocket costs, and 20% public costs, if you get sick you
are the one who pays for most of the drugs and the diagnostics.
In that sense, it is fair. This paper from The Lancet
says that the Indian Government need to get out-of-pocket expenditure
down from 80% of the total cost to 20% by, I think, 2024 or 2025.
It also says that public health spending, as a percentage of
GDP in India, which is 1% now, needs to go up to 6%. That is
what this call to arms, published in The Lancet a month
ago, said.
Q63 Chair:
That presumably would imply a transfer from the betteroff.
Professor Haddad:
Yes. I think, as I put in my written comments to the Committee,
India is still not a rich country. As you know, its GDP per capita
is around $1,000 per year. China is $3,500, and Brazil is $6,000.
It is often compared with those two countries, but the magnitude
of difference is very big. Nevertheless I still think the scope
for doing more in terms of distributing and investing more in
health systems is enormous. Tax revenues are going up quite quickly.
Chair: Okay. Thank you
for that.
Q64 Alison McGovern:
Thank you for your presentation so far. Given the context of
what you have said about the research into India's health system,
where, in fact, do India's priorities lie in addressing the challenges
you have mentioned? I am thinking particularly of the Federal
Government.
Professor Haddad:
It differs from state to state, I have to say. That is a weaselly
answer, but I cannot give you a straight answer to that, because
it does depend on the states. In the nutrition field, where I
am much more familiar with the evidence —
Q65 Chair:
We will come on to that.
Professor Haddad:
If you look at the data state by state, DFID, WHO and the Global
Fund to Fight AIDS, Tuberculosis and Malaria try to direct resources
towards the things that that are causing the most disability-adjusted
life years. In other words, where the health burden is biggest,
you direct resources in rough proportions to those things. Obviously
there is a factor to do with effectiveness and efficacy, but nevertheless,
if a particular disease or a particular chronic condition is generating
20% of the health burden, you commit 20% of the health resources
to that. In nutrition, that is not happening at all. Every state
has a different burden of disease profile, and if you look at
the spending, it does not match the different burdens of disease.
Public health spending, whether it is nutrition or otherwise,
is very political in India. It is not driven by health burdens.
Why is it political? That is a difficult question to answer.
Q66 Alison McGovern:
With respect, it is political in all countries.
Professor Haddad:
Yes.
Q67 Alison McGovern:
I want to come back and ask you a further question, if that is
okay. Thinking about DFID's role, and that of the UK as a country,
our aid programme is small in comparison to the funds that are
required to address some of the issues that the WHO, and clearly
the article in The Lancet, picked up. Do you think that
the Indian Federal Government have an NHSstyle, acrosstheboard
distribution in mind? Are they prioritising investigating that
sort of provision?
Professor Haddad:
I cannot give you a definitive answer on that. All I can say
is that the person who wrote this article, Srinath Reddy, is a
very well respected insider-outsider in the Indian Government.
If he wrote this article, he must have some confidence that there
is some appetite for this within the Indian Federal Government.
How strong that appetite is, I don't know.
Q68 Richard Burden:
I would like to ask you a little bit about the effectiveness
and the rationale, and the way things could be improved, around
DFID assistance being channelled through national Government and
the states. Clearly different areas are handled at different
levels. TB, reproductive and child health, HIV/AIDS and various
other things are principally handled at the national level, and
then you have mentioned things that are principally handled at
state level, such as nutrition. From what we have read, you have
been saying that it is important that the states develop the kind
of administrative capacity they need to be able to deliver effectively.
I read from that a little bit—or I had read from that until
you just said what you were saying—that probably the emphasis
needs to shift to the state level, so that they can build up their
capacity. But then you are also saying that it is a very political
area, provision is very patchy, and the provision does not necessarily
match the need. Can you say a bit more about that? What lessons
do you learn about effectiveness? Are you saying that, in a way,
we need to angle assistance more to the state level or to the
national level, or change either of them, and if so, how?
Professor Haddad:
There are some very basic things that the central level needs
to do around standards, objectives, certification and those kinds
of issues. A lot of the effectiveness is at the state level.
Whether the population of India in a particular state is served
well by their health system is down in large part, I would say,
to the state government. The variation—
Q69 Richard Burden:
Sorry to interrupt, but even if, essentially, the programme is
a national programme—
Professor Haddad:
Yes. Yes. Yes. Again, the one I know best is ICDS, which is
a national nutrition programme. It is a national nutrition programme,
and it has the same template everywhere. It is a very cookiecutter
programme, everywhere, in a million different communities in India.
The heterogeneity and the variance in the effectiveness are astounding.
It is not just how rich or how malnourished a population is,
it is the effectiveness of the state government, but also districtlevel
governments and downwards. That makes a big difference. Where
I have seen DFID be very effective in India is helping different
states access central resources that are held, and helping districtlevel
governments to access statelevel governments. They have
been very effective doing that.
Q70 Chair:
It is a slightly odd role, isn't it, though, for an external
donor to be helping a state to apply for its own Government's
funds?
Professor Haddad:
It is. You can think of the central Government as a massive
donor in the backyard of the states. They are not a very forthcoming
donor. It is quite demanding in terms of the bureaucratic requirements
to get access to its funds.
Q71 Richard Burden:
Say that we help a particular state to access a national programme,
or through our intervention we develop a good practice or a best
practice, generally, is that just effective in its own terms,
in that state or that district, or does it have some kind of catalytic
effect elsewhere? Does it become best practice? Is there some
mechanism for replicating this elsewhere? Is that what we are
doing? Or are we saying, "We can add some good and some
value here, but the reality is that it is only here. It does
not have any effect elsewhere."
Professor Haddad:
Again, from my experience DFID tends to work at the state level.
If it is working in Bihar, it will work with Bihar officials
at the central level, and make sure that they are completely on
board and that any innovation, pilot or leveraging of resources,
any support of that leveraging, is understood and there are lessons
learned at a state level. Between states, the mechanisms for
learning are very weak right now. We are a part of a Gates Foundation
project called IFPRI, in India, to enhance lessonlearning
between states on nutrition. It is quite a big project, driven
by Indian organisations. We are providing a supporting role.
There is a sense that there is not much lessonlearning
here. It is surprising that there is not, because the experiences
in the states are so different. There are lessons to be learned,
but somehow they are not being shared and being adopted. Enough
pressure is not being put on officials, in the states where lessons
are seemingly not being learned, by the citizens of those states.
Q72 Anas Sarwar:
Good morning, Professor, and thank you very much for coming in
to see the Committee. In paragraph two of your written evidence,
you say quite clearly: "Often
it is difficult for States to get money from the donor centre.
States need to have very strong administrative systems and capacities
to do so effectively. The poorest states have the weakest tax
base and hence the weakest administrative systems." I have
two questions. Do you think there is a role for DFID to work
more on strengthening systems, tax bases and administrative processes,
rather than targeting specific programmes, in order for states
to be able to tap into central resources? Secondly, a point more
for the Indian authorities is: if they are collecting their own
tax base and their own tax systems, the money that they raise
within state, is that the money they spend via the local government
agencies on health? Or does that money on health come from a
central tax base to states to spend in their own regions?
Professor Haddad:
On the latter one, it is a balance. It is a different balance
in each state. I do not quite understand the allocation rules,
but it is a balance between Federal and state. The first question
you asked is the classic development question. Do you strengthen
systems?
Q73 Anas Sarwar:
Is it aid or development?
Professor Haddad:
Yes. It is a difficult one. DFID is very interested, obviously,
in strengthening tax systems. Again, at IDS we have a new Development
and Tax Research Centre, funded by DFID. It is a consortium of
organisations from around the world. DFID is clearly interested
in this, because it understands that domestic resource mobilisation
is one of the best ways of creating a credible state. There is
something for citizens and Government to negotiate over and engage
around. Aid can undermine the credibility of a state. A natural
resource income can undermine the credibility of a state. On
the other hand, India is home to, as we know, a third of all malnourished
children in the world, and if those kids do not get attention
in the first 1,000 days of their life, that is something that
will manifest itself in lower economic growth in 25 years' time
in India. If you do not meet those kids' needs in the first 1000
days of life, that is a onetime loss that they have to carry
with them for the rest of their life. In the nutrition field
we are torn between wanting to deal with a very narrow physiological
window of opportunity, and on the other hand you do not want to
see that being mobilised indefinitely by aid. You want it to
be sorted out by domestic resource mobilisation. DFID's programme
is tiny, really, relative to all the needs. My experience, from
being with them last September and the year before in September,
is that they are quite clever in using those limited resources
to leverage much larger resource flows.
Q74 Anas Sarwar:
Has any assessment been made of how much states are losing out
on tax receipts because of poor tax and administrative systems?
Professor Haddad:
Not that I know of, but I am happy to follow that up and find
out for you.
Q75 Hugh Bayley:
To follow up Anas's question, Lawrence, you have described the
certain intractable problem of malnutrition. What can be done
about it at Federal level and state level? Where are the useful
things that donors can do? Does the "1,000 Days"
campaign that Hillary Clinton launched have a presence in Indian
policy?
Professor Haddad:
It did not, back in September. It was launched back in April
or May of last year.
Q76 Hugh Bayley:
Okay.
Professor Haddad:
It did not then. The National Nutrition Council, which the Prime
Minister set up in 2008, only met for the first time late in 2010.
That gives you one indication of the level of seriousness with
which this issue is dealt with centrally—i.e. not very seriously.
I will try to be brief: developing country experience says what
when income grows by 10%, malnutrition should decline by 5%.
If income doubles, malnutrition should go down by 50%. In India
that ratio is about 10% to 2%, instead of 10% to 5%. There is
a much lower response of malnutrition to income growth. India's
income growth is astonishing, really astonishing; I do not need
to tell you that. Why is that? I think there are three reasons.
I will be brief. They come under the headings of capacity, accountability
and responsiveness. Let me try to identify things that donors
could do.
Under capacity, there is a low response of nutrition
to income growth, but there is also a low response of poverty
to income growth. Some studies done recently by the head of the
World Bank's research team, Martin Ravallion, whom you may know
of, have shown that the responsiveness of poverty to income growth
has halved post the 1991 reforms in India. Income growth has
accelerated, but the responsiveness of poverty to that growth
has halved. I think that has something to do with the lack of
investment in one of the most broadbased engines of economic
growth in India, which is agriculture, especially smallscale
agriculture. The Indian Government, supported by different donors,
could really revitalise agricultural growth and investment. That
is the thing that gets rural growth and poverty reduction going,
and gets nutrition on the upswing.
That is one thing. The other thing under capacity
is leadership. I told you about the Council. I was talking to
one of the big nutrition NGOs in India that runs very innovative
public-private partnerships, called Naandi. I said to Naandi,
"Why aren't you doing more stuff on nutrition?" They
are doing some, but they are doing mostly health and education
and water. They said, "There is noone to get angry
at. There is noone to engage with on nutrition on the national
level. Noone is responsible for nutrition at the central
level."
On accountability, there is a huge amount of exclusion
of access to nutrition programmes. I will leave with you an IDS
bulletin we did about a year ago, which documents all of this
exclusion. With the ICDS programme that I mentioned, which is
in a million different places, there is systematic exclusion.
It is not in places where scheduled castes and low castes exist.
It is not there, and when it is there they have less access to
it than other kinds of castes. Again, there is also gender exclusion,
which especially in the northwest of the country is a huge
problem. There is very little upward accountability. There are
very few mechanisms for people who are not getting the quality
of nutrition service that they should get to report back to districtlevel
and statelevel people. There are very few of those mechanisms.
DFID has supported, with local government approval and support,
some social audits, which are essentially community scorecards,
saying: "Are we getting it? How good is it? Is it going
to the right people?" There is not enough accountability.
Under responsiveness, they are using an outmoded
model, it seems to me. This ICDS programme is scaled out in a
way that is not sensitive to context. India is a land of many
different contexts. It is missing the underthree age group.
It is targeted towards the children who are three and above,
because they are the ones who are very demanding. They need the
food. The health worker is preoccupied with teaching those kids
above the age of three, and giving them hot food, and there is
only one worker per centre. They do not have any time to deal
with kids under the age of three. In many cases kids under the
age of need home visits. They are the ones who miss out. They
are the ones who are the most critical for malnutrition.
I will stop there.
Q77 Richard Harrington:
Thank you for that, Professor. I read an interview of yours
in The New York Times; you have developed cynicism,
it seems to me with very good reason, about the impediments to
helping to solve nutritional problems being very much structural
in Indian society and Government and the whole system there.
I am sure you are absolutely right on this. In the end, however
much money that DFID and other national and multilateral bodies
put into this problem, it would seem that unless there is a complete
change of structure and will in India, it will not make much difference.
Is that fair, or do you think that we can just continue plugging
away, all of us, and in the end it makes a significant improvement?
Or is it just: "We will do what we can, and some bits will
help, but we can't do anything else? There is no pressure that
can be brought upon the Indian authorities to change."
Professor Haddad:
I would agree with that, with the exception of one big area,
where I think DFID can make a massive difference. This is in
the area of improving the enabling environment for malnutrition
reduction. What does that mean? I was just participating in
the Government Foresight Report on the Future of Food and Farming.
In the course of that work, and in the course of my work in India,
it is pretty clear that civil society in India does not really
know the extent of malnutrition. It does not know the extent,
and it does not know the consequences. Every time I am interviewed
by an Indian journalist, I ask them: "Do you know what the
level of malnutrition is in your country, for children?"
They always give me an answer that is half the real rate. That
is the first thing; people are just not very aware of the extent
of it, and they are also not very aware of the consequences.
What I think DFID can make a huge contribution to
is to develop better ways of understanding the nature of the problem.
For example, every five years, India gets a tsunami of nutrition
data, but it is every five years. The Government does not know
whether its work is doing anything on a yeartoyear
basis. Civil society does not know whether the problem is getting
worse or better. They have to wait every five or six years.
India is home to innovations in ICT and mobile technology. You
could very easily, led by Indian entrepreneurs in the private
sector, develop global or regional or national malnutrition maps
that change every month. That would give you a monthbymonth
picture, georeferenced using some kind of Google mapping
technology. You could have a monthly map of malnutrition hotspots
in India. That would be a massive spur to civil society, and
also a massive help to the Government. That is one thing you
could do, very tangibly, and that is what I would encourage DFID
and other donors to invest in.
You could also help measure different commitment
levels to reducing hunger. A Government might say: "We are
very committed. We have set up a Council on this, and we support
the Right to Food," but what are Governments spending money
on? What are the policies that they are enacting doing? What
is the legislation saying? We do not have very effective measures
of commitment. Again, DFID could play a huge role in supporting
those who want to measure commitment—not just the Government's
commitment, but civil society's commitment, corporate commitment,
and donor commitment, to reducing malnutrition. IFRI, one of
my former employers, has developed a very simple hunger map that
has had a lot of media attention and a lot of play in India.
It is a very simple map of outcomes, but again it is only an annual
map. You can do a lot with these kinds of indices.
Finally, DFID can do a lot to help Government look
at curriculum and leader development. There are not enough antihunger
and antimalnutrition leaders in India. A lot of that has
to do with the way nutrition is taught in Universities. It can
make a contribution at that level. Those are three examples of
systemic interventions that can be made: looking at curricula,
looking at outcome data, and looking at commitment data.
Richard Harrington: Thank
you.
Q78 Hugh Bayley:
I have one further question to both of you, which goes away from
the theme of most of our questions, which have to do with basic
needs: health, nutrition, sanitation and so on. I feel the aid
paradigm is changing from a northsouth, rather paternalistic
relationship to much more of a global and southsouth relationship.
One of the things that I think DFID needs to do is change the
relationship with India. India has much more recent experience
than Britain of industrial revolutions, of increasing agricultural
productivity in tropical climates, and it seems to me extraordinary
that we send so many British experts out to Africa, rather than
working in partnership with India. What more could DFID do to
use India's expertise to support Britain's development ambitions
abroad? Should we, for instance, within DFID have a partnership
with the Indian civil service, so that 10 of the best Indian civil
servants do a threeyear secondment working for DFID in Africa?
How should DFID adapt to a changing global situation?
Professor Chambers:
I think this is a very important idea, and a very imaginative
idea. It would be excellent if DFID could explore it and give
it some pilot trials. In terms of the relationship, within India,
the history of good, close relationships, as I said in my note,
is more precious than money in assisting those in India who want
to do things that otherwise they may not be able to do. The additionality
of British aid in India is that a lot of it operates through the
level of people who trust one another, who want to do things together
that they could not do if it was not part of an aid programme.
Those alliances, which do not show up, are very important, and
particularly important sometimes at the state level, where there
are people who would like to pilot and try out new approaches,
but would not be able to without DFID support.
Professor Haddad:
I am just struck by an example from India. Santosh Mehrotra,
who works in the Indian Planning Commission, has developed and
piloted and analysed some fantastic ideas around conditional cash
transfers. How can you get conditional cash transfers to work
in a country of $1,000 GDP per capita? Most of them are working
in Central America or Latin America, where incomes are much higher.
It strikes me that a lot of the ideas that he has put forward
could be really important for Africa, for the idea of conditional
cash transfers, or even just regular cash transfers, in subSaharan
Africa. At the moment, there are not many mechanisms for that
to happen. When I talk to Indian organisations about the research
side, "Work with us on doing some research in Africa or Latin
America", part of the response that I have had is, "We
have too many problems here. We need to deal with our issues
here. We do not want to be distracted by doing work elsewhere."
Partly, however, there is a lack of mechanisms. We would love
to have Indian analysts and Indian policymakers, based at IDS,
and working with DFID and African policymakers, whom we also invite
to IDS, to begin to share stories and ideas and to develop joint
ventures together. It is very hard to find funding for that kind
of thing, however, from the Indian side and the UK side. It is
very, very hard.
Q79 Hugh Bayley:
Could you just make sure the secretariat have the note of the
name of this guy from the Planning Commission —
Professor Haddad:
Yes. I will send you that later, as well.
Q80 Hugh Bayley:
—and a very brief summary of the sort of ideas that might
be transferable?
Professor Haddad:
I will do. I will do.
Q81 Pauline Latham:
Do you think DFID has provided effective support to India on
undernutrition? Last year, they launched a nutrition strategy.
Are you aware of anything particularly innovative that has come
out of that since it was launched? Do you know if the Department's
policy team in India has actually met the pledges to create the
nutrition policy on health or published individual state nutritional
targets, as they promised to do?
Professor Haddad:
I don't know the answers to some of those specifics, but I will
know them in a week, because I am going to India tomorrow to meet
some of the DFID people. I do know that they have ramped up nutrition
as a result of the nutrition strategy. I have not been privy
to the expenditure figures, so I don't know what they put into
the BAR, either. I would imagine that, for the India Bilateral
Aid Review, they have highlighted nutrition a lot, partly because
the strategy has given them a green light to do so. However,
it is not clear what the status of the strategy is at the moment.
I hear rumours that there is no strategy. It would be helpful
for the Committee to find out what the nature of the strategy
is.
Q82 Chair:
There was no strategy until the Committee told them that they
should have one, and then they adopted one. So that is disturbing,
I think, that we have got to start again.
Professor Haddad:
I have heard rumours that it has been shelved. I remember being
in front of the Committee five years ago and talking about this.
I think they have been effective, but they have been slow to
realise how important the issue is, and the contributions they
can make. When Michael Anderson was there as the Country Director
they began to ramp up, and I hope under Sam Sharpe they continue
to maintain this emphasis. I think they have been effective.
Going around and looking at state documents, Government of India
documents, a lot of Government of India documents seem to cite
DFIDsupported work. That seems to me to be one indication
of effectiveness. The state officials I meet—not only with
DFID officials—seem to be saying DFID are doing a good job.
I have been to Bihar and MP. DFID is an active player in Delhi,
in supporting homegrown initiatives. There is a nutrition
initiative—the key one, I have forgotten the name, but it
is headed up by M. S. Swaminathan, who is one of the éminences
grises on nutrition in India—DFID have been playing a quiet
but supportive background role. They have been trying very hard
to play a leveraging kind of role, so they have been investing
in rigorous evaluations of innovative interventions, with the
idea that that is a public good that is available to everyone.
They have been, as I have said, quite good at helping to raise
the profile of the issue within the Indian Government, but there
is only so much they can do. There are only so many meetings
you can have with the Ministry and the Planning Commissions.
I think they have been quite effective. I do not have a very
good measure of that effectiveness other than the atmospherics
of it all.
Q83 Pauline Latham:
Thank you. How do you think DFID can best support the demand
side, the interventions on nutrition, for example, building stronger
upward systems, whereby the communities themselves demand some
action? Do you think they can help with that aspect?
Professor Haddad:
As I said, DFID has invested, working with local governments,
in social audits. Social audits are a good way of mobilising
communities—and Robert knows about a million times more
about this than I do—and helping to articulate their demands,
needs and preferences, in a way that is nonthreatening to
local government officials. I would like to see more of that
kind of thing. It sounds terribly boring and you would expect
a researcher to say this, but there really is a data deficit on
nutrition in India. There is a mass of data that appears every
five or six years, which takes five or six years to analyse.
By the time you have analysed it, it is all out of date. You
need much more frequent but much slimmer nutrition updates every
month or every quarter. That would be a huge contribution. Nutrition
surveillance has fallen out of fashion in the last 10 years.
I don't really know why, and it is a bit of a scandal.
Q84 Pauline Latham:
Can I take you back to something that you said about how only
1% was being spent on the health service? Does that include international
development aid or not? Is that actually 1% of their budget,
or does it include money from outside?
Professor Haddad:
I do not think it includes it.
Q85 Pauline Latham:
It doesn't.
Professor Haddad:
I do not think it does, but I can find out. Even if it did,
it would not make that big a difference.
Q86 Pauline Latham:
Really?
Professor Haddad:
It is a trilliondollar economy. My maths is not good enough
to say.
Chair: I think we have
had some information that the percentage of aid relative to the
national budget is very, very small—almost immeasurably
small.
Pauline Latham: A very
small proportion. Yes. Thank you.
Q87 Alison McGovern:
I have a very brief supplementary to that. You mentioned working
with local government. You have not mentioned trade unions.
Certainly in the industrial revolution in this country, and in
most of Europe, nutrition standards would not have been raised
without organised labour being one of the strongest advocates
for the way that poor people lived. Do DFID work with trade unions
in India? Should they, in your view?
Professor Haddad:
I am not sure. I do not think they do, at the moment. It hasn't
come up in any of the conversations or documents I have seen.
Again, Robert might know more than I do on this. Should they?
The trade unions seem to have ceded the nutrition and food agenda
to the—I am going blank—the Right to Food campaign.
The Right to Food campaign is a very powerful political campaign
that has been successful in getting the NREGA programme, which
is the public works programme, the Employment Guarantee Scheme,
nationalised. They seem to have taken up the mantle of mobilising
the workers, if you know what I mean. It is a good question.
I do not know the answer. I am waffling a bit, but the Right
to Food group seem to have captured that labour movement.
Q88 Alison McGovern:
And who are the Right to Food group?
Professor Haddad:
It is a very loose connection of activists, lawyers, media people;
there may be some trade union people, but it is a very loose collection.
It is a disciplined but loose, diverse collection.
Chair: I think, Alison,
we should try to make sure that we meet with some trade union
representatives when we are in India.
Professor Haddad:
Yes. That would be a good thing, and the Right to Food people
too. It is very important.
Alison McGovern: Yes.
Q89 Anas Sarwar:
Does DFID sufficiently target support to nutrition at the most
in need in India, notably children, pregnant women and mothers?
What else could DFID do to improve targeting to those people?
Professor Haddad:
DFID understands who to target and how to target, both in a geographic
sense but also in a life cycle sense.
Q90 Anas Sarwar:
How would you rate DFID's wider efforts to achieve MDG 3 on gender
equality and empowering women in India?
Professor Haddad:
That is a good question. Again I don't know the answer to that.
Some of the country assistance plans that I have seen over the
last 10 years have put women and girls in the centre. Sometimes
they are called, "Putting Women and Girls at the Centre of
Development". However, I have not actually gone through
the programme and said, "How well is this targeted towards
women and how well is that targeted towards women?" I have
not seen a gender audit. It would be useful to see one.
Q91 Anas Sarwar:
Obviously we have the new UN Women Agency, which is going to
put women and girls at the heart of global development strategy.
How far do you think DFID should be supporting the UN Women Agency,
both in India and more widely?
Professor Haddad:
I think it is absolutely vital. Women are the key to so many
parts of the development puzzle, and so many of the MDGs. They
are central to nearly all of them. You name it: agriculture,
education, poverty, HIV/AIDS; the list goes on. I would expect
and hope that DFID can give its wholehearted support to the new
UN Agency. It is past time that this Agency has been created.
I just hope it has some teeth. I hope DFID can help it get some
teeth.
Anas Sarwar: Thank you.
Q92 Richard Harrington:
I know time is very short, but sanitation is a huge issue, and
in many ways when speaking to people it is almost an unfashionable
issue. Compared to nutrition and emergency aid and all the other
things, sanitation is not something that you can publicise and
get the heart of the public into, including all of our electors.
However, I think that all of us on this Committee know how important
it is. Obviously DFID is involved in a programme in India, dealing
with more sanitation, in a very small way compared to its total
expenditure. I would be appreciative of your comments on that.
Given that it is such a huge country and there are such huge
problems, should it be concentrating on urban areas? Should it
be concentrating on rural areas? Have they got the balance right?
What would you recommend for them to improve things?
Professor Chambers:
I am very glad that you have raised this. In my submission to
you there is a diagram that shows the proportions of open defecation
in the world. 58% of the open defecation in the world takes place
in India. It is an absolutely astonishing phenomenon. Even just
rural India is more than double the open defecation in the whole
of subSaharan Africa. The WSP, the Water and Sanitation
Programme at the Bank, have recently done an assessment of the
costs of this to India, and every year they estimate $54 billion,
which is $48 per head, which is far higher than any other countries
in the region. Open defecation is a massive problem in India,
largely ineffectively dealt with. Yes, the answer is that DFID
could do much more, and indeed I think that there is a move in
that direction at the present time.
It also connects very closely with issues around
nutrition, because the link between sanitation and hygiene on
the one hand, and nutrition on the other, has been largely missing
from the analysis. The normal tendency is to think about getting
food into children; there is availability of food and access to
food, and that is what most of the programmes are about. They
are direct. When you look at it, however, there is the whole
issue around absorption of foods, and the parasites carried in
the gut, which are actually stealing food from children and from
mothers. There are the diarrhoeas, which get an awful lot of
attention, and are killers. It is about 350,000 children a year
that are estimated to be killed by diarrhoeas. They get the attention.
They get measured. However, there are other things going on
in the body of a child that do not get noticed, because they do
not manifest in the same dramatic, measurable way. There is a
phenomenon called tropical enteropathy, which means that bacteria
get into the bloodstream and have to be fought with antibodies.
The antibodies require energy, and so that is another drain on
the child's nutrition. Then there are other pathogens: there
is hookworm, for instance, which is a major cause of anaemia,
I am informed. 200 million people in India have hookworm. When
we look at things like mothers' anaemia, we look at deaths in
childbirth, and one can ask: to what extent is it the result of
these fecallyrelated infections? There are so many of them:
schisto, hepatitis, polio, trachoma, typhoid, some epilepsies,
and liver fluke. All of these, if you will forgive me, can be
stopped here. You can cut off the whole lot in preventive terms
just here. Medical and nutritional thinking simply is not on
that wavelength, that it can be cut off there.
Sanitation is a huge, huge priority, given this estimate
of 6% of GDP being lost through bad sanitation, through sanitationrelated
infections. One can ask to what extent the poor response to increase
in GDP, which Lawrence has pointed to, is related to the quite
exceptional levels of open defecation in India. It may be that
there is a close link. Lawrence mentioned the need for research.
This is a very, very important area to be researched, including
research into: if you take one malnourished child, what infections
does that child have? It is not just the diarrhoeas. It may
be a lot of other loads of things that are being carried. We
know that deworming programmes have very good results, but
they only last for about six months, and then they are infected
again, unless you can deal with this at source.
Chair: I think Hugh Bayley
had a supplementary.
Q93 Hugh Bayley:
Just a very quick one. I remember taking a train from Delhi
to Agra, and for the first hour it goes at 4 mph, because the
railway lines are full of people shitting. Does it need research,
or does it just need a pit latrine dug every 100 metres throughout
every slum in India?
Professor Chambers:
That would help. DFID, through the slum improvement programmes,
has been involved in better sanitation in slums. It is people
actually using the toilets that is really important, and also
washing their hands. The Indian Government have a major programme
called the Total Sanitation Campaign, which has been going for
10 years. It has had some moderate successes, but only when communityled
total sanitation has been used, as it has been in Himachal Pradesh.
Q94 Chair:
We will come to that almost immediately. I just wanted to back
up Hugh's question. When the Committee visited Ethiopia, we saw
their health worker extension programme, which had been jointly
supported by DFID, the World Bank and the Government of Ethiopia.
In that context, they would usually look for a young woman in
the community whom they trained, who went back as a health advisor,
advising on sanitation, handwashing and other related public
health issues. It seemed to be remarkably successful. We saw
this and were astonished, I have to say, to see a 20yearold
young woman explaining to the male elders of the village why they
should use the pit latrine, and why they should wash their hands,
and various other things. They were taking it. It was all accepted.
In the hierarchical situation you might not have expected that.
Is that something that could work in India, or is there a huge
cultural problem?
Professor Chambers:
I think it would vary by state and by local context. In general,
really committed young people can have a big influence. Children
can be the most powerful of all. I know you are going to ask
me about communityled total sanitation. They have a very
big role in that, and are very, very effective.
Chair: Let Richard ask
his question.
Q95 Richard Burden:
Tell us about it. What are the benefits of it? I think in principle
we can see that if the community own it then it is likely to be
more effective, and that is borne out by what we saw in Ethiopia,
as Malcolm has just mentioned. How does it work? How aware is
anybody else, whether further up the administrative level, state
government, or the Indian Government centrally? What could DFID
do to help spread that message or to replicate the scheme elsewhere,
either directly or indirectly?
Professor Chambers:
I think that it could do a lot. I need to tell you what communityled
total sanitation is, briefly. It turns almost everything on its
head. The old idea was that poor people need toilets, they need
decent toilets, and we need to build them for them. It has not
worked anywhere in the world. They are used for stores, or they
are not used at all. Sometimes 50% of those that have been built
have not been used. That subsidised approach, unfortunately,
is still the official Indian policy, with the Total Sanitation
Campaign, although there are many within the Indian Government
who are aware that they need to change, particularly at the state
level.
CLTS, which was developed by an Indian, is radically
different. You do not teach anything. You do not give anything.
You simply go to a community and you facilitate their own analysis
of what is happening. They make a map, they use yellow powder
to show where they go and I am going to use, if you will forgive
me, the word "shit", because we use the word shit.
We have an international glossary of 100 words for shit. India
is leading that, I may say, in terms of the number, with more
than 15. Nothing is hidden. It is all brought out into the open.
People go and stand in the place where it happens, and there
are other details that I will not inflict on you. The point is
that it dramatically brings home to people that—and these
are the words that are used—they are eating one another's
shit. After about two hours of this, usually someone will say,
"We are eating one another's shit. We have got to stop this."
There is very strong disgust. There is a lot of laughter, as
well, but it is a community decision that they will all do something.
What this means is that the poorest people, very often, are helped
by the people who are better off, because it is in everybody's
interest that they should become open defecationfree.
Q96 Richard Burden:
Who are the facilitators on this? Who is it that goes to a village
and goes through that process, and how?
Professor Chambers:
I will take the example of Himachal Pradesh, because they have
gone, in four years, from 2 million people with toilets to 5.4
million, out of a total rural population of 6 million. It is
an absolutely amazing story. These were Government staff who
did this—people like block development officers. They had
very, very good training, they had commitment by the Chief Minister,
they had champions within government—it is really important
that there should be champions within government—who sustained
this programme. It is quite remarkable what they have achieved,
and it shows that it can be done, and it could be done elsewhere.
I think Bihar is a very high priority place for this.
Q97 Richard Burden:
What has happened to the champions? Are they championing it
anywhere else? Is anybody else listening?
Professor Chambers:
They are in government, so they have their government jobs to
do within their own states. There are issues about how this movement—because
it is a movement, an international movement—can be spread.
In IDS we try to work with supporting and helping Indian colleagues
in this, but it is a question of people becoming released, so
that they are fulltime. There are some very good trainers
in India, and they need to be fulltime on training people
in doing this. Not everybody can do the triggering, because it
is a performance on the part of the person who is facilitating
the process.
Q98 Richard Burden:
And is there something that you think DFID could do to help with
that?
Professor Chambers:
DFID could help by supporting piloting this in the states of
concern, particularly in Bihar because Bihar does not have any
CLTS yet. There is some in Andhra Pradesh, there is some in Orissa.
I think they should offer quiet, lowprofile support for
these incipient movements, and enabling people within government
to have the experience and to understand it. I suppose you will
not have the opportunity when you visit India, but if you are
a fly on the wall at a triggering, it is quite amazing what happens.
It is so counterintuitive, the way in which people respond
to the visible recognition of what is actually happening and what
they are doing.
Q99 Chair:
That is interesting, because that was also what happened in Ethiopia,
although there it was the women who led it, because they were
collecting firewood and were picking all this stuff up, and then
saying, "This is terrible." It did involve providing
a clean water point, as well, but they acknowledged at the end
of the process that the incidence of diarrhoea and other illnesses,
especially amongst the children, had almost disappeared. They
were able to perceive it. Over the last Parliament, it was one
of the things that most impressed me, when you actually saw something
systematically done, led by somebody within the community, and
seemingly making a difference. It is something I am sure we shall
want to do.
Professor Chambers:
Could I make one important point about women? Women in South
Asia, and particularly in India, suffer the most terrible deprivations
as a result of the utter taboo upon their being seen doing anything
during daylight.
Q100 Chair:
So they have to go at night.
Professor Chambers:
They have to go either before dawn or after dark, or pretend that
they are not doing it, and stand up if anybody passes. The effects
of this on women's health, again, I think are underresearched.
They suffer so much. How much maternal mortality and other phenomena
are associated with this taboo? It is difficult to say, but travelling
to Agra, when you saw all these bottoms in the morning, they would
almost certainly be entirely male.
Q101 Hugh Bayley:
Yes.
Professor Chambers:
Women have to get up early and go, and it is risky at night,
and it is extremely unpleasant and dangerous to have to do this
in the dark. There are many, many deprivations associated with
this, including loss of sleep. If a family has a private place,
then the whole issue of menstrual hygiene also becomes something
that it is easier to handle. The dimension of women, and women's
well-being, is central to this.
Q102 Chair:
We need to come to the end of this session. I suppose the summary
of all this is the extent to which DFID can interact with partners,
state or national Government partners, to accelerate these kinds
of processes. That, essentially, is where the value for money
would come in. It is not the money, but by applying in this way,
you accelerate what otherwise would have happened.
Professor Haddad:
Yes. Yes.
Q103 Chair:
That is something very helpful for us to explore a bit more.
Can I thank you both very much indeed for coming in, and for
your written evidence, which certainly has been very helpful both
in terms of the quality and the statistics, as Richard has pointed
out? If you can follow up with one or two of those points of
information, that would help us a lot. Thank you very much.
Professor Haddad:
Thank you for inviting us.
Professor Chambers:
Thank you for inviting us.
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