Examination of Witnesses (Questions 104-131)
Q104 Chair:
Thank you very much for coming in and helping us with this Inquiry
into DFID's relationship within India. I wonder, for the record,
if you could introduce yourselves very briefly, so that we have
it on the record.
Dr Osrin: Good
morning. Thank you very much indeed for inviting me to this meeting.
My name is David Osrin. I am a reader at UCL in Global Health,
and also a Wellcome Trust senior research fellow, but I am wearing
many hats this morning. My job is that I am based in India, where
I live in Mumbai, and I am today representing two civil society
organisations, three nongovernment organisations. One is
an urban women's and children's health organisation called SNEHA,
and another, a purely rural women and children's health organisation
called Ekjut, which is based in the states of Jharkhand and Orissa,
and the third one is Woman and Children First (UK), a UK based
international development agency
Q105 Chair:
Okay. Thank you.
Toby Porter: Good
morning. My name is Toby Porter. I am director of government
partnerships with Save the Children UK, but on 31 December I finished
three years as director of programmes with Save the Children India,
based in New Delhi.
Q106 Chair:
Thank you both very much. In fact, if I can pick up on what
you said to us—that is, Save the Children—you said
that there is a strong case for the UK to continue an aid programme,
at least in the medium term, that supports the development of
the MDGs, although that does not stand alone, as part of the overall
relationship. As you know, we have closed to richer countries
than India—we are in the process of closing our programme
in China on the grounds that effectively it has graduated and
does not require our assistance. Indeed there are very few bilateral
donors operating in India, and the UK is clearly the biggest one.
Indeed aid is a very small proportion of India's GDP, and an
even smaller proportion of its national and state budgets. Why
do we need to be there? How long should we be there? Given that
it is, in financial terms, almost infinitesimal, how can it make
a difference?
Toby Porter: Very
simple questions to start with, then. The main reason for DFID
to remain in India is because you are having an impact there.
We are at a period of time with the Millennium Development Goals
where there is a degree of consensus in the global community about
what we are all working towards. That is completely unprecedented.
There is in many countries, of which the UK is an example, a
high degree of public support for international development and
relief, which obviously we all have a common interest in maintaining.
However, the focus is moving very much to results.
Let us, for example, take our field of interest, MDGs 4 and 5,
for today's discussion, the global fight for reductions in child
mortality, reductions in maternal mortality. The global targets
will not be met, if they are not met in India. That is absolutely
clear. The Indian targets will not be met if they are not met
in a handful of states in northern India. If we take three of
those northern states—Madhya Pradesh, Orissa and Bihar—Bihar
of those three is probably the frontline state of all. It is
not just the UK that thinks so. You are probably aware that the
Gates Foundation is also focussing a very large investment at
the moment, again based around that principle.
In those states, you are not only the largest bilateral
donor by financial volume. Far more important than that is the
influence you have because of the degree to which DFID's staff
and technical approaches have a tremendous influence. I fully
understand why you raise the issue about the relatively small
significance of the financial investment, but we would see that
weakness as an incredible opportunity. You, or DFID rather, is
better placed than anyone else to have concrete influence on how
the state governments in Orissa and Madhya Pradesh and Bihar use
the tremendous financial resources at their disposal in a strategic
way that has impact. I would say that over the next three, four
or five years, you will see even greater acceleration towards
meeting MDGs 4 and 5. It is a fantastic testament to the historical
investment in the aid programme in India, to the quality of the
relationships of the technical staff. I understand that there
have been written letters by the Chief Ministers of each of those
three states in support of the UK aid programme in their states,
ahead of the Prime Minister's visit to India. DFID has an opportunity
that other bilateral donors would dream to have in terms of that
position of leverage and influence in the absolute frontline battle,
if you like, where MDG 4 and 5, which are really key Millennium
Development Goals, will be won or lost.
Q107 Hugh Bayley:
You talk about other donors dreaming of having the same leverage
as DFID. Just give me a couple of examples of policy that has
changed for the better as a result of DFID's leverage.
Toby Porter: One
of the big problems in India is getting the services out to the
people that need them. As you know, India is not a place where
you have to look hard for good policies on paper, or for well
resourced schemes in Exchequer terms. Often, however, the key
issue is the question of implementation, the policies of implementation,
rather than the macro policy per se. One of the key issues is
recruitment of doctors, teachers, etc, to work in the outlying
states, where you have the highest rates of child mortality, the
lowest rates of school enrolment, etc. Take the concrete work
that I believe that DFID's programme did —I think it is
in their submission—in Madhya Pradesh and Orissa that has
brought down that vacancy rate as regards rural doctors. That
is the sort of area. Think about how many resources that state
government is managing. DFID's technical programme allows them
to use software and management tools and strategic approaches
that allow doctor vacancy rates to come down from 43%, I think
it was, to 20%. If you think about what I was saying before,
that you have the chance to amplify that through the resources
that the Government of India has in those states, I would say
that is a terrific example.
Q108 Hugh Bayley:
For me this is the critical question. If we spend £500
million in India, inevitably you will see some benefit to some
people. The development challenge in India, it seems to me, is
that there is intractable inequality. Despite strong growth you
have very little growth lifting poor people out of poverty. Although
there is huge need in India, the question I have is, does DFID
make a significant strategic difference beyond what it is able
to buy with a purse of hundreds of millions of pounds?
Chair: I wonder whether
we could bring Dr Osrin in.
Dr Osrin: Yes.
I will try to respond to that a little bit. I am a pessimist
who builds on a foundation of unyielding despair, but nowadays
I do not take your view, because I think that things change everywhere.
We do not necessarily notice them changing fast, but I think
some changes are happening in India. To a large degree, changes
happen on the basis of the activities of charismatic individuals
having creative ideas. However, I think that over recent history,
not only in India but also regionally—I did a lot of my
earlier work in Nepal, where DFID has a strong presence—there
is a situation in which DFID's presence is catalytic. It is a
conduit for international opinion and it is a backstop and support
for the sort of change that is going on.
I was very happy that Professor Haddad mentioned
the Lancet series. It turns out that I am one of the merry
band of people that authored this. There is something going on.
It seems to me that there are some tides of change. One of them
is that there seems to be some disillusion with status quo politics
and corruption among the electorate, and we are seeing that in
the media all the time at the moment. There seems to be a disenchantment
with inequity, the kind of inequality that you are talking about.
I think that India is connected very intimately to the wider
world, and this disenchantment with inequality and inequity is
a quasiglobal phenomenon. DFID is one of the players that
acts as a conduit and a backstop to support activity and thought
in that direction.
There is something happening—there may be something
happening—with a kind of return to a universal healthcare
agenda. We are talking about people like Srinath Reddy, who is
on the National Planning Commission, and other authors, including
I'm proud to say, myself, calling for some kind of integrated
national Indian health service. This kind of tide, or feeling,
has not been felt since postindependence with the publication
of the Bhore report. As a sceptic, I can agree with you and say
that we do not know what will actually manifest in terms of political
realities, but I think now is not the time to withdraw from our
commitment and the good work that has been done in this area.
We now have a new National Health Bill in India, which was drafted
in 2009. If you will permit me to just read a little bit from
it: "The Bill will provide protection and fulfilment of rights
in relation to health and wellbeing, health equity and justice,
including those related to all the underlying determinants of
health, as well as healthcare, and for achieving the goal of health
for all, and with matters connected therewith, or incidental thereto."
My feeling is that this is essentially something of a return
to the rightsbased approach. The last 10 years have been
dominated by a fairly economically pragmatic approach, and we
may be seeing some upswell of public opinion here.
The extraordinary opportunity—I agree with
Toby that it is an opportunity—is for us to contribute to
something that the views of our electorate in this country are
entirely consonant with, in the sense of the social determinants
of health agenda, the Marmot report, etc. This is something that
has featured very heavily in Britain, in the media, and in your
own circles, I am sure—I am talking about things like Professor
Wilkinson's book, "The Spirit Level". This is an international
agenda on which we can all agree. DFID's historical role has
been in modelling beacon projects, and taking the work of beacon
projects that can then be tested in terms of their effectiveness,
or primarily their efficacy; however, I think that DFID's input
should primarily be in effectiveness, the evaluation of effectiveness,
rollout, scaleup, and effects on general population indicators
such as women and children's health, mortality, etc. DFID enjoys
good will that I would say is disproportionate to the amount of
ODA that we are currently giving, which has been recurrently mentioned
by this Committee. Now is the time to continue to provide that
extra value for money with the older relationships and the support
for these issues of the democratic rollout of integrated health
systems.
Q109 Hugh Bayley:
A cynic's question: if you mix with people who are the recipients
of your money, if they are your professional partners, they are
bound to speak highly of it. However, we had a group of Indian
politicians over here at our Parliament recently, accompanying
the Speaker. I asked them what they knew about DFID's development
programmes in India, including an MP from Bihar, as it happened,
and whether it was helpful, and whether they wanted us to continue
it. They had no knowledge of it at all. They said, "If
you want to do it, that's fine by us." There was no sense
that we had any kind of profile or traction amongst India as a
whole. Of course, with our partners you would expect support.
You go to Tanzania, and everybody knows of DFID, and what it
is doing, and probably in Nepal, too, which is a country you know
to a greater extent. One understands why, in terms of proportionality
of the scale of the problem and the scale of the DFID input.
So the question is the opportunity cost. I am sure £500
million will make £500 million of difference, but maybe it
could make £1 billion worth of difference in Tanzania or
Nepal.
Dr Osrin: Suppose
I agree with you. If you canvass my colleagues, who are not primarily
working in DFID's four priority states, which makes a big difference,
they are largely unaware of the work of DFID. I, in my daytoday
work, am largely unaware of the work of DFID. My colleague Prasanta
Tripathy, who works in Orissa, is highly aware of the work of
DFID in that area.
Let me give you an example of where DFID has been
enormously helpful. The definitive paper was published last year
in The Lancet: Prasanta Tripathy and his group, Ekjut,
tested the effects of a community mobilisation intervention, a
demand-side intervention. They were working with women's groups
in rural Jharkhand and Orissa, on newborn survival and also on
mental health in women with maternal depression. They found substantial
reductions. The programme worked. DFID right now, through its
connections with the programme, has brought that team down to
Madhya Pradesh, where they are working with DFID people and the
state government to try to synthesise some kind of pragmatic way
of rolling that out at state level. That is exactly the sort
of thing that has huge added value. However, in another context
people might not have heard about it, and you might perceive that
we were not getting massive bang for our buck. What is actually
happening is that novel and extraordinary interventions are being
subtly rolled out across the country. I could give some other
examples, if you like, but maybe I will let Toby say something.
Q110 Hugh Bayley:
Could I put one final question? The conclusion that I think
I am drawing from what you are saying is that aid at the Federal
level has virtually no leverage at all, but if you are putting
a large amount of aid into a poor state, like Bihar, you might
have as much impact as putting a lot of aid into a poor state
in Nigeria, shall we say. It is worth concentrating your effort
in particular places, with local policymakers.
Dr Osrin: With
respect, I probably was not that clear but I do not think that
is what I was driving at.
Q111 Hugh Bayley:
Okay.
Dr Osrin: I was
driving at this added value, beyond the ODA, that comes with championing
and acting as a conduit for new ideas, and helping them spread
through the system.
Q112 Hugh Bayley:
I understand that point, but I cannot see that happening at all
at federal level. You are convincing me that it may happen at
state level, however.
Chair: Is it not the
case, in any case, that this programme in the states is as agreed
with the national Government?
Dr Osrin: Exactly.
Q113 Chair:
So it is not a question that we just pick a state. It is where
they have mutually agreed with us.
Dr Osrin: Exactly.
I read the transcript of the previous meeting, and I think there
is an issue about the balance between the central and state funding.
That is something that you need to think hard about, but there
does need to be central funding. As Toby said, there is a lot
of paper policy, but it is Delhi where the policies are made.
If the issue is implementation and rollout of the policy at state
level—its manifestation through streetlevel bureaucracy—the
issue is also, to some extent, the development and the political
will for that policy at the centre. That needs to be there.
Toby Porter: I
would add, in terms of your first question, that we all know the
politics surrounding this question of whether India should continue
to receive bilateral assistance. We know that the Government
at a central level take a rather dismissive view at times of the
fiscal importance of bilateral assistance vis-à-vis the
domestic investment in social programmes, etc. I suppose one
of the questions is that it is absolutely obvious that you will
not see the same levels of central invitation and welcome and
gratitude for UK investment that you would find in Dar es Salaam
or Freetown or Kigali, or whatever. In India, for the next four
or five years, you have to say, "How can we remodel the traditional
donorrecipient relationship?" Or rather, "Is
there a way that we can remodel the traditional donorrecipient
relationship, to find a partnership that fits the contemporary
relationship between the UK and India, and also allows for the
tremendous opportunity?" Here, probably more than anywhere
in the world, you really can make accelerated progress towards
the Millennium Development Goals, precisely because of the wealth
and the HR capacity and so on that you find inside the country.
Are we in the UK prepared to accept, in exchange for that greater
opportunity for greater impact, a role where we not only do not
really get thanked for our aid programme, but in a way we almost
have to sneak it through under the covers? I would hope that
you would answer "Yes" to that question, because the
opportunity is so good.
Chair: Wait until you
see our report.
Q114 Alison McGovern:
Very briefly, just to say, insofar as we believe in social justice
rather than charity, I don't think there should be any thanking,
actually. That is an important perspective. I just want to go
back to what you said, Dr Osrin, about leadership and the global
movement towards public health systems, especially building on
the excellent work and understanding we have heard about, and
the research that has been there. How important do you think
Government Ministers, even perhaps the Prime Minister, ought to
show global leadership about health systems? Insofar as relationships
are had between country leaders at that level, how important is
it to the development of health in India that leadership comes
right from the top.
Dr Osrin: Absolutely
crucial. Our Prime Minister is busy.
Q115 Alison McGovern:
Yes, he is.
Dr Osrin: I think
that this is an issue where there would be substantial secondary
gain from taking a position on this. It has to come from the
top. Indeed, that is the rock on which this contemporary feeling
will founder. People are already saying that the people who were
the authors of this report are basically technocrats. I am one
of them. I am not one of the senior clinicians, but they are
all very powerful senior clinicians with experience in advising
Government. However, they are not actually political actors in
themselves.
There is also a countervailing, or a simultaneous
force, which is coming from people's health movements. People's
health movements have been active in India for a long time, particularly
movements such as the Jan Swasthya Abhiyan. What we are seeing
now is, in a sense, them being taken more seriously. That may
be because of other prevailing political realities, which I would
rather not go into here. The point is that leadership for any
change in the health system has to come explicitly from the highest
level, because we are in a situation where it is a largely unfettered
and unplanned combination of private and public sectors. Part
of the calls that are going on at the moment are for, number one,
some kind of dialogue with the private sector, and number two,
for some kind of ratification and registration of the private
sector. That is not going to happen unless we get the highest
level of political commitment.
Q116 Pauline Latham:
How far do you think the UK Government have focused more on the
symptoms of poverty, rather than on the causes of poverty? I
do not mind who answers it.
Toby Porter: That
is a very good question. It has already been touched on this
morning in some of your earlier answers. The key cause beyond
and inside the historical poverty in India is the social exclusion
factor. One of DFID's civil society programmes in India, which
is the International Partnership Agreement, focuses specifically
on the area of social exclusion. The idea is that NGOs such as
Save the Children would work at community level to make sure that
excluded families were aware of and did access social programmes,
and were assisted in organising themselves to be able to claim
their rights in a more structured and organised way. Obviously
I work for a civil society organisation, but I do not believe
I am saying this because of the interest organisationally for
us to say this. Look at India at the moment: at the resources
available to the state, and at other inherent and wonderful characteristics
of India; a free press, an absolutely vibrant civil society movement,
people of absolute brilliance, whether it is on the health or
technical side—we work with Abhay Bang, whose work is also
featured in the Lancet series there—or the brilliance
of social activists. I would say that if you looked at those
characteristics of India, and then you looked at the fact that
DFID's current spending in India is allocating about 1% of their
annual investment to India, to my mind you have a fairly obvious
misalignment there.
Please do not take this as a selfinterested
proposition, but I would hope that over the next few years you
would see DFID investing more in civil society, because the game
is changing now. It is about not just strengthening the supply
side of programmes, which you do primarily through the state coffers
and through UNICEF and World Bank investments and technical assistance.
It is also meeting that with strengthening the demand side for
social projects. The gentleman before, who was talking about
the sanitation work, gave a very articulate and true illustration
of why a lot of these deeprunning problems, like sanitation,
school absenteeism and inappropriate care vis-à-vis newborns,
which not only do not help but actively increase the risk of children
dying, and so on, are actually much better dealt with at the community
level and therefore through civil society organisations. Obviously
civil society organisations have a very good role to play in holding
Governments to account, which they can do in India, because it
is a democracy, and it is a democracy with a vibrant and free
press. Although I am very supportive of DFID's India programme,
I do believe that there is a degree of realignment that could
take place, to better adapt to current realities and particularly
future looking.
Q117 Pauline Latham:
How open do you think the Government would be to donors criticising,
or pointing out, the gender inequality, and that the caste system
is not helping problems to be overcome? Do you think they would
welcome that, or do you think that they would just say: "It's
none of your business, get out, you have nothing to do with it"?
Dr Osrin: This
is the finesse. There are plenty enough people pointing out the
parlous state of gender inequality in India. There are plenty
of people talking about the need to focus on girls and women,
and we would support that. The issue is that a context should
probably not arise in which a Government representative tells
someone off. The person they would be talking to is fully aware
of the issues, and is indeed beset by hyperarticulate members
of their own community who are making those criticisms. I think
the finesse is to bring some of DFID's expertise to bear in brokering
relationships to take these arguments forward, so that they do
not become conflictual, they become catalytic. That is a bit
of a vague final sentence. I apologise for that.
Q118 Pauline Latham:
That is all right. But can you see that it could move the discussion
forward, if DFID took that role?
Dr Osrin: Yes,
I think it could. I have three issues written down here. One
of them is equity, which is a global issue, but the equity agenda
is something that DFID can embrace. The second one is effectiveness,
and DFID is good at that. It is good at evaluating the effect
of interventions. It does not have a 100% track record, but it
at least has an organisational mindset that favours good evaluation.
I think of inputs in terms of evaluating the effectiveness of
these changes that are going to be coming about, we hope, and
then accountability. This is something, again, where we could
see quite a lot of SouthNorth dialogue on issues of improving
accountability. Professor Haddad was talking about the ICDS.
Information disappears upward in the ICDS. It has been a "one
size fits all" programme that has been almost universally
criticised. DFID is playing a small but appropriate part in trying
to work out new ways to revitalise it.
Toby Porter: Can
I just add to that? I think that one of the changes that I hope
one will see within India is a sort of greater appreciation on
the Government side that funding civil society groups to work
on issues of social justice is not a subversive activity. It
is not like funding the political opposition; it is funding civil
society, which is a different thing. As you know, for example,
all of the large civil society groups in the UK have their programmes,
and they also have their advocacy agendas and everything else.
Sometimes we interact with DFID with a funding relationship,
talking about our programmes, and sometimes we will talk to them
about their programmes and policies. There are times when that
dialogue is easier, and there are times when that dialogue is
less easy. It is quite restrictive at the moment with the civil
society programmes that DFID has in India. We all have to submit
a staggering amount of paperwork, not just on ourselves but on
the local organisations that we were due to have. It is a matter
of regret that an aid programme in a free country like India is
currently subject to that degree of supervision by the Government,
when it is about a civil society programme.
Q119 Chair:
We started a bit late, and that is our fault, but we still have
quite a few questions, and, as you can see, some pressure. If
we can try to be crisper, we can get them all in. I am actually
having to pick one up. In the context of maternal health, we
have discussed nutrition and sanitation, but this is another area
where India is performing badly. What is the reason for that,
and what could be done to turn it around? One has to be delicate
about what one says, but there is an element one gets when one
engages that there are sections of society that are almost shut
out of sight and out of mind, whether for tribal or caste reasons.
Is that a significant part of it, or is it more to do with organisation,
poor administration, lack of advice, support, or whatever? What
are the factors that are making it a problem, and what can be
done to turn it around?
Dr Osrin: I think
there are three reasons. The first is the position of women,
with a large agenda beneath that expression: so, the historical
realities. The second is a lack of usage of public sector health
services—if we are talking about maternal mortality—primarily
for pregnancy care, delivery, and postnatal care. The third is
the quality of services that are provided. There are two parallel
approaches to dealing with it that need to be brought together.
One of them is the general international safer motherhood agenda,
which is to increase the number of women that give birth to their
baby in the hospital or at least with a skilled birth attendant.
That skilled birth attendant could be somebody that comes to
your home, or it could be you going to a hospital that provides
quality care. That has been, and remains, the primary international
guidance around that.
Something extraordinary has happened in India, the
Janani Suraksha Yojana, which is the incentive for giving birth
in an institution. The recent public health history of that is
quite interesting. Before you introduce something it is easy
to explain all the ways in which it will not work, but something
odd happened, which is that last year they had 10 million beneficiaries.
There are an estimated 26 million deliveries per year, so that
is more than a third of all the people who had a baby, with low
rates of skilled birth attendance, who have now been bootstrapped
up to another level. That then begs the secondary question, which
is: if you increase demand so rapidly in services with equivocal
quality, are you going to be able to meet that demand with quality
care? That question remains open. There is some early evidence
from recent assessment, also published in The Lancet, that
at best it can be said that it does not seem to be doing any harm,
and there may be some indication that neonatal mortality rates
had fallen. That is equivocal evidence, however. It does not
at this stage appear to be a negative thing. That is one side:
increased skilled birth attendance, which again has implications
for human resources. That is another issue. There is the supply
side, human resources, birth attendants, quality of care, and
then there is the community input agenda.
We have seen, again, coming from South Asia, a burgeoning
in civil society initiatives. The classic one is that of Abhay
Bang, from Maharashtra, from the 1990s and published in 1999.
Substantial improvements in the maternal and newborn care and
outcomes happened just through community action—just through
the kind of things that Professor Robert Chambers was talking
about. This meant communities identifying a problem where no
problem had had the light of day cast upon it, and then doing
something about it themselves. These things have largely developed
in parallel. The other thing is the whole Chambersian—if
I may use that word—paradigm of communities developing their
own system, taking their own action to deal with the problem.
We have also seen this in India through the work of Abhay Bang,
which is now being rolled out and has gone to UNICEF and WHO guidelines.
I think those are the twin axes.
Q120 Richard Harrington:
We have covered it, but specifically on maternal and child health,
how aware do you think the Indian Government are of the inadequacies?
We talk about it very much in terms of our values—for example,
before, we compared services in the list of 130 or whatever.
How aware are the Government of India about this, and is it a
priority for them? Obviously to bring about any form of improvement,
apart from just piecemeal things, is going to involve a huge infrastructure
and everything. It is not just paying for a few hospitals and
things. Do you feel optimistic that, if this was done, it would
lead to a reduction in maternal and child deaths? Is there any
possibility in the short term, or do you think that this is all
a project for the long term?
Toby Porter: Those
reductions are already happening.
Richard Harrington: Slowly.
Toby Porter: It
is a question of whether one can accelerate them further.
I think it is high on the agenda. There are at the moment not
just technical programmes, but a lot of media coverage and social
mobilisation on this area. At the moment obviously India is very
mindful of her place in the world and her emergence as a global
superpower. Therefore it is very important as well as very effective
for civil society organisations, the media, opposition figures,
etc to hold a mirror in front of contemporary India and say, "How
much is the existing high rate of child mortality and the existing
high prevalence of child labour consistent with being a great
power?" if you like. They can force a much greater political
engagement in addressing some of these things.
You see this even at the level of the UN, for example,
where at the moment India's attention is very firmly focused on
the opportunity of a permanent seat at the Security Council, but
is also currently, in a way, the laggard with MDGs, if you like.
You can see the embarrassment and the complexity of these two
processes and these two realities coexisting. People talk of
two Indias—India shining, India sinking, if you like. That
is there in all of our work.
I will give you one very nice example of something
that Save the Children has done recently. We held a public inquiry
where we brought inhabitants from some of Delhi's most marginalised
slum areas, where there is no free Government health provision
at all, and where Save the Children runs a basic mobile clinic
service. This is the same community that the Secretary of State
visited when he made his visit to New Delhi at the end of last
year, and he very kindly visited our project. We took inhabitants
in January from that community to meet with Dr Syeda Hameed, who
is a very distinguished civil society representative on the Planning
Commission. There was that direct interface between the Government
of India, at a senior level, and her most excluded population.
As a result of that, Save the Children and other partners working
in the health and nutrition field have been invited to give a
presentation and a body of recommendations to the full Planning
Commission. That will happen later this month. It is the Planning
Commission, as I am sure you know, that decides the fiveyear
plans, which are still the major vehicles for changes in policy
as well as changes in investment level.
There are many different changes that need to take
place: GDP expenditure is still a derisory 1%, which is just not
acceptable for the country with the highest number of children
dying every year. There are also other policies that we think
need to be turned to. You may have a view. One of the reasons
why Abhay Bang's model was so successful in bringing down child
mortality, for example, was that his community health workers
were able to prescribe injectable antibiotics to treat primarily
sepsis and pneumonia, which untreated kill kids in a day or less.
Those are the sorts of areas where we think the policy still
needs to change. Here the only thing that will save a child's
life is an injectable antibiotic, and yet the policies say that
the only people who can give an injectable antibiotic is the referral
centre, which the child or the mother may have no ability to access
whatsoever. How could there be a more fundamental breach of a
human right than the limitations in these policies?
Chair: We are going to
have a problem holding a quorum for the next few minutes, so if
you don't mind I am going to bring in Richard Burden.
Q121 Richard Burden:
Okay, thank you. Just going back to the issue of maternal health,
you talked about the two prongs: initiatives coming up from the
bottom, and also topdown initiatives, increasing the number
of skilled birth attendants, and so on. On DFID's support for
maternal health—very specifically our interventions—what
do you think we are best doing? Where can our intervention best
add value in those and perhaps other things, like transport schemes
for getting expectant mothers to hospital?
Dr Osrin: I think
that we are best placed, as the UK electorate, to answer some
questions. What is so exciting about the opportunity now is that
we are able to not necessarily provide transport schemes, but
answer some questions. In the current prevailing climate, where
we have a pluralistic system of health provision, unregulated
private provision, 80% out of pocket expenditure, etc, with calls
for some kind of integrated care free at the point of delivery,
how do we do that?
These are the questions, and I can itemise some of
them. For the maternal care, how do we deal with the human resources
issues of improving provision of good quality maternity care for
women? How do we train people? How do we do task shifting?
How do we take people, say nurses or paramedical people, or people
trained in other disciplines of medicine, socalled AYUSH
practitioners, and allow them to task shift? How do we implement
that at scale? Can we develop models for practically doing that,
and evaluating whether it works or not? That is an example of
an area where DFID has strength—technical strength and North
and experience strength—in that dialogue.
These are questions for the whole world, and that
is why India is so exciting at the moment. One of the other questions
might be, how do we incentivise people? Another question might
be that planning has to come from strongly led central policy,
but there are a great number of calls now for decentralised planning
of healthcare delivery to the district and block. Remember, a
district in India is 2 million people. A block is about 200,000.
The question that DFID could input to is: how do you do that?
How do we create job roles, support and training in public health
of district level political cadres and administrators to physically
articulate this planning and delivery at district and block level?
That is a tremendous question and a global question.
Finally, how do you broker the civil society engagement?
We live in a big society, I believe. How do we do that? We
have a de facto neoliberal environment in India. We have an unfettered
private sector. How are we going to broker the relationship between
civil society, community mobilisation and participation, perhaps
through panchayati raj institutions, the private sector, third
sector actors like nongovernment organisations, such as
Save the Children and indigenous NGOs, and the public sector?
What does that physically look like in Bihar? These are questions
that DFID would greatly add value to answering, rather than modelling
small scale things, perhaps modelling that kind of integrative
approach. I think this is all fresh fields.
Q122 Richard Harrington:
About maternal and reproductive health, obviously I bow to your
expertise. What concerns me is to what extent are maternal health
programmes regarded as being completely separate from other programmes:
for example, programmes to do with AIDS, infectious diseases,
and things like that? To what extent are they integrated—or
should they be integrated—and where are DFID in this?
Dr Osrin: You
are looking at me, Mr Harrington. Shall I answer? I will just
follow on from the last thing I said. This is hard stuff, but
I think this is the stuff that we should be doing. They are largely
not integrated, and they should be. There are bigger questions
in the global area about the Global Fund, etc, but I think that
at India level, ICDS has been operating essentially in a very
large silo. We should also bring in water and sanitation—it
is lucky that it was discussed earlier—and nutrition. We
have traditionally had conflict between mother and child health
communities, which is really not constructive. This in some ways
mirrors the global situation. It has happened in most countries,
including this country, I think.
What the delivery of an integrative package of services—this
is supply side I'm talking about—would look like at block
level is a great question for contemporary global health. That
is a question that DFID could be trying to answer. The same holds
for the community and civil society thing. How do we integrate
community action and civil society components? Is it a sanitation
initiative? The team that I work with is working on urbanisation,
and we worked on newborn survival in the slums of Mumbai. It became
obvious to us after about five years: why were we doing newborn
survival and not violence against women, or mental health in urban
poor women, or sanitation? We have reconfigured our planning,
and that is hard to do, but I think that is what people ought
to look at.
Richard Harrington: Thank
you for that.
Q123 Hugh Bayley:
In West Bengal, for example, infant mortality levels have fallen,
which is good, but to what extent would donor input have contributed
to that? Is there evidence that DFID's work in West Bengal made
a difference?
Dr Osrin: In brief
I am not aware of that evidence, but I suspect that there might
be some, because quite a lot of DFID input went into the West
Bengal health policy realignment, didn't it? Do you know anything
about that, Toby?
Toby Porter: I
don't know the specifics of that.
Dr Osrin: I suspect
substantial, but I can't answer the question.
Q124 Hugh Bayley:
DFID in its evidence has asserted but not shown evidence that
this is the case. Where you have, at state level, a good development,
what evidence is there that DFID is able to persuade federal policy
to change as a result and, if you like, learn from the experience
and roll it out in other states?
Toby Porter: That
is a good question. I don't know how much DFID is directly inputting
into things like the fiveyear plans, the various policy
developments. There is just about to be the first child health
policy in India, which has been held up at the postdrafting
stage. I would be extremely surprised if DFID had not somehow
been inputting into that. As I am sure you know, DFID is working
more closely at the state level at this point in time, in terms
of direct relationships and people inside the Ministries. I don't
know of any direct input, do you?
Dr Osrin: That
is out of my sphere.
Q125 Hugh Bayley:
Okay. Coming back to your previous answer, Dr Osrin, about the
need to integrate services. If you could give advice to newborns
in the womb, you would say, in India, "Don't be born a girl,"
wouldn't you? What can be done to reduce gender inequality in
public policy? And once again, what can donors do to exercise
some leverage on state and national federal authorities?
Dr Osrin: The
main thing is to continually underline the importance of the issue,
and not to waver in our commitment to it. That is what I meant
when I said that DFID should be reliable. I think about the inequality
issue, the propoor issue, and the gender issue. We all
agree in this room that the likelihood of major influence on national
policy is limited, and so I think we have to be a safe pair of
hands, who will always go back to those fundamental, important
things. There are extensive calls for work on gender in India.
Probably the best thing to do, I suspect, at this stage is just
to keep foregrounding it. An example of what Toby was saying
is that a few years ago, living in Mumbai, we were talking about
Mumbai being Shanghai. We are not really talking about that so
much anymore, because just foregrounding the actual differences
between Mumbai and Shanghai did do quite a lot in terms of the
motivation of the municipal corporation to improve healthcare
for the urban poor.
We should continue to highlight the issues, all of
which have policies in place, so we are talking about the gap
between policy and its implementation on the ground here. These
issues include sexselective abortion, the need for school
enrolment in girls, the need to take a girl to the doctor when
she is ill, as much as you would take a son, the need for family
planning and safe abortion. There are specific technical areas
that we can put an emphasis on, such as family planning, safe
abortion, feeding girls, marriage age and age of first conception.
Again, it is law in India. You are not allowed to get married
until 18, if you are a girl. I think it best to continue foregrounding
those things, and to walk the talk on those issues.
Toby Porter: I
am sure you know this, Mr Bayley, but it is not just a poverty
issue. Obviously the most shocking crime of all, in a way, is
female infanticide—foeticide, rather. The states which
have the lowest numbers of female live births for male live births
are Haryana, Punjab, and not the poor parts but the wealthy parts
of Delhi.
Q126 Hugh Bayley:
These figures are staggeringly different. They are clearly not
biological.
Toby Porter: It
is about 830 to 850 live female births per 1,000 boys.
Q127 Hugh Bayley:
It is 15% to 20% less.
Toby Porter: But
it is not going on in rural Bihar and rural Uttar Pradesh.
Q128 Hugh Bayley:
You see, these things are so deeply culturally entrenched, it
seems to me that foreigners are never going to change it. Who
are the great Indian champions, and what can we do?
Toby Porter: There
is a big civil society organisation in the Punjab called Nanhi
Chhaan, which goes around planting trees, a tree representing
the girl child.
Q129 Hugh Bayley:
A dead woman.
Toby Porter: I
think it will change. It will be globalised social attitudes,
eventually, that will do it.
Q130 Hugh Bayley:
So work with civil society is one bit of advice. What about
champions? I remember when, in relation to the AIDS programme,
we went through a stage where we said: "Unless the President
of a country leads the Commission in Country X in Africa, nothing
will happen." That is a bit mechanical, but you understand
the policy driver. Unless a British Prime Minister says, "We
are going to do X," you do not get it. Where do you find
those national leaders?
Dr Osrin: I think
I have met someone who is more pessimistic than myself, Mr Bayley.
Chair: Or maybe just
a devil's advocate.
Dr Osrin: The
Prime Minister of India has spoken out on the sex selection issue.
The Prime Minister of India is a Sikh, and there has been action
at the highest level of Sikh Gurdwaras and advisory committees
of clerics about this specific issue, because it is largely cultural.
As Toby pointed out, it is largely a lower- and middlemiddleclass
phenomenon. It is very clearly demarcated in its distribution
around the subcontinent. There are southern states, Tamil Nadu
and Kerala, where sex ratios are appropriate, and other states,
such as Haryana, the seat of Government, where it is appalling.
Most people are aware of those things, and there are many activists.
I think it is going to get better. They have law: sexselective
abortion is illegal. There is public debate and discourse on
this, and we do have a fairly high level commitment to the issue
from policymakers and leaders, to just continue to make
sure that that is put. Perhaps I am optimistic about this.
Q131 Chair:
Thank you very much. We have just managed to hold our quorum
to the end. It is very important, because obviously getting your
evidence on the record is extremely helpful. Thank you, both
of you, for giving both your written submissions, as well as your
verbal ones. Clearly the Committee will learn a lot more on a
visit, but I think the information we have had from people who
are engaged on the ground and have a lot of experience is extremely
helpful. I don't think anybody has said to us yet that they think
that we should accelerate our disengagement, but we should perhaps
transform it. The Committee wants to be fairly rigorous, and
say, "What is it we can do?" rather than assuming that
it is bound to be a good thing. As Hugh Bayley has said, we really
do want to challenge the Department to think quite hard, and perhaps
challenge the Indian partners, as to what they really want from
us.
Toby Porter: Can
I just make one suggestion, which I did not make, for when you
go to India and when you speak to other people? There is one
other final point. Considering DFID's unquestioned global leadership
amongst donors on the humanitarian stage, both in financing but
also in policy and coordination and the support and strategic
coordination of others like the UN, the humanitarian programme
in India is a sort of timid, nonthing. For example, three
years ago in Bihar, an absolute key DFID state, half the state
was underwater for about two months, and DFID had no kind of intervention
at all. Again it was about permissions, and because the Government
at the central level, for her reasons, said "We don't need
international assistance, we can solve this ourselves."
I think there would be creative ways to help, and recurrent emergencies
are a permanent feature of being in India as a donor. I would
urge you, when you have more time, to have a little look at the
humanitarian side, specifically.
Chair: We will take a
note of that. Thank you very much indeed.
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