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CFR Symposium: Rethinking Maternal Health: New Agendas and Solutions (Session 2) [Rush Transcript; Federal News Service]

Speakers: Paul Fife, Director of the Global Health and AIDS Department, Norwegian Agency for Development Cooperation, Purnima Mane, Deputy Executive Director of the United Nations Population Fund, and Dr. Walter Gwenigale, Minister of Health and Social Welfare, Liberia
Presider: Ann Starrs, President of Family Care International and Co-Chair of the Board of the Partnership for Maternal, Neonatal and Child Health
June 17, 2008

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ANN STARRS:  I hope you all feel refreshed and energized and excited by the discussion that we've just had, which we are now going to continue with a slightly different cast of characters.

I'm going to start with a question here for Paul Fife since he was here for the morning discussion and had the opportunity to hear what some of the other panelists had been saying and also had the experience of speaking and semi being grilled in Washington yesterday.

Paul is the director of Global Health and AIDS Department at NORAD, the Norwegian Agency for Development Cooperation.  He has been working hard on this issue of maternal health and, in particular, working with the Prime Minister of Norway Jens Stoltenberg who has shown very strong commitment to the issue of maternal health in the context of what we call the continuum of care, maternal, newborn and child health.

So Paul, I'd like to start off the discussion.  Last September, Prime Minister Stoltenberg announced 1 billion (dollars) for maternal and newborn health from the Norwegian government over the next 10 years.  Is any of this additional 1 billion (dollars) that has been promised by the Norwegian government going to be earmarked specifically for maternal health?  And if so, why?  And if not, why not?

PAUL FIFE:  Thank you, Ann.  It's a pleasure being here and also it's terrifying.  (Laughter.)  But I think the terrifying aspect is actually quite important because we speak to a variety of communities, to women's health, to medical professionals, to rights activists.  And one of the challenges we see, I mean, and it's slightly reflected in your question in terms of, how much should we work on a broad basis, how much do we need to work on specific projects and earmarks?

And by earmarking, we immediately flag something as something extremely important to work on, yes.  But at the same time, we fear that we might lead some people away.  So how to get this balance?  And interestingly, in Norway, we did away with the earmarking for gender issues a few years ago, and it came back with the new government three years ago.  So we have additional funding earmarked for gender and women's rights issues and including sexual and reproductive health and rights.  And we have a debate, is it right to earmark?  Is it right not to earmark? 

And on your question of the $1 billion that my prime minister pledged last year for the next 10 years, which comes in addition of $1 billion to vaccine which is also -- have authority for child health and women's health, and regular contributions to the U.N., to multilaterals, to bilaterals.  The majority of this funding would go to women's health.  Exactly how much, I'm not able to say.  But about 10 (percent) to 15 percent is going to the World Bank-managed project on results-based financing.

And we have the first four countries coming up.  And it seems like all the countries have put maternal health, in particular institutional delivery, as the key indicator for their programs.  This is not going to solve the issues of human resources.  It's not going to provide the broad financing to the health sector.  But we hope, and there are indications in other programs -- it's somewhat not been useful -- that by earmarking -- on account of incentives, one can actually achieve a change in both the quality of service delivery on the surface and not least on the community aspect, on the demand side.

There is also, like Eritrea has put up funding for transport and food for pregnant women.  So half of this $1 billion is going to bilateral collaboration.  And one of the fascinating things with my prime minister is that he's very bold.  I mean, Norway's a tiny country.  And there was a question yesterday, what does it mean that the U.S. government comes in and really big time into maternal health?  My response was it's extremely important.  That's because of the volume of funding and because of the political leadership that is needed.  And I need to say, when I look around this room, the brain power in in the U.S. is needed globally.

In terms of the -- (inaudible) -- talking about in terms of goals of my prime minister, he's working with some of the countries which are on the map here, which account for the highest number of child and maternal deaths -- India, Pakistan, Nigeria and Tanzania.   The large countries, and shall we dare say, with all respect to these countries, difficult countries to work on because they are federated, and they are also the countries very often where we need the most poverty and governance issues at the local level.

So my -- it was a long answer.  My short answer -- the majority of the $1 billion is going, yes, to women's health and to maternal health.

STARRS:  Great.  Thank you very much.

Puriname and Dr. G., I should let you know something that was announced earlier, which is just for the record.  This symposium and this panel is being webcast and is being both recorded and will be transcribed.  So just so you know that that is --

WALTER GWENIGALE:  (Inaudible.)

(Laughter.)

STARRS:  Well, in all fairness, it was important to have you know that.

Puriname Mane is currently the deputy executive director at the U.N. Population Fund and has previously held positions in U.N. AIDS, in the Population Council and in the Global Fund to Fight AIDS, TB and Malaria.

Puriname, you missed a little bit of the discussion this morning, so I'm going to put you right straight into the hot seat, which is that we discussed this morning the issue of the perception that reproductive health and even in some cases maternal health is interpreted in this country, in particular and in particular by politicians in Washington, as equated to abortion.

And the question that I wanted to ask you is, from your perspective, working in an agency, a U.N. agency that has prioritized maternal health, has made enormous and significant contributions financially and otherwise and has recently established a specific thematic fund for maternal health, do you think that the issue of maternal health would generate more funds and more commitment globally and, in particular, in the U.S. if maternal health were de-linked from reproductive health?

PURINAME MANE:  Thanks a lot, Ann, for putting me in the hot seat as soon as I arrived.  (Laughter.)  I think -- first of all, let me just say what a pleasure it is to be here and apologies for not being able to be here earlier.  I know the discussion must have been fascinating. 

Let me just say that for us as UNFPA, we strongly believe that linking the two is integral.  We see maternal health as something that is a part of the broader framework of reproductive health.  Women need attention before, during and after birth and also various other needs.  So for us, the de-linking would not do what we as UNFPA are expected to do, which is to be technically sound, to do the right thing by the populations that we serve.  So we would stand very strongly in terms of keeping the linkage.

Yes, it might make some governments, more than the U.S., and I'm not just referring to the U.S., happy if we would perhaps de-link it.  But you have to remember the U.S. has also funded maternal health in a different context and in quite an extensive fashion.

Let me also turn to some other aspects.  I think if you look at it today, maternal health in the last two years -- and a lot of credit goes to FCI for the work that it has done with various other partners -- maternal health is getting attention.  And at the same time, we have a new target on universal access to reproductive health.  And this is exactly the time where we're seeing more funding, more commitment from donors such as Norway.  But more than Norway, you have many other donors coming in.  You have U.K., you have Canada, France, many other donors getting interested at the exact time when we're actually reaffirming reproductive health.  I think that's a great sign, and we need to remember that.

And I think UNFPA as, you know, the proponent of  reproductive health, as one of -- in the U.N. system is actually quite proud that the funding, for example, that we get has actually gone out.  We have 182 countries that are funding us.  So -- and we make a very strong link between the two.

So I think it's important to keep this linkage and to promote the linkage to the extent that we can.  I mean, there's a lot more I can say, but I know you have many more questions, so I'll keep to those two points.

STARRS:  And you should have seen the number of hands that were up earlier in this audience that I know people are eager to share their own opinions, comments and questions.

Dr. Gwenigale -- Dr. G. as I understand you are familiarly known, if we may be familiar with you -- is currently the minister of Health and Social Welfare in Liberia and has held that position since 2006.  I understand you were trained in Puerto Rico which is an interesting place for a Liberian to go for medical education.  And you are, obviously, dealing in your home country with some very challenging issues in terms of the deterioration of the health infrastructure, et cetera.

With so many needs and demands in developing countries, in general, and in Liberia, in particular, and with the challenges of trying to reconstruct the infrastructure of the country at large, what arguments have you found to be effective or ineffective in dealing with your fellow politicians and decision-makers in the Liberian government to try and prioritize the health sector generally and, to the extent that Liberia has been focusing on maternal health, the maternal health issues specifically?  So what arguments resonate with the decisionmakers in your country?

GWENIGALE:  Thank you.  And I'm sorry for coming late and not being here earlier.

For people who have not been following Liberia, we have come out of a long, brutal civil war that started Christmas Eve in 1989 and lasted for more than 14 years and destroyed the country.  And during the war, over 90 percent of our health workers left the country.  Many of them are in this country.  Some are in Europe.  Some are in other African countries, even like in Botswana.  (Laughter.)

And so, a little over two years ago, Ellen Johnson-Sirleaf was inaugurated as the first woman president in the African continent.  And she is now trying to rebuild the country.  And to her credit, she has chosen health and education as priorities to the point that in the first budget that she put out, health, although the money was small, health was number one in her budget.  In the following year, that we are now ending, education was first and health came second. 

Now, we are trying to rebuild the country, and we are trying to talk about poverty reduction.  And  it's easier to say to people health is wealth because you cannot create wealth with people who are sick. 

Coming to the topic that you are discussing today, we did a demographic health study and we found out, and it's not surprising, that our statistic has gotten worse from more than 500-and-some to 100,000 births.  It's gone up to almost 1,000 -- 994 to 100,000 births.  So this is a terrible statistic.

And so you can see, when I start talking to the other people, why they have to look at health and make it a priority.  So the argument is there, and we know the reasons why these statistics are so bad.  And we have been trying to tell them what needs to be done to make this statistic correct and so that that has to be funded.

So this is where I start from when I talk to the president and to the other Cabinet ministers.

STARRS:  Great.  Thank you very much.

Puriname, I'm going to come back in this direction.  You come from a background where you worked extensively in the area of HIV and AIDS.  Looking at the agenda that we have for maternal health and in fact for reproductive health writ large, are there lessons learned from the HIV and AIDS movement that we could draw on for advocacy around maternal health?  And what do you think those lessons are?

MANE:  Well, let me go back a little bit to the lessons we've learned from the maternal health movement itself.  I haven't been asked and I have to confess there are so many experienced advocates here on maternal health.  Compared to the work they've done on maternal health, I haven't done an iota of it.  So pardon me if I'm speaking as a little bit of a newcomer.  Though I have been an advocate, I have not worked in that field, and I need to say that upfront.

I think the important lesson that I drew from attending the Women Deliver Conference and reviewing is I think in the maternal health movement, the thing we did wrong, and I'm going to start with that, was we were never able to come together cohesively around a couple of things that we wanted to advocate around.

I think we all felt very strongly about the various things that needed to happen, the various elements of a strategy which we all feel passionately about, and everything is important, everything needs to happen.  And when you have a list of things that need to happen, without a few priorities, often you are unable to capture the attention of the audience.  You know this better than I do because you are such a strong and such an  effective advocate.

And I think in maternal health, the success that we've had in the last few years and why we're getting the attention is because now we're able to say these are the three things as part of the strategy that we want.  We want to see emergency obstetric care, skilled birth attendants and family-planning access.  There are obviously other elements of the strategy that we do think are important.  But we have some agreements in the maternal-health movement, as such, around it. 

I think in the case of -- if I turn to HIV, there's actually a similar problem there right now, which is that different constituencies within HIV often are now -- this is today as compared to earlier -- advocating for different aspects around prevention, care, treatment and the impact of the epidemic, in a sense.  In the earlier years, I think there were just a few asks, and they were very clear.  There was stigma and discrimination, there was more access to, first of all, availability of treatment, so more research and more funding for treatment, more access to treatment in the developing world, which was probably the biggest ask.  And it's an ask that's been fulfilled.

So I think the early lessons I would say -- I don't think that the lessons of today's HIV movement would be the same.  But I think the early successes that HIV had was to have few asks and to go at them strongly.

Also the involvement of communities who are affected made the biggest difference in HIV.  You had sex workers, you had men who have sex with men, you had injecting drug users, constituencies that were invisible, silent, were not heard by those who funded or those who made policy decisions, actually at the table or at least making enough noise to be finally invited to the table to put their ask forward.  And I think that made a huge difference, seeing people who are infected with HIV, seeing the courage they're showing, seeing their in fact incredible understanding of what their needs are makes a big difference. 

You saw that at the Women Deliver Conference where women who had obstetric fistula, where there talking about their own stories.  I think those stories make a big difference rather than many of us, for example, talking about them.  I think that's the thing that we could learn quite a bit from.

But I think the maternal health movement has matured enormously and come to a point where I think it's at a point where it could teach a few lessons to the HIV movement.

STARRS:  Great.

Paul, I'm going to ask a follow-up question to you.  Puriname has talked about some of these issues, some of the challenges in advocacy around health issues in general but in maternal health.  Specifically, I know that NORAD is particularly interested in an issue that also came up this morning, which is the role of civil society in generating pressure, in generating movement, in generating a sense of there being a constituency out there that expects and demands progress on these issues nationally and, ideally, globally.

What is your perspective or NORAD's perspective on this issue?  And I'm going to add a little tweak to this question, which is, do you think that we face a particular challenge with the maternal health issue because, again, as was discussed earlier, it is an issue that affects only women in comparison to the issue of HIV and AIDS? 

I know that within the maternal health advocacy community, that is an argument that we have used to  perhaps, in some cases, to excuse ourselves for the lack of progress or the lack of success.  And when we've compared our impact with that of the HIV and AIDS movement and the sense of there being greater support and greater demand for progress on HIV and AIDS. 

And one of the comments that many of us in the maternal health movement have said is, well, HIV and AIDS affects men and maternal mortality does not.  So I'd be interested to hear your thoughts on that.

FIFE:  Thanks.  I work for government so, I mean, I'm obviously disqualified about talking with greats.  That's an understanding about civil society, but I'll try.  (Laughter.)

I mean, first of all, it's beyond any doubt that non-state, to put it that way, service providers, be it in private sector for profit or not-for-profit play an extremely important role for maternal health.  And in many countries, they provide more than half, and much more than half, sometimes more, of the services.  So we need to be able to engage, work with them, pay them and resource them, and also, I would say be able to check for the quality.  So some kind of oversight function is needed very clearly.

And many countries have shunned away in moving in that direction, getting a good partnership between the public and the private sectors.  Extremely important also in the field of AIDS and the scaling up.  It wouldn't have happened if the global resources had not been linked in a quite effective way to civil society at local level.  And that's something we need to replicate.

The important part that we further need to work on -- and really, we are in a learning mode from the government side, I would say -- is how can we engage the part of society that really is key to demands, demand services, demand accountability?  And it's really about how to empower citizens in countries.

And in many countries, unfortunately, the AIDS business, to put it that way, has made ministries of health more accountable to the donors down to the people themselves or the Parliaments.  And this is something we need to address.  And we do think we can address it with the issue of maternal deaths, maternal survival, women's health and MDG5.  There is enough power behind this to try to overcome the obstacles.  So how do to do that? 

And what we see civil society in the south, in countries need to encompass, shall we say, the typical health communities.  It needs to go into the right communities.  We have some very effective communities working on sexual minorities, on all kind of discrimination, whether it's in the traditional sector. 

Women's associations in my country, maternal mortality came down when the women's association came on board.  They play -- of course, maternal mortality is not an issue for women only, but women  play a key role.  And how to unleash that, how to resource? 

And I think from our side, we are willing really to work in ways to find effective ways to build capacity and empower, communities to collect information.  It could be -- (inaudible) -- information.  We have all kind of, shall we say, good promises being made, but are they being delivered in terms of funding going to district health services of funding going to health centers?  And we know this is the life of the health system.  We have the health workers, but they need to be resourced.

And also being able to empower communities to organize themselves and talk in perhaps not in a common voice because the diversity is there, we need to live with diversity, but to talk some key messages and really affect governance.  And this is basically the life of political processes in all countries.  And I think there are lots of lessons to learn from each of our own countries, from my country and from the U.S., for example.

Something you said Puriname, it's very important for us here to say, Norway's doing its fair bit of work.  But it's not going to succeed if only a few actors step up.  So a key message today is really we need to work on this collectively.  And like you said, there are many countries, the U.K., France, and your president is really making huge statements.  And we have President Kikwete, Gebuza.  We have been able -- you have been able to put on the agenda regional meetings.  The African Union, the Organization of Latin Conference (ph), MDG4 and 5 for the first time.  It's quite a feat looking back at maternal and newborn and child health not being on the radar screen.  So things are moving.

STARRS:  Yes.

FIFE:  The second part of your question is a difficult one, and I'll come back to that a bit later as part of another answer, I hope.

STARRS:  Okay. 

Dr. G., can I turn this question to you, looking at it specifically in the context of Liberia.  Is the issue of maternal health, reproductive health a priority for women, for women's groups, for civil society in Liberia given, as I said, the context that is happening in the country?  If not, do you think are there things that the government or donors could do to try and support that?

GWENIGALE:  It is a priority, not only for the government but for the women themselves and for the women groups.  And it's a big priority for faith-based organizations themselves because they -- before the government started really training people to take care of women issues, and especially pregnancy-related issues where the churches that had the midwifery schools that were missionaries that went in there and were looking at what was happening to women. 

And right now, the women lawyers and the -- (inaudible) -- there are -- other issues arise, especially with women issues.  But yes, civil society, the women themselves and the government, the problems are huge.  But to answer the question, yes, there are other people, but the resources for them to do the work is lacking.  That's why I was listening carefully. 

And we have been helped in many ways by UNFPA.  One of the problems associated with this huge and bad statistic I was quoting is that those who do not die are left with terrible problems like vesicovaginal fistula.  The women that come up with this are thrown out.  The husbands leave them and run away from them.  The women themselves are ostracized.  And to deal with that issue, we have now support from UNFPA to help not only the government but other groups that are interested to try to first teach the women who are pregnant what to do, where to be when they are ready to deliver so that they do not stay far away from hospitals and get this damage done.

And those who are already with this type of problem, we have now assistants to try to do surgeries to correct them.  Myself, as a surgeon, I have been involved in repairing them, and it's not easy.  It's not an easy operation.  Sometimes you have to do it two or three times before you can get it right.  And so yes, other people other than the government are interested, but they lack the resources, they lack the equipment, they lack the training to be able to do this.

STARRS:  Yeah, it is a challenge.  One of the -- this is a question for the two men on the panel.  We have a situation globally where there is, I think, a significant increase and promises of additional increases in funding for maternal, newborn and child health writ large, including specific maternal health interventions.

There are, from a number of donors, a pressure or a desire to focus on what are sometimes called quick wins or the low-cost, high-impact interventions.  Do you feel that, Dr. G., in the Liberian context, in terms of the donor aid that comes in for health and for maternal health, in particular, is there a pressure?

You have talked in other contexts about the importance of investing in health infrastructure in the training of healthcare providers in improving the kind of infrastructure and investments that take longer that take in the cases of training healthcare workers that can take a number of years.  Do you feel pressure from the donor side to invest instead in what are sometimes called the quick wins rather than the longer-term infrastructure improvements?

GWENIGALE:  Well, you have to invest in interventions that will last because in the end, for me to improve the bad statistics I was talking about, it is necessary for all pregnant women to be attended to by trained people.  And they have to be able to deliver in a safe place.

Now, there are other things.  Even though you may have the trained people, the people may not have access to them, so not be able to have the roads to come from their village or having the money for their husband to make it possible for them to come there are huge issues. 

But whatever you do must be lasting.  When I say lasting, I may not have -- it takes two years to train a midwife. And for me to get midwives to all the villages would be a difficult time, I mean, two years after high school.  But we know that if they are -- if you take a village lady, old lady who is already doing the delivery in the village, if you train her and supervise her and show her how to make the referrals properly, they can function and they can help us.

So I don't know why they were called quick fix.  If the quick fix is to teach that old lady how to do delivery properly in a clean manner and supervise her and make it possible for her to transfer her patients, that would be acceptable.  But it has to be something that you can build on and that can last.

STARRS:  Right.  Because the place that she transfers to has to have --

GWENIGALE:  It has to have --

STARRS:  -- they have to have the midwife and the qualified providers.

GWENIGALE:  You have to be able to take care of those people.  And to take care of the obstetrical emergencies because if a woman comes bleeding, you must be able to give transfusions.  And with these days of HIV and AIDS, you must have the test kits to be able to make sure that you are giving safe blood.  So there are a lot of things that need to be done and be done properly.

STARRS:  Okay.  I'm keeping an eye on the clock.  We have a little more time.

But Paul, before we open it up to the audience, I wanted to ask you this question.  From the donor perspective, as the Norwegian government is, of course, accountable to its people for the progress that is made in terms of the effectiveness and the impact of donor aid, do you feel a pressure within the context that you work to highlight what are sometimes termed these quick wins or the high-impact or measurable-impact interventions?

FIFE:  I think it's a critical question because, again, we are -- define the movement by talking against cost-effective, high-impact interventions.  The question is how to deliver them in a way that builds institutions and exactly promotes stability.

If we look at countries, several countries have been able to reduce by half maternal mortality in less than 10 years.  So -- and that's the positive message I think we need to get out.  It is possible.

From a -- I think two messages.  First of all, each country has its own specific context.  Ownership needs to be at country level, solutions at country level.  I mean, the large countries that is also at some national level.  So as an external partner and supporter, what I do know is that, both in terms of our people, the patients and also what we personally feel engaged in achieving, we have results.  So the focus on results has never been that high in developing -- (inaudible) -- I mean, AIDS as it is now.  And that's good.  It's very challenging, but it's good.  It really forces everyone in the system to focus on results.

And that's why also maternal survival is so powerful because it is THE basically indicator for functioning health systems and also for delivering on gender equality and on women's rights.  So we just need to be very critical in our communication.  And at country level, we really need to empower governments and civil society to be able to deliver.

STARRS:  Great.

All right, Puriname, last question from me to you.  We have, of course, a Millennium Development Goal, MDG5, which is improve maternal health, and it has a specific target, now two targets, both to reduce maternal mortality and to ensure access to reproductive health for all by the year 2015. 

There is a call that has recently been issued by the Partnership for Maternal, Newborn and Child Health, which I am the co-chair of the board just to be transparent there, for an additional $10 billion to be invested in maternal, newborn and child health by the year 2010.  And that if we can achieve that, that we can achieve MDG4 and 5.

From your perspective, is MDG5 achievable?  And at what price?

MANE:  I can't -- (audio break) -- the price since we were part of agreeing to of agreeing to, you know, the figure that we came up with jointly, which includes, by the way, and I hope I'm right -- Hedya (ph) can correct me -- 1 billion (dollars) to meet -- of the unmet need for family planning which was very critical to be a part of that.

You know, when we have the goals -- MDG goals, I think what they are are -- (inaudible) -- for countries, the motivation, the commitment that they make in front of, as partners, in a sense, peers, other governments to put in place systems that will make the achievement of those goals feasible.  It also adds the burden, in a sense, on the whole development assistance framework to make sure that that kind of funding is available.

But I don't think funds alone can ever achieve any of the goals.  We know that very well. Sometimes we've seen that, you know, in the case of the Global Fund as well, just the money hasn't always led to success.  There are many other elements that, again, I don't need to tell this group what those elements are, the involvement of critical partners, political will, sustainability, making sure that these funds are -- you know, that this is for a longer period of time, that domestic funding has also been coming in along with international funding which at some point will dry up.  And there are many elements of how you can achieve success.

I think in certain countries where we have a good chance of achieving the goals, but in others we are going to really face problems.  And that's why we are trying to put in place all of us working on special funding for maternal health -- like as in the case of Norway, UNFPA has put together a thematic trust fund, and there are many other mechanisms that we're trying.  Focusing on the particular -- particularly, say, we have chosen 25 priority countries, looking at the, you know, indicators and where things are.

If we really choose and make strategic decisions to focus on countries which are going to need the most help, what happens, of course, as you rightly said a little while ago, that donor attention is often on the quick wins.  But I think that climate is also changing, as Paul has indicated.  I think there is a recognition you need to be in it for the long haul.  You need to build systems, health systems in particular if you are going to make a difference and not just, you know, quick fixes.  That recognition is coming.

But if we focus on the countries that are right now doing the worst, that are often left out because nobody wants to deal with them, there's no governance issues, there are all kinds of issues, if we do that like UNFPA has decided to start off with, and other donors are coming in as well, I think we will be close to it.

I'm hopeful.  I'm a, you know, optimist at heart.  I think everybody here is, otherwise we wouldn't be working in this field.  (Laughs.)  We need to be optimistic, at the same time recognizing where we are going to have to focus, where we're probably going to miss the boat and what more needs to happen.

You know, 2015 is not that far away.  And that's not the end of the world.  There's a lot more beyond that that needs to happen.  And we need to already start thinking about what's beyond 2015.  I don't think that thinking is starting yet.  If we can start that thinking now, what about those countries who are not going to -- are they going to be dropped?  Are we never going to think about this?  Are we going to move on to the next issue which often, you know, could be climate change, could be anything because there are so many issues that we have to deal with?

That's, I think, the critical thing for the maternal-health movement and all of us to start thinking about.  What do we do beyond 2015?  Yes, let's put all our efforts together. 

STARRS:  I think the entire development community in the year 2015 is just going to go to bed for a couple of years.  (Laughter.)

MANE:  Oh, no, please don't say that.

STARRS:  Okay, I'm going to open it up to questions.  Before I actually take any questions, I wanted to give an opportunity to Mary Ellen Stanton who is here from USAID.  We had a little bit of a U.S. bashing session this morning.  And I think it's important to recognize that while there are, of course, political constraints and other constraints, that the U.S. government has been investing a significant amount in maternal health, obviously with some constraints.

But I wondered, Mary Ellen, if you'd like to have an opportunity to just talk a little bit about what USAID has been doing and is committed to doing in this particular field.

MARY ELLEN STANTON (USAID):  Thanks very much, Ann. 

I'm delighted to have a minute to talk.  We've got a lot of challenges with our political process and so forth.  But have a, I think, growing maternal, child health program.  And I liked what Paul said when asked which portion is maternal. And he said, well, the countries are really asking for this.  And this is what we're finding.

We have a little bit more money in this fiscal year.  And thanks to good work by Global Health Council and others, close to another 100 million (dollars) in maternal and child health.  A lot of that is going to maternal.  We've chosen 30 priority countries, which means that much money doesn't go that far but a good bump-up in a number of countries in Sub-Saharan Africa, enough that they're very excited about doing some more strategic things to really move forward.

I would say just one other thing on programming choices.  Our program does put a lot of value on both promotion of high-impact interventions and improving health systems so that we haven't taken an either/or approach.  We're very strong on reducing financial barriers for women and human resources.

At the same time, I think, going into any country, while we want long-term, sustainable results, we want to save lives this year, which I know everybody else does.  So we're trying to go after it both ways.

STARRS:  Thank you.

Okay.  We have some --

QUESTIONER:  Thank you to all the panelists.  My name is Susie Pew (sp), and I work on speaking books.

And I'd like to pick up on a theme that was raised several times, how to help women mobilize, demand services, empower citizens, become those to whom all of us are accountable.  I haven't heard the theme of literacy raised at all, and that is a huge obstacle worldwide and notably is stronger among women. 

It raises, of course, what we discussed in the earlier panel, the question of complexity.  But we've done some pretty complex things as countries and all of us together.  So I'm thinking maybe we can comment on where literacy would come in.  Thank you.

STARRS:  Dr. G., would you like to take a stab at that?

GWENIGALE:  Well, you know, if those of us who live in the third world, if you compare the health conditions of the educated women as opposed to women who do not know how to read and write, you will see a vast difference.  The educated women take care of not only their own health but the health of their children.  They know the importance of that.  So clearly, it is important to have, as part of the health system, helping people to be literate.

Now, our president right now has a big program that is called the Liberia Education Trust Fund.  And she's looking for money for that.  She was here last week trying to raise funds for education, not only for the young girls that she wants to have more of them go to school but even for adult literacy for market women and for other women.

So yes, education is very important.  It's very important for us to be able to help people understand the issues related to their health and to help them improve their health.  Education is a part of this.

Now, even if the people do not know how to read and write, some of them can understand the issues if you piece it to them, if you explain it to them. But those that can read and write are better off.

STARRS:  Yeah.

Okay, I'm going to go to some inside folks here because we tend to prioritize those on the outside. So yes, go ahead.

QUESTIONER:  (Off mike.)  Thank you.  I'm Vandana Tripathi with Doctors of the World which was founded by Dr. Mane. So I was really taking what you said earlier to heart. 

I want to follow up on Ann's question.  At the Global Health Council in D.C. a couple of weeks ago, a meta analysis of maternal and child-health programs was presented using the Bellagio "lives-saved" calculator.  And what was seen, what was shown was that those interventions in community that are closer to the households -- pneumonia case management, a lot of actually newborn life-saving interventions cost a lot less per lives saved.  And when benchmarks were set, unfortunately, it's those maternal health programs at the facility that ended up having a lot higher costs per lives saved. 

I believe in this already.  But what is a concrete argument that you would use to convince a donor or an MOH person with scarce resources that it's important to think past those costs, that the numbers can be interpreted differently or that despite that higher cost the money should also be invested in those more expensive facility interventions that may save fewer lives?

STARRS:  Puriname, do you want to take that one on?

(Cross talk.)  (Laughter.)

GWENIGALE:  Let me say, I had to learn.  My background is -- my training is that of a surgeon.  So technically, I'm supposed to be in the hospital and operating.  But I have also supervised community health work.  I was in al-Mahattah in 1978.  So I know the arguments.

There are some things that it saves money to do things at the community level, and I believe in it and am pushing it.  But there are some things that just cannot be taken care of at that level. What happens if you have a young girl who is pregnant and her pelvis is not yet developed and she cannot have this baby in the village?  She has to pass even the clinic and go to the hospital. You have to be able, if you want to save her life and save that baby, to take her from the community past this small clinic to the hospital for the c-section.  What happens if, even for the woman who may be able to deliver in the village in the hands of a village midwife that has been trained to do it safely?  What happens if she starts bleeding and she has a ruptured placenta and you have to take her to a place where she will have to have not only make that delivery possible, whether it is through a c-section or whatever means, but you also have to do a transfusion.

So when we talk about primary health care, we are talking about a full range of things from the community by referrals to the highest possible place where you can get the care that you need.  So we have to tell people who are trying to fund us that these are the issues.  They must understand what it means to make delivery safe for the woman. It's not really at the village level, but it's all the way by referral to the highest place. 

What happens if for those people who are not able to get there and they wind up with a vesicovaginal fistula?  How do you prevent them from being thrown out of the community because of this bad smell of urine leaking on them continuously?  You cannot do that operation at the village level.  You have to bring them up to a hospital to be able to do it.

So anyone who wants to fund these have to be educated to the fact that you need the funding not only for the village level where it is cheaper but for the few people who have the complication you also have to save them.  I say the same thing not only of the women but even of the men.  If you are doing your farm work and you come up with an incarcerated hernia and you know that if you don't do the operation, the bowel will get rotten in there and the person will die, you have to move them to a place where an operation can be done.

So as much as we want to work at the village level, at the community level, we have to be able to look at the referral system that is inherent in that care so that actually where the small cases can be taken care of, even though they are expensive, they need to be funded also.

STARRS:  Thank you.  We have both Paul and Puriname eager to jump in on this one as well. 

Paul.

MS. NAME:  Paul, you go ahead.  I don't -- he said it all. (Laughs.)

FIFE:  No, I think Dr. G. said it all.  I mean, the only thing -- I really like the question, and that's the type of question that needs to be asked and discussed at country level.  And what you raise is it needs to be based on evidence, the best possible, contextual factors and then the most difficult thing, priority setting in resource-constrained environments.

So from a donor side, we see there needs to have -- to provide predictable, long-term, flexible funding that basically can encourage this kind of discussion at country level and international level and earmark as little as possible.

STARRS:  And I think, just to chip in if I may, that I think the challenge here is that there is a tendency to pick what is sometimes called the low-hanging fruit.

MANE:  Yes.

STARRS:  And the challenge is that if you only pick the low-hanging fruit, who's planting the trees?  Who's taking care of -- you know, you can pick those low-hanging fruit, but then it means that there's no investment in the infrastructure and in the longer term services and capacity that needs to be built to deal with the high-hanging fruit.

So -- all right, other questions.  Yes.  Wait for the mike -- sorry.

QUESTIONER:  Hi.  My name is Connie Williams.

Given the prevalence of perinatal and postnatal depression, should this be an area of concern, or can it be an area of concern for women's maternal health?

STARRS:  Puriname, yeah.

MANE:  I think the way health is accepted, the definition of health, by the -- (inaudible) -- which we all adopt does include mental health as well.  And I think it is critical.  And adequate attention is never paid to mental health, in general, whether it's men or women.  And of course, women get neglected even more.

In the developing world, I think, very often this is not a phenomenon that is recognized.  It's not a phenomenon that there's much sympathy for, in general.  And I think part of the reason is because of cultural norms around motherhood which is supposed to be the best thing that can happen to women.  It's supposed to be a time of happiness.  It's supposed to be something that makes a woman complete, in a sense; every time she becomes a mother, more complete.

And I think the idea that there would be any emotional problems around it is just often incomprehensible.  The understanding is growing, however, and I think we need to build on it.  In view of the absence of just sheer medical-health facilities which are lacking, attention to maternal health has tended to focus on those areas. 

So I would agree with you that much more attention needs to be paid around this area.  We don't even have data from the developing world, very strong data, from any countries around the phenomenon.  And if you don't have the evidence, it's kind of difficult sometimes to convince people that the phenomenon even exists. 

So I would say yes, it is important.  But with the range of issues we're dealing with, I would admit that it does tend to get neglected.

STARRS:  Adrian.

QUESTIONER:  Adrian Germain, International Women's Health Coalition.

Next year, as we mentioned this morning, we'll have a new president and a new Congress in this country.  And I wonder if each of you would care to name at least one aspect of foreign assistance that you hope might be changed that would help move us forward on this agenda.  Because there's a lot of talk in Washington these days that whoever comes into the White House and however the Congress is configured, taking a good, hard look at the U.S. foreign-assistance policies and budgets will be on the agenda.

STARRS:  Paul, do you want to start?

FIFE:  I think some comments were made on the first panel, which are very good in terms of basically opening up.  And if I would look at one investment which is totally feasible to do and where the U.S. already shows a lot of leadership is family planning. 

STARRS:  Puriname.

MANE:  Again, there's a lot in the broader reproductive health area that the U.S. has funded in a variety of ways over the years.  I think there needs to be coming back to some of those areas that have, for various reasons, been neglected along the pathway because the U.S. has the best history in fact of having taken a very comprehensive look in terms of foreign assistance and being able to address the needs of specific countries the way their needs are.  And I think that's where one would like to see foreign assistance going. 

So broader attention, obviously, from our perspective -- and I can only speak from our perspective; there are many other areas of obviously need for foreign assistance -- but from our perspective, broader attention to reproductive health and definitely to come back to being in the lead on family planning, which the U.S. has always been actually.

STARRS:  Dr. G., any thoughts on that?

GWENIGALE:  Well, right now, you know, if you are in the village and you are in the village clinic by yourself, if you get support from four or five different people and you have to write a report for each of those people, it takes all your time. You will not be able to do anything. 

And what I would like to see is right now we are trying to fund all our programs or many of our programs from what we called the basket funding or from the pool fund.  Many countries are willing to put their money in there.  If it is well taken care of, then you write one report for all the donors.  The U.S. right now, as I see it when we talk about pool funding, don't want to put their money in there.  They want to give it to us by themselves directly. 

If someone was to say, okay, we can work with the World Bank, we can work with the European Union, we can work with the other people and put our money together in the pool fund so that it will be used by the country for the program they have listed.  We brought here some copies of our health plan and our health policy document.  We have put as the centerpiece of that what we'll call the basic programs that we want to do, the basic package for health services.  These are the things we want to do at the community level, at the clinic level, at the hospital level.

If people look at that and want to fund it, then they put their money in the pool fund, and then we can use it.  But if you come and say, I have my money, but I'm going to use it only for this, and we have to go through you to get it only for that, it is good for us because we need the money, but it complicates the way we have to do our work.

So if -- whoever is president, if they can say, okay, we will participate, we'll work with other countries, and we'll put our money in the pool fund.  That would make my life easier.  (Laughter.)

STARRS:  Let me ask you a follow-up question, however.  If the donor money were put into a pool fund, how much of that would then go for the training of midwives and for the costs and equipment that are specifically for maternal health?

GWENIGALE:  Okay.  That is in the health plan

STARRS:  Okay.

GWENIGALE:  Because we have put there that the centerpiece is our basic package for health services, we have said that we'll use about, like, 52 percent of our money in the pool fund for the basic package of health services.  We'll have reproductive health.  We'll have immunization. Then we'll say maybe we have 10 (percent), 15 percent for infrastructure.  We will have this much for health services strengthening.  It's there, but you will have to look at what we want to do before you can put your money in the package that we want to put in.

STARRS:  Dr. Tlou, are you -- do you have a perspective on this from your -- ?

MS. TLOU:  Yeah, it's --

STARRS:  Let's wait for the mike -- sorry.

MS. TLOU:  Yeah, thank you very much.  It's slightly different.  I mean, yesterday, I did mention -- I mean, really categorically state that when you look at developing countries, we need to look at them as countries that have unique -- each of them has unique needs and unique priorities and concerns.  So, you know, money in the basket is great.

But then, from our experience in Botswana, we've dealt better with PEPFAR than we have with the Global Fund because PEPFAR came in and it's like, okay, we are going to deal this way with you now. And we simply said we also have -- (inaudible) -- principle, and we've worked quite well with that. Rather than with funding, for example, such as the Global Fund, which nearly kicked us off.  Why? Because they're supposedly middle income.

And, you know, that's where -- you have a basket funding.  But then once it's in that basket, sometimes people come in with strange criteria that leave out some countries.  You know, it's always great when I hear the word "target countries." It's great.  But, you know, what about countries that are doing well for themselves but also struggling? Should they be left so that they go down the drain and then you get them out the drain again?  No.

So you need to be able to look at funding and help each individual country in a way they can be helped rather than seem to punish those that seem to be doing well, you know.

STARRS:  Paul, do you want to comment on this pooled-funding issue?

FIFE:  Yes.  I had the time to think through Adrian's question and just would like to emphasize that PEPFAR, I mean, there are even bigger opportunities to build on the PEPFAR successes at a country level, which is significant in terms of resources.  I mean, PEPFAR represents a big proportion of health funds going to many countries. 

So to think even more what is started now in terms of look at the issue of healthcare workers, human resources, the link between HIV prevention and reproductive health is something that can be done within the existing resources.

In terms of the pooled funding, we have a policy of as much as possible really going for pooled funding with the United Nations institutions, with countries.  And we think it is very important to do that.  It lowers transaction costs enormously.  On the other hand, we do know that in all countries, at local and national level, what needs special focus on issues that are of specific priority.  And as I said earlier, we do think that women's health is one such priority.  And we have examples that budget support, with all the good things -- I mean, one can address the issue of human resources far more powerfully through general budget support and dialogue than working at program level.

At the same time, we do know that we need to work at all levels here.  So that's one of the challenges, I think, that with countries and bilaterals, NGOs and U.N. agencies, we need to perform better to be able to work with countries at different levels of the policy and budget cycles and provide advice and make sure that funding arrives to the right people at the right time.  And it's not happening today, and that's a big, big problem.

GWENIGALE:  Well, actually, I prefer for the help to be given to the country so that the country where their budget support will give me the money I need to do my work.  Because if I get the money from a donor and the government doesn't know about that money or is not yet able to give me that money at that level, when the donor's money is finished, I will still be down there with the services that I need to deliver.

So yes, I prefer it direct.  But give support to the government and let the government give me the money I need to do my work because then I can say this is what you need to give me to do the work.  Where the government gets it from, that's a different issue, but actually, not going to look for the money without the government knowing about it or the government not being able to give it to me at the level that I'm receiving it from the donor.

So if it is possible, give the government the money in budget support.  Let the government give me what I need to do my work.

STARRS:  Anika.

QUESTIONER:  Hi.  Anika Rahman, president of Americans for UNFPA.

I would be doing a disservice to my mission if I didn't comment on Adrian's question and say I hope that the new president will re-fund UNFPA to make this government part of the international community.  I cannot let that go.  But I'd like to also add a question to that, both to Paul and Dr. G. is that, obviously, we want the U.S. government to fund UNFPA.  And I'd like you both to make the argument for why a government should participate in multilateral commitments also.

So to Paul, obviously your government participates bilaterally in providing assistance to governments and obviously funds UNFPA.  So I'd like to hear from you why you also do that in addition to bilateral funding.

Similarly, Dr. G., at your country level, you obviously get both multilateral assistance from agencies like UNFPA and bilateral assistance.  What would you say were the advantages for funding from UNFPA and the work that UNFPA does so that we can make an argument to our government for the importance of funding UNFPA? 

Thank you.

STARRS:  Paul.

FIFE:  I mean, around half of Norwegian aid goes through multilateral institutions.  In health and AIDS, it's 60 (percent), 65 percent.  So the multilateral channels, be they U.N. institutions or the Global Fund, is actually important.  This year, we'll provide, I believe, around $65 million to UNFPA.  And we look to UNFPA for leadership, I mean, both in terms of women's health, maternal health but also the issues that are so interlinked, gender violence, in particular.  And I mean, we do think that UNFPA does a tremendous job.

And -- but your question also raises issues of the changing, shall we say, architecture in the world.  And again, there are huge changes and we can see, I mean, new bilaterals coming up.  We see the global south coming up as a very strong partner to -- (inaudible) -- both in the commercial and in the government sector.  I mean, what China does in Africa is extremely important for development. 

So we observe with great interest the changing, basically, architecture.  But maybe I should point to one trend we see is that the bilateral footprint, meaning the presence of bilaterals such as Norway and Sweden and even the U.K. which is larger, is actually decreasing in countries.  There are fewer countries and also less technical capacity in our embassies to deal with the issues that need to be dealt with, for example, when it comes to the technicalities of having a health system deliver maternal health of good quality.

And then we move back to the multilaterals as key partners at country level to accompany governments, to work with governments and to provide good policy advice.

STARRS:  Dr. G.

GWENIGALE:  Well, in Africa, in Abuja, the countries said, we will give 15 percent of our budget to health.  Now, if you look at what I have is less than 10 percent of the government budget.  So for me to do my work, whether it comes from multilateral or bilateral, all I'm trying to look for is the money to be able to do the work that I have to do.

So it is -- where the money comes from is really immaterial as long as I'm getting the money to do the things that -- the tasks that need to be performed.  So if it all came from one place because -- to fill my needs I will go for it because it doesn't come from -- UNFPA is doing a tremendous job for me.  They have a program to help me deal with the issue I was discussing just now about not only taking care of the disease of fistulas but also preventing them because they are helping with the education part, helping with the training part.  So that is good.

But that by itself, that money from them is not enough to do all the work that I need to.  So if I have an opportunity to do a bilateral with a different donor, I will do it because I need to fill my needs to be able to do the work that I have to do.

MANE:  And can I just comment, one --

(Cross talk.)

MANE:  Just that most multilateral organizations, like UNFPA for example, we're not really donors, and that needs to be emphasized.  Our role really is to assist with technical areas, you know, to assist with policy dialogue around critical issues, provide the best practical information that we have to network for technical assistance within the region.  That's the function, I think.  That's the value added that many of us, like UNFPA, bring to countries.

We certainly aren't donors, so I just wanted to clarify that.  We're often , you know, seen as donors, but that's not really our role.

STARRS:  Okay.  I'm sorry, everybody, but we are at our time limit for this particular session. Thank you very much.  Those of you who have had your hands up, I apologize for not having been able to call on you but remind you that we will be able to have an ongoing dialogue over lunch for everybody who can stay.

Thank you very much, and thank you to our panelists.  (Applause.)

MS.     :  Just quick shopkeeping here.  First of all, for those of you who weren't here for my earlier announcement, Representative Betty McCollum is unable to join us, but it's for very good reason.  She has to vote today on the Iraq emergency supplemental appropriation and on unemployment insurance, both rather vitally important issues with close votes. 

What we're going to do right now -- and I want to very much thank this last panel.  Weren't they fantastic?  (Applause.)

What we need to do right now is take a 10-minute break.  And I'm rigid about this.  We really are going to be back in the room here at 12:25 precisely.  During that break, all these places are going to be cleared, so please take your things with you.  And you are going to be served a meal, so you're going to want to come back.  And we're going to need to fill every single seat in the room because there are so many of you which we're delighted to see.

And when we come back, we're going to have a very exciting discussion that's going to engage all of you.  And Isobel Coleman will be presiding.

I also want to make a big point right now in case any of you are going to be leaving us of thanking Judith Helzner and the MacArthur Foundation for providing the support for both yesterday's gathering and today's.  Thank you, Judith.  (Applause.)

So 12:25 back in the room.

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