Rethinking Maternal Health

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This event was made possible by the generosity of the John D. and Catherine T. MacArthur Foundation.

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LAURIE GARRETT:  Good morning.  My name is Laurie Garrett, I'm the senior fellow here at the Council for Global Health.  We have a real treat for you today, and I'm delighted to see so many of you here.  I'm going to take you through a little bit of a lead up to how we come to this moment before turning to our incredible, spectacular panel here. 

And first the housekeeping rules:  I think most of you have been to the Council before but, first of all, turn off every single electronic device.  It's not just the ring, it's -- when it's silently ringing it interferes with our wireless microphones.  So, please turn your Blackberries off even if they're receiving just e-mail.  Yeah, just e-mail -- that doesn't occupy all our time. 

Also today -- a little unusual, we're entirely on the record.  As many of that are regular Council attendees know, we often have off-the-record or Chatham House rules, but that is not the case today.  So, have at it. 

This meeting follows a meeting we had yesterday in Washington on The Hill organized by the Council, together with the Global Health Council, and with spectacular help from a number of organizations including the International Women's Health Coalition, CARE, and the partnership, all coming together on The Hill to try and forward the issue of maternal survival as a piece of foreign policy in the minds of Congressional staffers, Senate staffers, and so on. 

I'm delighted to say that the turnout was so massive that we actually got complaints from House security -- Congressional security, that we had too many people in the hallways, too much overflowing, too much of a presence -- whoopee!  (Laughter.) And we -- some of you may know if you're ever on The Hill, that you're not allowed to have amplification in any of the meeting rooms, unlike what we have today.  So we also had complaints that there were so many people that they couldn't actually hear everything that was being said.  I consider that a victory.

And some of the speakers that are with us today were with us yesterday, and very forcefully made the case.  Today we're going to go further with that discussion, and we're going to leave a lot of time for your engagement in the discussion as we go forward today. 

One change in our program:  It's a little unfortunate, but we hope to make up for it with a very lively replacement conversation.  Because today on The Hill there are two critical votes that were not expected and were just moved onto the agenda -- the Iraq emergency supplemental appropriations bill, and the unemployment insurance bill, both issues I'm quite sure all of you want your representatives to vote on -- Betty McCollum will not be able to join us today.  She sends great apologies. 

She did, however, have a long meeting with us yesterday over lunch, and we will replace her presence as best we can.  She's somewhat irreplaceable, but we'll do our best by talking about what we had a conversation about over lunch yesterday.  Very, very, I think, important, critical strategic and tactical issues for any of you interested politically in seeing this question of maternal health move forward as a piece of U.S. foreign policy. 

And what we will try to do, Isabel Coleman and I, is bring that discussion forward and invite all of you to engage in it, in real strategic thinking, where are we going with this issue?  So while Betty will not be with us, I think it will move the ball forward. 

So today, as you all know, it is traditional at the Council that the biographies of the speakers are in your folders.  I need not spend a lot of time going through telling you who they are.  I hope you'll take a look because we have stellar individuals here.  What I want to do is just immediately jump right into our questioning for a period, and then we'll open it up for general discussion. 

I want to begin with Brian Brink, because Brian started out on -- being a visible feature on the stage of global health, when he was pioneering HIV/AIDS treatment programs for employees of AngloGold in South Africa.  At that time it was considered radical, wild.  There were lots of people in the business community that said it couldn't be done.  And today, if I'm right, AngloGold is one of the largest HIV ARV providers, and tuberculosis treatment providers, in the entire corporate world. 

From that, you end up being -- switching out of the HIV arena into an arena that says "women first," and, in particular, maternal survival, maternal health.  Why?  What takes you on that arc from corporate world -- HIV world, now women's health and maternal health world? 

BRIAN BRINK:  Thank you, Laurie, for the introduction, and it's a great pleasure to be here and share with you some experience from Sub-Saharan Africa where we have a devastating HIV epidemic.  And I've been involved with it for some 20 years, and most of that time has seen a failure of our response to contain the epidemic, and it's been a great frustration. 

But certainly, over time, and looking back, (ones ?) can see that the things that you got wrong in the years before.  And the most striking thing that I see today is the huge burden of HIV disease that is borne by young women and girls, and the extent to which we missed that when we had the opportunity, early on in the epidemic, to get it right, to protect young women and girls from HIV infection. 

And for us now, in Sub-Saharan Africa, I guess it's too late.  But it's not too late in countries like India, and in China, and in Latin America -- in fact, all over the world.  So, I hope that the world can actually learn from the mistakes that we made.  And so today, and fortunately, we have treatment for AIDS which is stunningly successful. 

It's amazing how you can save people from certain death and get them back to a normal life.  That's one of the most rewarding pieces of the work.  But the tragedy today is that for every two people that we've -- that we put on treatment, there are another five new infections.  And so that treatment just cannot be sustained unless we can stop the new infections. 

So always you have to do the prevention and the treatment together, but we've got to rethink the prevention and we've got to start getting it right.  My analysis of that is that the big deficiency has been not to adequately protect women and girls from HIV infection.   And the bottom line is it comes down to their sexual and reproductive rights -- I must say first, because that's what's just they're universally trampled on, ignored, denied -- and then their health services. 

And reproductive health services are fundamental to protecting women.   And it's one piece of the health system which is just totally inadequate, certainly in developing countries.  If we don't get those services right we're not going to beat the AIDS epidemic.  And the thing that really disturbs me, it seems that in this country when you say "reproductive health services," that's immediately translated to mean abortion and, therefore, we can't talk about it, and that's something that won't be done. 

Well, I think that's the most horrific discrimination against women if people take that attitude, because reproductive health services are a broad spectrum of care uniquely for women.  And it's just never been done properly.  And we can -- we can talk about the kinds of things that could be done to make those services better. 

But it certainly amounts to looking after women during their pregnancies, during childbirth, and after childbirth.  It certainly means making sure that women have access to contraceptives.  It certainly means -- and good family planning service -- it certainly means that women must have access to good services for the treatment of sexually transmitted infections.  And in that is included HIV infection.  And that's the spectrum of what we mean when we talk about reproductive health services, and we simply have to improve them. 

The outcome of all these shocking services is the maternal deaths that we see, which are over 500,000 a year, of which some 13 percent of those are due to unsafe abortions.  Because abortion services are not available, that doesn't stop the abortion happening.  It just means that it's done in an unsafe environment and that the usual outcome of that is death -- or is often death. 

In fact, what a lot of people ignore, if the outcome is not death, what it does end up is in grievous injury to women.  And so the number of injuries that results of the inadequate services -- I think, you'll be quite staggered.  The number is some 30 million women every year are grievously injured because of lack of access to maternal health services. 

So these numbers are staggering.  And the world has recognized this and put it in as one of the Millennium Development Goals, of which there are only eight.  This is one of the key goals.  The tragedy is that this 500,000 number stayed the same for the last 10 years.  There's no progress -- at all. 

And why is there no progress?  Because there's no investment.  There's no investment in trying to improve these services.  And actually the amounts of money that are acquired are not that much in relation to the lives that could be saved, in relation to the cost of providing AIDS treatment the money is really trivial. 

So, I can't understand why these investments haven't been made.  And maybe I should stop there and we can pick up some more later. 

GARRETT:  We love it when men become new converts to women's health.  (Laughter.)  And you've summarized the issue quite well. 

Sheila Tlou also comes through the prism of HIV/AIDS in Sub-Saharan Africa.  What is your -- Tlou means elephant -- what is it? 

SHELA TLOU:  The might of an elephant. 

GARRETT:  The might of an elephant.  That's what her name means. (Laughter.)  So watch out. 

TLOU:  That was my husband's name, Laurie. 

GARRETT:  Okay.  (Laughs, laughter.)

TLOU:  And he does look like an elephant.  (Laughter.)  And his children look like their mother.  I look okay.  (Laughter.)

GARRETT:  (Laughs.)  And what's interesting as -- first of all, I have to point out that some of your admirers from Merck are here.  Some of you may know that one of the first truly important and successful antiretroviral roll-out programs was in Botswana, and it was a collaboration between the government of Botswana -- when Sheila was the minister of Health, and the Merck Pharmaceutical Company, and the Bill and Melinda Gates Foundation.  And that was a -- has been a huge breakthrough. 

But yesterday we were talking about the political vulnerability of not only the antiretroviral movement in Botswana but, generally, of health and health programs, including the piece that would be maternal survival programs in Botswana, the fact that Festus Mogae, as president, had made it a central feature of the government, but that it's all about the leadership in your country. 

TLOU:  Yes, it's all about the leadership.  And, you know, people have often asked me, what do you think it takes for any one program on HIV/AIDS -- you know, prevention, treatment, care and support, to succeed the way ours has succeeded in Botswana?  And I usually say, to me, it's like about four ingredients.  The first, of course, is political will and commitment -- a government that says we're not going to just depend on donors, we'll be able to put our own money into, you know, HIV/AIDS programs. 

So our leaders in Africa pledged in 2001 that they should devote at least 15 percent of the budget to health and HIV/AIDS.  And Botswana has also put in 20 percent or more.  So that really helped us, so that when the donors came in, it really accounted for 10 percent of our program, but 90 percent has been taken care of by the government.  So that that's really the political will and commitment. 

But it also takes zero tolerance for corruption, because in a lot of countries the resources are there but that money does not get to where it's needed most.  It lines people's pockets -- it buys (Benzes ?); it makes (kaffir castles ?); it buys presidential jets.  So that it's really that zero tolerance for corruption. 

And good governance, that is important.  A good governance that says, we're a government, but we have partnerships, so that we have to work with civil society -- especially, you know, those community-based organizations, to really get to know, at grassroots level, what (they had ?) is like, and work with them to see how we reduce that. 

So, those are some of the, you know, the areas that I think are very important for, you know, a lot of the countries.  And, unfortunately, it is also lacking in a lot of the countries. 

GARRETT:  I should point out to everybody here that we are live on cfr.org.  The whole nation -- in fact, anybody with access to the internet, can be following our proceedings today. 

Nils, in 1987 we created the Safe Motherhood Initiative.  We haven't moved that ball forward in 11 years.  Same tactics, same medical policies, same policy decisions on a political level have gone forward year, after year, after year with no real net progress. 

How are we going to move this ball forward?  What can we learn both from the HIV/AIDS movement, and other initiatives in global health that can -- and what have we learned on the scientific front, in terms of priorities for maternal survival, that can take this to some new strategic step? 

NILS DAULAIRE:  What you need in order to really make change is to marry three different strands.  You need will, you need knowledge and you need capacity.  There has been certainly a dearth of will in many places in the world, and much of the advocacy that many of the people in this room have been involved with have been aimed at changing that fundamental dynamic -- but recognition, awareness, outrage is necessary but not sufficient. 

We've had, for too long, an internal debate in the scientific community, in terms of the knowledge of what it is that needs to be done to make a change.  And I think we've finally gotten to a point of reasonable resolution on that, in terms of knowledge.  The issues that have to be addressed if you're going to have an impact on maternal deaths is that all births need to be attended by a trained birth attendant; that emergency obstetrical care needs to be available to all women who develop complications, or who are high risk; and family planning needs to be universally accessible, available and useable by women who are either at high risk or who simply wish to limit, space their pregnancies. 

You put those three pieces together and there is strong evidence that this has terrific impact.  But then the third one is capacity.  And that has been an area that's been enormously underinvested in the parts of the world where maternal mortality is the greatest.  One of the challenges with, dealing with maternal deaths -- unlike things like polio eradication, where you go out once a year and you give somebody polio drops, it's simple, it's straightforward; or vitamin A supplementation twice a year; even immunization programs where you put -- you sweep through every three months or so and you immunize every child and every mother -- a maternal health service program has to be on every minute of every day, because women are very inconvenient, they deliver babies at all hours of the night -- and even occasionally day.  (Laughter.)

GARRETT:  Occasionally.  (Laughs.) 

DAULAIRE:  Yeah, and so it's really a fundamental test of an overall health system capacity.  If it can deal with safe motherhood, with providing those attended births and emergency care, it can deal with pretty much anything else.  And, at this point, we've had several decades of focused health care on specific problems which have not worked, really, in concert adequately to build the lasting health care systems. 

I think the renewed attention onto maternal health gives us the opportunity to refocus on those sustainable systems on the continuum of care from pre-pregnancy -- family planning through pregnancy, through early childhood, infancy care and child care, because that's all really a package that needs to be there all the time.  And to build the robust, sustainable low-cost health care systems that are needed.

GARRETT:  But let's be concrete about this.  To all three of you, if I'm a member of Congress or of the British Parliament or of the G-8 which is soon to have its summit in Japan, I may think that this whole question of women's survival, let's just focus on childbirth survival, is overly complicated -- that you're coming to me and saying you need roads so that the woman can get to emergency care.  You need 24/7 health service access.  You need immunization and you need HIV testing and you need family planning.  And my goodness, this sounds so big and so complicated.  How in the world can you ask the rich countries to fund this, and what exactly are you telling them to target?

Brian?

BRINK:  The first thing I would say is please stop obstructing access to reproductive health services.  That would a simple thing to do. 

GARRETT:  Yeah.

BRINK:  Just take the obstruction away so that actually the people who know what to do can get the funding that they need to go and do it.

GARRETT:  Is that a significant problem on behalf of any government other than the United States?

BRINK:  Well, the United States --

GARRETT:  And the Vatican.

BRINK:  The United States is a very big funder of programs in developing countries.  And you take a program like PETFAR, which I think is a magnificent donation from the American people to the developing world, and is fighting AIDS very effectively. 

Why you would want to weaken that program by denying access to elements of care which are essential in the fight against AIDS, most of us working in developing countries can't understand.  And so -- I'm just making a simple point.  Let's stop obstructing, but then let's move on to what -- where can specific investments be made. 

And looking simply at maternal health, one simple thing is proper antenatal care for mothers.  Because it's during that time before the delivery that you can diagnose whether this is going to be a difficult birth or not.  And in order to do that, we need stronger health systems at the community level.

We need to improve the capacity of clinics to perform and actually to develop diagnostic capacity.  That so often is missing at a clinic level because you have a nurse there who's trying to do her best.  She has no tools with which to do the job.

So if it's a question of diagnosing placenta previa, for example, or a potentially obstructed labor, the nurse just can't make that diagnosis at all.  So you wait until the labor starts and then you discover it's a disaster.  Well, the end result is death. 

If we could somehow improve the systems, and I think really what we need is something in between a clinic and a hospital.  That's the problem is when the clinic can't cope, everybody gets taken to hospital.  We need more community health centers that have diagnostic capacity.

And by that, the simple things that you need there are some doctors; you need laboratory services, x-ray services.  For maternal health you need ultrasound.  This is a new technology that has transformed obstetric care.  It's just somehow we say, well, that can't be available in the developing world.  I think that's nonsense. 

If we could start using these technologies effectively, it would make a huge difference.

GARRETT:  Whoa, whoa, whoa.  I'm sitting there in the G-8 summit and I'm the head of one of the rich states and you're telling me that my shopping list that I'm supposed to pay for is going to include antenatal care, strengthened health systems, diagnostic capacity, doctors, nurses, some entities between clinics and hospitals, laboratories, ultrasound and x-rays. 

Nils --

(Laughter.)

DAULAIRE:  Well -- you know, one of the challenges is talking to policymakers who have rarely, if ever, set foot outside of capital cities, or the high-tech hospitals in which they receive their own care, and who don't have a conceptual context of -- while we're talking about lots of things, they're actually low-cost things.  They're reasonable things to do.

We are actually a people who are capable of walking and chewing gum at the same time.  And this is about as complicated as the fact -- you could say it's not possible to drive a car because how can somebody do the steering wheel and the clutch and the brake pedal and the gearshift all at the same time?  Why don't you just give us a car with one of those?

And there's a limited number of pieces that have to be done.  The membership of the Global Health Council are implementers.  They do this on a daily basis.  Nurses, doctors, paraprofessionals, program managers working in the poorest corners of the Earth, they understand that these things aren't really hard.  They require a certain level of resources.

We've been resourcing global health at the level of -- well, right now the U.S., including PETFAR, puts about $6-1/2 billion a year into global health programs.  That's almost a tenfold increase from the late 1990s.  But when you think about the fact that there are 2-1/2 (billion) to 3 billion people in need, it's about $2 a person.

We spend about $5,000 a person here in the United States.  Two dollars to $5,000, big gap.  Maybe we could make it closer to $10 with contributions from host governments and from other donors; bring it up to 35 (dollars), $40, and you can actually have a working health system at 1 percent of the cost of what we pay as part of our routine here in the U.S.

GARRETT:  To play devil's advocate to you, Nils, one out of five women in the world today who die in childbirth are in India.  India's the second fastest-growing economy in the world, soon will overtake China in economic growth.

Everybody knows we're outsourcing all sorts of labor-intensive work and high-level professional work to India.  Why in the world should the rest of the world and the G-8 pay the price necessary to build the health infrastructure to save that one out of five women in the world that's dying in childbirth in India?

DAULAIRE:  Well, that's a terrific question, and it's one that we in the development community ask a lot. 

There are countries that do have the capacity, do have the manpower, do have the technology.  I was just in India a few months ago and saw a remarkable program run by the Aravind Eye Hospital where they have broadband, live-time access to eye examinations of people, paramedics, in their rural clinics with an ophthalmologist in their central hospital looking on-screen to see what those eyes look like and to make diagnostics.  This is very doable.

I said there were three elements.  Will was the first.  I think the -- in India and in parts of South Asia as well as other parts of the world, there is an issue of valuing women.  It's where I've spent most of my career working, and that's critical.

I think this is not a matter of us funding Indian maternal health services.  It's a matter of us helping to identify the key things that will work and that have been proven to work and to helping to shine a spotlight on some of the issues that are keeping their own government and services from working.

GARRETT:  I love this.  At Harvard University they have a program called "World Mapper."  I urge people to check it out.  For almost any issue you could think of, it will exaggerate the planet based on the prevalence of a given problem.

So for women dying in childbirth or childbirth-related issues, well, yes, you could see North America and South America just about disappear.  Australia doesn't even exist.  Look at where the child deaths -- I mean, the women's deaths are:  India, the Indian subcontinent, and sub-Saharan Africa.

And when you look at this and think about the lesson in this, the real question that I'd like to ask Sheila, since you come from one of the best-governed countries on the African continent.  But you look at the case I was just discussing of India where last year, 0.9 percent of India's GDP went to health, all health.  Not just the little itty-bitty piece that was maternal survival.

What is the obligation of the rich world to save the lives of women in pregnancy in countries where the governments of those countries devalue women overall, and place very low priority on women's survival?

TLOU:  You know, I'm going to answer that by simplifying that complex shopping list that we had before.

In there, the two gentlemen mentioned human resources -- doctors, nurses -- and see if they are there.  But I must say that right now they are not there.  You know why?  Because they have been siphoned by the G-8 countries so that even when we send a shopping list -- you know, that scan, examination, whatever -- sometimes in a lot of countries those people are not even there.

So I think one of the things that we need to do, at least in the West, is to ensure that we work with those countries, developing countries, to ensure that we can develop in some collaborative effort enough human resources to go around.

The West stopped at one point to produce the human resources -- I guess it was too expensive -- and simply decided that we are going to get them all from Africa, India, the Philippines, wherever.

So we are talking right now of issues where we're saying in any health facility the nurse should be able to do that.  In a lot of countries, those nurses are not there.  Those doctors are not there. 

So we can help India, for one thing, by simply saying, look, you have the facilities.  How can we help you to produce enough nurses, doctors, and other health human resources to ensure that enough goes around and your women don't suffer as a result of that?  That's one thing that a lot of people are not aware of, that the West has continued and continues to denude human resources.  Granted, people are free to move.  But countries also have the right to expect (pay ?) from the very people that they have put so much money in training. 

So I think we need to be able to sit down and say, look, how do we help?  And I think one of the first places to go to is really health human resources.  I work in the -- I serve in the Global Health Worker Migration Advisory Council.  (Laughter.)  And right now, we're working on a paper that we're hoping can be presented before the World Health Assembly, where ministers of health can see them.  But I know already the United States is not for that paper.  Already they have the reservations to say yeah, I know, but people should be allowed to migrate. 

So you have PEPFAR in Botswana, and I'm very grateful.  PEPFAR comes in; it takes some of our human resources.  That's fine.  It's in-country they're helping us.  But at the same time, there's another U.S. agency setting up house in Botswana to recruit what is left to bring here.  (Laughs.)  So it's like giving one hand and taking in many hands.

So really, I think we -- I would say that a lot can be done, even for countries such as India, to ensure that at least the human resources are there.  And then those can be able to start advocating for that value as far as women are concerned.

GARRETT:  I should point out that we're honored today that Dr. Allan Rosenfield is with us, and Allan really pioneered some of the very earliest research on bringing paraprofessionals, or lower-skilled, lower-trained health professionals to the task of such things as caesarian sections and lifesaving interventions for women going through delivery, both prenatal and antenatal (sic) care. 

And Sheila, you're a trained nurse, and I'm sure you have a pretty clear idea of what are the larger boundaries of the skills a nurse could bring to the task of saving lives, when we are in a human resources crisis.  And you're never going to have enough doctors, even a the comparatively wealthy country like Botswana or a truly wealthy one like South Africa.

But where do you see those boundaries on the limits of what a nurse could do to save lives?

TLOU:  I will say before the advent of HIV/AIDS we had one of the best primary health care systems in the world, and it was all run by nurses.  We had very few doctors.  It's only, actually, after I became minister of health that we started training doctors, sending them out, and we are now going to start a medical school.  But before that, we are functioning very well without doctors.

We had nurses.  We had nurse midwives.  We had nurse practitioners, and they could do anything.  So it was really that we needed very few hospitals for some of that emergency care for someone with injuries, so that's where the doctors were.  But basic health care at community level was done by what we called (feminine works ?) educators, and those are the ones who ensure that women delivered in a health facility, encourage them, got them there in time because also in our culture, when you first start feeling labor pains, you don't just run to a clinic.  You know, otherwise the old women are going to laugh at you and you come back and it was false labor.  You are coming back with your little suitcase, you know?  (Laughter, chuckles.)  So people tend to then say wait for a while, let's ensure it is really labor so we don't get, you know, ashamed.  But then by that time it's late.  So it was the (feminine worker ?) educator who would say, let's go, get transportation and go.  And it was these (feminine worker ?) educators who ensured that women were immunized.

So basically that kind of primary health care was very much existent.  And of course, HIV then meant we needed all those specialists and all that, and that's when, you know, we are having, you know, doctors.  But really nurses could do quite a lot.

GARRETT:  Nils, you said something at lunch yesterday to Representative McCollum about the value of nurses.  What was that?

DAULAIRE:  Well, it was also about the over-inflated value of physicians.  (Laughter.)

This is -- this is really a question of task-appropriate training and deployment. And what I said was that an old colleague of mine who had worked for years in Haiti said the best thing that could happen for public health in Haiti would be to take all the doctors out on a barge and pull them out into the Atlantic.  (Laughter.)  That, of course -- (laughter) -- you know, there may be exceptions to that.

But let me be clear, one of the challenges that we have in this country as well as in all of these other countries is an over-medicalization.  And in fact, studies that have been done at Dartmouth Medical School have shown that areas that have the highest per-capita number of doctors do the largest number of unnecessary procedures and have the highest per-capita cost.  So simply training more doctors doesn't answer your problem.

I was trained to do tubaligations, minilaparatomy tubaligations, by a Bangladeshi paramedic in 1976.  I came back and did my residency, and the obstetrician who had me on his service and who wanted to see my technique was very impressed and said, did I learn that at Harvard Medical School?  And I said "No, a 19-year-old, illiterate Bangladeshi woman taught me."  (Laughter.)

It's very true -- and Alan has certainly shown this -- that many of the tasks that need to be done can be done at very high quality at very appropriate level by effectively trained local people who also are far less likely to leave their communities and migrate internationally.  There are some issues that require a higher level of skill and training, and we have to have that entire spectrum, but I think it's a big mistake to make this into an issue of doctors.  For the most part, nurses, nurse midwives and paramedics are not only more than capable, they are better than physicians at dealing with the kinds of things that are addressed every day and on a very different kind of arena.

In childhood pneumonia, where I worked for years when I lived in Nepal, our paramedics who we trained to do the diagnosis and the treatment of children based on simple protocols at very low cost were far better at doing it than the trained pediatricians and the national children's hospital because every doctor thinks that he knows better or she knows better than the protocol, and they personalize their approach.  And that's not the way you get the biggest bang for the buck.

GARRETT:  Well, I guess this is good news for the richest country on the African continent, South Africa, because you're literally having your medical staff sucked away by the British National Health Service and, to a lesser degree, the Canadians, Australians and New Zealanders.  And I don't know how many doctors are going to be left in South Africa at the rate at which this is happening.

But it points out the pressure that then shifts to the South African government to actually make wise use of its nursing staff and to place appropriate priorities on things like prenatal care, appropriate maternal care and antenatal care.  Can South Africa meet the challenge?

BRINK:  Of course they can.  And a lot of it comes to what Nils is saying about the will to do it.  But just to reinforce what they've both been saying about shifting these tasks down the line.  In the end, it's about building a team of healthcare providers, which includes nurses and community health workers, paramedicals and the doctors.  In fact, I think doctors need to start operating much more as managers of health care than as direct one-to-one providers of health care.  And if you can have a team like that, you can get much more effective care out of one doctor working as the team.  And I know that's possible.

I'll tell you an interesting anecdote out of South Africa.  We built a community health center in a very poor, rural area.  Before we did it, I went around to every clinic.  And I spoke to the nurse in the clinic and said, when did you last see a doctor?  And on the average, the answer was, we haven't seen a doctor for five years.  They simply won't come and work in these poor, rural areas.

We built a community health center which is nice, and it's got good facilities, and it's well organized, and it's well managed.  In the space of one year, we found three doctors who have come to work there full time because you provide them with the right environment to work in.  And they can see that they're making a difference.  We're not paying them any more money than doctors anywhere else, but what they see is that they're making a difference working together with a team supporting 10 clinics from one community health center.  And it's just exciting to see what you can do in those poorer areas if you get the delivery side right.

So I think the developing countries themselves must also -- I know they're complaining about doctors being stolen and nurses.  But often they go away because the facilities that they're asking them to work in are just so badly managed that they feel that it's pointless to stay.

GARRETT:  Well, the last thing I want to ask each of you to talk about for a moment before we open it up to everybody here in the room is, again, back to the notion that the G8 is soon to meet and perhaps on a more parochial level.  But it isn't parochial because everything in the United States affects everything in the rest of the world.  We're about to have a new president.  We don't know which of the two candidates, obviously, is going to be THE president.  But clearly, the reauthorization of PEPFAR and the whole global health and development package is going to go on that president's desk.  And there will be 15 seconds of time for that new president to give to that package compared to Iraq and the economy and everything else, food crisis and so on.

One of the great heroes of the HIV/AIDS effort was somebody that may be familiar to some of the people in this room, passed away some time ago, Dr. Jonathan Mann.  He created the first global program on AIDS.  And Mann used to say that what HIV had done was hold up a prism on every single society in the world and show where all the divisions were, where the discrimination was and where the failures were that resulted in people becoming vulnerable to infection with HIV.

It could be argued to either the next president or to the G8 that what maternal health constitutes is the prism that shows all the failures in your health system, in your concept of what is health for your society and, of course, in your view of the relative value of females versus males in your society.  I wonder if each of you would like to comment on that.

Brian.

BRINK:  I just think that I actually agree with what you're saying.  And I really believe -- I have a document here produced out of IWHC, Adrian Germain who is the author.  And it's called "A New Agenda for Girls and Women's Health and Rights."  And in a very simple, short explanation, it sets out here the things that really have to be done if we are going to make the changes that have to happen. It's going to start with recognizing the problem, recognizing the deficiencies up to now and committing to invest specifically in the actions that are needed to provide access to these rights and health for women.

So this is available.  And I think it's available on the website on iwhc.org. I would encourage everybody who's seriously interested in this to have a look.  It's written in the form of advice for a new president coming into office.  These are the things that you have to do.  I don't have time now to go through all of it, but I would encourage you to do that, and it will give you the best answer you'll ever get for the question.

GARRETT:  Nils.

DAULAIRE:  What Jonathan taught me was that if something is not a right, then it's a privilege and a commodity.  And if you commodify fundamental health, then it simply is a matter of going to the highest bidder.  The U.S. system comes to mind.  But this is a system that's, in many ways, although at much lower levels of spending, reflected throughout the world.

We have a responsibility, I think, of making it clear that women have the right to good, decent health care and protection and that the poor do, and that until those are encompassed in our polity and not just in big-worded U.N. documents which sometimes have a lack of resonance, shall we say, at local levels, but are really reflected in terms of the dialogue at national levels, and that takes a long time.  Until that happens, then we're automatically going to be in a situation where this is going to be very spotty.

Now, I said originally you need all three -- you do need the knowledge, and you do need the capacity as well.  But this fundamental framing that Jonathan put forward, which he pertained to HIV/AIDS but which pertains with, at least equal strength, to women's health and rights generally, is fundamental to making a difference in maternal mortality, in sexual and reproductive health, in global health and in even development.

GARRETT:  Sheila.

TLOU:  Well, my husband is a historian, so his influence on me has been to always look back at history.  And I will simply say that for women and girls, the ICPD original document of 1994 and the Beijing platform for action are still as relevant today as they were then.  What has happened is that along the way, governments have decided to water down a lot of that language.  Now, for those of us -- as a young woman, I participated in the crafting of those documents.  I remember sleeping at 4 a.m. in Beijing trying to come up something on women's health and having to negotiate with the Arab states and ensure that, okay, let's put this sentence -- okay -- and really doing a lot of negotiation.

Now, almost 20 years later, we still haven't fulfilled any of that.  Yet all of the views, whether it's abortion or whatever, they are well in creating that, and it's an agreed language.  So I would simply say, look, let's go back to that and really see if we can at least fulfill some of what we had meant to care for for the sake of, you know, reproductive health and rights for women. And I think that would go a long way towards that.

GARRETT:  Well, I think you can see why Sheila and Nils wowed them on the Hill yesterday and why everybody connected to IWHC is so pleased that Brian Brink has moved to the forefront for that organization.

We're going to open it up now to all of you.  What I will ask you and remind you is, one, let's try to actually have some questions, not just speeches -- though comments are okay, I won't forbid it; two, please identify yourselves; and three, please wait until the microphone gets to you, if for no other reason than we want to make sure those following us on cfr.org are able to hear your important questions and comments.

Let's start right here.  Wait for the mike, please.

QUESTIONER:  Yes.  Janet Benshoof, president of the Global Justice Center.

I have a comment and a question, I think, for Dr. Brink, although I want to say to Sheila Tlou I totally agree with her about going back to Beijing and original principles.

My question relates to your comment about the millennium goals on maternal mortality, that there's a failure of investment.  I'm not sure what you meant by investment, but I think I disagree.  I think that what we're not hearing here, and which I'm sure is not being discussed on the Hill, is the affect of the Helms amendment worldwide, the fact that United States is now trying to develop a CEDAW that has an anti-abortion clause.

When we talk about money and abortion and maternal mortality, Albania in 1990 legalized abortion and spent not one penny more for maternal health and divided its -- halved its maternal mortality deaths in five years.  The Constitutional Court of Colombia in Latin America struck down its criminal abortion law based on international law, CEDAW -- I was involved in that, the definition of CEDAW, which the United States opposes -- and said, we're going to half maternal mortality with no costs, no increase in cost in health care within five years.  This was from the court.

You talk about -- I think we all know the indices of maternal mortality.  Let's educate women, let's have later marriage.  Well, when you look at Burma, that's totally wrong. Burma has increased the age of marriage from 19 to 26.  It's got female literacy, and yet it has 59 percent deaths from illegal abortion on maternal mortality, and no one says a word.  More orphans are created every year than by the orphans created by Cyclone Nargis.

And I think what we're talking about here is political will and the effects of a pro-population --

GARRETT:  Do you have a question?

QUESTIONER:  My question is, is it on the policy forum of the countries of the Global Health Council to say that the United States has to eliminate the Helms amendment and that on in the indices for reducing maternal mortality, legalizing abortion has to be number one?  Thank you.

GARRETT:  I'm going to turn this first to Nils.  But Nils, could you also, for those who may not be familiar, explain what the Helms amendment is?

DAULAIRE:  The Helms amendment was passed in the 1970s, named after the famous Senator Helms.  And it forbad the use of any U.S. funds for abortion services.  That's a separate provision from the current so-called Mexico City or global gag-rule provision which is not part of U.S. law but which is an executive decision put in place by President Reagan, the first President Bush, removed by President Clinton, put back by the current President Bush, which does not allow any U.S. funding for family planning services to go to organizations unless they commit to not supporting, promoting or, in many cases, even talking about abortion with their own money.

So Helms is about U.S. funds not going to abortions.  Mexico City is about not giving any funds to organizations exercising their own free-speech rights.

The challenge that is faced in Washington, of course, is that American politicians don't really look outside their own constituency much less the United States borders, for the most part.  And I've been in this environment now for 15 years, and it certainly hasn't gotten any better.

During the time that I was in the U.S. government, I represented the Clinton administration in both Cairo and Beijing at these conferences to open the doors to a discussion about abortion as an important cause of women's ill health and mortality and the importance of promoting safe abortion while, at the same time, promoting family planning to minimize the number of abortions -- long response.

But the question here is not what's right, I think, from a technical standpoint, no issue there from anybody who has studied this.  And Allan Rosenfield, I think, is the master of these issues, and he's been a very strong proponent all along.

The question is, what is possible?  It's certainly possible and likely to get ride of Mexico City.  We're going to have an election in November and a new president in January.  It will be a question of which one of those two candidates becomes president as to whether Mexico City is taken away.  And possibly with a president who rescinds Mexico City and a Congress that's willing to pass a law promoting freedom of speech saying that the U.S. should not restrict other's ability to speak freely about issues that they themselves feel are important, that might be put to rest forever.

The Helms amendment, from a political standpoint, I can't see the likelihood of that being overridden in Congress in the foreseeable future.  It is a United States law.  And the question becomes, how do we make sure that women have access to safe and legal services according to the laws of their countries?  Fortunately, the United States is not the only donor.  And they have their own laws, their own structures and many other sources of funding.

GARRETT:  Well, I will say that Paul Fife will be joining us later, and we'll hear about a very different donor perspective on reproductive health, abortion and family planning.

But let me -- you know, here in the U.S. -- when we were planning this symposium, which is an outgrowth of one that Isobel Coleman and I put together a couple of years ago here at the council, we were warned by absolutely every political official we talked to that if the word abortion came up once, the effectiveness of our entire effort would be eliminated in the United States.  We were also repeatedly told by Democrat members of the House that there is no issue more partisan at this moment on the Hill than the question of anything that has the word "abortion" in it.  And that for some of the members of the Republican Party, the word "maternal" is viewed as code for a hidden fight for abortion, so that talking about women's survival and maternal survival is perceived as a cover for raising money to provide abortions. 

We have tried to disentangle this issue and to find ways to see it as a bipartisan issue.  Why should anybody be opposed to mom and apple pie, the great jargon of American politics?

But let me ask Brian and Sheila, have these two things, the Monterey initiative and the Helms law, actually had an impact on the ground that you can see, you can identify in your countries?

Brian.

BRINK:  I would go so far as to say what Nils described to you was a disinvestment in reproductive health services for women.  And I think that's an act of gross discrimination against women, something that they need.

What I want to see is that turned around completely.  And I want to see earmarked investments specifically directed towards reproductive health services for women.  And I'm not speaking in code when I say reproductive health services.  (Laughter.)  I've described the elements of care for women during pregnancy and childbirth.  Access to family planning and contraceptives, good services for treating sexually transmitted infections. 

That's what we mean, and women are being denied those because the money is not flowing.  And I think it's a direct result of the policies that currently exist.  And I think that comes close to being an atrocity.

GARRETT:  So one donor can have that much impact.

BRINK:  I think certainly, we see it because what happens -- the end result, is you don't want to be bothered with the administration and the paperwork, so you skirt around the difficult issues and you simply -- everybody's desperate to get the money, so they'll compromise their principles in order to get the money.  And I think that that is completely wrong. 

GARRETT:  Sheila, yeah.

TLOU:  I think he said it all.  With us, for example, in the PEPFAR grant, we could not buy condoms with that.  So what we had to then do is -- (inaudible) -- and say, okay, we'll use our own money to buy condoms.  But the catch there is that with PEPFAR money, the supply chain management is that we were able to get things on time.  Now, if while using our own money then to buy condoms, it means they take a long time, we have to go to other distributors, whereas if it was included in there, we could get them very, you know, easily and quickly.

So there have been instances when condoms were not there -- you know, the free condoms in the clinics were not there because we had to now use a different mechanism of acquiring them using our own funds.  So it is that kind of impact and indeed what Brian has said.

GARRETT:  Allan.

Could we get a microphone to Allan Rosenfield?

QUESTIONER:  I'm not going to ask a question -- (inaudible) -- make a couple of statements if that's okay.

GARRETT:  Okay.

QUESTIONER:  One is that -- (inaudible) -- very good friend of mine for a long time. By coincidence, he was born in Boston, and my dad was his obstetrician -- (inaudible) -- remember that.  And the same is true for Drew Altman, who's the president of Kaiser.  So obstetrics can be very interesting.

I became an obstetrician over 40 years ago.  I've been working on maternal and reproductive health for 40 years with a number of years in Asia and in Africa. But I'd just like to make a few comments about what we were discussing this morning.

In many poor countries in Africa and in South Asia, the obstetricians do not work in rural areas.  Very few doctors work in rural areas.  And even in many countries, nurses and midwives prefer to work in rural or urban areas but not in rural areas.  And so the conduct of training others to be available for emergency care -- (inaudible) -- are the best examples, part of that being in Tanzania.

(Inaudible) -- have a paper available that you could pass out that describes the extraordinary Mozambique experience by coincidence -- (inaudible) -- 15 years ago Pascoal Mocumbi became the prime minister of Mozambique -- (inaudible) -- with some help -- (inaudible) -- Mozambique, which in rural areas has had a major impact.

So I think it's very important to watch some of those to experience it because it's very difficult to get people who are well trained in interesting urban areas to leave the urban areas to be available 24 hours a day, seven days a week, which is what -- (inaudible). 

I also want to take one -- I have a comment on Brian.  As long as the complications will kill people, it's not always predictable in prenatal care.  Some of them come about without being able to predict in advance.  There are obviously many you can treat but not all.  But in my mind, the most important thing is that we have to develop facilities within reasonable distance.  For example, you didn't talk much about fistula, which is one of the worst complications for those people who survive (uncertain ?) labor, and those women become total outcasts.  (Inaudible) -- take three days to get to an urban area for a c-section -- (inaudible) -- develop a fistula.  But if there's a rural facility where she'd get emergency care, it would make a big difference.  So I think there's a lot of issues. 

And the other thing I think is very interesting now with HIV/AIDS, the ministers of health -- (inaudible) -- integrated -- (inaudible) -- maternal health and HIV/AIDS together.  And I agree with that completely.  And that ought to be a major goal of global health for women to have all three of these integrated is very important.

I'd be happy to answer questions rather than ask them.  But it's good to be here.

GARRETT:  Thank you, Allan.

Let me point out, Allan mentioned two very important papers on Mozambique and Tanzania and maternal survival.  Some of you may have seen this marvelous series on maternal health that ran in The Lancet.  I believe it was at the end of '07 or the beginning of '08.  I'm not sure.  But those two studies were included along with a paper that Allan and Lynn Freedman from Columbia University co-authored that helped update us on where we stand with maternal survival.

And on the urban-versus-rural question -- and then I want to give Brian an opportunity to respond to Allan's direct question to him -- it's very interesting. It was pointed out to me by Kammerle Schneider, my research associate here in the Global Health Program, that you could actually achieve MDG5, on a statistical basis, simply by fixing all of the largest OB/GYN services in the big urban centers in key target countries and have no impact whatsoever on the death rate of women in rural areas.

And it is a danger to overemphasize, in a sense, the statistic nature of MDG5 because the cheapest, easiest and politically most strongly supported solution in most poor countries will indeed be to simply fix the OB/GYN delivery in the capital city and the one or two biggest cities in the country at the expense of any real improvements in the rural areas.

And Brian, did you want to --

BRINK:  Well, I talked about building community health centers as something in between a clinic and a hospital.  And I think that that really is the beginning of the answer.  And the community health center could be equipped to actually carry out emergency obstetric procedures right there in the community.

And if you can't get that capacity, at least you would have the diagnostic ability to realize that you've got a complicated labor and try to then get the person to a hospital in time before it's too late.  So I think by doing that, I think Allan and I are actually on the same page.

But we can't just rely on having the emergency services in hospitals, which often the roads are impossible, often washed away.  So you know, to get there in a hurry, you can't do it.  And the end result of that is either death or massive disability as Allan described.

GARRETT:  We have nine minutes remaining and lots of hands up.

So Allan, if you'll forgive me, I want to give a lot of other people the opportunity.

Let's see, over here.

QUESTIONER:  Thank you.  Sorosh Roshan, president of International Health Awareness Network, an obstetrician/gynecologist that heard Dr. Allan nearly 40 years ago in Albert Einstein College of Medicine.  I'm honored to be here.

My organization has been involved with doing health care in countries like Sudan, South Africa, Ethiopia, many others.  But my question is, in the 40 years in my life as an obstetrician/gynecologist, many changes have happened that we all have experienced.  I learned maternal death was 500,000 a year.  Four years later, it's 600,000 a year.

We have done movements, we have brought changes.  How can we bring this to the attention of all citizens?  Six hundred thousand deaths and we are not doing anything drastic about it?  Just last night, Korean people got into the streets over American beef.  How we can get all women, men, young and old, put this subject on the top list of priorities, the value to lives of 600,000 young women in the world?

And I myself and many others who work with us, we are ready to do anything to help.  This is my question.

GARRETT:  Who would like to take that on?

BRINK:  I just wanted to refer, though, to a program that was devised in Bangladesh, which was an initiative between government, civil-society NGOs and donors where they made specific investments in basic, simple improvements to the maternal health services, including prenatal care.  And getting from I think it was something like 25 percent of people who had prenatal care, getting that above 50 percent.  And in that short period that that project was going, they cut the maternal mortality rate by 22 percent.  And that's a big reduction.

Now, it can be done, and it can be done without great expense.  So we need to take that Bangladesh example which is written up and apply it and invest in doing more and more of those kinds of things.  The lack of will is there.  You can see it.  There's a lack of will and a lack of investment, so it's not happening.  The deaths continue, and the world seems to think that's okay.

GARRETT:  Well, yesterday over lunch, Betty McCollum told Nils and Sheila that the answer to Dr. Roshan's question was we have to mobilize civil society. What did that mean to you?

DAULAIRE:  I think the key here is getting activists and professionals together.  It's -- again, it's a, emphasizing rights; and b, emphasizing the know-how to move forward.  Making it not a black box and making it an issue that becomes a top political priority.

Certainly, in the broader context of women's rights, this has to be a topflight issue.  And I think the United States and other Western countries have to very actively engage in a dialogue with the countries where maternal mortality is the highest to make sure that, from a political and diplomatic level, this is raised while the pressure is coming from below.

GARRETT:  Sheila.

TLOU:  Yeah.  I would say mobilization of civil society is very important because they are the ones who are seen as, you know, the watch dog.  And they are the ones who really know what is happening within the communities well enough to be able to advocate what they think would be able to work.

But at the same time, we have to be aware that civil society needs to be capacitated.  Sometimes we talk in civil society that we need, you know, for them to be able to have that capacity to articulate their needs, to do research and to come up with possible interventions because without that and that kind of funding, then it's -- they're not that effective.

GARRETT:  You told me yesterday that when you were first minister of Health in Botswana, I think you said there were only two of you that were women who were ministers of Health for all of Sub-Saharan Africa at the time and that part of the answer to her question might have been how difficult it was for you to just mobilize the male ministers of health around the issue.

TLOU:  It was.  It was horrible.  (Laughter.)  No, there were seven of us of the 53 -- there were only seven.  And of course, of the seven, then you think who's agenda (away ?), you know.  So that then, of course, left like two. The rest could have cared less, you know. 

So I became the chairperson of the African Union Ministers of Health.  And the first thing I decided to do was I'm calling a conference in Botswana, and we are going to look at sexual and reproductive health, come up with a framework.  Next day in Maputo, we're coming up with a plan of action.  I thought it would be simple.  (Inaudible) -- we can't bear.

And the first thing, those men have never heard of Beijing or ICPD.  So it starts to be a learning thing.  And you are teaching people who don't want to know anyway.  But we managed to come up with a framework document of course, because a lot of the officials were very much, you know, into it.  In Maputo, I mean, some of them were saying yeah, but abortion -- it's like in my country, we can't even mention the word "abortion."  I said yeah, in a lot of countries, but let's go to what, you know, Beijing platform for action says.  And that language -- (inaudible).

And under no circumstances must abortion be made a form of birth control. But countries need to review their laws because in the ultimate, we do know that quite a certain percentage of women are killed by unsafe abortions.  So we did try to adopt.  I don't know how I managed that because in there we had men from, you know, quite a lot of -- (inaudible) -- religions that you know would not really want to handle that.  But we do have those two documents.  Whether then they'll be implemented, of course, is a different story.  But at least we're hoping that where the grassroots organizations are well aware, they can hold them accountable to say look, in 2007, this is -- (inaudible) -- are going to do.

GARRETT:  Nils.

DAULAIRE:  Let me add one thing.  This needs to be clearly highlighted as one of the great moral and political issues of our time.  It's not a women's issue. And what's problematic is the number of men who sort of write it off that way. Look around this room.  What are we at?  Ninety percent women who are here today. I'm delighted that my hero Allan is here and that Brian is here.  This ought to be an issue for everybody.  And we need to reach out to the men as well as the women because it needs to be on everybody's agenda.

GARRETT:  Well, if nothing else, even if the women are not valued, the child of a dead mother has a 75 percent greater probability of itself dying in the first year of life.  So even if this simply boils down to the male offspring of the dead mother, it ought to be an issue. 

We have only -- I can see the clock -- one minute.  Do I have -- how much time?  I can't see the -- oh, it's 11.  Oops! 

So unfortunately, can't take more questions in this session.  However, we have two more opportunities for all of you to forward your comments.  And we're not going to take a break.  We're going to simply switch our presider and our participant group and ask you all to quietly remain in your seats.

And I want to thank our panelists and give them a good round of applause.

(Applause.)

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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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