Oral evidence: Recovery and Development in Sierra Leone & Liberia, HC 1204Tuesday 13 May 2014

Oral evidence, 13 May 2014.

Witnesses

Simon Wright, Head of Child Survival Policy and Advocacy, Save the Children, Catherine Slater, Regional Director, Marie Stopes International, and Tanya Barron, Chief Executive, Plan UK, gave evidence.

Chair

Thank you very much for coming in to help us with this inquiry. For the record, could you just introduce yourselves?

Tanya Barron

Hello, I am Tanya Barron. I am the CEO of Plan International UK.

Simon Wright

I am Simon Wright. I am head of child survival for Save the Children UK, which is health policy and advocacy work.

Catherine Slater

I am Catherine Slater, and I work for Marie Stopes International. I am the head of a regional programme, funded by DFID, which includes Sierra Leone. I have also spent three years living in Sierra Leone.

Chair

Thanks to all of you for coming in. When we were preparing for this session, it was made clear to us we have had very little evidence for this inquiry, which has the effect of making us think it is even more important that we conduct it, rather than less. Given what has been said about Sierra Leone in the past, particularly that this was a success and we are rebuilding it, we are really rather surprised that so few people seem to want to tell us how wonderful it is and how successful they are. Does that mean that Sierra Leone has fallen off the priority list, either for NGOs or, indeed, for the multinational agencies? Is it becoming forgotten?

Simon Wright

We are obviously an organisation that did submit on it, so we have an interest in it and it is hard to speak on behalf of the ones that did not. Clearly, we know that they are important countries for DFID. Catherine was saying a moment ago that it is stable in the way that DFID has been supporting it for quite some time. It is perhaps not one of the most controversial countries in terms of DFID’s support; maybe you saw, in your Middle East inquiry, there were perhaps more exciting questions. There is certainly an issue for us, which is that we see quite a bit of emphasis on countries with large populations. There is now an acceptance that, if you are going to try to affect things like global Millennium Development Goal numbers, you want to make the change in the countries with the biggest populations, because there is a single state you can work with. Of course, that ignores the fact that, for an individual living in Sierra Leone or Liberia, the risk of mortality or health problems might well be higher than it is for Pakistan, India or Nigeria. However, because the populations are quite small, that potentially drives attention away from the countries.

Chair

Before the others respond, one could obviously say it has been a success and is just about to graduate, but I do not think the first session entirely showed that to be the case. Perhaps another way of saying it is: the UK in particular, and the international community in general, have concentrated on wanting to provide support to tackle countries emerging from conflict, of which this was a classic example. Wouldn’t you have thought, that being the case, instead of saying, “There are bigger, brighter and better challenges,” people would see this is a unique opportunity to demonstrate that we can take a country, stop a civil war and then build it to successful development? Isn’t there a worry that we have lost sight of that long-term vision?

Tanya Barron

I thought it was very interesting that there were so few submissions, but I absolutely agree that, for most of us, there is a great deal of work going on. I have heard several agencies saying that their offices are so busy that they are almost saturated in Sierra Leone. There is a lot of good funding from DFID and the European Union, so I would sense—and we can only sense it—that people are reasonably satisfied with what DFID is doing. I do not know anybody who thinks that it is time to pull out or go away. There are huge structural problems, still, in Sierra Leone, and perhaps even more so in Liberia. I would say it is not a lack of interest; I would perhaps say it is almost business as usual.

Catherine Slater

I agree. We were discussing this earlier. It is maybe not as controversial as some of the other countries. There are still a lot of agencies operating in the field who may not have submitted because they are getting on with business, and they are happy with how DFID is operating.

Chair

There has been quite a lot of turnover of DFID staff on the ground. Has that had any impact on any of you?

Simon Wright

It has for Save the Children. We think that, in the sectors in Sierra Leone where we are working on water and sanitation, and on education, we have had very good engagement, but maybe we have not had much of an overview of the social development sector in Sierra Leone. There is a new head of programmes coming in to Sierra Leone, whom I know my colleagues there are looking forward to working with. Liberia is a different situation, because it is a small satellite office. I can ask my colleagues whether they think there should be more capacity for DFID in Liberia, and they would like that. They would like to see DFID more engaged in monitoring and working on the programmes they are supporting, but they also think, if DFID is going to have an influence among the donors and a good dialogue with Government around the policies they have, particularly on health, that they should have more capacity there, certainly.

Chair

I appreciate that you are providing services for DFID and you are a client of DFID, so we are not necessarily expecting you to put the boot in, but there may be constructive comments to be made. I think we are talking about four heads of office over the course of a year. That does not sound like an office that is in full flight.

Catherine Slater

In terms of MSI, I do not think so, because we have had consistent health advisers over the period I was there.

Chair

So at the level that you are dealing with, you have had continuity.

Catherine Slater

Absolutely, and consistency, and seen through the contracts. We have had regular engagement, which has been helpful—we see it as genuine engagement—in what we are doing. At that level, that has not been an issue.

Tanya Barron

It is a Sierra Leone problem as well, not just a DFID problem. Let me speak for Plan. If you looked at several of our offices, there is a lot of turnover. A lot of good staff get pinched to go and work for much bigger payers so, for locally‑employed staff, it is a huge problem. The capacity is low. As I say, lots of our offices are absolutely saturated with work. There is still a lot of donor interest, and the competition for good staff is very high. That is a problem. Some of the DFID staff would probably be turning that around and saying, “It is really hard working with you guys, because your staff keep turning over.” There is a lot of churn.

Chair

No doubt we will find out more when we visit, which we should be doing next month.

Jeremy Lefroy

Could I ask what you believe the prospects are for either Government—Sierra Leonean or Liberian—funding essential services like health, education and water themselves in the long term, over the next 20 to 30 years?

Simon Wright

Clearly, that is the direction the Governments want to go in, and it is the direction we would want to see them go in as well. Liberia is quite often talked about as perhaps ending its aid dependency by 2030, which is an ambition that Ellen Johnson Sirleaf has set out. Sierra Leone is engaged, at the moment, in looking at how it continues to deliver health services with less reliance on donor money coming into it. These are very important but, as we heard in the last session, these are still extremely poor countries with really quite weak governance systems and a low tax take coming in, especially in Sierra Leone, as was talked about earlier, so it is very clear that donors are going to continue to be a very important part of the profile and resources for these countries for quite some considerable time, which puts a lot of importance on how those donors operate. How they work together and they support the Government, and the balance between project support and budget support, are all, therefore, incredibly important. We all aspire in that direction. We are working with Sierra Leone around a social health insurance scheme that it is looking at bringing in. We have a lot of views on the style of how it should do that but, clearly, it is a direction it should be moving in: making sure that the extractive industries are benefiting the social sector, and that there is a fair system of raising funding and pooling it in order to pay for essential public services. At the moment, the amount of Government expenditure on the public sectors such as health is very low.

Tanya Barron

Again, I would like to hark back to what Mr Vines said earlier. I would separate out, in a sense, your question into two bits, because I think they are different. The question of whether the Government can afford to run services is one issue—I am probably less qualified to answer that—with the taxation and so on. The other is whether they have the capacity. That is a really serious issue: the lack of state or the smallness of state that is there in Sierra Leone. I worked there in the 1980s for quite a long time, and there almost was no state. The lights were all on generators, even in the city. There is very little feeling of a systematic state beyond the big conurbations, such as they are. You are really dealing with these two systems. They referred frequently, earlier today, to the informal system, the Paramount Chiefs and the fact that there are still two structures, and, if you go up to places like Kabala, in the north, you will see most of the services are, in a sense, under the jurisdiction of the Paramount Chiefs, and it sort of works. That was a rather long answer. I think there is still quite a way to go, certainly, to what would feel to us like a state system of delivery of services.

Sir Tony Cunningham

Can I focus on health care in both countries? How important, from your perspective in both countries, is free health care, and how can it be sustained?

Simon Wright

Maybe I can answer a bit on this one and be let off a few a bit later, because this is the area we are particularly interested in.

Sir Tony Cunningham

Which is why I want to focus on it.

Simon Wright

Sierra Leone and Liberia are fascinating situations that we find ourselves talking about globally all the time. Here are very weak countries, very aid dependent with very poor indicators, particularly on child and maternal mortality, but which have made commitments to the principle of health care that is free at the point of use. They have listened to the evidence. They have also listened to international partners, including DFID, which played a very big part in encouraging those moves. Clearly we think that the evidence works and, if you look at Liberia, you have some very good improvements in indicators, which have certainly speeded up since the removal of direct payments for health care. In Sierra Leone, the evidence is not yet completely clear around outcomes, but there have certainly been big increases in the use of services; that seems quite clear. Clearly to the earlier discussion around security and the role of the state, this is key to the relationship between citizens and their state in terms of whether public services that people want are being provided, and whether people understand they have an entitlement to it. In both countries, DFID, as I said, has played a very important part. There are a lot of question marks around the future of that, though. In Sierra Leone, the support that was given to increasing health sector work force salaries was instrumental. I went to Sierra Leone several times in the aftermath of the Free Health Care Initiative to talk to different partners who had been involved in it, and that stood out. The work that DFID did in reviewing the payroll, removing ghost workers, and then putting in recurrent funding committed through to 2015 to allow an uplift in salaries was vital. That money comes to an end. We are not quite sure exactly whether some of the other pots of funding will continue to make sure that the Free Health Care Initiative and the salary bill is covered, and that was crucial for reducing informal payments—staff demanding cash from patients when they attended. In Liberia, the situation is perhaps a bit more worrying, because DFID was so crucial in setting up the Health Sector Pool Fund. It put in the recourses and the capacity, and provided staff to help to get that set up. As we said, we think that has been a very big success, and you can see that already in the indicators for Liberia. DFID’s contribution to the pooled fund finished at the end of March, and we are waiting for a review that DFID is doing of its portfolio in Liberia to decide whether health will even be a priority next year. Save the Children did a campaign last year when we had people writing to Justine Greening and expressing a concern that Britain should carry on being involved in health, particularly because Britain has a very different experience from other donors. Sometimes we hear from DFID that it wants to leave the US to lead on health in Liberia. That concerns us a bit, because we think Britain probably has the best model for how you can develop and aspire to run a health system, so we are keeping that pressure on DFID, and we hope, when it does come back and says what its portfolio review has concluded, that will include health care and a commitment to free health care. The Liberian Government have already introduced a policy that says they will reintroduce some cash payments for some health services. It is not clear that essential maternal and child health services would be protected, and we think they should be. We have also asked for an agreement from the Secretary of State to say that she believes in the principle of free at the point of use, and she also said that she could see the reintroduction of cash payments, in some cases, as being justified. That is something we do not agree with. We think one success in Liberia has been blanket free health care.

Sir Tony Cunningham

Could I ask whether donors are doing particularly good work in both countries on health system strengthening?

Catherine Slater

I would just like to touch on the previous question. I think, absolutely, the Free Health Care Initiative has been a great success, and the team really welcomes it in terms of providing access. There is a long way to go, though. When you look at the DHS that just came out in 2013, it suggests that there has been a doubling of women who are attending deliveries within a facility. I hesitate to say “safe”, because, if you look at the data that have just come out from the WHO, it suggests that maternal mortality has gone up, so there is obviously something going on there in terms of women deciding to go to the facility, presenting on time and, if they get there, whether they are really still getting quality care. DFID has put a lot of money into infrastructure. In 2010, there was one facility that did emergency care in Sierra Leone; now there are 20. There has been a lot of input, but there is a long way to go, because the health outcomes are not now being reflected. The Health For All Coalition, whom DFID supported, did some research, and there are still informal fees being paid. If people go to the facility, it costs money, and that is a hindrance to people accessing it, and they also cannot afford the drugs. So, yes, it is a success, but not without its issues, and I think the DFID‑funded health care evaluation will be really insightful in terms of lessons learned.

Sir Tony Cunningham

It is certainly something we will be looking at when we visit. It has been suggested that Liberia has made much better progress than Sierra Leone in the number of child and newborn deaths. Could you explain or try to give some rationale as to why?

Simon Wright

It is not an easy one to try to answer. There are differences between the two countries, and we heard a bit earlier about, perhaps, the capacity of government in Liberia being higher than that in Sierra Leone. Certainly, what Liberia did at a much earlier stage was to make a commitment to reform the health sector and very actively involve partners in it. In both Liberia and Sierra Leone, because of their size, because of the weakness of government and because of the low budgets, donors have been incredibly important. Liberia was very proactive in the pooled fund, and in steering donors into a pooled fund that they could manage and control, but then contracting out. For quite a long time, Save the Children was one of many NGOs delivering health services. We were doing it in three counties. Those have now gone back more under the direct control of Government, with the Government paying the salaries of the health workers, but our role is still there supporting and developing those health services. So perhaps that was done at an earlier stage, more comprehensively, with a bit more commitment from the donors into the delivery of a whole package of health services and perhaps some different models of delivery that helped Liberia through that period. In Sierra Leone, the Free Health Care Initiative has come later and, as Catherine was saying, the indicators of outcomes are not yet clear enough. Maternal mortality may be being documented in a way that it was not before if deaths were in the community and were not being documented, so there is still a lot to watch in the model for Sierra Leone, and perhaps lots for it to learn from Liberia.

Sir Tony Cunningham

Could I finally ask, from the point of view of Marie Stopes, why there is an increasing number of pregnancies in girls under the age of 15 in Sierra Leone, and what can we do to deal with it?

Catherine Slater

Under‑15 teenage pregnancy is not something that is well documented in terms of the data, although 15 to 19 is, and the DHS data that has just come out suggests that the fertility rate has dropped in that age group of 15 to 19 from 146 to 125 out of every 1,000, so there is a slight decline—it is nowhere near enough, but there is a decline. In the same report, you are seeing that the contraceptive rate has increased, I think from 6 to 8, so it is a very small increase but, within that age group, there is an increased use of contraception and lower fertility rates.

Jeremy Lefroy

I have a supplementary question. By my calculation, according to the figures we have been given, there are fewer than 2,000 doctors, nurses and midwives in Sierra Leone—under two per 10,000 population. I wondered what is being done to train more staff in both countries, given that this seems to be a major factor in the poor health statistics. Also, do you by any chance know—there is no reason you should—how many Sierra Leoneans are working in the national health service?

Simon Wright

On the second question, we do not have that, although you hear anecdotally quite a lot of comparisons between the numbers of medical staff from other countries working in the UK. We can certainly try to look for that, and see what we can find of the most recent, up‑to‑date data. In terms of specific action on the health work force, I do not have an answer for you about that, but could maybe get some information and send it to you. Certainly, we know that part of the Free Health Care Initiative in Sierra Leone was to do that. When I was visiting just after that, I was hearing quite a lot from the Ministry of Health and Sanitation about the importance of recruiting. They were bringing some retired health workers back into the system. They were even, at one stage, quite excited that maybe people who had gone and worked in the private sector wanted to come back and work in the public sector, once the wage bills looked like they were going to get paid, so people were going to get their salaries, and there had been some uplift for nurses and doctors. There was certainly a lot of enthusiasm at that point. I do not have an answer for you about what they are doing in terms of investing in education and, then, the specific health-worker education, but I will find something for you.

Catherine Slater

I am glad you raised it. It is one of the direst challenges that we have in terms of provision. From talking to the team when I was there, I think there are under 100 doctors within the whole of Sierra Leone, so there is a link between that and maternal mortality rates now. It is a real challenge at the moment for Marie Stopes. We have to bring doctors over from Ghana to provide services. There really are not the health workers available to provide the services. There are some solutions other than providing doctors. There are some procedures, for example, that a clinical officer could do. We have permanent methods that we have to bring people over from Ghana for, but in Uganda, a clinical officer would do. Working with the Government to shift that down a cadre would increase access, if their standards allowed that. I think it is a challenge to get doctors to come, to stay and then to be retained, even within the private sector. Within that, then, we have to find innovative solutions to provide access by shifting the cadres of providers that are required for different procedures.

Jeremy Lefroy

When we visited the Aberdeen Women’s Centre in Freetown, we noticed that quite a lot of the trained medical staff were from other African countries, and particularly from East African countries—Kenyans in particular. I wondered if that was an increasing trend: we are seeing other African countries provide them and, where they have if not a surplus but perhaps more trained medical staff, seeing migration within Africa.

Catherine Slater

I think that is the case.

Pauline Latham

It seems to me that the life of women and girls in Sierra Leone is pretty grim. They do not have many opportunities. The education is getting better, but it is not perfect. It is difficult to inherit land. There are even fewer female Members of Parliament than we have, and we are not good at that. Many women have no education, and sexual exploitation and gender-based violence is rife. Also, FGM is at a very high rate in Sierra Leone. What can DFID do to change attitudes to domestic violence and FGM in Sierra Leone? I am not sure what the situation is in Liberia, but maybe you could explain that. Are they doing enough? FGM is entrenched. It is a very difficult situation. It is a cultural thing. How can we get people to accept that it is child abuse and not just cultural? It is child abuse and it needs changing. Could you tell me if you know if Sierra Leonean girls from this country are taken back to have FGM done in Sierra Leone, or does it happen here?

Tanya Barron

We might need to divide that question up.

Pauline Latham

Yes, absolutely.

Tanya Barron

Thank you. There is still a persisting, huge problem about gender-based violence in Sierra Leone and Liberia, and all those things that you have just mentioned. I think still over 60% of Sierra Leonean girls are married underage—the figures that we have suggest at least 60%. FGM is absolutely rife, especially further north. One positive thing, though, I would say is that the Sierra Leone Government set up something called the Family Support Unit, which would really be worth going to look at and to talk to people about. It was a very good initiative, some of it supported by DFID, which started in 2001. They have had some very good results. They work with the police. They train the police and have also trained social workers, which is a first. What we have found is that there is a really good result of a great increase in the reporting of rape and violence. There is very poor—almost non-existent—reporting of child marriage, and almost nothing on FGM. The reason I have a small bit of optimism is that at least they have put in a structure.

Pauline Latham

If it is being reported, though, what is being done about it?

Tanya Barron

On rape, there is evidence that there are prosecutions and that they are taking it seriously. It does feel as if the social norms are still absolutely accepting of FGM and child marriage, but are not accepting of rape and certain other aspects of sexual violence. As I say, there is modest cause for hope, but because there is a structure there, one of the things that we know is that it is underfunded and needs more support. In a very practical sense, that is something DFID could look at and see how we can use that system—it is there and it has been quite well bedded in, over 12 years—and how we can make it a vehicle to get to these really serious issues. If I can just tag on to that, we know the other side of the same coin is keeping girls in school. DFID has done a good job on education in Sierra Leone. The Global Partnership for Education, to which DFID is the biggest donor, has also done a really good job. Gender parity is almost there in primary education in Sierra Leone, which is really interesting. There is not bad retention in primary, but it is appalling in lower secondary—for girls, maybe 25%. Of course, the relationship with girls dropping out at lower secondary age and early marriage is known.

Pauline Latham

Is part of it because they do not have access to sanitary protection and they can go only three weeks out of four, not four weeks out of four? Instantly they start to drop behind. Is that something that could be addressed over there to help girls to stay in school longer? That is something that happens in other African countries and, if you can provide them with some form of sanitary protection and proper latrines that are separated from the boys’, they are more comfortable about staying in school.

Tanya Barron

Yes, and there is also evidence we have, because we have a lot of youth groups in Sierra Leone, that the additional problems are that they are not comfortable with people knowing that they are menstruating. The whole thing is culturally difficult.

Pauline Latham

It is embarrassing for teenagers.

Tanya Barron

It is embarrassing, exactly.

Pauline Latham

It does not matter where they come from: it is embarrassing.

Tanya Barron

Yes, so private, lockable toilets and sanitary protection are very important. There are, however, also the cultural issues that, when a girl hits puberty, in some parts of the country it is assumed that that is just fine, and that she has grown up and ready to get married. It is complex, isn’t it?

Catherine Slater

Just to add to what you were saying, I have a couple of points around FGM: as you say, it is huge. In a recent DHS, 97% of rural girls have had the procedure. It is one of the highest countries, I think, globally, so it is a huge issue. My understanding is that UNICEF is currently providing a strategy on FGM, and CARE is leading a consortium and there are some agencies working on it. My understanding is that, at the moment, DFID is not directly funding anything on FGM. The suggestions are that there are a few key strategies that it could take to address it, looking at encouraging the increase of the age of initiation within the societies.

Pauline Latham

What age is it currently?

Catherine Slater

I knew you were going to ask me that. We are advocating that it is increased to 19. I can find out for you what the starting age is now.

Pauline Latham

Increase to 19?

Catherine Slater

It is about 14.

Tanya Barron

It is about 14.

Pauline Latham

That is fine. We saw a very good project in Ethiopia where, although it was being done with funding from DFID, it was a bottom-up approach in a village where the village elders—the men and the priests—as well as the women all worked together to decide themselves that this was the wrong thing to do. It was slowly changing in villages, and that was then going to be spread out to other villages. It has to be bottom-up, though; it is no good the Government saying, “You have to change.” They need to do that as well, but they have to change the culture. Clearly, then, this is a major problem and it is going to take generations, probably, to change, but do you think DFID should be tackling that at this stage, or are there too many other things for them to tackle? It is abuse.

Tanya Barron

I think DFID absolutely should be. I think it is such a crime against human rights. It is criminal, and it is criminal in that country, too. I think that DFID will have to think about it, as we all will, and PLAN is involved in working against FGM in this country and overseas. It is a very difficult subject, and changing social norms is difficult, but we are not going to be put off by the notion of not stepping on people’s cultural norms, because, as Naana from FORWARD said so wonderfully, culture is manmade and it needs to be changed. I do think, though, that one of the things that we really would ask DFID for is that it takes seriously the idea of putting a gender lens on all its work and not having, again, stand-alone Girls’ Education Challenge programmes. They are fantastic, but we are celebrating the International Development (Gender Equality) Bill here tonight, and I do think that we need to crack on with working with DFID to make sure that gender is not a standalone issue. It must spread its way through all works.

Chair

They claim it is, of course, but we have to pursue the practicalities of what they are doing on the ground.

Pauline Latham

What is the answer to the question about whether girls from Sierra Leone who are here are being taken back for FGM, or is it happening here?

Simon Wright

The event that DFID is going to run with the Home Office at the end of July is going really to highlight this, I think, about interlinks in travel. A woman was arrested at Heathrow at the weekend who was accompanying a young girl coming back here. She has been arrested for conspiracy to commit FGM. I do not think it is bringing Sierra Leonean girls here; I think the traffic is the other way, generally.

Pauline Latham

There are girls who now live here who have come for whatever reason—immigration—into this country and are too young to have had it done. Are they being taken back to Sierra Leone to have it done, or is it happening here?

Simon Wright

There are a lot of views that girls are being taken back. They are taken out of school and they disappear for a while. There was a big campaign whereby Michael Gove has now written to every school to make them more aware of sudden absences of young girls of African heritage and to be raising questions about where they might be going and letting child-protection services know about that, if that is happening. That is incredibly important. It is undoubtedly happening. We do not know a lot about it or have reason to have any arrest at all in the UK on FGM, and the renewed attention that has been given to it by this Government has really helped to put it in the front of people’s minds. If immigration is now starting to watch what is happening, that is really important. It is part of a whole package, however. You were right to introduce your question by talking about the systematic levels of discrimination and abuse of young women. Early marriage is one that is a very serious problem, as is early motherhood. The President has set up a campaign. His latest campaign is Let Girls Be Girls, Not Mothers!, and Save the Children has been involved in that. We did some qualitative research speaking to young girls about their lives, and the really interesting thing was how much sexual relationships are about economic survival—how they manage to stay in education and how they manage to protect their futures—and having multiple partners around providing different needs, and that continues. Legal polygamy is quite high in Sierra Leone, at least as documented in the DHS surveys, and we certainly see that in young girls as well, because they are surviving in that way. We have to get to the root of that. The earlier evidence session talked about the bulge of youth unemployment, and girls are particularly suffering from that.

Pauline Latham

In terms of family planning, we hear that Marie Stopes in particular has reported that there is an improvement in the rate, but it is still pretty low, in that it has gone from 7% to 16%— not huge—of women who are using contraception. That would clearly help the situation. What more can you do, and how can that increase, small though it is—it has more than doubled, but it is still a very small percentage—be improved? Is it that women do not have access to it, or do they choose not to take it up?

Catherine Slater

I agree that 16% is low, but a doubling in that period of time, if you look at many countries, is quite impressive. The bottom line is that women want to have family planning. I was with a lady who is accessing our services in rural Sierra Leone. She had had 12 live births, six of whom had died, and she was probably way younger than me. She came and we provided her with a permanent method. She took it straight away. It was very powerful. When one in 23 women dies in childbirth, it is very necessary. The numbers increased exponentially in terms of accessing family planning over the last few years. Certainly, from Marie Stopes’ perspective, that has been to do with two key aspects: providing access; and knowing what they want and understanding what the barriers are. We have introduced implants, so women have more choice, providing them with every different type of method. We have confident and competent providers. It is also to do with making sure that the commodities are available. Often, within the Ministry of Health, you do not have the commodities or the skilled personnel, which are critical components of any access system. There is also the demand side: doing a lot of work with community radio, working with imams and working with the men. It is not a girls’ issue; it is very much a family issue, so it is about coming from those two perspectives. Now, Marie Stopes has provided 50% of all family planning in Sierra Leone and has seen an increase like this in terms of how many people are accessing services. Girls and women do want it; a lot of it is around access, and myths and misconceptions. Addressing those two things concurrently means that it is possible to change.

Simon Wright

Can I add just one point, which goes back to economic dependence? If you look at the big DHS health surveys that are carried out every few years, the number of women who report being able to go and visit a health facility without the permission of a male relative is very low, and that is undoubtedly driving whether women can go and demand contraception, so you have to address that as well.

Mr McCann

It is probably best to direct this, in the first instance, to Tanya. DFID is going to spend £23.4 million up until 2016 in the education sector. Given the concerns that were expressed earlier about the turnover of staff, was DFID right to enter that sector in 2011? Does it have sufficient resources and skills to be able to do this job effectively?

Tanya Barron

I think it is a real pity that DFID waited until 2011 to go into the sector. I remember having a discussion with the head of DFID in 2005 or 2006, and he said to me, “We do not do education. We do not do health. We do not—” and the list was long, because they were doing security very well. That was what they had strategised to do and they did a very good job. I do think that we are still seeing the knock-on effect of there not being enough input into education, and literacy is still hovering at around 60%—slightly higher for boys than girls, but not much. I am really thrilled, then, that DFID is concentrating on education. It is a very young population. I do not see how we are going to shift youth unemployment unless we really get on with the education part of it. The good news is that there have been some quite quick wins in education. DFID has focused very well and we did a lot of work with it on primary, and it is now moving into lower secondary. It is strategically right, and I do think it is getting a lot of it right. Seeing a 10% rise in recruitment to school and in retention in school and literacy is very good, in really a very short space of time.

Mr McCann

If I just throw into the mix the consortium approach that is applied in Sierra Leone, how does that differ from the approach that is adopted in Liberia? In terms of progress comparing Liberia with Sierra Leone, who would you say is doing better?

Tanya Barron

I think we were all quite nervous about the consortium approach at first, to be honest. I think it has been overwhelmingly good and beneficial. Certainly, from our work, it has enabled us to work in partnership with disability organisations and to have truly inclusive education. We have managed to get, just in the last year or two, 20,000 more girls into school. The consortiums, I think, have been really successful. I think they have worked peacefully and very efficiently, providing really inclusive education, so that we can all do what we are best at. I would say, then, that our evidence is that the results would be better in Sierra Leone than in Liberia, but it is slightly complicated as to why that is. I do not think it is just the consortium approach, but we would now seek out consortiums, especially in education.

Simon Wright

We participate in the education consortium in Sierra Leone, and I know we see that as a very useful model and would like to see one for health in Sierra Leone. I think, for all the reasons we have talked about, in a country that has so many NGOs involved, including so many international NGOs, and which has so much aid money coming in through different routes, anything that ensures good co-ordination across a sector, and makes sure that we are planning together and dividing up responsibilities and different areas that we are looking after, is something you see with a stronger Government. A stronger Government are better able to insist on where NGOs operate and how they support the national plan, but the consortium approach is absolutely right, and we would like to see more of that for health, particularly in Sierra Leone.

Mr McCann

You mentioned youth unemployment, Tanya, which is often seen as a main risk for a return to conflict in both Sierra Leone and Liberia. Are either of your two organisations—Save the Children or Plan—working on any programmes towards skills and employment for young people in both countries?

Tanya Barron

We have not started yet. Our next phase is going to be youth savings. I have some information from some interesting, big youth employment programmes, if I could mention them.

Mr McCann

Sure. My supplementary was going to be: if you are not doing anything, do you know of anybody else who is doing something?

Tanya Barron

Yes, and some very different experiences. As you might expect, one of the biggest youth employment programmes is the World Bank’s cash-for-work programme. I would say that some of it has worked, but I think one has to be quite critical of it. It is a big programme: $20 million, with an aim to get 30,000 youths into employment. There are two problems. One is that it has been primarily road-building, which is fairly typical. Sierra Leone does need more and better roads, but the problem with that is mainly that it is taking on young men—there are very few young women involved in the road-building programme. Secondly, it is a really stop-start programme. Cash for work is okay, but it is not really bedding in any sustainable work. Once the road is built, the road is built.

Mr McCann

Or skills necessarily.

Tanya Barron

Or skills. It is mostly manual labour. Having a job and turning up for work is a skill, so there are some benefits. I think the UNDP programme is more interesting: Youth Empowerment and Employment Programme. You can tell from the title that it is a much more holistic approach. It is much smaller—about $3 million and 850 young people—but there is training for employment, employment preparedness and working with employers. It is a much more interesting programme to look at. Both of those are ongoing, so you could have a look at both. The German GIZ is targeting and training urban and rural youth in three districts using public-private partnerships. That might be worth looking at. In particular, they are working in the cocoa and coffee industries. There are various other smaller initiatives, but I would certainly say the UNDP and the World Bank would be worth looking at for a contrasting approach.

Simon Wright

In both Liberia and Sierra Leone, there are a number of programmes that are working on youth employment.

Mr McCann

For Save the Children?

Simon Wright

For Save the Children, yes. In Liberia, it is particularly about working with ex-combatants. It has an ultimate aim of stability, peace and state building by working with young people around employment. In Sierra Leone, it is called EYE: Education for Youth Empowerment. Interestingly, Sierra Leone and Liberia have connected with Save the Children China, because there is so much Chinese investment going into Sierra Leone, to work with some big Chinese companies around how we can develop youth opportunities for young people in Sierra Leone.

Mr McCann

Do you feel any conflict there with China?

Simon Wright

There is always going to be a conflict, but we always try to work out what it is, and try to avoid it and steer through. Clearly there is a lot of investment coming from China into countries like Sierra Leone. In Sierra Leone, it is going to make a big difference. It changes the landscape substantially, of course. All the discussions we have had have been very much around traditional donor money coming from the UK, whereas Chinese investment does change a lot of that dynamic in terms of understanding who is benefiting from that. Are all the skilled jobs done by Chinese staff coming in to run those while using a few low-paid local workers, or can it be done in a way that becomes more sustainable and helps to build skills and the economy? It needs to be managed very carefully.

Mr McCann

We have witnessed that in other countries, but we will not open that particular can of worms.

Chair

A few years ago, during this Parliament, Claire Curtis-Thomas, a former Member of Parliament, gave evidence to us of a proposal supported by the UK construction industry to set up a library trading facility for construction industry workers, which I do not think went ahead—or I do not know whether it went ahead. Are you aware of that?

Simon Wright

No, I was not.

Chair

The whole idea was to try to upgrade the skills of Sierra Leonean workers to enable them to perform on international contracts and meet international standards.

Simon Wright

It is not something I am aware of, but I would be happy to look into it to see if we can find an update on it.

Chair

We might explore that when we get there. In terms of these wealth creation programmes, I think there was a point that Peter Luff was making earlier on: you set targets, but how real are they and how effective are they? What is your evaluation of them?

Simon Wright

I do not really have that kind of overview, so it is hard for me to answer that. I think we know what we want to try to get from them. I am sure that we have some reasonable outcomes from that work but, if you would be interested, I would be happy to provide some more information in writing.

Chair

The problem, presumably, is the lack of a dynamic economy that needs workers, so you are creating jobs in order to create jobs, but not necessarily to create an economic dynamic.

Simon Wright

The point that we heard in the earlier session was about extractive industry being the source of most Government revenues, but not employing that many people. The wealth does not get shared, but goes out of the country quite quickly, because it is not going into salaries, and people are, therefore, not paying money into the economy, which is not letting it grow in the inclusive way that we would all want to see.

Tanya Barron

I think there has been some good progress in Sierra Leone. I think there is a lot to be encouraged about. When you look at the rejuvenation, for example, of their ginger market, or the development of really quite interesting and quite functional co-operatives of agriculturalists coming back together to go a little bit more to scale, there are some good examples of a re-energised co-operative agricultural development, which is now going to market with products that they have not been marketing for probably 20 years.

Chair

It was suggested that, after the conflict, a lot of the young men in particular who had been released were not particularly willing to go back to the land, so they were all hanging around in Freetown with not enough to do. Presumably, however, we are moving into another half-generation, where the young people can stay on the land, if there is enough for them to do and if there is enough added value for them.

Tanya Barron

Yes, I think that is right, and that is why I think, with things like the newly regenerated ginger stuff, of which Sierra Leone used to be a huge exporter, of course, and the better management of coffee and cocoa, we are starting to feel, especially in the rural northern areas, that is now providing a viable alternative to young people.

Chair

Thank you very much indeed. I think it has been a useful first session from our point of view, and I hope, if there is anything you reflect on, you might feed it back into us as the thing continues. Oral evidence: Recovery and Development in Sierra Leone & Liberia, HC 1204 21