Oral evidence: DFID’s programme in Nigeria, HC 676Tuesday 10 May 2016

Oral evidence, 10 May 2016.

Witnesses

Georgia Taylor, Director, WISE Development, and Ojobo Atuluku, Country Director, ActionAid Nigeria, gave evidence.

Chair

We move swiftly on to our second panel on the theme of women and girls. As with our first two witnesses, we will start with questions, but please do introduce yourselves when you answer the first question. Thank you very much to both of you.

Mrs Grant

Good morning. What are the major issues faced by women and girls in Nigeria today?

Ojobo Atuluku

Good morning and thank you for having me. My name is Ojobo Atuluku and I am Country Director of ActionAid in Nigeria. I was a Chevening scholar 22 years ago on women’s rights. ActionAid Nigeria is currently a partner of DFID as well, and I am happy to see some of you who I met in Nigeria.

Chair

We met in Abuja, didn’t we?

Ojobo Atuluku

Yes. We have implemented some DFID projects, and in the past I have also been a consultant reviewing DFID projects, so these are the experiences on which I base some of my responses. In terms of the issues facing women in Nigeria, how much time do we have? The 12 critical areas we agreed on in Beijing are still critical today, including exclusion from power and decision making, lack of access to health services and lack of access to quality education. We have stereotyping of women in the media. There are environmental challenges that women face. We have issues of violence against women, as well as discrimination, cultural restrictions and barriers. In almost every sector you can think of, women face several challenges. Incidentally, DFID has also been working in some of these areas. Unfortunately, the work DFID does sticks to the mainstream of women’s rights, women’s issues and so on. One of the experiences I have is that, once you mainstream issues of gender, they become invisible and difficult to target and to hold on to. DFID has a few programmes that are focused on women, like the Voices4Change programme, which targets violence against women and also works with the federal Government on issues of gender, trying to see how it can seek space for the Government’s mandate in terms of working with women and so on. But on the whole, there are a lot of areas that still need work to be done.

Mrs Grant

What areas do you think DFID are doing particularly well in? Where is DFID’s involvement having the most impact as far as women and girls are concerned?

Ojobo Atuluku

GWIN—Growing Girls and Women in Nigeria—which is part of the Voices4Change programme, has a lot of potential. It is still very much a pilot across five federal agencies, but if that work can be deepened, a lot can be achieved, because it is looking at supporting Government to use its own resources and ensure that within its mandate women and girls are catered for. That is the way to go.

Georgia Taylor

My name is Georgia Taylor, and I have reviewed and worked on several programmes across different sectors, including private sector programmes—“Making Markets Work for the Poor”, health, community engagement in health, and I have also recently done the Voices4Change annual review. Consultants I work with have also worked on education; we seem to have touched on it but might not have had the depth that ActionAid have. In relation to GWIN, there is a massive barrier in the leadership and commitment to really integrate gender into budgeting. Whilst there is a beginning and there are some pilot projects, they are very mini projects and it could even be a tick‑box exercise. A lot more work needs to be done, and women within those organisations need to be given the chance to take leadership roles. There is a big issue around women in leadership, and it is another thing that the Voices4Change programme is trying to work on in terms of women in political leadership positions, which is really important. It is incredibly challenging even working with political parties, and I would suggest that one of the things that they are not doing is funding mass movements and women’s organisations, and that is absolutely crucial. Traditionally, donors have not been funding women’s organisations and have not been strengthening them—there are all sorts of reasons why they do not do that, but there needs to be a start. With Voices4Change, they had started trying to focus on funding men’s groups, and one of my main recommendations was that you cannot fund men’s groups and not fund women’s groups. That is absolutely crucial for some kind of mass movement and leadership from women.

Pauline Latham

DFID’s A Theory of Change for Tackling Violence Against Women and Girls proposes four main types of intervention: first, building political will and legal and institutional capacity; secondly, changing social norms; thirdly, supporting women’s and girls’ empowerment; and fourthly, strengthening service provision in health, education and social services. What do you think DFID’s priority should be, and in which of the areas do you think they are most likely to have an impact?

Ojobo Atuluku

The areas that you have listed are critical. One of the challenges we have in working on women’s issues is the fact that women’s rights and women’s issues are not just in one box: there is a whole range across the space. You need to approach an issue from different angles. It is about the combination of how much of each ingredient you need to put into the pot to bring about the right results. DFID is working a lot on building the empowerment of girls and women and creating safe spaces for girls in the north. It has a health programme, an education programme and so on. But in terms of the services for women and girls who are facing violence, that is a very weak area not just for DFID but for almost every actor, including the Government and other donors and development actors within the country. This is an area that needs to be strengthened, because you cannot just say that people should go to the police, even though DFID has an access to justice programme, because the police are just not the solution to an issue of violence against women. Once you go to the police, it becomes a criminal issue and you find that many women and girls who are victims of violence do not want a criminal solution; they want the violence to stop. How can we use both responses to not just criminalise the act but provide a service that responds to the needs of the women and girls? The response to violence against women and girls needs to be holistic and not just about picking one item here and another item there. When you hide issues of violence against women and girls in a generic programme of women’s rights, or even in a programme that is not covering women’s rights, and you just target an aspect of violence against women, you are likely to miss it. It is not just about creating awareness or saying that men and boys should stop perpetrating violence; it is about the services that are available and about where women can go for support and relief. What kind of psychological support can women receive? These are the gaps that still exist within the environment.

Georgia Taylor

Within the Voices4Change programme, we have done a lot of work to build awareness around violence, and it has been supporting the movement to get the Violence Against Persons Bill approved, so that was quite a step. But within the programme there does not seem to be any provision for these response services; so, whilst they are raising awareness and people might start to stand up even to family members and colleagues, they do not have anywhere to go with that, and it could be creating more dangers. There need to be corresponding response services. I know that the justice programme that DFID has just finished was funding response services to a very limited extent, but that was not connecting up. Voices4Change were not even providing information to the people they were working with in a rigorous way.

Pauline Latham

Is that one of the main barriers to women getting satisfactory justice?

Georgia Taylor

Not only justice, but services to be able to get out of the violent situation that they are in. There is nowhere to go. A community will possibly expel you if you leave your husband; or it might be your family who are being violent, so you do not have anywhere to go if there are no other services there. It is about being safe and being protected.

Pauline Latham

This is about social norms; it is about changing attitudes, isn’t it? Is that not one of the problems with the Chibok girls and other girls who are being taken by various groups—that sometimes their own families will not take them back because they have been violated? Is that not a problem?

Ojobo Atuluku

It goes further than social norms, because when you are talking about the Chibok girls, it is about how you reintegrate women in areas of conflicts. The girls have been away with the enemy and they have been there for some time, and when they come back people do not trust them any more because they have been with this feared group of people and so on. They are stigmatised and they face discrimination even from their own families, especially when they come back pregnant or with a child. They become a physical manifestation against which people can express their negative feelings because they cannot see the insurgents. They become a symbol of the insurgents that people target. There are a lot of barriers, not just the social norms. There are issues around how friendly women find the police station, for instance, to go into and report something. How friendly is the hospital? How friendly are different spaces? The federal Government instituted a family section of the police recently, but I think it is only seen at the federal level, so, by the time you go to the states, you do not see that. The judiciary in some jurisdictions have family law courts where a magistrate or judge is designated to a case relating to children or families, rather than having a professional space that they can have access to. There is also the barrier of finance, and there is the barrier of people abusing the system. When you come and do a report, the officials who are supposed to help you instead traumatise you further. There are so many things going around there. One of the things that you find women’s rights organisations doing is training groups of women on paralegal issues, but this just creates an awareness; it does not really transfer the skills of how you can help yourself.

Mr Sharma

Do you think the training of decision makers, judges and lawyers on the new way of thinking and moving away from those cultural backgrounds needs to be taken on?

Georgia Taylor

There are some trainings happening, but how effective they are is another matter. Just going to one training, particularly if it is technical training, does not necessarily change people’s minds and attitudes. I have done these trainings and I have watched other people doing the trainings, and sometimes you just will not get any change in attitude. People may know about the Beijing Platform for Action or they might know about the law, but they will still say, “I am in charge at home and I am the one who makes the decisions”, and that feeds into all parts of your life as a man. I am not sure how effective it is yet, but this programme of Voices4Change where they are really opening up the discussion with men is interesting in general, as a way of really starting that discussion and raising some of these issues with men and women together. I am not sure how effective one-off trainings are.

Ojobo Atuluku

There are parallel systems of governance in Nigeria whether we like it or not. You find the judges, the police and so on make up one system, while there are traditional systems in communities and so on. Usually programmes do not spend much time on them, and those are the places where the social norms are more difficult to break and those are the places where you need more time. Most DFID programmes are three years or five years at the most, maybe with an extension of several years, and you do not change social norms within that kind of window.

Chair

You have both touched on the question I wanted to ask, but I will still ask it in case you want to add any additional points or develop them. In the written evidence that we have had from DFID, it says, “The main driver of change must be Nigerian decision‑makers and the Nigerian people who together hold the key to achieving gender equality across Nigeria”. We have talked a bit about training and other factors, but what do you think is the best way in which there can be influence on the attitudes of policy makers to secure gender equality?

Georgia Taylor

As I touched on before, women and men who are champions in Nigeria need to be supported in holding the decision makers to account. It cannot be voices coming from the UK. Therefore, organisations need to be funded. There is always this challenge of what it means for the UK to be funding something and whether that means the UK is influencing it. There is a big philanthropy movement in Africa, and potentially there could be some work with organisations to support some of the management processes and fund the technical areas that could be supported to bring that movement on, because indigenous funding for these issues could be quite effective. But in general, supporting political leadership and women’s movements is important.

Ojobo Atuluku

One of the accusations we face as female activists in Nigeria is that we are driving a western agenda. My response always goes back to history. In 1929 women who had never heard about the West had riots against excessive taxation in a place called Aba. They succeeded and the tax was removed. We have women across our history like Hajiya Gambo Sawaba from the north, who never left Nigeria but was the epitome of women’s rights. There are other such characters across the country. Once Nigeria has signed up to any international commitment, the international community does have a responsibility to, in any way it can, facilitate each Government to be able to meet the responsibilities they have signed up to. That is the kind of role that I see DFID playing: facilitating. DFID cannot come in and change attitudes, but there are processes whereby local citizens and local influencers can be supported to bring about those changes. The problem is that if too much attention is focused on an individual, the system does not change—so how can you use the individual to work with others and change the system? It is a systemic and institutional change that we are looking for, not just a one-on-one individual change.

Jeremy Lefroy

Could we turn to considering the growth of employment in the states programmes? Georgia, I think you have been involved in them, particularly GEMS4. Do you think they have helped to bring growth that is more inclusive of women?

Georgia Taylor

I have worked on GEMS4 and on Propcom, which is more rural whereas GEMS4 tries to cover rural and urban. There has been a big struggle in trying to include women in these programmes, partly because the underlying analysis and research at household level is not happening well enough and there are all sorts of assumptions about what women do and do not do and their roles within the family. You cannot just make assumptions in terms of the family-based businesses. That has been a big barrier to doing effective work. Whilst there has been some progress and some interesting initiatives, there needs to be much more understanding; and also understanding about some of the barriers that are not related to markets, because women face barriers of unpaid care work and sexual and reproductive health—not having access to family planning or safe abortion is a massive issue for women trying to run businesses or go out to work. Some of those links are not being made for women within these markets programmes because they are just about the market. We have had discussions with the programmes to try to get them to understand some of the non-market-related areas. We define women’s economic empowerment as not just about earning money but about being in control of that money and being able to make decisions around assets and income, which means that you have to take into account these other issues. Because of the dogmatic approach to “Markets for the Poor”, this is not happening and we are finding it very difficult to bring in these other aspects, such that if it is not a market-based solution you cannot do it. Some of these things need to be subsidised, and there needs to be a much greater understanding of the power that women can have over their own income even within home‑based enterprises.

Jeremy Lefroy

Where is that dogmatic approach to “Markets for the Poor” coming from?

Georgia Taylor

It is partly the way people are applying it and possibly not understanding the depths of “Markets for the Poor”. If you look at the “Markets for the Poor” framework, you see “social norms”. You see “working with civil society”. You see all sorts of aspects in there, but the way it is being applied is not looking at the diversity of approaches.

Jeremy Lefroy

Applied by whom?

Georgia Taylor

By the programmes themselves. It is also partly to do with the social norms among the teams and the leadership. When I work with teams I say, “If your team leader is not behind this, you are not going to get the change that you need”. It is about putting team leaders into these markets programmes who are really committed to gender equality and to understanding the multiple barriers that women face, and also the rather creative solutions that are much more locally driven and that you can get behind. If they are not willing to do that and they are just looking at the next big company to make a contract with, which is really what happens, you do not get the whole team behind them.

Ojobo Atuluku

We need to learn from the past. Overnight Nigeria became the biggest economy in Africa, and the reality was that poverty also grew bigger, so there was something wrong with the economic system that was being touted. The fact is that, once we start driving the economy, we lose sight of civil rights and political and social issues. If these are not right, there cannot be equality in the economic sphere as well. When you look at programmes that are training women, they tend to focus on dressmaking, crafts and so on. In certain places, if everybody is making clothes, who is going to buy from each other? There are new opportunities in ICT and so on. The primary business to start with is education, because education is supposed to be the equaliser. Once quality education is there, people have the opportunity to choose the kinds of jobs that they want to do and the kinds of careers that they want to follow on. There are also other issues around the economy and altering the tax system so that the economy is not only for those who are able to use the system—the more you earn, the more you also give back to the community, and then those who are challenged can face it. For instance, you have tax relief for foreign companies but you do not have the same for local companies, which are even more challenged.

Jeremy Lefroy

In terms of education, it has often been said to us that you look at a curriculum, and even though most people are going to live the rest of their lives self‑employed, working for themselves, there is nothing in the education curriculum at primary level to prepare them for being an entrepreneur, which in effect is what most people end up being—90% of them will end up working for themselves, whether that is farming or something else. Do you see any sign of that kind of thing getting into the curriculum even at a very basic level in terms of how to look after yourself and how to be self-employed?

Ojobo Atuluku

The Nigerian Government recently introduced some reforms in the education curriculum whereby it insists that secondary schools should provide some practical lessons like photography, cookery or other particular courses that you can use to survive even if they do not go further into university and so on. The problem is that developing a real academic curriculum has been a challenge, so now we are using the National Youth Service as a training ground where we are teaching basic skills of business and so forth. Really that is not the right space.

Jeremy Lefroy

Sorry—the National Youth Service?

Ojobo Atuluku

After university you spend a year in the National Youth Service.

Jeremy Lefroy

But this is not at primary level.

Georgia Taylor

We should not underestimate the amount that young children can learn from their own families and their own communities, and also from informal apprenticeships. We were doing research on girls’ economic opportunities, and there were these informal apprenticeships. I myself learned from a family business. There is a huge amount you learn growing up in a business, as there is economic activity going on in the home, on farms and outside. I wonder whether building on that work that is already going on would be better rather than taking it into a school situation where you do not necessarily learn from real things. It needs to support and recognise what is going on already. There are also examples like the Women for Health programme, where young women who are not getting the grades they need in secondary school are given extra support when they graduate to become health workers so that they can get into those colleges. They are addressing things like childcare within the colleges and stigma against women’s employment within the communities they are coming from, so they are working with some of the rural communities to change their attitudes to women being employed and making sure that they have jobs afterwards. It is about looking at the whole trajectory right from education to higher education to employment, and even making sure there is more female leadership within the colleges. It is a really interesting example of how you can encourage people and address some of the barriers within each stage of the education and employment continuum.

Dr Cameron

During our visit to Nigeria, many members of the Committee were very struck by the fact that we met people at all levels of the political spectrum but very few women were within that sphere. My colleague Pauline raised it a number of times in the many meetings that we attended. How important is increased representation of women in Parliament—the Senate and the House of Representatives—to achieving gender equality? What can DFID do to facilitate that?

Ojobo Atuluku

I do not know if you saw the lady who was sitting here. She is one of the rare species as a Member of the Nigerian House of Representatives. Year on year, there has been a reduction. We have been having more women contesting and fewer women winning positions. I see it as the fightback of patriarchy, because there is an active agency of actors who keep women out of politics, out of power, out of decision making and so on. DFID has been funding work around democracy, and ActionAid are implementing a project funded by DFID that is looking at citizens’ engagement in the electoral process. In terms of the focus on women, DFID was recently working with the NDI, starting a specific strand of work on women in politics in Nigeria. Without women in the leadership, it is very difficult for anyone to focus attention on issues as women experience them. Yes, men may feel benevolent and they may feel kind, and a few men understand it as an issue of rights, but unless we are able to get more women in appointed positions at the national and local level, we will not be able to have the kinds of policies needed to bring about change. Men and women are victims of the patriarchy, so there is also a need to work with them—especially with women’s organisations and the women’s movement—to lead them out of that patriarchy and to be able to see things as individual rights and as a collective society’s progress.

Dr Cameron

To what extent was the rejection of the Gender and Equal Opportunities Bill a major blow to the advancement of gender equality? What do you think the Nigerian Government’s next steps should be?

Georgia Taylor

It is a blow. I was surprised that it was brought to the House so quickly. When I was there, only in November, it seemed that there was a longer timeframe planned and there was an awful lot of preparatory work that needed to happen. I don’t know; I am assuming that a lot of that preparatory work had not been possible. But it is also about using the word “gender”. There seems to be such a problem with it, and also with putting women at the centre. It is a big issue until people accept that something needs to happen, and it is a lot to do with lack of knowledge and understanding of what the issues really are. That is why I say this preparatory work is absolutely essential, and there is still potential and a bit of a groundswell, with people fighting back. The issue around women’s leadership within Parliament is that there are barriers as well, so even though more women might be coming forward, there are all sorts of challenges—as you will find in this House as well—around women participating within these kinds of spaces. What is enabling about it, and do we understand what some of the challenges are and the attacks that people might be under? That needs to be addressed before the Act can move forwards.

Dr Cameron

I was informed, when I was in Nigeria and when I was speaking less formally with some of the groups that we met, that access to economic empowerment is very important in terms of being able to access political empowerment. I wonder if you think that there is a connection between those.

Ojobo Atuluku

There is a big connection between the economic wherewithal of a woman and her access to politics. The political parties have set it such that, if you want a position, it is up for sale to the highest bidder. Unfortunately, the Independent National Electoral Commission has decided that it is independent and it cannot interfere in internal party issues. Even though we talk about the constitutional provision of protection from discrimination on the grounds of sex, the position is that, if it steps in, it is discriminating against men for protecting women’s rights. Yes, there is a massive correlation, and that is why a lot of programmes around women and politics are not working, because they build their capacity and understand the environment but they do not have the money to be able to do the kinds of activities that politicians need. Party financing is a grey area that we are talking about where we are advocating for transparency and limitations, which will go a long way to help. The gender equality Bill is something that was taken on from the last Assembly, which is why there was little work done on it. It has shown the women’s movement the picture of the fundamentalism that the women’s rights movement is facing in Nigeria and how there is a huge barrier, especially when you look at the statements by some of the male senators when it was being considered.

Chair

I am afraid we are out of time but thank you both for being superb witnesses. We have covered a lot of ground in just over half an hour, so thank you very much. We are going to move to the third panel on health. Feel free to stay in the Gallery to listen if you would like to. Thank you very much indeed. Examination of Witnesses

Witnesses

Dr Titilola Banjoko, Founder, Africa Recruit, and Dr Prudence Hamade, Technical Advisor, Malaria Consortium, gave evidence.

Chair

Good morning and welcome. Thank you both for being with us. You have been in the Gallery, so you know the format: we will go straight to questions, but please do introduce yourselves when you are answering for the first time.

Albert Owen

Good morning. I have a very general question to start this session: what are the main challenges that Nigeria faces in providing its citizens with basic health provision, given that it has some of the worst health indicators in the world?

Dr Hamade

My name is Dr Prudence Hamade. I am a medical doctor and I worked for 10 years with Médecins Sans Frontières in the field, and I have worked for eight years now with the Malaria Consortium. When I was with MSF, I was leader of the Malaria Working Group, which is the international working group of the five sections, and I also served on the paediatric and reproductive health working groups, because I am a paediatrician by background. I am not Nigerian, but I have visited Nigeria a lot of times and spent a lot of time there, particularly working with the SuNMaP programme from DFID. During the course of that, I did the first capacity needs assessment in Jigawa, Katsina, Lagos and Niger States, and the situation with regard to malaria control was pretty dire at that time. We also did a capacity-building approach in the federal national malaria control programme. The challenges faced are many, but a lot of them are to do with the number of health workers available and the type of facilities and the equipment in the facilities. It was interesting to listen to the education department, because exactly the same problem exists in basic health facilities. I am sure that, if you have visited them when you have been to Nigeria, you have seen that there are very few health workers, often with a very low level of training. Their training is often not reinforced once they leave their pre-service training. They do not know the latest guidelines and the latest policies from the federal Government. The national malaria control programmes were extremely weak. For example, in Niger State, there was just one very brave and noble woman who was running the whole programme. The equipment in health centres is broken and they have no drugs in storage. People do not come, because if you walk five or 10 kilometres with your baby to a health centre and find there is no equipment or drugs and, very often, not even any staff—or only the cleaner or outreach worker—you will not go. Instead they go to the patent medicine vendor and buy some drugs. Those are the challenges that still face Nigeria despite the big input from DFID and other funders. The health system does not really work. The new National Health Act is trying to put a functional primary healthcare facility in each ward at the LGA level, but that will take an awful lot of investment.

Albert Owen

You are painting a very depressing picture here. Moving forward—and of course we have some targets and Sustainable Development Goal 3 on health provision—do you think the national Government is taking this seriously? It has signed up to it, but is it moving forward?

Dr Banjoko

My name is Dr Banjoko. I am a Nigerian. I trained and worked in Nigeria as a doctor. Like most Nigerian people, I assumed the occupation that my parents had—my dad was a doctor who worked in the public sector and then went private because of course the income meant he could better sustain his family in Nigeria. We also support a clinic in a rural village in Nigeria where a doctor goes in to provide basic medical services. I think the Government is committed. About a month ago there was a statement by the Vice-President about revitalising primary healthcare centres, and “revitalising” was very crucial: it is not about building new centres but rather revitalising the ones that already exist. When I trained in Nigeria in the 1970s and 1980s, the healthcare was good. Sadly, I have watched the quality drop to a level where even people who can afford healthcare will not use those healthcare facilities in the country. That really is the challenge, but I think the Government is committed. As has been pointed out, there are issues around human resources, and it is not that there are no human resources but rather its distribution. The healthcare system in Nigeria is mainly private, as much as we like to believe it is public. The PwC 2015 report said that 27% of 3,500 healthcare facilities are public, with the rest being private secondary and tertiary care, and that is where most of the income is generated. As a result, you can imagine the deficit that exists. Healthcare insurance is something that the last Government and most Governments have tried to drive, but it is only 5% of the population. You therefore have constraints in terms of generating money privately. Again, access is the key thing, and that is where the challenge is, because it is not just the direct access financially for people who need it the most but also indirect access. If you think about the distance that people have to travel for healthcare, that means they are not going to access it.

Albert Owen

I have got two supplementary questions, one linked in to what was said earlier about the status of health workers; and, again in the previous session, we heard about the status of educationalists in Nigeria. Is that being taken seriously? I have met many Nigerian doctors in this country, where we value our medical profession. Is that improving in Nigeria? The other question is about universal health provision and the issues in the north. How are we going to get the best healthcare to the north of Nigeria, and how is the Government going to achieve that?

Dr Hamade

We have to take a different approach in the north, because access is extremely difficult. We have to start off by looking at a continuum of care. I do think that all of these vertical programmes that have been promoted under the Millennium Development Goals have been very good and have achieved, for example, a big drop in malaria cases even in Nigeria and even in the north; but we have to start looking at care across the board, and that includes the status of women and access for women as well as the overall health of a child. I am a paediatrician. If a person brings a child to me with a fever, I should not just say “Well, it must be malaria”. That may have been so in the past, but it is not the case any longer. You need to look at the whole child. Maybe the child has HIV. Maybe the child has pneumonia as well as malaria. Maybe the child has malnutrition, which is extremely common in the north. We have to have a much more integrated approach, and to improve access we also need to take care right down to the community level, especially where women do not have the ability to move away from their homes or even to go to the health centre very often. The SuNMaP malaria programme has been extremely successful in reaching its aims, but we now have to start looking at a more integrated approach and we have to bring care down to the community more, both for women and for children. We can train community health workers to treat pneumonia, diarrhoea and malaria and to diagnose malnutrition. Even in our programme in South Sudan, which we could use as an example, we can provide care for malnourished children right within the community. We have to start doing that where access is so poor.

Albert Owen

Would you like to comment on the status of the medical profession?

Dr Banjoko

It is not in a good state in terms of the way it is recognised by society, because generally speaking most people in the healthcare profession are struggling and therefore it does not prove attractive to people. Going into the healthcare profession is seen as going down the route of poverty. That was not the case years ago, but unfortunately that is what it is now. In terms of the model to adopt, we need to understand the ecosystem of Nigeria. When I said we run a primary healthcare centre in a rural area, it is using a religious institution because the networks and infrastructure are there, rather than starting a new infrastructure. In the north, as an example, you already have a number of religious institutions. It is about bringing in the community leaders and religious leaders to participate in healthcare service delivery so that people begin to understand their role in terms of accessing health rather than reacting when there is a crisis, at which point, more often than not, it is too late. How do you bring about that prevention agenda? We found it successful to use a religious leader who could talk in church about there being a clinic on a certain day and why people should go. By and large, even in the north, that is where it has been successful. It is more about partnership with the infrastructure that is already on the ground rather than trying to set up a new structure with the assumption that people will access that service.

Mrs Grant

You mentioned that the Vice-President wants to revitalise the health clinics, which sounds great, but in reality is the money there? They are not going to be revitalised on thin air.

Dr Banjoko

Everybody knows the fall in oil prices has obviously affected the budget. This government is more to the left in terms of their commitment to social investment programmes, so there is the willingness to do that. The feedback that I have received numerous times is: how does DFID work with other donors and philanthropy so that you gain a greater impact? The impact and scale will be much better than everybody running their individual programmes. That would possibly be something where the Government would welcome support from donors.

Jeremy Lefroy

Dr Hamade, you have already referred to SuNMaP and the success of that. Perhaps you could say a few words about that? You have also talked about the future. Do we need to have SuNMaP II? You were describing a more horizontal rather than vertical programme. How do we ensure that a more horizontal or inclusive health system does not lose the gains that have been made against malaria, and indeed other diseases under SuNMaP?

Dr Hamade

The SuNMaP programme, led by DFID, made DFID a real leader in malaria control, but it had a very novel approach in the sense that it was done entirely through the federal and state government programmes. It supported federal Government in its improvements and it supported the state governments. It had six outputs. The first one was capacity building, which involved building the capacity of state governments in planning, in finance, in budgeting and in making annual plans against which they could measure their progress. It also strengthened the federal Government in doing supervision of the state government. That was a really important and innovative approach from DFID that was done through the SuNMaP programme. It also focused on prevention and case management, but it had a particular focus on social and behavioural change and communication, which Dr Banjoko talked about in terms of involving communities at the community level and mobilising communities. Just telling people what to do is not good enough: you have to understand the constraints within a community and how to best work with communities to mobilise them. SuNMaP was very strong in that. The other area that was very important was operational research, and bringing the research community into the Government, so that the research community and the Government now hold annual meetings to exchange information about the way forward and applying research into policy. Those were very important aspects of SuNMaP. Some of those things would be good to continue. The malaria programme is now moving from control towards elimination, or pre-elimination. They have an aim to eliminate malaria by 2030, which would release a huge amount of funds etc. in health to the community, because malaria is still one of the major causes of mortality and morbidity in Nigeria. To move towards elimination, they have to change their way of operating. They have to put much more emphasis on data collection and surveillance. Surveillance is very important for all sorts of reasons and Nigeria, amazingly, managed to not have Ebola. That was a really important thing that Nigeria did, and it did that because it had labs that could diagnose very quickly. It very quickly took action to stop Ebola spreading and we really need to strengthen that surveillance system, both for health security but also for the elimination of malaria. That is one of the things that we really need to focus on if we want to eliminate malaria. Looking at general delivery of healthcare, we have to take the patient as a whole person, not a disease. We have to see what influences health right from childhood through adolescence, through maternity, through delivery, through infant care. Nutrition is one of my major interests, and I recently went to Sokoto State in the north of Nigeria to look at the services provided through DFID’s strategic funding and the provision for children. In some of the northern states, 70% of the children are stunted and 20% are severely malnourished. In that situation you cannot produce a healthy child, and so that child is much more likely to get malaria, pneumonia and diarrhoea, and we have to focus on those. It is about the continuum of care and looking at the whole person.

Jeremy Lefroy

I know we are very short on time, but I would like to ask one very quick question. Last week the Global Fund indicated that there had been severe corruption in its programme in Nigeria, which was being tackled, to be fair, by the Global Fund and the Nigerian Government. Is corruption a major problem within the health system of Nigeria?

Dr Banjoko

Yes. Obviously, you cannot take things out of the system in which they operate. It is a massive issue and challenge even in terms of contracts being awarded for large-scale healthcare procurement, which is in the media quite often. There is a role for civil society. There is a very active and vibrant civil society in Nigeria, with the programming and planning to become watchdogs of the funding that is given to the Nigerian Government and its budget. It is also about making it more transparent in terms of going down to local government level and making spending more visible and accountable so that the public themselves can see. Most citizens only became aware of the fact that something was not right when it came out from the Global Fund, whereas if there was a process by which this was transparent in terms of how much was given and where the money was going, and if people had seen it, we might have started making noises much earlier. The way the system is set up at the moment is that they mark their own homework, so in terms of quality there is not an independent healthcare body like we have here, where someone assures the quality of the service provision that is given. Only when you read horror stories do you realise that nobody is doing that. The healthcare providers trumpet their own successes in terms of the spend and the impact, but it is time for a totally independent watchdog that holds the Government to account. Citizens can also report malpractices that they see at every level. The corruption is not only at the top; it is down to the bottom, even in primary healthcare. When you say that primary healthcare is free at the point of access, more often than not they might have to pay for the drugs. Some parts of the service are free and other parts are not free; hence the need for an independent body.

Pauline Latham

You touched on malnutrition and the fact that there are a lot of under-five deaths and maternal mortality: the worst in Sub-Saharan Africa and the second worst in the world. What should DFID do to help that? Should they prioritise more systemic issues—for instance, hospital infrastructure—or should they focus more on tackling specific causes of maternal and infant mortality?

Dr Hamade

There is room for both, to be honest. In a recent study we did a survey in Katsina State and 79% of the people were not able to read a sentence. I do not know how you can make changes to women’s lives unless they have access to education. The education part was very interesting. We need to look more at the continuum of care. Why are girls getting married at 13 and 14? I recently went to a feeding centre and most of the mothers there were very young, aged around 15. They cannot breastfeed properly; they cannot feed the child properly. We need to focus on adolescents and, if adolescents are not in school, we need to have some intervention at the community level. We need to look at antenatal care. If women cannot come to antenatal care, we need to do something to bring the antenatal care down to them. We need to focus on the whole of the woman. We need to look at HIV, malaria, TB and the sexually transmitted diseases that affect women, but we also need to look at nutrition and at their access to safe delivery so that, if they cannot come to deliver in a centre, perhaps we need a flying midwife service that would go out and allow them to deliver in their own homes. We have to think outside the box. We have to teach family planning. Family planning is really important. The average number of children in the north is six, and if there is no food, how can they feed six children? We need to look at immunisation. We need to look at all of those things across the board, but we need to think in general about how we can bring the service down to the people rather than expect the people to come up to us.

Dr Banjoko

It is important to look at what already works. In Ondo State, for example, the governor happened to be a medical doctor, so they prioritised health, and they delivered excellent gains and used different technology such as mobile phone access. It is about looking internally within Nigeria to see what is already working and whether that can be done at scale across Nigeria.

Chair

Can I ask about HIV and, in particular, the areas that DFID should be working on both in seeking to stop the further spread of HIV but also, crucially, in supporting those who are living with HIV in Nigeria now?

Dr Banjoko

My experience of HIV in Nigeria is that many people do not have it, by which I mean there is a stigma around having HIV. A lot of people would not admit to having HIV and would not admit to spreading HIV. There is a massive cultural norm around HIV that presents a barrier where things spread rapidly. Of course there are a lot of cultural norms around multiple wives or multiple partners, which further exacerbates the problem. There needs to be a lot more mass awareness of what HIV is, bearing in mind how you can still protect people so that the implications of having HIV do not affect their livelihoods. If people do come out and say that they have HIV, there are implications for family, work and everything else. It is about protecting people while creating mass awareness, including the fact that it does not lead to death. It is about the perception. Nigeria is a very religious country. People would listen to the religious leaders, and there is a perception among the religious leaders that it does not exist or that it can be cured. You spoke about Ebola. One of things about Ebola and the success in combating Ebola was that the governor came out and categorically made a statement that no religious statement should be made about curing Ebola, which dispelled any informal process of people going to seek help from religious leaders. There needs to be a lot more leadership at state government level in terms of mass awareness and communication of what HIV is and what it is not, so that people are aware and can seek help and support.

Dr Cameron

In written evidence submitted to the Committee, DFID explained that its approach in Nigeria is about influencing how Nigeria uses its own resources. In your assessment, how can DFID ensure that the strengthening of health systems is prioritised by both the federal and state governments in Nigeria?

Dr Banjoko

There has been a lot of talk about public-private partnership in Nigeria and the fact that healthcare is mainly private in terms of the percentage of healthcare providers that offer services. There has also been a lot of talk about how they can use a private-public partnership to be able to do things at scale. This is an area that DFID should look at. It is estimated that Nigeria loses about US$1 billion annually to medical tourism as a direct and indirect cost of people who can afford it leaving the country to seek healthcare abroad. We need to think about how we can retain that money in the country, such that institutions can build and deliver better services for the population. The Government can also use some of those facilities if there are incentives to deliver healthcare to those who cannot afford private care. That really calls for a public-private partnership and the role that the Government can create in enabling the framework for that to happen.

Dr Hamade

Ensuring quality of care in the private sector is also very important, because the private facilities that I visited are of very poor quality. People see them as better because, for example, they might have an echogram but they do not know about malaria care or about diagnosing HIV. The people providing that care are often poorly trained and are not involved in any Government training or capacity-building programmes because they say they do not have time to spend on a training course and they need incentives to go to training. Public-private partnerships have worked in other places, particularly around malaria, because if you want to eliminate malaria you need the data from the private sector. SuNMaP, in fact, worked with the private commercial sector in producing nets, for example, so that nets were available. We have also worked with the private sector in training patent medicine vendors to test for malaria before treating. These things are really important to engage the private sector, but I do think that, if the quality of the public health sector improved, people would go less to the private sector. Although there is a perception that quality in the private sector is better, it often is not.

Dr Banjoko

It is better than the public sector, but it is not up to standard, and that again calls for an independent person to quality-assure services and for people to understand the implications of that. Additionally, the public who are receiving the services know what is not working, but there is nowhere for them to go. Nobody has data on harm in hospitals in Nigeria but rather will tell you individual stories. Here, I know that there is data; you can see where harm is happening and you can investigate and bring an end to it, but there is nothing like that in Nigeria. People are left to seek compensation themselves and, more often than not, it does not happen.

Chair

Thank you so much for your evidence today. You have been great witnesses and, again, as in the previous two panels, we have covered a lot of ground and we are really grateful to you for joining us today. Thank you, everyone. Oral evidence: DFID’s programme in Nigeria, HC 676 7