Foreign Affairs Committee on April 23rd, 2015

[Marc Garneau, Liberal, Westmount—Ville-Marie, QC]

Very good.

[A voice]

I was going to let Eva answer that one.

[Marc Garneau, Liberal, Westmount—Ville-Marie, QC]

Sure, absolutely.

[Eva Slawecki, Interim Executive Director, Canadian Society for International Health]

I just want to add that, as Mr. Morley pointed out, many of these records departments are just filled with paper. There often is a culture of collecting useless information—a lot of information. Physicians, community health workers, nurses collect information. What's lacking is the collecting of the good information and using it properly.

One of our projects in Tanzania witnessed an interesting event wherein one of the districts reported a vaccination rate of 120%. We said “Something's wrong here. Are you fudging the numbers?” The physicians weren't and the community health workers weren't fudging the numbers, but the census data—the denominator data they were using—was terribly outdated. The population had grown. The number of vaccinations that had been provided was correct, but they were basing it on a poor denominator from poor census data.

So it's all tied together. How can the planners ask for more resources for their vaccination programs or other health programs when the numbers they're using don't support it? It's all tied together.

[Marc Garneau, Liberal, Westmount—Ville-Marie, QC]

Good. Thank you.

Dr. Bhutta, you mentioned one of the millennium development goals respecting mortality at birth or soon afterwards, and maternal mortality as well. I'm certainly encouraged to hear that there has been an improvement with respect to these rates.

I can guess what some of the factors are that help to reduce the number of deaths. Can you zero in on any particular measure or set of measures that have been particularly effective in allowing us to diminish the number of deaths?

[Dr. Zulfiqar Bhutta]

Yes, thank you.

In particular, what has been successful in the last decade for child mortality reduction is immunization. The scaling up of vaccinations and the provision of these vaccines to countries that would have had no hope of ever getting them through GAVI and other mechanisms has been an extremely important factor.

There has also been a considerable impact of improvements, where they have taken place, on provision of skilled birth attendants. Maternal mortality reduction, to a large extent, has been related to changes in practices, moving from home births to births within facilities, and thereby there have been reductions in some of the morbidities and causes of maternal deaths.

Be that as it may, as I pointed out, this progress isn't universally distributed amongst the countries that have the highest burden. A lot of this is, in the global scenario, dictated by a relatively small number of countries, countries like Brazil, China, and perhaps to a certain extent India. There are also remarkable examples of countries like Bangladesh, which has made tremendous progress through concerted government effort and a focus on provision of care to remote areas, to women, through community health workers, through provision of interventions, through innovations, and again, through health workers who can reach populations that were difficult to reach.

I did want to take the opportunity of making just one point around this important issue of reaching babies early, reaching mothers and babies within the critical period around childbirth. There is a huge opportunity with this important focus on birth registration. Now, we don't necessarily only do this because it makes good sense; it can actually have an impact on mortality. Our data indicates that it does: a post-natal visit to a mother and baby can have an impact on survival, on picking up on problems. But I think there is a huge opportunity here of incentivizing that.

In many countries there is this importance of linking some of that early documentation, such as immunizations, to things like school entry and admissions. I wonder if there isn't an opportunity of tying it all together to incentivize the important issue of registration at birth, coupled with strategies to reach those families in difficult-to-reach slums and rural populations, with the benefits that will come out of such a birth registration process that are tangible and visible to families, such as benefits in terms of school entry and other benefits that can be linked to conditional cash transfers, etc.

[The Chair, Conservative, Dean Allison]

Thank you, Mr. Garneau.

We're going to start our second round, which will be five minutes.

We're going to start with Mr. Hawn, sir, for five minutes.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

Thank you, Mr. Chair.

Thank you all for being here and for what you do around the world.

Dr. Bhutta, I want to start with you. You talked about what we would certainly call barbaric practices: female genital mutilation, early and forced marriage, and so on. I think you said the FGMs are being carried out by medical professionals for the most part, or a lot of them are. You focused on the 29 countries in Africa and the Middle East.

How much of that is culturally and religiously rooted? Can we ever change that, particularly on the religious side? Can we ever hope to change that? We may tap dance around this, but is there a religious determinant of health?

[Dr. Zulfiqar Bhutta]

Mr. Hawn, thank you so much for that question. I'm glad you asked it because I've been asked this before.

The answer to that is absolutely not. It's a lot like some of the religious misinformation around vaccines. The campaign against polio vaccines, that there is some idea that they're against religious tenets, is misinformation that we have now shown can be very effectively tackled.

In Nigeria, where there was such a pushback against polio vaccines because they were considered un-Islamic—or for that matter containing things that would somehow or another produce sterility or infertility—it's now been shown over the last year that, with education, with community engagement, and with mobilization of community volunteers, this can be addressed very effectively. My group has done so also in the federally administered tribal areas of Pakistan.

I think that, around female genital mutilation, there is a very promising trend of gains and improvements. When I mentioned the health care professionals as being responsible for 20% or so, from available statistics, I also pointed that out as being the low-hanging fruit. As a group, we can tackle that much more efficiently than trying to get through to a lot of lay workers and quacks out there.

There needs to be a very clear focus on engaging communities, sir, and also religious leaders, in getting the message out that this barbaric practice, which actually precedes both the Christian faith and the Islamic faith and any others in the region, has absolutely no roots in religion. There are now very strong religious edicts, available from some Islamic scholars, against this practice.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

That's encouraging.

Mr. Morley, I think you talked about your reporting and so on, and the difficulty in some places of getting accurate data. There's mounds of data that mean nothing. It sounds like we're making progress. How important is that to give donors comfort that they're actually putting their money somewhere that matters?

[David Morley]

Absolutely. First of all, for the donors it's important that we can really show what we do when it's with UNICEF, the Government of Canada, or if it's somebody who's given us a hundred dollars at Christmas. So we put a lot of work into that.

But it also means we can do a better job of figuring out what to do next when we have the right information and when we look at it honestly because it helps shape the programs that we would be doing or that colleagues would be doing, because UNICEF gathers a lot of data that we share and others use as well.

That notion of accountability and transparency that I know the Government of Canada has been leading on in the last few years is extremely important, not only just in our field, but in all of these efforts, because if we just go with rhetoric, it's not going to be good enough.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

Yes, I understand.

Mr. Chauvin, you talked about—and Dr. Bhutta mentioned it too—immunization and getting over some of the misinformation, and so on. I'm assuming that Jenny McCarthy is not part of your program.

[Voices]

Oh, oh!

[Laurie Hawn, Conservative, Edmonton Centre, AB]

You talked about the importance of organizational development. Obviously that does take time, and so on. Do you have an example from your experience of somewhere out there that has made significant progress, and the ability to use that as a template somewhere else?

[James Chauvin]

Yes, thank you. I'm going back to my former work with the Canadian Public Health Association. It was a CIDA-funded program that also received funding from the Pan American Health Organization and the World Health Organization. This was the strengthening of public health associations program in which we helped nurture the creation and organizational capacity development of non-governmental public health associations.

Over the 25 years that we received funding for that program, we helped create 32 public health associations around the world. Some of these are now leading public health associations in their own right. For example, the Ethiopian Public Health Association, which was founded in the late 1980s, has done an incredible job of advocacy on different health issues with its own government, and actually convinced the Government of Ethiopia in the early 1990s to create a women's directorate within the Ministry of Health. It was the first time that had ever happened.

When they achieve things like that, I think it's a feather in their cap that we have to applaud. It takes time. In Ethiopia, the public health association is now one of the leading organizations in that country and has sought to partner with UNICEF and other organizations. When we have this happen, this is the type of thing we want. We want to build that local capacity. It's not CPHA or CSIH being there; it's their being there, but we're giving them the support to help make it happen.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

Thank you.

[The Chair, Conservative, Dean Allison]

Thank you very much.

Now we're going to turn it over to Madame Laverdière for five minutes, please.

[Hélène Laverdière, NDP, Laurier—Sainte-Marie, QC]

Thank you very much, Mr. Chair.

I'll start with a few comments. Maybe I am more optimistic than Madam Brown. I am not quite sure about donor fatigue, as the OECD registered a significant increase in ODA from various countries—not Canada, of course—last year. This year there is still an increase, so I am not quite sure we can speak about donor fatigue. Sorry, it's a French word and I can't pronounce it in English.

I was quite struck by your comments, Mr. Chauvin, that we should look at ourselves also. Would it be used in Canada or public health institutions, or even the census maybe? That is my point of view. I think it matches very well with the sustainable development goals that are being developed and that are going to be universal, which means that we will have to look at ourselves also.

I was struck by the answer you gave, Dr. Bhutta, about female genital mutilation. I lived in Senegal for a few years, and they basically managed to get rid of female genital mutilation, which indeed was not linked to a religious belief or anything like that. As you said, it was through working with community leaders and religious leaders, and also offering an alternative job to the women who used to do that, which is a very practical thing—training them to become nurses, midwives, and other things—along with education. It did work.

I am finally getting to my question. The issue of education is absolutely key. Do you think that sexual education is also important and can help prevent early and forced marriages?

Maybe Dr. Bhutta can begin, and then anybody else who has something to add. It's sexual education and women's empowerment, of course.

[Dr. Zulfiqar Bhutta]

Madam, thank you very much for your comments.

I completely agree with you in terms of the innovations and strategies. I would say that perhaps the order in which these have to be included within the curricula and programs in the countries has to be culturally contextualized and be pragmatic. Where the issue is just getting girls into school and ensuring that the drop-out rates are reduced and that, if girls are going to school, there are career and development opportunities and something tangible that families can see, I think that has to come first.

When I talk about girls going to school, Madam, one of the big issues is the infrastructure of the schools. I work in South Asia and east Africa where if you do not have adequate structures, if you do not have adequate toilets and running water in those schools, then to expect girls to stay in those schools the moment they reach puberty is impossible. One of the biggest reasons for dropouts in many of the environments is that these structures are just not girl-friendly and are therefore a barrier in terms of families sending young girls to these schools. I think getting girls into school and having a formal education system are extremely important. Once that is in place, and once the community and families are comfortable that the education the children are getting is meaningful, tangible, and has some social value, then I think including things like reproductive health and sexual education within those curricula is absolutely fine. Where we run into trouble is when we put the cart before the horse. Even before education has permeated and families have confidence in the whole system, if we start with things like HIV education and education on some of the issues that have hitherto been taboo subjects, they become an additional barrier to attracting people to schools.

I think there is a process. In that process, I absolutely support the notion of having health, reproductive health, and sexual education within those schools and within the confines of cultural acceptability.

[The Chair, Conservative, Dean Allison]

Thank you very much.

We'll now finish off the second round with Mr. Trottier for five minutes.

[Bernard Trottier, Conservative, Etobicoke—Lakeshore, ON]

Thank you, Mr. Chair.

Thank you to our witnesses for being here today. Thank you for your presentations.

Doctor Bhutta, you mentioned in your presentation that the last decade has been a “phenomenal decade in human history”. I sense that a lot of that was based on different countries working together towards a common set of objectives. I think the millennium development goals were very helpful in getting countries focused on the countries that were providing some of that development assistance and providing some of that effort, and also on the countries that were on the receiving end.

You mentioned a couple of things. One was about the need to be more involved in terms of adolescent boys. Part of the problem is with regard to social determinants around things like teenage pregnancy and so on. Are there development goals currently, or are there development goals being discussed for the next round of development goals, associated with that challenge of adolescent boys? What are some things we can try to marshal our thinking around to try to focus on that challenge of adolescent boys in developing countries?

[Dr. Zulfiqar Bhutta]

Thank you, sir, for your question.

This is indeed an extremely hot topic as we speak. In the quest for getting a democratic and engaged process worldwide, the development of sustainable development goals and the indicators related to that has been one of the most involved processes I've ever witnessed. It's quite a contrast from the way we set up the millennium development goals in the year 2000. It has also led to this plethora of everybody wanting their favourite target and favourite indicators in. But we are now in a situation where, in the final stretch, I think there is consensus.

I'm looking at a document in front of me, which is for global consultation, that says there should be targets related to adolescents, and there should be targets related to what the world should set itself to in terms of particularly specific goals that it can achieve within its own countries. It talks about universal health coverage. It talks about access to reproductive and other services. It talks about quality education.

Now, in quality education, there is a target percentage of youth and adults proficient in literacy and numeracy skills. I think on balance we are moving towards measurable things that governments can potentially begin to recognize and give value to.

As you mentioned, the millennium goals were successful because country X versus country Y versus country Z could see a common metric for comparison. As we move forward, I hope that in the sustainable development goals for adolescents, for both girls and boys there will be tangible goals: boys will not be ignored just because our focus has been on adolescent reproductive health in girls in particular.

[Bernard Trottier, Conservative, Etobicoke—Lakeshore, ON]

Some of the other witnesses may have comments to add to that.

Go ahead.

[David Morley]

I've read through the 17 goals and 169 indicators, and I am concerned that....

I think you've raised an important point, that when gender inequity is discussed, what is discussed is girls. That's very important, and of course we have to do all that. But clearly, how do we work with boys who are not then going to be threatened by the empowerment of girls as things start to change? We have to show that everybody wins when there's greater equality.

I've only read these—I haven't tried to unpack them too much—but in my reading of them, I haven't seen enough about boys. When we talk about gender, I think it's only girls and not that relationship. It's important, I think, that we talk about both. Otherwise there will just be backlash.

[Bernard Trottier, Conservative, Etobicoke—Lakeshore, ON]

Mr. Chauvin, you had some comments to add on that?