Select Committee on International Development Minutes of Evidence

Examination of Witnesses (Questions 560 - 579)



Mr Worthington

  560. Getting one's mind around this, what is the proper response of DFID, what is the proper response of a development department? I can see that your work on prevention is crucial, is absolutely fundamental. Where I have difficulty is where it gets into care and the provision of drugs. It is a bit like you are saying the problem with education is that the elite in a country want to put all the money into higher education and neglect primary education. Is there not a danger that development budgets will get skewed by AIDS as the demand comes for more and more high expenditure there and that is for someone else to do rather than for a development department? Does that make any sense?
  (Clare Short) It does indeed. Just as the same problem that there is with education, there is with health care. If you look at a lot of developing countries, of the health care budget, which is usually inadequate, a major part is spent in hospitals in the capitals and in the cities and very little on a primary health care system reaching across the country. This is very important for treatment of basic illnesses, immunisation of children, access to reproductive health care and so on. We have that same battle, it is elite versus poor people. It is a very big battle for us in all our programmes. On HIV/AIDS the French Government and a lot of American AIDS lobbyists are making this demand for antiretroviral drugs to be made available and saying "This is an absolute moral issue. It is prolonging life in developed countries. If they are not available this is unjust". These drugs are extremely expensive even after the drug companies have said they will supply them at cost. They are something like three dollars a day. There are a lot of countries in Africa that spend less than ten dollars a head a year on health care. That is my biggest worry, that the fashion will be access to antiretrovirals. We have not got primary health care, we are not even reaching people. They have not got enough food, soap, water, very, very fundamental care. Budgets could be sucked into a kind of fashionable campaign to make antiretrovirals available which again would necessarily be in the cities and would not reach all the people. I think there is a danger there. I think if we stick, as a Department, with our poverty objectives and we mean by care, primary health care for all, get to scale, include all, focus on the poor, care for orphans, we are going to have an awful lot of children growing up in households without enough food who are going to be stunted. Their education is endangered. That is a priority for our Department, but if we, as a department, protect our focus on the poor it keeps us right. It is when fashion pulls them in other directions that—and I think this is a danger for the international system and for many countries—their spend will be focused on getting antiretroviral drugs to the elite and the poor old poor will just be left out.

  561. Can I stick with the prevention aspect and ask what you think our priorities are in terms of prevention activity? One of the areas, just to throw in, is that we receive continuing reports that, not just DFID, but the world community, cannot get a basic issue like the issue of prevention. There just is not an adequate supply through the sub-Saharan Africa. Why is it that we cannot get—not only DFID, but the world community—a basic issue like that sorted out within that issue of prevention? Do you think we have our priorities right in terms of investment or, for example, in terms of microbicides, or in terms of vaccines, or generally?
  (Clare Short) Could I say, Chairman, I have to go to a Cabinet Committee at 12.00.


  562. We have been notified that you have to leave at about 12.35.
  (Clare Short) That is fine, yes. Sorry, I am wrong. I am going to ask Bob to come in on prevention. On condoms we are very interested in social marketing and helping to provide supplies, but again you cannot just throw money around, it has to be good procurement and supply systems, and I think that is where the restraint lies. Again, it is gesture spending when you have not got systems that take through the supplies to people who need them, you will suffer, and then you get into corruption and all sorts of other problems. On the point of microbicides and the vaccine, we have been backing work. We were the first Government to contribute to the vaccine research and we are very interested in that and determined to support it. A microbicide that works has not been found yet, but we will continue. Would you like to comment on the condoms and prevention in general and whether we are putting our efforts in the right places?
  (Mr Grose) As a general statement first, I think we are putting our priorities in the right places and that is condoms and STD treatment.
  (Clare Short) Can I just say that STD treatment is massively important. It fantastically slows the spread.
  (Mr Grose) The condoms and STD treatment is work that has been going on for a long time, but there needs to be more done, it needs to be intensified. The vaccines and the microbicides will not become available until sometime in the future, so they are a longer-term strategy. It is a bit difficult to say what is more important. What is more urgent is getting more condoms out and getting more access for people to STD treatment.

  563. What is the—
  (Mr Grose) Some of it is simply that they are not in the right places at the right time because of lack of cash, but more often—we have done a bit of looking at this over the last week and getting feed back from UNAIDS and from our people in our own field—the problem is in logistics management. Governments are not forecasting their needs accurately. Several of the countries in the southern zone of sub-Sahara Africa do not have condom logistics officers in their national AIDS programmes. Some of the external agencies that are supporting them are providing those logistics officers. We are hoping that that part of it will improve, but as the Secretary of State was saying, it is not just a matter of shortage of product, it is also a matter of planning.
  (Clare Short) Often it is organisation and will, and its system. Poor countries have systems that just do not work and there are often people running their systems who have ulterior motives and are not focused on making them work. If you inject supplies of condoms into a system that will not deliver them across the country—

  564. Is this saying that any reasonably functioning Department of Health can get the condoms?
  (Mr Grose) I think they can.

  565. So there is no real supply problem, it is an organisation problem?
  (Mr Grose) We are not aware that there is a global shortage of condoms, it is more a factor of getting them to the right place at the right time.
  (Dr Lob-Levyt) There are enormous problems with forecasting needs of individual companies getting them and bringing them in, and that is largely a systems issue. There are stock-outs from time to time. Certainly we need to get that organised, but globally there are sufficient resources and sufficient condoms.
  (Clare Short) If we got a big improvement then supplies would have to be increased and we might have the other problem, but it would be a good problem to have.
  (Mr Grose) If I can just add, the concern is not only a matter of getting them into the country, it is a matter of getting them to the right people at the right time. We do know where there are social marketing programmes, they are not necessarily always available and of the highest behaviour, but there are condoms getting to the right places.
  (Clare Short) That is the high risk population of course, but spread that out into the main population.

  Chairman: Can we move on to care and health planning, and we have been talking about antiretrovirals?

Mr Khabra

  566. I am going to ask a straightforward question. Given the scarce resources that are available to developing country health services and the many aspects to the ill health of the poor, resulting in some cases in TB and malaria, in your opinion what priorities for expenditure should be adopted by health services in countries of high incidence of HIV/AIDS?
  (Clare Short) I believe that all poor countries need a universal primary health care system, and for something like as little as $12 a head a year you can get a basic primary health care system reaching all, then you have a mechanism for immunising children, giving people access to reproductive health care, proper supervision of TB treatments and malaria advice. Then you have a network. In most countries we have not got that and it is not the property of the Government to get a universal primary health care system. That is our passion in health and our work. You need them, it is not just the odd clinic here and there, you have to get a Ministry of Health that is determined to have that outcome that will reform itself and its budgets, and train its people and get a service right across the country. I think there is no divergence then between the priority for better HIV care and reaching people. The other health care issue is to get a primary health care system right across the country. We have an enormous battle to get that. It is elites versus poor again.

  567. Would you agree that with a country like India with a massive population that a primary health care service that is universally available to people is impossible?
  (Clare Short) No, I do not agree. I think what we are seeing in India is a massive divergence state to state with the quality of development and service provision, and I think India has enough capacity and highly educated and capable people that with real will it could have primary health care across the nation. I think it is a matter of will.


  568. Is it true that over 70 per cent of India's health care is provided by the private sector?
  (Dr Lob-Levyt) That is correct, I think that is the idea of the future. When we need to look at health sectors we are not just looking at the provision of health care. There is a rapid expansion of the private sector to deliver public goods, that is as true in HIV as in anything else. In India we are seeing an increase in households' private spend on health care. That is enormously important. We need to understand that and work with that.
  (Clare Short) If I may, because it is the same in Africa and often when you have useless public systems people turn away from them and spend money that they can hardly afford in the private sector, sometimes on inappropriate drugs or on inappropriate care, but if you look at the health spend of poor people a lot of them are spending ineffectively in private interventions, whereas if you can pool that resource and get the public sector provision cleaned up and improved in quality, but recognise that people are willing to spend money on drugs and somehow pool it, then you can get them a better service for less money than they were spending in the first place, and that is the kind of way we tend to go. That is the kind of way in which we tend to go. If you are very purist and you say "we do not want any private sector input" you do not get any reform and you cannot improve the quality for people.

  569. That is the point. We also got reactions from Indian people whom we met saying "if you do not pay for it, the medicine is no good". You have got to roll with what they believe and what they do to get the proper programme.
  (Clare Short) I think we are.

  Chairman: We must run on quickly to multilaterals.

Mr Colman

  570. You said at the beginning that UK DFID work is only part of the international system and we cannot do it all on our own. I wonder if you could comment briefly in terms of the European Community, the World Bank, IMF and the UN family. Starting with the European Community, what are the strengths and weaknesses of the European Community HIV/AIDS programme, what is its added value and where in the future should it concentrate its resources?
  (Clare Short) If I could make one short preliminary remark. There has been a tradition in the past that bilateral is best and that spending into the multilateral system is an obligation that is regrettable. We have changed our view on that because, of course, getting some leverage into the multilateral system and getting it to be more effective is getting an international development system that works everywhere rather than just having some nice UK programmes. We have put much more energy and effort into improving the quality of the multilateral system and we have put more resources into bits of it that work to try to get a more effective system and I am sure that is right. A more effective system, talking about the EC, the one thing my father always used to say when you did badly at school was "if things are very bad it is quite easy to improve"—

  571. Did he say that to you though?
  (Clare Short) He always said it to us when we did badly and the other thing when we did well. The EC's technical work, there have been some very, very good people in Brussels doing some very good thinking that the Department admires but not much implementation. It is better to have good thinking in the middle than bad thinking in the middle and not much implementation, so that is an advance, but we think that with an agency of that size and with that funding the EC could do more to implement and release good analysis.
  (Dr Lob-Levyt) I completely agree with that. There are some good initiatives under discussion at the moment with the European Commission to actually pay money in partnership with WHO to advance the HIV agenda, looking at commodities and services. I think that kind of way of spending for the EU where it acknowledges that it is, as yet, less effective on the delivery on the country level may be one way forward.
  (Clare Short) The WHO is an agency that was poorly performing under a reforming leadership, so we have to watch. The fact that the leadership is reforming does not mean it is necessarily always an effective implementation agency but I think the EC are thinking about putting some resources through other agencies to get some spending going and we have to watch then that it is quality and not just speeding up the spending but not doing it well. Then you have World Bank investment.

  572. If I can say, particularly we were interested in terms of whether there should be an HIV/AIDS focus in the poverty reduction strategy papers arising out of the HIPC initiative? Should the structural adjustment be handled differently in such areas as, for instance, charging for health and education or the slimming down of public services staffing?
  (Clare Short) We believe the poverty reduction strategy papers is an enormously important shift in the way of working of the IMF and the World Bank. I have been recently to Tanzania, Rwanda, there is one being prepared in Kenya, Bangladesh is just about to start. It is a totally different and better way of working for the IMF, the World Bank and governments where you look at your macro-economic strategy, the whole of your public expenditure, that means revenues, debt relief and aid money, the priorities in different sectors, and within that, because otherwise people say it is health if it is all hospitals or education if it is all university students, having it published and open so everyone in the country can be part of it and then all donors collaborate behind that instead of having lots of separate projects. That is the big shift. It is very important. We need to drive it forward into implementation and then, within that, absolutely HIV should be there. It is a development challenge to countries and it should be part of the programme that they have a programme for the nation. I think the World Bank has been a bit slow on HIV. Is that fair? It has declared 500 million, has it not?
  (Mr Grose) Yes.
  (Clare Short) At Durban. But people have to borrow from the World Bank. It is all very well saying "here you are, here is 500 million" but governments have got to be wanting to make use of it, so that is a bit of a notional fund for headlines. The Bank is put under enormous pressure to do that. I think the Bank is taking it more seriously, is that right?
  (Dr Lob-Levyt) Yes, the Bank is definitely taking it more seriously.

Mr Rowe

  573. In relation to the EU, my understanding, and I may have got it wrong, is that at the moment the EU has difficulties when a notional figure is put into its accounts and it is not allowed to set against that figure the administration of the programme costs. I think one of the things Chris Patten is trying to do is to enable them to have the administration costs taken out of the project money. Am I right about that? If I am, do you approve of that?
  (Clare Short) There is a new agency to deliver services. It will be allowed to use running costs for some stuff, that is right, which we do as a Department. We think a separate agency is not ideal but it is the best way for the EC to go. It does not mean it will be good. We have to watch it and try and make sure that it is an effective agency. One of the big excuses is they do not have the staff, they want more staff. We say "use the staff you have got better, do not ask for even more weak resources to be thrown at this wasteful operation". So, you are right, but watch the excuse that it is all hopeless because we will not give them more staff and what they need is even more resources and more effective programmes that we all run in our nations.

Mr Colman

  574. The third part of this sort of hierarchy is the World Bank/IMF, the UN family. You mentioned about the EC working with the World Health Organisation. Do you think there is an effective co-ordination within the UN family and amongst all donors? At which point, if you like, in this hierarchy do you think it is most effective for DFID to get involved? I agree with you that a multilateral approach is important but which particular area would you see as being most effective?
  (Clare Short) I think we think that Peter Piot is an enormously good man, UNAIDS, very dedicated and good analysis. He has been given a very difficult mandate and a difficult way of working, getting a whole series of UN agencies to work together. Their implementation has not been very good by the UN family. The commitment to do more implementation and make it more co-ordinated is very important. In general the UN family is much less effective in general than it should be. The reforms that Kofi Annan has brought in to get them all in one UN house in a country and have some co-ordinated view of what is needed in that country so they can complement each other, not compete with each other and work separately, is absolutely right but there is a long way to go to get that implemented. I think that is true on the HIV/AIDS work too. I think we are strongly supporting the effort to have a co-ordinated programme in Africa but that has yet to be implemented.
  (Dr Lob-Levyt) I think I would agree with you. An example of a new partnership is the International Partnership Against AIDS in Africa which has taken a long time to get going. It is beginning to look a lot more promising. We have been actively involved in discussing how that partnership will operate, what it means, and ensuring that African governments are very much in the leadership of that. That is the way we see ourselves interacting.

  575. Is that working with EOAU?
  (Clare Short) Are the EOAU involved? The Economic Commission for Africa?
  (Mr Grose) They have been. They have been discussing it. They are now proposing a major conference for presidents, ministers of finance, ministers of agriculture, ministers of education and so on.
  (Clare Short) Is that the Economic Commission for Africa?
  (Mr Grose) That is the Economic Commission.
  (Clare Short) The UN body based in Addis Ababa.
  (Mr Grose) Through the Africa Development Forum. Again, to say it is happening is not to comment on its effectiveness.
  (Clare Short) The real collective answer to your question is there have been bits and pieces of different parts of the system. We need this sea change of government lead looking right across all the sectors using all the best knowledge of the international system, getting it to scale and applying it across the board. We are just at the beginning of aspiring to that. That should be what the next real push is about. Everyone needs to improve, donors need to collaborate more, governments need to give more lead, UN operations need to come in much more collaboratively behind that effort and we are nowhere near that yet.


  576. That is where we have to get to if we are to tackle this problem.
  (Mr Grose) If I can just add to give you a specific example of coordination. I think DFID works with headquarters of the UN organisations individually as well as with the UN sector. We also work with the UN officers in countries. One particular area where there is a lot consultation going on at the moment is in education, so there are informal work groups going on at the moment which involve the DFID, the World Bank, UNAIDS as well. It is a specific example of how there is a lot of flexibility around the kind of co-ordination that is beginning to happen more and that needs to happen more and the umbrella. It is also an example of how many players there are and how you can spend all your time co-ordinating and not getting anything done.

  Chairman: Can I ask Mr Rowe to lead us in mainstreaming?

Mr Rowe

  577. That leads us neatly into the next question. Is there a mainstreaming in HIV/AIDS into the thinking of other Whitehall departments, for example, the MOD, MAFF, DTI and ECGD? What advocacy does DFID undertake within Whitehall on these issues?
  (Clare Short) The first part of the answer is this is one of the big sea changes in the Department since it was formed as a separate department. The old ODA was an aid distribution department. We now are invited to take the lead on all areas of policy affecting developing countries and getting them into the mainstream of United Kingdom policy. It has been a very, very important change in our relationship with the DTI and with the Treasury on poverty and debt and so on, and it is starting to work through our government and it is unlike other governments. On our work with the Department of Health, the Foreign Office and so on, I am on a Ministerial Liaison Committee that meets every six months. These guys do the official level.
  (Dr Lob-Levyt) I would say that we are actively engaged with our colleagues in other departments on HIV/AIDS, and Okinawa was a joint effort between several departments. DFID happened to take the lead on the health aspect of the briefing, but we closely consulted with our colleagues. It is the same on issues like intellectual property rights, we consulted very closely with the Department of Trade and Industry. I think these are active and very live discussions to ensure that there is a common line across government.
  (Clare Short) It could always be better, and this is a new kind of way of working, but it is improving considerably.

  578. If there was an effect of HIV on rural agriculture would it be something that you would talk about with MAFF?
  (Clare Short) Agriculture in developing countries? That is our lead. MAFF is not out there. They are too busy distributing.

  579. Your strategy paper, "Illicit drugs and the development assistance programme" makes no mention of HIV/AIDS, despite the fact that the unsafe injection of drugs is in many parts of the world the main cause of HIV infection. Similarly the issues paper on tourism makes no mention of HIV/AIDS despite the relevance of sex tourism. I wonder whether you intended to revise the illicit drugs strategy paper to take account of HIV/AIDS and what does it propose to support? Do you propose to support to reduce the risk of infection among drugs users?
  (Clare Short) There is a drugs paper that I should have asked the Department to prepare and this is because there is a terrible danger in anti-drugs work of throwing money around to bribe people not to grow drugs, so you get the next group of peasants starting to grow them and waiting for the bribes to come, as they did in Afghanistan, and it is hopeless, or you bomb people who have no other option for their lives. I have the Department—I presume this is the document that we are talking about—to talk about the conditions in which anti-drugs work would be developmental, which is basically to offer very poor people who grow drugs a legitimate life that is better, which is both crops and legitimacy in their lives, that their children get to school and so on. We are not willing to have our budgets sucked away in gestures and bombing campaigns. It happened in Afghanistan. UNCD paid a lot of peasants not to grow drugs, so a bigger sway of peasants all around then went and planted some.

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