Examination of Witnesses (Questions 560
- 579)
TUESDAY 25 JULY 2000
RT HON
CLARE SHORT,
MR DAVID
CLARKE, DR
JULIAN LOB-LEVYT
AND MR
BOB GROSE
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.
Chairman
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.
Chairman
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.
Chairman
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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