(pt 1)

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Westminster Hall

Thursday 26 January 2006

[Ann Winterton in the Chair]

Health Services (Developing Countries)

Motion made, and Question proposed, That the sitting be now adjourned.—[Mr. Coaker.]

2.30 pm

The Parliamentary Under-Secretary of State for International Development (Mr. Gareth Thomas) : I am grateful to Mr. Speaker for allowing this debate on strengthening health services in developing countries.

Achieving better health is vital if the poor are to break out of the cycle of poverty. We know also that better health is central to the achievement of the millennium development goals. Three of those eight goals—maternal health, child mortality, and AIDS and communicable diseases—are directly influenced by the provision of better health services.

The truth is that progress is slow, and without an accelerated effort those millennium development goals will not be met in much of Africa during this century. I am sorry to say that there remains a massive health divide between developed and developing countries. Life expectancy at birth in the United Kingdom is 70 years; in Malawi it is only 35 years. Similar divisions exist also within countries, where child mortality in the poorest groups is typically double that among the richest.

The global health statistics remain stark. Eleven million children still die each year from preventable or readily treated diseases such as measles, malaria, diarrhoea or pneumonia, and half of them are malnourished. We know also that 500,000 women die in childbirth, and 99 per cent. of them are from developing countries.

Despite recent progress with increasing access to antiretroviral treatment, AIDS remains largely unchecked, and some 25 years into the epidemic, 5 million people are newly infected with HIV every year, adding to the 40 million people already infected. About 20 million people have died as a result of the epidemic. Sadly, 120 million women still have no access to reproductive health.

Malaria, tuberculosis and other communicable diseases remain a major concern, but developing countries face a double burden of disease. Chronic diseases are linked also to lifestyle choices such as diet, smoking and exercise. Those are becoming increasingly important. For example, it has been estimated that tobacco use will have been the likely cause of 10 million deaths every year by 2020.

Better health clearly depends on progress in many areas, including economic growth.

David Taylor (North-West Leicestershire) (Lab/Co-op): The Minister mentioned malaria. The World Health Organisation has made it fairly clear that using monotherapies over a long period can build up
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resistance, which makes them much less effective. Have the Government taken that into account in their investment in tackling malaria in its various forms?

Mr. Thomas : I am grateful to my hon. Friend for that intervention. It allows me to confirm the substance of his question, and to point to the £10 million being committed over the next five years to the Medicines for Malaria Venture, one of the bodies looking at resistance to malarial drugs. It is considering the new drugs that are available and what we can do collectively to spread best practice in treating the disease.

As I said, economic growth is important to better health. Education, particularly of women, is equally important. Access to safe water and sanitation, dealing with social exclusion and challenging gender inequality, too, will contribute to better health. However, accessible and high-quality health services are particularly important in places with a high burden of communicable diseases, where health conditions affect mothers and children and where people have limited access to basic care. Investment in those high-quality services will make the most profound difference.

We know from World Bank research that we could reduce child mortality by up to two thirds and maternal mortality by up to three quarters if we could deliver near universal access to a range of available, proven and affordable health interventions and commodities.

The continuing health divide is a threat to us all in a globalised world. A communicable disease respects no international boundaries, as AIDS and severe acute respiratory syndrome have shown most recently. Following the temporary withdrawal of the polio vaccination in Nigeria back in 2004, the virus spread rapidly to 18 previously polio-free countries as far away as Yemen and Indonesia. Today, people are rightly concerned about the rapid spread of avian influenza to Europe and its potential to trigger a human pandemic that could kill many thousands of people.

The threats of unchecked population growth have largely fallen off the international agenda, but inevitably they, too, remain a concern for those of us who are considering the need for better health services. We believe that by 2050 the global population will rise to 9 billion from 6.5 billion today.

Ms Sally Keeble (Northampton, North) (Lab): Does my hon. Friend accept that although there might not be the same threat of population explosion, the need for reproductive health services continues because of the need to protect people against HIV/AIDS and to ensure that there is proper birth spacing, so that women can recover from births, be healthy, look after their children and protect their health, too? Does he therefore agree that although the immediate threat might have gone, the need for the services is as great as ever?

Mr. Thomas : My hon. Friend is right. We need substantially to improve access to services to promote maternal health for the reasons that she outlined. The support that is being given to women for proper birth spacing, for example, is not as good as we would like it to be, and it is nothing like the support that is given in the developed world. Part of our effort to increase the quality of basic health services in developing countries must be directed to better maternal health.
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The continuing rapid population growth will make it harder to invest in key social sectors such as health and education, so we also need to continue to focus on that. A newcomer to international health may sensibly conclude that it should be straightforward to strengthen basic health services. After all, we have long known about these health problems, and we have proven, effective and often low-cost interventions for most of them. We know that health workers, often with only limited training, can deliver many of those interventions outside a formal health setting, but we also know that they remain massively underused, particularly by the people who are most in need.

The truth is that health systems in developing countries face many challenges. They often face severe and long-term underfunding, and in some cases they have to deal with a deteriorating infrastructure, unreliable or inadequate supplies of essential drugs, as my hon. Friend the Member for North-West Leicestershire (David Taylor) said, weak institutions and governance, and increasing shortages of trained health workers, particularly in the rural under-served areas, a point that was brought home graphically to me when I visited Malawi with the Minister of State, Department of Health, my hon. Friend the Member for Doncaster, Central (Ms Winterton).

David Taylor : Will the Minister pay tribute to a charity in Leicestershire, staffed at least in part by people from North-West Leicestershire, called Inter Care, which collects surplus medicines and matches them to specific requests from partner health units in Africa? He talked about rural areas. Many rural clinics have the staff to deliver essential basic health care, but cannot afford or obtain essential medicines and basic equipment, while medicines that are of perfect quality but are unwanted are being destroyed in Britain. The charity recycles medicines to a number of English-speaking countries in Africa. Is that not the sort of initiative that can help the main thrust of what our Government are doing?

Mr. Thomas : I pay tribute to the work of Inter Care. My hon. Friend's intervention proves that non-governmental organisations can play a role when the capacity of Governments to provide those health services is not what we would wish for. However, we have to continue to work towards a situation in which the work of an organisation such as Inter Care is not necessary and we have developed health services to such an extent that we do not need to recycle the drugs not needed in developed countries.

Where health services are available, the poor often cannot overcome the financial barriers posed by user fees. AIDS, which has reached every country on the planet, is undermining efforts to improve health and reversing the development gains of recent years. There are a number of critical barriers to progress to which we need to direct our attention if we want basic health services in developing countries to improve substantially.

We have to start with finance. The World Health Organisation estimates that it would cost only approximately £20 per person to provide an essential
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package of services to deal with the major causes of ill health. Ministries of Health in many low-income countries typically spend less than £5 per head; that is a pretty daunting gap. When we consider that much of that spend benefits the better-off urban populations, that too little is spent on primary care and that, by contrast, the UK NHS budget is nearer £1,300 per head, we get some sense of the scale of the financial challenge.

We need a step change in funding from domestic budgets and international assistance. We need to train and hire staff to ensure a constant supply of life-saving drugs and to enable health workers to reach unserved communities—in short, we need to provide the fuel that keeps a health service running. We also know that aid needs to be longer term and more predictable, rather than in the form of the multitude of short-term projects that we often see.

Ideally, that long-term, predictable assistance should be provided in Government budgets. When services are provided, too many of the poor are precluded from using them because of prohibitive costs, which can push families into crippling debt and intractable poverty. When the Government in Uganda removed formal user fees, attendance at health facilities doubled from 6   million to 12 million over a 12-month period. UK budget support to Uganda has helped the Government there to fund their priorities within that national health plan.

Achievements as a result of that budget support include a doubling of the budget for essential drugs, the recruitment of an additional 2,700 primary care workers, the doubling of doctors' salaries and the construction of 482 health centres. As a result of that investment, national immunisation coverage increased from 41 per cent. of the Ugandan people in 1999 to 89 per cent. in 2005—a huge step change. Although it is too early to demonstrate improved health outcomes in Uganda, more people are clearly able to access better-resourced services.

Sadly, many developing countries do not prioritise health in their national development plans and budgets. There are a few exceptions, such as Sri Lanka and Kerala state in India, which have demonstrated a significant commitment to expanding access to services and to equity and accountability. They have achieved some impressive outcomes. For example, child mortality in Kerala is now 19 per 1,000 people, while the figure is 138 per 1,000 people in Madhya Pradesh.

Our second challenge is to deal with the mounting crisis in staffing health services. Trained health workers are in short supply in many low-income countries. Poor conditions of service and poor prospects have led many to leave the health service to work in other countries or sectors where pastures appear greener. We need to expand training opportunities and find imaginative solutions to retain staff and encourage deployment to under-served areas—rural areas, in particular.

The expansion of our own health service and an ageing population have contributed to the trouble by attracting many nurses to the UK. However, we are working closely with the Department of Health to address that. Many countries are revisiting the use of mid-level workers and training them to provide services that have traditionally been provided only by doctors or senior nurses. In Mozambique, for example, there are
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now nurse obstetricians while, in Malawi, there are clinical officer anaesthetists. The problem of recruiting health workers from developing countries faces only the United Kingdom, but Organisation for Economic Co-operation and Development countries in general. By 2015, the United States alone will need an additional 1 million health workers and will inevitably try to import them from other countries. Many countries in Europe face the same challenges. It is undoubtedly a global issue that will require global solutions.

We need to work with all providers of health care in developing countries, such as in the public sector and in the third sector that was highlighted by my hon. Friend the Member for North-West Leicestershire. The information and commodities that can improve health are usually delivered through a range of formal, as well as informal, providers. Faith-based organisations, for example, have a long history of providing services in under-served areas. Non-governmental organisations have a strong presence in many countries, particularly in sub-Saharan Africa and in much of Asia.

The private sector is also a major provider of services in many countries. However, it is often unregulated, separate from the mainstream and works outside the Government plans. Many services are provided informally in small shops that stock a few key medicines and by traditional practitioners. While Ministries of Health in developing countries must provide the overall framework to achieve better health for the population as well as monitoring progress, often they cannot be the main service provider. There is a need to exploit all the opportunities that exist in developing countries to deliver services.

One obvious example is the social marketing through NGOs that has long provided most of the world's contraceptives and is now an important provider of insecticide-treated nets. The private sector is being increasingly drawn in by Governments as a partner as a result of contracting out the delivery of district-level services, leading to a doubling of the use of health services in Cambodia and to the franchising of reproductive health services in Pakistan.

Ms Keeble : Does my hon. Friend recognise the important role played by the private sector in occupational health services? For example, Anglo American has tested all its staff for HIV/AIDS and provided services not only to its employees, but to families and communities.

Mr. Thomas : I join my hon. Friend in paying tribute to the work of Anglo American. Several large multinational corporations in South Africa have set an example for the private sector in testing provisional antiretrovirals in respect of their work force and the communities that they serve more broadly, helping to deal with HIV/AIDS. We need more private companies to be willing to follow that lead, but Anglo American has certainly done an important, helpful job.

Another barrier is the weak voice of civil society and the poor accountability of health service providers to the people whom they are trying to serve. Sadly, no Government of a developing country have fallen because of their failure to provide health services, yet often when we talk to the poor in developing countries it
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is their health and the catastrophic expenditure that they will have to face when dealing with serious illness in their families that are of major importance to them. We need to support civil society to demand more of Governments on health care and to be more willing to hold them to account.

We also need to deal with weak performance management. With a few exceptions, efforts to monitor performance and demonstrate the results of investment in health have been inadequate and ineffective. More effective information systems will be vital if we are to help to match resources to the delivery of results, and to continue to argue for mobilising additional resources in the pursuit of better health services. There are many challenges and debates on how we can best channel aid. In settings where the health system is very dysfunctional, there are particular attractions in using targeted approaches to deal with the major diseases, and there have been some impressive gains in past years as a result of such approaches. For example, smallpox was eradicated in 1997, and polio is expected to follow in a few years.

David Taylor : It is possible for even a small organisation to have a significant and disproportionate impact on health care. An organisation in Leicestershire provides support to about 2.5 million people in rural communities in Cameroon, Ghana, Malawi, Tanzania, Uganda and Zambia. So it is not just the size of the organisation that counts, because an organisation can lever in and catalyse activity in its own region and country.

Mr. Thomas : My hon. Friend is right that NGOs, regardless of their size, can make a huge contribution in addressing the gaps in health care provision in developing countries. I pay tribute to those British and international NGOs based in his area that are working in sub-Saharan Africa and elsewhere.

One of the most significant targeted investments in recent years has been on AIDS, TB and malaria—three key poverty diseases. There have also been significant reductions in child mortality in very poor countries such as Tanzania, Malawi and Mozambique, again through approaches that deliberately target the major childhood diseases.

However, we need to recognise the limits of focusing on single issues, and we need to ensure that it is not done to the detriment of efforts to strengthen the broader health system. We might prevent deaths from measles through targeted vaccination programmes, but the child that benefits from that programme may then succumb to malaria because there is no constant supply of an effective medicine. The same health worker who delivers AIDS education could deliver malaria treatment, vaccination programmes or maternity care programmes. Those health workers need to be enabled to deliver the full health package. We have learned in recent years that if we are to have a lasting impact, we need to address the problems affecting the whole health sector, rather than just specific parts of it.

The UK has a long and distinguished history in international health work which goes back as far as the 19th century and the establishment of the School of Tropical Medicine in Liverpool. We remain at the
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forefront of international health policy, maintaining a substantial investment in health in poor countries. In recent years, many new global partnerships have emerged, such as the Global Alliance for Vaccines and Immunisation and the Global Fund to Fight AIDS, Tuberculosis and Malaria, which are partly based on British expertise. They have helped to raise the profile of, and rejuvenate efforts against, particular diseases, and they have helped to raise significant additional resources for health at a time when overall aid declined globally. Also, the private sector has become more engaged with health and philanthropic foundations—notably the Bill and Melinda Gates Foundation—which provide more funding for health than many UN agencies.

Health probably has a higher international profile than ever before. It has been the subject of discussions in the UN General Assembly, and of course last year at the G8 summit and during our presidency. It is one of the obvious recipients for some of the extra $50 billion of aid that was agreed at Gleneagles. We have to ensure that those additional funds are spent on the right things and target those most in need. As I said, that aid needs to be long-term and predictable. Only then will countries have the confidence to scale up their health services and invest in the necessary training, and only then will they have confidence that they can recruit and pay for additional staff at the same time as revitalising their health infrastructure. Only when there is that long-term, predictable aid will Finance Ministers and Health Ministers have the confidence and ambition that we want them to have for health care spending in their country.

It is important that we find the right balance between targeted investment through specific funds and long-term investment in systems building. We must ensure that targeted approaches, such as the Global Fund, complement the broader effort to develop health systems, rather than undermine it or divert resources from it.

As hon. Members know, our aid budget is committed to rise to 0.7 per cent. of gross national income by 2013. In the interim period, we are still looking for innovative ways to front-load investment in health and education. One powerful example is the international finance facility for immunisations, which will provide an additional £4 billion to the global immunisation efforts over the next 10 years and will, we believe, save some 5 million lives in the process. A larger international finance facility is under development and is expected to channel significant support to health and education. With our European allies, we are exploring a number of innovative approaches to increase aid. We are also considering how we can stimulate investment by the pharmaceutical industry in a new generation of drugs and vaccines, through advanced market commitments.

In 2005, G8 leaders committed themselves to trying to secure universal access to AIDS prevention treatment and care by 2010, which is an ambitious goal that will require rapid attention to the systems-wide constraints. In post-conflict and fragile states, we will face particular challenges in building even basic health systems from scratch.
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We are trying to work with other donors to simplify the international system for health and AIDS. Too many agencies—be they UN, World Bank, or the various global funds or bilateral donors—are working in developing countries, often with unclear and overlapping mandates. Many of those agencies deal with specific disease areas, without engaging with the broader health system on which they all depend. They operate in a competitive global funding environment in which country-level needs are often only poorly articulated. With OECD colleagues, we need to try to hold those various agencies to account for their performance in providing more and, crucially, better aid. We have to support countries' efforts to achieve the universal access to AIDS services that they want, as well as making progress on the child and maternal health MDGs.

The UK makes a substantial investment in health, through a wide range of instruments. When we are satisfied with a country's policy environment and governance standards, we provide direct support to its budget to implement its poverty reduction plan. However, in other settings, where we do not have confidence in the policy environment and the commitment of leaders to reform, we work with a variety of partners to support country-led efforts to address the whole sector plan, through pooled funding. In fragile states, for example, we employ project approaches implemented by a range of partners, particularly NGOs and private sector organisations.

Of course, we work closely with other Departments, such as the Department of Health and the Foreign Office. Our country efforts are complemented by a substantial research agenda, our current priorities being AIDS and other communicable diseases, reproductive health, maternal and child health, future concerns—about tobacco, for example—and some things that are more neglected internationally, such as mental health.

We are supporting a number of public-private partnerships that aim to increase access to health services or seek to fund research on future generations of vaccines, such as the international AIDS vaccine initiative, or the Medicines for Malaria Venture. Better health has to be at the core of the international development agenda as we look forward to the next 12 months.

Sadly, progress has stalled or been reversed in many countries. Without a major effort, many of them will not meet the millennium development goals on health for years to come. The commitments that were made last year hold out the possibility of making much more substantial progress on health once again. I look forward to hearing hon. Members' comments on how we might make the progress that I think we all want.

2.59 pm

Mark Simmonds (Boston and Skegness) (Con): May I say how pleased I am to be under your watchful eye in this important debate, Lady Winterton? I congratulate the Minister on applying for this debate on an important area of international development policy, and Mr. Speaker on granting it.

The Minister mentioned the Government's policy of spending 0.7 per cent. of our gross national income on development aid, which he knows we support. We
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support the millennium development goals, including the three that are specifically relevant to the debate this afternoon, which the Minister outlined in his introductory remarks. We also support the Global Fund to Fight AIDS, TB and malaria, although we are disappointed that other countries and private organisations do not, perhaps, share the UK Government's enthusiasm, and ours, for that fund, or accord it as much importance as we do.

We also share the aspirations that were set out at G8 on the international finance facility for immunisation, which could make a significant impact on health care provision in the developing world. There have been past successes with regard to health in a global context. Smallpox is a good example, and we all hope that polio will be eradicated shortly.

It is only fair to put it on the record that since 1997, the Department for International Development has provided £1.5 billion for strengthening heath care systems in developing countries, which is worth while and admirable, and we support it. The UK was the prime mover in setting up the high-level forum on the millennium development goals on health in Geneva in January 2004, at which developing and donor countries discussed concrete actions to increase health service capacity to meet development goals. Again, we applaud that.

We welcome the G8 Africa communiqué, which said that people should have access to basic health care and encouraged countries to drop user fees, but recognised that that decision can be made only by the Governments of developing countries. I shall say more about that later.

I should like to sum up the current situation. We must prioritise the provision of basic health care services in the developing world. As the Minister rightly said, one third of the world's poorest people—about 2 billion of them—do not have access to essential health care services and medicine. Sadly, that enormous problem cannot be solved in a short time.

The disease crisis in the poorest countries is staggering. The approximate numbers of deaths per year are as follows: malaria, 1 million; TB, 2 million; HIV/AIDS, 3 million. Infection and death rates for those three diseases are continuing to grow. Approximately every minute, a woman dies as a result of pregnancy and childbirth.

3.2 pm

Sitting suspended for a Division in the House.

3.17 pm

On resuming—

Mark Simmonds : I was speaking about the number of women in the developing world who die as a result of pregnancy and childbirth; it is one every minute, or 529,000 a year. As the Minister said, 99 per cent. of those deaths occur in developing countries. The World Health Organisation estimates that more than 10.5 million lives a year could be saved by 2015 by expanding health care intervention for infectious diseases, maternal and child health, and non-communicable diseases.
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Sadly, some recent initiatives have failed to meet their targets, and I would argue that the "3 by 5" initiative failed significantly. It was stated yesterday morning at International Development questions that of the 40   million people with HIV/AIDS in sub-Saharan Africa, only 550,000 are taking retroviral drugs and receiving retroviral treatment, rather than the 3 million anticipated in the target. That is a significant disappointment. The G8 aspirations on HIV/AIDS seem a long way adrift. Initiatives such as "3 by 5" require strong health care systems to be put in place to ensure that antiretroviral drugs can be delivered. The lack of such systems is often the main reason why targets have not been met.

Like the health care burden, the economic burden of epidemics such as TB, malaria and HIV is enormous. Those diseases are crippling economies, devastating key sectors of workers and reducing investment that could be used to stimulate economies and alleviate poverty. The World Bank estimates that TB costs the average patient three or four months of lost earnings. Malaria slows economic growth in Africa by about 1.3 per cent. a year. When the prevalence of HIV/AIDS reaches 8 per cent., the cost in growth for sub-Saharan Africa will be about 1 per cent. a year.

Good health care systems would go a long way to meeting many of the millennium development goals, including improving maternal health and child health, and meeting targets on disease. Good health care systems would also contribute to the achievement of other millennium development goals, such as access to education, as fewer children would be required to drop out of school to care for sick or dying relatives, or to care for siblings because both parents had died. There will also be more teachers. It is a staggering statistic, but in 1999 in sub-Saharan Africa nearly 1 million children lost their teachers to HIV/AIDS.

The links between pandemic diseases and national security must not be overlooked. The Minister has recently been to Malawi. He will therefore be aware that because of HIV/AIDS, troop strength in Malawi has fallen to 50 per cent. of the minimum capacity needed to guarantee state security. In Mozambique, police recruits cannot be trained fast enough to replace those who are dying of AIDS. Strong health care systems are essential to ensure that law and order can be maintained. I saw that for myself in Mozambique last year.

We are greatly concerned about some specific problems with regard to the provision of health care in the developing world. Of course I understand that the Minister cannot give answers on those problems today. Of course I understand that the issues are immensely complex and that the Minister, the Secretary of State and the Department for International Development alone cannot solve the problems. There must be international consensus and co-operation to reverse the trends, particularly in many parts of Africa.

The first issue is health care fees in the developing world. The British Medical Association has calculated that abolishing user fees for health care facilities could prevent approximately 233,000 child deaths annually across 20 African countries. User fees are in place across most sub-Saharan African countries. Initially, they were introduced to tackle severe underfunding, but clear evidence now demonstrates that such fees do not generate much revenue, significantly deter people from
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seeking access to health care, are unlikely to improve efficiency and disproportionately affect poor people who require health care most. Will the Minister explain what steps the Government are taking to encourage developing countries to abolish their fees? I am aware that there have been successes, but further work needs to be done to ensure that basic health care will be free at the point of delivery for all those who require it.

The second issue is drug availability. The Department for International Development needs to do more to encourage the pharmaceutical industry to allow the manufacture of generic drugs for use in the developing world. The former director general of the World Health Organisation's HIV programme suggested the designation of a humanitarian corridor within which leading drug manufacturers would allow rivals to produce drugs at low prices for modest royalties. Does the Department support that suggestion? If not, why not, and if so, what is it is doing to encourage the proposal?

There is also great concern about the number of medicines being developed to tackle diseases that predominantly affect poor people. The drugs for neglected diseases initiative has estimated that less than 1 per cent. of new drugs coming on to the market are related to tropical diseases. Does the Minister think that the Department can do anything to increase that percentage, to ensure that there will be more of the research and development that is required to increase the number of generic drugs available to the vast populations who suffer from those diseases? This is not just a matter of the availability of drugs. Once the drugs arrive in the developing world, there must be adequate facilities for transporting, storing and distributing them, including reliable refrigeration, transport and sufficiently trained staff. All those areas are currently lacking.

The hon. Member for North-West Leicestershire (David Taylor) made a point about drug resistance, which is becoming prevalent, particularly with malaria. There is concern that malaria parasites have developed resistance to the cheapest and most common drugs used to treat the disease. Resistance to treatment can be delayed by using therapies that combine different medications. However, 18 pharmaceutical companies are producing and distributing drugs that risk exacerbating drug resistance and jeopardising the fight against malaria. That needs to be dealt with, or the problem will only get worse. I understand that that problem is more prevalent in Asia than in Africa.

There are also problems with tariffs—internal tariffs between African countries as well as tariffs that raise taxes on imports to Africa. Those, unbelievably, still apply in some instances to basic health care products such as malarial bed nets, which can significantly reduce the transmission of malaria, in particular, by as much as 63 per cent. As of 2003, 18 countries have reduced or eliminated the taxes and tariffs on bed nets. I urge the Government to encourage Governments in the developing countries to go further and introduce legislation, if not wipe out tariffs on health care products altogether—particularly the bed nets in my example. More people would then have access to the health care that they deserve and require.
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The Minister also mentioned staffing, which we think is a major issue. We welcome the fact that the Government have signed up to the code of practice for the international recruitment of health care professionals, under which the public and private sectors make it a policy not to recruit actively in the developing world. However, that does not prevent doctors, nurses and other clinical staff from leaving Africa and other poor countries. About 23,000 leave Africa each year, not necessarily through active recruitment but through what is termed the "vacuum effect". They are pulled to the developed world—to the prospect of better conditions and better earnings, and we can all understand that. Malawi has just 100 doctors and 2,000 nurses for a population of 12 million people, 15 per cent. of whom suffer from HIV/AIDS.

However, we must balance such facts by understanding remittances and the important role that they play in alleviating some severe economic problems in poor countries. In the British NHS over the past three years, the number of full-time clinical academics has been reduced by 14 per cent. That will further increase the national health service's dependence on overseas recruitment in forthcoming years. I hope that the Minister and his counterpart in the Department of Health will put that at the forefront of their discussions.

It is essential that all groups in the community have access to health care, especially women and the poor. For that to happen, however, there must be better co-operation and co-ordination between public, private and NGO initiatives. As the Minister rightly pointed out, there needs to be a degree of certainty that the money is going where it is intended to go, and much greater control over duplication, as well as cross-country and cross-organisational co-ordination to ensure the best use of the money available. For example, TB is responsible for up to half of all AIDS deaths in Africa, so there needs to be greater collaboration and co-ordination between TB and AIDS programmes. As we heard earlier, a strong civil society is also essential to the maintenance of good health care.

I have a few final questions for the Minister. I do not necessarily expect him to answer them today, but I should be grateful if he gave them some thought. If he does not respond within a certain time scale, I shall fire off a letter in the usual way just to nudge him. Although aid and debt relief are necessary, economic development and international trade offer the best hope of sustainable solutions to poverty in Africa and elsewhere in the developing world. Like everyone else, we were disappointed by the outcome of the World Trade Organisation meeting in Hong Kong, particularly because a key commitment of the millennium development goals is to create an open and non-discriminatory multilateral trading system. At the moment, we are a very long way from that.

The reform of trade rules is essential if Africa is to trade its way out of poverty and to create the capital necessary to invest in its health care systems itself, through its own Governments. We urge the Government and DFID to continue to work for a resolution to the Doha round of trade talks. They must strike a balance to ensure that freeing up trade does not necessarily exclude African and other developing nations from generating revenue through modest tariff
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barriers. Those nations can then spend that on public services, particularly health care, so that they move away from dependency on aid, donations from the developing world and direct budgetary support.

On budgetary support, there is a balance between maintaining the continuity of funding necessary for recipient Governments to guarantee income flows, and thus the provision of services, and ensuring that British taxpayers' money goes where it is intended to go. As the Minister is aware, the Conservative party is concerned that, at the moment, quite a lot of anecdotal evidence—I shall not put the percentages on the record—suggests that a significant percentage of budgetary support money is unaccounted for and does not end up where it is intended to go.

I would like the Minister to think about putting in place more stringent transparency and accountability procedures, to ensure that direct budgetary support from the British taxpayer goes where it is intended to go. Of course we understand that there is a balance to strike between ensuring both that there is transparency and accountability and British taxpayers get value for money, and that the recipient Government are democratically accountable for the money that they get. At the moment, that balance is not necessarily correct.

On debt relief, we welcome the heavily indebted poor countries initiative, which has benefited a number of countries so far, although we believe that it could go wider and deeper. However, the G8 debt deal will provide less than $l billion extra this year for vital services such as health care. Will the Minister tell us what percentage of the debt relief agreed at G8 will be spent on the provision of health care in developing countries? Serious questions are now being asked about whether the promises that were made will be delivered on. Germany has gone on record as saying that it is highly unlikely that it will meet the targets that it thought that it would. What impact will that have on health care in the developing world? What steps is the Minister taking to ensure that money from debt relief is used in the recipient countries specifically to alleviate poverty and on health care, in the context that we are debating?

The Minister gave a fair and articulate introduction to the debate. As he said, Africa is struggling with many diseases, not just the three big killers that I have talked about, and may prove to be the weak link in preventing bird flu, especially as the Rift valley, which runs 9,000 km from Syria in the north to Mozambique in southern Africa, attracts millions of birds each year. Indeed, Tanzania has gone on record as saying that it has only $120,000 to spend on strategies to prevent bird flu. Have the Minister and his Department made any assessment of the risk caused by Africa's inability to finance prevention measures, particularly against bird flu? If, so, what is their reaction? Will funds be allocated specifically to allow African countries to prepare for the potential global pandemic? I accept that there is a degree of uncertainty about that.

Economic growth is impossible if a country's population is dying, so strengthening the provision of health services must be a focus for all our efforts. Tomorrow, I am travelling to Yemen to discover how Oxfam has improved basic health care services in a district there by enhancing community participation, piloting community financing and strengthening district
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health services. Schemes such as those, which include civil society, NGOs, regional government and donor country Governments, must be replicated where appropriate if we are to see lasting improvements in the health care services of developing nations, which all of us, across the House, want to see, as those are essential building blocks for alleviating poverty and improving lives in developing countries.

3.33 pm

Greg Mulholland (Leeds, North-West) (LD): I might not be able to stay for the winding-up speeches, as I promised to attend an event in Leeds. If that turns out to be the case, I apologise and assure hon. Members that I will read the speeches in Hansard.

I want to talk about the recruitment of health professionals from developing nations, which the Minister and the hon. Member for Boston and Skegness (Mark Simmonds) mentioned. The code has been tightened up, but there is clearly a loophole that needs to be closed. Private agencies can still perfectly legally recruit health professionals from countries on the banned list if they do not work in the NHS in the first instance. They often work in private nursing homes and care homes instead, and frequently do not do the jobs for which they were trained. Their skills are entirely wasted, never mind not being utilised in their country of origin, where we all agree they should be. Private homes sometimes make money from the practice, which is scandalous. They charge a fee so that they can put the health professionals through the process and then, after the allotted period, people are naturalised, live here and are eligible to work in the NHS. It is clearly recruitment from banned countries by the back door, and we need to hear more about that from the Minister.

Why does the Department of Health still leave it to NHS employers to monitor the code rather than do that itself? I realise that that question is not directed at the Minister's Department, but I hope that it will be considered jointly by the two Departments. The Department of Health should monitor the code and not leave it to self-regulation, which could lead to a conflict of interest among NHS employers. As for figures in connection with the loophole, I am sure the Minister accepts that between 2004 and 2005, 3,301 health professionals joined the UK register who were from banned countries. Although the code is welcome and has made the position better, it is not working sufficiently. I hope that the Government will give it serious consideration.

There is a more complex problem, and I am not suggesting that we have a solution to it. It is creditable that the Government are investing in Malawi. It is hugely welcome work and we thoroughly support it, but what is the Department's assessment of the effect that it is having on attracting health professionals from neighbouring countries? I am not criticising the work, but Malawi is the focus of DFID funding, which is likely to suck in health professionals from neighbouring countries. The Department and the Government need to deal with that and the situation needs to be monitored. That is not simply a theory. It happened in Botswana, where the Bill and Melinda Gates Foundation put a lot of money into services. It attracted health workers from neighbouring countries, such as Angola, where there is a crisis in the health service.We must accept that the
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impact of development is often more complicated than we would expect it to be. Sometimes, development work distorts local labour markets. We must be aware of that and do whatever we can to ameliorate the position.

We welcome the overall thrust of the debate. We are all happy to be involved in it. We shall support any action that the Government take to strengthen health services and will assist them in finding solutions to the problems.

3.39 pm

Ms Sally Keeble (Northampton, North) (Lab): I am pleased to take part in the debate. Although my remarks might seem critical, I support the Government's action. I recognise the enormous financial commitment that has been made and the expertise and thought that have been put in. It is partly because the United Kingdom Government have been so active in such matters that the debate is developing. One reason we are pressing the Government is that they can make a difference and affect what happens in the countries that many of us care so passionately about.

I shall discuss three issues. The first is the need to make sure that when we consider health care systems in developing countries, we look into both acute care systems and community health care systems. Secondly, we need to track funding from the Global Fund down to community-based clinics. I have spoken to my hon. Friend the Minister about that and today I shall talk about one project in which I have a particular interest. I do not mean a financial interest; I mean that I have seen the project's work and am very much committed to it. Thirdly, I shall talk about maternal and infant mortality, because that is the subject of one of the millennium development goals on which the international community is lagging. We are also lagging on the MDGs on infectious diseases and HIV/AIDS reduction.

On primary care systems, I thought that rather than talk about statistics, I might recount what I saw when I went to Africa with my Schools for Africa project before Christmas. I went to see the distribution of boxes for children in a slum called Kiandutu, just outside Nairobi. "Kiandutu" means jiggers, which are horrible little biting things, and if hon. Members saw the slum, they would know why it was called that; it is a truly appalling place. I went with my friends from KENWA—Kenya Network of Women with AIDS—to the house of a woman called Tabitha, who had a three-week old baby.

Tabitha is HIV-positive and is on antiretrovirals. It was thought that her baby was probably okay, as far as anyone could tell, because the birth had been made as safe as possible, but one of Tabitha's other children was very ill. One of the main routes of transmission is mother to child, and there is a big need to block off that type of transmission. Once the birth has been made safe, the next thing is to make sure that the mother does not breastfeed, so a lot of effort was being put into making sure that Tabitha did not breastfeed her child. She was keen to avoid doing so, because she obviously wanted to make sure that the baby lived.

KENWA, which, as my hon. Friend the Minister knows, is connected to the Global Fund, gave the woman some powdered milk. KENWA had to give the
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baby ordinary powdered milk because there is no powdered infant formula available. Kenya, which is a big, sophisticated country, is not the only country affected by that lack of supply. HIV-positive women who are trying to avoid breastfeeding their babies in order to save their lives do not have access to supplies of powdered infant formula. It is available only in westernised shops, and it is too expensive for them.

Another problem was that there was no water. Supplies of water were being sold, but they were expensive and Tabitha did not have any money. In addition, the water was not safe for a small baby, so KENWA gave her bottles of sterilised water. However, there was no fuel, either, so nothing could be heated up and the mother could not sterilise the bottle. Although KENWA told Tabitha to feed the baby with a cup and spoon—one can do that with a little baby—she thought that it was proper to feed the baby with a bottle, even though it was an unsterilised bottle left all day in a filthy little hut. At least clean water was used—we hope—but there was no proper nutrition.

KENWA put massive effort into trying to make sure that that woman fed her baby safely. It supplied the powdered milk, which it had difficulty getting, and the water, and it tried to help her to manage the sterilisation issue. The woman, who is on antiretrovirals, had to struggle because she had three other children to look after, including one who was very sick. She had to cope with all the difficulties that I have described to do something that we do quite routinely.

I was struck by the fact that it is well within the capability of the donor community to make sure that such problems are dealt with. I thought back to when I had my own children in Guy's hospital just across the river. Because it is expensive to sterilise bottles, the hospital provides women who choose not to breastfeed their babies with little disposable bottles with the formula already made up. You may have seen them, Lady Winterton. They have a disposable teat, so the whole lot is thrown away after one feed. Of course, there must be an agreement with the producers that they do not sell them in supermarkets, or any efforts to encourage women to breastfeed their babies will be completely on the skids because those little things are so convenient. Instead, if one so chooses, one can buy small one-feed cartons of ready made-up formula in supermarkets and chemists. They are completely sterile: one simply opens them and put the contents into a bottle and away you go.

I described them to my friends from KENWA and asked whether they had seen them and whether it would help to solve part of the challenge of persuading a woman not to give up the unequal struggle—persuading her not to breastfeed her baby and risk finding that the baby is HIV-positive. They did not even know that such products existed—they had never seen or heard of them. They did not know that they were available.

I know that there are all sorts of debates about Nestlé milk. We talk about giving mothers antiretrovirals, making childbirth safe and trying to block transmission, which is the biggest problem, but unfortunately everything comes down to what was happening in that little hut and the woman who was facing the problem of how to feed her baby safely and avoid the baby becoming HIV-positive.
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Real thought must be given to how we draw the lines that need to be drawn between acute services, primary services and community-based services. That is as much an issue for this country as it is for the developing world. It is extremely problematic for us to deal with. It is just as important for us in this country, when we talk about improving health and health care systems, to consider the areas that produce the biggest change in health care.

I turn to the problem of tracking the money. KENWA was running a project in that slum, as well as seven others in Nairobi and the surrounding area. The Global Fund considers KENWA a model organisation. If one asks the Global Fund about its work on community-based projects, it will hold KENWA up as an example. KENWA does not receive money from the Global Fund, although it did for a few years. I pay great tribute to the DFID office in Nairobi for helping KENWA through a difficult patch by providing it with funds, but it worries me that we pay a vast amount of money—I forget the exact amount, but the Government are rightly proud of it—into the Global Fund and the money is not tracked. After a great deal of unpicking, I finally found out what had happened.

The Global Fund provided the funds for KENWA for three years. Then, because the Kenyan Government had their own plan, the fund was supposed to go through the Kenyan Government, who were to decide where the money should go. In fact, the money went to the Kenyan Government and stopped. I understand that it is not known what will happen now, because of the problems in which the Kenyan Government find themselves. Meanwhile, the staff at KENWA have not been paid for several months, and the organisation is in crisis.

My hon. Friend the Minister might say, quite rightly, that KENWA is one organisation among many and that it is not right to use an Adjournment debate to lobby for one organisation, but let me explain why this particular organisation is so important. I did not realise until quite recently that KENWA provided support for 2 per cent. of all the people in Kenya who are on antiretrovirals. Because of the horrors that await those people if the funding comes to an end and they have no antiretrovirals, the organisation has been trying to find other programmes in which to put them. Some have migrated to the Government hospitals, which cannot do the outreach work that KENWA does. KENWA works in the slums, and is good at doing such work. Although the Kenyan Government figures for treating people with antiretrovirals might look good, the reality is that that great capacity is at risk of being lost as a result of the basic problem of getting the money from the donors—all credit to them—to those who spend the money and deliver the services.

Secondly, in addition to those on antiretrovirals, KENWA supports and feeds 1,400 orphans, and arrangements have not yet been made for the future feeding of those children. As my hon. Friend the Minister knows, caring for HIV/AIDS orphans is a major problem. I have been extremely concerned for some time about what will happen to such children, particularly given the risk of infection with HIV/AIDS and other health problems if they are not properly supported and maintained.
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The hon. Member for Boston and Skegness (Mark Simmonds) spoke about tracking the money through the system and ensuring that all the benefits that the UK taxpayer and the individual donors who provide support expect are delivered. I do not blame the Global Fund for the problems—they are the result of a series of circumstances—but the problems certainly need to be unpicked. That story is a reminder of the vulnerability of health care systems in countries where governance is fragile.

My hon. Friend the Minister was right to say that that things have improved in many health sectors. The Government, DFID, NGOs and donors can take great credit for the amount of work that has been done and the outstanding progress that has been achieved. However, as my hon. Friend said, in some areas things have not improved, and in some they are getting worse, particularly infant and maternal mortality rates.

I am greatly concerned that although it is recognised that things are getting worse, the attention of the international community has not focused clearly enough on those indicators and on what health care is needed to tackle them. There are a number reasons for that. One that springs to mind immediately is the problems of women. Women come very low in the pecking order under many Governments, especially those of developing countries. Women and children are treated as a job lot. If the health care for women is not good, you can bet your last dollar that the health care systems for the children will not be good. I remember hearing a doctor in Soweto saying that the failure of the mother predicates the failure of the child. It is that simple.

In Kenya, the women are fed well because doing that means that they will be able to look after their children. I puzzled long and hard about the practice, which I have seen in a number of countries, of putting people on antiretrovirals for six months. It was done for only six months because after that there were no more drugs, but people said that it was terrible and asked what was to happen then; if people have a second course, the reaction is even worse. The response is, "If we can keep the mothers alive for a year or two, that will give the children protection for that much longer and a better chance later." It was as simple as that.

The professionals in developing countries and the UK who have to deal with such problems often say, "We know what has to be done and about the interventions needed to make a birth safe. We know what kind of facilities we need. That stuff can be done, but it is a question of will." The UK Government can make a real difference; they can make the arguments and encourage and cajole the rest of the international community, including the Governments of developing countries, to give such issues a higher priority.

Some things are making the situation worse. One is HIV/AIDS: we know that the disease has a female face and, increasingly, it is a young female face. We also know that the biggest form of transmission in many areas is now said to be from mother to child. There is also the issue of the number of orphans and what happens to them. I have often spoken to my hon. Friend the Minister about such issues; the figures are truly shocking. Just before Christmas, I went to Zimbabwe as well as Kenya. I had always thought that there were about 900,000 orphans, mostly HIV/AIDS orphans, in
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Zimbabwe, but I learned from a UNICEF book that the number of orphans in Zimbabwe is now 1.2 million, and the person at the UNICEF mission in Harare responsible for child health said that the figure was closer to 1.5 million, out of a population of about 12 million or 13 million. The implications of providing care for those children in years to come are startling. The hon. Member for Boston and Skegness has already pointed to the economic cost of HIV/AIDS—the costs incurred if health care systems are provided.

We must also consider the profound impact of conflict on the health of women and children because of their position as refugees and as victims of abuse by combatants, and because of the destruction that conflict causes to whatever health systems already exist. Changing sociological factors—changing patterns in child care, adult lives and family structures—have left children more vulnerable at different stages of life. Previously, birth was particularly dangerous; later, weaning becomes so.

Finally, there is the unresolved problem of the status of women. The UK Government have pressed on that issue, but the message needs constant reinforcement. I have seen women in Bangladesh who had to wait several days in labour until their husbands came to give permission for them to be taken to hospital because of complications during birth. That can simply be too late.

This is a slight diversion, but my hon. Friend the Minister talked about the improvements in Mozambique and seemed to link them with the need to make sure that there is work with community-based care workers. He is absolutely right to say that community-based care is important—not just the community care centres of the type that I saw in Kenya, but home visiting services, which are desperately important, especially for supporting HIV/AIDS victims in the community. It is important that the people who go out are properly equipped. In quite a few countries, I have seen people go into the community to provide care without the equipment they need. I met some midwives in a very rural area of Sudan, who had been given training and care packs by the DFID, but a couple of years on, all that was left was the drum for hearing babies' heartbeats—they had lost everything else and had one of those between them. The supplies need continually to be sent down the supply chain.

In Mozambique, I walked with a community care worker around some of the semi-rural slums in a town called Xai-Xai in Gaza province, just north of the capital. There were good roads, so there should have been good access for people to get in. I walked up a path to a hut from which the most awful moaning was coming. Inside, a woman was dying of AIDS. She was simply lying on the floor, because everything else had gone. All her family was dead. Her child was dead. There was just her and a care worker from Kuvumbana, the organisation that I was working with. The carer was there just to comfort the woman; she did not even have any basic painkillers.

If we are serious about providing care in the community, we need to ensure that people are properly trained and have proper supplies  that are replenished. We also need to make sure that there is some joining up of provision. Not only did the carer in Xai-Xai not have
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painkillers, but the project had only intermittent supplies even of food. The supplies that were needed to make care in the community effective were not there. All the structures were in place, including a storage room to keep the stuff in, but things were simply not joined up.

I should just like to say something relating to what is specifically needed for health care services. We are focusing on things that are normally bottom of the pile, as it were, in terms of focus for Government attention. I fundamentally disagree with the hon. Member for Boston and Skegness on one point. He said that he thinks that economic growth and trade is a way to resolve sub-Saharan Africa's problems. Of course, economic growth and trade are needed, but sound policies for redistribution of wealth and service development have to be developed along with that if we are to tackle the kind of problems that the Minister talked about, which we all know exist in sub-Saharan Africa.

I have to say that thinking there is some simple solution sells the problem short. If the hon. Member for Boston and Skegness wants one example of why this is not just a matter of economic growth, he need only look at China, which has the fastest economic growth anywhere in the world, by a long shot, and is recognised as a future economic superpower.

Mark Simmonds : Let me clarify. That is not the point that I made. Economic growth through trade can make a serious contribution, but that alone cannot alleviate all the many problems that exist in sub-Saharan Africa.

The hon. Lady is right to mention China, where there has been extraordinary economic growth, but not all the population of China have been dragged out of poverty. Many rural parts of the far west of China have the same economic affluence—or lack of affluence—as Burma.

Ms Keeble : I shall press this matter a little further, because the details have to be spelled out. It is no accident that that is happening in China. It is happening because China does not have any policies to redistribute wealth, for example, in terms of sensible tax policy, and it does not have a regional development policy, so it has no means of getting proper transfers from the overdeveloped east of the country to the underdeveloped inland areas of the west. There are major difficulties there. We see China taking jobs from this country, while we have to support and develop its health care systems, particularly on HIV/AIDS.

Mark Simmonds : I do not agree with that last point. That is not the reason for disparity of economic growth in China. The fundamental reason is that in the east of the country there is a free market and free trade, and in the west there is still communist control. That is the fundamental reason for the disparity in economic growth.

Ms Keeble : If the hon. Gentleman asks the Chinese Government what regional and economic development policies they have and how they plan to tackle the unequal growth in different areas, they will say that they cannot do that. The same is true of the way their economy is growing and the way they develop their services. There are gaps in their policy development.
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That is why it is so important that when we talk about strengthening health care services in sub-Saharan Africa we consider the problem in terms of the policies that are being developed and how those countries will be able to effect change.

We cannot apply simplistic solutions—we cannot think, "One, two, three: economic growth leads to an end to poverty," although of course the one is not possible without the other. We must also consider the areas that will not be touched in hundreds of years by trickle down.

Infant and maternal mortality have been shown to be the most difficult problems to solve. Tackling them involves looking at some of the most complex policy areas and prioritising them. Will my hon. Friend the Minister ensure that those areas receive the attention that they need? In particular, will he study the problem of tracking funding, and ensure that the UK Government's enormous financial, policy and service delivery contribution includes giving proper priority to attention to services on the ground?

4.7 pm

John Barrett (Edinburgh, West) (LD): The hon. Member for Northampton, North (Ms Keeble) made an interesting speech and gave us a good reason for strengthening the health services of developing countries. We need only look at facilities in this country to see what could be. Some people say that our facilities could be improved, but we should compare what we have across the road and in my city of Edinburgh with what some of us have seen first hand in developing countries.

Like the hon. Lady, I had first-hand experience in the Sudan, where I spoke to nurses who worked for Médecins sans Frontières. They said that they often had to put young mothers back together again after they gave birth, following Caesarean operations done with a spear. That can be compared with what I saw recently in the Edinburgh Royal infirmary, where my daughter, who now has a young baby—I am a proud grandfather—had first-class facilities. There were problems, but the care was expert. Why, through bad luck, should there be two patients to a bed in children's wards in some parts of the world—sometimes with a child under the bed on the floor—while we have expert staff and equipment in spotless hospitals? It is simply because those children live in some of the poorest countries of the world.

The health services of the poorest countries are overstretched, underfunded and understaffed. HIV/AIDs, TB and malaria were mentioned by the Minister, the hon. Member for Boston and Skegness (Mark Simmonds) and my hon. Friend the Member for Leeds, North-West (Greg Mulholland). They have left huge scars on the world. However, the poorest countries, which are least equipped to deal with the problems, have suffered the most. The problems are well documented, and the challenge for us is what we—the Department for International Development, the Government, and the people of this country—can do to help.

Improving access to retroviral drugs, for example, has an enormous impact on the health of people in developing countries. Current estimates suggest that there are 16,000 preventable deaths a day from HIV/
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AIDS, TB and malaria. The impact of HIV/AIDS, in particular, is well documented. The harsh reality is that we are losing the fight against the disease, with 4.9 million people newly infected last year, the highest number in the history of the disease. Improving access to antiretroviral drugs is currently making a real difference. It is helping to turn the tide in the fight against the disease.

TB is also making a comeback in several nations and in certain parts of the United Kingdom. I have witnessed how the fight against the disease is increasingly undermined by poverty, the breakdown of communities and social problems, such as drug abuse. The highly effective direct observation of treatment that was devised by TB pioneer Sir John Crofton, one of Edinburgh's most famous sons, has been adopted universally, but more must be done to ensure that it is implemented effectively. I am sure that there is a greater role for the international community in that regard. A year or so ago, I saw at first hand the excellent work that DFID is doing in the fight against TB in India.

However, there is only so much that the international community can do without the co-operation of those in charge on the ground, where the problems are worse. It is hard for the international community to help developing countries improve their health services when some refuse even to acknowledge the difficulties that they face on their doorsteps. The slums of Kibera on the outskirts of Nairobi were well publicised recently in the film "The Constant Gardener", which dealt with the problem of drug testing in developing countries. About 1 million people—the population of Edinburgh and Glasgow combined—live in those slums, yet the Nairobi Government did not even accept the existence of what was happening. Such matters did not feature in plans, and the area does not have a fresh water supply or sanitation. We must press the Governments of developing countries to accept that they have a key role to play in the fight against diseases and in the development of good health services.

I visited an excellent clinic in Nairobi at which the staff and health workers were doing a great job. However, they wanted to move to better facilities across the road. A building existed, but the Nairobi local authorities had not connected water or electricity supplies. The doctors told us that they had been waiting eight years for the building to be connected to supplies. One of the reasons they were told why they could not be connected was because new hotel developments were being built in the city centre and needed the water supply for bedrooms and swimming pools. There must be an acceptance by the Government that, if they work with other Governments, certain advances can be made.

I am sure that the Minister will agree that part of our struggle is forcing those Governments to do more to help their countries. The international community and NGOs will be fighting a losing battle for ever if Governments show a disregard for the well-being of their citizens. I urge DFID to step up the pressure on those Governments, to force them to help their own people whenever possible.

Mention has been made of the importance of Governments recognising their role in recruiting staff. Such practice has often been described as poaching nurses and doctors from abroad. I had a similar experience to my hon. Friend the Member for Leeds,
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North-West when I visited a care home in my constituency. The care assistants were fully qualified nurses and I was told that a fully qualified doctor had worked there for a next-to-nothing wage as a care assistant, until his qualifications were recognised in this country. Clearly, there is a long way to go. However, given that such matters have been mentioned by previous speakers, I shall not dwell on them.

I am sure that many hon. Members will be familiar with the work of Dr. Gbary of the World Health Organisation. He is the adviser on human health resources. His research estimated that 23,000 of the best trained medical staff leave Africa each year for the developed world. It is a particularly frightening statistic when we consider that there are only about 800,000 medical staff in the whole of Africa. The hon. Member for Boston and Skegness referred to Malawi and said that, out of 12 million people, there were 100 doctors and an estimated 2,000 nurses.

To put such matters into perspective, almost half of the recent 16,000 staff expansion of the NHS came from the recruitment of health professionals who were trained outside the United Kingdom and Europe. My hon. Friend the Member for St. Ives (Andrew George) raised the extreme case of Swaziland, where, in the past two years, 200 nurses have been trained, and 150 of them have since moved to the UK. I am sure that the Minister will agree that those are sobering statistics.

Hon. Members may be aware of the recent study by the university of London. It noted that although the serious consequences of a brain drain are increasingly recognised, the UK's demand for health professionals has affected the countries of sub-Saharan Africa more than any other part of the world. That has not been fully appreciated. We cannot hide the shameful fact that we have played a particularly prominent part in the process, with an estimated 31 per cent. of our practising doctors having been trained overseas. That compares unfavourably with rates in other European countries of a similar size. In France and Germany, for example, the proportion of practising doctors trained overseas is only about 5 per cent. I hope the Minister agrees that we have a responsibility to take a lead in tackling the problem.

We cannot be surprised that skilled people will want to move in search of a better-paid job. However, the tragedy is not only that we employ many skilled medical professionals from countries that desperately need them, but that when they arrive in this country they often end up working in lower-paid, lower-skilled jobs.

I do not want to be unfair to the Government, because they and the Department for International Development have done an awful lot of good work on the problem, which is very complex. I acknowledge that efforts to prevent doctors and nurses from coming to the UK will not necessarily prevent them from going elsewhere. The point is that it is our responsibility, as a major beneficiary of that medical brain drain, to take the lead in addressing the problem. The real challenge is to improve conditions back home so that medical professionals want to, and can, stay in their own country, where they are most needed and will make most difference. So far we have not done enough, and what we have done has not had maximum impact. However, I   compliment DFID on its work in Malawi. The
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£100 million pledged for better health services, better training and higher salaries for doctors, nurses and other health workers in Malawi has been a great success.

It is important to improve awareness and understanding of health issues in the poorest parts of the world. In just over a week's time, I, along with a few other members of the International Development Committee, will visit Sierra Leone to see how a post-conflict country can develop, and develop its health service, too. That country currently has the highest risk of maternal death in the world. The vast majority of cases have easily preventable causes, including infection and obstructed labour. In Sierra Leone, as elsewhere, part of the problem is the lack of basic health education. In some areas there is a history of beliefs that it is natural that some women will die during childbirth. The idea that that is somehow the price that is paid is clearly outdated and simply not true. The price is far too high.

In many areas of Sierra Leone, lack of basic health education results in pregnant women shunning medical facilities and choosing instead to give birth at home with the help of a traditional birth attendant. Consequently, infection, disease and serious complications during birth are commonplace. There is little point in providing health services if people do not want to use them or do not understand why they should use them. Improving the basic understanding of health issues is another thing that we must address if we are to improve the effectiveness of health services in the poorest countries.

The challenge is to improve health services in such countries, and action must be twofold. We must do all that we can to tackle the serious problems that the countries face. Antiretroviral drugs, more hospitals, more staff and better education will all play their part. However, we must not pretend that we can treat those problems as we would do health issues in this country. We can spend money on drugs, we can help to halt the exodus of trained medical staff, and we can help to fund hospitals, but if the underlying reasons for the poor health of a country are not dealt with, we will for ever be firefighting.

Hon. Members will be aware that the greatest advance in health provision in this country was the advent of universal access to safe, reliable drinking water supplies. In the long term, no one single thing will do more to improve the health of people in developing countries than securing a clean drinking water supply. That would make a huge difference across sub-Saharan Africa and beyond. I often hear talk about targeting aid where it will be most effective, and securing that drinking water supply would be as effective an outcome as we could hope for.

The basics required for a healthy population are still missing in many parts of the world. Until we get to grips with such basic problems, we can only do so much with hi-tech medical equipment and the latest drugs. Crippling poverty, poor sanitation and lack of clean drinking water are not problems that can be solved in the hospitals and medical centres.

As well as support from outside, there must be political will and determination within developing countries. How often do we see desperate conditions and non-existent health services in countries with natural resources, corrupt Governments and high spending on the military and small arms? Sudan is just
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one example that comes to mind. We must keep up the pressure on such Governments so that the good work done out in the field by DFID, NGOs and many others is not cancelled out by the actions of the very Governments with whom they should be working.

4.21 pm

David Taylor (North-West Leicestershire) (Lab/Co-op): I am grateful to be able to make a brief contribution to the debate, in which I shall flesh out the points that I made in my interventions.

Here we are in 2006, 100 years on from the formation of the Labour party, whose presence in Government we now enjoy. I have been a member of that party for well over a third of its life. Could its founding fathers and the other people in that upper room ever have envisaged that we would reach the present position in international development from what was then the empire of Great Britain in Africa, Asia and elsewhere? Could they have envisaged that 100 years later there would be a Labour Government with a solid and substantial majority and a good track record over nine years on international development issues? That is a serious achievement. Two of our most talented colleagues have been Secretaries of State for International Development: my right hon. Friends the Members for Birmingham, Ladywood (Clare Short) and for Leeds, Central (Hilary Benn).

The target of 0.7 per cent. of GDP is substantially within reach. The debate is about strengthening health services in developing countries, and part of the money will be used in just that way. Our economy is worth about £1,200 billion at the moment; 0.7 per cent. of that is about £8.4 billion. We are not there yet, but we are heading in the right direction. I hope to live long enough to see resources developed and allocated to health services, education, and all that comes with that, at 1 per cent. and beyond; who knows? We have played a big part in moving toward that objective.

I intervened earlier because our debates on international development are rightly sometimes dominated by the potential and activities of big government—national Governments and international organisations such the United Nations and the European Union. They are sometimes devoted to the    activities of large multinationals such as the pharmaceutical companies and large charities such as Médecins sans Frontières, Save the Children and Oxfam. That is fine—of course the great bulk of development work and the contribution made by countries such as ours is through such channels. That will always be the case, but it does not tell the full story.

There are many small organisations that could play a part and tap into previously unused resources. They can use energy and ideas, they are quicker on their feet and more flexible, and they can target their support effectively. That is why I mentioned the work of Inter Care, based in Syston, Leicestershire, which I think is in the constituency of the former Secretary of State for Health, the right hon. Member for Charnwood (Mr. Dorrell). It is a few miles away from my constituency and some of its volunteers live in north-west Leicestershire.

Inter Care is not some informal organisation that does not work within proper professional guidelines with high standards. The people working in it are
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qualified pharmacists who have taken a career break or retired early and who have worked in Africa and Asia. The purpose of my contribution is to persuade the Minister, and through him the Secretaries of State for International Development and for Health, that there is considerable scope for activities such as those provided by Inter Care.

Inter Care can contribute simple medicines, equipment and educational materials to health centres in the six English-speaking countries in sub-Saharan Africa that I listed earlier. I am talking not of some scattershot approach, but a targeted one. Each donation is sent directly to specific clinics whose staff and medical needs are known personally to the Inter Care team in the UK.

Although organisations such as Inter Care are not in a position to respond to or donate medicines for emergency or disaster situations, they are able to help significantly. They support the basic health care provided by local African medical staff as they try to develop their national health provision.

Earlier, we talked about the nature of the countries that receive help. They are often the poorest countries on the planet—the poorest countries in Africa, Africa being the poorest continent on the globe. If organisations such as Inter Care were not active, the poorest people in the poorest country on the planet would have no health care or pharmaceuticals at all. Those have to be given free, because such people do not have even the necessary income to acquire medicines.

Where do the resources come from? They are unused, unwanted but in-date quality medicines that are returned every day to GPs' surgeries throughout our land of 60 million people. Inter Care is tapping into only a tiny proportion of that, but is able to help 2.5 million rural people in the six countries that I listed. I am trying to encourage the expansion of such activity, rather than to allow such medicines to be wasted and destroyed.

Ms Keeble : Does my hon. Friend agree that stocks that have to be held by GP practices and are often disposed of—not necessarily because they are out of date—are available in addition to those returned drugs? They represent a huge loss for the NHS, but can be recycled as my hon. Friend describes.

David Taylor : My hon. Friend is right; enormous amounts of medicines in this country are incinerated or disposed of in safe ways. What a waste—not only of the production costs, but mainly of the benefits that would come from their use elsewhere on the planet. Sample packs unused by GPs are destroyed every day along with pharmaceutical waste. The small pack sizes that typify those trials are ideal for the small rural health units supported by Inter Care, which also benefit from gloves, stethoscopes, face masks and other items that reps leave with GPs in the UK.

My hon. Friend mentioned other sources such as batch orders, cancelled orders and so on. A large pool of material is being wasted, incinerated and set aside, but it could be used, given the will and the means. What sorts of medicines? Like us, a poor African patient is entitled to appropriate medicines of appropriate quality. No one is suggesting that any other category be utilised.
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The choice of which medicines are sent is made during careful consultation between the qualified pharmacists at Inter Care and the medical staff at each clinic. The medicines sent are appropriate to particular needs and resources and are specifically requested by the clinic concerned. They must meet high standards, must not be damaged or out of date, and must be legally recognised as safe and effective in a recipient country. There may be different standards in operation in other parts of the world.

Of course, World Health Organisation guidelines are observed at all stages. They are observed when assembling consignments bound for rural parts of Africa. There will be up-to-date information on the dosages, contra-indications and side-effects and all the things that we in the west would expect as routine.

I have made a brief contribution to highlight the work of my constituents and others in Leicestershire and show that, through partnerships with local health providers, they are about the regular supplies of essential, basic medicines to nearly 100 hospitals, clinics, health centres and dispensaries in six of the poorest countries in Africa. Almost half those units receive additional support with essential drugs in the palliative care of patients with HIV/AIDS, about whom we have talked. Inter Care is active in that area as well. Like the regular consignments, those drugs are sent by Inter Care in response to specific requests, for as long as its help is needed.

I shall conclude with one quote from Sister Rosemary, who works at Matai health centre in Tanzania:

That is as good a testimony as there can be for a smallish voluntary organisation, working in a rural part of an east midlands county in the United Kingdom. That work can be replicated, and more work can be done. We are just pump-priming at the moment. To be part of that in a tiny way—to be part of a Government, as a Back Bencher, that is achieving so much in terms of the development goals that we have played a large part in shaping—fills me full of pride.

A remote member of my family, Arthur Henderson, was once leader of our great party. He would have been tremendously thrilled and excited by the progress made by our Government, elected in 1997 and hopefully re-electable in 2009–10. We will be happy to carry forward the goals and improve them. Some of the greatest achievements that political historians will be able to identify, looking back on this era in 20, 30 or 40 years time, are the changes that we have made. We all came into politics to make changes for our communities, our countries and, in some cases, our globe. This area, along with others, will stick in the memory of future generations in this land and others. We can rightly be proud, without being complacent, of the successes that we have achieved in international development.
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4.33 pm

Mr. Thomas : With permission, Lady Winterton, I should like to reply to the many points made by hon. Members from all parties.

Given the propensity of the hon. Member for Boston and Skegness (Mark Simmonds) to write letters requiring a considerable amount of reflection, I thought that I would start by dealing with the points that he made. He rightly talked about the importance of the Global Fund and highlighted the fact that as a Government we have doubled our funding to £100 million for both 2006 and 2007.

Nevertheless, the global fund needs more resources than were pledged at the September replenishment conference that we held in the UK. Since then, the American Government have approved more money than had been anticipated for the Global Fund, which is enormously important. A further mid-term review of the Global Fund will assess its performance and provide the opportunity to mobilise additional funds. One donor that has not yet pledged resources is the European Community. Because its budget has only just been agreed, the details have yet to be worked out, but we hope that the Community will pledge substantial funding at the mid-term review to allow the Global Fund to do even more.

The hon. Member for Boston and Skegness suggested that "3 by 5", the WHO initiative, had been a failure. I accept that it did not achieve its headline ambition by the set date, but I do not see it in those same gloomy terms. The initiative has catalysed people's focus on a treatment that is beginning to make a significant difference in sub-Saharan Africa. In 12 months we saw a trebling of the numbers having access to antiretroviral treatment, which is important progress. The international attention that has been given to such treatment, and to what needs to be done to extend access to it, is hugely important. I accept that the ambitious target of getting 3 million on treatment by the end of last year was not achieved, but there is more to do on that front, and I shall return to the subject in a moment.

The hon. Gentleman rightly touched on the importance of continuing to focus on TB. A proportion of the Global Fund's resources are directed at TB. We are also contributing £5 million over the next three years to the Stop TB Partnership. The latest international global plan for tackling tuberculosis will be released tomorrow at the world economic forum in Dallas. That, too, will give the subject the international attention that, as the hon. Member for Edinburgh, West (John Barrett) said, is so important.

The hon. Member for Boston and Skegness also spoke about user fees. We want to see them abolished. I absolutely accept that they are a huge deterrent, particularly for poor people, by preventing access to health services. We need to help developing countries with the resources that will be lost as a result of abolishing user fees, and help them to go beyond the size of their budgets so that they can expand significantly the services that they make available to all those who will want to use the health care provisions once the fees have been abolished.

The hon. Gentleman raised a number of points about drugs, and cited some statistics about their availability. Our understanding is that the market for new drugs is
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horribly skewed towards the developed world and away from the developing world. Indeed, some 50 per cent. of the world's drugs market is located in the Americas and 25 per cent. in Europe—but only 1 per cent. in Africa. Those bald and stark statistics give a clear indication of the need to rebalance the international drugs business towards the needs of developing countries.

I hope that the flexibilities in TRIPS—the trade-related aspects of intellectual property rights—will help developing countries to gain access to the generic drugs that they need. We accept that we have a responsibility to help the trade and health Ministries in developing countries to take advantage of those flexibilities. Indeed, we are helping the Ministry of Trade in Ghana to develop manufacturing capacity for drugs, and to take advantage of the TRIPS flexibilities.

Ms Keeble : May I press my hon. Friend on the problems being experienced in Zimbabwe? Local factories cannot buy the necessary supplies, and the Government will not allow the import of drugs. There is a real risk that the drugs supply will fail and leave patients with no help.

Mr. Thomas : Zimbabwe, as the hon. Lady and indeed all hon. Members will know, poses particular challenges for those of us interested in the cause of development, for all sorts of very obvious Government-related reasons. Donors such as this country, NGOs and UN organisations operate in an extremely difficult environment, and we have to think very carefully about what we can do to try to secure the immediate humanitarian assistance needed for people who have been very adversely affected by the Zimbabwe Government's policy. Drugs are, of course, one of the problems that we must consider.

One of the ways in which we are trying to encourage the pharmaceutical companies to support access to drugs in developing countries is to pay close attention to their pricing regimes. We seek to encourage developing countries to have different levels of pricing from those of developed nations.

We also seek to extend the number of research partnerships with the pharmaceutical industry, in which huge talent resides, to develop the drugs that developing countries need. Again, we hope that advanced market commitments will help to encourage large pharmaceutical companies to invest in research, knowing that there is the possibility of a guaranteed market for the new drugs that they deliver.

David Taylor : Of course it is important for there to be appropriate research that will be effective in the treatment of illnesses and conditions that may be found in the countries that have been supported through international development, but does the Minister accept that in the absence of a substantial framework in those very poor countries to deliver pharmaceuticals to the poorest people of all in those countries, those people cannot pay any price at all for those drugs, and that there needs to be a mechanism to ensure that they can access medicines freely, even if their nation and their Government tend to charge for that type of product?

Mr. Thomas : I am grateful to my hon. Friend, because I was going to talk about the distribution of drugs,
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which was the last point in a series made by the hon. Member for Boston and Skegness. It will be a huge challenge to meet the goal that G8 leaders first said that they wanted to be met, and which the world summit endorsed, of almost universal access to antiretrovirals by 2010, not only in urban areas but particularly in rural areas where the greatest challenges lie.

One of the things that we will need to consider is how we scale up investments in health systems in the next few years, so that there are health workers in rural areas and other underserved areas with the necessary resources—drugs are one obvious resource, although not the only one—so that we can help to meet that target. That is one issue that DFID is considering.

Several hon. Members, including the hon. Members for Boston and Skegness, for Edinburgh, West and for Leeds, North-West (Greg Mulholland), talked about human resources, which were fundamental to the point about distribution that my hon. Friend the Member for North-West Leicestershire (David Taylor) made in an intervention. We do have a code of practice in this country. Indeed, we are the first, and I believe currently the only, OECD country to have such a code of practice. It is not a perfect solution to the problem of health workers leaving developing countries, but the debate in this country on the code of practice has not yet focused enough on the reasons why people want to leave developing countries in the first place.

When I visited Malawi in October with the Minister of State, Department of Health, my hon. Friend Member for Doncaster, Central (Ms Winterton), we began to understand clearly why many of the health workers who have left Malawi wanted to do so in the first place. Poor pay and conditions, a lack of accommodation close to where they want to work, the great unattractiveness of working in rural areas, and an occasional lack of access to training and career development are some of the reasons why people have wanted to leave developing countries in the first place.

There are often huge pools of former nurses in African countries, either working in other parts of the public sector or the economy or, indeed, doing other things. We need to find ways in which to support developing countries and make working in the health service attractive to those nurses and workers. Perhaps those here in the United Kingdom will want to return, but more importantly, we must help to attract people in developing countries into the health service. We have put funding in Malawi to help it to expand by raising pay levels and bringing in people from the United Kingdom to boost the training capacity to begin the process of doubling the number of doctors and trebling the number of nurses over the next five years. Initial signs suggest some success, although the programme has been running only since the beginning of this financial year.

However, back in October, officials from the health Ministry in Malawi said that they were beginning to see a slight increase in recruitment and certainly the drain of people out of Malawi had stopped. We must continue to discuss such issues as an international community. It is on the agenda in Europe, as a result of which I hope that
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a code of practice will be established. I also hope that other OECD members will similarly consider taking a more ethical approach to recruitment.

Mark Simmonds : Is the Minister aware that the code of practice needs to apply not only to OECD members but to NGOs? A specific situation has arisen in Mozambique whereby an NGO from another country—not Britain—has poached from the Mozambique Government a senior civil servant who was in charge of health care provisions, so that person had no one within the Mozambique Government with whom to discuss the money that he had received to spend. Clearly that is a ridiculous situation, and it would be helpful if the Minister could plug it into the debates that he is having.

Mr. Thomas : We must recognise that a series of organisations beyond bilateral Governments need to engage in the recruitment of health workers. Clearly, the example cited by the hon. Gentleman is scandalous. There is no other term to describe it. While NGOs in general, such as Inter Care, near the constituency of my hon. Friend the Member for North-West Leicestershire, are an example of the huge good that they can do, we need to hold them accountable for their practices on occasion.

The hon. Member for Boston and Skegness referred to trade and the importance of a good deal in the World Trade Organisation's current round of talks to help countries ultimately to boost their economic growth, so that they have the resources to fund their health service themselves. The hon. Gentleman may be aware of the Abuja declaration back in 2000, in which African countries pledged to work towards spending some 15 per cent. of their national budgets on health. Several countries are getting closer to that, while some are still a long way from the target. He will be pleased to know that they also pledged in that declaration to abolish tax on insecticide-treated nets. Again, some have done so, while others have not. We must continue to engage in the dialogue.

I recognise the essential difference of emphasis between the hon. Gentleman and me on budget support, but we cannot make progress on strengthening health services in developing countries without budget support, or at least, without support to the health sector in the budget within the Government. I accept that we need to make sure that the most stringent financial management practices are being pushed and adopted in developing countries, and that is why extensive external reviews are being undertaken by organisations such as the World Bank, the International Monetary Fund and regional development banks, as well as undertaking our own stringent practices before we commit to budget support. I say again that simply giving money through NGOs or UN organisations will not see the revolution in health care that we so desperately need.

The hon. Gentleman rightly says that we need to ensure that countries outside the UK deliver on aid commitments. He specifically mentioned Germany. One reason why we continue to push the international finance facility with enthusiasm is because it will help to bring forward those aid commitments. He asked how we
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safeguard the way in which debt relief moneys are spent. We do not give debt relief until an effective poverty reduction plan is in place, and we expect there to be stringent financial safeguards. It would be astonishing if an effective poverty reduction plan did not include investment in health care. That is part of the dialogue.

On bird flu, we have committed an additional £20 million to the World Health Organisation, which is leading the assessment of the preparedness of developing countries to deal with the threat of bird flu.

The hon. Member for Leeds, North-West raised specific points about the code of conduct, which I have addressed. He also talked about our investment in the health sector in Malawi, and the possibility of people from Zambia, Uganda and other nearby countries being sucked into that sector. We are working on strengthening health services in a range of sub-Saharan African countries, so we are addressing the problem that he is worried about.

My hon. Friend the Member for Northampton, North (Ms Keeble) talked about Schools for Africa: an excellent initiative, the launch of which I am privileged to have attended just before Christmas. I pay tribute to her campaigning for orphans and vulnerable children, particularly the campaign that she has persistently waged with my right hon. Friend the Secretary of State and me to ensure that we track the way in which money is getting to the grass roots in developing countries, so that organisations such as KENWA, which she mentioned, have the resources that they need. They are a fundamental part of the capacity required to support orphans and vulnerable children.

The next meeting of UNICEF's annual global partners forum is approaching fast and will be in the UK. My hon. Friend will know from our discussions that on its agenda is the issue of getting money to the grass roots and what we should do about the blockages in some countries that stop money getting to organisations such those that she mentioned. She went into some detail about the problems faced by KENWA. I already have a commitment to write to her as a result of our correspondence, and I repeat that commitment. I will look into the problems faced by KENWA and come back to her.

My hon. Friend was right to remind my Department and the Government of the need to focus on the health of infants and women. We are increasing investment in safe motherhood programmes in several countries including Malawi, Pakistan, Bangladesh, Kenya and Nepal, which I visited in July 2004. Simple things such as bicycle ambulances have made a huge difference there in helping to get women who are having complications with their pregnancies into local health facilities. The programme is helping to fund investments in better equipment and training, so that when mothers and would-be mothers get to the hospitals concerned, they have access to the necessary services.

I come back to the point about the need to scale up, which we as a Department accept absolutely. That plays a part in our conversations on the comprehensive spending review, and I am sure that there will be further discussions on it in the coming months.

The hon. Member for Edinburgh, West made several points, which I have broadly covered already. The one that I have not covered is his point about the need to
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continue to encourage the international community outside the UK to focus on investment in basic health services. The focus of the World Health Assembly and the UN summit on these issues is hugely important and must continue.

In reminding us of that great day in history when the Labour party was formed, my hon. Friend the Member for North-West Leicestershire rightly paid tribute, by implication, to the leadership of my right hon. Friends the Prime Minister, the Chancellor of the Exchequer and the Secretary of State for International Development for the way in which they have
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championed investment in international development and health services. He also rightly paid tribute to the excellent work done by many NGOs in sub-Saharan Africa, in particular, in the absence of any other support. He talked about Inter Care, too, and I commend him and that organisation on their work.

I hope that hon. Members feel that I have done justice to the points that they raised. This is a debate that we will return to, and we should continue to do so.

Question put and agreed to.

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