Examination of Witnesses (Questions 20
- 25)
TUESDAY 22 NOVEMBER 2005
MS SANDRA
BLACK, DR
MANDEEP DHALIWAL,
DR TOM
ELLMAN AND
MR BEN
PLUMLEY
Q20 Joan Ruddock: We have not heard
from Ben Plumley. I am wondering if there is a real difference
here. Tom Ellman is saying that if it is not free and it is a
range of drugs, not just the ARVs, then the universal target is
not going to be reached. Is that the view of UNAIDS?
Mr Plumley: I have to be honest
and say it is not. I would say that free treatment at the point
of delivery is certainly an option. Mandeep has referred to the
debate that is going on within the 10 co-sponsors of UNAIDS. We
have to be realistic about what can be achieved. We do not have
the full funding for a comprehensive response to AIDS in place.
We believe it needs to be around £22 billion by 2008. It
is a question of what will work in different circumstances. We
are very interested in free treatment at the point of delivery
as one of those mechanisms but it may well not be possible—and
our co-sponsors have looked at different settings—in the
short to medium term. If that is the case, then that should not
hold us back in terms of pushing universal access and support
for countries developing targets across the prevention, treatment
and care agenda. I would just point to one thing that backs up
what Mandeep said about the evidence. The evidence that we have
around user fees having an impact really relates to prevention
and around some of the experiences we have seen in India and indeed
in the mines in Zambia and Botswana on access to condoms. If there
is a very small user fee for the purchase of that, then that has
been seen to have had an impact in encouraging use, but we have
not see that in relation to treatment.
Q21 Ann McKechin: We are all aware
of a very severe shortfall in health care workers in the developing
world. Can I ask the panel how realistic this is? If we are going
to aim for universal access by 2010, do we have sufficient human
capacity to deliver that form of ARV treatment? A secondary question
is: has there been sufficient planning to make sure that ARV programmes
are not going to be expanded to the detriment of general health
care?
Dr Dhaliwal: I think Sandra mentioned
in her opening comments[12]
that if we are going to have sufficient human resources to deliver
anti-retroviral treatment and prevention in developing countries,
we have to ensure that we have standardised, simplified approaches
to treatment, we have fixed-dose combinations which are proven
to be easier to deliver, that we have task shifting and we have
better use of community resources to deliver treatments and not
just westernised, doctor-led approaches as the necessity for delivering
treatment. This is important if we are going to make better use
of the human resources that are there. Other than that, in terms
of having human resources, there are several points. There is
an opinion piece published by the ODI recently[13]
about having strategies to compensate developing countries for
the health care staff that we poach from developing countries,
ensuring that we have training partnerships and investing in developing
country medical education programmes and education programmes
for nurses. That discussion is going to feature heavily at the
Hong Kong WTO meeting in December 2005 and outcomes of this meeting
will be critical to how we scale up to universal access to treatment
and prevention.
Dr Ellman: That does not necessarily
need to appear as part of an aid budget. It could be from the
Department of Health. This is a direct recompense in many ways
for the brain drain benefiting the NHS.
Q22 Hugh Bayley: We can ask the Secretary
of State for Health about that. Perhaps it can be made easier
for nursing schools in Lilongwe.
Dr Dhaliwal: Policy coherence
across the British Government is very important on this issue.
We see a lot of people at Barts, for example nurses, many of whom
may even be HIV positive, who have ended coming here; they live
here now and they work for the NHS. How are we going to compensate
the Zambian and Zimbabwean health systems where a lot of these
nurses are coming from?
Mr Plumley: There is an issue
around capacity not just in the health sector but in other public
sectors. One might even call that a crisis in a number of countries.
Our co-sponsor WHO has done work in looking at particularly southern
Africa, and I am thinking of Malawi. We do have a health sector
crisis in terms of capacity in which HIV has played a part, both
in decimating health care workers but also in terms of moving
staff from public to private sectors in these countries and also,
as has been discussed, the movement of trained staff to industrialised
world health care settings.
Q23 Ann McKechin: Do you think it
would be better that, rather than trying to wait for people in
the Western world to give back for the brain drain, there should
be more emphasis on wages and conditions for medical staff in
developing countries and that agencies such as the World Bank
and the UN should be putting greater priority on making sure that
those issues are addressed?
Mr Plumley: Absolutely. This is
very much part of the work that the World Bank, WHO and UNAIDS
are looking at—innovative mechanisms to keep trained health
care workers (and not just health care workers) in posts where
they can make a major difference.
Dr Dhaliwal: DFID has done some
exemplary work in Malawi where they have invested in working conditions
and improving working conditions and salaries for health care
workers there. We think that work needs to be scaled up to many
other countries. For example, we are hearing stories of South
African health care staff now wanting to go and work in Malawi
because of the DFID programme in Malawi. There is an urgency for
scale there. In a recent evaluation of World Bank AIDS funding
there is a very strong message about investing in and strengthening
health care systems. If that becomes World Bank policy, all of
our jobs will be much easier in the years to come.
Dr Ellman: In terms of coherence,
we should question why it is that public sector spending levels
are still being pushed for capping by the IMF and how can we have
the World Bank, WHO on the one hand saying, "we want to increase
public sector spending specifically for health workers",
but of course in the long term across the board, while on the
other the IMF saying, "no, you cannot do this". I would
like to reiterate the importance that at the same time as ensuring
we have motivated, well-paid doctors and nurses in the system,
we are absolutely clearly going to need a new cadre of health
workers to deliver AIDS care and AIDS prevention across Africa.
Those people are not currently being paid: they are volunteers,
community health workers, people who by definition will stay where
they are within the community, and of course people living with
HIV and AIDS themselves. Finding ways to pay those people to train
to do the work and to take the load off the doctors and nurses
is the only way that we are going to achieve a scaling up.
Dr Dhaliwal: We have done this
in many countries now. A lot of international civil society organisations
such as the International HIV/AIDS Alliance, Christian Aid and
others do this work. We have models and examples where this has
been taken to scale but we need to invest in it. This is where
I would like to take us back to the discussion with DFID, which
at the global level has made fantastic commitments and has some
good country level experience, but that really needs to be strengthened.
There needs to be not just multilateral funding from the British
Government and bilateral funding through budget support and the
SWAps,[14]
but also funding for existing initiatives on the ground which
are already delivering a substantial amount of AIDS prevention,
care and support services to communities.
Q24 Mr Singh: Moving on from that
very serious problem that Ann McKechin has raised, there are evolutions
and other problems in delivering the 2010 target. The Stop AIDS
Campaign in its evidence to us on health care services says: "In
many cases, inadequate health care is the result of World Bank
and IMF fiscal constraints that discourage government spending
on public health."[15]
Recently, we put these very complaints to the World Bank and IMF
and they flatly denied them. It did not help our case with them
in terms of what we are trying to achieve. I would like some comment
on that. The evidence goes on to say: "This lack of investment
leads to poor infrastructure. Healthcare in developing countries
is characterised by a lack of clinics, diagnostic technology,
drug procurement . . . .". On that particularly point, is
the UK Government doing enough to deal with that situation and,
if not, what more should it be doing?
Dr Dhaliwal: We have alluded to
the answers to those questions. I would like to draw your attention
to the OED evaluation of the World Bank AIDS funding.[16]
I think that is very important evidence and information to be
used to pressure the World Bank and the IMF to change their policies.
It critically says that if we are going to make a difference and
if we are going to make our increased AIDS investment work at
country level, we have to strengthen health systems and we have
to invest in that. I think the answer to the question about whether
the British Government is doing enough comes with wonderful stories
like Malawi where they have taken tremendous steps, but that is
not enough. The British Government has to do much more of that
kind of thing. They are investing in improving working conditions
and salaries for health care workers; they are investing in capacity
building and supporting civil society. The British Government
are not just putting all our AIDS money through budget support,
which can often disappear in ministries of health. They must also
invest significantly in other ways, in programmes on the ground
that are already making a difference, that are providing valuable
health resources, even though these people may not be officially
classified as doctors or nurses.
Q25 Hugh Bayley: Perhaps I could
say to all four witnesses thank you very much indeed for your
evidence, your comments and your insights, which are very useful
indeed. We are very grateful to you for coming and sharing your
knowledge with us.
12 Q2 Ms Black Back
13
Overseas Development Institute, From Brain Drain to Brain Gain:
How the WTO can make Migration a Win-Win, November 2005: http://www.odi.org.uk/publications/opinions/59_labour_mobility_nov05.pdf Back
14
Sector-Wide Approaches Back
15
Ev 34, para 1.6 Back
16
World Bank Operations Evaluation Department, Committing to Results:
Improving the Effectiveness of HIV/AIDS Assistance: http://www.worldbank.org/ieg/aids/docs/report/hiv-complete-report.pdf
NB the Operations Evaluation Department (OED) is now the Independent
Evaluation Group (IEG). Back
| 
