5—Memorandum
submitted by the Tropical Health and Education Trust (THET)
1. THET (founded in 1988) is the umbrella
body for long-term Links between NHS institutions and medical,
nursing and other health professional training schools in the
UK and their counterparts in developing countries globally—fruitful
partnerships for development as championed as a Millennium Development
Goal. It also mounts demonstration projects with African partners
to model accessible health care in Ethiopia, Somaliland, Ghana,
Uganda and Malawi, typically addressing the needs of people with
chronic conditions (such as epilepsy, mental illness, diabetes
and chronic heart and lung conditions) in more remote rural areas.
In all of THET's work the training and continuing medical education
of health workers, to create long term capacity, is key. The overall
aim is to strengthen basic, sustainable health care services for
the general population.
2. Coherence with other Government Departments.
NHS Links bring threefold benefits: to the developing country
via building of healthcare capacity; to the NHS or UK teaching
staff involved, because of the insights, skills and personal development
that result; and to development awareness in the UK, because they
create an important constituency of involved people and their
supporters within NHS institutions or medical schools, committed
to the cause of international development.
3. These three interrelated dimensions inevitably
pose a challenge to separate Government Departments and compartments.
Possibly for this reason, DFID has perhaps been a little slow
to grasp the potential of Links as a means of harnessing the immense
resources of the NHS and UK health professions to international
development efforts. The efforts to collaborate with the Department
of Health (DoH) are recent and as yet less steady than the collaboration
with DFES over school links and development awareness. Most individual
Links get no DFID support either for direct international development
contributions or development awareness. There are, however, good
signs for the future: there have been high level meetings between
DFID and DoH about better support for health links; DFID has recently
awarded a grant of some £500,000 over three years from the
Civil Society Challenge Fund to THET to support its Links work;
and DoH has in parallel seconded a senior manager to THET to assist
our promotional work among NHS institutions. We sense an openness
to further change for the better, eg a more strategic and systematic
approach to funding Links work at different levels, and recognising
in concrete ways the contribution of such Links to development
awareness as well as international development goals. These good
possible trends need reinforcement.
4. There is a particularly significant strategic
opportunity now, because Sir Nigel Crisp has been asked by the
Prime Minister to report to him and the Secretaries of State for
International Development and Health by the end of the year on
how the UK can give greater assistance to strengthening the health
systems of developing countries. This should open up ideas for
further collaboration across Departmental boundaries, clearer
recognition of the potential of Links at different levels for
the threefold benefits already identified, a more strategic and
determined approach to foster and support them, and integrate
them in sector wide approaches to supporting the healthcare systems
of developing countries. It would be very helpful if the Committee
were to shine a light on this area and lend impetus to the efforts
being made by DFID, DoH and Sir Nigel and his team, and NGOs like
THET, to make the most of this opportunity.
5. Increasing Aid Volumes. It follows
that one important area for increased assistance should be the
encouragement of Links activity in health both for its direct
impact on international development goals and its role in the
international development awareness and commitment of the health
workforce and medical and nurse training student bodies in the
UK. More generally, THET can testify to the great importance of
long term support by international donors such as DFID for human
resource planning for health, as advocated so persuasively by
the WHO. Promoting the supply and continuing training of health
workers in developing countries cannot be properly undertaken
in three year or even five year fits and starts. Health Ministries
need reliable and long term commitments (even though they cannot
be completely unconditional), linked to strategic plans to meet
heathcare needs as a whole. In THET's view, this is a more promising
approach than investing in vertical programmes defined by particular
diseases such as HIV/AIDS. All too often the latter inadvertently
undermine the basic health services of the country by setting
up separate UN or NGO systems, paying higher salaries than the
health services and sucking vital health workers out of the basic
health care systems where they are desperately needed. THET commends
the efforts by DFID to strike a new balance in favour of more
support for health systems and human resource plans "owned"
by the developing countries' own authorities. Links should be
integrated in these plans and co-ordinated by indigenous Ministries
of Health. Such donor support, if related to the needs highlighted
by the WHO and sustained for the long term as it needs to be,
could absorb fruitfully a substantial part of the increased aid
volumes. We hope the Committee will agree and encourage this direction.
6. The organisation of the Department.
The international development universe is now very complex globally,
and traditionally DFID has helped UK-based NGOs to navigate it.
This ability to help UK NGOs make the most of their contribution
could be affected by three organisational developments. One, DFID
is so decentralised that we are sometimes told, in effect: "for
an answer to that you really need to speak to DFID's representatives
in half a dozen or more separate country offices". This can
be unrealistic for smaller NGOs. Two, the consultancies to which
important DFID functions have been outsourced are no substitute
for expertise in house which can more readily be integrated with
policy and strategic considerations and brought to bear in a manageable
set of relationships with DFID officials. Three, if DFID in the
interests of aid harmonisation surrenders its own active presence
in Ghana or Tanzania to other countries, it is important that
NGOs which may find it difficult enough to maintain good relationships
with a range of DFID officials, let alone those of the Netherlands
etc too, are helped to achieve good access to the officials of
such other countries. Otherwise, what may seem sensible or neat
from the point of view of rationalising DFID's efforts may end
up making it more difficult for the NGOs and other players in
the UK to make their contribution in countries where the UK has
had specially strong traditions. The Committee could helpfully
explore these issues.
7. Aid Modalities. There is no one
means of support which is uniquely right for every circumstance.
THET supports the direction of current policy in favour of more
support through budgets or sector wide approaches to systems of
health and to strategic plans for balanced health care services,
including crucially human resources. We recognise that such schemes
of "horizontal" support cannot be unconditional; there
must be conditions relating to the transparent use of the funds
for agreed objectives, to progress made and to certain values
which are non-negotiable if UK public support for international
development aid is to be sustained. The potential clash of imperatives
creates arduous dilemmas for DFID Ministers which are appreciated
here, and which should not discourage them from persevering with
the best long term approach as circumstances allow, and finding
second best ways of continuing to achieve the most important strategic
objectives where necessary.
8. In particular, we would emphasise the
importance of long term support for human resource plans owned
by the developing country's Ministry and health authorities. Without
it, all kinds of promising projects cannot be replicated and excellent
efforts, including NHS Links, cannot reach their potential and
may not be sustainable.
9. This involves making sure that the indigenous
health authorities have the capacity to assert and keep control,
keep the multitude of development agencies and NGOs in their place
and achieve a reasonable balance of power in the relationship.
For this reason, DFID's grant to THET for promoting NHS Links
includes provision at our request to support pilot Links Co-ordinator
posts in four developing countries, so that the promotion and
co-ordination is not all at the UK end, and so that Links with
other developed countries can be taken into account.
10. Nevertheless, within this broad framework
we must beware a simplistic and "one-eyed" approach,
with the pendulum swinging from one extreme position to the other.
The case for some conditions has been acknowledged above. The
Committee will also be well aware of the importance of assisting
civil society in developing countries to thrive and exert influence,
not least by providing a voice to groups who would otherwise tend
to be unheard, and to hold the authorities to account. Moreover,
even with capacity-building support, Ministries of Health and
other indigenous health authorities will remain under great constraints
and almost overwhelming pressures. In order to develop plans for
health care in different dimensions, they will often need ideas,
experience, resources and skills from outside, and continuing
support and engagement from those who have won trust as faithful
partners genuinely working to the priorities of the developing
country partner and not imposing their own. It would be unrealistic
to conceive of writing a cheque and leaving them to get on with
it unassisted. As enshrined in the Millennium Development Goals,
proven global partnerships for development are to be celebrated
and supported, and should not fall foul of a narrowly interpreted
ideology of budget support.
11. These are the issues on which THET feels
it has the experience to testify to the Committee. We are glad
that the Committee is undertaking this Inquiry and should be glad
to elaborate on this evidence in any way that would be helpful.
June 2006
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