Examination of Witnesses (Questions 60-79)
MR IVAN
LEWIS MP, MR
MALCOLM MCNEIL
AND MR
ALASTAIR ROBB
30 OCTOBER 2008
Q60 Chairman: Thank you very much.
I think you will probably appreciate that the Committee has undertaken
to look at the progress on meeting the HIV/AIDS targets on an
annual basis and we have looked at different aspects of it each
time, and this is part of our process. I perhaps also need to
say that we are on a tight timescale because we want to publish
our report in time for World AIDS Day, which actually is on the
first day of the Committee's visit to China, which is a bit tricky,
but we thought it important to coincide that. Obviously, we appreciate
that DFID has a very substantial commitment to meeting the HIV/AIDS
targets, but clearly there is some discussion as to how that can
be achieved and what is the most effective way. Perhaps we could
start with the funding. The Department is putting £1 billion
into what would be called "vertical funding" to the
Global Fund, but £6 billion into broadening funding for health
services. I think the first question to ask is: can you put this
in context? Is this new money or is this simply a reclassification
of the money that is committed that the Department is, if you
like, relating to its AIDS strategy?
Mr Lewis: First of all, can I
welcome the opportunity to appear before the Select Committee
for the first time. It is not entirely a voluntary arrangement,
but I really do look forward to having a positive and constructive
relationship with the Committee, and I am obviously very pleased
to have a brief which, I think, is so central to the values of
my Party and my Government, but I think the values of many Members
of Parliament in terms of what matters in terms of our capacity
to make a difference and, therefore, I am very much looking forward
to developing my knowledge of the brief as well as obviously assuming
responsibility for Africa, health and education across the developing
world and also improving governance. Directly in response to the
question, as far as I know, it is new money and, as the Committee
is aware, we had a very generous Comprehensive Spending Review
settlement which demonstrated both the Government's and particularly
the Prime Minister's commitment to aid and development. The way
we have chosen to direct the resources is very deliberate. We
would argue that, in the early stages of the strategy in terms
of tackling HIV and AIDS, the 2004 Strategy, if you like, we demonstrated
very clearly world leadership and, as a result of our world leadership,
we triggered a whole range of activity and investment from other
donors and from multinational institutions which, frankly, would
never have happened without that leadership. We believe stage
two though is to continue providing that leadership and that leadership
has to be about adding value and making the most difference, and
we believe that making the most difference is actually now, in
terms of the UK's distinct contribution, about investing and making
the case both internationally and in every country of building
universal healthcare systems. If you look at the inter-relationship
between HIV/AIDS and other diseases, if you look at the interaction
between HIV/AIDS and other social factors in those countries,
the case for long-term sustainability, making a difference and
tackling this dreadful disease, the case for ensuring there are
universal healthcare systems in all of these countries has been
the only way credibly on a long-term basis that we are going to
achieve our goals in this area. We think that case is made and
we believe that, for the UK to sustain its international leadership
role, at this time the most appropriate way to do that is to focus
on building healthcare systems, not simply focusing the resources
on the whole, although we are putting some money into the international
Fund, as you know, not simply focusing those resources on to one
disease or on to one group of people.
Q61 Chairman: We understand that
point and it has certainly been expressed to us both at country
level and by the Department before. The evidence we had on Tuesday,
for example, was slightly saying, however, that the funding in
so many developing countries is so small that it is almost impossible
to deliver adequate healthcare of any kind and that, if you happen
to be an HIV/AIDS sufferer or, taking one witness we had via videolink,
Lucy Chesire, who is a TB-affected HIV/AIDS sufferer, her concern
would be that in that generalised funding, these people could
get lost and they would not get the benefit of targeting. Indeed,
I think one comment said that what you're proposing is generalised
insufficiency as compared with the benefit of targeting, at least
ensuring that some sectors get the resources they need. So how
can you ensure that, by doing what you are doing, you do not lose
sight of addressing the people with HIV/AIDS and other related
diseases specifically, that it just does not get spread too thinly?
Mr Lewis: Obviously in our country
offices it is made very, very clear to them, in terms of the money
that we are investing both in healthcare and HIV/AIDS, that it
needs to be done in an integrated way with other donors and with
NGOs, where appropriate. It is true that there will always have
to be a judgment about where the UK's resources will add the most
value and make the most difference, and that is the judgment we
have now made, having, we believe, triggered an unprecedented
level of investment and activity in this area and a different
level really of commitment from donors, if you look at the US
programme, for example. If you look at the progress that has been
made in recent years, but, despite that progress, the overwhelming
nature of the challenge, as you, Chairman, have just pointed out,
if we are serious about long-term sustainable change in terms
of tackling disease and preventing disease, because that should
be our ultimate aim, it has to be about building those universal
healthcare systems in those countries. If we can provide a leadership
in that area, which over time leads the rest of the world to recognise
that it has to come to the table in terms of supporting the building
of healthcare systems, not just targeting money at one disease
or one group of people, then that will be the best service that
we can do for the developing world. Now, that is the judgment
we made. It is not a judgment everybody agrees with. I have to
say, from my knowledge, and I am new to the Department, as you
know, initially it was highly controversial, there were a lot
of concerns about the direction we were taking, but by the time
we made the announcement, having consulted very extensively, I
think there was a broader consensus that actually, in terms of
the UK's continued world leadership in this area, this was the
right thing to do. Now, it is a judgment call and not everybody
agrees with us, but we are absolutely convinced that this is the
right thing.
Q62 Chairman: If we can set aside
the vested interest, clearly there are some groups that benefit
from vertical funding who are worried that they will lose out
from horizontal funding, and we just have to make a value judgment
as to how legitimate their complaints are, but I think there is
a genuine concern which says that, if you are just creating a
good health service, but inadequately resourced, is there not
a danger that some of the programmes, which are currently delivering,
stop delivering?
Mr Lewis: Well, we have weighed
that risk up. We believe that we have made the right decision.
It is true, Chairman, by the way, that, if you look at, for example,
in the developing world some of the achievements around education,
there is beginning to be a debate, is there not, about yes, we
have increased massively the number of children in school, but
the debate is moving on to quality, what kind of access and what
kind of quality education are those children and young people
receiving. I suspect that inevitably we are going to go through
that cycle of debate in terms of healthcare, but should we be
seeking, as a major part, frankly, of strengthening civic society
in any nation with any chance of being successful long-term, should
we be seeking to build, as an integral part of that state-building
process, universal healthcare systems? It is absolutely essential,
not just to the social wellbeing of such countries, but also the
economic success of those countries, so we are saying that, if
we do not do this at this time, nobody else will do it. As a consequence
of that, the time-lag in terms of developing universal healthcare,
we are talking decades ahead, so we believe, in terms of the UK,
that this is the right thing to do and we believe that this will
be a catalyst for a step-change in the way that the international
community sees its obligations in terms of healthcare.
Q63 Chairman: I have just one final
question before I bring in Richard Burden, and it is one that
you will be familiar with, indeed the Secretary of State was challenged
with it on Tuesday. When we had the new Permanent Secretary in
front of us in July, we had a discussion about staffing constraints
and pressures within the Department and her reply to us was, I
think, honest because she knows the parameters, she knows that
the Secretary of State accepts the constraints and I guess, therefore,
that you, Minister, will be obliged to do so as well, but she
said, "We are coping, but we are struggling". The Committee
certainly is increasingly concerned that DFID has very ambitious
commitments both to deliver and monitor what it is doing, and
that is important from the taxpayer's point of view, that we know
that what you are spending is actually producing results, but
how are you going to ensure, with the staffing constraints that
you have, that you can do that?
Mr Lewis: We have to work smarter.
I have been in DFID three weeks and, I tell you what, I am very,
very taken with the sense of mission amongst the staff of this
government department, both in London and in Scotland. I went
to East Kilbride this week, I have had videolinks with some of
the people working internationally and I met all of the governance
advisers who go there for an annual retreat within the last couple
of weeks, and I have rarely come across a group of people so motivated
and so passionate about what they do.
Q64 Chairman: I think the Committee
will have no difficulty agreeing with that, but they are under
pressure.
Mr Lewis: I understand and I will
come on to the point that you make. I think we all recognise that
there is a clamour from the public, quite rightly, and from politicians
of all parties to shrink the level of resource that the State
spends on bureaucracy and to get as much resource as possible
to the front line. I think one of the strengths that DFID has
is its country offices and its country programmes where there
is a very high level of devolution within this organisation compared
to many other government bodies, so I think the challenge for
us is going to be to recognise the realities, as you have said,
of a shrinking centre and to consider carefully, as a consequence
of that, our relationship with the country offices and also of
course our relationship with NGOs as well and to make sure that
our interventions are as smart as they possibly can be. Yes, it
is a time of change, we are having to adjust to the realities
of perhaps, in reality, less people at the centre, but I think
that focuses the minds of the people who work within the organisation,
and it will certainly focus some of my attention, as a Minister,
and in the end this is one area of public policy where we need
to get money to the front line. I think it goes beyond the relationship
between the centre and the country offices, it is also about those
real projects out there in the developing world and making sure
that our money is really achieving change and making a difference,
so it is difficult, it does require a very different view, for
example, of human resources, and it is not just about numbers,
but it is about the skills mix amongst DFID's staff, and there
is a whole debate going on at the moment about how we create the
right kind of workforce that cannot just, in a sense, deal with
the challenges of the past, but how we implement this new opportunity
where we have got record levels of resources. It is a much bigger
priority for the Government than it has ever been in the history
of any UK Government, so how do we adjust to those new challenges
and deliver on the expectations that people, quite rightly, have
without diluting the brand and the reputation that DFID has both
in this country and around the world, but I do not think it does
organisations any harm actually to say that the reality is that
you are going to have to be much smarter in the way you do business
and the way you operate and that you need a real focus on the
front line.
Q65 Chairman: I would just add that
an awful lot of people who deal with DFID, surprisingly enough,
comment on how under-resourced they think they are. That is not
usually the complaint you get about government departments.
Mr Lewis: That is true. That says
it all really.
Q66 Richard Burden: Welcome. If we
just return to the issue of, these horrible terms, horizontal
funding, vertical funding and so on, the clear evidence we have
had so far is actually across the piece, that you need both, that
there is a role for vertical funding, disease-specific funding
and so on, and clearly you have made a very powerful case for
the importance of building up universal healthcare systems in
the developing world. You have used the term on various occasions
that this can be Britain's contribution to add value to what is
going on, so my first question really is: how far is DFID's emphasis
on horizontal funding for building up healthcare systems and so
on driven by the fact that other donors, perhaps most notably
PEPFAR1[1]
from the US, focus on disease-specific funding? How much is that
a fact?
Mr Lewis: I think it is very significant
because that, in a sense, again three weeks in, in my view, is
the big question I keep asking myself: how do we add the most
value, how do we make the most difference, how do I indeed, as
a Minister in this area in terms of the use of my time and the
decisions I will have to make, make the most difference? I thought
social care was a big enough challenge in this country, but Africa
is on a different scale, but I think the serious point is that
it is not just the debate about whether we target money on particular
diseases or particular groups of people, it spreads the debate
about budget support more generally in terms of whether you support
where a state has achieved certain benchmarks, whether you support
civic society and the government in that state to actually build
its own capacity, its own infrastructure or whether you continue
to target resources on specific projects. Those judgments, if
you look at DFID's role, have been made on an ongoing basis, so
I think in this area you are absolutely right to ask if we have
looked at the contributions that others are making, yes, and if
we have looked at the difference that we have been able to make,
if you like, since the 2004 Strategy, and we have now produced
2008, so, in a sense, it was right to review progress, it was
right to review lessons learned, and we believe that all the evidence
from those lessons led us to make the decision that we made.
Q67 Richard Burden: Given that, it
is important that, somebody is providing substantial vertical
funding to, in a sense, create the space for you to be able to
concentrate Britain's resources on more horizontal funding with
PEPFAR being very important to that with $90 million, is it, over
the last five years going into that, but PEPFAR itself is fairly
selective as a vertical fund. First of all, apart from Vietnam,
it is almost entirely concentrated on Africa and Vietnam is the
only Asian country that gets PEPFAR funding, and obviously there
are limitations on what PEPFAR will fund anyway, most notably,
I guess, the restrictions, the limitations, they place on condom
provision and promotion. I suppose my question is that, if part
of what we are doing is adding value and relying on the fact that
vertical funds are happening, if there are big gaps in those vertical
funds either geographically, large chunks of Asia, or in terms
of what they can fund, for instance, condom provision, how far
do we factor that in, as DFID?
Mr Lewis: Well, first of all,
I think it is important to recognise that we accept that there
is a gap. UNAIDS estimates a resource gap of £8 billion,
so we acknowledge that that gap does exist. Of course, we want
the international community to step up to the plate and in this
area the United States, I think, has a positive record and, when
we are talking about legacies of any particular President or another,
this may be one of the few, dare I say, but this is quite an impressive
level of investment. However, we know that other donors, and I
am not going to get into a name-and-shame situation, but we want
to—
Q68 John Bercow: Go on!
Mr Lewis:—but we want to
see others do more. In other words, we are not in denial about
the point you make, Richard, there is a gap and, despite the expansiveness
of the US programme, that in itself is not enough either, but
we still have made the judgment that at this stage our most effective
contribution can be in the way I have described it. Of course,
we are also giving, which should not be forgotten, £1 billion
to the international Fund which is being targeted vertically specifically
on HIV/AIDS, but this is a judgment call.
Q69 Richard Burden: I accept that.
Mr Lewis: I suppose the other
point I ought to make is that we should remember that there is
quite a lot of devolution in terms of country programmes, so there
is still the opportunity, when country programmes are making decisions,
for them to look, country by country, at where targeted investment
in particular projects and in particular ways could make a difference.
Q70 Richard Burden: I understand
that and, who knows, it may be that some of the limitations which
have been placed on PEPFAR so far may change—
Mr Lewis: May be removed, yes.
Q71 Richard Burden:—after the
events of next week, and we wait to see on that. I suppose what
I am getting at really is that, given the fact that there are
those judgments to be made and given the fact that different donors
will make different judgments on that, how do we try to ensure
that the judgments that we make are properly integrated with the
judgments that others make? I suppose that is what I was getting
at when I was saying that there is a very good reason for targeting
universal healthcare systems and I accept other people are doing
vertical funding, but, if there are big gaps in those vertical
funds, how do we ensure that the jigsaw fits together?
Mr Lewis: I think in two ways.
One is obviously through international institutions and through
international agreements. The Prime Minister personally has been
heavily involved in providing leadership around the world to say
that this is not just about saying that we need to make a whole
set of headline commitments, but actually how we are going to
make sure there is delivery and how we are going to constantly
hold other donors to account, and, frankly, they are not, some
of them, honouring their commitments, so international institutions
and continually applying the pressure, and there was a conference
not that long ago, was there not, where that was one of the objectives.
The other, increasingly through our country offices, is looking
at the interconnectivity between DFID, other donors on the ground
and indeed NGOs operating in those countries to make sure that
we are getting best value for the resources. Now, obviously what
you want, frankly, where you are talking about the donation states,
you want signals being sent from their governments that they want
a joined-up approach in terms of tackling HIV/AIDS, health, education,
poverty reduction and social protection. Ideally, we will get
to a situation where the same messages are being sent through
donor organisations about the importance of joining up. We know
that, for many developing countries at the moment, one of the
nightmares they face is managing all these donors, whether it
be, as I say, NGOs or whether it be nation states or whether it
be multinational organisations, and we know that, for them, this
is one of the major problems. If you like, as a new Minister,
what would be one of the things that I would hope to achieve in
some of the countries where we are very active and very involved
is to try and persuade other partners to come together, not just
at a very high level when the prime ministers and the ministers
of finance meet around tables, but actually on the ground to come
together and look in a more holistic way at how we can make the
most difference. Obviously, one of those debates is about budget
support, it is about building civic society, it is about social
protection, it is about how much of our focus is to help nation
states stimulate their economic growth and not just providing
kind of social support, so I would say that a big part of the
next stage in DFID's leadership role, and I do not think we should
be timid about using the term `leadership role', is to seek, wherever
possible, a joined-up approach. Now, we need to recognise that
we do not always share the same objectives, we do not always have
the same values driving our respective contributions and there
is sometimes realpolitik at play which gets in the way
of joining up those responses, so the Foreign Office responsibilities
are almost more than the DFID responsibilities, but we certainly
think that we should be increasingly, country by country, seeking
a maximum joined-up approach.
Q72 Sir Robert Smith: Some of the
evidence we have had, which was generally welcoming the Strategy,
was concerned about the outcomes and how you plan to monitor the
impact of the Strategy. In three years' time, what key indicators
will be used to assess whether it has had the impact that you
hope for?
Mr Lewis: Perhaps I could take
you through how we intend to do that; I think it is important.
We intend to publish on World AIDS Day a monitoring and evaluation
document which will define how the UK will monitor and track progress
against the commitments made in the Strategy. This document, Achieving
Universal Access, includes a commitment to commission an independent
review of implementation after three years of the Strategy being
in place, so that will take us to 2011. We have also committed
to review our position on orphans and vulnerable children after
every biennial Global Partners Forum on Children Affected by AIDS,
and there is a cross-Whitehall working group on tackling AIDS
which will monitor the implementation of actions across Whitehall,
so we do have in place, I think, quite a significant approach
to monitoring and evaluation.
Q73 Sir Robert Smith: But why did
you decide to leave the development of the monitoring and evaluation
until after the launch of the Strategy? It seems that the two
should be going together and delivered together because obviously
the Strategy could be better evaluated if it has been developed
together with the evaluation.
Mr Lewis: Well, I am used to reading
out this phrase in previous jobs, so I will do it here: "Ministers
were in protracted negotiations with the Treasury regarding the
resource allocation round, and it was not clear, therefore, whether
it would be a three-year or a seven-year strategy", and that
is the Department's position.
Q74 John Bercow: Did they duff you
up?
Mr Lewis: Did they duff my predecessors
up? I have no idea! No, I think we were very happy with being
able to commit because I think that one of the other things we
should have said is that we believe very strongly that part of
our capacity to deliver in this area is some long-term certainty
about the nature of our input and to have the capacity to have
a seven-year strategy, which takes us to 2015 and the Millennium
Development Goal period, that is really, really helpful, so the
answer to your question is that it would have been much better
to have published it at the same time, but you have heard the
answer; it is the Treasury's fault!
Q75 Sir Robert Smith: Maybe you should
be looking at a recommendation to the Treasury that, if they want
an efficient use of resources, then they should allow the efficient
development of strategies and monitoring together.
Mr Lewis: If you were ever in
government, you would realise it is never quite as simple as that!
Q76 Sir Robert Smith: A lot of our
witnesses are concerned that in the past we have been wanting
a results-focused approach, and in the previous Strategy I think
there were 126 targets and now there are hardly any targets. On
World AIDS Day, will we be given a clear idea of targets that
will be used to measure that Strategy? Is it going to be a target-orientated
evaluation?
Mr Lewis: In terms of our objective,
yes, it will be quite clear, not just about how we are going to
monitor and evaluate, but equally what will be the best of progress
and success. That is crucial and we have got to have those indicators,
so it will be clear about how, at the end of that seven-year period,
we will define this as being successful and having made a difference.
Q77 Mr Crabb: Just continuing on
the theme of monitoring and evaluation, one of the issues that
gets raised with us quite frequently is around the difficulties
inherent in how you track and measure the outcomes from the contribution
that we make to multilateral initiatives and multilateral agencies,
so how do you propose assessing whether the £1 billion that
we are giving to the Global Fund is an effective way of tackling
HIV/AIDS?
Mr Lewis: Disentangling the value
that we have added and the difference we have made is difficult,
and I am not sure that it is ever going to be simple to do that,
but, if you look at both the scale of the global challenge and,
country by country, the challenges that those countries face and,
in a sense, where you have clarity of what this country most wants
to achieve or needs to achieve for itself over any given period
of time, I think what we would say is that it will be clear as
to how many of those outcomes and how many of those goals have
been achieved, and it will be clear how significant the UK Government's
contribution has been in those areas. Now, it is very difficult,
so one area is the leadership we provided in terms of international
institutions, and, without the leadership of this Government and
this Prime Minister and, I have to say, parliamentarians on all
sides because there has been a lot of consensus in this area,
without that leadership, I do not believe the international community
would be where it is on development. There is then the question
of specific challenges, like access to universal primary education
and HIV/AIDS and then there is state-building and the progress
that individual nations make, and we are dealing in some countries,
as you know, with trying to get to a situation of stability, some
basic level of stable security to even begin to build the state.
In other countries, we have been through that, and I did a debate
yesterday on Sierra Leone and, although many of the indicators
in Sierra Leone are still pretty dreadful, if you benchmark that
against the state that Sierra Leone was in only a few years ago,
actually that country is starting to do a lot better. Now, most
people accept that, without the contribution we made to stabilising
the security situation in that country, that would never have
happened, so I have to be very honest with you, this is not easy,
it is not like measuring other outcomes, but I think, as I say,
in terms of international commitments, without Gleneagles and
without the UK using its Presidency both of the EU and then the
G8 and without the other leads we have taken globally, would we
be in the position we are in in terms of the developing world?
The answer is almost certainly that we would not. You would then
have to look nation state by nation state and, in some countries,
there is absolutely no doubt that DFID's contribution has made
a significant difference. In others, we are a secondary part and
our being there is very, very important, but are we making the
most difference? No, but by our being there it is really important
and our contribution is valued. I think that is trying to be as
frank as I possibly can in response to the question.
Q78 Mr Crabb: Just to press you a
bit further on the Global Fund, and forgive me if this is a bit
unfair on you being three weeks into the job, but how satisfied
are you with the accounting mechanisms of the Global Fund and
how robust they are?
Mr Lewis: Well, I think we are
always a country in this area that is arguing for greater transparency,
greater accountability and a much closer synergy between money
spent and outcomes achieved, so I would argue that we still will
continue to argue that that alignment needs to be better. We would
not be contributing £1 billion to the Fund if we did not
have some level of confidence that it was going to make a significant
difference. Does it need to get better in terms of transparency,
accountability and the relationship with achieving outcomes? Yes,
definitely.
Q79 Mr Crabb: It was reported recently
that the Global Fund is about to give, I think, £307 million
to Zimbabwe. How concerned are you that the money will not reach
those for whom it is intended?
Mr Lewis: Well, I think that is
a bigger-picture discussion. Three weeks in, I am not sure I should
start getting into FCO business, but I will try and give you a
sensible answer. We all know the situation in Zimbabwe is fraught
and we are all extremely concerned about the political and humanitarian
situation in Zimbabwe. We all also believe that Mugabe should
be made to honour the political commitments that were made to
Mbeki and, if there is going to be some sense of shared way forward
for Zimbabwe, however much we believe that the MDC probably won
that election, we believe that the prerequisite to significant
additional support to Zimbabwe has to be Mugabe honouring the
commitments that he has made to Mbeki, the basic standards of
conduct that we expect in any state that we are willing to support,
and we have not reached that state yet. We all know that those
negotiations have not progressed well so far and we remain hopeful
that the negotiations will progress in the right direction, but
I think we have to be very careful not to say anything which is,
frankly, going to undermine what is a highly delicate political
and humanitarian situation in Zimbabwe. As to the things that
we say in London, we should be very, very careful, but of course
part of achieving some level of political stability and obligations
being honoured will then enable the international community to
get resources where they most need to go in terms of humanitarian
support.
1 1 US President's Emergency Plan for AIDS Relief. Back
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