Examination of Witnesses (Questions 80-99)
MR IVAN
LEWIS MP, MR
MALCOLM MCNEIL
AND MR
ALASTAIR ROBB
30 OCTOBER 2008
Q80 Mr Crabb: I appreciate your answer,
and it was less of a big-picture question and really a question
about how well the Department assesses and manages the risks that
are attached to the funding that you are providing.
Mr Lewis: That is slightly different.
Yes, obviously the reason it is a good example is because we are
working in countries and, when I met the governance advisers,
we are working in countries often which are described as `fragile
states' where the security situation can be problematic, in some
states where there are no seriously strong civic institutions,
where there is no transparency and accountability and in some
states where there are known high levels of corruption. In all
of those states, our country offices do their best to make the
right judgments and to ensure that our taxpayers' money is being
spent in the way that we want it, and expect it, to be spent.
I believe that in most cases they get those judgments right. Do
I believe that we can somehow pretend to the taxpayer or to the
public that we are working in some countries in ideal circumstances?
Of course we are not. That is why you then get into another debate
about devolution. We do have quite a high level of devolution
in terms of DFID to those country offices because, in the end,
in each country you are dealing with very, very different sets
of circumstances, but I think you can always highlight the negative
in this area, you can always point to concerns, you can always
say, "Did all of the money get to the place it needed to
get to?" I believe the vast proportion of resources does
lead to significant improvement in the countries that DFID operates
in.
Q81 Chairman: There is quite an important
point here though given that quite a lot of DFID's money is going
through multinational agencies or international agencies, like
the Global Fund or the World Bank or what-have-you. I think, to
back up what Mr Crabb is saying, that there is a concern and this
report about Zimbabwe in the Telegraph is slightly concerning.
Now, you, DFID, may not be able to be entirely accountable for
a substantial amount of taxpayers' money going through international
agencies or, in other words, your country programme does not monitor
the Global Fund's spending in Zimbabwe.
Mr Lewis: Okay, when you pool
resources, you do relinquish some extent of the total control,
but, as a partner in those international institutions, again in
terms of leadership, the UK has a very clear record in demanding
maximum accountability and maximum transparency, and we will continue
to do that. It is back almost to the discussion that you, Chairman,
raised about the level of staffing and resources within DFID and
I talked about my concern that our focus should be on getting
money to the front line, that should be what it is all about.
We all know in some of these international institutions and organisations
that one of the concerns is how much of the money gets tied up
in the bureaucracy and how much of it actually gets to the front
line, and we will continue to use all of our influence and all
of our power to make sure that the maximum amount gets to the
front line. That is what the UK has done on every occasion in
terms of discussions within those international institutions.
Mr Robb: I would just give an
example of Uganda which was a country where there was a misuse
of Global Fund resources and we were in country both to highlight
that issue, but also to think about how remedial action could
be taken in the future to move the Global Fund from its project
support to incorporating it as one of the finances that go to
the budget that can be monitored using the financial management
system within Uganda, which is what we use for our budget support,
which is a more efficient way of tracking the resources and the
way that they are allocated, and to move the Global Fund to joint
attribution for results. Where we see the Global Fund as a very
useful instrument is that it highlights results-based financing
and that is something that others are now moving towards in Uganda,
so Uganda has actually brought the Global Fund much more into
the fold rather than allowing it to run parallel so that we have
a better collective scrutiny over the way that the Global Fund
resources are used.
Q82 Mr Crabb: Minister, perhaps I
could just ask about the target in the Strategy to increase the
staff:patient ratio to 2.3 health professionals per 1,000 people.
Several previous witnesses that we have heard have criticised
this target and they have said that it is too broad for it to
be really meaningful and it is not country-specific. How would
you respond to that criticism?
Mr Lewis: Well, I think again
it is a judgment. It was based on the best available evidence
and, if you look at the baseline situation in individual countries,
but across the developing world, we believe, therefore, that that
target is the most appropriate in terms of driving the system
in the way that we want to drive it, but there will always be
differences of opinion about specific proxies, but this session
opened with concern about the scale of the challenge in terms
of achieving universal healthcare across the developing world
and, frankly, if we achieved the target that you have just said
some people deride, that would be a massive advance and step forward.
I think it is very hard to find a proxy. Let us give a domestic
example. There are many, many people who have been critical of
the 18-week target in the Health Service, many people for all
sorts of reasons. At the end of this year, for most treatments,
people will wait a maximum of 18, an average of maybe nine or
ten or 11 weeks from going to see the GP to hitting the operating
theatre. At the end of the day, in terms of 1948 to now, that
is a revolutionary change in terms of the quality of healthcare
in the United Kingdom, but it has taken 60 years for us to get
there, so sometimes you need to set very clear targets to achieve
radical change.
Q83 John Battle: On the point of
clear targets, I wonder if I could look particularly at the issue
of HIV/AIDS and women because 60% of adults with HIV/AIDS are
women, three-quarters of young people who are HIV-positive are
women, HIV-positive women are four times more likely to die in
pregnancy and childbirth and there are two million HIV-positive
women who become pregnant every year, so I think there is no doubt
that the focus should be on women. However, when we look at the
Strategy, there is an acknowledgement of the fact that women are
disproportionately affected, but I do not see any detailed indicators
on targets or any real meat of how that challenge is going to
be addressed. How can the Strategy become more focused on the
needs of women, in particular?
Mr Lewis: I will try and respond
directly, John, to the question. First of all, you are right,
we do accept that women and children are disproportionately affected.
The Strategy stresses the need for the international community
to work with governments and civic society to ensure that the
needs and rights of women are fully integrated into the AIDS response.
We recognise that social protection, including cash transfers,
is an effective response and, for example, we have committed £200
million to social protection programmes as an effective way to
reach both orphans and vulnerable children and their families.
We also recognise the need to increase access to paediatric anti-retrovirals
and other treatments, committing £90 million to UNITAID in
2008 to 2011. I think the other point I would make is that, in
terms of individual countries in terms of HIV/AIDS programmes,
we are saying in those countries that there needs to be a focus
both on women and children, and that, both in terms of our spend,
but also in terms of the messages we are sending out in terms
of those individual countries, there is a clear recognition that
right at the heart of those strategies has to be a specific focus
on women and children because, if that does not happen, we are
not going to put that right.
Q84 John Battle: Let me just put
it as a reservation, if you like. If we were talking about obviously
people like sex workers, street children, children who are orphaned
who have HIV, the social transfers will not reach them, so I would
just put a caveat there where the social transfers are directed
at family units because, if you have kids wandering around the
streets, it is not going to affect them, so I just want to put
that as a caveat into the response that you gave me because I
think we have got to take seriously where the action is, and I
am not quite convinced that a kind of blanket social protection
approach will reach everybody. It will not reach the parts we
need to get to, and that is what I am saying, I am not against
that strategy. If I could just say, we did a report and it ties
in with maternal health and it is worth recalling that MDG5, is
it, on maternal health, it is the furthest one behind and, in
terms of gender, we have an appalling international record, not
just on HIV/AIDS. We have made some effort, and I have to say
here that the Prime Minister and indeed his wife have tried to
raise this issue courageously internationally, and we did a report
on maternal health on this Committee and we drew attention to
some of the DFID programmes in Nepal, in Bangladesh and South
Africa that have been addressing the gender issues. One of them
that came across quite strongly in our last session was violence
against women in this whole business, sadly, and I just wonder,
it seemed to me that those strategies in Bangladesh, Nepal and
South Africa, as attempts to reduce violence against pregnant
women and women at risk of HIV, were good. Can it be replicated
elsewhere or can the Department give us more examples of how that
approach can be actually spread out across the world in a stronger
way?
Mr Lewis: I think one of the things
that maybe I should have said is that, if you look at our new
Strategy, one of its priorities for action is that gender analysis
should be integrated in every national AIDS plan and that specific
targets and indicators should be developed to measure the impact
of AIDS programmes on women and girls, so that is actually quite
important, that, in terms of a national attack on HIV/AIDS, we
are saying that we will argue in each of these countries for them
to be at the centre. In terms of the point you make about tackling
some of the underlying issues, violence, you are absolutely right.
One of the things I need to get my head round is that, whilst
DFID is very proud of its devolved approach country by country,
I have a sneaking suspicion that there are certain things which
are relevant in every country and maybe, if you have a completely
devolved approach, you miss the point, for example, on an issue
about how you tackle violence against women, which may be a problem
in most of the countries we operate in, and, if programmes in
particular countries are working through innovative approaches,
then surely we should be spreading that practice to all of the
countries where that is an issue that we are working in. That
is probably one of the things that, as a new Minister, I am going
to want to have a look at because, if that particular programme
has made a real difference, then it seems to me that we should
be mainstreaming that strategy, where we have the capacity to
do that, in the countries that we are working in.
Q85 John Battle: If I were to give
a mild criticism of DFID, and it is only a sense of direction
that I would want to change or direct differently, that is that
I think DFID is world-class in its approach and world-class in
its reach and in tackling the challenges that we face, whether
it is looking at governance or actually developing strategies,
but I am just slightly worried that the strategies on paper are
praised worldwide, but we have got to make sure that we keep in
touch on the ground and check them against it. We have good staff
in the field and it is our job to go to the field and, may I add,
it is yours as well, but we need all the time to check it against
experience in the field, and I think in this area, in particular,
I am just slightly anxious that what looks a good strategy on
paper might not actually reach and do the job where it is needed
to. If it does, we really could be leading the world in how we
approach this particularly difficult challenge.
Mr Lewis: Well, I can assure you,
John, that my focus will be on delivery. I do not think there
is a question about DFID's overall strategy, its reputation, its
brand, its mission, its commitment. What, I believe, is crucially
important is that all that matters is the interaction between
our programmes, our resources and our workers on the ground and
the poorest people in the world and, if their experience cumulatively
of our efforts and international efforts is that they are not
making the difference they should be making, that is where we
need to focus our energies and our efforts. I think part of that,
if you take on board the point I have made, is that, in countries
where we have proven successful programmes that have really made
a difference, we should be spreading that best practice across
all of the countries that we work in, and the danger with maximum
devolution is that you miss that.
John Battle: I will just flag up two
very small points, if I could, just to finish the point, if you
like. Spreading best practice, but also looking to deepen the
Strategy all the time, I will give one practical example. In the
written evidence is the importance to empower women to negotiate
safer sex, and I would be interested to know what specific strategies
might work out on the ground, so can we put a bit more thought
into those strategies, I am saying through you to the Department?
Secondly, in negotiations with the World Health Organisation and
the UN Population Fund, could we think out a deeper strategy of
how we actually get them and UNAIDS, to acknowledge the linkages
between HIV and sexual reproductive health and the violence questions
as well? Are they really taking them on board at depth because,
otherwise, I think we have gone round this issue for 10 or 20
years actually? The first time round was being aware of the crisis,
the second time round was that we sat in here and did reports
on the need for anti-retrovirals and the Global Fund, but I am
not convinced that those approaches have got the depth that DFID
is getting strongly towards now and we still need to embed that
strategy with detail of how we push the agenda forward.
Q86 Chairman: Just following that
through, you mentioned a question I was going to raise anyway
which is the specifics of children because we know, certainly
in the past, that children are more vulnerable to dying if they
have AIDS and the treatment available until recently appears to
have been not so adequate. I just wondered if you could give us
a little bit more information on how you are going to target that,
particularly their access to drugs and co-trimoxazole, a particular
drug which appears to be effective, which UNITAID have said should
be given to children who are at risk, yet they are not getting
it, so how are you going to try and ensure that your funding achieves
that objective?
Mr McNeil: Perhaps I could respond
on the issue of co-trimoxazole. We feel that it is very effective
in reducing co-infections in patients with HIV infection, and
it is a very cheap drug. For some reason, there appears to be
a view that DFID is not actively promoting this approach, and
I would like to assure you that that is not the case. DFID is
actively promoting the use of the drug, but the ultimate decision
on whether a drug is adopted or not lies with the national authorities,
so we have been pressing the individual governments to make sure
that co-trimoxazole is on the essential drugs list and that the
staff are effectively trained. The side-effects are relatively
few and rare, but, when they come, they are quite serious, so
staff do need to be effectively trained to use this.
Q87 Chairman: That of course makes
the fundamental point about having a stronger health service to
do that. Is that part of the problem, that there are not enough
people?
Mr McNeil: Yes, and WHO have come
out with particular guidelines that patients who are on co-trimoxazole
should be given information about the potential side-effects,
so there is an issue on staff training, but we believe that it
is a very effective drug and should be actively promoted.
Q88 Chairman: The £90 million
that you are targeting to UNITAID, is that a major part of it
or what else is that designed to achieve?
Mr McNeil: Certainly the funding
for UNITAID, UNITAID, as you know, is an attempt to make essential
drugs and supplies more widely available across the board, so
the UK has supported UNITAID with £20 million when it was
launched and were given a 20-year commitment, so we see UNITAID
as being a key step forward. It has been slightly slow in starting
and getting off the ground, but we feel that it has huge potential.
The key thing is for all the different donor agencies to work
effectively together to make sure that drugs and supplies are
made available.
Q89 Sir Robert Smith: I see it is
funded mainly by a tax on airline tickets. Does that mean that,
as obviously the global economy changes and air travel is likely
to be badly hit, its future plans will be affected by its funding
stream?
Mr McNeil: I have not had up-to-date
information on that. In most of the countries, it is on the basis
of the tax on tickets for air travel, but I think in the UK, if
I remember rightly, the decision was that the money would be separately
allocated. My understanding, and I am no expert on this, is that
we will certainly see a downturn in air travel, but then it is
likely to pick up again, so the long-term scenario is probably
not so serious, but, if you would like, I could check with the
staff who are involved in this and get back to you.
Mr Lewis: I think it is too early
to say, is the honest answer.
Q90 Chairman: I think British Airways
had a reception last night and they were quite clear.
Mr Lewis: Yes, but what I am saying
is that I think we sit here in a situation where we have almost
a unique economic challenge that the world faces, and much of
our agenda is going to be affected by that. One of the things
that we are doing at the moment is analysing, if you project economic
change now and over the next period, what effect that is going
to have on the developing world and what effect it is going to
have on donors and their engagement with the developing world.
Of course, we would argue very passionately that this economic
situation has demonstrated more than any other the interdependency
of our world and now is not the time to retreat from commitments
to the developing world, but now is the time to step up to the
mark and redouble our efforts. Whether everybody will share that
view in the world remains to be seen, but that will be what we
will be arguing very strongly and very assertively.
Q91 Chairman: I think I can predict
that the Committee will give you strong support in that. The other
thing is that you have got a commitment to do social protection
programmes in eight African countries. Can you tell us which countries
those are and, picking up the point that John Battle has already
made, how can you ensure that they also reach the ones that fall
outside the logical net or how can you be sure that the children
will get a direct benefit from them?
Mr Lewis: I have not got that
list of the countries to hand. We can get that for you, Chairman.
How do we ensure? At the end of the day, there are a number of
different ways that we are, country by country, intervening, so
there is budget support, there is support for specific programmes,
there is the building of civic society and there is the governance
work that we are doing, so the key is, in a sense, not just in
the work that we are doing in each country how we make sure that
the hardest-to-reach groups are not losing out, but we also have
to look in each country at the contribution of other donors and
other organisations. Again, this is the whole point about joining
up. By joining up, by being clear about the contribution of the
different organisations and different donors, it gives you a much
better chance of making sure that particular vulnerable groups
do not actually fall through the net. Certainly within our country
programmes, there is a very strong commitment to vulnerable children,
to women, to a sort of focus of our interventions where we need
to focus those efforts.
Q92 Chairman: But you are not at
the moment able to give us the list of countries. Are you able
to say what were the prime criteria? In other words, is it the
incidence of HIV/AIDS or was it to do with the quality of their
ability to deliver social programmes or what were the factors
which determined which countries were selected?
Mr Lewis: It is back to the discussion
we had earlier in the session about how we add the most value
and how we make the most difference. If in a given country us
investing in social protection in our judgement is the most powerful
way we can make a difference in terms of the other contributions
that are being made and the progress that has been made in that
country over a period of time, those are the criteria that we
apply.
Q93 Chairman: I think it is quite
important to know which are the eight countries. "We do not
know which the countries are and we do not what the criteria are"
is not entirely satisfactory, so I do not know whether you are
able to clarify that, Mr McNeil.
Mr McNeil: I have not been directly
involved in this work but I know that the list of eight countries
is in the process of being finalised now and there are specific
criteria that are being used. This is particularly for programmes
where we have highly endemic countries, so that is a key factor.
Q94 Chairman: Given that we have
a very tight timescale, if you are able to give us a quick indication
of where you are at on that in the next day or so it would be
helpful because otherwise I think this is going to be a gap in
our report and in the evidence. Another point is about the money
that goes to assisting orphans and vulnerable children, which
was £150 million that has been allocated in the past. How
are you ensuring that you can track that effectively? It is obviously
highly desirable that you are trying to reach those people. While
you are thinking about that, this is an anecdote, but when we
were in Malawi visiting an orphanage three years ago we asked
the staff of the orphanage about the incidence of HIV/AIDS deaths
or illnesses for the children and their answer was, "We do
not have that here", and then when we said, "Do you
not have any child deaths?", they said, "They die of
coughing". It was quite clear therefore that there was no
screening; there was a denial, and I just wondered if you had
ways of ensuring that the money gets through and has real results.
Mr Lewis: I can give some examples.
We have a situation where a specific action plan for those children
has been developed and now involves 30 countries and we think
that is a major step forward. There are 30 countries which have
a national approach specifically focused on the needs of orphans
and vulnerable children. We believe that the social protection
programmes have been shown to be highly effective in reaching
those vulnerable children. If I give you some examples, in South
Africa cash grants have resulted in increased height for age in
children under three years, indicating that the impact of AIDS
can be mitigated through these approaches. In Zambia cash transfers
to households have helped reduce overall school truancy by 16%.
Obviously, again, we believe that education is important because
it does reduce the risk of HIV infection. In southern Africa we
are providing a loan of £40 million to scale up national
plans of action in seven countries in this area. In Kenya, Ghana
and Zambia we are supporting innovative cash transfer programmes
which are benefiting the most vulnerable, including children affected
by AIDS. I think there is quite a step-change. Part of it is not
just what are our programmes directly doing. Part of it is in
each of these countries are they having specific approaches to
orphans or vulnerable children. It seems to me that those statistics
demonstrate a real recognition in an increasing number of countries
that this is very important.
Q95 Chairman: That is a more general
suggestion though because each year you produce an annual report,
and we also report on your report, and I think if you incorporated
that kind of information in the annual report it might be helpful.
Mr Lewis: Yes.
Chairman: I think that is what people
like to see—what works. When there is a practical outcome
it is always helpful to your cause as well as to the wider public.
Q96 John Battle: If I can just emphasise
a point, I think I have spent probably far too long crossing the
phrase "hard to reach" out of every Government document
that ever crosses my desk because I do not believe people are
too hard to reach. I think we have to make the effort to get there
and give it serious attention, and I am encouraged by what I have
heard this morning and the work the department is doing. Could
you give me a bit more encouragement on that gap in the service
that I detect for really marginalised groups like drug users and
sex workers? Is there anything in the strategy that will give
me some encouragement that we can really move into those neighbourhoods
and those groups?
Mr Lewis: What I would say to
you is that the way we should judge the effectiveness of our strategy
is the difference we make with the most vulnerable groups and
that runs all the way through the new strategy that we have produced,
but, as you said to me, quite rightly, the proof of the pudding,
to use a good northern expression, is in the eating. It will be
about delivery in the streets, in the neighbourhoods, and the
leverage that we are able to deploy to make sure that happens.
One of the things you said was that you do not believe that anybody
is impossible to reach. I agree with you, but you also would agree
with me that you have to be innovative and imaginative and you
have to think outside the box. When people talk about hard-to-reach
groups in this country it is often because we try the same old
solutions and interventions that have failed over the years and
we do not take a step back and think about how you get to those
people. They are influenced by different peer groups, by different
networks, by different interventions. We have to do the same in
the developing world, and that was why, when you talked about
best practice, I think where we have had major success with particularly
vulnerable groups in some countries we should be looking at what
worked there and how we had that success and then making sure
that happens elsewhere. What I would agree with on what you have
said so far is that that is very much at the heart of our strategy,
but is it at the heart of our delivery in each of the countries?
That is my job to consider in the period ahead.
Q97 John Battle: I am not criticising.
I am just not so convinced that it is at the heart of the strategy.
By that I mean I do not want any gaps in the strategy so that
staff can say, "I do not need to be sent out there. I have
got enough on". That is what I am saying. I am wanting you
to continue to encourage the staff—and DFID staff are among
the most policy imaginative in the world at tackling challenges.
We need them back here to work on some of the challenges, is my
view. In that context, if they can just be encouraged to make
sure we flag up those two groups I would be a bit more encouraged,
but it may need to be written into the strategy as well as being
understood as the interpretation of it.
Mr Lewis: As far as I know, and
I have not read it, to be honest, cover to cover, it is quite
significantly mentioned, but I agree with you: that is not the
point. It is then how that is transferred into delivery. One of
the things I have to reflect on in the country plans that we are
now being asked to agree is how adequately do they reflect the
need to respond to the needs of those groups. That is all I can
say at this stage, but I think you are absolutely right to raise
it as a concern. It is a concern.
Q98 Chairman: It will not be timely
for this report but, for example, when the Committee was in Vietnam
we were shown examples of work with sex workers and intravenous
drug users which DFID successfully piloted. It would be interesting
to know what the follow-through from that was and to have other
examples. It will not be in time for our report but I think it
is useful information.
Mr Lewis: That is why I raised
this question before of the virtues of maximum devolution, but
also the dangers of not identifying and disseminating what works
and then making sure that you provide that information in every
country and you start implementing the strategies that work. That
is a concern that I have at an early stage.
Q99 John Bercow: I apologise to the
Minister for my extremely intermittent attendance. The fact that
he is the witness and that I have been in and out are not in any
way causally related. Just on this point, it occurs to me that
in a document fairly recently published by DFID about development
policy, which admittedly does not narrow the field very greatly,
there was a reference to an Indian organisation, the Indian Association
of Positive People Living with HIV/AIDS, or something like that,
and I have the very distinct impression that DFID had devoted
quite a significant resource to that, specifically looking at
vulnerable groups, for example, intravenous drug users, women,
men who have sex with men, and, if memory serves me right, Chairman,
prisoners. It seems to me that one should extrapolate from that
and I have a feeling, and I feel I ought to forewarn the Minister
of this, that some written questions will be winging their way
to his officials on these matters pretty shortly in my name because
the question is: do you think the resource is being well spent,
what are the results and can we expect that those results will
be replicated elsewhere, simply because you are saying, "This
programme has worked. Let us do something similar in other parts
of the world"?
Mr Lewis: I look forward to receiving
those questions.
Q100 Chairman: The issue here is
that, of course, your strategy is to strengthen health services
and at the moment we are discussing target groups. How do these
two things interact?
Mr Lewis: It is a bit like in
this country, that central to strengthening the NHS is tackling
health inequality. If you do not tackle health inequality, frankly,
long-term you are not creating—
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