Examination of Witnesses (Questions 101-119)
MR IVAN
LEWIS MP, MR
MALCOLM MCNEIL
AND MR
ALASTAIR ROBB
30 OCTOBER 2008
Q101 Chairman: I am not disputing
the objective. I am just talking in practical terms. How will
you ensure that this continues to happen within the context of
targeting strengthening the health services?
Mr Lewis: I would say again, Chairman,
that the strategy makes it very clear that in creating universal
healthcare systems there still needs to be a recognition of the
targeting of particular groups who are most vulnerable and any
creation of a universal healthcare system has to recognise and
acknowledge that. The issue is how you make that real in terms
of delivery and implementation.
Q102 Chairman: Can we assume that
it will be part of the discussions country by country to try and
incorporate the strategy?
Mr Lewis: Absolutely.
Q103 Mr Crabb: On Tuesday we heard
evidence about the specific issue of the interaction between HIV
and TB. Do you see generalised increased funding for healthcare
systems as the main way that DFID plans to tackle the interaction
between HIV and TB?
Mr Lewis: In short, yes. In a
sense we would argue that the interaction makes the strongest
case for the importance of going towards the creation of universal
healthcare systems, so yes, we do believe that in a sense that
strengthens our argument, very much so.
Q104 Mr Crabb: You do not see the
need for any additional actions to try to build effective strategies
to prevent deaths from TB amongst people who are infected with
HIV, for example, improving diagnostics?
Mr Lewis: Sure, but I would say
that improving diagnostics is right at the heart of creating improved
universal health systems.
Q105 Chairman: We had evidence on
Tuesday by video link from Lucy Chesire. It was a slightly difficult
link; it was a fairly short session as well. She was very critical
of the diagnostic status with chest X-rays 100 years out of date
and yet it was all treatable, it was all doable; it just was not
being done.
Mr Lewis: I think that reinforces
the importance of seeking improved healthcare systems rather than
simply targeting money condition by condition. Diagnostics is
right at the heart of creating any healthcare system which is
going to be effective. I just think it strengthens the importance
of that.
Q106 Chairman: Just as a comment,
I think the concern that we have had from a number of our witnesses,
and it is not a fundamental criticism of DFID strategy at all,
is not, as you are saying, Minister, that you wish to achieve
all these things. It is how you can ensure these interactions
will happen. I think what we are getting from you, which is fair
enough three weeks into the job, is your commitment that that
should be the outcome, but it is not entirely clear how you can
ensure that is the outcome.
Mr Lewis: How you can ensure it
is the outcome is that first of all in a sense we have had a two-stage
approach. We had the 2004-2008 strategy which we believe demonstrated
success, achieved the objectives that we set for ourselves but
also triggered a lot more investment and activity from the international
community. We now have the 2008 strategy going forward which is
about building in each country healthcare systems rather than
tackling this disease by disease. In a sense I do not think I
can give you the solution today. What I can tell you is that our
objective is as outlined in the strategy but I am very conscious
that what will matter is delivery on the ground. I think a lot
of the comments from members of the Committee today have been
about delivery and implementation. Nobody has questioned DFID's
mission or its strategy but there are some serious questions to
be asked about delivery and also about our interaction with donors,
with NGOs and with governments in terms of achieving what we say
we want to achieve.
Q107 John Battle: Just to help clarify
that, there is not a linear strategy just as there is not a magic
bullet answer to this problem and we are all learning as we work
through it. If I may just give two examples, I mentioned anti-retrovirals,
stage one and stage two. We were not focused on that too well.
Zambia was held up as the great example of success but it failed
to take into account TB and we are now picking up the pieces of
that. It is just whether the strategy is subtle enough, responsive
enough. I think it is that which we are looking at rather than
it simply being a clear roadmap through. It is the positioning
along the way. It is a bit of a journey in the dark, actually,
but we need to take others with us.
Mr Lewis: I take that.
Q108 Mr Crabb: This is a comment
rather than a question. We heard evidence on Tuesday about the
enormous rates of recurring infection. In sub-Saharan Africa people
are living both with TB and HIV, and I think it is fair to say
that DFID has picked up the importance of the relationship between
HIV and TB, at least on the face of the document that we have
been discussing. The Malaria Consortium has also given us evidence
claiming that the relationship between HIV and malaria is not
being picked up to anything like the same extent as the relationship
between HIV and TB, and I am not sure whether you are going to
have the information at your fingertips to respond to that criticism.
Mr Lewis: I will certainly go
away and look at it. I think it is something we need to go and
look at and respond to the Committee on.
Q109 Sir Robert Smith: What the strategy
sets out, again which is welcomed, is a general commitment to
increase its engagement with civil society. However, the strategy
only provides two concrete examples of such engagement—partnerships
to work with injecting drug users and on social protection issues.
The International HIV/AIDS Alliance has expressed concern that
DFID's focus on health sector support risks undermining the capacity
of civil society to engage with and contribute to the response
to the epidemic. Most of your funding is actually going through
in-country health sectors rather than engaging directly with civil
society. How can you reassure civil society organisations that
they will be fully involved in implementing this new strategy?
Mr Lewis: I can give you a cast-iron
assurance that they will be full partners. If you want me to give
examples of our engagement with civil society in numerous countries
I can do that but we will here probably for the rest of the day.
I have got examples of Uganda, Tanzania, Ghana, Angola, Swaziland,
Lesotho, Zambia. I could go on. There are loads of examples of
where our ability to achieve objectives in this area are about
engaging with civil society in many countries.
Q110 Sir Robert Smith: But if the
bulk of the funding is going through the in-country health system
how do you ensure that they have systems in place to engage with
civil society?
Mr Lewis: I would argue that first
of all that is not the sum total of our investment. We are also
investing in building civil society in many of these countries,
so at the same time as investing in, if you like, state-ist healthcare
systems, we are also investing in civil society. This comes back
to another debate I think we need to have about public service
development in these countries. We are only getting to the stage
where we recognise in this country that part of reforming public
services is about active and involved citizens, and it seems to
me as we are building health and education systems in these countries
part of what we need to be doing is not just looking at the structures
and the systems but we also need to be looking at the investment
in civil society. Let me give an example about quality. We are
going to be increasingly concerned not about development of new
services and improved services but there is a real quality issue
as we are increasing volume. One of the ways you tackle that is
to have a strong civil society asking difficult questions about
quality. The point has been made about innovation and getting
to (I will not use the term hard-to-reach groups) some of the
more vulnerable groups. Sometimes civil society is in a better
place to get to those vulnerable groups than any state-ist-type
institution. It is not an either/or. We are continuing to invest
quite heavily in our relationships with civil society in each
of these countries.
Q111 Sir Robert Smith: So there will
be direct funding to civil society groups to advocate for people
living with HIV and AIDS?
Mr Lewis: Yes, where that is appropriate
in some countries that will be our aim.
Q112 Chairman: I wonder if people
are getting confused between budget support and building up general
healthcare. There is an assumption that if that is what you are
doing it is mostly going through budget support. I think the answer
we are getting from you is that country by country it will not
all go through budget support because you will need to support
these other groups. If that is what you are saying I think that
probably helps reassure people. They will obviously want to see
how it turns out in practice but—
Mr Lewis: It is also about the
value that civil society can add in terms of our healthcare objectives.
In some countries that will be massive. In others it may not be
very well developed. Some of those judgments have to be made country
by country where NGOs can make a tremendous difference and can
demonstrate that we have to have a positive funding relationship
with them. It is about effective partnerships and collaboration
but there are numerous examples where that is happening country-to-country
and just because the strategy talks about building up universal
healthcare systems, which is clearly the direction of travel now,
that does not mean that where civil society has not got a significant
contribution to make we will not be working closely with it.
Q113 John Battle: Can I ask about
the question of middle-income countries as well because we have
talked primarily about Africa and south east Asia? Some of the
facts and evidence seem to suggest—and the department will
probably be able to tell me better—that there is an emerging
crisis of HIV/AIDS in the West Indian countries. Could we pay
attention to them? Are they on the radar at all? Do we include
them under middle-income and will they be included in the strategy?
Mr Lewis: If you look at the use
of resources we are saying that 90% of our bilateral funds we
are going to spend in low income countries. In terms of middle-income
countries, our contribution is about working with the FCO, largely
bilateral and multilateral partners, civil society and private
sector organisations. There is specific reference in the strategy
in terms of the FCO's role with regard to middle-income countries.
Clearly, we recognise that we have responsibilities in this area.
I do not think we apologise for spending the vast bulk of our
resources in low income countries but the question is what role
we play other than resource allocation.
Q114 John Battle: I understand the
shift in the resources to Africa in the Strategy. What I am simply
asking, perhaps international bodies as well, is if it needs to
be flagged up could it be flagged up, because some of the information
I am receiving, and I am just asking for it to be checked out
really, is that there is an emerging real difficulty in some Caribbean
countries. If that is the case then it would be a bit negligent
not to include it in an overall strategy, and whether the WHO
picks it up, UNAIDS picks it up or we pick it up, somebody has
to, and I am simply putting in a plea could it be included and
could the department look at it?
Mr Lewis: Yes, certainly.
Q115 Chairman: We have had discussions
several times in the past about the 90/10 split in relatin to
middle-income countries. I do not want to go into that but in
that specific context, if you are going to achieve some of the
MDGs, and the shortfall is significant in middle-income countries,
then DFID's ability to deliver those MDGs—and this one particularly—might
be compromised by that split. The question therefore is how the
relationship with the Foreign Office is going to help achieve
that? Particularly one is thinking of Caribbean and Latin American
countries where effectively DFID's presence is minimal, and therefore
it might be quite crucial to our contribution in achieving the
MDGs.
Mr McNeil: May I respond to that?
In my previous job I was the senior health adviser for Latin America
and the Caribbean. A key thing in these middle-income countries
is that the countries themselves have resources, so what they
need is technical support to try and get the resources being allocated
for the—
Q116 Chairman: I think Mr Battle
is saying political will.
Mr McNeil: Indeed, and that is
a key part of it. In the Caribbean in particular a key issue on
HIV and AIDS has been the pervasive stigma and discrimination—
Q117 John Battle: Absolutely.
Mr McNeil:— and DFID has
supported region-wide work and is now opening a new unit.
Q118 John Battle: And we have delivered
work in South Africa on this agenda.
Mr McNeil: Indeed. The point I
would like to make is that the key thing is that these countries
often have resources but they may lack technical direction or
the political will, and I think that is an area where the FCO
can be helpful. Although DFID's programmes are small we do not
need a lot of money to provide technical support to these countries
and, of course, the Global Fund is under their regulations. They
can still provide substantial resources for middle-income countries.
Q119 Chairman: In a practical sense
does that mean you have to have some kind of training or engagement
with Foreign Office officials?
Mr McNeil: Indeed, we have very
regular discussions with FCO colleagues, both at headquarters
level but much more so out in the regions, very regular contact.
Many DFID officers are co-located with the FCO and so they have
day-to-day contact.
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