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CORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 1068-ii House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE INTERNATIONAL DEVELOPMENT COMMITTEE
MR IVAN LEWIS MP, MR MALCOLM McNEIL and MR ALASTAIR ROBB Evidence heard in Public Questions 59 - 120
USE OF THE TRANSCRIPT
Oral Evidence Taken before the International Development Committee on Members present Malcolm Bruce, in the Chair John Battle John Bercow Richard Burden Mr Stephen Crabb Sir Robert Smith ________________ Memorandum submitted by DFID
Examination of Witnesses Witnesses: Mr Ivan Lewis MP, Parliamentary Under-Secretary of State, Mr Malcolm McNeil, Team Leader, AIDS and Reproductive Health Team, and Mr Alastair Robb, Senior Health Adviser, DFID Uganda, Department for International Development, gave evidence. Q59 Chairman: Good morning, Minister. It is nice to see you in front of us for the first time and I hope you do not find it too unpleasant an experience, but welcome. Could you perhaps introduce your team for the record. Mr Robb: My name is Alastair
Robb. I am DFID 's Senior Health Adviser,
working in Mr McNeil: I am Malcolm McNeil. I am the Team Leader for AIDS and reproductive health in the Policy and Research Division. 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 could 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 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 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 PEPFAR[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 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 Q78 Mr Crabb: JustJust 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 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 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 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 MDG 5, 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 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 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 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 ----- 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 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 relation 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 Q116 Chairman: I think Mr Battle is saying political will. Mr McNeil: Indeed, and that is a key
part of it. In the 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. Q120 John Battle: But we do not have many people in middle-income countries. Mr McNeil: Not many, no, that is true. Chairman: Thank you very much. Can I repeat specifically the point about the African countries and the social protection criteria? If you could provide us with a quick note this week it would be helpful to our report but also to reflection on you.[2] I think that is a bit of a lacuna for us but otherwise thank you very much for coming in. It has been very worthwhile. The Committee is obviously very pleased that the Government has these very big ambitions and commitments but I hope that the interaction between us and yourselves is constructive and trying to focus on how we get the delivery we all want. I trust our report will make some useful additional comments. Thanks very much. [1] US President's Emergency Plan for AIDS Relief [2] Supplementary memorandum submitted by DFID |