Examination of Witnesses (Questions 1
- 19)
MONDAY 4 FEBRUARY 2008
Professor David Harper CBE, Dr Stewart Tyson and
Dr Carole Presern
Q1 Chairman:
Welcome and thank you for your time and expertise. You will have
an opportunity to see the evidence that is given in transcript
form so that you can correct any matters or fact or clarify anything
that is in need of that. I particularly want you to feel free
on future occasions to submit further evidence if that is the
result of this process this afternoon. If you want to send us
in anything else, that would be very welcome. In the questioning
that takes place now, although the questions may be directed to
one of the three of you, if one other wants to respond as well,
please indicate and you can certainly do so. In other words, I
want full participation. If I may, I will start. One of the things
I have been aware of for a while and have been focusing on, I
suppose, myself particularly, and it comes out in your evidence,
is this need for clarity over role and vision or, if you like,
the architecture which I think you refer to of these governmental
organisations. I was struck by one of your comments in Paragraph
16 of your wording where you said that "the current architecture
is crowded and poorly coordinated. Within the diverse group of
organisations there is no agreed vision or clarity over roles."
I wonder if you could expand a little on that and also say what
you think needs to be done. I would also like, as a follow-up
on this, an idea of how much that is a problem, particularly for
the World Health Organization and the way we use the World Health
Organization.
Professor Harper: I will turn to my colleague
in a moment. First of all, may I say how pleased we are to have
the opportunity to be here this afternoon to follow up our written
evidence with a discussion on this really important issue of the
global control of infectious diseases and diseases such as tuberculosis,
malaria, HIV/AIDS and avian influenza with the prospect of it
becoming at some point a human pandemic. These are truly global
challenges and they require global solutions of course. It is
very important that we have a coherent and robust approach to
the international institutions. I am also very pleased that I
am joined this afternoon by my colleagues Carole Presern from
the Foreign and Commonwealth Office and Stewart Tyson from DFID,
because I think these huge challenges cannot be tackled by one
Department of State or Agency. We are looking forward to our discussions.
On your first question, Chairman, may I turn to Stewart Tyson?
Dr Tyson: I do not know what the procedure is,
but can I submit three pieces of paper to circulate that will
give you a picture of the problem in health. There are more than
a hundred of these specific disease-focused initiatives, set up
for good reason because of perhaps perceived failures to address
Leprosy or Micro-nutrients or TB or Malaria. Each of them has
their own structure, their own process, their own interaction
with countries, and it causes large problems, not least of which
is transaction costs for government. One example is Vietnam, which
in 2005 had almost 800 donor missions in one year. The combined
administrative burden on countries of all of these well-meaning
partnerships is very significant. The second slide is about how
donors fund drugs as one example. This was in Kenya in 2005. Instead
of working to an integrated national plan and to trying and strengthen
the procurement and logistic system—this would be typical
of many countries—lots of donors are funding specific drugs
through parallel channels that bypass the national system and
really leave little behind. We know that when the project finishes,
the money goes elsewhere and the national system has not been
strengthened. The third one was an attempt in Tanzania to try
and work out the architecture around AIDS. If we look at a typical,
highly donor dependent country, we might see 20 UN agencies, 35
bilateral agencies, 20 global, regional banks or financial institutions
and 90 global health initiatives. Trying to get all of these to
work collectively together has, I think, been one of the great
challenges. If I can pass that round, it will give you at least
a picture of the starting point.
Q2 Chairman:
Are you going to send us copies?
Dr Tyson: I can send email copies later. That
really was the basis of the International Health Partnership that
the Prime Minster launched towards the end of the summer last
year. It is an accelerated effort in eight countries to try and
apply the principles of aid effectiveness as signed up to in Paris
in 2005 and to apply that to the health sector. There was a great
deal of enthusiasm on the part of governments to try and hold
donors and other partners to account, to get us all behind a nationally-owned
plan, to align our support to national planning processes and,
where possible, to channel more resources through the government
system and, perhaps most importantly, to commit us to a joint
process of mutual accountability. We will help strengthen the
plan; we will provide resources to help deliver it; and there
are obligations on the part of both governments and donors and
non-government organisations to try and get us working together.
I would suppose the second big area where attempts have been made
to rationalise this architecture has been the process of the last
UN Secretary-General, Kofi Annan, who set up a High Level Panel
on which the Prime Minister of Norway and Gordon Brown, when he
was the Chancellor, both sat. That is trying to make sense of
the UN process at country level and trying to move the UN from
being lots of different agencies working on well-meaning agendas
but not collaborating very well, to working to a coherent, single
country plan for the United Nations. That process again is being
rolled out, I think, in about ten countries with the plan to take
it through to a higher scale. You asked a question specifically
about the World Health Organization. I would say that from our
perspective at DFID we are extremely positive about the leadership
of the World Health Organization at the moment in Margaret Chan,
who shares many of our concerns on the architecture, the complexity,
the fragmentation and the overlap. She is working very effectively
with her counterparts in the World Bank. I think, for the first
time in many years, we see WHO and the Bank working very well
together to try and progress these agendas, but it is a big challenge
and one that is going to be with us for some time.
Q3 Chairman:
If neither of you want to come in on that, can I ask about the
One-Country plan, then? Do you see this as one way in which you
can try and bring the fragmentation together, if I can put it
that way?
Dr Tyson: I think it would help, but there are
also other interventions that we can support. I will give you
another example. It would not be atypical, in an African country
where there is a high prevalence of HIV, for UNICEF to come along
to a DFID office or to another donor with a proposal to do more
on orphans and vulnerable children. Then UNFPA may come along
with a proposal to do more on condom distribution. Then UNAIDS
may come along to do more on rights and stigma. The response of
many of the country advisers that have found themselves in this
position has basically been to send them away and to try and get
them to work together, to put together a more coherent and collaborative
plan, where each of them will work to their own strength but they
will be working to one plan that will be embedded in the country
plan.
Q4 Chairman:
I am interested in what you are saying about the World Health
Organization making some improvements. One of the things I picked
up in your note is that, when you are talking about the diverse
group of organisations, you say: "This is particularly the
case for WHO (WHO is either engaged in, or hosts, multiple partnerships)."
I read that not so much as a criticism as that this is where the
problem is. Was I reading that right? That was in Paragraph 16
of the evidence.
Dr Tyson: I would say that is a problem. It
has happened by default really. Many of these global health initiatives,
as I said, were set up because of a perceived failure of the international
community adequately to reflect a particular issue. Roll Back
Malaria I think was one of the first; it was established in 1999.
Because of the scale, I think, we were seeing many deaths of children;
we had seen malaria fall off the priority list as AIDS and other
health agendas have come up. At the time that these initiatives
were set up, there was a desire to see them embedded or hosted
by part of the multilateral system. Typically, that was either
WHO, which hosts many of them, or UNICEF as the two big health
agencies. So GAVI (Global Vaccines Alliance) is closely allied
to, and administratively hosted by UNICEF. Most of them are in
WHO. The scale of expansion of these partnerships has required
a re-think of that. It may be that a partnership was set up to
progress an agenda, to raise the profile, to strengthen advocacy,
to generate more resources to get to countries to deal with a
particular issue. At some point, we have to re-think: is there
still a role for the partnership or could it be absorbed back
into WHO? The last point is that many of these were set up because
of the then perceived nature of WHO, which as an inter-government
organisation, was good at dealing with governments but really
was not very good at engaging with civil society, academia and
other international stakeholders on these issues.
Q5 Chairman:
Are the other organisations of a similar view to you? Do you think
some of the organisations you are talking about would agree with
you that this is a problem and that this is one that needs to
be addressed?
Dr Tyson: I think most organisations would see
that it needs to be addressed but it sometimes comes into conflict
with different models of aid delivery; for example, many of the
European donors would favour supporting a national plan through
programmatic instruments, pooling resources, providing sector
budget support or general budget support. Japan and the US traditionally
have been much more focused on very specific projects with tight
control over inputs and a focus on delivering outputs in the short
term. The classic example is PEPFAR, the huge US investment in
AIDS. It is there; it is providing very substantial resources.
We try to work with the group to find where we overlap and where
we can complement each other's activities. Most donors would recognise
the need, including WHO, to re-think the architecture, to look
where there are possibilities to either merge some of these single
issue partnerships or, in some cases, to reabsorb them into the
World Health Organization or another parent body or, in the most
extreme cases, perhaps to disband them, but that would probably
be some time in the future. So far we have seen one merger. We
had one group, the Safe Motherhood Initiative that had been around
for 20 years, working on trying to improve health outcomes of
mothers in pregnancy. We had a second group called the Healthy
Newborn Partnership looking at just the problems of neonates,
children in the first month of life. Then we had a very strong
Child Survival Initiative supported by UNICEF that was looking
at childhood beyond the pregnancy period. We successfully argued
that it was ridiculous to have each of these knocking on the door
of donors or the door of the Minister of Health or Finance in
a developing country and that there was a great deal to be gained
from them working collectively together. That has emerged as an
international agreement really to work around a continuum of care.
You cannot further reduce child mortality unless you deal with
newborn mortality, and you cannot effectively deal with newborn
mortality unless you have a healthy mother who survives pregnancy.
These individual partnerships have all merged into one. So far,
that is the only example where we have taken a step to rationalise
the architecture.
Q6 Lord Hannay of Chiswick:
Could I carry on a bit from there but moving away from architecture
to substantive responses to communicable diseases? Have you identified
yourselves, the British Government, areas where intergovernmental
and international co-operation in this field is lacking and where
there needs to be such co-operation or more of such co-operation
than there is at the moment? As the opposite side to that coin,
have you identified areas where not just there is confusion through
the multiplicity of instruments but where too much is being done
or things are being done which are not very effectively done intergovernmentally?
Dr Tyson: I would argue that there is a case
for more international co-operation to make sure that we are all
on the same page, that we are supporting a coherent, comprehensive
national plan. AIDS again would probably be a good example. We
have seen investment in health aid increase from $6 billion to
$14 billion over the period 2000 to 2005. A great deal of that
money has gone into AIDS, TB, malaria and childhood vaccination,
but very little money has gone into nutrition, which is associated
with 50 per cent of child deaths; there is very little progress
in improving the half million women who die in labour every year.
The only way that we can get a better balance of those investments
and to make sure that the money that we spend builds a health
system for the long term is through intergovernmental processes.
I would argue very strongly that the International Health Partnership
gives us that model that we can build on. That is moving forward.
As for the balance, is there too much aid going into some areas?
I do not argue that there is too much money going into AIDS. I
would say that there is an imbalance with what is going into broader
health services and, within the AIDS opus, there is an imbalance
between money going into prevention, treatment, care and palliative
care at the end of the day, because really only about one-third
of those people who need treatment for what is a deadly disease
and can turn into a chronic disease are getting treatment.
Q7 Lord Howarth of Newport:
I am sure that almost everybody concerned wrings their hands.
I imagine a great many people involved in different organisations
with different kinds of activity within the international health
scene wring their hands about the incoherence, overlap and rather
chaotic aspect that it sometimes assumes. I was in Northern Uganda
a couple of years ago and saw this very vividly and talked to
UN organisations there, voluntary sector organisations, representatives
of the Ugandan Government and to DFID; they were all very unhappy
about the ineffectuality, the poor value for money and the disappointing
effectiveness of all the goodwill and all the effort that goes
in. We all know that it is very difficult to corral the big bureaucracies,
or indeed the smaller voluntary organisations, because they have
their own accountabilities and their own raisons d'être.
It would seem that very energetic and active diplomacy is going
to be needed to make an impact on this problem and that targets,
timetables or milestones would need to be set. Can you talk a
little more about what determination there is internationally
actually to try and make an impact on this problem rather than
just note that it is there and set up another committee to try
and deal with it?
Dr Tyson: We are making an impact. Take AIDS
again; there are two million people on antiretroviral treatment
now. That figure was 100,000 not too long ago. The number of women
who are getting preventive treatment in pregnancy is increasing.
Prevention is a difficult area because what works in one place
may not work in another.
Q8 Lord Howarth of Newport:
Is it almost despite the system that this good progress is being
made? It could have been even better and more coherent across
the system.
Dr Tyson: I would say that over the years, and
Uganda is a good example, we have seen a switch in our donors'
new business to what they saw as a more effective way of doing
business. Getting behind a nationally owned plan is critical,
trying to put more of the resources through government systems
to strengthen them. Today we need a health system that can deliver
against AIDS, TB and malaria, the big major problems, but, in
ten years' time, heart disease, diabetes, cancer, cardiovascular
diseases generally will dwarf the current figures on AIDS. At
the moment we have very large amounts of resources for the major
communicable diseases. Our challenge is to use them in ways that
build a system for the future: adequate numbers of a trained health
workforce where they are needed; information systems that can
track changes, one way or another, in health services; basic infrastructure
and basic outreach. They are as applicable to the three diseases
that you are focusing on now as they are to future challenges.
Again, returning to Uganda and going back five or six years, Uganda
had persuaded donors to support the national plan and had made
a shift away from the situation where two-thirds of all external
resources had nothing to do with the national plan; they were
not funding the priorities that the Government of Uganda had set
out. Over five years that turned two-thirds to one-third. Putting
money into strengthening the financial systems meant that the
Minister of Health could go along to the Minister of Finance at
the appropriate time and say, "This is the budget you gave
us last year. It has all been used and it has all been accounted
for. As a result of this, we have trained 5,000 more health workers.
We have renovated 200 health facilities. Our immunisation data
have gone up from 60 per cent to 80 per cent. We are making headway
in the following areas." Those are the sorts of processes
that we want to be supporting in many countries. It has been confused
by the rapid expansion in project-tied assistance, I think, which
is looking at one aspect of health. It is looking through a TB
lens or an AIDS lens or a malaria or a nutrition lens without
seeing the bigger picture and seeing the need to invest in those
systems.
Q9 Lord Howarth of Newport:
I think to a certain extent, diplomacy goes with this?
Dr Presern: You were asking whether there was
recognition of the chaos. I think there has been fairly clear
recognition that the situation could not go on. A number of Member
States pushed that WHO had a discussion on Partnerships, which
went to the Executive Board in January. That will result in a
World Health Assembly paper which is going to look, I think, a
lot more at the sorts of criteria that WHO accepts for partnerships
at a global level. How this plays out in the country, though,
is what Stewart has been alluding to. Quite some years ago a number
of countries—France, the US and several others—got
together to create a global task team on AIDS because there was
a recognition, particularly in the AIDS sphere, that there was
again chaos at country level. That played out into one-country
teams, the stopping of people banging on different donor doors,
a clearer division of labour amongst the UN agencies involved
in AIDS, and recognition from us centrally that we should not
be funding agencies that were contributing to the chaos; we should
reward those that were actually helping the governments do their
job better. Finally, perhaps on the Global Fund, which has sometimes
been accused of adding to the chaos by putting other layers of
co-ordination at country level, there is a very clear recognition
and demand, both globally and from country partners, that the
structures that were set up around the Global Fund have probably
got to cease to exist. The country co-ordinating mechanism should
be merged with national AIDS councils, with the Departments of
Health and so on. I think there is a clear recognition and some
proaction; there could probably be more but it is definitely on
everyone's radar at country and global level.
Q10 Lord Geddes:
I have three quick questions. The first I suppose is a NONIE question.
You dealt almost exclusively with the global situation. Given
your representation as witnesses, are each of the three of you
entirely confident that there is no fragmentation within the United
Kingdom?
Professor Harper: I think to say "entirely
confident" is perhaps difficult. We have improved enormously
in recent years in terms of engagement at the various levels.
I was going to give, in the context of a recent question, examples
of good practice. As well as looking at the operational level
and what is happening on the ground, and of course that is vital,
I have seen change in some areas where there is a clear engagement
between the different players at the political level. We have
been focused very much on the African situation and some of the
other developing countries. However, the UK plays an important
part in other areas, other regions. The European region is broader
than the European Union, and the UK plays an important part in
the WHO Euro region. For example, just recently there was an inter-ministerial
conference on TB which specifically set out to attract Health
Ministers and Finance Ministers, so that there could be that dialogue
between the different key groups. Nationally I think the dialogue
at a political level has really improved a great deal, but that
goes through the various levels and across the agencies. It is
hard to be absolutely confident that all of the links that are
necessary are made because it might imply, apart from anything
else, complacency, and we are absolutely not complacent. Politically
in the areas that we are considering this afternoon, and a lot
of others, there is real engagement across the different agencies.
Q11 Lord Geddes:
Going to the other end of the spectrum, if you like, on the global
scene, do you think there is ever going to be the possibility
where you could get one international organisation to lead globally
on health matters? In other words, if I might be over-simplistic,
to solve the fragmentation problem? That is half the last question.
The second part of it is: is it only by achieving that single
entity to sort out the fragmentation that the UK taxpayer can
get value for his money?
Professor Harper: Perhaps I could answer first,
and then turn to Carole Presern. I think it is reasonable to work
towards having a single agency or a smaller number of agencies.
From the UK perspective, we would see the World Health Organization
as being that agency for a variety of different reasons. It is
a challenge, and I think there will be interfaces of one type
or another because of the multitude of players that have a legitimate
role in this. I think we recognise that in order to make improvements
in the health area, whether nationally or internationally, very
often the key players are outside the health sector. So it is
very important to have those necessary levers and the ability
actually to deliver in a broad constituency.
Dr Presern: I think WHO is that agency but we
have to recognise that the landscape has changed and, with players
like Gates and so on coming along, this has changed much of the
way that international aid is financed. Something that has been
started is an informal meeting of the eight heads of the health
agencies. It is a very embryonic group but it was encouraged by
the UK that these people should get together—Gates, UNICEF,
WHO and several others—and see whether there could be a
very real dialogue and discussion about who should be taking this
leadership role. Things have fragmented and it has really become
quite out of control. WHO under Margaret Chan, I think, is well
poised to step forward and accept the challenge. Other people
respect her greatly and I think will defer to her leadership.
Professor Harper: If I may add one other comment,
if we come on to talk about avian influenza and pandemic influenza
situation a little later, I think that is a good example where
the majority of countries, if not all countries, that are playing
a key role in that area specifically look to the World Health
Organization for their leadership. I can say a little more later
but, looking at it nationally, one of the reasons for really beginning
to develop our ideas on a Global Health Strategy with Department
of Health leadership but recognising that this is very much an
cross-Whitehall, a cross-Agency strategy, was to try to brigade
the interests so that we have a more efficient system. I am happy
to expand on that a little later.
Q12 Lord Avebury:
Briefly, could I bring together two of the answers that you have
given so far? First, on the International Health Partnership,
you said that this was the means by which we hope to obtain a
more co-ordinated approach through governments at the recipient
level. Then you also said that there was an imbalance between
prevention and treatment and palliative care. I think that was
particularly in relation to HIV/AIDS. Are there not going to be
different attitudes to this split within the recipient countries
that would make it more difficult to obtain a shift in resources
such as you were aiming for? If it is correct to say that this
imbalance has existed and you need to move resources away from
treatment towards prevention, then the ownership of the process
by the recipient governments would mean that you have a persuasion
job to do, which may not be equally successful in all the countries.
It might be possible for you to illustrate your answer to this
by reference to the eight countries in which the International
Health Partnership is already working.
Dr Tyson: It is early days for the International
Health Partnership but the high level compact that was signed
in Downing Street in September committed donors to a direction
of behaviour, governments to a direction of behaviour, and civil
society also to try and get them, again working to a single plan
and working in a coherent way. I will be going to this meeting
where the government spends £3.50 per head per year roughly,
$7, and the figure of $10 public spend would not be atypical for
most of the countries we work in in Africa. Very little of that
money is provided as flexible, on-budget resources that enables
governments to move money in different directions. A great deal
of it is provided as tightly-focused project support, which can
only be used for specific interventions, not just AIDS interventions
but only for treatment or only for prevention or only working
in sectors. So it is a terrible juggling act if you are one of
these governments where there are many donors and there are many
development banks and whatever in trying to make sure all the
pieces of the jigsaw in the national plan are filled. The challenges
for donors are to put more money through government systems to
give governments that flexibility. The challenges for governments
are to embrace the fact that 70 per cent of health services are
being delivered by either the private sector or civil society,
and many countries do not quite accept that yet. There is still
a strong culture of public provision and public delivery rather
than perhaps public provision and pluralistic delivery. There
were also obligations on the part of civil society to work more
collaboratively with government. I have just come back from Nepal.
There are somewhere between 20,000 and 30,000 non-government organisations
working in Nepal, a country emerging from conflict with very weak
institutional capacity to manage them. If not anarchy of delivery
of services, it probably is not too far away from that. The International
Health Partnership, we should not forget, builds on 15 years of
experience in trying to get all partners, donors, civil society
and the private sector working behind the national plan. It has
not come out of the blue. We do have quite a lot of positive experience
to build on. I think in all of those countries the principles
have been wholeheartedly taken on by governments for one very
clear reason—that they feel that the heads of these agencies,
the eight major UN and Global Partnership agencies, and many of
the bilaterals and a number of private partners like the Gates
Foundation, all signed up to the principles. They really have
something to hold in the face of the German Government if they
are doing strange things at the country level, or WHO if they
are going on a different track. There is great enthusiasm there.
At the moment, those high level compacts are now being translated
into country level agreements and memoranda of understanding to
take country programmes to the next level. We are supporting countries
with catalytic funding to help them go down that route. In some
cases it might be that the national plan is a little bit divorced
from meaningful resources; the plan could be strengthened. Some
countries have highlighted the health workforce crisis as an issue
that needs to be urgently addressed and they are looking to work
with others within that mix of eight countries to look at current
best practice: what can Ethiopia learn from Zambia or Mozambique
from Kenya.
Q13 Lord Jay of Ewelme:
I should declare an interest, first of all, as Chairman of the
medical charity Merlin, which operates in many of the countries
we have been talking about and indeed receives support from a
number of agencies we are talking about. I wanted to ask a slightly
more detailed question about WHO, if I may, picking up something
which I think a number of you have said. I think it must be right
that, in so far as there is to be a lead agency, it should be
WHO, and I was interested and glad to hear what you were saying
about the increasing effectiveness of WHO under Margaret Chan
and also the willingness, as I understood it, from the donor community
to see that more needed to be done in the direction of greater
coherence. What I sometimes hear said is that that is all fine
in Geneva but that WHO at regional level is less effective and
the rather more political structure of the WHO's regional offices
means that there is a bit of a conflict sometimes between Geneva
and the regions and this can affect at times the effectiveness
of the country offices in the delivery of WHO and other programmes.
I just ask for your comments on that and whether you think, if
WHO were to have more of a role in pulling the architecture together,
it itself will need to reform.
Professor Harper: Perhaps I could start with
that question. I will come back again to one particular region,
WHO Euro, which is a region that perhaps people do not automatically
think of in the context of the diseases that we are talking about
this afternoon. But, of course, particularly with some of the
more easterly countries, the issues around HIV/AIDS and TB in
particular are very similar to the sorts of situations that exist
in sub-Saharan Africa and some of the countries that we have been
touching on. I have heard the criticism, of course, that WHO has
in the past been seen as working as different organisations. I
can say that I have seen some evidence of that in times gone by
at first hand. I am currently the Executive President of the Regional
Committee in WHO Euro, and I would say without a doubt that the
situation has transformed under Margaret Chan in the way that
she personally relates to the regional offices. I am told through
the Regional Director in WHO Euro that she has frequent teleconferences
and frequent meetings; she goes to the regional committees. She
has brought the organisation together as one organisation in the
last 12 months I think in a very encouraging way indeed.
Dr Presern: There has been a lot of internal
reform in WHO in terms of recruitment of staff. You will always
have the situation, when you have Regional Directors elected,
that you have to be extremely careful how you then appoint people.
There has been a lot of HR reform and most of the jobs now are
openly advertised and selected on merit. I think they have a way
to go still but there is definitely willingness there.
Q14 Lord Jay of Ewelme:
Could I ask a follow-up on that and then one question picking
up something that Professor Harper said? Would you, perhaps from
a DFID and a Geneva perspective, recognise the improvement in
the regional offices that Professor Harper has described as happening
in Europe? Perhaps Professor Harper could comment on the relationship
between WHO Europe and the ECDC, which has been set up in Stockholm,
and how they relate to each other?
Professor Harper: The relationship between ECDC
and Stockholm and Copenhagen, I think, is settling down. It is
fair to say that, when an organisation is new and looking to establish
itself, it can take some time for the relative roles and the complementary
roles, and particularly working towards some sort of synergy,
to develop. There are some very good examples, not least in the
area of pandemic influenza, where teams of scientists from ECDC
and from the European Commission separately and from WHO Euro
have been visiting countries to assess their state of preparedness.
That is a very good example of where it can work, but I am bound
to say that it will take some time before we realise the full
potential of the various organisations.
Q15 Baroness Flather:
There is not a straight answer to my question. I am very interested
in the smaller organisations which work in that. You have mentioned
that Nepal has 20,000 to 30,000 and most countries have lots of
small NGOs. Some are, in fact, funded by the governments of the
countries and by other countries and so on. I have always felt
that they are very jealous of their own little domains, so to
speak, and they are very frightened of co-operating with other
people because they feel they are going to be submerged and their
funding will disappear as a separate organisation. I suppose a
number of people who work in the field also feel threatened by
that and there is a sort of silly competitiveness about a lot
of the organisations. I wanted you to comment on that and see
whether there is anything in the future that you think might be
able to persuade them to work together.
Dr Tyson: I think that is a fair description
of many of the challenges. Many European NGOs in particular have
a very strong focus on service delivery, and that may be appropriate
in a setting like Nepal where there has been conflict for ten
years and services have all but disappeared in many parts of the
country. Nepalese, European or American NGOs can deliver very
basic services, bring services to people and start to set up the
building blocks for the future system. In other countries where
government capacity to deliver is much stronger, they do need
to re-think their timeframe of getting out of direct service delivery
and perhaps to focus more from my perspective, and most of my
experience is in Africa, on demand and accountability, advocating
for governments to do more on health and to make it a greater
priority and holding governments to account for what they do deliver.
I have this view that people in Africa have many challenges and
many problems and they do not ask a great deal of their political
leadership; too often that political leadership does not prioritise
health. There are many challenges: growth, education, the environment,
whatever, and health often comes rather low down that list. I
think NGOs also have to look not just at how they engage or impact
on the development effort at country level but what the consolidated
impact of 20,000 or 30,000 is and how they can work together,
how they can be speaking the same language as government and working
to support national priorities. I give you a very simple example.
A couple of years ago in Malawi, at an annual review of the national
health plan, there was a small NGO called the Child Health Lung
Project, which was trying to do something about pneumonia in young
children but which was essentially establishing a completely vertical
structure. It had European staff; it had an office; it bought
drugs—not through the government system, it delivered the
drugs down to the country level; it trained staff just in improved
treatment for kids with pneumonia; and it reported back. It is
good work; it could demonstrate in a small pilot project that,
if you give kids an effective drug and you train the staff well,
you can reduce deaths from pneumonia. But in the grand scheme
of things, after three years, when the money ran out and they
had gone somewhere else, it left little behind. I think that issue
also has to be at the back of any NGO. Think sustainable.
Q16 Baroness Flather:
I have known many projects that train workers to teach ordinary
people about the effect of HIV and then the money goes and those
people who are being trained have nothing and they cannot keep
working for nothing. You have done the work and wasted the money.
I also wanted to ask about accountability, which you mentioned.
That is a big problem in a lot of the African countries. How can
these organisations hold governments to account? What do they
do to make sure that the money that will go to the government
will be used for health?
Dr Tyson: I think money going to the government
and being used effectively is not a great problem. In many, if
not most, of DFID's African partners we have moved a large part
of our resources into budget support. We have confidence that
the policy environment is good, the practice is good, and the
audits tell the same story. I think NGOs have got to get into
a relationship where they are seen as a supportive part of a government
and they have to use appropriate channels to lobby government.
Nothing is worse than seeing a European or an American NGO haranguing
a Ministry of Health in an annual review. That voice needs to
come from well-respected national civil groups who are focusing
on their particular area of added value. On the Tanzanian review
not so long ago there was a very interesting advocacy group of
Tanzanians who were really just focused on accountability. They
produced the audit report from the year before and they asked
the government what it had done about these anomalies and what
action it had taken. Undoubtedly, next year the pressure will
rise and rise and governments will respond accordingly, but it
is a difficult balance.
Q17 Lord Geddes:
This follows that to an extent and I will be brief. The Health
Protection Agency in their written evidence to us was more than
somewhat damning about the UK influence on WHO relative to the
amount of money put in by the UK. It said, and I quote: "The
UK has relatively little influence on the direction of WHO activity
compared to other countries who frequently contribute less but
take an active role in influencing global policy." That is
a Government agency. Can you give your views on that?
Professor Harper: Yes. It surprises me to hear
that. I think that at least part of the comment, as I understand
it, related specifically to Phase 1, 2 and 3 clinical trials.
If it is a broader comment than that, it does surprise me, as
I say. I think the UK has reasonable influence, some might say
even substantial influence, within the WHO environment; not least,
we are currently members of the Executive Board, which is the
governing body for the World Health Assembly. At an operational
level we also have very strong links scientifically; we have the
operational links but we also work at a strategic level. For example,
at the recent Executive Board meeting just a couple of weeks ago,
the UK presented a draft resolution on the health impact of climate
change. This is something that we had been considering for some
time. We have discussed it internationally with a number of countries
and it received, I think, if not unprecedented support, very substantial
support from of the order of 40 countries. This is, I hope, an
example of a specific area where the UK feels strongly we should
be playing a global part in tackling that particular global challenge.
This is now an area that will form, I would expect, a big part
of WHO's future work: the health impacts of climate change.
Dr Presern: I think there are several examples
where the UK has exerted influence, but I think the power of influence
is not always to do it yourself or to be seen to be doing it yourself
but to work with others, as we often do in the European Union.
When we were co-ordinating positions in the World Health Assembly
or with other Member States, particularly on UN reform for example,
we felt it was more effective to work through Asian and African
countries that have more to benefit,, and the UK taxpayer obviously,
through efficiencies gained. We can point to several examples
on: sexual reproductive health, specific thematic issues and the
medium-term strategic plan, which sets the direction for the organisation.
The UK had a key role, I think, in trying to shape the objectives,
particularly trying to streamline some of them on health systems.
I could point to several other examples.
Q18 Lord Geddes:
In a nutshell, you would refute that HPA evidence, is that right?
Dr Tyson: It would be interesting to find out
what was behind it. I also think that we do have huge strategic
engagement with WHO but we are working at a fairly high level
to try and provide our resources in a way that enables WHO to
deliver more with its resources. Remember that WHO is a little
bit of a hostage to fortune in the same way that we could do a
similar diagram of the bilateral agreements with WHO. The last
time I looked they had 4,600 bilateral agreements with donors.
A great deal of the money that comes in to WHO is just for this
issue and you cannot use it for anything else; you cannot use
it to strengthen your staffing in neglected areas; you cannot
move it across to another area. We are at the moment coming to
the end point of a joint strategy with WHO between the Foreign
Office, DFID and the Department of Health. Our intent, and WHO's
intent, is that more UK resources are provided as flexible, long-term
funding. We will put in place a number of fairly robust indicators
of progress to take us in that direction.
Q19 Chairman:
When you became aware of this statement by the Health Protection
Agency, did you think: we had better have a word with them about
this?
Professor Harper: To the best of my knowledge,
the comment was made in relation to operational issues and particularly
in relation to TB and clinical trials, but I will follow that
up and perhaps we could clarify the situation before the HPA.
The HPA will be able to clarify the situation for the committee.
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