Examination of Witnesses (Questions 20
- 39)
MONDAY 4 FEBRUARY 2008
Professor David Harper CBE, Dr Stewart Tyson and
Dr Carole Presern
Q20 Chairman:
I think it does need clarifying, does it not. If they are saying
that and it was in the evidence to us, it is a rather different
picture in a sense than you are presenting today.
Professor Harper: We will certainly have a discussion
with our colleagues at the Health Protection Agency and ask them
to clarify the situation for the committee.
Q21 Baroness Whitaker:
You have told us some very positive things about what the Government
is doing to promote the harmonisation of health programmes with
all the countries and also quite a lot about getting other governments,
IGOs and NGOs to share our view of the need for some rebalancing
between health systems and specific projects. This is obviously
of crucial importance to our inquiry, so I think we should check:
have you told us all that you are doing in this area? And what
more do you think could and should be done on rebalancing and
creating a general international consensus?
Dr Tyson: I think it is a critical issue whose
time has come, this focus on building health systems for the longer
term or focusing on short-term deliverables against specific diseases.
If we look at the major bilateral programme on AIDS, the US President's
Emergency Plan for AIDS Relief (PEPFAR), PEPFAR has spent $19
billion in its first five years. The indications we have from
discussions with the Congressional Committee are that, whichever
administration gets in in the US election, PEPFAR's budget is
anticipated to be between $30 billion and $50 billion over the
next five years. This brings massive responsibilities to use that
money in ways that build the long-term health system. For example,
in Zambia PEPFAR works through contracting NGOs, gives them short-term
targets and very rounded targets. They have to get so many people
on treatment by the end of Year Two, Year Three, Year Four. How
do they do it? They put an advert in the paper in Lusaka and they
hire 400 health workers. Where do they take them from? They move
them from one part of the health system, where they are delivering
children and providing general health services looking after kids,
to work just on AIDS. This is a no-win/situation; it is robbing
Peter to pay Paul. PEPFAR and many other big agencies that work
in this targeted approach have recognised that they cannot go
any further unless they deal with many of the systematic barriers,
particularly getting adequate numbers of trained health workers
where they are needed at the right time, and we are working very
closely with them on that. There is a lot of talk about whether
we need vertical approaches or whether we need horizontal approaches.
We need both. We need to be building the long-term system to deliver,
as I said, against the future challenges as well as the current
ones, and we need the benefits of short-term targeted investment.
I think it gets confusing. For example, I have seen people talk
about the diagonal, and the Japanese are currently talking about
weaving the vertical and the horizontal. The Japanese Minister
of Health, I thought, had the best slogan, which was, "Campaign
vertically. (Get the money where the money is) and spend it horizontally".
Spend it in ways that both deliver AIDS outputs—that is
what the focus of the resources is for—but also deliver
for the longer term. Finally, the Japanese also have taken up
this issue and it will be the core of the preparatory meetings
in a couple of weeks' time in Japan for the G8 meeting later in
the year. They, more than any, have been very influential in channelling
much more resources into AIDS, TB and malaria and were very influential
in setting up what became the Global Fund, but they have recognised
the need to balance and the need to do much more on MDGs 4 and
5, child health and maternal health, where there has been limited,
if any, progress to date.
Q22 Baroness Whitaker:
That will be interesting to watch. What about rebalancing beyond
health? I think you mentioned nutrition. There is also piped water;
there is also education in washing your hands after defecation,
which I think UNICEF did—and I should declare an interest
as a Trustee of UNICEF UK. Those are things which are not exactly
the province of health professionals or of health ministries in
funding.
Dr Tyson: I think increasingly they are. The
health strategy that DFID launched six or nine months ago was
one of the streams of work, working with education, with social
protection, with water and sanitation, these areas that do impact
on health. But we cannot pretend that all the health problems
are going to be realised through actions in the health services
area. Again, on the Japanese agenda, that is one of the critical
issues, to look at the broader contribution beyond the health
sector.
Q23 Baroness Whitaker:
I recognise that DFID does that. In fact, I have seen it do it
in action. But what about the international organisations? Would
you say they are equally seized of ancillary-to-health issues?
Dr Tyson: I think groups like UNICEF are, yes.
WHO, being a largely technical and normative agency, is perhaps
less so, but then their programmes at the country level are often
more modest than those of UNICEF. UNICEF has a very substantial
investment in all of these areas.
Q24 Baroness Whitaker:
In your document if I can call it your document, Professor Harper,
"Health is Global", the Chief Medical Adviser talks
about a Government-wide Steering Group in the first part of last
year, which will lead the process. I wondered what the impact
was so far of the Government-wide Steering Group.
Professor Harper: There is a Ministerial Group
that is chaired by the Minister of State for Public Health, Dawn
Primarolo. She chairs a Top-Level Group of Ministers from various
Departments, including of course DFID, the FCO, Treasury, Ministry
of Defence, Defra, what is now DBERR and others—the Devolved
Administrations, for example. That is the Group that has oversight
of the development of the Global Health Strategy itself. There
is a shadow group of officials who are working to pull together
the strategy, which is due shortly to go to Ministers for their
consideration.
Q25 Baroness Whitaker:
So you are not at liberty to say what the results are so far?
Professor Harper: Not of the strategy at the
moment.
Q26 Baroness Whitaker:
When is this likely to be available?
Professor Harper: In the next few months.
Q27 Lord Hannay of Chiswick:
You say that accountability is not a problem if you are dealing
with your preferred programme—rather—than—project
approach. But surely it must be a problem in quite a number of
countries where there is serious maladministration and corruption,
although there may not be in the one example you gave of Tanzania.
To what extent do you think that, in fact, these issues of corruption
and maladministration are going to be a seriously inhibiting factor
against your desire to see more and more done through sustainable
programmes and less through projects. And, secondly, to what extent
is, say, the American approach, where I would imagine this is
very clearly identifiable, of a preference for projects over programmes
driven by domestic political and social preferences, their determination
not to help family planning programmes, et cetera? And is that
remediable?
Dr Tyson: With regard to the first one, we would
use the aid instrument applicable to the country situation. So
in Nigeria or the Democratic Republic of Congo, or in a country
that is emerging from conflict where we have grave concerns about
governance and accountability, we would use project approaches.
We would work through NGOs, we would work through the UN, and
that is very much how we do work in these settings. As things
developed, we would try to put in place a mixture of approaches.
Nepal might be an example where it is emerging from a long period
of conflict. We pool the resources with other donors to support
key elements of the national plan but we also have a substantial
programme working on efforts to reduce maternal mortality in a
big part of the country. If things deteriorated, we would go in
and out of those instruments as we have done in Ethiopia. On the
second one, the changes will come with the change of Administration.
Do not forget that the US was (and probably still is) the largest
supporter of contraceptives and family planning programmes in
the nineties. It has changed fairly radically with this Administration
but, if the Democrats get in, we have heard from colleagues in
the USA that they would expect investment in family planning broadly
to double or even treble.
Q28 Lord Howarth of Newport:
Given the recognition that Dr Tyson has described of the imperative
of building healthcare systems in developing countries, can we
have an assurance from Professor Harper that our own NHS has now
foresworn recruiting qualified medical staff from those countries?
Professor Harper: As you will probably be aware,
we have a code of practice for an ethical approach to recruitment,
one of the first countries in the world to do that. It is something
that our ministers feel very strongly about.
Q29 Baroness Flather:
I was going to bring up population and I was very glad that Lord
Hannay did bring it up. How is it going with DFID itself, because
the Millennium Development Goals will not be met without focusing
on population? That is one thing. The second thing I want is how
does Gates spend his money? You have told us how PEPFAR works.
It is becoming huge now. It really is almost like a government
now.
Dr Tyson: Yes, I think Gates dwarfs many of
the UN programmes. We had a list of what we were putting into
other agencies, but I was looking today, in anticipation of this,
to see what Gates is spending, and it is probably around $3 billion
a year. We work very well with Gates. I suppose in their first
phase, their first five or so years, they have been looking at
the magic bullets—what needs to be researched, where are
the quick wins. But I think, as their resources have increased
and as they have covered many of the investment needs and some
of the focal areas, they have recognised that they have to address
this issue of health systems. We had a meeting with them a week
or so ago. They are doing two pieces of work at the moment. One
is developing a maternal/child health strategy, and they got together
with experts from the London School of Hygiene and the Institute
of Child Health to look at what they are doing and where there
are opportunities to support it. Again, at a meeting of IPPF last
week the Gates Adviser who was there was saying that they are
developing a reproductive health strategy, and that will be on
broad-based family planning. It will exclude abortion, but I think
all the other areas will be appropriate. It will be interesting
to see the nature of these and how they have made that switch
from low-hanging fruit, as it were, to getting involved in some
of the difficult areas.
Q30 Baroness Flather:
The low-hanging fruit are hydrolysides(?) which are not going
to come, are they?
Dr Tyson: Something will come in the next two
to three years. It will not be perfect.
Q31 Baroness Flather:
It has been going for a while.
Dr Tyson: The AIDS vaccine as well, we think,
will be there for another 10 or 20 years.
Q32 Baroness Flather:
The AIDS vaccine is further away.
Dr Tyson: Well, we could have one tomorrow.
That is the challenge.
Q33 Lord Jay of Ewelme:
Could I go back to one question which I did ask but which did
not in the end get answered earlier on, and that is whether you
think that the regional offices for WHO, other than in Europe,
are going to make the same positive efforts as the Europeans?
Dr Tyson: The big worry is, say, AFRO. I think
that Gro Harlem Brundtland, when she was the Director General
of WHO, started to make positive outreaches to the regional directors
and tried to bring them more into the fold, and I think Margaret
Chan is taking that up. We have always seen it. If you asked any
DFID adviser in Africa, they would say the weakest link of WHO
is the regional office, but I think there are signs that they
are talking of decentralising their staff to put them in country
offices to support governments in developing their national plans.
There is also, I think, strong pressure from the African Union
on WHO to do more, and they have developed a very sound and what
I would say is a very sensible health strategy for Africa that
WHO/AFRO has clearly contributed to. I could answer this question
better in about a week because the meeting in Ethiopia I am going
to is a meeting of all the health advisers in Africa and AFRO
will be a big issue. So, if it is acceptable, I will say no more
now.
Q34 Lord Jay of Ewelme:
It would be very helpful to have a note after the meeting
Dr Tyson: I will send a short note on what their
collective view is.
Q35 Chairman:
That would be very helpful. Does Dr Presern want to come in on
this?
Dr Presern: We are members of PaRRO and RIPRO.
I think there have been improvements in those areas. I suppose
the area we know least is EMRO, the Eastern Mediterranean, because
if we are not members of the regional committee we can only go
as observers, so again I would not be able to comment on improvements
in EMRO. I do not know if Professor Harper can.
Professor Harper: No, I cannot. In a sense to
reiterate a little of what I said earlier, the regional director
of Europe does meet with his regional director colleagues from
the other regions and, at least as far as hearsay is concerned,
he tells me that the relationship between the regional offices
more broadly and the centre, the headquarters in Geneva, has improved
quite substantially over the last 12 months.
Dr Tyson: There is a unique situation at WHO.
WHO is the body that governments trust. They see that it is their
organisation, it is the first place they will go to for a source
of technical advice and they are in a very privileged position,
and so I think it is up to us really to find effective ways to
support them. That does not mean pouring money into Brazzaville
or elsewhere but finding ways to work more effectively and strengthening
the reforming part of the organisations as best we can.
Q36 Lord Avebury:
Can I ask you about co-ordination of activities on TB and HIV?
I am sure you have seen RESULTS UK's criticism of our efforts,
which is based on research they carried out in what they call
18 high-burden countries where DFID has a bilateral presence.
They say that only two country offices reported that they were
providing any direct support for TB and HIV collaborative activities,
and five others that they were indirectly supporting those activities
through acts of assistance to national TB and/or HIV programmes.
Why have we not gone further down this line? And have DFID got
plans for remedying this situation?
Dr Tyson: I think I would probably accept the
criticism in the same way that I would accept the criticism that
we have not been as proactive as we could have been in making
sure that investments in AIDS are benefiting wider reproductive
health. Many advocates would say that as we have seen AIDS resources
increase, we have seen a corresponding drop in investment in broader
family planning, abortion, whatever—the broader opus of
reproductive health. I was looking today at a response to a Parliamentary
Question or some briefing that was done for a Minister on this,
and I did not find the answer very credible really, and I think
we do need to go back and look again. I would say that part of
it is that in many countries, such as Tanzania, Uganda, Malawi,
we are providing substantial resources into the budget or health
budget of the country to enable the government to deliver on its
priorities as reflected in the national plan. In essence we are
putting money into the government's systems so how governments
spend that is of great interest to us, but we cannot then say,
"We want you to carve out ten per cent of it to strengthen
your work on HIV/TB". But I think the comments and results
are completely rational. This is a focus of the work of one of
the research consortia that we fund as well, looking at models
where we can work together and learn from emerging good practice.
Q37 Lord Avebury:
I think Tanzania and Uganda are two of the countries where RESULTS
UK gave really good marks, but that does not alter the fact that
for the majority of these 18 high profile countries we did not
have adequate programmes for collaborative efforts with TB/HIV,
and it would be good to see some sign of that. Can you tell us
of any further plans that DFID has for rectifying the balance?
Dr Tyson: Perhaps I could submit on that again
after the meeting in Africa. It should not be too difficult. There
are so many areas of overlap, not just in the people who are coming
with TB or HIV but in the approaches that are needed to deal with
chronic care, to provide treatment, often through or supported
by community networks, making sure that patients comply with medicine,
decent information systems. I think, if I were an adviser working
in a country again, I would turn away people who are coming with
single-issue projects and say, "Go and talk to your counterparts
in TB or in AIDS and come back with a consolidated approach".
I suspect that Malawi will tell us a very strong story but I could
not get any data before leaving the office tonight.
Q38 Chairman:
Before I move on to the Medicines Transparency Alliance can you
clarify for me this problem with avian influenza viruses and the
problem with Indonesia in sharing information about that? I am
not sure I understand what is happening there.
Professor Harper: The Government in Indonesia
some while ago now, the best part of 12 months, took a decision
for a variety of reasons to stop sharing the virus that was circulating
and causing human cases and deaths in Indonesia. The significance
of that for the global community is that very early access to
the virus itself is essential in terms of determining whether
the virus is changing genetically where it could become closer
to or even change into a virus that is readily transmissible from
human to human. So there is a global security issue. But also,
of course, for vaccine manufacture, if that were to be necessary,
the earlier the access to the virus itself the sooner the process
can be conducted to end up with a vaccine. So the manufacturers
are very keen, through the collaborating centres and the Global
Influenza Surveillance Network, to access that virus. It is a
very complex area that has been discussed a great deal internationally
with the Government of Indonesia and many countries, most recently
at the Executive Board, a couple of weeks ago, of the World Health
Assembly, but also in November at an intergovernmental meeting.
The essence of it seems to be the lack of transparency that Indonesia
feels exists in terms of where the virus goes and what is going
to be done with it, whether it is going to be used for research
or for the development of medical counter-measures such as vaccines.
In a sense they are prepared to hold onto this as a bargaining
chip. That is the view from the rest of the global community.
Q39 Chairman:
It is not predominantly an embarrassment that that is a problem
there, as it was with China and SARS originally?
Professor Harper: It is very important in the
context of the International Health Regulations because, as you
will be aware, the International Health Regulations came into
force in June of last year and this is the first test case, if
you like, for an incident of public health significance between
different countries. So, for global surveillance, this is a test
of the International Health Regulations and that is a big concern
to the global community because we worked long and hard to develop
the International Health Regulations. This is one of the examples
where we would like to see them fully in effect.
The Committee suspended from 5.30 pm to 5.43
pm for a division in the House
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