Examination of Witnesses (Questions 60
- 79)
MONDAY 18 FEBRUARY 2008
Professor Gill Walt, Dr Richard Coker and Professor
Janet Hemingway
Q60 Chairman:
When you say the WHO, is that the regional structure of it? Or
is it the international structure? There is some suggestion that
maybe the regional structure is not as effective as the international
structure. I do not know whether you would agree with that, but
do you think that is a factor?
Professor Hemingway: I came back last week from
a meeting of AFRO, where they are at the moment looking at how
they set up a global surveillance system for pesticide resistance
in malaria. It is clear that there is a complete lack of understanding
within AFRO as to the level of complexity of what they need to
put together if they are going to properly integrate information.
They were talking about working at the level of Excel spreadsheets
and Access databases in the current climate, where we have really
good GIS systems that properly integrate with databases.
Q61 Chairman:
Sorry, what are GIS systems?
Professor Hemingway: Geographical Information
Systems where you can display your information properly, you can
integrate that information and you can query that information.
The fact that an organisation like AFRO does not understand what
needs to be done—and, even worse in some ways, does not
understand that it does not understand what needs to be done—I
think causes us to step back and think that we have a serious
problem here. I think we have moved hugely down the path of being
able to understand how we should integrate this kind of information
both with the animal systems and with the genomic systems, where
we have got used to dealing with huge amounts of information on
a global system that we need to share. That has not been translated
into infectious diseases for the developing world and that needs
to be done. I do not see that happening and the leadership for
that actually coming from the WHO at the moment.
Q62 Chairman:
Who should it come from?
Professor Hemingway: I think that is the obvious
place where it should be coming from and getting the right people
within the communities who do understand how these systems ought
to be operating, but it just is not happening at the level that
it should be at the moment.
Q63 Chairman:
You talked about "us" having a good understanding, by
which I presume you mean "we, the medical profession".
But you then talked about the way the structure does not understand
it sometimes not understanding that they do not understand. I
am not quite sure which ones you are identifying as having that
weakness.
Professor Hemingway: I think there are a large
number now of very efficient and very effective global databases
that have been designed for sharing large amounts of information
and those are now integrating together in a way that actually
allows the international community to query those databases. Genomics
is an obvious example of that and is the one I am most familiar
with, but others are hot on the heels of that. We should not need
to re-invent the wheel and invent that all over again and learn
the lessons all over again for the health systems. If we know
how to put those very large information systems together and we
know how to integrate them with geographical systems, with health
systems data and all the rest of it, then that information ought
to be transferred between communities.
Q64 Chairman:
I am still not quite clear on who is not doing that. You are saying
that we have all this, but is it government, is it the WHO, is
it the regional level of the WHO? Who is it?
Professor Hemingway: I am saying that for the
WHO, certainly at a regional level, it is almost counter-productive
trying to establish these things from ground level without getting
the right people around the table to start with. The understanding
is there that the information is needed. I think there is a very
poor understanding at AFRO level—maybe someone else can
comment on central WHO but I worry it is true of central WHO—of
what ought to be pulled together and where really the information
is to be able to do that quickly and effectively.
Q65 Lord Howarth of Newport:
Successful global surveillance pre-supposes, I take it, a willingness
on the part of the authorities within particular countries to
act rigorously and honestly. How confident can we be that that
will be the case? Was I too cynical in suspecting that in the
People's Republic of China they did not want the world to know
the extent of SARS—possibly they did not want their own
people to know? Would there be other cases where countries would
be alarmed that there might be negative implications for trade
or tourism or whatever? Is it a problem to get a genuine willingness
and an honesty and fullness of response from regimes in some parts
of the world which we really do need to know about.
Professor Walt: That clearly could be one of
the problems but it is not just a political problem, it is also
a problem of capacity. The information has to be gathered from
the ground and there are often simply not sufficient systems to
collect that information and to feed it upwards, so there is a
real problem of lack of capacity.
Dr Coker: I would like to touch on the point
that you raised which was about HQ and Regional Offices and then
perhaps Country Offices and surveillance. I can comment with more
familiarity around the EURO office, where the TB surveillance
systems in Geneva have been pretty good; they are a very strong
team. EURO has a lot of technical capacity but sometimes one wonders
what it is for, what does it do that adds value beyond Geneva?
That question is more profound when one recognises the ECDC. In
terms of surveillance do these different agencies contribute beyond
what HQ could do, given that now we have very effective communication
systems from when the Regional Offices were set up?
Q66 Lord Jay of Ewelme:
I should declare an interest as Chairman of the Trustees of the
medical NGO Merlin. I wanted to pursue the WHO point a bit, if
I may. One of the points which quite early on in our inquiry has
been stressed by a number of people is that there are too many
organisations in the health field, but I think there is a general
view that WHO is—or certainly should be—the most important
among them. We have already heard evidence of a certain amount
of criticism of the WHO, but we also heard from Government representatives
last week a sense that under the present Director-General things
were getting better and that the curve, in a sense, was upwards,
certainly in Geneva (there is a question mark, I think, about
the Regions). I just wondered if, from your perspective, you could
say what you think the WHO is doing well and perhaps doing better,
and the things that you would say are definite failings and what
it definitely ought to do better. I know that is quite a broad
question but I think it is going to be quite an important part
of the inquiry.
Professor Walt: I think that the difficulty
for WHO—this is one of the things that is creating major
problems for all of us thinking about what is happening globally—is
that WHO is not acting as an agency by itself. Where it used to
be the dominant agency it is not any more. It is having to deal
with the Gates Foundation, which is hugely influential, making
a huge difference to the way people are thinking about health
problems. I do not know what Gates is doing in relation to surveillance—I
would be interested to know—but those are the circumstances
within which WHO is working. What it can do well and where I think
it has legitimacy is in the way it is seen by many countries around
the world—especially the middle and low income countries.
It is perceived as being more neutral than any American organisation
or any British or European organisation. For that reason, if that
one only, I think there are good reasons for supporting it. It
is probably still doing too much; it probably does the normative
things better than some other things. It also provides some support
to countries at country level in thinking through plans and so
on, which is still useful in some of the low income countries.
I think it is quite difficult to say which are the clear areas
where it is doing well and those that it is not ; I think it may
depend on the needs of the countries with which it is working.
Q67 Lord Jay of Ewelme:
Thank you. I wonder if your colleagues have a different perspective.
Professor Hemingway: Clearly the landscape has
changed around the World Health Organisation and I think the World
Health Organisation has actually found it quite difficult and
has felt challenged by that change around it. Gates is an obvious
one but there are also other foundations starting to come up and
it is having to share that space that it is used to being a master
of. I think Margaret Chan has been a breath of fresh air in that
she has clearly decided that she is going to work with the foundations
rather than fight against them. I think some of those lower down
the system are still intent on fighting. Anybody who read the
New York Times yesterday, with Kochi Arata's outburst and
the memos on malaria and fighting against the Gates Foundation,
will be able to see that. I think there needs to be a mechanism
where we are all fighting on the same side to try to achieve the
same ends. The question is who really is in charge of the international
agenda and how are we going to try to take things forward. The
Gates Foundation and others are trying to work with the WHO; the
WHO has made it quite difficult for those organisations to work
sensibly with them.
Q68 Lord Jay of Ewelme:
Would you say that the Gates Foundation or other foundations and
their rather sudden appearance on the scene is acting as a kind
of spur to make the WHO more effective? Or is it rather confusing
them and making them not quite certain in what direction they
ought to be going? Is it a positive or a negative development
in that sense?
Professor Hemingway: I think the jury is probably
out on that one. My views are coloured by malaria, because that
is where I spend a lot of time working, but certainly in malaria
WHO did not work well and did not respond well to what was going
on externally. There was almost a feeling that, if it did not
have WHO's mark on it at an early stage, then it was not good.
Policy should not be driven that way; it should be driven by evidence
and WHO should be able to stand above that. For a while it did
not do that well in the malaria field; I think it has done it
better in TB and some of the other areas.
Dr Coker: You raise an interesting point which
is around this issue of closure: when is the evidence sufficient
to drive the policy? I think there is a tension—or there
has been a tension in the past—with WHO because it is a
technical agency; at times it is an implementing agency and it
is a strategic policy generation agency. I reflect on the DOTS
strategy for TB, where there is still a debate in academic circles
about whether that is an effective and efficient approach. WHO
attempted to close the argument, saying that that was the way
the strategy should be developed and it needed a WHO label to
be adopted in different countries. Although the debate is still
on-going in academic circles about whether that is an effective
way to go forward, the brand of DOTS is still required by countries
if they want to adhere to a WHO strategy. So this tension comes
out, never mind the issues around surveillance and other issues
that WHO deals with.
Q69 Lord Jay of Ewelme:
From what you have been saying, would your advice to our Committee
be that we should not look at the WHO as one large organisation
but try to disaggregate it a bit? You talked about different approaches
to different diseases, different approaches in some Regional Offices.
Do we need to try to look at it in a rather disaggregated fashion
do you think?
Dr Coker: WHO has traditionally focused on disease
specifics and therefore you have all the problems of vertical
programmes and lack of integration and the on-going debate about
that. But, if you look at diseases, you can look at some good
programmes and then you determine how you measure whether that
is a good programme or not, and there is a debate within that.
Malaria may be a contrast to TB, but that does not actually tell
you what are the problems of WHO in its entirety, it tells you
about the programmes within WHO.
Q70 Lord Desai:
When I hear this, hear echoes of the World Bank and IMF. Do we
still think that a single organisation can rule the world in any
topic? Once upon a time when WHO was set up, it was possible to
imagine it, but now countries have more capacity themselves, they
have different interests. So is it not time that one re-thinks
how much WHO can do and what they should not do?
Dr Coker: I think that is what Margaret Chan
has attempted to do: what is WHO for? What niche does it fill?
Q71 Lord Desai:
What do you think?
Dr Coker: I think it should be clear what WHO
stands for and I think it should focus on what it does well: it
should be issues around surveillance, coordinating rapid responses,
focusing on specific diseases that it has programmes and technical
expertise in; it should perhaps have a focus on countries that
will most benefit from that expertise.
Q72 Lord Desai:
Should it get out of rich countries altogether?
Dr Coker: If it has a global surveillance programme,
then that should be global and it should not be broken down.
Q73 Chairman:
It is a question of decentralisation; it can be a centralised
body that oversees everything but, if it decentralises, then there
is a problem about how good the decentralised units are at actually
feeding back up to the WHO. Have I understood that correctly or
not?
Dr Coker: Yes, I think that is right. In a sense
it touches on what the Regional Offices are for. If you have a
very good spoke and you have a good hub, then why do you need
the bit in the middle, as it were?
Q74 Lord Avebury:
Is there not a mismatch between one of the answers you gave to
a previous question concerning the failure to develop large-scale
surveillance systems that were integrated with GIS and the suggestion
that the WHO should focus on what it does well? Clearly it does
not do that very well, because that was the gist of your answer
to the previous question—that nobody has been looking at
how you produce very large scale databases that do integrate with
GIS. I would imagine that the WHO is the only supra-national organisation
that would take an initiative of that sort, yet it has not done
so. If it focuses only on what it has done well, then it would
not be involved in that particular enterprise. I wonder if you
could reconcile these two incompatible statements.
Professor Hemingway: I think we are talking
about technology and I think the technology in this area has moved
so quickly that the Centre within WHO in this case has not kept
up with what technology can now do. It used to do it better in
some ways than it does; I think it needs to take that technology
on board that may not be coming from a health system itself but
may be coming from others externally. We know, for example, that
the Google Foundation are now getting into that area; they have
a huge amount of expertise in IT systems and WHO ought to be working
very, very closely with these guys, where Google is talking about
putting one per cent of its staff time into those systems. I do
not know whether they are; I would be interested to find out.
They should have been knocking on the door, not waiting for the
world to knock on their doors to say, "Come on, guys, you
need to be taking this technology forward".
Q75 Lord Avebury:
Since Google is a dominant enterprise in its own field, would
there not be a difficulty if WHO approached them and asked for
assistance with these global IT systems? Other companies like
Yahoo or Microsoft would say that this was an unfair preference
being given to a particular company.
Professor Hemingway: We are talking about the
Google Foundation and not Google itself. But using the free systems,
in terms of Google Earth just as an external viewer, if you like,
that is free, but not necessarily using Google's products for
any gain in that sort of sense.
Dr Coker: A month or two ago Google launched
InSTEDD which is funded by Google, Microsoft (drawing on Microsoft's
computerisation skills), Rockefeller and WHO. This is in regard
to pandemic flu, particularly in South East Asia. I think these
discussions are on-going.
Lord Avebury: Could we have a note of
that, please? I would be very interested to pursue that.
Chairman: If you are able to do that,
it would be very helpful. I now want to move onto multisectoral
initiatives.
Q76 Lord Desai:
Following on from what we have said before, we are very concerned
about the confused architecture of health intervention. You said
something about a multisectoral initiative being adopted by people
in an uncoordinated fashion. Do you think countries or agencies
adopt these multisectoral initiatives because they are aware of
WHO's shortcomings or because they have a different view on how
this issue should be tackled?
Professor Walt: If you are looking at low income
and middle income countries who have to deal with huge numbers
of donors—whether they are UN agencies, whether they are
the Global Fund, whether they are bilateral agencies—they
have a huge problem to coordinate between those. The countries
which manage that well are the countries where they have reasonable
systems in place and they are able to get budget support, and
then they do their own thing (they have a national plan which
everybody then to some extent works to). To coordinate those efforts,
though, is really difficult because the donors have their own
agendas, they have their own constituencies to whom they are responsible,
they all want to attribute changes to their own inputs. There
have been a number of examples to improve coordination and I am
sure you know about them: sector-wide approaches, the attempt
to have one UN Office at the country level, and the Paris Declaration
to harmonise donors and so on. But each individual agency has
its own particular interests which challenge any coordination
attempts. I think you are right in saying that we need to look
at the countries to see how strong they are in terms of being
able to develop systems where they can actually take control.
That is where a lot of aid might actually go and would be very
well spent in doing so. In those countries which cannot do that,
then you need to have the various donors trying to harmonise as
best they can.
Dr Coker: A really good illustration of this
challenge and of the burden that is placed on some countries is
when one looks at monitoring and evaluation. We have just done
some research commissioned by the Bank to look at the indicators
for progress on HIV. We looked at all the indicators for determining
success and there are something like 140 or 150 indicators. They
vary across all the different sections between the Global Fund,
between WHO, between UNAIDS, between UNGASS, and we were looking
to see which ones are similar or whether there is duplication
and how much coherence is there. There is a huge variety. If you
are sitting in a Country Office and you have to fill in the indicators
for each of these, then it is going to be hugely time-consuming
and that is in large part why, I suspect, they are not filled
in.
Q77 Lord Desai:
Does it arise from the desire of each donor to have a kind of
recognised bang for the buck? Or does it arise from a genuinely
different opinion as to what causes a certain disease or what
cures it?
Dr Coker: I suspect that it is both. The issue
of attribution is important—that you can say that your dollar
has achieved such and such—but I think also there are people
who really believe that certain indicators tell you that you are
succeeding and there are differences of opinion.
Q78 Lord Desai:
So is the confused architecture a reflection of a confused situation
and you cannot simplify it—there is no way of simplifying
the architecture of health intervention? There is no way everybody
would agree on what the causes and cures for disease are and how
best to approach it and, therefore, there will always be differences?
Are we hoping for simplicity where there is no simplicity possible?
Dr Coker: I suppose we can talk about what is
a measure of success but ultimately, if you can reach a consensus
that that is the measure of success—and hope that that does
not distort the response such that you are trying to meet the
target rather than actually achieve the public health goal—then
this would surely be a good thing. If the public health goal is
achieved as well as the indicators being measured to give some
insight into whether progress has been made, I would say that
this was a good thing. Many of the indicators that one sees are
very similar but they are slightly different.
Q79 Lord Desai:
Is that because people do not differentiate?
Dr Coker: A sceptic might say that people like
to develop indicators.
Professor Hemingway: Sometimes it may be sheer
bloody-mindedness, basically that this group over here has set
up that set of indicators and is not prepared to agree that this
group over here has a better set of indicators or that the two
are similar. I think there is a fair amount of that out there.
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