Examination of Witnesses (Questions 80
- 99)
MONDAY 18 FEBRUARY 2008
Professor Gill Walt, Dr Richard Coker and Professor
Janet Hemingway
Q80 Lord Avebury:
I was wondering whether an incremental approach to the reduction
of these 150 indicators would be most likely to succeed. If you
start by saying you are going to bang everybody's heads together
and force them into accepting a common set of indicators across
the board—which might reduce the numbers by half or a third
of its present level—then you will meet with a lot of proprietorial
opposition. However, if you look at the 150 indicators and you
have, as you say, some that are barely distinct from one another,
then getting the two proprietors of those indicators together
and saying, "Could you two agree to harmonise and have one
indicator that would cover both your fields?" That might
be a more productive approach.
Dr Coker: Yes, I think that is what the World
Bank is trying to do.
Q81 Lord Avebury:
In what sense?
Dr Coker: They are trying to get a consensus
on what would be a useful limited number of indicators. It is
interesting that the Bank is leading on that.
Q82 Lord Avebury:
Where can we find that information on what the World Bank is doing
to enhance to harmonise the indicators?
Dr Coker: There is a meeting in about two months'
time on that.
Q83 Chairman:
Presumably one of the problems here is that particularly some
of the private sector who are putting money in want to solve a
specific disease, whereas there is also this wider healthcare
issue; you are torn between those. Is that right?
Dr Coker: Yes, what I have been talking about
is disease-specific rather than health systems.
Professor Walt: That is a major problem because
there are some indicators which are much easier to measure than
others and the health systems indicators are much, much more difficult;
they are more difficult to gather, more difficult to agree on
and need to be evaluated in a completely different way from measuring
whether, for example, somebody has had an immunisation.
Q84 Chairman:
Measuring the specific disease might not work anyway if the healthcare
system is so inadequate that you think you have dealt with the
problem when in fact you have not.
Professor Walt: Indeed.
Q85 Lord Desai:
I get the impression that a country receiving these visits from
the donors, can handle them, it is possible it does not need their
help; and those who need their help cannot handle the donors.
Would that be too simple a way of looking at it?
Dr Coker: That is a useful indicator, is it
not?
Professor Walt: How would you measure it though?
Q86 Chairman:
I want to move onto our Government's influence on the WHO. We
pour enormous sums of British tax payers' money into intergovernmental
organisations and the WHO is no exception. Do you think we are
getting the sort of influence we need over the WHO, bearing in
mind the amount of money that we put in. Or could we increase
our influence?
Dr Coker: My personal take on this is that I
think the UK influences WHO quite strongly through both formal
and informal channels.
Q87 Chairman:
Can you say what those are? Do you mean by medical input, for
example, or academia?
Dr Coker: Yes, through the strength of academia
in this country; the research to policy links, although not as
strong as perhaps they could be, are relatively strong from the
UK in the fields that I know but that may not be the case in others.
We also have expert committees. DFID is considered very highly
within the WHO, the messages from DFID are not totally narrow
and it does have a breadth.
Q88 Chairman:
Bear in mind that Parliament has a duty about the way British
taxpayers' money is spent and this is a very large sum of money
going into the WHO; is it being used effectively is what I am
asking to you?
Dr Coker: You are asking a question about attribution?
Q89 Chairman:
Is the money being well-used?
Professor Walt: WHO has very little money in
comparison with many of the other agencies that are working in
health. One of the criticisms is that it spreads it too widely
but the difficulty is that it is very hard to get precise agreement
on what WHO ought to be doing. I think it is one of those conundrums
that there will always be tensions about: should you be spending
more on public health and less on disease, or more on chronic
and less on infections, and so on? There are never really enough
resources but WHO as an organisation, it has always struck me,
has very little money and in comparison with the sort of money
that is now flowing into particular diseases it is actually working
with few resources. I think we may be putting money in but I do
not think that we are putting too much in at all.
Q90 Chairman:
It is not so much about the amount, it is how well it is used.
At the end of the day that is the question you ask about taxpayers'
money, is it not?
Professor Walt: Then it comes down to the question
of how do you measure how it is used and that is a difficult one,
I think.
Q91 Lord Jay of Ewelme:
When you say that DFID is highly regarded, would you say that
that high regard for DFID translates into positive influence on
the way in which the WHO operates?
Dr Coker: That is the sense that I have got,
particularly at HQ in Geneva and in the areas I have been working
with.
Q92 Lord Avebury:
One way of looking at how the money is spent in WHO is to look
over a period of time at the overheads in comparison with the
amount which is spent on its programmes. Is that something that
anyone looks at? Or would you think it would be worthwhile examining
the relative expenditure on things that happen on the ground and
things that happen within WHO's bureaucracy?
Dr Coker: Where does the money end up? Does
it end up in countries? Does it end up in Geneva? Does it end
up in the Regional Offices?
Chairman: Maybe this is a difficult area
for you. I suspect that you are not too familiar with the way
the money is used at the WHO.
Q93 Baroness Eccles of Moulton:
I was just wondering whether generally speaking the arrival of
Gates and Google—no doubt there will be others—with
very large sums that can be introduced into this area is actually
changing the balance a bit about where the funding is coming from.
Previously much more of it was coming, broadly speaking, from
public sector government sources and now, with this wave of new
funding coming in, what effect might that actually have? I might
be getting the terminology wrong but I rather gather from what
has been said that WHO is more concerned with, as it were, the
horizontal input and the Gateses et cetera with what I think is
described as the vertical, which is the disease-specific; and
whether, as the balance matures between the private sector and
the public sector—to use simple terms—the private
sector input might see that it will be advantageous perhaps to
start to fund WHO directly itself to a certain extent. Could that
be a possibility?
Professor Hemingway: When organisations like
the Gates Foundation first came along they believed that the space
that they needed to occupy was in the discovery and development
of new products for disease control and that, if they produced
those new products—ie new drugs, new vaccines—the
world could take them up with no problems. The delivery mechanism
was there, with WHO and others being able to pick these things
up, integrate them into policy and practice, and away you go.
What they have found out to their cost is that that delivery system
is deficient as well as the discovery and development programme,
and therefore Gates and others are now moving into that because
they believe they are not going to have the impact that they want
unless they get in there. I think that is where you have seen
more and more tension building, because WHO do believe that the
foundations are actually starting onto their territory. They need
to work together rather than fight at that point in terms of how
they do that.
Chairman: That is a very important point,
thank you. I want to move on now to the global initiatives. Lord
Howarth?
Q94 Lord Howarth of Newport:
Can we come back to a dilemma which is touched on recurrently
in these sessions between the disease-specific approach and the
approach of developing a strong health system—the vertical
and the horizontal? Budget support to assist countries to develop
effective healthcare systems presupposes good governance in the
sense that there is substantial administrative capacity, an absence
of corruption and, I would also say importantly, an equal benevolence
to all the people of country, untainted by tribal considerations
or whatever. Where do you think, if you can generalise, we get
better value, in the vertical or the horizontal? Generalisation
is obviously very difficult; if you want to give specific instances
where one works well and the other works well, please do.
Professor Walt: I personally believe that you
have to have both, that there are times when you have to prioritise
a particular disease—it may be because it is a major problem
at the time—and you try to tackle it through your health
services or your health system, so that you address it in an integrated
way. There may be a period in which you just go for that one particular
issue to resolve it and later you integrate it with other activities.
I think that the juxtaposition of these two as completely separate
is probably a bit unreal. There are times when you need both.
However, simply having largely or only vertical systems is hopeless
in the long run because you cannot sustain any changes that you
make, so you have to have a good system in place. But, within
that system, I would argue that there would be times when the
vertical programme would be justified.
Q95 Lord Howarth of Newport:
Do you think it is appropriate to invest money provided for global
health in the development of good governance?
Professor Walt: Yes, I do, very much so. We
need to feel confident that there is managerial and financial
capacity in the countries. In the end I would have thought that
is what everybody wants for those countries which are struggling
to build systems. The way to do it, is to build capacity at the
country level. I think that is one of the things that the British
have been good at doing.
Q96 Lord Howarth of Newport:
Could you give us now or later any specific examples of success
in one dimension or the other?
Dr Coker: I can give you an example which illustrates
something else I think. We were working in Russia in the prisons
and in the civil sector on TB control, multi-drug resistant TB
control and HIV control. What we did was to implement the WHO
vertical DOTS programme, which was probably unsustainable once
funding had been removed, because it was not integrated into the
broader health system. That brings me to the point that I think
you do need very strong vertical programmes which are well integrated.
That is a counsel of perfection perhaps, but if you do not have
a good, strong vertical programme then what you have is ineffective
programmes; and, when it comes to communicable diseases, one could
argue that that results in a worse scenario than having no programme
because you generate drug resistance; you generate it with HIV,
you generate it with TB, you generate it with malaria and undoubtedly
you will generate it with pandemic flu, which has huge knock-on
consequences. If you do not have it integrated, then you do not
have a sustainable programme, so there are inefficiencies. When
we were discussing this issue of vertical programmes and horizontal
programmes a few years ago with WHO, I think we reflected on this
notion of non-negotiable elements of a vertical programme—that
you absolutely have to have certain elements. If you do not have
these elements, then you generate a problem in generations to
come which is going to be incredibly costly. Because I am an infectious
diseases specialist in the first instance, I would argue that
you need good, strong, non-negotiable elements embedded first
of all.
Lord Howarth of Newport: Are there examples
that you can think of where horizontal programmes to strengthen
healthcare systems in developing countries have been funded by
international sources and have worked usefully? Can you provide
models?
Q97 Chairman:
If you have examples that you think give us these core issues
that apply on the horizontal and vertical, it would be quite useful.
Dr Coker: The Thai 30 Baht scheme was a very
powerful cross-sector health system reform programme. I do not
know what the position of it is now, but it addressed issues of
vaccination levels, of maternal mortality and reproductive health;
it touched on a wide range of different health issues.
Professor Walt: It was built on a good infrastructure
that already existed.
Chairman: I have heard some good things
about that but it did have a certain basis to build onto, whereas
in some countries the basis is not there. Lord Howarth's question
is quite important; if, after this session, you think of examples
which give factors which you think are necessary in the way that
you have talked about, Dr Coker, I think it would be useful to
have those.
Q98 Baroness Whitaker:
I have been on the receiving end of quite heavy NGO advocacy about
the Global Fund from those NGOs who are associated with it, that
it is much more effective than direct budget support. I do not
necessarily subscribe to their view. I rather take your balanced
view, but I should be interested in your comments. They say that
the Global Fund is more accountable and long term, not least because
it has several representatives of civil society on it and budget-to-budget
support given to a country with a weak Parliament which cannot
call its own government to account—as is often the case
in a developing country—(for some strange reason, governments
do not always want to strengthen their parliaments!), then civil
society is absolutely necessary to draw in as much capacity as
can be done from the regions concerned. That is one point. Of
course the global fund does also attribute benefit as part of
its modus operandi; I think they outsourced malaria to Dr Kochi,
whom Professor Hemingway mentioned; there was an interesting article
in The Economist a couple of weeks ago on this point.
The final point I should like your views on, going wider, is that
these same powerful advocates criticise DFID's international health
partnerships—which we thought was rather a useful idea to
draw together all the donors so that programmes would be more
coherent and less of an ordeal for the receiving countries to
deal with—because there is no space, again, for civil society
on the IHAs. Partly it relates to Lord Howarth's governance problem;
it goes back to the weakness of the national parliaments in being
able to pursue the government's use of the budgets, and obviously
NGOs have a role in this vacuum. If you have any views—I
hope I have made this rather convoluted argument clear—could
you pick out a few points which you think would be helpful?
Professor Walt: I think the Global Fund has
been amazingly transparent and has given the opportunity for a
great deal of participation by NGOs in a number of ways, not least
through the internet, and there has been a lot of debate about
it. It has also tried very hard to involve NGOs at the country
level in the CCMs (the Coordinating Council Mechanisms) with some
success and some failure. In fact, there are increasing suggestions
that the CCMs are not working terribly well and that they should
be amalgamated into National AIDS Councils and so on. The difficulty
with that is that it is very contextual and does depend a great
deal on the country that one is looking at; some countries' NGOs
are weak and do not have much voice and, therefore, are not able
to stand up to government or donors et cetera. I think one does
have to look country to country and in that sense the Global Fund
has been quite successful in trying to bring in NGOs.
Q99 Baroness Whitaker:
Is it effective in reducing infectious disease by these means?
Professor Walt: We do not really know that yet.
There is an evaluation being carried out now of the first five
years of the Global Fund.
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