Examination of Witnesses (Questions 100
- 119)
MONDAY 18 FEBRUARY 2008
Professor Gill Walt, Dr Richard Coker and Professor
Janet Hemingway
Q100 Baroness Whitaker:
When is that going to be published?
Professor Walt: This year. It is a five-year
evaluation.
Q101 Baroness Whitaker:
What about Dr Kochi? Is his work completed do you know?
Professor Hemingway: I am not quite sure what
the context is on that one.
Chairman: I am afraid we are going to
have to adjourn for ten minutes because of the division.
The Committee suspended from 5.05 pm to 5.15
pm for a division in the House.
Q102 Chairman:
Baroness Whitaker, would you like to continue? Have you had time
to think about the question?
Professor Hemingway: We have been conferring
and I must say we are still struggling over the context. I think
the question was around Kochi Arata and the WHO?
Q103 Baroness Whitaker:
That was just one example. What I really wanted was your take
on this conceptual philosophical struggle between the advocates
of budget-to-budget support, which gives the governments ownership
and therefore has a more long-term health effect, arguably, if
they have a strong Parliament, and the Global Fund model, which
is more accountable (they say), more long-term (they say), more
transparent (they say). Which should our money go to? The NGO
people say DFID is giving the Global Fund less and putting more
into direct budget support and they think that is wrong from the
point of view of the prevention of disease.
Professor Hemingway: It is difficult to turn
that into an either/or. If you do not do something about strengthening
the health services and health systems within a country in many
of these places and all you have are vertical programmes, like
the Global Fund, then in some ways you are contributing even more
to what is going on in the health system.
Q104 Baroness Whitaker:
People say it is the opposite with the Global Fund; it is not
from the top, it penetrates much more into the health systems
themselves.
Dr Coker: It is focused on AIDS, TB and malaria
but it is not focused on the health system more broadly, so by
its nature it has to be contributing to the vertical programme.
A sceptic would say that the NGOs would say that, would they not?
Q105 Baroness Whitaker:
They would say that, absolutely. I do not know whether you have
seen examples of direct budget support which has reduced the incidence
of, say, malaria; malaria has gone down in some places.
Professor Hemingway: It has, but how do you
actually attribute where that has come from? Sometimes it is very
difficult to get at that because you have multiple factors all
sitting in there that interplay together. Speaking personally,
where I have seen the Global Fund operating best is where the
Global Fund programmes have been integrated with the health system
and the health service—for example, in Zambia they are operating
that very well there and that works. I have also seen it operate
very badly elsewhere and I have seen budget-to-budget support
not work very well, so I think it is very difficult to give you
a generalisation of what works and what does not work.
Q106 Chairman:
Is there a note of scepticism about why the IGOs might be saying
this, if I understood you correctly?
Dr Coker: And also why the NGOs might be saying
this.
Baroness Whitaker: It sounds as if there
is not a magic bullet anyway, like the rest of life.
Q107 Lord Howarth of Newport:
Do we have to assume there will never be effective audit, there
will never be value for money assessments that we can trust?
Dr Coker: Value for money?
Q108 Lord Howarth of Newport:
We are asking where money should most usefully go. We do need
answers to these questions if we are to channel our money responsibly.
From what you are saying it is very hard to discern where we are
getting effectiveness and value for money.
Dr Coker: Can I give you an illustration of
where I think this is problematic? When I was working in Russia,
an NGO was working there and the NGO had brought in its own doctors,
its own laboratories, expensive systems and set up a completely
parallel system to the Russian system, which was costing huge
amounts and was clearly going to be unsustainable. They were arguing
that this was a humanitarian crisis and we needed to respond;
we were arguing, on the other hand, that we needed to develop
a health system, we needed to integrate a TB control model and
so forth. If you say, what is value for money? Well, some people
would say that there was a humanitarian disaster unfolding and
we offered value for money because in the immediacy, in that timeframe,
we saved lives. We would have argued that actually over a ten-year
period they would not necessarily have saved that many lives but
it would have cost a lot more. It really touches on your philosophical
point, over what time frame is one interested in terms of value
of money?
Q109 Baroness Whitaker:
Moving onto resource allocation, do you think too many resources
are going to HIV, malaria and TB at the expense of others which
arguably undermine the health of the whole country, like leprosy
or pneumococcal disease, or eboli? Should they have more money
than they get because they are not up there in lights in the same
way that TB and AIDS and malaria are?
Dr Coker: You could argue that not enough money
is going into those diseases because they are still a huge problem,
a huge burden. Does it cause distortions? It causes substantial
distortions. Does it pull money away from the resources that might
also usefully be going to those other diseases? Yes, it does.
Q110 Baroness Whitaker:
Does WHO have a good system for judging what money is going to
what?
Dr Coker: WHO does not decide at a country level
what resources go to what.
Q111 Baroness Whitaker:
In its own programmes?
Professor Walt: It certainly evaluates its own
work, so many of the programmes that it does will be evaluated
by external independent evaluators and they will learn from that
how successful they are being.
Q112 Baroness Whitaker:
The balance of its investment between surveillance, prevention
and treatment—do you find that acceptable?
Professor Hemingway: I would not know what WHO's
balance is there. It is not the kind of information that we are
given in any shape or form.
Chairman: Maybe we need to pursue this
with the WHO.
Q113 Baroness Whitaker:
Finally, I think the London School listed a wide range of blockages
to better control of infectious diseases. In trying to remove
some—presumably one cannot remove all of them—including
upstream issues like economic development and downstream ones
like investment in drugs, where you do you consider that intervention
by the international organisations would be most effective? Or
what are the points of maximum leverage? What should they focus
on?
Professor Walt: My personal view would be that
international organisations need to be building capacity within
countries and you do not do that through two-week training programmes,
you do it over a very long period and you train and set up systems
so that people can be managed and supported through their work.
I think that would be a very good long term aim for organisations
to improve health.
Q114 Chairman:
That seems to be the thrust of your comments, improvement in relation
to this. Is that right?
Professor Walt: That was a personal view.
Q115 Chairman:
Would either of your colleagues wish to add to that?
Professor Hemingway: It is also clear that health
benefits go hand in hand with economic development; there is no
question about that. Having worked in places like Thailand, Sri
Lanka and others over a 20 to 30 year timeframe where you have
seen the economic benefits move, you have seen improvements in
health systems move hugely. That goes along with improvements
in housing, which brings you improvements again in a whole raft
of other disease related issues. Unless there is something that
tackles poverty alongside the health systems, you are fighting
a losing battle in many ways. Somehow you need not to just think
of health in its own silo, but ask what it is, for the region
or for the country, that is going to give it the economic benefit
that goes hand in hand with the health improvements that you are
trying to put in. If you can tie those together, you can get something
that is sustainable; if they are not tied together, then anything
sustainable is very, very difficult to actually move forward.
There is too much of a tendency just to think in one block and
not across the breadth.
Q116 Baroness Eccles of Moulton:
Is political stability a very important factor there?
Professor Hemingway: I think it helps, but if
you look at Sri Lanka, in Sri Lanka there is no political stability
and yet they have almost got rid of malaria and it has not been
because they have swamped the place with indoor residuals, spraying
or bed nets. It is because they have improved housing and they
have done that against a civil war and a reduction in some ways
in parts of their economy—tourism has gone—but they
have had some of the key improvements that have pushed some of
those diseases out.
Q117 Lord Avebury:
One of the comments that was made by the London School was that
without HIV control, TB control is likely to remain a mirage.
I would like to ask you whether the converse of this is also true—that,
if you like, without more effective treatment of TB, the death
rate from AIDS is going to continue to rise. Could you say something
about the synergy or lack of synergy in IGO programmes to tackle
these two diseases? Could you also, in answering that, explain
how the DOTS strategy fits in with the programmes for integrating
anti-TB and anti-AIDS programmes in different countries?
Dr Coker: HIV lowers your immune system and
makes you more susceptible once you have been infected with TB;
TB does not make you more susceptible to acquiring HIV unless
you are in a setting where you are likely to transmit it to each
other. TB kills an awful lot of people who are infected with HIV.
In terms of the response, over the last 15 years or so the focus
was initially on TB control and in parallel HIV control, and never
the twain met and patients did fall between the gaps. I think
over the last five years, admittedly belatedly, that problem has
been recognised and there are efforts to try to ensure that patients
do not fall between the gaps, and there are policies developed
by WHO to try to address that problem. That said, many of the
vertical systems that deal with one disease are in a sense owned
by certain professionals, and so patients continue to fall between
the gaps as they move between HIV services and TB services. To
some degree that is understandable, partly because professional
expertise sits within those particular domains, but also, if you
are an HIV-positive individual, the last place you want to be
is sitting in a TB clinic. So there are real practical issues
as well. The response to those two diseases is that it is easy
to understand that we should have an integrated response, that
we should have a coherent response that delivers professionally,
good clinical care, but how one does that on the ground and ensures
that a lot of people do not become cross-infected is a substantial
challenge.
Q118 Lord Avebury:
Why is the answer not to deliver TB treatment and care within
the HIV clinical system?
Dr Coker: If we were sitting in an HIV clinical
care setting and I walked in with multi-drug resistant TB, we
would all be dead within six months or so.
Chairman: That seems to be quite a powerful
answer.
Q119 Lord Avebury:
Do you consider that, if the delivery of antiretrovirals is successful
but there is no corresponding programme to change sexual behaviour,
then the incidence of HIV is going to continue rising?
Dr Coker: Yes, the incidence will continue to
rise and that rise will be because people who are at risk of acquiring
HIV do not change their behaviour but also it will rise because
the prevalence of HIV will increase, the number of people living
with HIV increases and they potentially pose a transmission risk.
It does raise the issue that I touched on earlier on, which is
what we mean by a successful antiretroviral programme and the
risks associated with a half-baked antiretroviral programme and
the transmission of drug resistance and so forth.
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