Examination of Witnesses (Questions 202
- 219)
MONDAY 3 MARCH 2008
Professor Sir Michael Marmot, Professor Anne Johnson,
Professor Angela McLean and Professor Neil Ferguson
Q202 Chairman:
Welcome to the Select Committee on Intergovernmental Organisations.
First of all, these sessions are being recorded. You will have
an opportunity to send in any written corrections, factual corrections,
that you think need to be made. I would also want you to feel
free to send in any other additional comments that you feel need
clarifying or you need to add something totally new. Please do
not feel that this is the end of your contribution. Each of you
does not have to answer every question but, if you want to come
in on something, do please indicate. Let me just say to you, because
of your particular backgrounds, that we are primarily interested
in the intergovernmental organisations and the effectiveness at
dealing with communicable diseases and the British Government's
involvement with that. In order to do that we do need a better
understanding at times of the medical side. We particularly need,
and are beginning to get, having taken a certain amount of evidence
now, an idea of where the problem areas are. We are not expecting
you to have great knowledge of intergovernmental organisations
per se, but it would be very, very useful if you flag up where
you think things are not being addressed on an international level,
if you like, as well as they could be or where the UK Government
might be able to make its contribution more effective. Be fairly
flexible in how you deal with this, do not worry if most of your
knowledge is medical and not so much of the intergovernmental
type. Just understand that is the bridge we are trying to cross
here. Can I perhaps start by asking you to introduce yourselves
so we have got a better understanding. Perhaps you could start,
Professor Marmot?
Professor Sir Michael Marmot: I am Michael Marmot,
Professor of Epidemiology and Public Health at University College
London. I also chair a commission set up by the World Health Organisation,
the Commission on Social Determinants of Health, of which Amartya
Sen is a member. I have a little bit of experience of how one
particular intergovernmental organisation works, the WHO.
Q203 Chairman:
This is very useful, Professor. Professor Johnson?
Professor Johnson: I am Anne Johnson. I am a
Professor in Infectious Disease Epidemiology at University College
London. I have a particular interest in HIV and sexually transmitted
infections and also some interest in other areas, such as influenza
and tuberculosis. I am involved to some extent in international
research programmes in HIV in an African context.
Q204 Chairman:
Professor McLean?
Professor McLean: I am Angela McLean. I am Professor
of Mathematical Biology in the Zoology Department in Oxford. In
that department I direct something called the Institute for Emergent
Infections of Humans. My research interest is the evolution of
infectious diseases.
Q205 Chairman:
Thank you. Professor Ferguson?
Professor Ferguson: I am Director of the Medical
Research Council Centre for Outbreak Analysis and Modelling at
Imperial College. Again, I have a background in mathematical epidemiology.
I have worked for many years on novel infectious disease epidemics
ranging from BSE to foot-and-mouth disease on the animal side,
but most recently on SARS, bioterrorism and preparation for a
flu pandemic. In all of those contexts I have worked quite closely
with both governmental and intergovernmental organisations. Until
the introduction of the International Health Regulations I was
a member of the World Health Organisation Global Pandemic Task
Force, which would advise the Director-General on when to call,
say, a Phase 4 pandemic. My group worked quite closely with Margaret
Chan, who is now Director-General of the World Health Organisation,
during the SARS outbreak. Whilst I would not say I am an expert
in WHO, I am there about every two-three months or so.
Q206 Chairman:
Thank you. We will have some questions on terrorism and biological
threat. If you have problems, if you are affected by the Official
Secrets Act, which I suggest you may be, let me know and indicate
that.
Professor Ferguson: Not in the context of the
WHO.
Q207 Chairman:
Let me know if there is a problem anyway. Thank you very much
for that. Let me start by asking you this. We have been made aware
of what seems to be a very crowded and fragmented architecture
between the various intergovernmental organisations, both the
voluntary private bodies and, indeed, the international organisations.
One of the things we are trying to work out is, whether there
is a need for some sort of rationalisation of these organisations.
Do they overlap in a way that is productive? Or is there overlap
which actually causes confusion? I wonder if any of you feel able
or not to talk about that particular area.
Professor Ferguson: I would just say I find
it unsurprising given the numbers of actors involved and given
the scale and number of challenges involved.
Q208 Chairman:
You do not find it surprising?
Professor Ferguson: I do not find it surprising
at all. I also think scope for rationalisation is somewhat limited
because those different actors have different funding, different
constituencies, and answer to different interest groups. I am
encouraged by the degree of co-ordination now compared with ten
or 15 years ago, and maybe we will come back to the drivers for
that. I think there is an implicit sense in the question perhaps
of global health being something which is more akin to a centrally
planned economy, whilst I think really it is a free market of
different interest groups interacting. My perception is that it
is a market working quite well generally at the moment, at least
in the areas I have dealt with. It is not perfect but it works
quite well and arguably better than the alternative of a more
directed approach, even if that were feasible.
Q209 Chairman:
If there is not too much fragmentation or the interaction is good
enough, if you like, in a way the question is: who is making sure
it is good enough? Is that the role of the WHO as you see it?
And is the WHO doing it well enough?
Professor Ferguson: It has varied over time
and there was a hiatus, under the last Director-General. Some
things went very well and some things went backwards. But under
the current Director-General they have really picked up the gauntlet
of co-ordination. I think the other big player on the scene, which
is an NGO but it has got a far larger budget than WHO, is the
Bill & Melinda Gates Foundation. Those two organisations working
together, which has not been a perfect interaction, have achieved
a good deal more co-ordination than has been seen in the past.
Q210 Chairman:
Before I bring in my two colleagues who want to come in on this,
just let me ask whether your comments are affected by a different
approach to the regional structure of WHO or the central structure
of WHO? One of the things we hear is that the regions are very
variable.
Professor Ferguson: I think that is true. First
of all, I should say most of my interaction is with the centre
and I have been specifically, mostly in the recent past, interacting
on acute outbreaks and things like avian flu, where there has
not been as much mismatch between regional interests and central
interests as is sometimes the case. So in that sense I have seen
co-ordination, not necessarily at its best but close to its best.
I have also been quite impressed that, compared with a few years
ago, WHO and other key players are willing to be rather more confrontational
of Member States than they used to when faced with lack of openness,
for instance. In the past that did not occur partly because of
the effect of regional offices' representational nature of WHO.
Q211 Chairman:
So you see it as more of a country-level problem or a regional-level
problem?
Professor Ferguson: I honestly do not see it
as a problem. Things are evolving over time. In other disease
areas there are issues about different agendas at the centre versus
regions, and probably my colleagues can talk more about that.
Particularly in the acute planning for a pandemic, the next SARS
emerging infections, those issues are a little less acute. They
may be more acute when we get other issues, for instance, like
the interaction between WHO and OIE and FAO where there are some
more fundamental challenges, but within WHO I see less of an issue,
at least on that side.
Q212 Chairman:
Before I bring in Lady Whitaker and Lord Geddes, would any of
the other three witnesses like to add anything?
Professor Sir Michael Marmot: I see it slightly
differently, I have to say. Looking from a country perspective,
my Commission met in Nairobi, for example, before the recent disastrous
chaos there and the impression we were given was of a huge bewildering
variety of specific programmes from specific sources, each with
a demand for "Do it this way. Account for it this way".
The countries did not have the resources for the accounting that
was required by this bewildering variety of specific programmes.
Looking at it from a country point of view, what they saw was
total lack of co-ordination and they found it very difficult.
Professor Johnson: In the field of AIDS I think
there is some similarity with what Professor Sir Michael Marmot
has described insofar as there are great gains that have been
made by some of the vertical programmes, for example in the roll-out
of anti-retroviral therapy. But in one area you may have several
different programmes operating in one town. That may have advantages
but it may have significant disadvantages if they are operating
in different ways as described. The second thing is how do we
build capacity within those countries. We are talking about intergovernmental
agencies, the role of WHO. But there is, of course, the whole
question of the role of governments within country and the capacity
of governments to develop their own health services, to develop
the skilled people capacity. This is critical, to deliver programmes
over which they have some greater degree of autonomy, which I
think has to be a long-term aim.
Q213 Baroness Whitaker:
In a way my question is just another way of putting Professor
Johnson's point. Professor Ferguson, when you mention actors and
interests, I quite see that there are a number of what in some
contexts would be called producer interests, very many professionals
and very many organisations. But from the point of view of the
people who are going to get ill, would you say there was an integrated
set of organisations?
Professor Ferguson: I am not sure if anybody
speaks for the people who are going to get ill in those cases.
We have governmental representation and WHO is an intensely political
organisation. The thing I have had most dealings with recently
has been the Indonesian controversy over virus-sharing and the
response to that. There has been concerted action by individual
countries and groups of countries achieve changes relating to
intellectual property, and to get more investment in certain basic
infrastructure, although I have to say with a lot of political
edge to the whole controversy. These actors are countries, they
are not people speaking for the individual. Turning to Professor
Johnson's point, it is perfectly true that, if you actually look
on the ground—not necessarily in avian flu, which is an
exception, but in many control programmes for well-established
diseases, such as malaria and HIV—you will see a bewildering
variety of programmes in many countries. I would not necessarily
say that this is WHO's responsibility or fault, however. They
attempt a degree of co-ordination, but really the situation is
that lots of individual NGOs are coming to agreements with individual
Member State governments to put in yet another programme without
necessarily any degree of co-ordination. The failure of governance,
if there is one at that level, is really with the individual country
involved.
Q214 Lord Geddes:
I am homing in on very much the same point as Lady Whitaker. In
your opening remarks, Professor Ferguson, you kept referring to
"interest groups" and I wonder what you meant by "interest
groups". Do you mean the people who are funding? Or political
interest groups? Or, as Lady Whitaker said, is it what I call
the recipients? They are all interested groups.
Professor Ferguson: It is a combination of both.
Because global health is almost a synonym for the health of developing
countries, quite often the funders and the people behind them,
have the controlling interests in those discussions. The sectional
groups within organisations such as the UN and World Health Organisation
are other interest groups. By sectional interests I mean they
are very technical organisations fundamentally, so you have people
with backgrounds in particular disease areas who advocate those
disease areas. There is not necessarily the overview of scope,
a truly comparative assessment of, say, the cost benefit of interventions
for different diseases across disease areas which you might wish
if you were planning this from scratch. The data do not exist
to allow one to balance investment in a malaria programme versus
investment in another vertical programme, such as HIV. So what
you get are very powerful interest groups which are almost built
organically between scientists, professionals, policy people within
those organisations and partner organisations, NGOs, academic
units, which typically advocate particular vertical programmes.
In my view, the things which suffer in this are arguably the less
sexy horizontal programmes which are much more difficult to implement
because they involve much more challenging interactions with Member
State governments on the ground and are more difficult to motivate.
That is why it is encouraging in the last few years that organisations
like Oxfam have got more involved in interactions with Gates and
the WHO, and also organisations like MSF which is growing in importance.
These interactions are on both the vertical and the horizontal
sides. So overall, interest groups are rooted in subjects and
diseases. That is what it is easy to raise money for and people
are trained in specific areas.
Q215 Lord Geddes:
If I may do a follow-up, and I would be interested to hear from
our other three witnesses. One of the great advantages of being
a member of this Ad Hoc Committee is I have never met so many
professors in such a short space of time in my life. It is a bit
awe-inspiring for us on the Committee.
Professor McLean: We are delighted you think
that is a good thing.
Q216 Lord Geddes:
Be that as it may, what you have just said, Professor Ferguson,
frankly frightens me because, if these interest groups are as
powerful as you say they are, and I can understand the logic of
why they are, is that not by definition a recipe for disorganisation
overall?
Professor Ferguson: I do not want to paint too
bleak a picture. People are aware of this and there are attempts
to join the dots horizontally. There are some big initiatives.
One of them is funded by Gates, which is a follow-up to an earlier
study by somebody called Chris Murray on The Global Burden
of Disease. Whilst it has its methodological flaws, the current
study and the previous study have the big advantage of being the
only attempts to compare across all disease areas the relative
importance, impact and severity of different diseases and also,
to some extent, how easy it would be to mitigate that impact.
That inter-sectorial comparison is starting to happen, but part
of the challenge is lack of crucial data. Part of the challenges
overall in this area are for the non-research intervention programmes.
The research programmes have well recognised metrics of success
though even these could be better defined because, but for the
intervention programmes quite often measurement of success is
done in a very ad hoc manner and not in an easily comparable manner
between programmes.
Q217 Lord Desai:
Professor Ferguson, you gave a very good analogy that it is not
like a central bank, it is like a market. But at the same time
Professor Marmot said what we have heard, and there are lots of
other specific things. It seems to me that specific agencies and
programmes give money which is non-fungible and it is like a market
with different foreign currencies operating, but there is nobody
to trade between foreign currencies. Do you think that reduces
the effectiveness of the resources because people cannot transfer
money. They have to do it the way X tells them to do it and, although
Y may tell them to deliver the same, it is in another way? Is
that a problem with the architecture?
Professor Ferguson: Yes, in part. There are
some finite resources and the finite resources are the capacity
of the global community at any one time to implement a certain
number of programmes. There is a limited number of people with
the technical background and experience to put in place certain
programmes on the ground and quite often those people have worked
on a whole range of different programmes in different disease
areas, so there is a degree of competition there. I would agree
in general with your remark. Officially, NGO funding is earmarked
for particular areas, and different NGOs raise their money from
the grass roots and they want to implement their own thing. But,
if you tell them "this is not necessarily the best way of
investing money", it is not a zero-sum game—the money
will disappear.
Q218 Lord Desai:
Would it be better if all the money was put in a nice big pot
and then spent?
Professor Ferguson: You could try to do that.
Q219 Chairman:
I think Professor McLean wants to come in.
Professor McLean: I was going to say I think
Professor Ferguson has just touched on a very important issue
which we have not discussed yet, which is local manpower, local
healthcare worker power. There are just not enough people to deliver
all of these things. As I am sure you all know, the problem is
getting much, much worse with healthcare workers leaving developing
countries to go and work in wealthy countries, and that is a huge
issue.
Professor Sir Michael Marmot: Lord Desai said
it as if it were an off-the-cuff suggestion, putting all the money
in one big pot, but surely that is what governments do. I do not
pay my taxes towards the NHS or education, I pay my taxes to the
Government and the Government decides what to do with then. The
idea that I would pay my taxes only for HIV/AIDS control and not
for anything else we have decided is an unworkable proposition,
and yet so much of the money coming in for healthcare in developing
countries is hypothecated. Not only does it take away from local
people to decide what is important to them, it takes away from
governments to decide what is important. Take the issue in Nigeria:
2,000 women die for every 100,00 live births and in Sweden it
is three; so that is the range. If you have a programme for HIV/AIDS,
it does not touch that maternal mortality at all. If a country
says, "We have got these billions coming from PEPHAR and
Gates and everywhere else for HIV/AIDS but we are not doing anything
about the fact that a majority of women who give birth are not
attended by skilled personnel, sorry, there is no money for that.
You can't decide what to do because there's all this specific
money coming in", we would not run our government that way
and why should other countries run their systems that way. I think
Lord Desai's point is really a very good one. It may not be just
throwing it into one big pot, but it may be working with governments
to decide how best to use the resources for their needs.
Lord Hannay of Chiswick: I want to follow
up on this point because I think quite a lot of what one hears
is that, indeed, it is the lack of health infrastructure in many
developing countries which means that, however many resources
you pour into targeting particular infectious diseases, you are
not going to have terribly good outcomes. Having described that
as the problem, I think one of the questions we are asking people
like you is, in that case, how do we get it better? Should a committee
like this be saying that too much money is going into specific,
very high-profile diseases and not enough is going into less well-known
ones? That is perhaps the more straightforward problem. The most
difficult problem of all is that nothing like enough is going
into healthcare systems in poor countries and, if you put more
money into healthcare systems, then a smaller quantum on the individual
diseases might actually produce better results. I do not know
what the answer to that is, but if you are able to guide us I
think this is one of the biggest issues we are looking at.
Chairman: I am going to bring in Lord
Jay on this because in a way this is very much the question you
were going to ask and it is a very logical follow-on.
Lord Jay of Ewelme: That was the question
I was going to ask and I do not think I need to re-ask it.
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