Examination of Witnesses (Questions 280
- 299)
MONDAY 10 MARCH 2008
Dr Christopher Conlon, Dr Maureen Baker, Dr Helen
Williams and Dr Imelda Bates
Q280 Lord Geddes:
Do you get the impression that they are frightened of admitting
that they do not know?
Dr Bates: I do think in some areas yes, but
I also think that their role is to find the gaps and to commission
people to generate the evidence. In some instances I have seen
people from the WHO themselves generating and managing projects.
They are not academics, they are not researchers; that is not
what they should be doing. They should be generating policy from
evidence; where there is no evidence they should ask expert researchers
to generate evidence for them.
Dr Baker: The point I would like to make is
that, from the point of view of the perspective of British GPs,
intergovernmental organisations by and large are pretty invisible
really. Certainly from the perspective of the Royal College of
GPs I suppose, being a professional body of primary care physicians
in the United Kingdom, you could consider that is fairly surprising.
For very many communicable diseases, GPs and primary care teams
are in the first line of seeing and treating people, yet it is
as if we do not exist. Is there a role for such organisations
to come to bodies such as ours and say, "What do GPs need
in the event of this condition or that condition?" but those
sorts of discussions never happen. I am just throwing this up
to you in that I do not know if that is the experience in primary
care in other countries, but I think it would be reasonable to
say that that is what it feels like for British GPs.
Q281 Chairman:
What would happen if you went to them and said, "We would
like you to look at this"?
Dr Baker: I do not suppose there is any reason
why we cannot, although because we are a generalist body and we
comment and participate in so many fields, we tend to be busy
enough dealing with people who come to us rather than to create
an area of activity for ourselves.
Q282 Lord Hannay of Chiswick:
I want to follow up on the same point. Do you not think that it
is likely that an organisation like the World Health Organisation
feels that it has to put most of its effort into developing countries
which have very inadequate health programmes and that probably
developed countries are perhaps not such a high priority because
they are better able to look after themselves? On the other hand,
the question Lord Soley asked is surely a very reasonable one.
If you and your organisation are generating very valuable material
from your own experience and your own practice, would it not be
a good thing if you were to share that with organisations, whether
they are at the European or world level, whether they come looking
for it or not?
Dr Baker: I suppose it is a question of what
comes first. I totally accept your point about developing countries
and the priority; I would not argue with that at all. I think
what we would consider is that we have been around as a professional
body for GPs and primary care physicians longer than any other
and, therefore, I would consider that we probably do have expertise
and networks that would be of value. To what extent it would be
our responsibility to say to whom is our expertise valuable and
go out and push it and to what extent it is our responsibility
to actively respond to requests should be debated.
Q283 Lord Avebury:
Are GPs not also members of an international body of general practitioners?
And do you not have links with other primary care medical organisations?
Would it not be more appropriate for the international organisation
that represents primary care to be the interface with the WHO?
Dr Baker: The only international body that comes
anywhere meeting that description is a body called WONCA. It actually
stands for something like World Organisation of National Councils
of Family Medicine; I do not know how the acronym arrived. WONCA
is an organisation that very much relates to the development of
research and education in primary care, so the type of organisation
you describe does not really exist.
Chairman: I think perhaps we need to
move.
Q284 Lord Hannay of Chiswick:
We have had a pretty persistent message in the evidence we have
taken so far that there is some tension between what you could
call vertical health initiatives, initiatives to eradicate specific
diseases (HIV/AIDS, malaria, TB or whatever it is). The evidence
suggests that they are not very sustainable if they are not properly
embedded with well-resourced and functioning healthcare systems,
which of course are lacking in many parts of the world. I wonder
if you could comment on this tension. We are not suggesting that
it would make sense to immediately abolish all the specific programmes
and put all the money on healthcare or anything silly like that.
But do you think that the balance is about right or not right?
If it is not right, how can it be shifted? Is it a question of
robbing Peter to pay Paul? Or can the imbalance side of the equation
be pushed up without pulling down the other? Perhaps, just as
a last point, you could comment on criticism that the word "eradication"
comes in rather too often in the publicity material, for instance
on malaria. I saw a quite powerful article last week suggesting
that it was really quite silly that you could very possibly reduce
malaria incidence by 80 or 90 per cent but you were not going
to eradicate it in the foreseeable future. Perhaps you could comment
on that eradication point as you go along as well, commenting
on the balance between public health systems and disease specific
initiatives.
Dr Bates: I came back from Nigeria where we
were trying to do exactly this, which is to integrate across programmes
in the field and it is very difficult. Some of the vertical programmes,
particularly HIV, are very strong and very focused on HIV activities;
there is huge potential in those vertical programmes for strengthening
health systems across the board for horizontal delivery of essential
packages of care, but nobody is making the donors do it. Essentially
the vertical programmes are mostly donor-run or donor-funded and
they run in countries where the ministries of health are not very
strong. If the ministries were strong, they could make those donors
integrate key activities across other programmes, but they do
not. It is difficult because the donors have funding for specific
activities which are very tunnelled on their individual disease.
Dr Conlon: I would agree with that. From my
experience of working in Zambia, which was HIV-related again but
in practice you cannot separate different diseases because they
interact. HIV and TB is a very good example, and Imelda has already
referred to the fact that many people come into hospital with
fever in the tropics and they call it malaria but actually they
have HIV or TB or something else. Part of the problem is that,
because of the infrastructure in the health system, it is not
uncommon for a disease to raise money among NGO donors or to be
a focus for governmental donation, and, although there is a lot
of money put into that, it neglects whatever else is going on
in the next ward or the next patient. The other problem, I think,
in terms of a ministries of health in developing countries is
that the Minister of Health is often a transient being, more so
than in the UK, so that causes a problem in trying to focus on
strengthening the underlying health service to meet the demands
that are more horizontal.
Chairman: I think we are all slightly
shaken by the idea that ministers move faster in other countries
than they do here!
Q285 Lord Howarth of Newport:
Would you actually go so far as to say that vertical programmes
can, albeit inadvertently, damage wider health services?
Dr Bates: Yes, absolutely.
Dr Conlon: A good example is people putting
a lot of money into HIV and then sucking doctors out of the clinics
to work for the HIV programmes and not running the malaria programme
or the child nutrition programme or whatever. That can be damaging
in that respect.
Q286 Lord Steinberg:
Would that not militate very much against a lot of large private
charity organisations giving money when they see the problems?
Dr Conlon: Yes, it is easy to think you can
fix something but, as Lord Hannay said, you cannot eradicate these
things. You need to manage them so you need a portfolio of management
and not a single-disease thing. You have to educate the donors
as much as the ministries.
Q287 Chairman:
How would you try to get this balance right between the vertical
and horizontal?
Dr Conlon: I think part of it is trying to get
education at a much lower level organised first, so people understand
what the processes are both in terms of secondary and tertiary
education, because it is very easy for the young doctors in the
tropics to be seduced by the big money for a disease and to go
into that sort of programme and see that as their way to make
their career and survive in difficult circumstances. A lot of
it is to do with making people aware of the interaction between
diseases and health.
Q288 Chairman:
There must be a problem in Nigeria because of their health system
being partly regional?
Dr Bates: Their system is challenging to say
the least, because within each state they have three separate
health tiers as well. It is challenging, but it offers opportunities
because, if you can deal with the local government, they have
the money. If you want to release money for communities you can,
so long as it fits with policy. You have to go to the top but,
so long as it fits with policy, you can then go to the local government,
who have money and who can deliver things on the ground.
Q289 Lord Geddes:
Lest you think I have an axe to grind, I am neither for nor against
the WHO. But is this not where the Country Offices of WHO could
come into play?
Dr Bates: I think the Country Offices in WHO
do not have a very high profile. Whenever you go to them, they
always refer you back to the ministry. They will not work separately
from the ministry, so it really means you have to get to the ministry
rather than the WHO.
Q290 Lord Geddes:
The point of my question was actually the reverse of that. If
the in-country offices were somehow enhanced, would that help?
Dr Bates: I think you would have to do more
than boost it. They sit on the fence, and they would have to sometimes
stand up and be counted if you want to push for vertical programmes
to integrate more horizontally.
Q291 Baroness Whitaker:
What you have just been saying is very clearly reflected in the
GPs' paper—Dr Baker's paper—about a holistic approach
to the problems in disadvantaged communities. But there is a consensus
generally over all your written evidence that poverty is one of
the major influences of the spread of disease and that non-health
factors—globalisation, urbanisation—are key. Of course
these are primarily dealt with, not by the WHO but by other IGOs.
Do you come across, in your WHO or other international contacts,
other IGOs? Do you have a sense that WHO brings in the World Trade
Organisation or the UN Development Programme at all? What is your
feel for the non-health reasons for disease?
Dr Conlon: I think they are often pretty separate
really.
Q292 Baroness Whitaker:
Not what they are but how they are being managed.
Dr Conlon: I do not get the impression from
my experience that somebody in the WHO would say, "Let's
go and find out what the UNDP is doing or UNAIDS is doing".
They would be on almost parallel—sometimes convergent but
not always—tracks.
Q293 Baroness Whitaker:
Would you say duplicating?
Dr Conlon: Not necessarily duplicating but I
think not necessarily focusing on what the problem is.
Q294 Baroness Whitaker:
Would you say there is more scope for integration and coordination?
Dr Conlon: There is certainly more scope for
integration but the question is how you would manage the integration
and who would have the upper hand in managing it.
Q295 Chairman:
It is the coordination rather than the integration, if I understand
what you are saying.
Dr Conlon: Yes, integration of effort but coordination
of services.
Lord Hannay of Chiswick: I should just
warn that the word coordination is a dirty word in the UN family.
It means that organisations join together, spend two days saying
what each is doing and go away and go on doing it. I think it
is actually a very real challenge to integrate more the way that
health and other programmes are involved and I think that, if
our report just talked about coordination, a lot of people will
laugh bitterly and say, "We've tried that fifty times before".
Chairman: That is a very helpful reminder
from Lord Hannay, who spent many years at the United Nations.
Q296 Baroness Whitaker:
Just to continue, do you have any thoughts about how this might
be better managed? We do not expect it of you, but if you do have
anything to say we would be very receptive.
Dr Conlon: I wish I could solve it.
Q297 Chairman:
Dr Bates, did you want to come in here?
Dr Bates: No, I do not have any dealings with
other organisations apart from WHO.
Q298 Baroness Whitaker:
Would you welcome that?
Dr Bates: Yes, because on a community level
in developing countries in Africa we deal with pro-poor issues
all the time and you see things like town planning, environmental
issues, agriculture and education. All these different areas bring
to bear on improving health.
Q299 Baroness Whitaker:
So you would see the need for more input.
Dr Bates: There is a need but it is really difficult
to do.
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