Examination of Witnesses (Questions 380
- 386)
MONDAY 17 MARCH 2008
Mr Elhadj Amadou Sy
Q380 Lord Howarth of Newport:
Are you optimistic that the accountability, the coordination and
the follow-through is going to improve?
Mr Sy: Indeed we are optimistic. We are not
there yet but I really believe that with the support of the Board
and the commitment that the Heads of Agencies will take, consequently
to that we may actually win because since what we call the Global
Task Team recommendations on coordination a lot of improvements
have been achieved, and this should be the extra mile to go and
we are quite confident that we will get there. We also have another
opportunity really to further explore that and come up with concrete
recommendations. We are planning now what we call the Second Evaluation
of UNAIDS, and it is looking particularly at the governance aspects
and accountability mechanisms between the Secretariat and the
Cosponsors. I am quite confident that it will result in recommendations
that will have to be enforced for the implementation of the programme.
Q381 Chairman:
Before I call in Baroness Eccles, there is a point you might want
to give some more thought to. If this governance structure is
so good for UNAIDS, why is AIDS so fundamentally different to
other diseases that we would not use a similar structure there?
One of the things we are constantly told is that this whole area
needs more rationalisation within it and you are describing a
particular system which you say works well for AIDS. Why would
it not work well for Malaria or TB and so on? If you have any
thoughts on that, I would like to hear them, because you are actually
advertising this model of governance as being a good one and we
are being told that there is a need for rationalisation across
the board in the way we deal with communicable diseases within
intergovernmental organisations.
Mr Sy: I would just re-enforce the point that
it is being copied by the Global Fund because it works for Tuberculosis
and Malaria and it is a governance structure that the Global Fund
also uses, but not exactly. They went a little bit further than
we did because they have introduced the private sector in addition
to NGOs and representatives of people living with HIV. It really
turns out to be the best way to agree on a policy and strategic
direction that will also minimise the differences at a country
level. For the other communicable diseases, it may be much simpler.
The technical intervention and the different things needed to
have the environment ready, the training ready, do the procurement
and then provide those treatments, and in most of the cases you
can treat those conditions. There are many statistics that we
can quote, but the most stunning one is that until today the vast
majority of people living with HIV do not know that they are HIV-positive.
Why do they not know? They do not know because in many parts of
the world they have absolutely no incentive to know. If you know,
then you will lose your job; if you know, you will be kicked out
of your home; if you know, then your whole family will be stigmatised
against; if you know, you pay sometimes with your own life. We
have seen this in many parts of the world, including Southern
Africa. When people want to know in most of these instances, either
you have barriers like simple infrastructure for testing and diagnosis
that are really lacking. Sometimes also, if people want to know,
there are all the social barriers that you have to deal with.
We are now seeing the specifics of this disease in comparison
with the others, with the arrival of the Global Fund and clear
funding from bilateral partners, we have excellent testing facilities
and we have good treatment centres with laboratories and everything,
and in some cases there are fewer patients turning up than were
expected. So we have to look at all the other factors and the
more advances we make the more we discover how complex the situation
is and that is the reason why we are trying to develop this complex
answer to this very complex problem. Parts of it are very simple,
but as soon as we get into the prevention areas and to the social
factors over which the individual do not have any control, that
may impact on the epidemic. That is where the complexity is and
we need to bring all the partners together to devise what the
most effective strategy.
Q382 Baroness Eccles of Moulton:
Mr Sy, can I start off by congratulating you on your first-class
clear and excellent English, which has made it very easy for us
to continue this discussion. I would also say that you have partly
answered the questions I was going to pursue by your description
of yet another complexity which of course is the psychological
aspect of the disease. What I was really wanting to discuss with
you was the question of the variety of infrastructure that is
provided in the different countries where AIDS is prevalent and
how this affects so much the delivery—whether it is through
diagnosis through the laboratories, prevention and actual treatment.
We have received evidence which does tell us that the infrastructures
are very variable. In some cases the horizontal provision—to
use that term—is really quite good, but in many areas it
is really very weak; and I think you referred to this in your
evidence to us, and that you cannot provide the diagnosis and
the treatment and even the prevention unless you have actually
got the infrastructure in place. A lot of it is obviously equipment
but even more so it is people. The other aspect of this which
is clearly a problem is that the initial funding sources and roots
down to the local level vary again because there can be obstacles
from the country level, down through the regional level, right
to the local level, where it is more difficult to filter through.
I wondered what sort of solutions UNAIDS perhaps had to some of
these problems.
Mr Sy: AIDS has revealed many of those problems
without necessarily causing them. The weak health infrastructure
in most of the developing world has been there long before HIV
but, when this already weak infrastructure has to deal with an
epidemic of this magnitude, it is being revealed at a higher level.
It is important to note also that we have learned that as far
back in 1997, when UNAIDS was established, the very first question
was how is it going to be possible to implement a good AIDS response
within the health sector in a poor setting. At that time the first
thing the programme did was to establish the sites in Co®te
d'Ivoire in Uganda, in Vietnam and in Chile to study, over a period
of time, how within a poor setting can a response to AIDS be developed
and also what would be the other activities in and around the
health sector that are needed to accompany that response. Three
years later, around the year 2000, we came up with very strong
evidence that it is possible, through a number of activities,
to come up with a very good health response. Those ranged from
the treatment of opportune infection, because we saw that tuberculosis
was rising and it was due to the co-infection of HIV and TB. We
also learned that the treatment of sexually-transmitted infection
and that early diagnosis and treatment were also contributing
to a good response to HIV. We also learned at that time that,
when basic service was being provided in the poor setting, it
was giving incentive for people to go for testing. We also learned
that what we considered at that time to be a very highly specialised
skill could be managed also by healthcare workers, not only in
university hospitals but also at the district level. That is where
the first port of calls for treatment now come in. These strategies
will continue to be scaled, up and now with what we call the healthcare
work alliance we will be strengthening the capacities of healthcare
workers at the district level and also at the level of the hospitals
and the level of even the periphery, to scale up all those activities.
I think that what we can say with great confidence is that we
have learned from this epidemic what can be done in those settings
which is not necessarily what we could find in a developed country
setting. The challenge we face is how to scale them up in a large
number of countries or even within the countries to reach out
to more regions. The only way I hope we can do it now is through
partnership with initiatives like the Global Fund, which is now
providing more resources to countries to scale up those interventions,
and bilateral programmes such as the US President Initiative and
the other European bilateral development programmes as well as
the ones that they are working together on with the EC. So scaling
up geographically, scaling up in terms of the variety of the intervention
and investing in the basic infrastructure, these are the combined
strategies to address those challenges.
Q383 Lord Avebury:
We have been talking already about the balance of resources between
prevention and treatment. I want to put a question to you, assuming
that I am Mr Warren Buffett and I have a hundred million dollars
to spend. I come to you and I say, "If I spend this money
on treatment, I will get a certain result through the provision
of ARVs and so on; or I could spend the money on prevention"
(for example, on Page 7 you recommend addressing structural factors
that influence HIV/AIDS, such as gender equality, and on Page
8 you say that keeping girls in school for an extra year is effective
in reducing the risk of HIV infection). So I have this hundred
million dollars and I come to you and say, "Where shall I
put it—in ARV or in keeping girls at school for an extra
year?" What would your reply be?
Mr Sy: The best illustration to show that there
is no dichotomy between treatment and prevention is the prevention
of mother-to-child transmission, where you treat and by treating
the result is that you prevent the transmission of the infection
from a mother to a child. We have also learned that, when we strengthen
care activities, prevention works better. As I have said before,
people will not develop health-seeking behaviour which is pretty
much related to the kind of prevention we want to see if, on the
other hand, the incentives are not in place, that you go for testing
and after that there is an opportunity to get treatment. If we
do not have treatment, we will not have the involvement of people
living with HIV in prevention. Evidence has also shown that the
best agents of change and the best people who could also deliver
the messages that can trigger behaviour change, who can talk to
young people, are those who are experiencing the virus in their
own bodies and are living that experience. However, in order to
recruit a critical mass of those agents of change, the only way
we can achieve that is through treatment on the one hand and then
fighting stigma and discrimination, so that they can be part of
the solution and not the problem, as they put it themselves. We
have also learned that, for every person that we are putting on
treatment, we are having three or four new infections in some
settings, and this is unacceptable. If we do not get the balance
right, then I think we will continue increasing the number of
people needing treatment while continuing to try to treat the
ones we know today, and in the long run the facilities will not
be able to cope. I think all those lessons, both from the treatment
side as well as from the prevention side, conclude in one direction,
that we do not have to make the tough choices between either/or.
We definitely need both to make a difference. The only thing I
would like to mention there is that we have also learned that
we have to develop some differentiated approaches in our prevention
programme because we do not have the same epidemic everywhere
in the world. In countries like the ones we find in Southern Africa
we have a generalised epidemic and we need a more generalised
approach. In more and more countries like Eastern Europe, Latin
America and the Caribbean, part of Asia and then in Western Europe
the epidemic is now more concentrated among certain groups, groups
of men having sex with men or groups of sex workers or groups
of drug users. Beyond the common good of prevention and raising
awareness for change, there is a need for very direct intervention,
depending on the profile of the epidemic. That is the reason why
now prevention is developed along the model that you know what
your epidemic and then you act on that. We all agree that we need
to continue to strengthen our efforts for prevention while maintaining
our achievements for care because the two go together.
Lord Avebury: I appreciate that this
is not an either/or, but I still think that donors need to have
some feel for where the marginal extra dollar is going and whether
or not it is better to pump money into, say, ARVs or, in the case
of Southern Africa, since you differentiate between the various
regions, where we know that keeping girl children in school for
an extra year is going to have an effect because you have quoted
studies that show that. I still think that, from the point of
view of donors, you have to come up with an answer. You cannot
just say it is not an either/or; you have to measure the effects
of the marginal extra dollar spent on prevention as compared with
treatment.
Chairman: I think underlying this question
there is another one in the sense of who evaluates the quality
of the work or the effect of the work that you are doing, the
evaluation process. Again, it is a bigger question which you may
not be able to cover now, but there is a question here which I
think Lord Avebury is touching on about who evaluates and how
that evaluation process is done, and how you then reach a balance.
We are a bit pushed for time, but if that is something you could
let us know about I would be grateful.
Q384 Baroness Whitaker:
Moving on to intellectual property rights, you say in your evidence,
rather diplomatically, that continued cooperation, especially
regarding the transfer of technology, should be encouraged and
strengthened by WTO member States and the IGOs. I wonder if you
can say a little bit more about what you would like to see and
which are the international governmental organisations that should
take action and what should be done?
Mr Sy: Access to medication, to drugs and to
diagnosis is really critical for the response to HIV. On the other
hand, we know that development of drugs and vaccines is very long
and it is very expensive. There should be an incentive for research
and development and then the challenge is how we balance the two—maintaining
the interest and incentive for research and development and at
the same time advocating for a wider access to treatment that
may lead into negotiating prices downwards as well as protection
of patents. Then there are all the possibilities that the international
agreement provides under the Trade Related International Property
Rights (the TRIPS). We work together with a number of partners,
including WTO, the World Health Organisation, UNDP (the lead agency)
to support countries, particularly developing countries, first
of all to understand what the issues are because the capacity
around intellectual property rights is relatively limited in many
countries and then to build up capacity and support them in their
negotiations with the partners, and by so doing make sure that
also the two parts are preserved somehow. What we have learned
in developing countries is that quite often unfortunately the
Trade Ministry does not necessarily know what the Health Ministry
is negotiating in terms of the pharmaceutical sector and access
to drugs, and then the negotiation on trade is put in a much broader
umbrella where drugs and wine are together and we do not have
to differentiate it afterwards to see how we can affirm public
health. We also know that no least developed country has to be
TRIPS compliant until July 2013 and LDCs—do not have to
grant any pharmaceutical patent until 2016 thanks to the Doha
Declaration. Given that environment which is now provided by the
international agreement, how can we facilitate partnerships within
the key actors so that we keep incentives for further research
and further development and return of investment, which is really
critical if you want to ensure that public health will be guaranteed,
and at the same help in negotiating greater access. What we see
is that the drugs are developed in countries which do not share
or carry the biggest burden of disease. Then the market should
be the less developed countries. There you cannot have economies
of scale if the price is extremely high. The way to go here is
to support countries in negotiating differential pricing because
we have seen that in some countries some pharmaceutical companies
are able to reduce the price of the drugs minus 80 per cent, which
is quite substantial. We also saw that the research and development
companies are even supporting the production of generic drugs
that are reaching now 90 dollars per patient per year compared
to the initial 12,000 dollars per patient per year that we used
to have. We also know that there is a system which can be put
in place, that you can have prices in middle-income countries
which are higher and even higher prices in the developed world.
We have different economic forms and different packaging and different
distribution systems for developing countries. What we are going
to do is to build in capacity, provide the technical resources
and information that will guarantee incentives for research and
development on the one hand, at the same time have an opportunity
for greater access, particularly in the least developed countries
through negotiating prices with pharmaceutical companies and also
access to generic production.
Q385 Baroness Whitaker:
You say this is a task for the UNDP working with WTO?
Mr Sy: UNDP was leading on that in very close
collaboration with the WHO and the UNAIDS secretariat.
Chairman: Mr Sy, we may have a vote in
a few moments. If we do, I will have to draw this to a conclusion
and make some final remarks, but I am going to try to fit in another
question if I can.
Q386 Lord Steinberg:
I am sure all my colleagues agree that you have given us detailed
answers to all the questions, so you will be a bit relieved to
know that my question is going to be comparatively short. You
referred in logistics to "weak forecasting, procurement and
distribution systems". Would you say that it is because of
the disparate nature of all the organisations surrounding you
that leads to this weak forecasting? What attempts or suggestions
would you make to improve the forecasting?
Mr Sy: Procurement supply management will make
or break most of the programmes. How do we find the right drug
and bring them to an airport or a harbour of any country in the
world? Then the challenge starts. When the drugs reach those harbours,
how do they get to the health facilities and then from the health
facilities to those patients who need them most. That chain reveals
a number of deficiencies in logistics and in forecasting. If people
do not have a good grasp of their own epidemic and the number
of people needing treatment, they may under-estimate the need
or sometimes, even worse, over-estimate the need and by the time
those drugs are going to be utilised they expire, because their
shelf life is sometimes relatively short. Then the conditions
under which the drugs are being stored in many of those places
are not the most optimal ones. So forecasting is extremely important,
not only to make savings in terms of exactly the quantities we
need but also to prevent waste of drugs from happening. The reason
why we highlight it even more as a very important issue is also
that procurement revealed some other dysfunctionalities, such
as good governance in terms of managing resources and managing
work and also how you minimise issues like corruption and a diversion
of drugs to other destinations where they are not supposed to
be going. Or they are used for other purposes outside public health.
How do we seek to address that?
Chairman: Mr Sy, I am going to have to
interrupt you there. I am sorry. You can probably hear the bells
ringing, which indicates a Division. We will not be able to return
to this, I am afraid, but thank you very much. The evidence you
have been giving is very clear and very helpful indeed. If you
have any further comments you want to add, then we would be very
pleased to receive them. Thank you very much.
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