Examination of Witnesses (Questions 440
- 459)
MONDAY 31 MARCH 2008
Mr Nick Partridge OBE and Dr Alvaro Bermejo
Q440 Lord Howarth of Newport:
Some might take the view that you are quite charitable about our
own public policy stance in that we are not without this contradiction
ourselves?
Dr Bermejo: Yes.
Q441 Lord Howarth of Newport:
If at UN level you have the World Health Organisation and UNODC,
the left-hand not knowing what the right-hand is doing, or at
least the two hands pulling in opposite directions, do you have
any thoughts as to how, the governance of the UN, this kind of
issue could be resolved? What would you wish to see?
Dr Bermejo: That is going into the whole issue
of UN reform, which I would not know. I cannot go too deeply into
that. Clearly something needs to be done, as you say, because
it is just making the response so much more difficult. Certainly
in many countries the epidemic will not be controlled like this.
With the best political will, if we look at the Ukraine programme,
where certainly well over 60 per cent of those infected with HIV
are active drug users, if one looks at those who are receiving
treatment, it is less than five per cent of their active drug
users and that is because (a) they have to register with the state
and recognise that they are active drug users, which already puts
them at a major disadvantage in many ways given the criminalisation,
and (b) because no substitution therapy has been available to
ensure that they can adhere to this treatment. That is right on
the borders of the European Union, the fastest growing epidemic
in the world right now, and it will not be controlled unless there
is policy change.
Lord Howarth of Newport: I do not criticise
you for not embarking on the question of how you reform the UN.
We will have to ask Lord Hannay to move round and be a witness!
Q442 Lord Avebury:
I wonder if you can quote any evidence-based studies comparing
the relative effectiveness of crime-based and health-based approaches
to HIV prevention and stabilisation?
Dr Bermejo: In particular to drug use or ---?
Q443 Lord Avebury:
We are talking about drug use, yes.
Dr Bermejo: All the evidence that exists—and
we could quote much, and it was recognised by the Surgeon-General
in the US even during the Clinton Administration, when it was
still illegal—is that crime reduction approaches do not
increase the use of drugs, as has been said, and do reduce the
new infections amongst drug users. In the country I come from,
Spain, the success in the AIDS response has been mainly through
the introduction of harm reduction measures in prisons with a
conservative government. That has caused a dramatic reduction.
There is plenty of evidence around about how this, from an HIV
perspective, is the right response from Australia and from the
US itself. It is not lack of public health evidence, it is political
will that is not there, and it is the difficulty of people saying,
"Well, that's OK, I just don't want these Centres in my constituency
or in my backyard" and all these things that are the daily
realities with which we are confronted. It is not lack of public
health evidence.
Mr Partridge: The public health evidence within
the UK, where you can track very clearly the criminalisation approach
in Edinburgh in the early 1980s, causing a very substantial spread
of HIV through injecting drug use, shared needles and syringes,
was completely turned around through the introduction of harm
reduction techniques, the availability of clean needles and syringes,
and the introduction of substitution programmes. That utterly
and completely changed the course of the epidemic. This is a very
real and clear example of how policy change has meant that within
the UK the level of HIV infection as a result of injecting drug
use has remained very low, consistently about five per cent, since
1985. That is a very real life and clear example in the UK.
Q444 Baroness Whitaker:
I think Mr Partridge has totally answered my question, which was
whether clean needles would not make all the difference.
Mr Partridge: They do make a huge difference.
Q445 Chairman:
Having experienced, as an MP in a previous existence, the opposition
to having such Centres in your constituency, is that really where
the opposition comes from? Or are there other strong voices in
the medical community or intergovernmental organisations saying,
"No, harm reduction is not the right road to go down"?
Where are the strong voices against? Or is it more general?
Dr Bermejo: In our opinion, in the countries
where we work the health professionals are generally in favour
of these approaches. It is not within the health profession that
the resistance comes; it comes from law enforcement agencies and
bodies. In the general public I think there is uneasiness with
the subject which contributes to that, but we have not seen it
really in the health profession.
Q446 Lord Jay of Ewelme:
Thank you, my Lord Chairman. I was interested in what you said
in the paper from the Alliance in Section 7 on the UN agencies.
You talk specifically about UNICEF, but then generalise it out
to talk about UN agencies more generally, and you praise their
co-ordination role but express a degree of scepticism about their
effectiveness at the operational level. I just wondered if you
could say a little bit more about that and the evidence you have
that they are not really operating effectively at the operational
level and whether you would draw the conclusion from that, which
does seem to be a logical conclusion, that the British Government,
for example, should be focusing more on their co-ordination role
and rather less on their operational role and spending what funds
they have got available on the more effective operational role
of other organisations, which we will come on to later I think?
I would be interested in your comments on that.
Dr Bermejo: We would certainly agree with that
conclusion and that is what we were driving towards in the paper.
We believe that, as an intergovernmental body on which the governments
sit, they have a key role that cannot be substituted around co-ordination
as well as setting norms and policy guidance on what best practice
is and the standards that should be met. In that sense we believe
that, if they did not exist, they would need to be invented now,
so we are very much in favour and have seen the benefits of that,
and a lot of the civil society organisations that we work with
look to WHO or UNICEF for guidance on how programming should be
done and for the policy framework in which we operate. I think
where their efficacy is much more questionable—and we have
seen that particularly with UNICEF and that is why they are quoted
here as an example, probably because they are, of all of them,
the most operational on the ground—is that in that role
they are much less efficient, first because their costs are much
higher than many other actors who can implement those things,
and because in the most enlightened cases where UNICEF itself
realises that, they hire other organisations to do that implementation
and the Alliance is sub-contracted in many countries to implement
some of the UNICEF programmes at country level. But then you realise
that, of course, the UK Government's money is going to UNICEF
to then contract the Alliance to then implement a sort of loans
programme in Mozambique and that is not a cost effective way of
doing business. None of these UN bodies is cheap, so we think
there need to be better mechanisms through which to do that. There
is also an issue that operations that are run by the UN agencies
at country level do not really leave lasting capacity behind in
the same way as operations that are run by local government or
local civil societies do. There are those two reasons, one from
a short-term cost effectiveness point of view and the other one
from a longer term sustainability point of view, leaving an enhanced
capacity behind. Needless to say, we believe that in the UN reform
process these operational interventions should not be where the
UN sees its niche is.
Q447 Lord Jay of Ewelme:
So your model would be that the British Government, or indeed
other aid donors, should give the money directly to the people
who are more effective at the operational level and then it would
be for them to carry it out or for them to work on behalf of UNICEF,
as it were, without the money having gone down through UNICEF
to start with?
Dr Bermejo: Yes.
Q448 Lord Jay of Ewelme:
You said earlier on that, if WHO and UNICEF did not exist, they
would need to be invented. I do not want you to get into UN reform
again, but I presume that you would not say that they had to be
invented exactly as they are now?
Dr Bermejo: No.
Q449 Lord Desai:
You know we have this purchaser/provider distinction in national
health elsewhere. Are you suggesting that those who purchase the
health should not provide it, that the UN is very good at purchasing
but not at providing it, and we should just bypass them and hire
anybody who is good at providing it?
Dr Bermejo: I think we should hire whoever can
do the job better, and better not just from a short-term perspective
but also from the long-term perspective of building capacity on
the ground and leaving it behind. I would not say as a matter
of dogma that they need to be separated. I would just say let
us purchase from the most effective providers, and I would say
that domestically here as well as internationally.
Q450 Lord Desai:
Is that what the Gates people do?
Dr Bermejo: I know Gates very well, but that
is another big story. I do not think they really do that, no.
Q451 Chairman:
It is a very good story.
Dr Bermejo: I do not think they really do that.
They are still setting up their systems. They are a pretty new
organisation.
Chairman: Can I move on fairly logically
from that to the effectiveness of some of the intergovernmental
organisations?
Q452 Baroness Whitaker:
Staying with the long-term success, the Alliance says that the
performance of the Global Fund is impressive, and I think I agree
with you. But do you think it has made the machinery to continue
after the Global Fund has departed? Is it sustainable, do you
say?
Dr Bermejo: Yes.
Q453 Baroness Whitaker:
As part of that, you also say, I think, that effective prevention
of the epidemic will be impossible as long as the human rights
abuses go unaddressed. Is the Global Fund capable of leaving behind
it that kind of organisation too?
Dr Bermejo: I think with the Global Fund one
needs to understand the principles on which it is set up and two
key principles in response to this are important.
The Committee suspended from 4.10 pm to 4.21
pm for a division in the House
Q454 Chairman:
Can we resume, please? Hopefully you have had a little more time
to consider your answer to Baroness Whitaker, Dr Bermejo, so perhaps
you would continue from where you were interrupted. My apologies!
Dr Bermejo: Thank you, my Lord Chairman. There
are two principles that are important for the Global Fund. One
is the principle of additionality, and it was from the very beginning
understood by the donor community and everybody who set up the
Global Fund that their resources should be additional to what
the country was spending on HIV and to what donors were already
providing on HIV. The second important thing, and it had a number
of conceptual changes in the way we looked at aid in the Global
Fund, was the whole issue of pitching sustainability not at country
level but at the international response level. The Global Fund
is built on the idea that the response has to be sustainable but
sustainable not just from a country perspective but from the international
community perspective. It is not based on the principle that it
will only fund interventions that the country can then continue
funding on its own. Some of them were very clear. Some of these
operations will need input for many years to come, for a generation
at least, and inasmuch as the countries that are still operating
on ten dollars per person per year investment for health are concerned
these responses are not sustainable just with the country resources.
It is based on the principle that we will as donors continue funding
the Fund for many years to come, and that is the basis on which
the Global Fund was created. I think that, when we discuss sustainability,
we need to look at it in that context. Many of the responses around
HIV treatment in particular will not be sustainable if the Global
Fund were to withdraw tomorrow or in two or three years' time
or when a particular grant comes to an end, so they are looking
at even changing the procedure so that it becomes, rather than
a round-by-round project approach, more of a credit line type
of approach, that as long as the country is performing it will
continue to receive that credit. It is important to understand
that in the way it is operated and it has in a way changed the
perspective with which we see international health and the joint
responsibility that in a globalised world we have. That is particularly
true for TB and less so for malaria. Malaria interventions are
probably more sustainable in the traditional sense because they
are short-term and because we will see, very quickly I hope, a
reduction in transmission. So in that sense, although not going
as far as the Gates Foundation have said, which is malaria eradication
and which I do not believe will happen shortly, we will get close
to that so the interventions will be more sustainable. On TB it
is the same thing. We need to understand, and others will talk
about it more later, that we cannot control TB, within our own
boundaries. If we want to control TB we need to look at investing
abroad and the Global Fund is a good mechanism for it.
Q455 Baroness Whitaker:
So you say it could be internationally sustainable?
Dr Bermejo: Yes.
Q456 Baroness Whitaker:
I was also thinking, in connection with the human rights aspects,
of the participative nature of the Global Fund, that maybe that
could, as it were, embed an idea of human rights protection?
Dr Bermejo: Yes. I am sorry; I did not comment
on that. That is another key issue of the Global Fund, the way
in which it has defined participation and national ownership beyond
national governments to include civil society in that governance
of the board at the international level but also at the national
level of programme oversight, and that in particular the most
affected groups are represented in the committees at national
level and that design proposals oversee implementation, et cetera.
If one looks at the proportion that the Global Fund is contributing
to national responses, it is about a third of the HIV response
and higher than that of the TB response. If one looks at the resources
that are reaching the most vulnerable groups, the proportion is
much higher. The Global Fund is a key provider of support to communities
which are highly vulnerable, whether they are sex workers, men
who have sex with men, drug users or prisoners. For many of these
groups the Global Fund is one of the very few that are actually
getting the resources to that level and they are key to the solution
to the epidemic. The Global Fund's programmes go beyond just health
interventions to address some of the human rights issues that
are causing the vulnerability of these groups to HIV.
Baroness Whitaker: That is very helpful.
Q457 Lord Hannay of Chiswick:
You spoke as if the statement that the Global Fund's funds were
going to be additional was enough in itself. But additionality
is a remarkably slippery concept, as anyone who has had to deal
with it will have found, and the further out you get the more
slippery it becomes. What criteria would you apply in judging
this? And to what extent can you be sure that this is additional
not just with respect to existing programmes for AIDS or TB but
also with regard to primary healthcare and so on? Can we be quite
sure that the Global Fund is not sucking money away from assistance
for primary healthcare in developing countries?
Dr Bermejo: That is a very good question and,
as you say, it is a difficult one to be sure about. I think we
can be sure of several things with Global Fund support. One that
is very important is that it is not subject to the same ceilings
and limitations as the IMF and other intergovernmental organisations
apply to direct budget support to sector-wide schemes because
they are seen as a project-specific grants. In that sense it does
not get capped and then put into the pot of money that budget
support does. Whether it really is all additional, from a donor
perspective or from a recipient country perspective, is hard to
measure but I think we know enough to know that it is not all
additional, even though that is one of its principles. We have
seen many donors—for example, the EU in Ukraine has made
a public statement saying it is not going to continue funding
HIV/AIDS intervention because it already supports the Global Fund.
Clearly there the principle of additionality from a donor perspective
is not operating. We have seen elements of what you say also at
country level, though I still think the more general reaction
that we have seen is the opposite one, which is governments saying,
"The money we were already putting into HIV/AIDS from our
own budget we are no longer going to put in because there is the
Global Fund money and we are going to use it for primary healthcare
or for something else", which is also worrying because it
reduces the political commitment from the national level to the
issue and that sort of substitution, and it also undermines the
additionality.
Q458 Baroness Whitaker:
I think you also say that DFID's money seems to be better spent
with the Global Fund than in some of the other intergovernmental
agencies. We have seen a National Audit Office report highlighting
weaknesses in DFID's management of international institutions.
I wondered if you had any views on the two institutions DFID made
to ameliorate this, that is, the Multilateral Effectiveness Framework
and the Multilateral Development Effectiveness Summaries. Do you
think this is important in DFID's investment strategy, as it were?
Dr Bermejo: On this one I have to confess that
I personally had no idea what these two were, even though we do
work closely with DFID, and I did ask around the office and none
of us knew. We did call a couple of colleagues at DFID saying,
"What is this, because we might get a question on it?",
and again they could not answer, so they might be very important
and useful but we are just not aware of them.
Q459 Baroness Whitaker:
They are not very old organisations; they are only a few months
old. They will be reported on later but they are meant to bring
all these different facets together.
Dr Bermejo: But we are concerned, which is what
I think the statement was saying, that we think DFID has not valued
this enough. In particular, its last contribution to the Global
Fund was below expectations and below what we thought we said
we had seen committed in the past. When one contrasts that with
the huge increase that the World Bank has got from DFID it is
hard to understand the logic of that, and certainly from the perspective
of the control of infectious diseases it does not make any sense.
It might make it from others but from that one it does not.
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