Examination of Witnesses (Questions 640
- 659)
MONDAY 21 APRIL 2008
Ms Diane Stewart and Dr Stefano Lazarri
Q640 Lord Jay of Ewelme:
Since we are all declaring an interest, perhaps I should declare
an interest as the Chairman of the Trustees of the British medical
charity Merlin, which does indeed work with the Global Fund in
a number of countries. I just wanted to go back for a moment to
this question, because I think it is a really interesting one,
of the funding for project preparation. We seem to be in a situation
in which we all recognise that there is a real need here and,
indeed, the success of all the various actors in this rather complicated
scene depends on there being properly prepared proposals and projects.
Yet we do not seem to have a mechanism, as I understand it, for
ensuring there are funds available for preparing the projects.
You say there is a conflict of interest for the Global Fund and
WHO are not quite clear whether it would be right or they should
be able to do it. Let me ask you: who do you think should be doing
this? Is it something for the World Bank? Should Gates be doing
it? Should bilateral donors be doing it? Is it something DFID
and others should be spending more money on ensuring that the
projects are prepared for others to finance? If there is more
and more money available for really well-prepared projects but
there are not the projects that have been properly prepared, it
is actually quite a gap in the system?
Dr Lazarri: External technical assistance is
only one element in the development of a sound proposal. What
is even more important than that is the function of the Country
Coordinating Mechanism, the participation of all partners in the
development of the proposal. There are already quite a number
of technical advisers in countries through WHO, through bilaterals,
universities, that can participate in this. In my view, the most
critical element for the development of a sound proposal is the
country's consultative process and the way they analyse the problem
and can express it.
Q641 Lord Jay of Ewelme:
What you are saying is that, if the Country Coordinating Mechanism
works well, then it will have within it what is needed to prepare
a project?
Dr Lazarri: Most of the expertise that is needed.
However, the Global Fund has a number of specific requirements
that require an understanding of the Global Fund mechanisms, their
monitoring and evaluation, the performance-based funding, which
might not be present in the country, and they might need some
technical assistance in this respect as they might need some technical
assistance in the actual writing of the proposal. There are skills
involved in translating the needs assessment into a well-articulated
proposal and sometimes language problems, because all the proposals
are assessed in English. These are all elements that a technical
adviser can facilitate. We would not wish to see the opposite,
having technical advisers going to countries with ready-made proposals
in their pockets. That would look good on paper but become terrible
in implementation because they would not take into consideration
the needs, the resources, or the complexity of the country. It
is mixing the two that works best.
Ms Stewart: If I may come in on that issue.
There are two things that we are trying to do on that. One is
that in the future we are trying to move towards the approval
of national strategies for funding, so countries will be able
to develop their national strategy, say which piece of it they
do not have funds for, what is the gap, and submit that to the
Global Fund for funding. You know a lot more about that than me,
Stefano. Essentially, in a way that completely circumvents the
need to develop a large proposal because that national strategy
would be it. Whether you have the capacity to develop your national
strategy is a different question. Essentially all countries should
be doing that anyway. We are in an interesting discussion about
how you would validate those strategies and so on, but essentially
that is the idea. Secondly, we have also started funding what
we are calling community assistance strengthening, which is a
way of pre-funding because you are going to strengthen civil society,
you are going to strengthen those actors that do not have the
capacity currently to play at the national level to be able to
accept funds, to understand what it is that they mean, and that
is really important especially for marginalised groups and people
who need to access funding for specific things and cannot. We
are trying to address that.
Dr Lazarri: We are also funding Country Coordinating
Mechanism functioning to a certain limit. The CCM can request
the Secretariat to provide resources for their own functioning,
so that we facilitate this dialogue and collaboration that is
required at country level. In some ways we are trying to address
that.
Q642 Lord Jay of Ewelme:
Thank you very much for that. I am sorry to have gone back to
that point but I thought it was an important one. Just to move
on for a moment to drugs and vaccines. In a sense, this is another
of the barriers that we have been looking at, and you say in your
evidence, for which many thanks, that there is "inadequate
financing of research and development for new diagnostics, drugs
and vaccines", and that "simpler, cheaper and more effective
tools, including simple rapid diagnostics and vaccines, could
greatly facilitate access", which indeed is a conclusion
we have come to ourselves. Here again, whose job would you see
it as being to try to take this forward? I might just say on vaccines
that it is not just a question of getting the cheap vaccines and
so on but also ensuring the delivery mechanisms, that they are
delivered in the right kind of condition and are cold when they
need to be cold, even when they have been taking them 12 miles
down a rural lane.
Ms Stewart: On a bicycle!
Q643 Lord Jay of Ewelme:
Yes, on the back of a bicycle, exactly, which I have seen. I would
be interested in your comments on that.
Dr Lazarri: There are only two limitations really,
two items that the Global Fund will not support in principle.
These are large infrastructure projects, large hospitals, large
schools of medicine, because we think this is for other agencies
to take care of, and the basic research and development of new
tools, vaccines and drugs. However, when it comes to operational
research, looking at how best they can be deployed and we can
increase coverage, scale up access in specific situations, that
is something the Fund would definitely consider and, in fact,
I think the TRP has commented several times that—
Q644 Lord Jay of Ewelme:
Sorry, the what?
Dr Lazarri: The Technical Review Panel. It has
commented several times that the proposals are not coming forward
sufficiently with operational research requests that they think
appropriate, so you study the best way to do it in your situation
before you launch a major effort. The Fund cannot do everything
and there are definitely other international institutions that
do finance basic research. What the Fund does do is create markets
for drugs, for diagnostics, for vaccines, where markets did not
exist before, because people did not have the capacity to buy.
The Fund can be a pull factor in saying, "If you develop
a vaccine for Malaria, we would definitely be interested in making
sure this is purchased and distributed". We can create that
market. A lot of the incentive in private research has not been
in tropical diseases or diseases of the poor because the market
forces were not there and there was no specific interest. That
can be created. At least for AIDS the research has not been neglected,
there has been quite a bit of support. It is more on TB and Malaria
where it is picking up just now. There are several global initiatives
now that are trying to address drugs, diagnostics and vaccines
for TB and Malaria. In a sense, that is a result of the renewed
interest and availability of funds around those diseases. It is
being addressed indirectly but the Fund does not have that mandate.
Ms Stewart: Maybe just an example, the Artemisinum
experience was very interesting in terms of going from a sort
of very elite drug, if I might say that, something very small
and available to only a few to suddenly being a mass production
product, and that was entirely because the Global Fund had the
money to buy it. We were right there at the beginning of it and
manufacturers were in discussions with us saying, "If we
produce, will you help" and there was an agreement between
countries, WHO and so on that, yes, this was a drug that was useful,
could be recommended, could be produced, et cetera, and the money
was there. That is a good example of how, if something new becomes
available, we can make it available very, very quickly compared
to how it would have happened historically.
Dr Lazarri: It is in some way an advance market
commitment that we can make because the Fund has resources, at
least around these three diseases.
Q645 Lord Jay of Ewelme:
Just one final partly related question which is about drug resistance.
You say in your evidence that: "global schemes for resistance
monitoring are limited and data are patchy". There again,
I wondered—is that something that you would see as something
for you to do either yourselves or encourage the recipient countries,
developing countries, perhaps with the CCM mechanisms, to ensure
they are monitoring drug resistance? How would you see that filling
that gap?
Dr Lazarri: Now I have to declare another conflict
of interest because I have been heading the WHO Antimicrobial
Resistance Programme for a year and a half.
Q646 Lord Jay of Ewelme:
We should have had you at our session this morning!
Dr Lazarri: I think that, from the very beginning,
the Fund has addressed the issue of resistance. For all three
diseases this is a major issue, but even beyond those diseases
it is a broader issue. We are encouraging countries to put money
both in the surveillance and monitoring of resistance and in containment
strategies. Again, I do not think it is accessed as much as it
could be, and this might be because of some of the technical complexity
of doing it and maybe weaknesses of our technical partners sometimes
in making this a priority for countries and convincing countries
technically that this is important. There is definitely a benefit
in setting up regional and global networks that collect it. There
is definitely a need to have supranational laboratories that can
perform drug resistance testing that is of such complexity that
it is difficult to see every single country having its own capacity.
The Fund has some limitations in its structure in supporting supranational
activities. We can and do support regional initiatives coming
together across borders on this sort of issue. The only real way
of doing that is if the countries agree to include resources in
their own grants and then pull it together, but this requires
a certain level of negotiation and I do not think we have seen
that yet. There is a gap there. In our response we have tried
to highlight where there is a gap. When it comes to country activity
on resistance, the Fund can and is happy to support more, but
when it comes to a supranational or global level then there are
other mechanisms and they should probably look at alternative
sources of funding and negotiating and networking is required.
I will stop there otherwise I will get—
Chairman: Into trouble.
Q647 Baroness Whitaker:
On that gap, say one of the members of WHO recognised that gap
and thought it was in their national interest to try and do something
about it, what would be the most helpful pressure they could bring
to bear—as national ambassador, minister or whoever?
Dr Lazarri: WHO is a technical advisory agency
at country level, so the pressure comes from the WHO representative,
from opportunities they have to influence decisions at country
level on what are the priorities. There are at least two ways
of doing that, there may be more. One is to have a global movement
that is approved by the World Health Assembly and becomes a global
priority and everybody is committed to participate in that. To
my surprise, antimicrobial resistance is not a global priority
yet, because I think it should be.
Q648 Chairman:
Could it be led by some of the science-based hospitals around
the world? Or is that not a role for them?
Dr Lazarri: One of the issues is that it is
seen as a clinical problem and not as much of a public health
problem as it should be, so it is dealt with as an individual
problem in a hospital or for a specific disease.
Q649 Chairman:
It is the link between science and medicine that you are looking
for, is it not?
Dr Lazarri: Yes.
Q650 Lord Avebury:
It is not on the agenda for the World Health Assembly?
Dr Lazarri: It has been on the agenda and there
have been resolutions at the World Health Assembly but backed
by global movement, as I think it should be. That is my personal
opinion.
Q651 Baroness Whitaker:
First, it should be reclassified perhaps as a public health issue
so that it comes out of the laboratory and into the political
arena?
Dr Lazarri: It is one of the issues, absolutely.
The other one is to demonstrate that it is a real problem for
the country and there you need to have a good surveillance system
in place. You have to have evidence and data which show this is
what is happening, because if you do not know you cannot address
the problem. That is the weakness of the drug resistance surveillance
systems in-country. We have evidence, especially from northern
Europe, that if you realise there is a problem and you intervene
you can contain the problem and achieve results. Yes, there is
a lot that WHO and other technical agencies could and should do
on this. We do encourage it. We cannot require but we do recommend
and encourage countries to address different problems that might
arise.
Q652 Baroness Whitaker:
Still with the Country Coordinating Mechanisms: this is a technical
point in a way. Many countries, for instance Tanzania, say that
they have got so many donors, so many accountability mechanisms
for monitoring, that they have hardly got time to govern their
country. How do the CCMs manage not to add to this or avoid it?
Is there some special way in which they need to interface with
other donors in their country?
Ms Stewart: We have been working very hard on
this. Firstly, the idea of the Country Coordinating Mechanism
is exactly to try and reduce some of the overlap of different
requests and so on. Because our proposals are supposed to be country-owned
it is not something that we impose on a country. It is not like
getting bilateral funds from another donor where that donor says,
"These are the five things I am going to fund" and so
on, it is very much owned and governed by that country. Depending,
of course, on the strength and political leadership within that
country is the extent to which that is easier or more difficult.
In countries where there are a lot of donors and minimum national
capacity, of course, it gets more and more challenging. The idea
is that the Country Coordinating Mechanism brings together many,
if not most, if not all of those players and, certainly in countries
like Mozambique, Malawi, Tanzania and Zambia, where there are
a lot of donors, most of them are on those Coordinating Committees.
The idea is that they manage Global Fund money, yes, but also
see how all these other funds are complementing that. For example,
in many of the countries where we work with PEPFAR, it is worked
out at the CCM, "PEPFAR will do this, the Global Fund will
do this, the government will do this and civil society will do
that," and they try and coordinate at that level. From our
perspective, we have been trying very hard through working very
closely with the implementation of the Paris Declaration to harmonise
and align our processes with national processes as much as possible.
I would not say we have got as far as we would like to be. For
example, the very process we have been talking about a lot, which
is the rounds-based process, is somewhat arbitrary; it does not
fit in at all with the national planning cycle, et cetera, but
we are trying to get closer and closer to meeting with that national
cycle. We also try as much as possible to involve those other
donors in those conversations in the country so they can try and
fit their funding profiles into a supportive environment. We have
participated in SWAps, for example, in a number of countries if
that is what the country wants to do.
Q653 Baroness Whitaker:
SWAps?
Ms Stewart: It is a Sector-Wide Approach, where
everybody pools their funding. In Mozambique, for example, all
the donors pool their funding to do a specific number of things.
Because we have a performance-based funding approach that we do
not compromise on, the Mozambique negotiation was quite difficult,
because we needed to get the agreement of all the donors that
we would produce X, Y and Z results with the money when it went
in. It was quite difficult to set up, but many of those donors
are now delighted because they are getting much more concrete
results out of that SWAp for their own reporting; and from the
perspective of the Minister of Health, he was very pleased because
it was one conversation with one group of donors. I would not
say we have had that amount of success everywhere, it depends
very much on the country. I know the Rwandan situation reasonably
well and the Rwandan Government is just very, very firm, shall
we say, with the donors and says, "You will do this, you
will do that and, sorry, if you want to do that you are not doing
it because that is not part of our national plan and our national
strategy". Unfortunately, that is not really possible in
all countries.
Q654 Chairman:
Could I just pursue that for a little bit. Is it your view that
there are not necessarily too many organisations involved in the
field, it is just a matter of coordination? Or are there too many
organisations and would some rationalisation help, or make it
easier?
Ms Stewart: I think in the best case scenarios
there are not too many and everybody is working in complementarity.
We have identified a number of things here today where Global
Fund funding does not cover X and does not cover Y. If you are
talking about just from our perspective, we are putting a lot
of money in-country but we are not there—there is no Global
Fund representative in Lusaka or any other country, we are nowhere.
We very much rely on the people from DFID, the people from Swedish
CIDA, or whoever it is on the ground, to help make our money work.
They are providing a lot of technical assistance to make that
money work in many cases or they are providing parallel funding
for maternal health, things that are complementary. Coordination
is an easy thing to say and a hard thing to do, it is not that
simple. We have tried to contribute to that by also saying that
our CCM does not need to be some sort of special Global Fund body
that sits in a corner, it could and should do other things.
Q655 Baroness Whitaker:
What happens when the CCM's, or the Fund's perception of priorities
differs from the host country's perception? For Uganda, say, in
their AIDS strategy, they have decided that abstinence is the
big thing and condoms has really dropped off the bottom of the
list, for all sorts of reasons. Presumably that might not be the
view of the Global Fund. How do you manage in that kind of situation?
Ms Stewart: In some ways this is the beauty
of our independent Technical Review Panel because they are a group
of recognised international experts and they would make the call
on whether the Ugandan programme was appropriate across the board
for a response to a disease. Perhaps all we would be asked to
fund is an abstinence programme but then they would look at the
totality of that programme and make sure that that programme is
holistic and balanced. That is a big and complex programme but
for other programmes, for example on some small island states
that I am familiar with, where they have come in with HIV programming
that has not addressed at all the issue of sexual minorities,
marginal groups and IDUs, where it is a small concentrated epidemic
driven exactly by those behaviours and those groups, the Technical
Review Panel has said, "Sorry, this is not going to address
your epidemic. You have not taken the appropriate action".
Q656 Baroness Whitaker:
So they do not get the money?
Ms Stewart: So they do not get the money. If
Uganda came in with a programme that the Technical Review Panel
thought was skewed entirely to interventions that were not going
to address their epidemic, it would not be considered technically
sound.
Dr Lazarri: One of the things they look at is
the balance of the intervention, the balance between prevention
and treatment, balance of different kinds of intervention that
together make up a technically sound programme.
Q657 Baroness Whitaker:
So what happened with Uganda, because I thought that was the case,
they had dropped condoms off their list of solutions?
Ms Stewart: I do not think for what we are funding.
Dr Lazarri: As far as I know, no. Going back
to your question on many donors and many coordinating mechanisms,
the national strategy application that Diane referred to is meant
to address that problem. In fact, the Board called for this possibility,
but as a possibility to share it with the other Partners. We would
like to have a system whereby, once a national strategy is developed
and validated as being technically sound and correct, then all
Partners would agree to finance as it is, and that is the coordinating
tool. A coordinating tool around which everybody can work is a
sound, strong national strategy with a government that can enforce
the rules. In some countries it works, and works quite well, and
most of the Partners go by the rules, but in other countries it
does not. We are trying to go in a direction where this coordination
becomes stronger, but it is based on national institutions and
a national strategic plan, it is not plans, strategies or mechanisms
imposed from outside.
Q658 Baroness Whitaker:
One of your great strengths is obviously your performance-based
granting. I just want to check the elements of performance. To
what extent they are outcomes. They are, presumably, things which
will happen in the future as well as pre-conditions they have
now. Would they be related to prevalence of the disease? Or is
it things like the number of personnel in place and the delivery
mechanisms? What I am trying to get at is how you can tell that
it is actually the person not getting ill which is the end outcome,
not all the machinery to create that?
Dr Lazarri: There are different levels of performance
that we monitor. There is a level which is specific to the grant,
and it helps us monitor the performance and the achievement of
the grant and is linked to disbursements. So, if certain targets
or milestones are not reached, then the disbursement can be questioned
and the amount of money can also be reduced. It is the internal
mechanism in monitoring the performance of the grant. Then you
can monitor the achievement of the grant, and these are the outcomes
that were set out in the proposal that you want to achieve at
the end of five years, the coverage of interventions, the number
of people under treatment, whatever that is. That is set by the
countries and agreed by the TRP and agreed at the moment of grant
negotiation.
Q659 Baroness Whitaker:
Is prevalence among them?
Dr Lazarri: Yes. Then you have the true outcome
indicators.
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