Examination of Witnesses (Questions 740
- 752)
TUESDAY 22 APRIL 2008
Dr Haileyesus Getahun, Ms Diana Weil and Ms Louise
Baker
Q740 Baroness Whitaker:
Are you and all of your staff employees? Will you return to some
other job in WHO eventually?
Ms Baker: I hope so.
Q741 Baroness Whitaker:
Could you?
Ms Baker: Yes, absolutely.
Q742 Baroness Whitaker:
What about the International Health Partnerships, how do you fit
in with all of that?
Ms Baker: International Health Partnerships,
the other partnerships?
Q743 Baroness Whitaker:
Yes. You call yourselves one of them?
Ms Baker: Yes, we consider ourselves to be an
International Health Partnership.
Q744 Baroness Whitaker:
How do you liaise with the others, because there are things which
affect TB like migration, transport?
Ms Baker: Absolutely. We have a Partnerships
Officer who is responsible for outreach to those kinds of International
Health Partnerships and developing those relationships.
Q745 Baroness Whitaker:
Sit on their committees?
Ms Baker: Yes. In fact, we are developing a
Memorandum of Understanding with the Global Health Workforce Alliance
and with the Health Metrics Network as two other International
Health Partnerships. We have a Memorandum of Understanding with
the Global Fund. We work very closely with the Roll-Back Malaria
Partnership and would represent each other even, if required,
on various boards. If one partnership was not able to be there,
then we would speak for each other, for example at the Global
Fund.
Q746 Baroness Whitaker:
For instance, might it be that a programme that you are anxious
to have promulgated would set up an infrastructure which would
also deal with Malaria, I do not know, training local workers?
Does that happen?
Ms Weil: For example, all the discussion around
Malaria right now, the provision of Artemisium—based therapy,
is a big challenge because it needs to be much more widespread
delivery through public and private channels than TB drugs. The
TB Global Drug Facility was established back in 2001, and a lot
of similar questions arose with the development of that Drug Facility.
So there is a lot of learning from that experience, not that they
are going to adapt it completely but using that. For example,
UNITAID, the mechanism for providing financing for supplies, is
supporting various of these partnerships working with the Global
Fund, working with the Global Drug Facility, working with the
Malaria community and AIDS community. There is a lot of cross-referencing.
Many of us are housed in the same offices, so we see each other.
Bilateral initiatives, like the US PEPFAR initiative, initially
started in a very unilateral separate way, but Dr Getahun and
colleagues have worked extensively, even though that is far from
partnership, and it is beginning to broaden out in terms of its
interactions and working very much on national plans with the
working group on TB-HIV in the partnership which Dr Getahun coordinates.
Q747 Baroness Whitaker:
Would you say that this very developed networking actually contributes
to infrastructure development at quite low levels in countries?
Can you see what we would call a sort of audit trail?
Ms Baker: The one I would highlight at some
point going forward is the Global Drug Facility is one aspect
of suppliers to countries and the development of drug management
capacity in countries, but our technical assistance is provided
by technical partners, WHO being the lead but then other technical
partners coordinated, which obviously helps as well. The new initiative
that is being developed at the moment by the Partnership is the
Global Laboratory Initiative, which may be coming back to the
idea of health system strengthening. In TB we certainly recognise
that we deliver TB programmes better when there is a good health
system, when you can diagnose people properly and treat them at
the most basic local level working so we are now collaborating
on developing a good network of laboratories and basic laboratory
kits so that people can do diagnosis at the lowest possible level.
Chairman: There is a wider issue
of health architecture here on which I would like to bring Lord
Desai in.
Q748 Lord Desai:
One of the things we have been told in our evidence by the British
Government is that the architecture of international health intervention
is "crowded and poorly coordinated". We have been exploring
this. We would like to have your views on this. Do you think there
is scope for rationalisation, for a merging of people?
Ms Weil: Compared to maybe three years ago there
has been a lot more coalescing around this quandary of how we
deal with this proliferation of partnerships and the issues around
harmonisation, the concerns of governments and dealing with this
flood of new money but also the imbalances in their use. I attended
a meeting that the GAVI Alliance organised on their health system
strengthening investments, and they invited all the major donors,
all the major partnerships, those of us from WHO involved in health
system strengthening issues and disease control. One of the things
that came out of the meeting was that somebody said that the international
health architecture, they meant to say is changing every year
but they said every day—and, in fact, everybody laughed
because it is changing every day. How do you deal with
that? The question is that there are more networks now of people
communicating at the global and regional levels than there were
before across diseases which is relevant. At the national level
there is much more focus on common responses, like on the human
resources front—we have not solved civil service reform
but at least people are investing again in community health workers,
so if they are going to invest in community health workers they
are certainly not going to be TB-specific. Some of them may be
HIV-specific right now, but that is not the ultimate aim. How
do you ensure that you can give the capacity to a community health
worker that is not going to overwhelm them but they could actually
do work on Malaria, TB and HIV, immunisations and maternal health
all at once. That is a tall order. We have a long way to go because,
while people say they want to combine efforts, some independent
donors and governments still are funding in a very directed route
because of their rules and regulations, and that is necessary
to feed the results back to their governments and parliaments.
We want to produce consolidated reports, only one report per disease,
but in fact we have multiple responsibilities to multiple donors.
So how do we ensure, for example, that reporting requirements
and financial requirements might be streamlined a bit more because
that is really what takes up a lot of people's time.
Dr Getahun: Having many stakeholders is good
for resource mobilisation and giving attention to those diseases,
but an important line should be to work under the national government,
under the national plan. For example, UNAIDS for HIV is promoting
this Three Ones policy: one monitoring and evaluation system,
one coordinating body and one national plan. The comparative advantage
of WHO to make sure all the stakeholders and partners are coordinated
is really high, because our comparative advantage is to work with
ministries of health and governments to make sure that their plans
are coordinated and responsive to their needs. Our comparative
advantage is also high from that aspect.
Ms Weil: One more technical point to raise is
that, as Dr Getahun says, in the global plan, for example, we
did costings on what we believe it is going to cost to reach the
MDGs, and WHO monitors through data received from national governments
every year how much they are receiving. The next step is to say
the Global Fund has relied on project proposals over the last
few years and now they are moving to the notion—they are
having their Board meeting in a couple of weeks, they are still
discussing this—to fund disease control strategies and national
health plans. So you do not have to do a project every time, but
you give your partial support to a national plan. The Partnership's
help is to ensure that we can come up with costed medium-term
plans for TB that can get slotted into a national health plan
following the same criteria that other people are using for costing.
We are doing that right now with about 35 African countries to
help them be sure we have fully-costed five to eight year plans
that can go into a national health plan along with immunisation
and child health, et cetera.
Q749 Lord Desai:
Is the problem that the way governments give money makes things
complicated because the donor governments themselves have confused
architecture, ie they give money separately for separate diseases,
they want separate accounting, they do not believe in pulling
everything together? If the governments were more sensible and
just gave a large dollop of money, would that make life easier?
Ms Baker: It comes back to your health system
strengthening. I may be being politically incorrect here but,
if I make a parallel to a country I know best, we would look at
a national health service and say absolutely we want a functioning
national health service, but there are political pressures on
governments of whatever shade in any country to provide specialist
cancer treatment that is perhaps above and beyond what the basic
national health service provision is. Yes, there is a crowded
and uncoordinated even, perhaps, global health architecture but
that is about saying the national health service, the basic health
services in countries, need funding. So they do need that pool
of funding into a national health service but, in order to deliver
the results that donor governments and national governments—whether
they are in endemic countries or in donor-rich countries—want
to see, you also need a coordinated effort and attack on the real
health issues in the country, the real killer diseases in the
country.
Ms Weil: Our biggest concern right now is that
the other extreme would be to fund just a national health plan,
but most governments do not have very specific national health
plans. If you funded in many countries now a basic four-page or
30-page national health plan, what you could be funding is just
the old practice of over-funding of hospitals, not enough financing
of primary care, not clear deliverables. So it is somewhere in-between
producing results and also helping strengthening national health
plans, so that they get more specific and it is clear what their
strategy is for creating a better health service as opposed to
just funding the status quo.
Ms Baker: I think the Partnership contributes
to that. The idea, and I think we are succeeding relatively well,
is that in each country we are able to speak with a common voice
and contribute to that discussion and debate.
Dr Getahun: In my personal view I do not think
there will a one-size-fits-all approach, especially for the donor
governments, because it depends on the local context and the local
governments. One thing that has to be emphasised is that these
are specific programmes that are important for those underprivileged
communities, particularly in Africa if you take HIV, TB and Malaria.
Caution has to be exercised to make sure that things are not dismantled
or whatever. That is why I say there is no one-size-fits-all answer.
Q750 Lord Avebury:
We have talked a little bit already about MDR and XDR drug resistance.
I must say the figures you give in your pack are pretty alarming—for
example, that there is half a billion shortage of funding and
only six countries in Africa have got any ability to provide data
on MDR-TB. That is one of the reasons why the map which indicates
where XDR-TB has been confirmed concentrates heavily on the developed
countries. It is not because that is where XDR-TB is occurring,
it is simply because it is detected there. I wonder if you can
tell us what your Partnership is doing to address these enormous
gaps between the actuality of MDR and XDR-TB on the ground and
what the donor governments and funding agencies are doing about
it.
Ms Baker: There is a working group on drug resistance
that brings together all of the Partners who are working in the
field of fighting drug resistance. There is a plan in the Global
Plan to scale up from treating a relatively small number of patients
with drug-resistant TB to a much larger number to hopefully try
and control the growth in the epidemic. The emergence of XDR-TB
at the end of 2006 has reshaped the way that we are looking at
drug-resistance, in that multi-drug resistant TB is horrible,
it is nasty, you are using the drugs we do not use in the first-line
fight against TB because they have horrible side-effects, they
are very old, and they take at least two years of not very pleasant
treatment to cure a multi-drug resistant TB patient. XDR-TB is
even more resistant to those second-line drugs and for very many
patients, particularly if they are HIV-infected, there are few
very places you can go, so the mortality rates are incredibly
high and the experience in South Africa was quite terrifying in
a clustering of cases. We are very much pushing the Three Is,
particularly in terms of dealing with people who are also co-infected
with HIV, so infection control. We are very much encouraging a
scale-up of dealing with drug resistance, the capacity to do diagnostics,
particularly in Africa. We are looking at trying to do more research
to find the tools that enable us to do the diagnosis better and
to be able to treat people better.
Ms Weil: In follow-up to that there are two
things to note. One is that, while we do not have enough laboratory
capacity in Africa—and that is what this Global Laboratory
Initiative is meant to address—we do have quite rapid response
from some sources. It is insufficient but it is a beginning. At
its last Board meeting UNITAID awarded a joint approved proposal
between the Stop TB Partnership's Global Drug Facility, the Global
Laboratory Initiative, whose secretariat is based in WHO, and
FIND, which is an innovative not-for-profit public-private partnership
just across the street largely funded by Gates which is opening
up access to new diagnostics and working on market mechanisms
to reduce the price of those new diagnostics. They have just awarded
$26 million to begin to try to expand laboratory capacity in some
countries. We did receive financing through discussions with Gareth
Thomas when we first learned of the XDR documentation in southern
Africa and how to quickly respond, which did make possible some
of our initial surveillance work and some of the technical assistance
to do assessments in some of those countries. We have had some
response, but certainly insufficient to create the capacity for
an onslaught of the degree that we need. Investment in public
goods, particularly from the UK Government and other bilaterals,
in addition to the financing for the Global Fund, which is really
country-specific, we have global needs around surveillance, innovation,
piloting of new approaches and coordinated technical assistance
that are under-financed. One further thing to say is we do not
expect that the levels of MDR and XDR in most of Africa are going
to be equal to those, for example, in Eastern Europe, so it is
not just a matter of documentation. The rates are higher also
where you have had more access longer to second-line drugs than
first-line drugs. One of the good things—it is not a good
thing from an access perspective—is that we have had less
access to Rifampicin, which is one of our prime drugs, in Africa
than we have in other parts of the world; there is a shorter history,
so the drug resistance levels to begin with in most countries
is lower. Our biggest worry is that, if we do not stop private
sector supply of Rifampicin and many of these other second and
third-line drugs that are uncontrolled and poor quality, and if
we do not institute good normal practices for initial TB control,
then we are going to be in deep trouble five or ten years down
the road. Our biggest worries are countries like southern Africa,
Cote d'Ivoire and Nigeria, where you have very vibrant private
sectors, some disposable cash, more private access. We have seen
this in Asia as well, like in China when there was not much control
and everything was privatised. You can see where the emergence
of drug resistance might be happening. Our best action is to prevent
the misuse of these drugs to begin with.
Q751 Lord Avebury:
This Global Response Plan which is in the pack is June 2007, so
presumably it is well out of date?
Ms Weil: Yes.
Q752 Lord Avebury:
And the developments that you have just been speaking of have
occurred since this was published?
Ms Weil: As Louise said, that was an initial
response for the first two years, and clearly we produced it part-way
through 2007. In essence, we were just trying to show what it
would take in the first couple of years. We have now done the
calculations for how it revises the Global Plan we have sent around
and we are looking to a medium-term strategy and how to address
that. We are clearly behind, it is not a lost cause, and trying
to figure out how we mainstream. One of the things Louise said
was that we cannot have a parallel effort on MDR and XDR that
is wholly out of whack with all the other things we are doing,
so how do we mainstream this. We have just had a meeting of our
XDR taskforce, and the biggest recommendation coming out of that
is how do we mainstream into overall planning for national control
efforts, finding centres of excellence so you can train people
and people recognise how they balance their investments in basic
TB and TB-HIV and MDR, how they do all of that. It is not easy
but we are trying to figure out a way so that it becomes a normalised
approach.
Ms Baker: I think we also need to look particularly
at the Eastern European region for this issue as well. For example,
the UK development budget would deal with less developed countries,
so there is not very much money in the UK's development budget
for Eastern Europe and the former Soviet Union. That is not true
from a European perspective, there is quite a lot of money for
Eastern Europe and the former Soviet Union, but something like
this, a health issue, struggles to get on the agenda. When you
are talking about countries in Eastern Europe and the former Soviet
Union, you are talking about trade, issues of markets talking
to emerging markets and developing infrastructure, and there has
to be a recognition that it is in the common interests of European
Member States to try and tackle something like drug resistance
in Eastern Europe and the former Soviet Union.
Chairman: I fear we are going to have
to conclude it there, but that was very helpful. Thank you very
much indeed, we are very grateful. If you do have any more thoughts
or ideas, or there are things you want to elaborate on, then please
write to the Clerk and send them through. Thank you very much
for your comments—and good luck with your work!
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