Examination of Witnesses (Questions 1100
- 1116)
TUESDAY 20 MAY 2008
Dr Nils Billo
Q1100 Chairman:
Therefore, do you think International Health Partnerships will
help sort this out or not?
Dr Billo: Yes, I think these Partnerships are
very helpful and a lot of things that we used to do completely
independently in the 1990s are now much better co-ordinated, at
least at the global level. The co-ordination at the regional level
with, for instance, the regional Stop TB Partnerships, where the
technical agencies, the governmental agencies, meet with the NGOs
and the funding agencies, has helped a lot. At the local level,
the country level, you have these Country Co-ordinating Mechanisms
which are working quite well. I can give you an example. At the
moment we are preparing a Global Fund application in India on
the NGO side. There were about 20 NGOs that came together, meeting
to see what the needs were and discussing with the government
at the same time how they could fit into the overall Global Fund
application. This co-ordination is being addressed much better
these days but still could be improved.
Q1101 Chairman:
Are you saying the International Health Partnership is crucial
to that? I am not quite sure how much emphasis you are putting
on the importance of it as a co-ordinating mechanism.
Dr Billo: I think it is critical, because otherwise
there will be counterproductive actions if, let us say, an organisation
buys 20 microscopes for a certain area to improve diagnostics
and at the same time some other organisation does the same thing
and all of a sudden the government has bought microscopes with
the Global Funding, that is not co-ordinated and is not healthy.
Q1102 Lord Howarth of Newport:
Can I just follow up on that one before going on? You mentioned
that application procedures for funding can be burdensome, but
presumably well-devised application procedures, while being demanding,
could be helpful in, as it were, steering governments towards
addressing the right questions?
Dr Billo: Yes, certainly. On the other hand,
there are applications which demand the inclusion of certain things
because at the moment the buzzwords need to be used. What happens
very often is that governments hire a professional grant writer
who helps them to write those grants, to use those words, and
the buy-in is sometimes not there.
Q1103 Lord Howarth of Newport:
They do not think at all?
Dr Billo: Again, it is the lack of management,
the lack of knowledge and how to think through what do we need,
so somebody comes from outside and writes an application that
will please the funders and come through. The problem after that
is that the money will be available but the country will have
difficulties in absorbing the money. It comes back to the issue
of management, management skills in all areas, health, accounting,
financing, budgeting, planning, that is not adequate and at national
level not speaking to the sub-national or local levels. That needs
to improved, addressed and funded, because only then will we have
a better buy-in from countries and they will apply for what they
really need rather than things they do not really need, in fact.
Q1104 Lord Howarth of Newport:
Can I come back to a point you made in the discussion about DOTS,
and that is what more precisely your thinking is to prevent the
uncontrolled supply and misuse of drugs for treating TB. The Stop
TB Partnership told us that preventing the uncontrolled supply
and misuse of prime drugs for treating TB, such as Rifampicin,
is the best way of stopping drug-resistant TB. In your view, what
can be done to limit the spread of multi and extremely drug-resistant
TB, particularly in HIV—infected patients?
Dr Billo: At the moment everybody is talking
about XDR and MDR-TB and we need to fund those programmes. That
is important, but it is much more important to fund basic TB control
to avoid these cases. I think what we are doing at the moment
is a mistake, where funding agencies were scared by Mr Speaker
who was travelling through the world and infecting Americans probably,
a big disaster, and now they say, "Let us fund MDR-TB, or
not even MDR but let us fund XDR-TB". It is a panic reaction.
I always say it is important to fund the basic things to prevent
new cases. That needs to be addressed. Unfortunately, we do not
have a standardised approach to treat MDR or XDR-TB, it is a lost
cause in most of the AIDS communities anyway; we do not have that,
it is much more complex, the treatment is much longer, the drugs
are very toxic, so it is a complex issue to treat MDR and XDR-TB.
It needs to be addressed for various reasons, for humanitarian
reasons.
Q1105 Lord Desai:
It is the same thing that it attracts much more public attention
than ordinary TB.
Dr Billo: Obviously. One agency called and said
"Can you do something for XDR-TB" and I said "Yes,
but we need to do something for MDR-TB" and they said "No,
we are not interested in MDR-TB, we are only interested in XDR-TB".
It is this lack of understanding that we need to prevent rather
than treat the most complex cases and XDR-TB, as I said, is hard
to treat.
Q1106 Lord Howarth of Newport:
You have spoken very energetically about the need for burden management,
administrative capacity and infrastructure. Is it your view that
in the balance of priorities and the balance of funding too much
effort by certain intergovernmental organisations is going into
treatment and not enough into detecting, identifying and preventing
TB? If so, how would you get the shift that you might want to
see?
Dr Billo: We need to improve case finding. You
mentioned before the issue of the marginalised, the poor who are
not getting the treatment or inadequate treatment because they
do not get the service, and this needs to be improved. In our
organisation we are trying to get funding especially to address
that issue of how to address the poor. We have good links with
the Liverpool School of Tropical Medicine and Dr Bertie Squire,
who was very interested in that question, and other partners to
address exactly that issue. If we are not able to service the
marginalised, the poor, they will get a few drugs here and there,
pay for it, not get properly treated, and then we may have these
issues of MDR-TB.
Q1107 Lord Howarth of Newport:
It is the vertical-horizontal dilemma again, is it not? While
it is a false distinction in some ways, it does seem that not
enough of the big money is going into the horizontal. Do you have
thoughts as to how to get it there?
Dr Billo: Many development agencies favour the
so-called "basket" funding, and I think DFID is one
of those development agencies that gives money to the government
and the government then decides how they will invest that money
for whatever infrastructure and so on. Unfortunately, in many
instances I would say the money sticks at the top. It maybe goes
one level down but it does not trickle down to where it is really
needed. That is the problem.
Q1108 Lord Howarth of Newport:
Is that to do with inadequate procedures for contractual arrangements
or for auditing? There would be ways, you could imagine, in which
you could improve performance and do more to ensure that the money
is appropriately spent, not just handed over and then not worry
too much about what the end result is.
Dr Billo: Again, there is an issue of how to
plan this, to budget, monitor it, audit it and report it. That
needs to be improved. Also, the development that I have seen over
the last ten years is that development agencies give more flexibility
to countries, they have to decide what they do. Many development
agencies do not attach many strings.
Q1109 Lord Howarth of Newport:
One can see that diplomatically it may be difficult to attach
those strings, but are you aware of examples where this has been
well-handled which could be a model?
Dr Billo: This is not dependent on the money
they receive. Many countries have millions of dollars in the bank
and are not using them, so they are not getting it to where it
should be. One example where I have seen the government has put
a lot of money into infrastructure is in Peru. By doing that,
they have dramatically improved TB. Everybody asked why they have
improved TB, and it is because they have improved the basic health
services, and they invested in the late 1990s in beefing up health
services; they had nurses, drugs, everything there, and had a
reach-out to the community and things started to improve. That
is a model I would see as positive. On the other hand, when the
government changed this collapsed a little bit.
Q1110 Baroness Hooper:
May I come in there. DFID, if we are just talking about the UK's
involvement, removed its person in post from Peru, so that obviously
affected the DFID funding; and similarly in Central America, where
in Nicaragua they had a very good programme, not just health-related
but rather more general, they have removed their field officer
who controlled and managed it. If other countries are doing the
same thing, then that is where things go wrong.
Dr Billo: It is interesting that you mentioned
Nicaragua, which is a country where we have been for many years
and they have an excellent TB programme. The Americans had a huge
problem with TB in the early 1990s and I compared Nicaragua with
New York, which had a big epidemic of TB because they had not
invested in infrastructure, the same issue in New York, and did
not have enough money to co-ordinate TB activities and said "This
will be taken care of by whatever is available". It was a
huge problem. In Nicaragua, with about $300,000 they had an excellent
programme because they had developed centralised services in all
their provinces. In New York, with the same number of cases, approximately
3,000, they had to invest about $50 million to get that back on
track. They did it, but at a huge cost because they had abandoned
the proper financing of the health services. I am not sure if
in the UK you have a similar problem. You have to invest, otherwise
these people who are difficult, very often homeless, alcoholics,
diabetics, immigrants, do not have the facility to go to their
GP, and that special infrastructure needs to be there.
Q1111 Lord Howarth of Newport:
So it is less about the total of funding that you have available
to invest as about intelligent investment and continuity?
Dr Billo: Absolutely. I do not think we have
a huge lack of funding, we have a lack of intelligent investment
of the funding we have.
Q1112 Baroness Falkner of Margravine:
I should declare an interest because I ran an AIDS NGO working
in southern and eastern Africa. To flesh out a little bit what
Lord Howarth was saying, one of the problems we found with DFID's
strategy, or the main agencies, CIDA and so on, of giving money
to the ministry of health was that first, as you said, it stayed
in the capital on the whole and, if you were lucky, it went to
a few regional centres; but the other problem was that you had
very differing results, so in Country X you had a very enlightened
ministry of health, so the NGOs were able to do the work on the
ground in the very poorest rural areas, and in the neighbouring
country you had a different attitude from the ministry of health.
So there was exactly the same source funding from the World Bank,
DFID and CIDA, but it was being used in very different ways and
in one case it would get stuck in a bottleneck and in another
case some enlightened officials would make a decision to trust
you to dispense it. Do you think that the mix between bureaucracy
and the practitioners, the grassroots activists, in these very
poor developing countries where you have a real problem is right?
Or does the money get caught up in the bureaucracy and does not
actually get out to the activists because of the problems of audit?
Are developing countries risk averse in this area?
Dr Billo: The bureaucracy is a big obstacle
to development. You should not mention governments in the first
place, but look at the World Bank. Sometimes they take two, three
or four years to get a grant out to a country. Some development
agencies take a long time as well, it is a huge bureaucracy. I
like what you said, "intelligent investment", but this
is not happening; there is too much bureaucracy to get the funding
to where it should be and it gets entangled in the bureaucracy.
The money is there, it is in the bank accounts. I think the Global
Fund has several hundreds of millions of dollars that are waiting
to be disbursed, but they are not disbursed because the channels
of distributing the funding are not well-defined and they are
afraid they will get entangled with bureaucracy. That is something
we absolutely need to improve. In the Union we have realised that
and started to train technical people in management. We tell them
how to plan, how to budget, how to monitor what they are doing
and be more efficient in what they are doing. Obviously this is
a drop in the ocean but we should convince other people to improve
that governance issue which is really deficient in almost all
the countries. In one country it may work better, but I do not
think it is necessarily the ministry of health that is at fault,
it is the administration of the country that is not able to work
properly at federal level, the national level, and is not able
to communicate well with the regional and local levels. That is
one of the main obstacles and all of the other problems come with
it.
Lord Desai: I look at it occasionally,
Indian bureaucracy or the World Bank bureaucracy, and it is precisely
because they have all the requirements of auditing, monitoring,
such a lot of things to check off, that they get risk averse.
They do not want to do this because, "If I do this, what
happens when I get the money into the country?" There is
a dilemma between doing what Lord Howarth said is quite right,
we need the money well-spent, but that money has to be spent and
quite a lot of them do not spend it because they do not want to
get into the hassle of having to answer as to where it went. That
is one of the problems. In India, apparently 85 per cent of any
grant given to the poor ends up in civil service costs.
Chairman: Scary!
Q1113 Lord Avebury:
You have mentioned several times differential access to treatment,
particularly in countries where people's first point of access
is through paid-for services. What I am wondering is, if governments
were made to realise that failure to treat people in these categories
led to a greater risk for the general population, then they might
wish to invest in the services that these people are lacking.
I am wondering whether the Global Fund, or somebody like that,
ought to be undertaking this kind of motivational research, if
you like, that would point governments in the direction of spreading
the health services to those who do not get access to them at
the moment. Is that what is lacking, that in the treatment of
these marginalised groups governments are not seeing a sufficient
incentive in terms of the protection of the general population
that they cannot directly connect the infection of somebody who
is a poor migrant worker, for example, with the threat to the
health of the general population?
Dr Billo: That is a good question and it is
complex. You were addressing the issue of the economy and accessing
health and that is critical. If you look at the migratory worker,
the migratory worker is not going to stay here and have access
to the health centre that is there, this worker will move to the
place where he will have work and will not think about his health,
he will think about how to get money. Obviously this migration
will not help to improve his access to health. To organise health
services for these large quite populations, and in India there
are large movements of people back and forth depending on where
they are working—
Baroness Falkner of Margravine: Truck
drivers with AIDS travelling in southern Africa all the way up
the east coast of Africa.
Q1114 Lord Avebury:
In Afghanistan the same thing, truck drivers.
Dr Billo: It is the same as if you have a heart
infarction in Switzerland in the Alps. If you are unlucky enough
to be on holiday on the Alps somewhere, you will not find an ambulance
coming straight away. In many countries you cannot have access
points everywhere because it is just not realistic. We need to
have at least those services working where there is basic infrastructure
and, if those work, then also invest heavily into the communities
to make sure they set up their infrastructure. It would be unrealistic
to think that we could guarantee up-to-date or state-of-the-art
treatment for almost everybody. This is not realistic and will
not be possible in our opinion.
Q1115 Baroness Hooper:
This is a slightly different question. May I ask about your organisation
and, indeed, maybe I ought to know the answer to this. Where does
your funding come from? You referred to a grant from the Canadian
Government for a project, but do you receive it from other sources?
Are you ever in a position not only of perhaps managing a particular
project but distributing funds on the ground?
Dr Billo: We have a budget of about €40
million a year. Funding comes mainly from USAID, the French Government,
the Norwegian and Swiss Governments, the Canadian Development
Agency and a large grant from the Bloomberg Philanthropists for
Tobacco Control. These funds are project-related, it is not basket
funding. It is for very specific things and we have to report
on those activities. We have had the opportunity to do exactly
what we are asking, which is to contract organisations in countries,
and there was a project called FIDELIS, to find local solutions
for improved access to TB treatment. We had over 50 grants given
to governments but also to NGOs in high burden countries. We had
quite good results with this, although also some failures. Some
projects, where they said they would improve case finding among
private practitioners, did not work, but in other areas it worked.
We have a lot of experience in granting projects in different
countries. This model is also used for tobacco control, where
we are doing the same thing. The advantage is that you can really
boost a local government or NGO and you do not have to pass through
the national government, because that would often stall the whole
system. We were in China and people said, "This FIDELIS project
was really nice because we submitted the proposal, we got the
OK and three months later we had the money and could start working.
With the World Bank or Global Fund, we apply and then it takes
forever until we can start". The motivation there is not
so good. However, we cannot fund like the Global Fund or the World
Bank. With small grants like this, you can create some crystallisation
points and pilot test a few approaches and, if they are successful,
they can apply for larger grants from the Global Fund. That was
quite a good example. Our organisation works on TB, that is our
main area of work. We work on HIV, tobacco control, on pneumonia,
especially in children under-five which is a very neglected area,
a lot of kids die, more than four million a year. We also work
on asthma, a very neglected area which affects ten to 15 per cent
of the population and is very expensive treatment for them. We
have about 200 staff and consultants and several offices throughout
the world, one in India, one in China, one in Egypt, Mexico, one
in DR Congo, one in Uganda and probably one opening in South Africa
very soon, and one in Russia.
Q1116 Chairman:
Dr Billo, thank you very much indeed for your evidence and thank
you for the work you are doing too. Is there anything else you
would particularly like to add at this stage? Or have we covered
everything we need to cover?
Dr Billo: No, you have asked excellent questions.
My plea would be if you can influence what I liked hearing—more
intelligent investment of what is being transferred to countries;
and, if we can improve that, that would be brilliant.
Chairman: More intelligent decisions
is always something that is open to interpretation by people who
have different interpretations of intelligence, but I understand
and hear what you say and it is important. Thank you very much.
If you do get any other ideas or points you want to elaborate
on, then please contact the Clerk and we will take those on board
as well. As I said, you will see a transcript of this evidence
and you will be able to correct any factual matters and then it
will be published in due course. Thank you very much indeed.
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