Oral evidence: Health Systems Strengthening, HC 948Thursday 10 July 2014
Oral evidence, 15 July 2014.
Witnesses
Lynne Featherstone MP, Parliamentary Under-Secretary of State, Department for International Development, Jane Edmondson, Head of Human Development Department, DFID, and Angela Spilsbury, Senior Health Adviser based in Ethiopia, DFID, gave evidence.
Chair
We will make a start. We are just waiting for Jeremy and he will be back in a minute. Thank you, Minister, for coming in. I am sorry that we have taken a bit longer on the first evidence session, but we obviously found some interesting issues to explore. I wonder if you could just introduce the team for our records.
Lynne Featherstone
Okay. I will let them introduce themselves. Angela?
Angela Spilsbury
Thank you. Angela Spilsbury, Senior Health Adviser from DFID Ethiopia.
Jane Edmondson
I am Jane Edmondson, head of the Human Development Department in the Policy division.
Chair
Okay, well, thank you very much. The issue that has really emerged is the conflict between health systems strengthening and delivering outcomes—the difference between doing that and the global funds. Dr David Evans from the WHO felt that strengthening systems was becoming much more important, and that we should be moving away from the focus on quick wins and measurable outcomes. He feels that that has run its course. Do you accept that that is a reasonable analysis, and has it had an impact on the way DFID approaches its health delivery policy?
Lynne Featherstone
This is a really interesting issue as time has moved forward. When development aid started and was going into countries with no health systems, or that were so low on the capacity scale there was nothing there, it would have been incomprehensible to have waited for a health system before you went in and targeted vaccinations, or maternal mortality or those sorts of things. In terms of a country’s readiness for a health system, I think there is an issue around timing. However, obviously as we have gone on and as these amazing global funds have done such brilliant work, there is a change. DFID itself has always been an advocate for health systems strengthening because there is no sustainability around the vertical approach to disease. One of the things DFID is very advised of and acts on is supporting national systems, building health systems, strengthening health systems, but also trying to influence those who run the global funds to do likewise, so that you use the opportunity of a vertical operation to actually build some resilience and strength around its capability. If you take those countries where there are not really recognisable health systems at all, if you have maternal birth clinics of some sort, then it would be obvious, and DFID encourages this cross‑fertilisation, to build a system around that so that when someone comes in to have a baby, they are recognised in terms of bringing their babies in for vaccination and so on. There are a number of ways of strengthening health systems. These are different in different countries. Ultimately, you want everyone to have a health system that is as good as the National Health Service, but they are starting from very different bases and they started with different people being willing to do different parts of that whole agenda.
Chair
Just on that point, you will not be surprised to hear this because it is not the only context in which it has been said, but NICE International, who we have just been talking to, said that a fixation on achieving short‑term measurable outcomes is “perhaps the biggest obstacle to DFID fulfilling its role in systems strengthening”. Do you recognise that tension?
Lynne Featherstone
No, I do not agree with that. I know it is a criticism that is often levelled because of some of the ways we measure health outcomes.
Chair
Well, the MDGs encourage you to do that as well.
Lynne Featherstone
Yes, the MDGs as well. If you looked globally at, say, the DFID budget, part of our input goes towards the results in the MDGs—which are driven by results and outcome‑focused. I very much agree with that. I also think it is a very good way of measuring health systems when you have put it back. However, half of our money does not go on those results and is not narrowly focused, and actually is there to build the health systems. So, while I accept that we do have results and we do measure by outcomes, I would also say that where you have good outcomes you also tend to find good health systems. We are not so narrowly focused; we measure outcomes because in the end that is what we are trying to achieve, but in the individual programmes we track indicators of health system performance such as rates of skilled birth attendants, for example. So I do not think this is an absolute criticism.
Chair
Just to summarise, the first strand of evidence we had was that the perception was that in its bilateral programmes DFID was definitely good at building health systems. That reinforces what you were saying. The question was whether or not the engagement with the multilateral organisations was as focused on delivering that. You do not need to answer that now, as I think our other questions will probably deliver that.
Lynne Featherstone
Will we come on to that? Okay.
Fabian Hamilton
This Committee, Minister, has heard praise for DFID’s continued focus on systems in its bilateral programmes. I wondered how you could ensure that those systems are prioritised in countries where DFID does not have a bilateral programme?
Lynne Featherstone
Where we do not have a bilateral programme, that is exactly why we use the multilaterals, because we can reach countries that we have no ability to reach otherwise. For example, there are 53 countries eligible for GAVI, and obviously the Global Fund works in over 140 countries. We use our position on the boards of those global funds to push the health systems strengthening agenda. However, we also do other things in countries where we do not have bilateral programmes, for example, global public good. We have great emphasis on research, evaluation, product development and market shaping. They are available to all countries. If you take something like the Global Fund, these huge funds have an ability to drive down the price of commodities. The price of antiretrovirals for HIV has dropped by 99%.
Fabian Hamilton
Sorry, can you just say that again? Did you say 99%?
Lynne Featherstone
In low-income countries, yes.
Fabian Hamilton
So it is now 1% of what it was—how long ago?
Lynne Featherstone
I would have to come back to you with the date.
Chair
It is about five years, I suppose.
Lynne Featherstone
Is it five years? It is a phenomenon. However, it is not just about the fact that it has driven down the price; it is that when the price is low it enables a country to develop a health system, because the drugs become affordable by the country’s Government in a way that they were not before. We would never have got to that without the global funds being able to push down the price of commodities.
Chair
I am interested in where DFID’s health systems strengthening programme has been the most and the least successful. I wonder if you could tell us a bit about what lessons have been learnt where we have been involved in those programmes—especially the least successful ones.
Lynne Featherstone
I am going to use a successful one first. One example would be DFID’s support for health workers’ salaries in Sierra Leone. I know the Committee has just come back from there. That was evaluated in 2012, and the recommendations were then used to inform future support. So that is a successful intervention. I would have to turn to Angela or Jane to give me an unsuccessful one. It seems that we cannot think of an unsuccessful example.
Fabian Hamilton
That is good that you are not able to think of one. That is excellent news.
Lynne Featherstone
There are probably more and less, because we work in a direction; there is no absolute on these and they are all different. We do different things in different countries.
Fabian Hamilton
What are the lessons you have learned from the successful ones, then, about how to make them more successful—or why they are successful?
Lynne Featherstone
We have increased our focus on the evaluation of our health systems strengthening. When they are analysed and evaluated, that enables us to improve policy and programming effectiveness. I would say that what we have learned is the evaluation. I would have to send the Committee actual examples. I think I do have some in the back. Do you want me to scrabble through my papers?
Chair
No, no, it is okay. No, you can send us some examples.
Lynne Featherstone
They are quite complex and involved, but we do evaluate our programmes. That is how we learn in terms of our future programming and policy each time.
Jeremy Lefroy
Good morning, Minister. The additional commitments by DFID to the Global Fund and GAVI have been widely welcomed. When the increase in funding was made, was there any emphasis by DFID on health systems strengthening as an important component that both the Global Fund and GAVI needed to concentrate on? If so, perhaps you could give us some details.
Lynne Featherstone
Yes. I think there is a very important role for DFID in terms of our contribution to the global funds, both GAVI and GFATM, to add to their health systems. A focus on health systems strengthening really should run through all work to improve health outcomes. In terms of GAVI, the UK led the call for GAVI to prioritise health systems strengthening and was instrumental in GAVI’s HSS spending target. As I said, we use our board and committee positions to push this all of the time, and we very much use funding as leverage in terms of the direction in which we think they should be going. We have no hesitation in putting that forward, because simply financing vaccines is not enough. We see in-country that it is just not enough. Obviously, as I said, in a country where there is nothing else, you are not going to wait for a health system to go and do vaccinations. Nevertheless, now we have these massive global organisations, strong systems are needed to get the vaccinations to the children who need them. In a country that has a UK bilateral programme and is a recipient of GAVI, we also push them to be complementary to what we are doing in‑country, each working to comparative advantage. In countries such as Malawi, Ethiopia and Uganda, we would fund core health systems support including human resources for health, drugs and equipment. GAVI finances the vaccine cost and the grants to strengthen the immunisation system. So we work together with the global funds in the country. In terms of the Global Fund, we have encouraged—and will encourage—GFATM to continue to invest in health systems strengthening. They have moved from dedicated health systems strengthening grants to actually ensuring that the grants for each of the diseases have a strong health systems strengthening focus. We think that they strengthen their health systems in three main ways. Targeted health systems strengthening funding has helped to directly fund issues such as data systems, supply chain systems and human resources for health. They are encouraging the use of national systems for data and other requirements, thereby strengthening these systems by using the national systems and not building parallel systems—which just ends in madness, to be honest. Indirectly, they are having a huge positive impact on health systems by funding successful prevention and treatment programmes against the three diseases. Fewer health staff are actually dying of those diseases, which has also been an issue. Their patient load has dropped dramatically. So, yes, we do push them. That is the short answer.
Jeremy Lefroy
We seem to be getting a slight contradiction in views. We have some people telling us that DFID has reduced—and some would say almost abandoned—its thought leadership on health systems strengthening. They give examples such as DFID declining to send a Minister to the Third Global Forum on Human Resources for Health, and lagging in the implementation of the International Health Partnership Plus principles. However, on the other hand, we are seeing very substantial DFID leadership in these very important programmes of the Global Fund and GAVI—and also, as we have seen on the ground, to be quite frank, substantial leadership where we have bilateral offices. So I wonder where you think this is coming from, and whether there is something more that DFID could do to allay the fears of some people that we are ceding thought leadership in this area—if indeed we are.
Lynne Featherstone
Thank you for giving me the opportunity to say publicly that we are committed to health systems strengthening. We are certainly regarded as a world leader in terms of our bilateral programming. In everything else we work with others to push that agenda. However, it has to be said that institutions like the World Bank are incredibly strong in terms of strengthening health systems. We do not have to lead on absolutely everything and be at absolutely everything. It is simply not possible. However, I just want to give the assurance that even if we did not send a Minister to that particular meeting, it does not mean that we are not committed to health systems strengthening; we are. However, I am very happy for there to be other world leaders on these things as well, so long as we support, encourage and push, and grow that agenda, and make sure that the money we have is used to that end. That is a good structure on which to be based. So I would love to be world leader on everything, but I think it is not possible for DFID to do absolutely everything and to be at absolutely everything. However, I am very pleased to have the opportunity to put on the record that it is one of our modus operandi.
Jeremy Lefroy
Thanks for that. We heard evidence in our first evidence session about gap filling, in which organisations focus on what they do well. I wonder, Minister, if you think that we have a comparative advantage in health systems strengthening, and therefore that this is something that we actually should take the leadership on—although clearly in certain ways we are already taking this leadership—because it is something where we have both national experience and a long history through our overseas development programmes.
Lynne Featherstone
I think that to an extent it comes naturally, directed by the context in which we are working in-country. As you know, our health advisers are very experienced at working with Governments, and generally know the mapping that goes on in a country in terms of that. We are generally working and aware of map gaps. We have stepped into gaps ourselves—for example, where we have seen a gap, say, in the Global Fund in terms of malaria in-country, we will step into that gap. We also have to learn how to step out of the gaps. There is quite a balancing act going on; where we have the comparative advantage and where we know, and where we are able, then we should not hesitate to. However, there was a very generous pledge this year to the Global Fund, and it is also part of the way of things that there are some things that they are better at, and we just need to make sure that we are complementary and working with them. I do not think it matters who does it, so long as it is done.
Jeremy Lefroy
I am sure we would agree with that. The concern that I have is that where we do have bilateral programmes, we normally have health advisers—and pretty strong ones. Certainly, the ones that we have seen are strong. However, we only have bilateral programmes in 28 countries. We are, through multilateral organisations, operating in far more than that. I wonder how DFID can be sure that in those countries where we are not operating bilaterally, but where nevertheless through multilateral partners we have a very significant programme, we are able to ensure that there is that same level of engagement by somebody else. I totally agree with you; it is not up to the UK to lead in every country and in every respect. We cannot possibly do that, nor would it be right for us to do so. However, it does seem to me that, where we are contributing large amounts of money through multilateral organisations in an area in which we are recognised to have expertise and yet we do not have that expertise on the ground, we may be missing something. How would you respond to that?
Lynne Featherstone
I will let my officials come in on this one. However, that is why we sit on the boards of the multilateral funds. We are not going to have every country coming to us.
Jeremy Lefroy
Yes. It is going to be very difficult for somebody sitting on a board, however much they do the work, to know what is going on on the ground with what may be very substantial programmes in health where we have no input.
Angela Spilsbury
One way that we have been working to promote health systems strengthening through others is with the International Health Partnership. This was a DFID‑spearheaded initiative that was set up in 2009-10. Within that, we created an agreement amongst the main partners in international health to really pioneer and lead on health systems strengthening. We put the WHO and the World Bank in the driving seat for that. Through that partnership they are working with Governments to make sure that countries, and donors working in those countries, are actually working towards supporting a systems approach—and supporting what the Government and the host country want to be achieved. So, even though we are not necessarily in those countries, we have set up the global governance structure that will enable other partners to lead on health systems strengthening and further the agenda that we have.
Lynne Featherstone
The other thing that is happening at the moment is that, with our development aid tracker, we are in the process now of geocoding what central funds and multilaterals do in each country. So it is not perfect, but I do not think we would ever say that we could absolutely identify everything going on in every country and every gap. However, there is a global way of tracking, if that is what you were asking.
Chair
I can follow that up. I do not dispute at all that that is what DFID is trying to do. We know it is doing it bilaterally, and you were telling us how you are influencing multilaterals. However, there has been a suggestion, first of all, that other donors take a different view, and that actually health systems strengthening is less important to them than delivering measurable outcomes. In particular, the Gates Foundation are very keen on delivering specific outcomes. They are now the WHO’s biggest donor. So how can you ensure that, in that context, you are not driven by other donors’ priorities? For example, if Gates is the biggest donor for the WHO, how can you be sure that DFID’s priorities and the WHO’s are going to be in the same direction?
Lynne Featherstone
Well, we fight.
Chair
Can you give us examples of where you have actually had to assert that?
Lynne Featherstone
The Bill and Melinda Gates Foundation, as you say, had a reputation for focusing mainly on developing new technologies to address problems with the health of the poor—most notably and most famously in terms of new vaccines and polio, for example. However, it is not correct to argue that working with the Gates Foundation, for example, reduces our focus on health systems strengthening. I would argue that it is the other way round: by working with the Bill and Melinda Gates Foundation, we have actually influenced them to understand that simply delivering a vaccine is not the answer and that you have to strengthen health systems if they are going to be sustaining. I will give a couple of examples of what we do. We are working jointly with them on a programme in Kenya, Ghana and Nigeria that focuses on improving the quality of care delivered by private providers. We are reducing barriers to access to care by supporting countries’ health financing systems, and supporting Governments to improve their stewardship of the whole health system. So, by working with us, they are now broadening the scope of their operation, whereas I think that when they started they were definitely focused in a very vertical manner, and would use that influence on the WHO for the same. I think there is a general acceptance across the board that that is no longer enough—that simply delivering a vertical system that is unsustainable and does not build a domestic strength in that capacity is not adequate. You are seeing quite a shift across to that view. We are jointly funding NICE International with them, to help countries make fairer, more transparent and more evidence‑based decisions about how to spend money on health. Health financing is another big area. They are a very important donor to GAVI, the Global Fund and the Global Polio Eradication Initiative. We work very closely with them on strategic engagement and how to strengthen health systems around that. We do not have control over them.
Chair
You are saying that you push them more in your direction than the other way round. That is what you are essentially saying.
Lynne Featherstone
Yes. I would think that they have come from that in a very strong way, but they are now moving towards broadening their scope.
Fiona Bruce
As I understand it, DFID have been working on health systems strengthening for some decades, yet you are still unable to tell us how much money you are spending on this. We have also been told in evidence that there is an absence of measurable targets for health systems work, and a lack of systems strengthening indicators. Do you think this is satisfactory after all these years, and what is going to be done about it?
Lynne Featherstone
No, it is not. It is probably a relatively fair target for a recommendation from this Committee. I am sure we will see it there. As I say, I think that we get a pretty good idea of health systems from the way that we measure outcomes, because clearly it measures the actual improvements in health, and you do not get them unless there is a functioning health system—unless they are very specific targets. As I said, we are doing some work with ARIES, which is our computer system. Our country advisers are now working more closely in terms of what is happening in each country, but we do not have a specific target on strengthening health systems. We have one, but I do not know what page it is on, sorry. I cannot find it at the moment. The argument is that we do perhaps need to get a better and clearer idea, but we have always believed that the outcomes were more important. I was trying to think what that might look like and I was thinking, “Well, how would you do it? Would it be the number of trained health workers, the number of doctors or the numbers of clinics? Would those be targets?” However, I am slightly worried that, if we went that way, that would become the focus, rather than the outcomes from the health systems that we were delivering. So I think it is really quite complicated to ensure that those things do not become an object in themselves, and that we do not lose sight of the health outcomes because we are being encouraged to have particular health systems strengthening targets. I would simply ask that perhaps when the Committee advises us, they also consider how to avoid falling into the trap of that becoming the object, rather than an outcome.
Chair
In Sierra Leone and Liberia, the respective Governments fed back to us that access to health facilities in terms of distance was one criterion. They also recognised in Sierra Leone that they had done the access, but they had not done the quality. So they then had to import some quality standards. But at least they were beginning to think about measuring. Presumably, by discussion, you could come up with indicators that would give you a better focus than you have now.
Lynne Featherstone
Yes. I will give you a couple of examples where we are doing it. If you take Ethiopia, we are providing sector‑wide health support to the Government through a pooled fund managed by the Ministry of Health—where I was yesterday with Angela—plus contributing to block grants to districts that are earmarked for basic service provision. So an example of the programme would be support for the Ethiopian health sector development programme through the Ministry of Health. We can send you these examples and charts, but I will just do Ethiopia.
Chair
That would be helpful, thank you.
Lynne Featherstone
The outcome “improved access and quality of health service” indicators include: contraceptive prevalence, skilled birth attendants, percentage of children under five sleeping under a bed net, immunisation coverage, and outpatient attendance per capita. Gaps between the richest and poorest socio-economic quintiles are also measured for some of these, and so on and so forth.
Angela Spilsbury
Can I just add to that? We also do actually track health systems strengthening indicators like ratios of nurses and doctors to population, the percentage of facilities that are able to provide emergency obstetric care for 24 hours a day, and also the availability of drugs. So there are some specific systems indicators that we track at the output level. However, at the outcome impact level, we are looking at things like maternal death and infant death, which are the outcome of whether or not a health system is there and effective.
Lynne Featherstone
We will send you some more examples.
Chair
That would be helpful.
Lynne Featherstone
It is emerging thinking. It is about asking, “How do we get these two things to both be beneficial, rather than contraindicators?” Jane wanted to come in on universal health coverage.
Jane Edmondson
You asked what we do about it, and I think there is a recognition that, while we do measure them in individual programmes and things, there is not a globally recognised set of indicators. So we are working, and we are supporting some work by the WHO and the World Bank to develop a set of indicators, with the idea that we could agree a set of indicators that could be used in post‑2015 goals.
Lynne Featherstone
I was going to go on to 2015. Our position in terms of health is that the goals in the post‑2015 framework should be outcome‑based—because, ultimately, what we are trying to do by 2030 is help people live longer, healthier lives. Others have been arguing strongly for universal health coverage to be the goal itself. We have been very consistent in supporting that. We are finding our way through, but those new MDGs will be very powerful, in terms of where we go as well.
Fiona Bruce
So you will have those and also, you say, you are working on health strengthening indicators. Obviously, a lot of money has been put into multinationals, as Ms Spilsbury said, on this very issue. As a Committee, whilst we have heard praise of DFID’s system focus on the bilateral funding, we have actually heard some quite concerning evidence about multilateral funding. I really would like to drill down and ask you for some examples of where you have had sufficient systems focus on projects that have already occurred with regard to multinational funding for health systems strengthening. Can you give us some examples that will give us confidence that DFID is holding these multinationals to account?
Lynne Featherstone
In terms of specific examples, I would have to go back to what we have done and what our interventions have been in terms of multilaterals. We have constant dialogue with them. As I said, we operate not just at board level but committee level. In terms of specific examples of an actual delivery in-country, I would have to go and find them and provide them.
Fiona Bruce
That would be appreciated. Thank you very much. Turning to the Global Fund, we have had some evidence on this saying that “spending leaves significant opportunities for efficiencies”. You mentioned, for example, bed nets. We have had some evidence that better-informed procurement of bed nets could save the fund $340 million over the next five years. A previous witness here today said that the new money for the Global Fund is a great opportunity to inject expertise and new evaluation opportunities—for example, that raw data should be put onto the web, so that we can really scrutinise what money is spent globally by the Global Fund. Could you comment on how we can ensure that, when we audit organisations like the Global Fund, this is done effectively?
Chair
This was witness evidence from NICE International.
Fiona Bruce
Yes.
Lynne Featherstone
DFID’s internal audit team recently conducted an audit of the Global Funds fiduciary assurance mechanisms. We will be working closely with the Global Fund, particularly over the next six months, to strengthen fiduciary assurance and to implement the recommendations of the audit. In terms of what they actually deliver, aside from the formal opportunities of being on the board or the committee to monitor funds and flows, the staff managing our investments and relationships with the global funds have continual and ongoing dialogues with the secretariats. They consult regularly with our country offices—who, as you say, have context-specific knowledge—to ensure that our funds are being spent appropriately and that the global funds are effectively militating against the fiduciary risks. You are talking more about value for money, in terms of whether we drove that price down in that country. We take an overview on that. Indeed, part of the benefit is that, when we did the multilateral aid review, these funds did extremely well in terms of expenditure. Having evaluated them and updated our evaluation, there will be another one next year. That is really how we examine what they are doing and where they are doing it, and if we think that is delivering our money well. We do not do that on a drill-down all the time. That would take an awful lot of resources, when we have evaluated any particular multilateral fund as being worthy of receiving such a large amount of our money. In a sense, after assessing them as the right organisation to deliver a particular thing, we then periodically examine that they are still the right organisation—that they have delivered and that we are getting value for money.
Fiona Bruce
One of the ways that we could all better hold them to account is with greater transparency. Would DFID use its influence on the Global Fund board to encourage them to be more transparent?
Lynne Featherstone
Yes.
Fiona Bruce
Did you want to add something, Ms Spilsbury?
Angela Spilsbury
From a country point of view, the majority of DFID health advisers are involved in supporting the countries to write the proposals for the Global Fund. That is often a great opportunity for us to really start drilling down into some of the detail—which we would not necessarily do from the centre but we can do at country level—to see why certain decisions have been made around commodities and which commodities to procure. That is where we can have a much more detailed analysis on the value-for-money aspects, and have those debates with the country.
Jeremy Lefroy
I perhaps should have posed this question to the previous panel. We visited the bed net factory in Arusha, not with IDC but with the all-party parliamentary group on malaria and neglected tropical diseases. The factory is very large, and DFID has been very much supportive of it. Indeed, DFID has got a sign on the outside of the factory. One thing we were told was a problem for procurement was the way in which the Global Fund procured on a free-on-board basis. This meant that even though a huge factory based in East Africa was able to deliver for a cheaper price to other countries in the region, because their free-on-board cost was perhaps slightly higher than from other factories across the world, it meant that they could not necessarily be competitive. To the Members of Parliament who were there, it seemed to be a bit of an anomaly. Have you had any indication that the Global Fund is looking at things like that? It seemed to us to make little sense. Local production was able to deliver cheaper, but was not competitive when compared with its actual free on-board or free-out-of-factory costs. I do not necessarily expect you to have an answer to that straight away, but it would be very good to put that on the record, and see if they have come back on that. That was a specific example that all three Members of Parliament on the trip were exercised by, in terms of strange procurement. The company was possibly very much talking in its own commercial interest, but it did seem to us to make sense. As you know, there are now quite a lot of mosquitoes resistant to straight insecticide-treated bed nets, which are done just with pyrethrum. Companies have developed a combination of insecticides in order to better protect those who are sleeping under the bed nets. Again, there was a concern that, because people were looking purely at cost and not at effectiveness—clearly, those combination insecticides cost a little bit more than the single insecticides—we were going to end up with less effective protection offered by the bed nets. Again, I do not expect an answer on this, but it would be good to have an answer back, either from DFID or from the Global Fund, as to whether these issues are being addressed at the moment or have already been addressed. That would make a significant difference in value for money and procurement.
Lynne Featherstone
You raise a good point. I do not know the answer off the top of my head. I do not know if Jane wants to come in on this, but it is certainly worth us going back to the Global Fund and finding the answer to your question.
Jane Edmondson
It is a well‑recognised challenge. There is a balance between reaching the most people with the cheapest product and strong procurement, and making sure that we grow markets that can compete. Clearly, that has much broader benefit. There are a number of ways in which we support that kind of work, including working with the WHO and with other organisations on market-shaping strategies. This is about thinking ahead: how can we grow markets for the future that will be able to compete? The WHO does a lot of work on this, in its schemes for accrediting companies. We have provided support to pharmaceutical companies, for example, in developing countries to get the WHO accreditation, so that they can start to compete in procurement exercises. We are ensuring that we keep a strong pipeline of new products coming in, as there is the same resistance on the drugs side. A lot of our research and product development is around that. The current generation of insecticide-treated nets, when they first came out, were extremely expensive. The cost of those has driven down. Making sure that we are planning ahead and investing, to keep that supply chain coming, is important.
Fabian Hamilton
Minister, to what extent is continued DFID funding for multilaterals dependent upon them exercising a systems strengthening focus? Would you consider withholding funds if those systems were not being strengthened through the money that we give to multilaterals?
Lynne Featherstone
Well, let us hope that situation does not arise.
Fabian Hamilton
Absolutely, but would you consider it?
Lynne Featherstone
We always consider. For example, with the Global Partnership for Education, I recently was looking very strongly at their words on disability and inclusive education, in terms of the relationship to how much I was prepared to pledge. I was satisfied.
Fabian Hamilton
That is good. Can you provide any specific examples of DFID using its membership of the Global Fund or GAVI to successfully promote a systems agenda? If you have not got them available, do not worry; you can let us know later.
Lynne Featherstone
One example is GAVI health strengthening system grants, which we have encouraged them to have. They have helped increase the pneumonia vaccine coverage from below 5% in low-income countries in 2000 to above 95% in 2013. We have used our influence, at board and committee-level, to ensure that GAVI enhances its focus on improving coverage and equity rates; strengthens vaccine supply chains for investments, which improve immunisation outcomes and mitigate the fiduciary risk; improves the sustainability of national immunisation programmes; and, further, shapes the vaccines market, including securing appropriate pricing for countries that graduate off of GAVI. At this year’s GAVI replenishment launch, the UK company GlaxoSmithKline committed to supporting developing countries that have growing economies by offering a five-year freeze on vaccine prices for countries that gravitate away from vaccines. That is slightly off topic.
Fabian Hamilton
They are all really important examples that obviously help the health systems.
Lynne Featherstone
They are the ways that those organisations help health systems.
Fabian Hamilton
But are you satisfied that they actually contribute to the strengthening of those health systems?
Lynne Featherstone
Yes, I am. Do you want me to go through the Global Fund as well?
Fabian Hamilton
No, that is fine.
Lynne Featherstone
I am happy that it does. It is not health systems strengthening in the sense that perhaps DFID would do it in-country or working with country Governments, but it does work with those kinds of systems to strengthen the parts that are appropriate to its central focus. They do not do a separate job on health strengthening.
Fabian Hamilton
This inquiry is about health systems strengthening. Our concern is that the large amount of money that DFID gives, very justifiably, to multilateral agencies such as GAVI and the Global Fund is actually contributing towards those health systems being strengthened.
Lynne Featherstone
I am happy that it is contributing towards it.
Fabian Hamilton
Especially in the countries where we have no bilateral programme.
Lynne Featherstone
Especially where we do not have any programmes.
Chair
Do GAVI and the Global Fund talk to each other about how their activities can be synergistic?
Lynne Featherstone
I am sure they talk to each other all the time.
Chair
I know, but for this particular purpose?
Lynne Featherstone
On that specific issue.
Chair
Yes.
Angela Spilsbury
There is one example from Ethiopia that illustrates this nicely. In Ethiopia, DFID was instrumental in setting up something called the MDG pot, which was a pooled donor fund, managed by the Ministry of Health, to support health system strengthening. This was started in 2008 with us and the Italians. Now, in 2014, we have 13 different donors that contribute to that pot, including GAVI, who give un-earmarked health systems strengthening money for the strengthening of health systems—not just for immunisation. It is a broad range, from training health workers, to building health centres, to buying medicines, vaccines and equipment that a country needs to run a proper health system. Now, we have just had announced that the Global Fund will also contribute un-earmarked money to that pot, as well as the World Bank. We have been seeing a real shift over the last few years, where GAVI and the Global Fund did a very particular, tailored bit of health systems strengthening to a much broader interpretation. I like to feel that is because they have been very much involved in the whole donor co-ordination mechanisms in Ethiopia. It is partly due to the incredibly strong leadership of the Ethiopian Government, who are very determined to make sure that the multilateral funding mechanisms work for them, rather than just doing their own thing. It has been very interesting working in different countries over the last 12 years. We have seen a really large shift, with GAVI and the Global Fund moving towards a much more health systems approach. They are very much talking to each other, and talking to DFID, at country level. Often, because they do not have country presences, they ask us to represent their views and positions in dialogue with Governments. In that way, we also have a chance to influence.
Jeremy Lefroy
The impact of the focus on specific diseases over the last 15 years or so has been huge: malaria, TB, HIV/AIDS and neglected tropical diseases. As a consequence, the burden on health systems from those diseases, even factoring in population increase, will have reduced. You would therefore expect there to be more resources freed up by national health systems, to concentrate on other areas, particularly around maternal and child health, and perhaps even more non-communicable diseases and so on. However, what we are seeing in several countries is not just no approach towards the 15% of gross national product to be spent on health—which they aimed for in the Abuja declaration 13 or so years ago—but actually a retreat from that. In certain countries, one consequence of focusing on diseases—and rightly so—through these funds is almost to let countries off the hook. Therefore, are the savings they have seen from a lower burden of those diseases actually resulting in a lower attribution of tax money towards health? That is what the figures in some countries look like. It looks as though, despite increasing growth in most of these countries, they are not putting more into health. Some are putting less into health. At the same time, we have had this reduction in disease burden on those major killer diseases that have affected them for so many years. It almost looks as though they are saying, “Right, we are taking that saving. Thank you very much indeed.”
Lynne Featherstone
Yes.
Jeremy Lefroy
Would that be a fair characterisation of some countries, or is that just a wrong view?
Lynne Featherstone
It is quite a job to persuade countries to allocate the appropriate percentage of their budget to health and health systems strengthening. Many of the countries in Africa who signed up to the Abuja declaration have not reached the 5% target that was set. Ministers of Finance are generally, in my experience, the issue. They often need to be convinced that health is a good buy. We are working hard to build the evidence that investment in health is money well-spent—for example, through funding the Commission on Investing in Health. The Commission report in 2013 showed that there are high economic returns to countries for investing in health. That is not to say, as you rightly point out, that all countries leap at the opportunity to spend that money in that direction. There are Governments that are much better at it, and there are Governments that appear to take an attitude of, “Well, other countries are paying for this; they are tackling it. Why should we put our money in there?” That is work that goes on. A very important part of our work is influencing and working with health ministries and finance ministries to prove the economic case to them and to continually indicate to countries that it is their responsibility. Public services are their responsibility. That is one of the great challenges. That is why we spend quite a lot of energy also on domestic resource mobilisation, which builds their capacity for taking tax revenue, so that they can actually pay for resources. We also persuade countries to put occasionally less into their security, or other, budgets, and focus more on those that would benefit the many people in need in their own countries.
Jeremy Lefroy
It seems to me that the key people to influence here are parliamentarians, because, particularly in a constituency‑based system, it will be their constituents who see the benefits of a good health system and the problems that come from not having a good health system. What work does DFID do specifically around health—I am not talking about general parliamentary strengthening, although that is another issue—to engage with Members of Parliament to help them understand what DFID and their own Government are doing on health, and what more can be done. They are the ones who can actually push, as we do here.
Lynne Featherstone
I appreciate that, yes, but most Parliaments are not like ours, in Africa. As we discussed at the last session, 40% of MPs do not ever even visit their constituencies.
Chair
Part of the reason they do not visit them is that they get people asking them to pay their health bills.
Lynne Featherstone
Indeed, and the systems work quite differently in many ways. In terms of elections and democracy in some of the countries I visit, there is not always a necessity for MPs to visit their constituencies. I very much was struck by your idea of NGOs publishing in each constituency what they do. We engage in parliamentary strengthening, public accounts committees. We are forever trying to build that capacity, and that work goes on. I could not answer specifically here today what we do on health. It is more to do with the whole system. We have, to an extent, focused on public financial management, public accounts committees, audit committees, but I will find out and come back to you. We have been supporting piloting of results‑based financing mechanisms in health that ensure that funds are only spent if services are actually provided. At country level, we work through partners like the World Bank to try to influence resource allocations. I accept that Parliament is one way of doing it, but there are some even more influential ways of doing business in Africa. We are supporting NICE International to help countries build their own capacity to make fairer, more transparent and evidence‑based resource‑allocation decisions. Through one of its research programme consortia, DFID is also funding research into how countries can raise more tax revenue for health, and we have worked with the Global Fund to ensure progressive co-financing, willingness to pay and sustainability approaches in funding models. There definitely is a difficulty in getting some countries in Africa to put the value on investing in health that we would put on it, but, as we progress, that argument is holding more and more sway, because, if you do not have the workforce to contribute to the development of a country, that is obviously an economic constraint on that development. I remember, some years ago, going to South Africa to look at AIDS programmes. That was a time when the Government in South Africa was recommending taking a shower as being the answer. I visited Anglo American mining and SABMiller, because it was the corporates that were active in this field and recognising that, with their workforce dying, it was not altruism; it was a good economic incentive that drove them to provide the most phenomenal facilities for their own employees, supply chains and so on. The country then stepped in, and now South Africa has a health system that works in terms of HIV and AIDS. That is the argument we have to continually make: this is a good investment if you want your country to develop economically.
Jeremy Lefroy
Finally, is there any sign of organisations such as the African Union taking a lead in naming those countries that have succeeded in reaching the 15%, of which there are a few, holding them up and almost—I do not like using the word “shaming”, but perhaps let us say “shaming”.
Lynne Featherstone
Naming and shaming.
Jeremy Lefroy
“Challenging” is a better word—challenging all the others and really informing the electorate and civil society in the countries that are well behind—and we are talking percentages here; we are not talking actual money. I mean, we are talking money, but we are not talking actual defined sums of money. Is there any evidence that that is happening?
Lynne Featherstone
I am not aware of that.
Angela Spilsbury
The African Development Bank held a meeting last year, bringing together the Ministers of Finance and the Ministers of Health from the different countries in Africa to talk exactly about the investment case for health. I know that was quite influential in terms of Ethiopia and Zambia’s own internal discussions about what should be done. I am not so aware of the AU, though. They do have a commission on social services and health.
Lynne Featherstone
There are really hard battles that go on, because a lot of the countries I visit are very focused on infrastructure as being the way forward to economic prosperity, so we make these arguments. The only way is to make the economic argument for investment.
Fiona Bruce
Your written submission emphasises its focus on community health workers and birth attendants, and certainly we have seen some very good work—for example, in Ethiopia—on the health outreach workers there. We have been warned in oral evidence that these fashionable approaches should not be seen as magic bullet solutions for failing health services. Could you anticipate DFID continuing to focus on this or perhaps taking an alternative approach?
Angela Spilsbury
You quoted the Ethiopian experience. The health extension worker programme that has been rolled out there has been incredibly successful, giving a very basic level of services to the majority of the population. In 1991, only 30% of the population had access to health services, which is defined as within 5km of a trained professional. In 2013, 93% of the country has it, so they have achieved universal health care. Again, these health extension workers are very good at being able to do a lot of preventative health care and very basic treatment on things like malaria, diarrhoea and pneumonia, which has definitely been responsible for driving down the child mortality in Ethiopia, and they have now achieved their MDG 4 goal, which is incredible. However, the Government and we as partners recognise that there is a limit to how much they can do, and, if we now need to try to tackle the bigger issue of maternal mortality, for instance, we cannot do that with community health workers; we need to have a fully trained midwife or doctor who can deal with the complications when they arise, like obstructed delivery or internal haemorrhage. Community health workers definitely have a place as part of a broader system, but you are always going to need a referral mechanism for referring people up the chain to more qualified health workers with more sophisticated services. It underlies why we have to do a health‑systems approach, because one cadre or one particular service will never be enough; you need the whole package.
Lynne Featherstone
At the moment, we are looking, in a sense, at tertiary education in a number of African countries because of this very need to have a cadre of internally trained health workers at different levels, whether they are nurses, midwives, doctors and so on, as the country can no longer be supplied at the level they need from other parts of the world. They have to be able to be educated and trained in country to a professional standard.
Fiona Bruce
In other words, helping countries have a public health system and a strategic approach towards it is really what you are working on across the piece.
Lynne Featherstone
Yes.
Jeremy Lefroy
Moving on now to making best use of NHS expertise, we have heard evidence that existing schemes to promote greater overseas work by NHS staff are often highly effective, but are fragmented and small scale. Clearly, we have the Health Partnership Scheme, which the Government set up in 2009‑10 and has committed more funds to. What is DFID’s view on this? Is it seen as a fairly small‑scale and marginal piece of work, or is it fundamental to our approach on health system strengthening?
Lynne Featherstone
I think it is fundamentally important, which is why we have the scheme and are continuing to invest in it. I visited a health partnership group—we were trying to remember before where; it began with “W”—in the United Kingdom who go with expertise to a hospital in South Sudan. I visited the Royal Hampshire County Hospital in February 2013.
Chair
You just remembered.
Lynne Featherstone
I just remembered. They work with the Yei Civil Hospital in South Sudan, and it was so fascinating. You, as a Committee, have visited some of these places, and you know that a hospital can be a dirty old room with a bed in the middle and broken windows; it is not necessarily a hospital as you think here. When you say “fundamental”, it really is fundamental, because, as well as the doctors, consultants and midwives who went over, and the amazing partnership working, interestingly, this health partnership said the most important member of the team there was the guy who knew how to fix equipment. It was not the medical staff, although obviously they were very important. It was that donors gave equipment to hospitals that lay disused and non‑functional because no-one knew how to mend it, drive it and make it work. It is beneficial on both sides, so I would say it is not huge in the scale of our budgeting, but it is a very important link between our National Health Service and those in-country.
Jeremy Lefroy
I declare an interest in being involved with the Friends of KCMC, which is a consultant hospital in Tanzania. There are real links all over the place between medical schools in the UK and medical schools in developing countries, particularly with a focus on training doctors, nurses, midwives and so on. What support is the Department for International Development giving, and does it recognise that this is one way in which we can counter the brain drain that has taken place over many years of skilled medical professionals into our NHS, from which we have greatly benefited as a country?
Lynne Featherstone
Yes, and we recognise that and feel very strongly about it. We have something called the Medical Training Initiative. That accommodates overseas postgraduate medical specialists to undertake a fixed period of training here in the United Kingdom for up to two years, normally within the NHS. It is a temporary route, and it seeks to promote circular migration, so that participants in a particular scheme can go back to their home country, taking that expertise and training, and apply the skills and knowledge that they developed in their time here, so that ensures the continued exchange of medical expertise and experience. We support NICE International to help countries improve the quality of the care they provide. We have started a new programme to make more use of the experience and expertise of NICE and UK universities in building countries’ capacities to deliver high‑quality care. In 2006, 57 countries were identified as having a critical shortage of health workers, and that was defined as fewer than 2.28 skilled health workers per 1,000 population. Since then, there has been little progress in reducing the number of countries with critical shortages, so it is a real area. The problem is not just one of numbers; it is the actual mix of skills. The national workforces have critical gaps, particularly among non‑frontline cadres such as public health specialists and health care managers. I would not even begin to go into mental health care in these countries, which is even further behind. We make the UK expertise available to other countries through a number of mechanisms. You raised the Health Partnership Scheme, which has recently been extended. I raised NICE International. We have the Making It Happen programme to improve emergency obstetric and newborn care, and the Medical Training Initiative. As I said, one of the things we are looking at is tertiary training in-country for all of those necessary skills.
Jeremy Lefroy
We tend perhaps to take a slightly silo‑based approach. This is all about health, but given that one of the greatest expansions in jobs and livelihoods in the next 20 or 30 years is likely to be in the health and care sectors, does DFID take the view that this is a major contribution not only towards health system strengthening but also to developing better jobs and livelihoods within developing countries? How does that fit in with our economic development programme?
Lynne Featherstone
I think you really gave the answer in your question. Yes, we do, and that is a very important element of higher-grade jobs and opportunities within country, because that is part of our economy development plan. It is not just all jobs but jobs of better quality with better pay and better accreditations, so that does all fit together. As I say, there is a discussion going on as to tertiary education—we are not there yet—in terms of what can be provided or not.
Jeremy Lefroy
In terms of the Health Partnership Scheme, we are very much focused on volunteers, and that is great. We want to encourage volunteers. I believe the Secretary of State has recently established an African legal fund, which is there to enable professionals, most likely from the UK, to go and support and advise, perhaps on a short‑term basis, Governments over contract. We discussed it in terms of natural resource contracts.
Lynne Featherstone
The African Legal Support Facility
Jeremy Lefroy
The African Legal Support Facility, thank you. I wonder if there is an opportunity around health, perhaps at the higher expertise end, where specific gaps are recognised either on the clinical side or on the health systems governance side, for us to set up some kind of similar facility to the legal facility that enables professionals, who might not otherwise be able to take that time out volunteering because of other commitments, to go on a professional basis.
Lynne Featherstone
I hear what you say. I think there is a critical difference with the African Legal Support Facility, which advises on contract negotiation, vulture funds and those sorts of things, in that there is a high financial dividend from the expertise being dispensed, so that the costs are covered, I imagine. The benefits to the country are huge and immediate in terms of the income that is generated. It is a good idea, in the sense that it would be very valuable to contract out particular specialists. There are some constraints, though, from our own national health system. We come into areas of how much we can afford to do with our own specialists. There is a national volunteer scheme. In the next few months, there is a plan to launch a new framework for volunteering in the NHS. That is a document that has been developed by NHS International Group, with input from the Department of Health and DFID amongst others. That skills transfer at all levels may be part of the recommendations. I do not know if we would be contracting in the same way as the African Legal Support Facility does, which had to be set up in law.
Jane Edmondson
There are also quite often constraints on the country side, on the demand side. We can deal with supply‑side issues, but there need to be demand and willingness there as well. As countries, partly with our help, are strengthening their systems and developing their own regulatory systems, it is about making sure that it is possible to transfer that expertise. We can deal with the supply‑side issues, but the demand also has to be there for that kind of expertise. We also work quite often to facilitate that demand.
Jeremy Lefroy
Has the NHS ever calculated the value to the NHS of the training that they have not had to provide to their workforce who have come into this country to take up jobs? I wondered if that calculation has been done.
Lynne Featherstone
I do not know. We could ask the Department of Health.
Jeremy Lefroy
It would be quite interesting to find out how we benefit as a country from training given in other countries, developing countries, in their own medical schools, which ends up by being of benefit to our population, and to compare that with what we are doing in reverse.
Lynne Featherstone
We would have to ask the Department of Health.
Jeremy Lefroy
Is that not something DFID should be interested in, given that this is a matter of development?
Lynne Featherstone
The issue, where this has crossed my path, is that there is quite a moral obligation, having had particularly nurses and midwives come from a number of countries to support our NHS. I doubt whether our NHS could function without some of the input of people who have come here to work in our system. The issue we would be looking at is how we can develop those countries, so that health workers want to stay in their own country and not come to this country. I am sure we have benefited, and we are looking at where advertising is done and whether anything that is advertised should be advertised here, not to draw people in in the same way. I do not think that is something we have focused on as a sort of quid pro quo.
Chair
The Committee, when it did its post‑2015 report, supported the case for a universal health coverage objective or goal in post‑2015 outcomes. Do you agree that this is a desirable idea and that, if you did have it, it would incorporate strengthening health systems as part of the mechanism?
Lynne Featherstone
This is a discussion that we are having at the moment. The United Kingdom’s position is that the goals should be outcome-based.
Chair
Sorry, does that mean yes or no?
Lynne Featherstone
It means that, while we absolutely support universal health coverage, we are not sure that having that as a goal would be the best way to get to universal health coverage. We think that outcome‑driven has been proved by the last MDGs to be more of a driving force than a goal that does not demand an outcome focus. I do not think there is a difference in the ambition; there is a difference in how we think we should get here.
Jane Edmondson
We support universal health coverage as a target underneath the goal that focuses on health outcome, and that is our current statement in the Open Working Group for the post‑2015 goals.
Chair
That implies that you would not just say, “We support a universal target.” You would say, “in order to achieve agreed outcomes” or something. You would want to reinforce in that way. A particular point has been made to us that the proposal going around at the moment does not appear to include a specific target for women’s health, which is surprising given that is one of the key targets that was in the existing Millennium Development Goals.
Lynne Featherstone
I would be very surprised. Are you certain it is not under the gender goal itself? I do not know.
Chair
The point has been made that it is not explicitly attached to the universal objective. These are all obviously under negotiation and in transition.
Lynne Featherstone
These are all under discussion at the moment, but I would not want that to go ahead without a woman’s health goal being there. I am sure it will be under the stand-alone gender equality goal, but we need to make sure that it is mainstream, because it was meant to have a goal in itself, plus be mainstreamed across all the other goals. That is the United Kingdom’s position. If it has been accidentally missed, I am sure we are still going to be lobbying for it.
Chair
Thank you very much. It has been really useful to explore this strengthening of systems by vertical outcomes. There is quite a bit for the Committee to reflect on as to what are the most useful recommendations we can make that pull those two things in.
Lynne Featherstone
I guess it is not either/or.
Chair
No, it is how you make them work together more effectively, so that one reinforces the other.
Lynne Featherstone
It is always a pleasure to appear before you.
Chair
Thank you very much. Oral evidence: Health Systems Strengthening, HC 246 2