Oral evidence: Health Systems Strengthening, HC 246Tuesday 24 June 2014

Oral evidence, 24 June 2014.

Witnesses

Dr Julian Lob‑Levyt CBE, Senior Vice President, International, DAI, former CEO, GAVI Alliance, and former Chief Health Adviser, DFID, Lord Crisp KCB, and Simon Wright, Head of Child Survival, Save the Children UK, on behalf of Action for Global Health, gave evidence.

Chair

Good morning, thank you and welcome. I am afraid we are probably going to have to finish at 12 o’clock and I will have to vacate the Chair slightly before that. Jeremy Lefroy is going to take over, so again could I ask you to please answer the questions, but be as quick as you can and we will get as much ground as we can covered? Again, for the record, I wondered if you could introduce yourselves.

Simon Wright

I am Simon Wright. I am Head of Child Survival at Save the Children, and am speaking on behalf of the Action for Global Health network, which is UK NGOs working on health.

Lord Crisp

Nigel Crisp. I am an independent member of the House of Lords. I used to run the NHS in England and was Permanent Secretary of the Department of Health.

Dr Lob-Levyt

I am Julian Lob‑Levyt. I have spent most of my professional career working in health and development, including as the Chief Executive of GAVI, as the former Chief Health Adviser in DFID, and most recently with DAI, a broader development company.

Chair

Thank you. I suppose we need to get straight to the key point: to what extent are health systems central to development? That is a key point. We have all our central indicators, but to what extent is that a major priority and to what extent do you think DFID’S approach to that is clear and strategic? Who is going to go with that one?

Lord Crisp

May I start? Perhaps I should have said in my introduction I spend most of my time working in Africa and India these days, so I have some knowledge of what we are talking about here. I think it is fantastically important that health systems are part and underpinning everything that DFID does and needs to. Particularly in a world where we are moving towards non‑communicable diseases as being the big problems for the future, we need to understand how the whole system can work together to deal with those sets of problems. They are not discrete things, like dealing with eye care or something of that sort, and also, as your previous discussion has said, health systems are fantastically important in terms of delivering both quality and efficiency. Here I will just make a very quick point that, where I come from, this point of health systems strengthening is really about how you make the system work effectively. It is not so much about the building blocks. There are five quick things I would say: firstly, it is about things like governance and accountability, which we discussed, and about things like NHS evidence and NICE—the things that make the system work. It is fundamentally about the people. I hope I have a chance to say a bit more about human resources. It is also about systems involving patients and the communities. These are not things that are done to people; you need to be taking that aspect into account. It also of course has to be culturally relevant and not make the mistakes we have made in the West. Also, health systems are messy. Some of the discussion about health systems makes it sound as if you can create a perfect system and, actually, the reality is that you can do things that will start to improve the systems that you have. What you need to do at different times is different.

Simon Wright

We are very proud of where the UK is in its aid work, globally. We reached 0.7% last year. We have also reached, within that, a target that we support, which is 0.1% of GNI being spent on health ODAs. Those are very important things for Britain. Of course, you have heard in the previous session as well about the very many important things that DFID is doing. For us, the reason for keeping a health systems focus and why this Inquiry is so welcome is that you also have to look at issues like equity. Yes, we may be achieving good results with aid money, but is it helping to build more equitable systems? You need to look at long‑term sustainability as well. Of course, we know that health is an area where donors have played a particular part. It is particularly welcome when it has come in, but is it helping to leave a transformed and strengthened health system, which is able to build on those gains? If it is not done in the right way, there is a risk that what it does is weakens that health system and draws staff out from general services into working on whatever particular donor priorities are at that time. That has to be a constant question, which is why it is a very relevant question to look at how DFID is championing building these sustainable health systems, both at national level and especially—an issue that I look at—at global level.

Chair

Could I add in the question: is DFID still a leader in this field? Do you think it is a world leader in health systems and are there particular things that they should be doing or you would like to see them doing that they are not?

Dr Lob-Levyt

I agree with your first question that health systems should be central. More attention should be paid to them and work in that area is generally under‑funded as a result of more disease‑specific initiatives, even though they may have been welcome in the past. DFID should and could play a more significant role in that. Like the last panel, I would agree that, in some countries, they have been quite effective in advocating and working with others to look at those more fundamental challenges. At the global level, DFID has become somewhat weaker, but partly because it has been more fragmented in the way it is both internally organised and the way it presents its views in those very different fora, which sometimes are not very consistently advocated across. As Andrew was saying earlier, that is a very key role for DFID as a major bilateral—its international influencing role of those agendas and where things are going. A little window has opened to paying more attention to health systems and I would certainly encourage DFID to re-seize that opportunity.

Chair

Maybe we can tease more of that out in the next session.

Mr McCann

Good morning, gentlemen. Can I ask whether DFID’s focus on immediate results has been at the expense of investing in health systems strengthening? Secondly, would you perhaps outline the pros and cons of using frameworks such as the World Health Organization’s six building blocks? Do you think DFID should use that system?

Simon Wright

If I could say first of all, one of the concerns we have is that we feel that we have lost DFID as a global, very powerful voice keeping other donors to keep a focus on building health systems, organising their aid effectively, making sure that the principles of aid effectiveness are being followed in each country. In the global debate that is going on at the moment, particularly around universal health coverage—this model that the World Health Organisation and the World Bank have adopted as their top priority—it is quite noticeable, and I hear back from developing country governments as much as anybody else saying, “Why do we not hear from the UK on this? You have an NHS. You have this model, but we do not hear you talking about it much.” Ironically we have a situation where the US Government, because of the reforms they have done to their health service, is very keen to champion universal health coverage globally, and the UK Government we are not hearing from so much. That change has definitely happened. We know when Andrew Mitchell came in that we saw a much stronger emphasis on how we show effective results from the spending of British aid money. They are important questions, especially at a time when aid is under attack. It is very important to be able to show demonstrable outcomes. We would not disagree with that at all. It has been incredibly important. If that is the risk, has it been at the expense of the more general influencing of countries to try to build the sustainable health systems that are going to take up this responsibility when aid money stops, which have to do the topics that have not become donor priorities. Donors choose particular topics that they want to have an impact on; governments need to plug those gaps by funding the other bits of work. That only happens if they are able to build a properly financed, properly staffed health system, which is taking on the responsibility of providing essential healthcare to the whole population. That seems to have been weaker. There are definitely good examples, and a lot of DFID staff at all levels subscribe strongly to the same sorts of principles that I am talking about. DFID staff are the world leaders in that and often have been. What we are not hearing is that it is a top priority coming from DFID. A number of international fora—the World Health Assembly, UN General Assemblies, the Third Global Forum on Human Resources for Health last year—were all great opportunities where we would normally have expected the UK Government to be there and very visible, but we have not seen them.

Lord Crisp

Very simply, I agree with those points. Actually, if you are going for specific targets or short‑term issues it should be done against the context of the bigger picture; otherwise it can be self‑destructive. I suspect that there are examples of both that being done well and not being done well from DFID’s point of view. I also think there is the second point that Simon’s made, which is the potential better relationship between DFID and the NHS, using the NHS and using some of our knowledge of health systems more effectively, and the whole debate about universal health coverage, particularly on things like quality.

Dr Lob-Levyt

I completely agree. Short‑term results have driven the way health is being delivered at the expense of broader longer‑term health system building. You can get around that with some of the more sophisticated indicators that could be used. DFID would hold some of those global funds accountable whilst at the same time delivering results, ensuring at least that they are doing no harm to health systems, but also actively contributing to broader health system delivery. That would be a concrete thing that could be done.

Mr McCann

You move on to the second element of my question, because obviously when we visit in country one of the things that we are very keen to see is sustainability. The question that we always ask is: when we leave, what are we leaving behind? Is it all going to collapse behind us? This is really getting to the heart of the matter. In the last panel, I mentioned the different percentages that have been suggested that DFID actually spends on health strengthening. In order that we can make sure that the Department is accountable for the money it spends and it is doing what it says it is doing, what changes would you make to make it easier to hold DFID to account for how their health resources are allocated?

Simon Wright

As part of the preparation for this, a number of organisations did some looking into how we can track DFID’s spending on health systems and it is quite hard; there is a coding for OECD reporting on health system spending that is pure health system spending. Save the Children had a look at it. We came up with 21%; I think a different organisation came up with a bit lower, around 14%. We do not know exactly, but we ought to be able to get from that to pure health system spending. What we will never know is, of the spending in other categories, how much of that is health system strengthening. That needs to be investigated much more clearly to have good data, because what you call health system strengthening can be a huge variety of activities as well. Yes, if you decide to support some work, such as the bed net distribution that Jeremy Lefroy was speaking about, then you may pay the health service staff to be involved in that activity for a period. Do you count that as health system strengthening or might you count that as potentially taking them away from their everyday work by delivering on one particular priority for a period. We do need some indicators. DFID has a results framework, which it has issued, which does not have any system indicators; it has outcome indicators and those are very important, but many of those you cannot see within a very short timeframe of two or three‑year aid projects, so you will also want to see some system indicators in there. We would encourage DFID to start using some of those as well as part of a broader health strategy to identify some measurable and accountable indicators for its work in terms of trying to build more strengthened health systems. Of course, you would use the building blocks or the WHO models for indicators for health systems strength.

Lord Crisp

The point I was going to make on this was to what extent the country itself is assessing that it has had its system strengthened. It seems to me that is where you might want to start, rather than with the inputs from DFID. The question of exactly what indicators you would use there would obviously need to be worked through, but I do not see why, in principle, they should not be particularly different from the way in which you measure health systems in rich countries. There has been a recent assessment, as you will know, of 11 of the richest countries in the world’s health systems, and they are about things like equity of access; they are about what people pay; they are about some very high‑level results and so on. There seems to be no reason why one should not be using the same sort of indicators as you would be using. I take Simon’s point that they may be longer-term but, even so, that is the trajectory they should be on and Governments anyway should have some kind of notion of what they are trying to do. It seems to me that would be a much more effective way to pick up on this and also to start to get people to focus more on the fact that, whenever you do anything, you affect the rest of the system. You have to be thinking in systems terms. The WHO building blocks are fine but, actually, building blocks could be put together in such a way that they turn out a lousy system. The key, right at the beginning, is that how the system works is really important, not whether you have good particular bits, but how the whole thing works together.

Dr Lob-Levyt

Could I disagree with Nigel on one particular point here? I agree with everything that both the folks here have said, but this assumption that least developing countries’ health systems are so fundamentally different from richer countries’ health systems I really would question. The pace of change now that is occurring in sub-Saharan Africa and elsewhere, the people who I meet and talk with, these are highly sophisticated people. There is strength in depth where there did not used to be. The world has fundamentally changed and it is also changing extremely fast. Certainly from my conversations with ministers of health and others, they want access to the best international expertise and there is not an assumption that they want a second‑best health service. This goes for some of the poorest countries. I actually think we ought to reassess this assumption that they need to be treated in some way differently. There is a lot to learn and a lot that can be shared with the National Health Service. More could be done in that area.

Lord Crisp

That is what I said, actually. You misunderstood. I said: why should they not be judged in the same way? Why should they not judge their health systems in the same way as we judge ours?

Mr McCann

Another supplementary question: would you agree with the statement then that, in terms of how we do that work, we have to ensure that the balance between outcomes and the balance between systems strengthening are blended to ensure that one does not eclipse the other? Would that be a statement that everybody would agree with?

Dr Lob-Levyt

As the last panel said, it is about, with a particular state of development of a country, with its particular level of financing, what the health outcomes or the health services are that should be delivered. What is the most effective integrated public and private, primary and secondary, system that can deliver that to the population?

Sir Tony Cunningham

DFID channels a large share of its health spending through multilaterals. What is the impact of this on DFID’s accountability for its health system strengthening work, and that includes the World Bank and the EU?

Simon Wright

Of course, it is at one remove. On one level, of course we want more multilateralism, because that is better coordination of aid than necessarily bilateral support based on particular topics, but it does take DFID one step away from accountability for that. That is definitely true. As the earlier panel said, it depends on the institution. At the moment, the World Bank is very clear on helping countries to build sustainable health systems under the banner of universal health coverage. Starting to look at how you might measure that, what we mean by that and how we answer the accusations that it is just a fantasy that countries could provide all services instantly to all people, the World Bank is coming back with strong answers saying that, actually, it is about identifying who you cover, what kind of contribution they make and how they make it, which services you provide and how you choose. NICE is a very good model for how you look at the cost‑effectiveness of different interventions and decide which you can afford to introduce at which stages. The World Bank is playing a very strong role in that. I have been involved in the civil society grouping around GAVI. GAVI has had a target from Julian’s time really, when he was Chief Executive, for health system strengthening as an activity of GAVI’s work. Now, we find it quite hard to track that; it is quite hard to know exactly what impact that has. There has been a lot of debate about how much GAVI is responsible for helping to build a comprehensive health system for all health needs, or how much it is about trying to build an immunisation system for immunisation outcomes. There has definitely been a tension between that. Our argument has been that, if GAVI is serious about increasing equity of coverage, getting to the poorest, most marginalised communities, and making sure that its services are not just getting to the easiest‑to‑reach segment of the population but getting to the hardest‑to‑reach, then you need to have work that is going to build a functioning health system, especially because that is what is going to take on the long‑term responsibilities. That is delivering the vaccines, even with GAVI’s support. Long term, it has to make sure it gets immunisation to all children, so it depends on the institution. A key question of multilateral aid reviews should be: is this work contributing to building a strengthened comprehensive health system?

Dr Lob-Levyt

It depends on the institution you are looking at. The WHO has highly fragmented funding; different donors and different agencies pick their favourite topics and fund them, and that can significantly distort the priorities that the WHO might want to set.

Sir Tony Cunningham

It is difficult for DFID to track that.

Dr Lob-Levyt

It is difficult. DFID can play a role in looking at where those gaps might be and also working with us to make the WHO’s life easier, in some ways. Also for the global funds, whether it is the GAVIs or the Global Fund to Fight AIDS, TB and Malaria, how the donors and the boards choose to fund that has a significant influence. I agree very much with what Andrew said: I think that the framework by which the GAVIs and the global funds work is becoming very narrow indeed on the health systems side. It might be fine if we acknowledge that, but do not pretend it is doing anything broader than just ensuring that its particular interests are being well funded.

Lord Crisp

This makes the point that was made earlier, does it not? Actually, the UK and DFID have got a significant role in influence and still have a significant role in influence. If they were clearer, perhaps, about the priority they are giving to health systems strengthening and some of the key aspects, then they would be better able to influence.

Sir Tony Cunningham

Second question: what in your view have been the consequences of DFID scaling down budget support?

Simon Wright

It is quite difficult to know exactly what is happening. DFID is going to move away from general budget support, and that goes against many of the principles of how to provide aid in the most effective way, which gets behind national systems, which helps to leave strengthened national systems. There has probably been an increase, we think, in sector budget support, so a move away from general towards ring‑fencing aid towards certain sectors, but allowing some flexibility with that. Actually getting the data is very hard, because what each donor counts as sector budget support can be quite different, in much the same way as we were saying earlier. It is quite hard to know, but it would be my estimate that while it has increased, it probably has not kept pace with the increase in aid overall, because we have seen multilaterals and bilateral aid benefitting more out of those increases. Generally, budget support is meant to be money that goes to the Government for it to use to support its priorities, of course with agreement on overall outcomes and overall indicators. Those are very important to have in place, because it is not just free money for no purpose; it is meant to get in their own providers and support to assist them. The less we do of budget support and the more project aid we do, the more we are looking for short‑term outcomes on very particular topics, the more we are expecting often quite unrealistic change from a two or three‑year project and, I fear, the less we leave a strengthened national system behind.

Lord Crisp

I would turn it on its head again, actually. I think that is absolutely true, but maybe what DFID should be doing is helping the recipient Government to hold us to account. I think it was mentioned in the earlier panel—forgive me; I arrived slightly late—that there is this problem with all these donors doing different things and operating off their own priorities, and so on. You need a strengthened governance system within the country itself in order be able to steer the donors in a more effective direction. Therefore, whilst there may be a problem about not giving relatively untied aid, which is what I understand budget support to be, actually if there was some focused aid on helping people with their governance, planning, development and health system strengthening, they would be better able to make sure that the stuff we did and the stuff the French did, if they are doing anything, and the Norwegians, the Americans and so on would be better used.

Fiona O'Donnell

Could I just quickly ask, Simon, do you think that DFID is rigorous enough in monitoring the impact of its aid that is spend on private sector health providers?

Simon Wright

Recently we have had some evidence that suggests that that is not the case. Actually, when a lot of the outcomes that were talked about are investigated—the transformational outcomes that are expected from the private sector—there is not really any strong evidence for that working. I would say that the evidence suggests that DFID is not strong enough on that and that there is a faith in the role of the private sector, but without necessarily the hard evidence to either justify that focus or for the outcomes. We all recognise the importance of the private sector: of course you want a vibrant private sector for employment, for commercial, for the economy in a country. The private sector is always involved, to some extent, in the provision of services within health as well. We hear a lot, and we hear it from all governments—it is not just from DFID; we hear it from many international institutions—around, “Let’s look to the private sector for solutions”. Actually, the private sector is good at spending our money; it does not generate our money. It does not find any more from new sources to put into health services. It is a way of us spending money, which is raised from our own pockets of course or the pockets of citizens of countries. We do need to be asking some very tough questions about when it is appropriate to use the private sector and when that is a distraction. If you want to build health services, the evidence suggests that public health services, publically funded through mandatory contributions, which the whole population contributes to, and then organised under government stewardship, are the way of delivering a fair healthcare system. You might have private providers within that, as long as it is stewarded strongly from Government. There are a lot of moves towards and lots of championing of different community‑based health insurance, private health insurance models, which are seen as voluntary ways that maybe people might contribute more. All the evidence is they may work for a small segment of the population that might use those, but they do not build more equity and they do not build universal systems.

Sir Tony Cunningham

Julian, do you have any comments to make on my final question?

Dr Lob-Levyt

On the private sector?

Sir Tony Cunningham

No, on scaling down budget support.

Dr Lob-Levyt

The evidence that we have heard is that budget support has not led to governments putting more of their own resources into the social sectors and health in particular, and that is a real concern. When you talk to ministers of finance in developing countries, they are pretty clear; they say, “The donors will pick up the health budgets. I am going to focus my resources elsewhere.” We have to move beyond that.

Jeremy Lefroy

If I am a parent in a developing country, the thing that matters to me most is that my child can get vaccinated, and my child has access to things like ACTs, paediatric ampicillin and the ability to get tested very quickly. All of these things have been delivered by the Global Fund through things like the Malaria Consortium or other partners that they work with. What really concerns me is that a move back towards health system strengthening, which I entirely support, will run the risk of taking our eye off this incredibly important ball, which is so vital to everybody, anywhere in developing countries. I think at least two of you have said that DFID is no longer exercising this kind of leadership role. I want to drill down a little bit in health system strengthening. I want to drill down a little bit and ask: please can you give me some examples in specific countries—I am not talking about the generalities, but specific countries—where DFID previously was very much engaged in health system strengthening where it is not now, because I want some evidence of the fact that you are saying that they are concentrating less.

Simon Wright

It is a good challenge and I think we have some, but could probably find some more for you and provide them in written evidence. There are countries like Liberia, which you have just visited, where the UK Government played a key role in getting Liberia to look at its health system and how it is functioning, especially the removal of user fees and the decision to provide healthcare free at the point of use.

Sir Tony Cunningham

Which has made a huge difference.

Simon Wright

Yes, absolutely, and has transformed the relationship between Government and their citizens around healthcare access. It goes to all of the concerns that you were expressing around if the family knows when a child is in pain or has something wrong with them, but they cannot tell what it is, or they need to make sure the child is vaccinated or protected, is the health service there and functioning, and can they go to it? All the evidence was that cash payments meant that that family might need the care, but they did not go forward for it, because they knew they would not prioritise that with the cash that they had. Recently, we know that Liberia itself is considering reintroducing fees for certain services, so it is considering reversing that principle. Which services? It is not saying necessarily it would be the most essential primary care services; maybe it is looking at other things, but we have heard—and Mary Macleod, one of your colleagues, came with us to Liberia, where she met the health minister, Walter Gwenigale, where he was saying, “We need DFID’s help. DFID has been a champion in this and DFID has been helping us to make sure that we have free healthcare in Liberia.” DFID is now considering at the moment whether to continue its support to the health sector in Liberia, or whether it decides not to focus on health in that country. It is not just the cash support; it is actually the influence that that cash support has given it that we fear is missing. The question we have raised a few times, particularly last year with the Secretary of State, has been whether Britain is going to carry on being a champion of building the kind of health system that, based on the evidence, is what can provide those services. We are not hearing that back at the moment from the Secretary of State.

Chair

The agreement was it was up to Liberia to build in the sustainability, but they have not done it. Part of the reason they have not done it is that the minister of finance has decided, precisely as Julian said, to spend the money elsewhere. DFID is saying we have been conned into extending something, when there was a clear understanding.

Simon Wright

That has been the condition in Sierra Leone as well.

Jeremy Lefroy

Something was specifically designed that was then spent on other things. That is not DFID’s fault and that is not DFID’s decision.

Simon Wright

True. We heard from the health minister that he would find support, direction and encouragement from DFID around continuing with the free healthcare initiative to be vital for its continuation, but I take your point on those other factors.

Dr Lob-Levyt

It is not just DFID; it is the context that DFID works in. To assume that DFID can fix all of this now, it is that influencing role in the country and more broadly. Let me give you a specific example of a country that I know reasonably well, which is Rwanda, and how that changed. When I first visited Rwanda some years ago, whilst I was with GAVI, visiting one of their district health services, I was very struck by a chat to a woman who had come up and brought her baby, who had a rash, to the clinic. She was HIV‑positive. She was there to pick up her medication. She wanted to take her child to be checked up; her immunisation was out of date, but that part of the service, funded separately, was not open. She had already walked 15 miles to get there. She also wanted to pick up her husband’s TB drugs, but that part of the service was not open. That is just complete nonsense, and that was a direct consequence of the separate fund streams by donors at that time. Visiting later, more recently, with a very strong minister of health, who said, “This is complete nonsense”, she was very adept at manipulating the donors into ensuring that services were integrated. It is the same group of health workers so that, if a mother turns up, she can get her kid immunised; she can pick up her HIV drugs and pick up her husband’s TB drugs. That is what we should be aiming for.

Jeremy Lefroy

I entirely agree, but the narrative is that DFID is moving away from such things. The Liberian example is a partial example and we will look at the decision potentially to move funding from the Health Pooled Fund to WASH, but you could argue that WASH is an extremely important part of public health, so it is similar. What I am looking for is clear evidence of this narrative of DFID not engaging at country level. I accept that there may be some things globally. We have all said that countries are individual; they have to make their own decisions, so it is at individual countries that it counts. I want to see clear evidence that there are programmes where DFID was engaging five years ago very meticulously with governments locally, and is not doing so anymore, because I have not seen that on the ground myself.

Dr Lob-Levyt

I think you are probably right. That probably is not the case, as you say exactly. It is these large powerful institutions—the GAVIs and the Global Funds—that then descend, where DFID also sits on those boards and should be influencing them to change their behaviour.

Jeremy Lefroy

We need to get this clear. What we are talking about is that it is at global, WHO‑type level where there is the concern, but getting involved bilaterally or even at a local level through multilaterals, DFID is still playing an extremely strong role there. It is very important to differentiate between the two, rather than just saying, “DFID is not engaging in this, full stop.”

Dr Lob-Levyt

DFID is playing a positive role from my experience—and I do not know all countries—at that level, but it is challenged in that it is now dealing, as countries are dealing, with a multiple series of initiatives. They are here to stay; they are not going to go away. They deliver results. It is about moving beyond that early stage of short‑term results to long‑term how we are going to finance and organise their health systems. It is an opportunity to seize. We have been through a useful phase of increasing funding to very important diseases; it is now about trying to get organised and make that more rational, efficient and accountable to the community.

Jeremy Lefroy

If I can just move on to the importance of community and faith‑based organisations in various countries—I am thinking specifically Zambia, where at least 50% of their health facilities are provided by faith‑based organisations and are reasonably well‑integrated into the Government system—is DFID engaging with them as an important part of health systems, or does it tend just to work with state‑run, nationally run organisations, as opposed to faith‑based or community health organisations and facilities?

Simon Wright

On this and your previous question, I would like us to come back to you, and I think we can, with some more national examples, because I think they do exist. It is just with the way that an aid project is shaped, the kinds of outcomes and indicators that are put into that would be quite different. I know from Save the Children, from the work that we did with DFID funding, we are often asked to come up with more outcome indicators within the short term and less that would let us do work that is around influencing the very factors of the health system and how it is going to be sustainable, so I would like to come back on some of that. In terms of working with NGOs, with faith‑based organisations and other non‑state actors, the ideal situation is that those are integrated into a state‑led health system. That is very important. Actually, the more that you bypass that system and work with other actors directly, the more you undermine that system, the more you reduce people’s expectation that their Government is going to be accountable for the delivery of their healthcare. I hear it many times when I go to areas; you hear communities say, “Oh, it’s fantastic. We go to the Methodist Hospital”, or “We value what Save the Children is doing”, or “We value what Sightsavers is providing in this area”. You hear all of these things, but that reduces the expectation that governments are actually the ones that should be accountable. Your local councillors, your members of parliament, and your Government are the ones that should answer to their citizens around the provision of healthcare. It must be integrated into the system. As I said before, using different types of actors I think is very sensible. It makes lots of sense in lots of health systems to try to do that, especially where it is cost‑effective, where they have some of the infrastructure there to try to deliver, but it is not a substitute for a functioning system. The Government is going to be the one that takes the step back and says, “Are we covering the whole country? Are we covering all wealth groups? Are we covering all ethnic minorities? Are we providing healthcare in a way that is aware of gender or other areas of discrimination?” We do need to rely on governments to do that. Again, I am not going to quote some hard national evidence, but I would like to commit to trying to see if we can provide some for you. We would find DFID probably working a little bit more, encouraging the use of non‑state actors. My fear would be that, in some cases, you might find examples of where the funding goes directly to those without necessarily being well coordinated by the Government and that is when it is a negative, I would say.

Dr Lob-Levyt

In particular, the Zambian Government does support the church. It is part of the system and it is integrated with it. I do not think internationally NGOs like Save the Children—with apologies—should be running clinics in countries. I think that is a retrograde step. It should be national if at all possible.

Jeremy Lefroy

Very much accepting that these non‑state institutions, whether community, faith or private, should be within an overall framework, one thing that was brought out quite strongly to us during our recent visit was this whole issue of parliamentary accountability. NGOs in particular are very good at bypassing parliamentarians and not engaging at all with the legislators and the people who are supposed to represent their communities. NGOs often talk about some accountability but, actually, the very people who are supposed to be accountable are the local members of parliament. I wonder whether you would like to say anything about that and whether NGOs need to up their game in terms of working through the local accountability mechanisms, rather than just deciding that they want their badge on every project.

Lord Crisp

May I give you a couple of examples of that? I do agree with that. If I take the example of Zambia, as we are on Zambia, I happen to chair something called the Zambia UK Health Workforce Alliance, which is chaired by myself and the High Commissioner from Zambia to this country. It is precisely about NGOs trying to get their act together. We run conferences twice a year, one in Zambia and one here, and the minister comes from Zambia to talk to the NGOs in this country. This is just a step in the water; we also run one in Uganda. This is only a step in this direction, but hopefully DFID’s new partnership scheme will now start to support these alliances as well. If the Brits at least can get their act together—at the last conference we were at in Lusaka, the permanent secretary who was chairing it with me said, “If you foreigners got your act together, you would double my budget. As it is, you add 20%.” That is a slightly different point from your one about accountability, but British organisations in Zambia and Uganda that join these alliances commit themselves to working within the framework. I think we could do more with that. I actually think it is even more important that Zambia and Uganda assert themselves in this area, rather than waiting for us to do it but, at the moment, we should be pushing down those lines. DFID has been broadly encouraging of us doing that.

Chair

Lord Crisp, I know you are keen on community health workers and we have seen them in action, particularly in Ethiopia, but to some extent elsewhere. That seems to bring together both prevention, by definition, health education and access, because you have a single channel. Do you think there is more scope for developing that as a system, and do you think DFID should perhaps give it a higher priority?

Lord Crisp

Thank you, yes. Let me be clear: community health workers are part of a system.

Chair

I appreciate they cannot do everything.

Lord Crisp

When I have talked to ministers of health about this, they have actually said to us, “Look, we can broadly train our own community health workers and actually most of our mid‑level workers. Where we really need your help is in the specialities.” In Zambia, for example, we support specialist training in five areas, which is not done within the country. I think DFID could do an enormous amount more to do this, because this is the health system. Other aspects of it are important, but actually having people on the ground is the greatest shortage in Africa. I could say more about this and maybe this might be something I might just drop you a note about, because I am conscious that you are conscious of the time.

Chair

The only other point I was going to say was just what you have just said. It will vary from country to country, and the priorities will vary, but are we sure that we inform ourselves enough by what works on the ground, when we are doing that kind of thing? I take your point that, as indeed in Ethiopia, you train your own community health workers, but you need to know what the rest of the system is for that to work.

Lord Crisp

Exactly right. In Ethiopia, the particular problem has been that the higher professionals have not accepted the community health workers. I think we need to do that, but I also think this is an area where the UK can do a lot more in terms of using our experience and expertise. I have talked to a lot of health ministers, as part of running a programme for new health ministers at Harvard, and one of the biggest things they want is education and training of health workers from the UK. DFID does a certain amount of that, but we could do a lot more. We have benefited, obviously, from skilled health workers coming to our country from other countries. We could do a lot more, it seems to me, to support the training and education of health workers, in their own countries, using our people. There is fantastic enthusiasm for it.

Chair

They tend not to leave the country.

Lord Crisp

It is cheaper and, candidly for some of our people, this is two‑way. It is a point that both of us were making earlier: this is one world. We are in it together and our people can learn from working in other countries, just as other people’s people can learn from working with us.

Dr Lob-Levyt

It is something that needs to be approached fairly systematically as well. If you look historically over time, community health workers have been seen as magic bullets for under‑funded and poor‑performing health services. It needs quite a good level of integration and sophistication, linking into that system of secondary referral to give credibility to make it work. Ethiopia and others are making some progress and we are learning lessons from it, but it is certainly not a magic bullet. There is a real risk that some institutions are going to rush in to funding it as yet another initiative.

Simon Wright

There is a risk that community health workers are being asked to deliver more and more services, particularly with aid money coming in from donors, which involves training community health workers in a new technique or a new condition or a new piece of work. These are people who, by the nature of the training, by the nature of the amount they are paid, are not going to be able to take on huge amounts of responsibility. They are right when they are used well, but there is a danger that too much emphasis is put on them. We celebrate the fall in the under‑five mortality rate, which has been achieved, and a lot of that has been achieved by vaccination, by bed nets—bed nets community health workers have a particular role in—and identifying childhood illnesses and getting children quickly into treatment. Where we are not seeing a fall is in the new-born mortality rate—deaths within the first 28 days. Generally that is because what you need there is a trained health worker who can support a woman during labour and who can act quickly if there are complications during labour. That is not something a community health worker can do. A health system actually needs to build that type of health worker, and get them in place, in reach of every birth. We must look for the short‑term solutions—the quick wins—but we must also build the long‑term change as well. There is a danger that aid money has a pressure towards the quick wins.

Lord Crisp

I would not over‑estimate that. I think more and more people understand that this is a system and there is a lot of evidence now about what works. The same is true for our country, where nurses do prescriptions now, which they did not do before. People have changed, and you must have a much more flexible workforce. That is the general point that is being made.

Chair

People recognise in Liberia that community health workers are not midwives.

Fiona O'Donnell

Julian and Nigel, you have both said that you are enthusiastic about better cooperation between the NHS here and health services in developing countries, but we have been told there is some resistance within the NHS, with people concerned about their career progression and services concerned about losing staff. I just wondered if you wanted to take the opportunity just now to make a pitch, because there is only £10 million just now spent on this scheme in the UK. How would you make the case for a bigger budget and how would you tackle those barriers?

Lord Crisp

Are you talking about the Partnership Fund?

Fiona O'Donnell

Yes.

Lord Crisp

Internally, what you will find—and I have talked to lots of people around this—is that individual nations may be enthusiastic, but they may find there are some practical barriers, in some cases. People can get around that and the enthusiasts do get around that. There is a fantastic amount that is happening. One of the big keys here, though, is to make linkages with health education in England. I had some doctors come to see me yesterday from Bristol. In GP training, you can take a year out. Do you go to Australia and have a good time or do you go and take a job in South Africa or in Zambia, in the government system for a year, where you are making a contribution but you are also gaining hugely from it? The third year in GP training, for example, is what they were specifically talking to me about. There is an organisation that facilitates that happening, which makes sure that you can get yourself on the register, you get insurance and all this kind of stuff. You get payment from the South African Government at the South African rate. The argument we are now putting to Health Education England and others is that a small facilitating amount of money would allow that to become systematic, so that of the 6,000 doctors who go through student training every year, a proportion of them may be able to do some work within a government‑funded job somewhere, on a systematic basis, and contribute.

Fiona O'Donnell

That is not just happening within NHS England though. Is it also happening with the devolved health systems?

Lord Crisp

To be honest, Wales is ahead of this. The Scots, I think, also do something, but I was thinking NHS England; you are quite right. It is happening in other countries too. There is a proposal in front of USAID that doctors doing this should be let off a proportion of their student loan, as an incentive. That is something again we will be proposing, following my meeting yesterday, to DFID, because actually there is a potential great win‑win here. We have people who understand health better because, if you are a doctor in London, a GP, the world walks in your door. You are a gate in global health. I think there is a lot more that can be done about that to make it systematic, and I think that is probably the level where it is easiest to do it. I would appreciate more money for the partnership schemes, but that would probably the level I would give priority to.

Dr Lob-Levyt

I have three brief comments about that. One is that West Bengal in India is already buying the services of the Royal College of General Practitioners for developing diploma programmes, paying for them itself. You are going to see more of that. Linking professional groups internationally in this way is something that should be encouraged and has a value. I also think that with the joint working of DFID and the Department of Health on global issues, I have not been in it recently, but it was always difficult and quite a strain, particularly over the WHO. The Department of Health leads the relationship with the WHO, and DFID has different sets of priorities and agendas. That was not always, in my experience when I was Chief Adviser, to be honest, an easy experience. It was nothing to do with Nigel; I think it was before Nigel’s time.

Lord Crisp

I understand what you are saying.

Dr Lob-Levyt

That is one where the two Departments could work better together. I also think, as we were saying earlier, there are a lot of other kinds of expertise in the National Health Service. We also discussed NICE, but I think there is expertise in management and organisational management of services, which is now globally appropriate to many developing countries. How do we do that? Do we now encourage some of that skill set to come and sit in DFID for a while to help them develop their programmes, interactions and relationships with the Department of Health? Do we need those kinds of skills at running services embedded within DFID itself and into its programmes? That needs to be funded. DFID has a reasonable budget; it could decide to fund that and decide to put a certain amount of funding into those kinds of innovative and new relationships.

Simon Wright

The only thing I would add to it is that I think that there is a lot of expertise in the NHS that is not necessarily doctors and nurses, although we have a key role in helping to train training institutions in those countries—that is the question: to make sure it is sustainable—but around health financing. Britain has the experience of funding a universal health care system, set up in a time of austerity, when there was not a huge amount of funding, and making quite tough decisions about which services it provided and when and to whom. That expertise would be of huge use to countries as they try to both raise funding and organise funding for health systems.

Lord Crisp

This was my point about understanding how health systems work. Engaging people who have run systems in those sorts of questions is really quite important.

Sir Tony Cunningham

I just wonder if DFID’s existing approach to health equips it to tackle major emerging issues, such as non‑communicable diseases, ageing populations, the growth of urban slums and issues like this.

Simon Wright

At the risk of repeating things from earlier, that is the reason why you need a functioning health system. It is clear that certain issues get to the top of the donor agenda, and then there is money for those, for a period. Sometimes those priorities change. One big issue with the Global Fund is that it is providing antiretrovirals to quite a large number of people that are keeping them alive. That is an open‑needed commitment that is needed, and yet donors are talking less and less about HIV, for example, and talking more about other topics. Therefore, you have to try to make sure that, whatever the work is, it leaves a strengthened, comprehensive system there. NCDs in particular are generally not addressed through quick wins, unlike infectious diseases, and so they do need a long‑term functioning health system, which is going to manage diabetes, support healthier behaviours and is going to be able to deal with chronic conditions over the long term. The risk is that, if a health service is judging by quick results, if we have looked at certain disease priorities but not at others, then we have structured our aid money and, therefore, influenced health systems to deliver on those and not to be ready to deliver on some of the long‑term NCD issues.

Dr Lob-Levyt

There is a very strong argument that, having sustainable health systems, you will see that decline in infectious diseases. There is a necessity—you could argue about that—for vertical funding. You are now seeing that double whammy of diabetes, hypertension and chronic disease coming in, and in many developing countries that is actually where the burden of disease now lies. You need this more integrated and better platform to help deliver those emerging priorities, which are not funded by donors at the moment. That is where the challenge for ministers of health in developing countries is. If you talk to them and say, “These are our priorities now but we are now getting no funding for this, and we are being dragged to these separate rather old priorities”, they are still necessary to fund but in decline compared to this double whammy that they now face.

Fiona O'Donnell

On the Millennium Development Goals, what do you think they have contributed towards progress in terms of child health? I know that, Simon, you mentioned the particular shortfall in new-born mortality. What do you think are the best indicators and targets for health going forward to post‑2015? I just wondered if you would comment generally as well on universal health and what that actually means, because it could mean different things in different countries and in different settings. Is it going to rely not on the model you have spoken about, Simon, but on private insurance? Is it actually the best way to focus going forward?

Lord Crisp

Maybe I can start with two very quick perspectives. I happen to co‑chair with Meg Hillier the All‑Party Parliamentary Group on Global Health. We got a group of other All‑Party Groups together to discuss this, and the single thing we came back to links those two points, which is what is happening to the poorest 10% to 15% in the country. That will be different in different countries, to pick up your point. There is a famous saying from Agnes Binagwaho, the minister of health from Rwanda, which is basically: if you get it right for the poor, you are going to get it right for everybody else. I think that is right and I think that is where we should be looking in any future goals. It is what is happening with the disabled and the poorest people who end up in that bottom 15%. Therefore, with another hat on, at Sightsavers, which I happen to chair, one of the things we have been arguing very strongly for is the disaggregation of data at that level, so that the goal is not the universal one, but it is actually if we are sure about what is happening about disabled people. Are we sure what is happening about women? Are we sure what is happening about different ethnic groups in communities? It is a focus on the poorest and the most disadvantaged in the community, which will be different in different countries. Frankly, going back to the theme that I keep hammering, Britain is part of the globe. When we are talking about this, we should be thinking of such targets applying to ourselves as well.

Fiona O'Donnell

Yes, exactly—inequality of health outcomes here too.

Dr Lob-Levyt

The Millennium Development Goals did powerfully shape agendas in health. There is no question about the 2015 goals. They helped drive a lot of the funding that resulted behind that. As we heard from the earlier panel, you have a slightly broader and more inclusive, possibly sustainable, agenda, even though health systems may not specifically be mentioned. We also have—and we know from research and other work—a good set of indicators that could be applied country by country, at different stages of development, which would help drive that. That is certainly what we hope DFID will continue to argue for, as we go forward. It will be captured otherwise by the foundations and others with their specific interests around specific diseases or specific technologies or specific ideas. It may have less value in this very fast‑changing world. I personally was very active in advocating for the kinds of goals we had for 2015. On this side, because this world is changing so fast, I think there is going to be less driving of agendas, because capacities and skills are changing. The international connections are changing. Aid dependency is in massive decline. The biggest challenge for DFID in the next five to 10 years is what justifies itself. What is its role? How is it going to shift to this very fast‑changing development world?

Simon Wright

I must just add that there are lots of lessons from the MDGs. One is that donor money did get behind some of the identified priorities, particularly HIV and, to an extent, malaria and TB, less perhaps to some of the priorities around child mortality, where aid money actually is more around catalytic change in the country. As UNICEF has done quite a lot of work on, the big fault with the MDGs was that there was no equity element to the data, so it looked at national averages. If you took a national average and wanted to reduce it, what they have shown is that, in some countries, the indicators have probably hardly changed for the poor. What they have been able to do is make improvements for the wealthier quintiles in the country. The same would be true if we had the data, I am sure, on ethnic minorities. One of the things we are calling for in the next framework is to say that no target should be regarded as achieved unless it has been achieved in every section of society, both on the wealth quintile and where you can get other data. That would be very important, because I think we would be able to show than the MDGs have not been achieved, even in the countries we celebrate. For the poor, they have not made that much difference. UNICEF has said in that, in some cases, they have even made things worse on some indicators, for the poorest. The answer to that is of course universal systems. UHC is much maligned and deliberately misunderstood a lot of the time, I think. There is a huge debate about what it is. For me, it is generally around health systems, but it goes a little bit further, because it is political and it is about a Government accepting and speaking to its responsibility to ensure that its whole population can access an essential set of services, and identifying what those are and how they are going to be funded. That is quite revolutionary in many countries, where really a lot of essential healthcare is left to chance.

Fiona O'Donnell

And free at the point of delivery.

Simon Wright

Generally, with UHC, I would argue—and this is the evidence—that the accepted framework is reducing to make sure people either are not pushed into poverty by the way they have to pay for it—and generally cash pushes people into poverty, so they have to come up with cash—or the accepted framework around UHC is to try to make sure that there is risk pooling. Acceptance of that responsibility is such a political step. There is some good work the World Bank has done, where they have looked at citizens who understand their countries. Their governments have made a commitment to UHC, and they are now better at holding the governments to account, because they start to have an expectation and you are not leaving it to the chance of whether there is a good, charitable hospital, a faith‑based service provided, or whether people have the cash to go to quality healthcare or have to pay cash when it is an emergency to go to very poor private healthcare. Once you take that out and say, “How can you organise your health system?” that is how we will achieve these universal goals and start to reduce inequities.

Fiona O'Donnell

The US is the most developed country in the planet.

Jeremy Lefroy (in the Chair)

Thank you very much. Just one final brief question from me, because I realise colleagues have to go. It seems from your answers that all of you would very much endorse universal health coverage as an overarching post‑2015 goal in health, but how would you flesh that out? How much would you flesh it out with subsidiary goals and how do you think it can best be achieved?

Simon Wright

Whether it is going to be a goal seems a little less likely at the moment, but it seems very strong that it will be a target within a health goal. We have recently had some parliamentary answers from the Secretary of State saying that she supports a universal health coverage target, including for increased financial protection, which is very important. We would try to make sure it is based around that. The indicator work that has been done by the WHO and the World Bank proposes a set of indicators of core services, with some of them picking up the MDG focus, some of them looking at NCDs and some of them looking at other essential primary care. They are looking at this package of indicators of health service coverage, with equity built into it, to judge whether a country is making the right progress towards universal health coverage. As Margaret Chan said, no country has universal health coverage. It is an ideal; it is a set of principles that every country should be working towards. You need to constantly watch what you are doing to make sure you are getting closer to it, but that is what we would like to see: a clear commitment to working towards equitable and universal coverage of key indicators.

Lord Crisp

I would just want to emphasise two things. One is, as has been said, this means a lot of different things. There needs to be a strong component of quality in there and understanding of what it is that you are actually talking about. In terms of not just coverage but quality, you can see this being gamed very easily, if one was not very careful. That is why I would start at country level. I really would start with the point that I made earlier, which is about what is happening with the poorest. Get it right for the poor and you have a chance of getting it right for other people within the country—I absolutely accept the point that has been made about equity there—rather than being too obsessed with trying to get into too much details about what it actually looks like. The Mutuelle in Rwanda looks very different from the system they are developing in Ghana, and that looks very different from South Africa, where they have the great problem of that huge amount of private sector stuff that is already there. It is going to be very different. The question and the test are about what is happening for the poorest 10% to 15% in each of those countries.

Dr Lob-Levyt

Universal health coverage does run the risk of previous goals and challenges we had in the past, like health for all by the year 2000, and things like that; it can be read very broadly. Therefore, it is very vulnerable to criticism. Organisations such as DFID could play a very good role in working with the World Bank, the WHO and others in articulating that a lot more clearly than it has been articulated at the moment. What is the message that you want your minister to say? What is it your staff are going to say in-country that crisply categorises what we mean by this? More specifically, taking that to the country level at this stage of economic development, what is a reasonable set of health deliverables that that country should aspire to and what is the route and pace to this universal health goal? I am a little concerned that it is read very broadly at the moment and means everything to anybody. People can pick and choose what they want from it. If DFID has endorsed it, as it seems to have in its policy paper in July, it needs to articulate more clearly what that means and how it is working with others. Most importantly, how are we going to measure that process? I think it is hard. It is always how you communicate these things. That was the beauty of the MDGs; you could just communicate the malaria, TB and HIV goals. They were easy to communicate to the public at wide, and this is a trickier one. These are smart people and we need smart people to get it right.

Lord Crisp

The strapline when the NHS was invented was, “In place of fear”. That is what I think universal health coverage should be: in place of fear. That is why I put the emphasis on the bottom 10% to 15%.

Jeremy Lefroy (in the Chair)

Thank you all very much indeed for your time. It has been an extremely useful session. Oral evidence: Health Systems Strengthening, HC 246 21