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Sir Malcolm Bruce (Gordon) (LD)
I am pleased to have the opportunity to debate these three reports, which as it happens are timelier in their outcomes than we realised when we started them. The Select Committee on International Development decided that we should visit Sierra Leone and Liberia to see how the Department for International Development was working in post-conflict situations and how it was working with development partners, particularly the Americans, in Liberia. That was an interesting and informative inquiry. When we visited the two countries in June, Ebola was present, but at the time, it was apparently not imminently as out of control as it has become. At the same time, we had also been doing an inquiry into DFID’s role in helping to strengthen health systems. One can see a certain irony in how those things came together at the time we were conducting our inquiry.
I will take things in that order, concentrating on health and then adding a couple of points about the development programmes. In those countries where we have a bilateral partnership and health is a significant part of the engagement, DFID has a good record, supported by all the evidence, of using the funding to help build stronger and more effective and coherent health systems.
About half of DFID’s health money goes in that direction, but the other half goes to the vertical and multilateral funds, where we found much less concentration on building health systems, perhaps for the understandable reason that targets were being set to deliver reductions in malaria and HIV/AIDS and everything was set in those terms. However, to achieve those targets, an infrastructure for delivering them is ultimately needed. We were anxious to ensure that the money going into vertical funds left a legacy of stronger health systems. What has happened with Ebola vindicates the argument that we made.
In Sierra Leone and Liberia, we saw health systems that were beginning to show some signs of effectiveness, but as we now know, they were totally overwhelmed by the Ebola crisis, which they are incapable of handling. The Liberian system was probably in slightly better shape than Sierra Leone’s, but then it was ahead on the curve. Nevertheless, both of them were overwhelmed.
One thing we are clear about is that if the international effort now going into bringing Ebola under control is to have a lasting legacy, it should also go into ensuring that when the immediate emergency is ended, Sierra Leone, Liberia and Guinea, on which there is more of a French lead, have health systems in place that will be resilient and robust enough to withstand any further similar outbreak. The situation also makes it clear that strong health systems are an essential component of development and in the global national interest, because such diseases, whether resistant, endemic or epidemic, can spread everywhere if not contained in their own territory. Strong health systems are in everybody’s interest.
One disappointing thing is that although the African Union countries made a declaration at Abuja that they should spend 15% of their Governments’ budgets on health, of the 50 members, only six have actually done so. Although I commend DFID—I am looking at the Minister here—we must urge the development partners to share the commitment. Without their commitment, they will never achieve effective health systems, which requires both political will and commitment. Therefore, we conclude that we need to put even more resource into completing the job that had only just started in Sierra Leone, and ensure that the legacy of tackling Ebola is not just that we get it under control but that we leave behind something much more substantial for the future of those countries. That is essentially the major point we must make.
Interestingly, the evidence told us that the UK national health service has a significant contribution to make in this area, in a number of ways. First, contrary to some popular opinion, in a Commonwealth evaluation of health services across the developed countries, the NHS ranked top, as the best health service in the world. We know that it is not perfect, but we should not sell short what it can do. We are seconding people right now from our own health service to work in Sierra Leone; perhaps not quickly enough, but we are doing so.
However, several issues came to light. One is that there ought to be a permanent partnership across Government to use DFID and NHS capacity and expertise to help build those health systems. That was and is being done in Sierra Leone, but our inquiry revealed—my hon. Friend the Member for Stafford (Jeremy Lefroy) raised this issue with the health adviser this morning—that we are not training enough health service staff for our own needs. I argue, and to some extent the Committee’s recommendations suggest, that we should be training more than enough staff for our own needs, on the grounds that we could then second people abroad without leaving our own health service understaffed.
Although we have a policy of not recruiting directly into the NHS from a long list of developing countries in a worthy attempt to avoid brain-draining qualified health professionals from poorer countries, the fact remains that they are not prevented from coming here or applying, and there are doctors and nurses from Sierra Leone working in our health service when one would like to think they would be working in their own health service alongside our volunteers and secondees to tackle the problem. This needs a cross-Government approach and it is not the responsibility of the Minister’s Department, but I ask him to take it on board that discussions with the Department of Health should address those issues, which are in the national and international interest.
I will touch on the reason why we went to Sierra Leone and Liberia before the crisis engulfed them. Those countries had been riven by civil war. The UK effectively intervened in Sierra Leone and ended the civil war, for which I can testify the people of Sierra Leone are extraordinarily grateful. It might amuse the House to observe that one sees more Union Jacks driving through Freetown than in Ayr. It is a declaration of appreciation. The partnership is constructive and is valued by both parties.
Sierra Leone is a bit of a forgotten country. The UK is the lead donor, and there are few others. It is literally a far-away country of which many people know very little, yet it and Liberia have an interesting history that is different from anywhere else in Africa. Liberia was settled by freed slaves from America in the early part of the 19th century. Interestingly, the country that first recognised Liberia as an independent state was not the United States of America but the United Kingdom, a fact that Liberians are anxious we should know.
I will say in passing, however, that some of us were a little shocked or bemused—I do not know which—by Liberia’s national flag and symbol. I think it has a ship with a pennant saying, “We came here in search of freedom.” The vast majority of Liberians never left, and there is a dichotomy between the freed slaves and their descendants, who are the elite, and the majority of the people, who have not had good governance over a very long period of time.
The current president is to be commended, in that the situation is changing and there is a much greater will to govern for the whole country. We made only a short visit; we were only able to go to Monrovia. However, people told us that while Monrovia looked a reasonable city, the rest of the country had virtually no roads, no infrastructure and no support. Again, that is a development challenge that needs to be addressed.
Sierra Leone was founded on a similar basis, by freed slaves from the Caribbean, and it has a definite Caribbean feel to it. Obviously, it enjoyed—I think “enjoyed” is the right word to use—administration by the British for many years, before it gained full independence. There is a legacy of roads and infrastructure that, again, the people value. However, it is still at a very low base; Sierra Leone is still a very poor, deprived country.
Our Committee recommends that, first, regardless of the Ebola crisis, we continue the current level of support. However, now we are where we are and both countries have been knocked back, the Department, although it has immediately given extra resources, needs to reassess its long-term programme, especially for Sierra Leone, which will need more resources than have so far been committed. That is not a criticism but a recognition of reality. We hope the Department will be able to provide those extra resources.
We made some criticism of the centrally managed programmes—we have engaged with the Department since on this issue—because, to say the least, we were a bit disappointed to find that we were not getting all the information on what the British Government are doing in Sierra Leone. We got it in bits and pieces from different sources. When the Committee visits a country where the UK has a bilateral aid programme, we almost expect—we have asked for this for many years—to get a full breakdown, or at least an assessment, of the bilateral programme, the multilateral programmes and engagement with the international agencies such as the World Bank and the African Development Bank; of course, it may not be an absolutely precise figure. However, we found that substantial programmes were being delivered in Sierra Leone that local DFID staff had no engagement with at all, and knew very little of. There may be good reasons for that, and we have asked DFID to give them if there are, but we still think that openness and transparency and an understanding of those programmes’ interaction would be helpful.
Fiona Bruce (Congleton) (Con)
The right hon. Gentleman is making an extremely good point. He will recall that exactly the same issue arose when the Committee visited Brazil: it was only almost as we were leaving that we were provided with a comprehensive plan.
Sir Malcolm Bruce
My hon. Friend is right; in fact, it was actually after we had left. We have now learned—I am smiling at the Minister—how to ask the questions. We asked in general terms what our official development assistance was, and DFID said, “We don’t have an ODA programme in Brazil, but HM Government do.” On returning from Brazil, we found that the Foreign Office had a £40 million ODA programme there. We do not object to that; we just think we should know about it, and the reason for it.
We had a similar concern regarding Sierra Leone. It is a question of transparency and understanding. Such knowledge helps us to make a good case: we are doing much more in Sierra Leone than is apparent, so why not say so? Ironically, when we went to Liberia, where our programme is a lot smaller, everything had been thrown into the pot to make the budget look bigger. So, the exact opposite approach to that taken in Sierra Leone was being adopted in Liberia.
I get the impression that the Department has learned something from this dialogue, and that the situation will change. We have asked the Independent Commission for Aid Impact to look at the centrally managed programmes, simply because the Department has not given us a clear explanation of strategy, listing exactly what should be done through centrally managed programmes, what should be done locally, and why. What is the rationale for choosing one method rather than the other? We are not saying that those ways are wrong and do not deliver, but it is not clear what they deliver and why, and we would like some clarity.
As the reports state, it is absolutely right for the UK to be the lead donor in Sierra Leone. We have a degree of responsibility, and the partnership works and is appreciated by both sides. Playing a supportive role in Liberia, with the US, benefits Liberia and the UK’s interaction with the US, because the UK and the US have a strong connection. We urge the Government, perhaps once they have gone a little further in dealing with the Ebola crisis, to tell us how they propose to set out a reconstruction programme for Sierra Leone in the coming years, because that is what is required. We urge DFID to take on board our recommendations on strengthening health systems. In particular, DFID should use its influence with the multilateral agencies to ensure that, where they put aid money into health—whether through vertical funds or other health programmes—they build in the objective of leaving a legacy of stand-alone functioning systems.
We should also open a dialogue with partner countries to get them to make health a greater priority on behalf of their citizens, not least because the aid community’s prioritising of health is almost giving some countries an excuse not to do so. The scale of the challenge is such that the aid community will never deliver a sufficiently strong health system on its own, and nor should it. Unless there is a partnership and a willingness on the part of Governments to contribute, we will not get the result we seek.
Notwithstanding the Government’s formal response, I hope the Minister will pick up on the points I have made. We are very appreciative of what DFID is doing. The circumstances have changed. There were a number of criticisms, which I hope the Department will address. Our engagement in these two countries is extremely important, but it needs to be ramped up if we are to get them back on their feet after the crisis that has engulfed them in the last few months.
Fiona Bruce (Congleton) (Con)
I begin by thanking the Minister for the Government’s detailed response to the Committee’s report, “Strengthening Health Systems in Developing Countries”, which I will speak to. I also wish to put on the record—and not just because we are approaching the season of good will—our appreciation of the International Development Committee’s Clerks and assistants for their expert help and invaluable contribution to our reports, and indeed to all the Committee’s work.
Strengthening health systems gets to the heart of much of what the Department for International Development must now be about, as we move from the millennium development goals to the sustainable development goals. Aid must be proactive as well as reactive, seeking prevention as well as cure. Clearly there will continue to be epidemics and tragic random events of nature or war, such as the Ebola outbreak or the current crises in Syria or Iraq. That is precisely when a robust in-country health system becomes so important. A mature and progressive approach must focus on the long-term goals of building the organisations, in-country institutions and the attitudes that will enable developing nations to become truly independent and truly developed.
One of the ways that is done is through building the networks by which health care resources can be spread, establishing training institutions that can make health care systems sustainable and bringing Governments to account, so that they realise the realistic and significant benefits of prioritising health care. If the latter in particular is not done, much of the health care action that this country’s aid workers overseas seek to undertake will be only half done.
I am reminded of the time that the Committee visited Ethiopia. We saw some dedicated community health workers, who were funded by DFID. They were young women who were going out into remote rural communities and talking to women in their homes about how to improve their health and hygiene with 10-step plans. Those women were visited and revisited until the good practices had been embedded. However, we visited the clinic in the same region, to which these women would go to give birth to their children and have treatment if they were ill, and quite frankly it was filthy. What was of even more concern was that when we challenged the Government Minister on this issue, he responded, if I recall correctly, “Yes, hygiene is a problem in Ethiopia.” Unless we have more joined-up thinking on the part of the Governments and institutions of the countries in which we are seeking to support the health systems, we will, as I say, find our work only half done. That is why this has to be a priority.
It is good that DFID takes this matter seriously and that the Government have responded positively to almost all the recommendations in our report. It is also good that much of our report recognises the excellent work that DFID does. DFID is an acknowledged leader in this field, particularly in transparency and sharing information. Our Committee is always reminded, wherever we go, of its significance in the field of development around the world.
Sir Malcolm Bruce
I agree, but does my hon. Friend acknowledge that we heard some evidence that, good as DFID was, it was rather hiding its light under a bushel, and that people felt that it should be doing much more to provide leadership and that it had slightly lost its edge in that area—not what it is doing, but in inspiring and encouraging others?
Fiona Bruce
The right hon. Gentleman pre-empts me, so I thank him for that pertinent comment. One of the thrusts of the report is that although DFID is in a prominent and influential position, it does not take advantage of that. Many of the Committee’s recommendations ask not for a change of policy, but for DFID to use its expertise and good practice to improve the practice and governance of the organisations, institutions and partners with which it works. It is good that the Government largely agree with that aspect of the report.
Let me turn to specific recommendations in the report. First, in response to recommendation 14, the Government state that they have shown leadership on working with women and girls,
“nutrition, female genital mutilation and early and forced child marriage, all of which require dismantling cultural barriers.”
I commend the Government’s work in this area, which gets to the heart of effective aid. It is not just about money pumped in or relief parachuted to problem spots; it is about dedicated work over time with locals on the ground to address fundamental barriers to health provision.
I cite, for example, the work done by aid workers in rural villages and rural communities in Ethiopia, where early child marriage involves children as young as six being married off and where children are even pledged to one another at birth. We heard a moving story of a young girl in her early teens who benefited from the teaching of some of the health workers in rural communities, who encourage young women not to allow themselves to be married early, but to stay in education and preserve their health and well-being, so that they do not end up with early sex and early childbirth. Instead, they can give themselves hope and a future and can contribute more fully to their communities than they would do were they married off early, which, in the misguided view on the part of their community, is somehow regarded as strengthening the community’s future.
It was really moving to learn that that young girl was only a few years younger than her older sister in her late teens, who had been married off early. She described how her older sister was already damaged and isolated, living almost alone, having been abandoned by her so-called husband, her education wrecked and her future looking very bleak. That is just one example of where the work of our DFID representatives, in strengthening health systems in a proactive, long-term way, is so effective.
Transparency is another area where DFID’s performance is exceptional in the field—if I remember rightly, it has been ranked second out of 68 countries. I commend this work. Will the Minister elaborate on the Government’s response to recommendation 6 in our report? The Committee recommended
“that DFID work harder to encourage its partners to make more data on their health systems strengthening work freely available.”
The right hon. Member for Gordon also mentioned that.
In their answer, the Government emphasised DFID’s good record, but regarding other organisations and partners they merely said:
“DFID will continue to set a good example to its partners on transparency and to encourage them to follow this example.”
Perhaps that could be more strongly stated. Perhaps the Minister will put some flesh on the bones of that statement. How will DFID seek to do that and what are its realistic aims and hopes in this area? The Committee’s inquiry showed that although DFID is world leading in this area, perhaps it is not leading the world as much as it could. I encourage the Minister to make use of DFID’s position, its reputation and its relationship with the various multinational organisations to have a greater impact in this area.
I now turn to recommendations that the Government partially accepted. I am pleased that the Government seem to be in general agreement with the Committee on how DFID needs to move forward to apply aid more effectively. Recommendation 4, for example, examines the need for an internationally agreed measure of
“system strengthening expenditure and efficacy as part of discussions about the post-2015 development goals.”
This is clearly an essential task over the next year.
The Government response states that such measures are not part of the post-2015 process. However, they also state:
“Some early thinking has been done about what would be required to develop a common framework for tracking health systems strengthening expenditure.”
Perhaps the Minister could expand on where that thinking is taking DFID and whether the Department has any time line on drafting such a framework.
Recommendations 15 and 16 relate to volunteering, which the Committee Chairman mentioned. I thank the Minister for his Department’s commitment to develop better frameworks and practices for volunteering in response to those recommendations. I should like to reflect with him, and with hon. Members in the Chamber, on the impact that nurses, doctors and even finance and management specialists—which the Committee made recommendations on—can have on health work in developing countries.
Let me mention the work of some volunteers with medical expertise in the Conservative party’s Project Umubano, of which the Minister—whom I am delighted to see here—is an august member, having been a part of that volunteer project virtually every year since its inception. Volunteers in the project go out for one or two weeks a year to Africa: Rwanda, Burundi and Sierra Leone. They are self-funded—so they are really on a minuscule funding basis—and go out there to make a difference in those countries. I remind the Committee of the difference that can be made, even in such a short time, and why it is therefore so important that we look at supporting volunteering from people with NHS expertise.
I should like to quote from an account from this year’s Umubano from Dr Sharon Bennett—who is, if hon. Members are not aware, apart from being a qualified and practising doctor, the wife of my right hon. Friend the Member for Sutton Coldfield (Mr Mitchell), the former Secretary of State.
“This was my 8th year in Rwanda, and it was wonderful to return to this special place, where I have made so many friends and treated so many patients over the last decade.”
She speaks of spending time at the Umubano health outpost, a clinic in a fairly remote area founded by Umubano volunteers, who raised funds to build it, and opened in 2011:
“I am happy to report that it is thriving, and we are now putting together a proposal not only to do preventative clinics—HIV, immunisation, ante-natal—but to have a daily minor ailments clinic there. This will bring healthcare closer to this extremely vulnerable group of people.
Every year I see the Health Centre grow, in all ways. The dedication of the staff at the centre is truly humbling.”
She is speaking about the staff that the volunteers have gone out to help train as they set up systems in the health outpost. She said:
“My most happy story this year, and possibly from all my visits, was reviewing a young woman with her happy and healthy seven month old baby. The outlook for mother and child was very different a year ago. In 2013”—
Dr Bennett went out in the summer of 2013—
“she came to see me late on in her pregnancy, when she was very short of breath. She had been treated for a chest infection. However, when I examined her it became clear that she was in heart failure, caused by a valve problem in her heart. If this had gone undiagnosed, she and the baby would almost certainly have died in labour from the huge amount of strain that is placed on the heart during child birth. She was transferred to Butare Hospital and put on medical treatment to take the pressure off her heart. The baby was delivered safely. In February next year, surgeons will be visiting from the United Kingdom to give her a new heart valve.”
Is that not a wonderful story and a microcosm of what can be done if we encourage volunteering from this country to such countries?
I want also to touch on the wonderful structural work being done by Mr Sheo Tibrewal, a consultant orthopaedic surgeon who has helped to set up a postgraduate orthopaedic course in a university in Rwanda. That is a wonderful piece of work he has done over many years. He has strengthened the structure of the university departments and ensured that medicine and dentistry are better able to implement a strategic plan, in conjunction with the Government’s work out in Rwanda. Those are just two examples of where volunteering can make a difference, and I am sure that, with greater support from DFID in conjunction with the NHS, we could see many more. Will the Minister update us on how deliberations on that are progressing? How can support be given to those NHS workers who would like to volunteer abroad, whether in the short or longer term?
That leads me neatly to recommendations 5 and 8, which touch on the difficult topic of how we can encourage other organisations or partners in other countries to take health system strengthening seriously. The Committee recommended:
“If DFID is not satisfied that system strengthening is being given sufficient priority by an organisation, and that organisation does not change, DFID should be prepared to withhold funds.”
That is strong—it may be a nuclear option—but as the Committee’s discussions with the Minister in Ethiopia showed, we have opportunities to challenge thinking at the highest level in those countries, and we should take them. I know how much those countries value the financial support and expertise that come from the UK and DFID, and we should not hold back from challenging Governments at the highest level on such issues.
The Government response rightly states:
“A decision to withhold funding to Gavi or the Global Fund would have a significant impact in developing countries”.
Although I am sympathetic to the Government’s caution, can the Minister satisfy the Committee that he intends to make progress in this area? Progress is vital and should not be seen as an optional extra. We should ensure that we take a tough line with Governments who are unwilling to take responsibility for the long-term health of their populations.
We also have a duty to take a tough line not only in-country, but in our country. That is critical. The Chair of the Committee touched on this, but we need to ensure that our people are made aware of the remarkable work done by DFID and representatives across the world, so that there is a greater degree of support than at present. The debate on the 0.7% Bill showed that there is a strong and vocal, but perhaps small group of people who are critical of what DFID is doing. One only has to look at the amount of private donations made to appeals to see how much the people of this country support what DFID is doing on international development. However, we need to spend some time focusing on that work to ensure not only that we challenge other Governments to take up the responsibility of communicating the importance of that work to their inhabitants and residents, but that we do the same here at home.
Hugh Bayley (York Central) (Lab)
This report on health system strengthening makes some important recommendations. It states that DFID’s work in the health field is often strong indeed. The Government’s responses to many of our recommendations are good, and I note and value all those good responses, but I want to talk about areas where the Government and DFID in particular should think further, because there are opportunities to strengthen further the good work that DFID does in this field.
In much of the Government’s response, they highlighted good practice in DFID’s work, but they did not say enough to convince me that Ministers and the clinical advisers in the Department are strongly committed to improving DFID’s health work yet further, especially its value for money. The hon. Member for Congleton (Fiona Bruce) rightly said that members of the Committee have a responsibility to challenge Government at the highest level to improve performance, not only on health policies relating to our partner countries—the developing countries with which we work—but on the health policies of our Government that relate to development.
I will build my remarks around two fundamental principles that underpin good health care universally. The first commitment in the Hippocratic oath, which every doctor takes before they qualify and go into practice, is “First do no harm.” We need to ensure that our health policies on developing countries do no harm, but in one respect our approach to the health services we provide for our citizens does immense harm to developing countries. I asked the Library to produce the latest figures on the number of health workers from developing countries working in the NHS. According to the hospital and community health service monthly work force statistics for September 2013, there were 68,673 health workers from low and middle-income countries working in the NHS. Included among that number were 16,615 doctors and 27,032 nurses. If those health workers were working in developing countries, they would hugely strengthen those countries’ health systems. We need to consider whether the way we run the NHS is appropriate.
In recommendation 10, the Committee said to the Government:
“The staffing of the UK health sector should not be at the expense of health systems in developing countries. We recommend DFID work with the Department of Health to review its approach to the UK recruitment of health workers from overseas. This review should consider options for compensating source country systems, promoting training schemes that involve a temporary stay in the UK, and strengthening local programmes”—
in developing countries, of course—
“to enable more medical training to take place in-country.”
By use of the word “medical”, I think the Committee meant the training of health workers more generally—all professional clinical staff, doctors, nurses and other professionals supplementary to medicine. In their response, the Government agree with our recommendation, but there was not enough detail to make me feel that our health system, strengthened as it is by many tens of thousands of health workers from developing countries, will change to enable more of those workers to work in their own country. I ask the Minister to think about that. The first line of the Government’s response to recommendation 10 states:
“The Department of Health (DH) and DFID will continue to work together to review their approach to the UK recruitment of health workers from overseas.”
It is the word “continue” that makes me think that they will carry on doing what they do at the moment. The Committee asks the Government to instigate a review and to think outside the box about how we could manage the UK’s health system in a way that does less harm to health systems in developing countries.
I remember suggesting many years ago to John Reid when he was Secretary of State for Health that we ought to undertake each year, as part of our aid work, to pay the Governments of developing countries to train one nurse for every nurse from a developing country working in the NHS, and to do the same for other disciplines. If we really want to ensure that good health care here does not come at the expense of the health care of poorer people in developing countries, that is the least that we should do. If we wanted to go further than that, we could train two nurses for every one in NHS.
We must remember that it is not only the NHS that sucks in the terribly valuable and scarce resource that is developing countries’ health workers. The private sector also does it, particularly private care homes, which suck in nurses in huge numbers. In fact, the private sector has a more predatory impact than the NHS on the health systems of developing countries, because the NHS has for the past few years—I remember discussing this with John Reid as well—instituted certain safeguards regarding employing people from countries where we can directly see a detrimental effect.
I ask for a discrete review to be jointly commissioned by the two Departments. If the Minister has not come with a brief to say that he will do that—I suspect that he has not—I would like him to discuss it with his opposite number in the Department of Health. Once it has been thought through, they could respond in writing to the Chairman of the Committee. We need to do more. The joint work that the Department does with the Department of Health should continue—I do not want to stop any of that—but we need to go further. I encourage the Minister to say that he will at least go back and talk with his clinical advisers, the doctors who work in DFID, to consider the question of commissioning a particular, discrete review.
In recommendation 16, which refers to volunteering and about which the hon. Member for Congleton spoke so eloquently, the Committee recommended that
“NHS staff should be supported in seeking to apply their skills where need is greatest.”
I agree with that. The Government’s response states:
“Over 650 NHS frontline staff and 130 Public Health England staff have volunteered to go out to Sierra Leone to help in the UK’s efforts on the ground.”
I welcome that. I hope that the Minister will tell us how many of those 650 and 130 staff have gone to Sierra Leone, what the total British complement of medical staff, including military medical personnel, is and how long they will stay. The hospital and community health service statistics provide a country-by-country breakdown that puts the issue in context. In September 2013, 567 Sierra Leonean health staff were working in the NHS, of which 347 were professionally qualified clinical staff. If for six months, a year, or a couple of years—or however long is needed to help Sierra Leone to respond to, deal with and recover from the Ebola crisis—we send a few hundred British health personnel to the country, but we typically take several hundred professionally qualified health staff from Sierra Leone, one of the poorest countries in Africa, year in, year out, are we helping or hindering its response to the health crisis?
Why are we sending staff? We are sending them now because the crisis affects us. If the epidemic spreads, there will be more and more cases in parts of the world other than west Africa—or central Africa, which has also seen some cases. We are doing it out of self-interest. If we are concerned about strengthening health systems in west Africa, and particularly in Sierra Leone, so that they can deal with this challenge, and if we are concerned about helping to build more robust health systems to raise health standards in Sierra Leone, we need to change the number of Sierra Leonean health personnel that we attract to this country to work in our NHS.
In recommendation 18, the Committee proposes that
“DFID publish a clear health strategy”.
I want DFID to explain why it does health work. We know that it is good and valuable, and we know the many things it does that every sane person would support, but let us get down to the real basics: why do we do it? Why do we spend DFID money on health systems rather than on job creation or other development measures? We do it because, going beyond the first principle of doing no harm, we want developing countries to use their limited resources for health—both the aid that we provide and the rather greater resources that they generate from their own revenues—as cost-effectively as possible. Cost-effectiveness must be measured in terms of maximising the number of lives saved from preventable diseases and maximising good health, while minimising the burden of ill health and disease in the developing countries that we aid.
In the National Institute for Health and Care Excellence, which is the UK’s health technology assessment system, a device called a quality-adjusted life year is used to measure the impact of a health intervention. I apologise for lapsing into jargon, but a QALY is a concept that marks each year of life that is lost through preventable disease. If somebody who would otherwise have lived to the age of 65 dies at the age of 45 through a preventable illness, 20 QALYs would be lost. If that person’s life is saved but they continue living with a disability such as blindness, the QALY will estimate what percentage of a person’s good life is lost. If they are a tailor, for example, they would lose their livelihood if they lost their sight.
We came across NICE International during our inquiry, and I would like to know whether the NICE principles of considering the cost-effectiveness of health interventions was being applied to the Government’s international health work. Does NICE International have a similar approach, and examine the impact of a health intervention? How many quality-adjusted life years on average does every £1,000 of locally or DFID-generated money buy, if the intervention is focused on immunisation, for example, perhaps through Gavi, the global fund for vaccines and immunisation? How many QALYs would that same £1,000 buy if it was sunk into maternal and child health, or into the purchasing and distribution of antiretroviral drugs for people with HIV and AIDS, and into backing that up with clinical interventions? Or the money could be invested in general health system strengthening, and training nurses in developing countries and encouraging them to work within the health system of that country; I implied earlier that we ought to do more of that.
We should be able to see how, if we targeted our resources better, the same amount of money could help more people, avoid more deaths and enable more people to return to good health so that they have viable and productive lives. For example, a woman with three children whose husband has died from AIDS and who is HIV-positive herself might be able to carry on looking after those children, instead of dying and leaving orphans for someone else to look after. We ought to quantify what benefit we get from different interventions.
DFID is well regarded internationally for its work on basic human needs, in health and education in particular. Other countries have especially strong records on using development finance to build infrastructure such as roads, which the European Union is much better at building than we are, or to support small businesses and create livelihoods, which I think the Germans do. We, however, are probably the global leader in using money effectively to provide for basic human needs. We should be proud of that, but if we could make our work more effective still, we most certainly should. That would improve the value for money that our taxpayers get from the money spent in developing countries to reduce the burden of ill health. Also, our practice would be copied by countries that look to the United Kingdom for a lead on how, through development assistance, we can strengthen the health systems of developing countries.
I want to mention one final recommendation. In recommendation 4, the Committee stated:
“It is impossible to know how well DFID is delivering its health systems strengthening strategy without knowing how much it spends or having indicators of its performance.”
I am not saying that we have to use QALYs, but they are certainly one indicator that it would be worth using. There are also other indicators. The recommendation continues:
“Nor can DFID allocate its resources efficiently in the dark.”
If we do not do the technical work of looking at how valuable intervention A is at reducing the burden of disease and disability by comparison with intervention B, we will not use as effectively as we might the limited money that we have for strengthening health care systems in developing countries.
The Government say that they agree partially. I want them to think further and to tell us what they will do to improve the technical work that their clinicians do, so that we can work out the effectiveness of health interventions. If we increase the clinical effectiveness of work done in developing countries, not only with our aid, but by the health system as a whole—funded by us, by multilaterals, by other donors and, more than anything else, by the country’s tax revenues—we will save lives. If we are trying to explain to our constituents why we put money into development assistance, saving lives is something that people understand, value and believe that we should do. That is why they think that the Government are right to respond to the Ebola crisis.
If we fail to do that, to raise our game and to do more to assess which interventions are most cost-effective, it will cost lives, because we will not be using the limited resources that we have as effectively as possible. None of us would want to explain to our constituents that we had simply not done the technical work to find out what works best, and so were spending their money less effectively than we might otherwise do in developing countries. Will the Minister think about that and write to us after the debate, once he has had the opportunity to discuss things further with his officials? Will he explain what more his Department could do to respond to the calls that came from our Committee?
It sounds as if I am complaining, but a lot of the Government’s response is good. I welcome it, but I was thinking out of the box in response to what the Government said about our recommendations. I want the Government to do 100%, not 50%, of what our Committee asked them to do. We have not got all the answers right; the Government have much greater technical expertise in Departments than we have in the secretariat of our Committee. Let us not be sloppy; let us be professional and focus on what we can do to improve the value for our health development money.
Jeremy Lefroy (Stafford) (Con)
It is a pleasure to serve under you, Mrs Osborne, and to follow the hon. Member for York Central (Hugh Bayley), who speaks with such knowledge and passion on these matters, and my two colleagues, my right hon. Friend the Member for Gordon (Sir Malcolm Bruce) and my hon. Friend the Member for Congleton (Fiona Bruce).
I was delighted when the Committee agreed to do a report on strengthening health systems, because the subject is not one that commands a great deal of attention. The report does not look at a particular country or disease, but instead seems more to do with bureaucracy than anything else, although that is not at all the case. As our report states, health systems are fundamental to the improvement of outcomes and self-sufficiency in health services in developing countries.
I hope that one of the sustainable development goals next year will be universal health coverage, which is impossible without strong health systems. Strong health systems are in place not only to provide better outcomes for life or to prevent morbidity and mortality, however important those things are, but to alleviate poverty, which is a direct responsibility of DFID. Strong health systems are also in place to increase fairness: if everyone has access to a health system, life chances are immeasurably improved. People who go to school and have worms are much less likely to be able to concentrate. If people have blinding trachoma, the consequences are obvious for their life chances. In so many other cases, disease brings not only disability—which we will discuss in the next debate—but an inability for people to fulfil their human potential. That is why health systems are so important to international development. In the Ebola tragedy in Sierra Leone, Liberia and Guinea, we have of course seen the consequences of weak health systems, to which my colleagues have already referred.
In this country, we have a unique thing to offer in the strengthening of health systems, which is our national health service. For all the brickbats sometimes thrown at the NHS—in my constituency we have had our difficulties, but I am glad to say that we are working through and overcoming them with the tremendous support of local staff and of the NHS as a whole—it gives us a system that is efficient, and acknowledged as such, and effective. It has its faults and failings, but it is not only chance that caused the Commonwealth Fund to put the NHS at the top of the league in an august company of health systems.
We have heard a little about the so-called problem of vertical as against horizontal programming in systems. I want to dwell on that a little. One of the things that people in our inquiry referred to was the great emphasis over the past 14 or 15 years, since 2000, on vertical programming, or disease-specific programming. The Global Fund to Fight AIDS, Tuberculosis and Malaria, Gavi and other programmes have all been successful, but there is always the risk that they will focus entirely or mainly on the disease without looking at how they can strengthen the health system within the country, which would bring far wider benefits than simply the elimination or reduction in prevalence of that disease.
I do not think this is an either/or question—that we need either vertical or horizontal programmes. Rather, it is a case of using both. I will give a couple of examples of interventions I have seen that were made through, and so reinforced, health systems. In June we visited Sierra Leone. I was privileged to go into a village on the peninsula near Freetown and see the results of the mass bed net distribution that was taking place—at a time, let us remember, when although Ebola had not reached a critical phase, it was beginning to become significant. That mass distribution of bed nets still went ahead, as far as possible, and did so through the existing health system, weak though it was. The distribution was effective: I went into homes where the new nets had been installed, and people clearly viewed them as being of great importance, particularly for their children and for pregnant women, who are the most liable to be affected by malaria.
Those mass bed net distributions, often through health systems, have resulted in the tremendous fall in the incidence of and mortality from malaria that we found out about this week from the World Health Organisation annual malaria report—I had the pleasure of chairing the launch of that report, in the company of His Royal Highness the Duke of York, in my role as chairman of the all-party group on malaria and neglected tropical diseases. Work by the global fund, DFID, and the US and many other Governments has probably saved around 4 million lives—mainly of young children and pregnant women—in the past 14 years. Even if we concentrate more on health systems and horizontal work, we should never let go of the gains that have been made. It is absolutely vital that we do not return to the situation we saw in the 1960s, and again in the 1980s, when, after a really strong effort on malaria, we let our grip on it go and saw a resurgence of malaria across the world. Vertical interventions are vital when they work through horizontal health systems as well.
My second example is from Tanzania, where I visited a programme run by the Tanzanian Government with the support of Imperial college, London, and various NGOs, such as Sightsavers. The programme tackles neglected tropical diseases. Instead of looking at only one—lymphatic filariasis, for instance, or worms—it is tackling four of those debilitating diseases alongside each other.
In other parts of the world we find the use of pooled funds—for example, pooled health funds in South Sudan and Mozambique, the development partners for health in Kenya and the health transition fund in Zimbabwe. All are excellent examples of people coming together to strengthen health systems locally, showing that it is not simply about one person making their one vertical intervention, but everyone working to bring the money together and make the best use of it.
The WHO identified six key building blocks in health systems: governance, finance, the work force, commodities —mainly drugs—services and information. In all those areas DFID plays a major role. I pay tribute to NICE International, an organisation already referred to by the hon. Member for York Central. I was impressed by the presentation it made to the Committee and its evidence to us, and I am impressed by its work. It is an example of something that most people will probably not have heard of, but which is helping health systems around the world to learn from our experience and that of others to bring better health care to their populations.
We have already heard about the financing challenges. It is vital that developing countries live up to their commitments—in the case of African Union countries, the Abuja commitment to spend 15% of their annual budgets on health. At the meeting I referred to earlier, the leader of the African Leaders Malaria Alliance—she is a former Member of Parliament and Minister from Botswana—made the same point, saying that countries with endemic malaria have to step up to the challenge and cannot simply rely on donors to fill the gap.
Indeed, let us take malaria as an example. It would take $5.1 billion of investment every year to see the elimination of malaria within our lifetimes. At the moment, something like $2.9 billion is being given. To put that into perspective, $2.9 billion would run our national health service for a week. Another $2.9 billion—another week’s worth of national health service funding—would see the elimination of malaria in our lifetimes. Surely that is not too much to ask from both the Governments of countries with endemic malaria and the international community to eliminate a disease that even less than 200 years ago was rife in this country and within the past 50 to 60 years was still present and killing people in countries in the south of Europe.
The hon. Member for York Central covered the ground on the issue of the health work force extremely well, so I will not repeat his remarks, save to say that by some estimates there will be a shortage of 13 million health workers around the world by 2035. The estimated shortage at the moment is somewhere between 4.2 million and 4.5 million, although I would say it is probably more—another estimate I have seen is 7 million. Here we have worthwhile jobs and livelihoods that could be created immediately if the training capacity was there. We know the work is there, because there is a shortfall, yet we are not training enough health workers, whether in this country or elsewhere around the world.
Those are great job opportunities for young people. As I said in our evidence session this morning, I urge the UK Government to look at providing more spaces for training doctors, nurses and other health care professionals, so that our young people can enter those professions. I was shocked to see in a newspaper this morning that half of the schools in this country do not have anyone going for training as a doctor. That figure astonishes me. There must be several pupils in every school who would both want to undertake that training and be capable of doing so, yet it is not happening. Let us put our own house in order, while helping others as they do the same to theirs.
I will not dwell extensively on the other three pillars the WHO mentions—commodities, services, which are absolutely key, but are far too big a subject for this debate, and information—except to say that the supply of pharmaceuticals to rural outposts has been a real problem for many years. I remember visiting a place in Uganda where even basic malaria drugs were not available, yet those drugs were in stock in the central store in Kampala. It is not beyond the wit of man to get drugs out from Kampala, or any other capital city, to where they are needed. It takes a bit of leadership and imagination and, possibly, some work with the private sector, which often has the logistics to get the drugs out even if the Government do not.
I have a couple of specific points to mention. In our report, the Committee referred to the work of the health partnership scheme run by DFID through the Tropical Health and Education Trust. That is a tremendous programme, and I am glad to say that DFID has continued it and added another £10 million to its funding. Partnerships have already been created voluntarily, such as the one between Northumbria health authority and Kilimanjaro Christian medical centre or the King’s Sierra Leone partnership—there are many others, and most Members will have them in their constituencies. Those partnerships can receive support for their work training professionals on the ground in their own countries.
Finally, I want to speak briefly about health education, which we did not cover substantially in our report, but is vital. Community health education programmes can provide enormous benefits, particularly when they are not thrust upon communities. My wife ran a community health education programme in Tanzania for 11 years through a training of trainers programme, training up local people who were not health professionals to work with their neighbours on improving health in their families. The success, for a small amount of money invested, was enormous. It could be seen in the health outcomes. People improved the hygiene in their households by constructing toilets and things such as dish drying racks at very little cost, with great benefits for their children in particular, who were often the victims of diarrhoeal diseases.
In conclusion, I reiterate the importance of this subject. I am delighted that DFID takes it so seriously, but it must continue to do so. Health systems and good health are at the heart of every nation’s attempt to counter poverty and raise the livelihoods and well-being of its citizens.
Anas Sarwar (Glasgow Central) (Lab)
It is a pleasure to serve under your chairmanship, Mrs Osborne. I congratulate the Select Committee on International Development on its two fantastic reports, the second of which we will debate in a moment.
I had the great pleasure of serving on the Committee at the start of this Parliament for almost a year and a half. Having worked with many of its current members, I can say that it is full of people who are dedicated to ensuring that we spread the values that we hold dearly in the UK around the world to maximise opportunity in the fight against poverty. Two of my former colleagues on the Committee—the right hon. Member for Gordon (Sir Malcolm Bruce) and my hon. Friend the Member for York Central (Hugh Bayley)—are retiring before the next Parliament. We all wish them both the very best for the future. The fact that both of them have used their last term in office to try to improve the life chances of the poorest and most vulnerable people in the world speaks volumes. The right hon. Member for Gordon has been a member of the International Development Committee since 1997, for which he deserves a special prize. I pay special tribute to the Department for International Development staff and health workers who have gone from the UK and elsewhere to help in the fight against Ebola and have risked their lives to protect the lives of others.
I am particularly pleased to be able to make the case for universal health coverage, as the Committee has done, given that the UK is a global leader on that issue. We should be the strongest global advocate for universal health care because our NHS is the envy of the world. It supports people from the cradle to the grave, and it is based not on people’s ability to pay but on their need. We should spread that health care model around the world.
In the current crisis in Sierra Leone, more than 1,600 people have lost their lives, and every week 200 to 300 people are dying and 400 to 500 people are becoming infected. That is a real and sad example of why sound health care systems are crucial. It also demonstrates why the UK and the Department for International Development are right to emphasise promoting private sector growth. Sustained economic growth, higher employment, strong infrastructure and other good development work can be lost in an instant during such epidemics.
Sierra Leone’s GDP growth has sharply declined, despite its positive growth in recent years. All its post-war achievements in the health, education, justice and employment sectors are in jeopardy. The Committee will know from its visits and from the testimonies it has heard that all the schools in Sierra Leone have been permanently closed, and there is a real risk of losing a generation. A generation of young people in Sierra Leone will never get the education they need to improve their life chances, get into meaningful work, break the cycle of deprivation, create a better life for themselves, their families and their communities, and create a better Sierra Leone in the process.
Let me compare three African countries with varied health systems. Sierra Leone, as my hon. Friend the Member for York Central said, has about 136 doctors and just over 1,000 nurses for 6 million people. That is the equivalent of one doctor for almost every 50,000 members of the population. Sadly, since November, more than 100 health workers, including five doctors, have lost their lives to Ebola. It is even worse in Liberia, which has an estimated 60 doctors and 1,000 nurses for 4.3 million people.
In contrast, Rwanda has more than 55,000 health workers for its population. The president of the World Bank, Jim Yong Kim, said:
“If this had happened in Rwanda we would have had it under control.”
That shows the difference that a meaningful health care system can have. It demonstrates that there is no substitute for adequate local health care cover. If there is no functioning health service, a single outbreak can turn into a global crisis.
Jeremy Lefroy
Will the hon. Gentleman also acknowledge Nigeria’s tremendous success in preventing the spread of Ebola? Some attribute that to the health systems built up through, for instance, the polio vaccination campaign.
Anas Sarwar
I thank the hon. Gentleman for that intervention. I recall our many travels and our debates on many issues. I pay tribute to his first-hand experience of development issues and the work he did in Tanzania before he became a Member of this House. He is absolutely right to point to the positive interventions that the Nigerian Government were able to carry out because of their pre-planning and their thought leadership in advance, which enabled them to deal with the Ebola crisis. Sadly, Liberia and Sierra Leone were not able to do that, but the lessons from Nigeria and Rwanda can be learned by other countries.
Universal health coverage not only helps to prevent outbreaks and improve health outcomes, but can help to reduce inequality and tackle the fact that 100 million people a year fall into poverty. That is why universal health coverage matters, and why the UK must make it a top priority. The UK must use the opportunity of the 2015 negotiations on the sustainable development goals to push for universal health coverage to be a key element of those goals. I say gently to the Minister that we must be an active, vocal advocate for that agenda and use our experience, expertise and our influence with multilaterals and institutions to make our case. The report makes it clear that the Committee is frustrated that the Department and the Government are not using the strength of our voice to make that case on the global stage. I hope the Minister will address that point. I ask him to outline what advocacy work the Government have done on universal health coverage.
As DFID’s budget increases, more money is going to multilaterals, at the expense of the budgets of many bilaterals; I will return to that point. A World Bank study showed that the economic cost of Ebola could be as high as $33 billion over the next two years if the virus spreads to neighbouring countries in west Africa. Although I welcome the support given to multilaterals such as the World Bank, the Committee said in the report that it does not believe that many of our international partners give the same priority to the development of health systems as the UK. When they do, the same priority is often not given by the recipient Government. Let me give a practical example: only $3.9 million out of $60 million of EU health sector support given to Liberia was passed on by the Liberian Finance Ministry to the Health Ministry over a two-year period, leaving the Liberian health system struggling.
The Minister of State, Department for International Development (Mr Desmond Swayne)
I have looked into that criticism; the EU denies that it happened, and it has checked in Monrovia. I have asked for that matter to be reinvestigated.
Anas Sarwar
I thank the Minister for that helpful intervention. In the spirit of transparency, and to ensure that we do not darken the name of any Government and that we have the strong trust of the people on every penny spent by the UK Government and by our EU partners, I encourage him to share any information gleaned from those investigations with the House and the Committee.
Sir Malcolm Bruce
I am very glad to see the hon. Gentleman back in the international development debate. To clarify how this issue arose, we were told by the Health Department in Liberia that the money had been earmarked for it and that it had not received it—that the Minister of Finance had either held it back or was spending it elsewhere. I am grateful for the Minister’s intervention, and I am interested in his reply that our Government have checked and found that that is not the case. I just want to be clear that this information was given to us in good faith and on the face of it, it was shocking. We just thought it was important, and if it has been checked and it has not happened, that is absolutely fine, but nevertheless, it was a significant factor. When money is given, sovereign Governments can, of course, in the end redistribute it, but the question of whether it went where it was meant to go should really be followed up on.
Anas Sarwar
The Chair of the Committee mentions an important issue, and it is right that the Committee raised it and that the Minister has looked into it. I think we would all welcome that information and clarity, but it also highlights an issue in recipient countries, where perhaps that information is not shared between Departments. That undermines both the way in which Departments can operate and the state-citizen relationship in recipient countries. That information should be shared with the Committee, and there should be a way to share that information with a recipient country’s Government, and particularly its Department of Health.
It would be interesting to hear what indicators are in place to measure how much of the money spent through multilaterals is used specifically on strengthening health systems, and in which countries, and how the success of that spending is measured. Transparency is again the key issue, in terms of gaining the public’s trust. That same principle should be reflected in our bilateral agreements, ensuring that where we do give budget support, an emphasis is put on universal health coverage by recipient countries. Aid should never be a blank cheque. Recipient countries must make a commitment to medium-term goals and take responsibility for long-term health system development. We should never be afraid to take a tough line with Governments who do not adhere to that principle.
However, we must not fall into the trap, as we often do, of believing that our biggest impact comes just from the money that we spend and the global influence that we exert. There must also be a recognition, as has been made clear by many Members today, that through our NHS, we have built up expertise, and if we share that, we can help shape global systems. We have the talent among our health workers to develop strategies and plans, to provide professional and personal development, and to manage and learn in a meaningful two-way relationship with recipient countries. That is why we should encourage volunteering, as the hon. Member for Congleton (Fiona Bruce) suggested.
I push the Minister to respond more thoroughly to the Committee’s recommendation to build schemes that are more co-ordinated, structured and scaled up. That should include detail on how the Government would support those people who choose to volunteer with specific benefits and entitlements. Such schemes would help to promote the good work that the Department and this country do on development and would also help build public support and trust at a time of public cynicism.
Linking that to the Ebola crisis, I want to re-emphasise the question that my hon. Friend the Member for York Central asked. We know that 650 NHS front-line staff and 130 public health staff have volunteered to work in Ebola-stricken west Africa, but how many have actually gone? We still do not have a specific figure from the Government, and I hope that the Minister will have an answer for us today. We should not shy away from giving all the support that we can to the people who are bravely volunteering their expertise and putting their lives on the line, in many senses, to go and protect the lives of others. We should absolutely support them.
Mr Swayne
Rather than wait, I can give the figures now. Thirty NHS staff flew to Sierra Leone on 22 November. A second wave of 25 arrived on Sunday 7 December. They will work on a rotation pattern of four to six weeks; then they will be replaced by others. Many more volunteered, but after negotiations with NHS trusts and others, the actual numbers travelling are somewhat lower. That is the picture so far.
Anas Sarwar
I thank the Minister for that response; I am sure that the Committee and many of the non-governmental organisations will be happy to hear that information. It would also be interesting to get information about the number of volunteers and health workers, or people with health expertise, who are not linked to the NHS, but are none the less based in the UK and who have gone to Sierra Leone and other territories specifically to help on the Ebola crisis, perhaps through NGOs or other schemes. I hope that the Minister can look into that for us.
The International Development Committee raised the important issue of the NHS pulling health workers away from Sierra Leone. In particular, my hon. Friend the Member for York Central made a powerful case about the no-harm principle that should be applied to the way in which we operate our education system and NHS system in the UK, so that we do not harm daily the very countries that we are seeking to help.
Sierra Leone is one of five African countries with an expatriation rate of over 50%, meaning that more than half the doctors born in Sierra Leone are now working in countries of the OECD. I have already mentioned the shocking doctor-population ratio. We can never find that situation acceptable. The right to migrate is not in question, of course, but it is unacceptable that a country with one of the weakest health systems in the world is, in many ways, subsidising the country with one of the strongest, if not the strongest.
Mr Swayne
I accept entirely what the hon. Gentleman and the hon. Member for York Central (Hugh Bayley) said. It is a very difficult issue, because some countries export health workers and draw remittances from them as a positive in their balance of trade, or certainly their balance of payments. However, I recognise that difficulty and I shall surprise the hon. Member for York Central: we are commissioning a review of NHS use of foreign workers in exactly the way that he challenged me to.
Anas Sarwar
Excellent. I think we all welcome that announcement from the Minister; it is amazing what people can achieve when they think on their feet. It would interesting to know when that will be reporting and what impact assessment is being done on that, in terms of our health service here in the UK.
To give an illustrative example, 27 doctors from Sierra Leone are believed to be working in our NHS. The data do not record a level at which they are working, so let us assume, for argument’s sake, that all 27 are junior doctors. It costs the NHS just under £270,000 to train a junior doctor. It would represent a saving of £7.3 million to the UK if those doctors were trained in Sierra Leone and came to work in our NHS. The Committee noted that the UK Nursing and Midwifery Council register lists 103 nurses who were trained in Sierra Leone. It costs the UK £70,000 to train a nurse in the UK, so that is a saving of £7.2 million. Together, that would represent at least a saving of £14 million—if not more, if many of those doctors were GPs or consultants.
I welcome the Government’s agreement that the NHS needs to review overseas recruitment, and the fact that the Department of Health endorses the World Health Organisation global code of practice on the international recruitment of heath personnel, and implements it through the UK code of practice for international recruitment. It is important, as the Minister has outlined, that the Department of Heath works closely with DFID on reviewing the definitive list of developing countries that should not be targeted for recruitment of health care professionals.
[Andrew Rosindell in the Chair]
Turning to the specifics of DFID spending, I think that it is unfortunate that DFID is cutting bilateral support, especially at a time when its budget is increasing and particularly after the historic vote last week, when, with support from hon. Members on both sides of the House, we were able to enshrine our 0.7% commitment in law. I note, though, that there were more Labour MPs supporting the Bill than MPs from all the other political parties combined.
Sierra Leone is a good example. In 2014-15, DFID reduced its bilateral budget for Sierra Leone by 18.6% relative to its commitment in 2013-14. That was central money that could have been used to strengthen health care systems. Since then, the UK has been the lead donor in Sierra Leone on the Ebola crisis, pledging £230 million of additional support as well as logistical support from the Ministry of Defence. That is of course to be welcomed. However, given that that crisis will have a lasting impact, will the Minster today consider reinstating the bilateral budget on a long-term basis?
It was unacceptable that, as the Select Committee found, DFID and the previous Minister—not the current Minister—did not know the total annual expenditure in Sierra Leone. I am sure that the current Minister would love to intervene to tell us the specific amount being spent annually in Sierra Leone. Equally, I am sure that if he cannot, he will, as with other things, go and investigate and report to the Committee how much we spend every year, not just in Sierra Leone but in every other country, in the spirit of transparency and accountability. I notice that he has gone slightly more silent than he was a moment ago.
Anas Sarwar
Also, how will DFID act on its commitment to develop indicators—knowing that they will be reviewed in 2015—and other mechanisms that allow it to track its investments in and impacts on health system strengthening in new programmes from 2015, both for use in its own work and to feed into global processes?
As we know from our UK experience, building an effective health care system requires sustainable revenue streams, if Governments are to fund these vital services. That is why greater tax transparency is crucial. Many of these countries suffer from the so-called resource curse: there is vast mineral resource, but that is not turned into a nation-building positive agenda. In 2011, Sierra Leone spent more on tax incentives than on its development priorities, and in 2012 it granted $224.3 million in tax exemptions. That is eight times the budget allocated for the health sector, which is $25.7 million. In addition, many of the tax incentives are negotiated between Government and companies behind closed doors, making the negotiation process extremely opaque and open to accusations of corruption.
To encourage domestic growth through tax collection, the National Revenue Authority of Sierra Leone needs to be fully involved in the negotiation and design of the exemptions. That is why DFID must make sure that its work with the National Revenue Authority links with its work with the National Minerals Agency, to ensure that Sierra Leone’s natural resource wealth is used to help to meet development objectives and not just for the benefit of a few international investors.
Finally, I want to deal with a couple of other key issues raised by the Select Committee. I see the Minister looking at me. He should not worry: I am almost done, and I am sure that he will be robust and succinct in his reply. A couple of other very important issues from the report have not been mentioned so far, but are worthy of comment.
First, there is the huge issue of female genital mutilation, which Sierra Leone is one of the worst countries for. I know that it is a politically sensitive issue in Sierra Leone, but that does not prevent the UK Government from doing something, or at least trying to do something about it. That is why it is important that the UK Government work with the victims and survivors of FGM to see what they can do to have a more meaningful programme and combat FGM in Sierra Leone.
The other important issue raised by the Select Committee was unemployment, particularly youth unemployment and the lack of formal jobs being created in the economy of Sierra Leone. Three million people out of a population of six million are unemployed, but only 90,000 formal jobs are available in the economy. An estimated 800,000 young people are actively searching for employment. It would be interesting to hear from the Minister what work is being done to try to improve the availability of jobs and employment in the country, especially as DFID set itself a target of creating 30,000 jobs in Sierra Leone by 2015. How many jobs have been created so far? Does DFID expect to meet the target in the next three weeks? How is it helping to create jobs? What measures are in place to ensure that the jobs created are in line with the International Labour Organisation definition of decent work? How many jobs have been created using small business enterprises in-country, and have any British companies benefited from any of the investment to create employment in Sierra Leone?
I thank the International Development Committee again for its very thorough and rigorous report and for its continued work. We look forward to working with the Committee as it pursues the issues that are of interest to it and to the wider British public. I look forward to hearing the Minister’s reply. I know that I asked several specific questions, but I can tell from the way he has conducted himself already that he has very good answers for us.
The Minister of State, Department for International Development (Mr Desmond Swayne)
It is a pleasure to follow such a well informed, if interrogative, speech from my opposite number, the hon. Member for Glasgow Central (Anas Sarwar). I thank hon. Members for their constructive, measured, informed and, if I may say so, welcome criticisms. They stand in some contrast to those made in other proceedings that have taken place at Westminster today—although this debate is not about Ebola, it is certainly stalked by and informed by Ebola.
I am glad that the Chairman of the Select Committee, the right hon. Member for Gordon (Sir Malcolm Bruce), referred to the flags being out in Freetown, because I believe we have a record of which we can justifiably be proud. We have launched an operation with military precision. We have put 850 military personnel on the ground, in addition to the NHS workers whom I have already mentioned, to support 750 beds, of which 282 are for treatment and 468 are the key, important beds for isolation. We have isolation centres in which people can be isolated while we determine whether they have Ebola. Seven out of eight patients will go home after what was just a bout of fever, for example; the others will go on to receive treatment for Ebola. It is a remarkable operation, costing £230 million, of which we have already disbursed £125 million, and people should not be critical of it. In Kerry Town, we already have 52 operational beds.
Hugh Bayley
I strongly support what the Government and the military are doing, and tomorrow I will visit the Army medical training centre at Strensall to see the hospital that has been created there, in which people are trained to deal with infectious diseases such as Ebola in a tropical climate. It is not just UK military medical personnel who are trained in that centre; military medical personnel from other countries, including the United States, use it because it is a centre of excellence.
Mr Swayne
As I said, there are 468 key isolation beds. We are supporting more than 100 burial teams—both the logistics and training, and their fleet. That has had a remarkable impact on the incidence of the disease. As I said in an earlier debate, people are almost most infective once they are dead. Removing bodies and dealing with local burial customs has been one of the main drivers of the disease. In the western part of Sierra Leone, in which a third of the population lives, we are achieving 100% burial within 24 hours, which will make a key difference.
Of course, the criticism will be made that we acted too late; that we should have spotted the problem earlier. Hindsight is the most exact of sciences, but when the Committee went to Sierra Leone in June, it was not obvious that the problem was going to be of the scale we have now discovered. Actually, in January DFID had already begun refocusing our effort in Sierra Leone to deal with the emerging problem. In July and August we started to pump in more money to deal with that. I was making telephone calls, I think in the latter part of July, to the chief officers of UNICEF, the Office for the Co-ordination of Humanitarian Affairs and the World Health Organisation to try to ginger up their response. Many of those organisations are in need of reform. I have some sympathy for the World Health Organisation, which does not have at its centre the levers of power to bring about immediate change in the regions and countries in which it operates.
Equally, we must remember what was happening in the humanitarian community at the time. First, we were distracted by the terrible events in Gaza. Then, we moved swiftly on to rescuing people from Mount Sinjar, and all the time we had the ongoing crisis in Sudan. It has been a busy playing field for humanitarian organisations and workers to deal with.
Starting from where we are now, we certainly have a proud record. Clearly, there are lessons to be learnt, but, having looked at both the reports we are considering, there is no doubt that both Sierra Leone and Liberia are among the poorest countries in the world and that they were so even before they were struck by this disaster. Our aid reflects that: Sierra Leone remains one of the largest per capita beneficiaries of UK aid. In 2010-11 it received £51 million in bilateral aid, and £68 million in 2013-14. Owing to Ebola, I anticipate that that figure will inevitably fall next year—I suspect by about 30%—as a consequence of being unable to spend on the programmes we had identified. Of course, that will be completely augmented by the £230 million we are spending on Ebola.
I hope that 90% of our programmed spend on health will continue, but there will be instances where we will be unable to distribute bed nets in the way my hon. Friend the Member for Stafford (Jeremy Lefroy) described. There will be an effect on our programmes, but we will seek to minimise that.
Jeremy Lefroy
I am grateful to my right hon. Friend for giving way and for his powerful remarks. The Committee concluded that, after a period of terrible civil war, Sierra Leone had made tremendous progress and was on the cusp of being able to go much further, when the Ebola tragedy struck. Will he commit the Government to being there for Sierra Leone as it emerges from the Ebola tragedy and seeks to build on its recovery from that terrible civil war? This is not the time to give up, but to reinforce our co-operation with and support for Sierra Leone.
Mr Swayne
Absolutely, I give my hon. Friend that reassurance. We have already established the post-Ebola team to take that work forward once we have got on top of Ebola. Of course, it will have to consider how we develop the programme on jobs and employment opportunities.
I was as surprised as the Committee, and indeed the former Under-Secretary, at the lack of a programme for female genital mutilation, as highlighted in the report. It is not within my bailiwick to commit to such a programme, but I accept that the Department has placed great importance on that issue, as our girls’ summit earlier this year demonstrates.
Sir Malcolm Bruce
One of the survivors in Sierra Leone, a brave and beautiful campaigning lady, told us that, the day before she met us, she received a phone call from a senior Government Minister threatening her if she continued to speak out against FGM. That indicates the scale of the problem. These secret societies in Sierra Leone have a powerful hold on the political class. We do understand how difficult the challenge is, but I agree with everyone who said that that is not a reason for not trying.
Mr Swayne
I agree entirely and take on board exactly what my right hon. Friend says about the secret societies and the role that senior females—the “cutters”—have in them. Given the priority that the Secretary of State has attached to gender and the role of women and girls, it is vital that we do not shy away from this challenge and put it in the “too difficult” box. We must deal with it.
Anas Sarwar
I completely support the Minister’s comments about FGM. He seemed to skirt quickly over the issue of jobs and employment, and he did not say whether he accepts that the commitment made to create 30,000 jobs by 2015 has not yet been met and will be reviewed after the Ebola crisis—or has that commitment been met?
Mr Swayne
I would be very surprised if it has been met, but I cannot answer that question now. Given what has happened, it is unlikely to be met, but it remains vital that we continue our work on employment, which should be taken forward by the post-Ebola team; however, much of that work has undoubtedly been disrupted by Ebola.
Anas Sarwar
Of course, Ebola has taken away the emphasis from much of the work going on in Sierra Leone. The Minister seemed to suggest that, after the Ebola crisis, the budget reduction in the bilateral agreement between Sierra Leone and the UK Government will be restored in full. We should remember that that budget was cut before the Ebola crisis, so is he suggesting that we will go back to the pre-crisis levels?
Mr Swayne
What I said—I hope I was not misunderstood—was that I expect the spend to fall next year, simply as a consequence of Ebola preventing us from fulfilling our planned programmes. Of course, we will be spending much more in Sierra Leone as a consequence of our commitment to dealing with Ebola, but I will come on to how we spend our money, whether bilaterally or multilaterally, shortly.
First, I want to deal with the questions the report raised about centrally managed programmes and how we co-ordinate with bilateral and multilateral programmes. The approach should work precisely as I described to the Committee a fortnight ago, when we discussed parliamentary strengthening: it must be context-driven. The country team, within the context it faces, examines exactly what is required and what our programmes are to be, and then goes shopping to find the best fit. That best fit might be a bilateral programme. I made clear then—I stick by what I said—that my prejudice is in favour of bilateral programmes and bilateral aid, not least because I want to see it badged with the logo: “UK aid from the British people.” That is important to me and, I submit, to our constituents.
However, it is clear that, in some cases, international organisations must have a role. If we are dealing with malaria, for example, which takes no cognisance of international borders, we will have more leverage if we deal with a large organisation that is dedicated to dealing with such problems. Equally, there will be times when it is desirable to take account of international expertise that might not be available bilaterally, or to use economies of scale, through working through a large global or regional organisation. They clearly have a place, and in my view it is for the country teams to work out what is the best fit.
I entirely agree with the Committee that it is completely unacceptable that the country team should almost be left out of the equation, and not know under precisely what terms the bilateral aid is being delivered, or what the projects are. So we are introducing a new protocol, to ensure that the country team will be involved in the specification, design and monitoring of any multilateral programme that affects their country. I believe that is fundamental. I retain my prejudice for acting bilaterally, but if we are going to involve multilaterals we must have that intimate connection with the programmes.
I was as shocked as the Committee was disappointed when I discovered that it is not immediately obvious how much money is being spent in a particular country. When I asked those questions, about countries for which I am responsible, I found it hard to understand that a straight, easy answer could not be given. Having now looked at the problem I can understand that to an extent we are at the mercy of the time-lag reporting of large multilateral organisations, or of the fact that it is not entirely clear how much of the administrative, scientific and research costs of a large multilateral programme are allocated to each country, or how that is done.
I understand the problems, but clearly we must be able to address those, so that we know and I can say with confidence “Yes, we may have reduced the bilateral budget to Sierra Leone, but actually we are spending more there because I am confident that with what we have put into a multilateral programme we will be spending a clear and understood amount in the country.” So things are changing. We have already begun a system of mapping expenditure from the multilateral organisations back to the country, so that we can have a clear idea of what has been spent. I understand that that is a largely administrative, manual process. We are looking for a much better solution to the problem towards the end of next year, but it strikes me as vital to address that.
What happened in Sierra Leone and Liberia was a powerful illustration of what happens when a country does not have robust health systems. That leads to a question, as well as a criticism: we are the largest bilateral donor, and have been working for many years in Sierra Leone and spending a significant amount of money on health—so why were the systems so lacking in robustness and so quickly overwhelmed by the crisis? We have been investing in important health care options in Sierra Leone. We have been training staff, providing for drugs and spending money on infrastructure, but we have also spent a lot of money on a programme to deal with malaria. We should remember that many more people in the region will die of malaria this year than will die of Ebola.
Anas Sarwar
That very issue has been raised with me by various NGOs working on the ground in Sierra Leone. They fear that issues such as malaria have taken a back seat, despite malaria costing more lives than the Ebola crisis. They fear that the funding that was going to those issues—or even the priority given to them within the country—has fallen down the scale. Does the Minister accept that, and, if so, what is being done to make sure that more lives will not be lost because of it?
Mr Swayne
None of us should accept that. We must be vigilant to prevent that from happening to our focus on important long-term development issues, and I will certainly make it my business to prevent it.
The investment that we have put into Sierra Leone has, I believe, made a significant difference; but we started from a very low base. The figures given to us—the statistics on doctors and nurses per head of population—are very low, and well below the regional average. I think the figure is 1.7 nurses to every 10,000 of population—I do not have it to hand; that is from memory—against a regional figure of 12. It is a very low base, and, frankly, it would have been a lot worse had we not done the work we did.
Building robust health care systems is vital; but what does success look like? What is a strong health care system? I believe that, ideally, it is a free one. The hon. Member for Glasgow Central challenged me and asked what we were doing about advocacy for universal free health care. I am glad to tell him, in case he was not aware, that tomorrow is universal health coverage day. We are making a presentation and speaking at an important event tomorrow—when I say “we” I do not mean myself personally, but DFID—promoting exactly that.
Mr Swayne
The hon. Gentleman is very kind; but quite right.
Clearly, it is important that health care, if not free, should be affordable—it should not impoverish the recipient—and available within a reasonable distance. When people arrive for treatment there should be someone there who will treat them and is trained to do so and able to deliver health care, whether by means of drugs or equipment, or anything else. That implies a level of funding to cover trained people who can distribute the drugs, of which there should be a guaranteed supply, and the availability of equipment. Also, taking up that health care should not make someone worse than they were when they sought the treatment. That implies sanitation, a water supply and electricity.
Anas Sarwar
I am aware of the time, so I promise that this will be my last intervention. The Minister mentioned the Government’s presentation tomorrow, but my point was different. I was asking about advocacy not for what will happen but for what has happened. What advocacy are we carrying out on the international stage to demonstrate that we are the global lead on universal health coverage, and to make sure that it forms a key part of our sustainable development goals?
Mr Swayne
We have been negotiating with respect to the post-2015 agenda. We are, I think, by virtue of the fact that we have the largest free, universally provided health care system in the world, among the lead players. However, we have been in this business now for more than 30 years. We spend a quarter of our development budget on providing such health care, and it is vital that we drive forward that agenda.
How do we do that? It is horses for courses. Every country is different. When we create strong health care systems, we must recognise that countries require different kinds of support, depending on the state they are in. The Committee was right to say that we do not have effective measures to chart our success. We are leading funders in the field to identify such measures. We are funding high-quality studies and research to come up with ways to chart improvement in health care. The hon. Member for York Central (Hugh Bayley) drew attention to the QALY measure, which is used by DFID, NICE and NICE International. Clearly, there has to be much greater knowledge about what works, particularly in low-resource economies. We have invested, and continue to invest, considerable resources into such study.
Health care strengthening requires a number of partners, and I acknowledge that that involves a tension, to which the Committee has drawn attention and which has been evident in the debate. One accusation levelled at large vertical funds, such as Gavi and the Global Fund, is that they do little or nothing to strengthen underlying fundamental health care systems. I understand that criticism, and I think there are elements of truth in it. I am less persuaded by the argument that because the targets and deliverables of the large vertical funds are so much more measurable, deliverable and reportable, we skew our budgets away from fundamental health care strengthening and into vertical funds. There must be an element of synergy. I was interested to hear my hon. Friend the Member for Stafford draw attention to the fact that bed nets were delivered by large international organisations through existing health care systems. The same thing can happen with immunisation. We must do better at negotiating with the funds to ensure that is the case, but we must recognise that that is not their primary objective and that they have a significant input into world health.
I agree that we must work harder at making our own experience and expertise count in the councils of the world. We are shy, to an extent, as the Committee has pointed out, and we need to take more of a lead. We will explore with the Department of Health new ways of making better use of what the UK has to offer. I have already dealt with the point about recruitment in an intervention. We must not allow the agenda of health care strengthening to slip backwards; it is fundamental that we drive it forward. I accept the Committee’s challenge on providing global leadership. To that end, I accept the recommendations that we have accepted. Most importantly, we will develop a framework to support health care strengthening, to tie all those things together and drive the agenda forward.
Sir Malcolm Bruce
I thank all colleagues who have taken part in this interesting and useful debate. I do not want to delay hon. Members, because we have an important debate to follow. I welcome the Minister’s response to the hon. Member for York Central (Hugh Bayley) about reviewing recruitment into the NHS and the implications for developing countries. Alongside that, I suggest that the Minister have a dialogue with the Department of Health about training. If we do not train enough, we will not solve the problem. I also welcome the Minister’s commitment to more transparency of spend, which has been a frustration for the Committee for a long time. He has identified some of the problems and given some commitments, and I am grateful for that. In anticipation of the next debate, I would like to say that its shortness does not in any way qualify its importance.