Health Systems (Developing Countries)

Anas Sarwar Excerpts

Thursday 11th December 2014 Westminster Hall

[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.

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[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.

[Mr Swayne]

No, I will be dealing with that matter.

[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.

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[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.

[Anas Sarwar]

You should be there.

[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.

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[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.