Health Systems (Developing Countries)

Fiona Bruce Excerpts

Thursday 11th December 2014 Westminster Hall

[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.