Health Systems (Developing Countries)

Hugh Bayley Excerpts

Thursday 11th December 2014 Westminster Hall

[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.

--- Later in debate ---

[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]

I hope the hon. Gentleman will convey the Department’s thanks to Strensall for the magnificent work it has done in providing build-up training to for many personnel before they deploy to Sierra Leone.

[Hugh Bayley]

indicated assent.

[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.