Health Systems (Developing Countries)

Jeremy Lefroy Excerpts

Thursday 11th December 2014 Westminster Hall

[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.

--- Later in debate ---

[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.