Universal Health Coverage

Philippa Whitford Excerpts

Wednesday 10th July 2019 Westminster Hall

[Alistair Burt]

Yes, the hon. Gentleman is correct. When I was in the main camp in Cox’s Bazar—colleagues will have visited it—with those who had been there a year, protected from the atrocities in Burma, I asked, “What happens next?”. I was told the biggest worries on the camp were: boredom and lack of things to do; education for the children; domestic abuse in the camp; and trafficking. That is a signal to all of us that just keeping people in a camp, protecting them from one thing but leaving them exposed to another, is a further tragedy.

Let us look at the state of the world’s health, concentrating on three areas in particular. The first is children’s health, where the picture is not all gloomy. Each day, 17,000 fewer children die than did in 1990, but more than 5 million children still die before their fifth birthday each year. Since 2000, measles vaccines have averted nearly 15.6 million deaths. Despite determined global progress, an increasing proportion of child deaths are in sub-Saharan Africa and southern Asia; four out of five deaths of children under five occur in those regions. Children born into poverty are almost twice as likely to die before the age of five as those from wealthier families.

Secondly, let us look at maternal health. Maternal mortality has fallen by 37% since 2000. In eastern Asia, northern Africa and southern Asia, it has declined by about two thirds, but the maternal mortality ratio—the proportion of mothers who do not survive childbirth—in developing regions is still 14 times that of developed regions. The need for family planning is slowly being met for more women, but demand is increasing rapidly. Again, we see that in the camps, where women who, in the countries they come from, had been excluded from reproductive health advice, perhaps for religious reasons, gain rapid access to it in the camps. That again is a lesson for the future.

Thirdly, I turn to HIV/AIDS, malaria and other diseases. In 2017, 36.9 million people globally were living with HIV, and 21.7 million people were accessing antiretroviral therapy, but 1.8 million people became newly infected with HIV and 940,000 people died from AIDS-related illnesses in that year. TB remains the leading cause of death among people living with HIV, accounting for about one in three AIDS-related deaths. Globally, adolescent girls and young women face gender-based inequalities, exclusion, discrimination and violence, which puts them at increased risk of acquiring HIV. It is the leading cause of death for women of reproductive age worldwide, and now the leading cause of death among adolescents in Africa, and the second most common cause of death among adolescents globally.

More than 6.2 million malaria deaths were averted between 2000 and 2015, primarily of children under five years of age in sub-Saharan Africa. The global incidence of malaria has fallen by an estimated 37% and mortality by 58%.

What is DFID doing in these areas, and where are we going? The UK’s significant boost to the Global Fund, the combined effort to combat AIDS, TB and malaria, was announced by Prime Minister at the recent Japan summit. The 16% increase to our already generous contribution sets a new standard for others to follow, and I thank the Minister and all those behind him who worked on that over a long period. My friends at STOPAIDS and ONE and many others welcomed the achievement. ONE said:

“This is global Britain in action.”

There’s a phrase! It continued:

“It is fantastic to see the UK reaffirming its position as global health leader, working in partnership with other donors, countries affected by the diseases, the private sector and philanthropy to make the world a safe, and healthier place”.

However, we must ask the Minister how he plans to ensure that others follow. Will he outline any changes or developments in transition strategies, as nations take on more of their own responsibilities and work towards what, in such areas, is often a difficult process?

Let me say a few words about vaccination. Gavi, created in 2000, is a global vaccine alliance bringing together the public and private sectors with the shared goal of creating equal access to new and underused vaccines for children living in the world’s poorest countries. From 2016 to 2020, the UK is providing a quarter of Gavi’s funds. We are its largest donor, and have supported it since its inception. Gavi’s first replenishment conference was hosted by David Cameron in London in 2011.

As well as providing direct funding to Gavi, the UK was also instrumental in creating the international finance facility for immunisation, which raises funds for Gavi by issuing vaccine bonds on international capital markets. The UK also helped create the advanced market commitment for pneumococcal vaccines, which have helped protect millions of children in developing countries against the leading cause of pneumonia, as well as the matching fund, which encourages funding from the private and philanthropic sectors by doubling donations. That is my point about partnerships. It is always tempting to think that this work can be done by one sector or another alone. My experience is that that is not the case. Partnerships can contribute to the whole, but they need to be handled carefully.

Let me mention polio. As we know, it has decreased by over 99% since 1988, but transmission has never stopped in three countries: Pakistan, Afghanistan and Nigeria. There remains a risk of failure. We must thank the development and health workers who are responsible for vaccination. In particular, we recognise that in some countries they face genuine physical threats and loss of life.

In other countries, vaccination faces a threat from anti-vaccination campaigns, which are run for all sorts of reasons. It is essential that anti-science is combated by evidence of science and evidence of success. As far as I am aware, vaccination is about Edward Jenner and smallpox in the United Kingdom, and about Pasteur and others worldwide. It is not about big pharma trying to sell vaccines; it is a proven method of saving countless millions of lives. As we have learned to our cost, we might find a good argument lost for want of it not being made regularly. Let that not happen with vaccination.

Finally on polio, I must mention rotary. I am an honorary member of the Sandy rotary club—my father has been a member of the Bedford rotary club and Bury rotary club for many years—and we recognise that rotary has helped vaccinate 2.5 billion people in 122 different countries and given more than £1.8 billion over 30 years. I have met Judith Diment, the national representative, a number of times. We thank those in rotary up and down the country and abroad for their efforts and voluntary work.

Finally, on behalf of Save the Children and others who have written to me on this issue, I turn briefly to the high-level meeting. The first ever high-level meeting on universal health coverage will take place in September at the UN General Assembly. It is a critical opportunity to galvanise global momentum behind healthcare.

“The theme…is ‘Universal Health Coverage: Moving Together to Build a Healthier World.’ This…will be the last chance before 2023, the mid-point of the SDGs, to mobilise the highest political support to package the entire health agenda under the umbrella of UHC, and sustain health investments in a harmonised manner.”

I am shamefully reading out the briefing from Save the Children. I am not pretending to claim authorship of this; I am acknowledging the support we get from our remarkable partners. The high-level meeting has the potential to be a transformational moment for children everywhere, but countries need to step up their efforts to tackle the biggest challenges in global health today, from ending the scourge of preventable diseases to reigniting action on stalled global immunisation rates, for the reasons I mentioned.

I know the Minister will have been presented with a series of challenges for the high-level meeting. Perhaps I could outline them. We hope that the Secretary of State will attend the high-level meeting. The UK should champion free-at-the-point-of-use health and nutrition provision, helping to deliver on the “leave no one behind” agenda and to ensure that we reach those furthest behind; it should signal its support for domestic resource mobilisation, which is essential for encouraging more countries to work on strengthening their systems; it should champion the full integration of nutrition and immunisation into national universal health coverage plans; and it should fund UHC2030 as the main institution that can make a difference in driving the UHC agenda and on accountability, with a focus on meaningful civil society participation.

I could mention much more. Sexual and reproductive health is vital. At the 2017 summit, we announced £250 million of support over the next four years. Access to sexual and reproductive health services is under increasing threat from some developed nations that ought to know better. It is essential that the United Kingdom follows its independent path, and is not browbeaten by any of its larger partners or friends into offering restrictive reproductive health facilities just because somebody else does not like them, for questionable reasons.

We must continue the work on neglected tropical diseases. We are protecting some 200 million people from 2017 to 2022 with support of £360 million. I have not mentioned anti-microbial resistance and the work of Sally Davies. She moves on from her post relatively soon, and we should thank her warmly for all the vital work she has been able to do. Ultimately, it will protect us all; if we cannot find answers, that threatens us all. I thank those involved in the collaborative work that we now do internationally with the Department of Health and Social Care, and I hope the Minister will be able to take that work further.

I could mention the contribution of water sanitation and hygiene—the foundation for good health. I have seen remarkable projects that the United Kingdom is doing around the world on that. There is no point having a global health system or a national health system if there is no effective sanitation. It makes a particular difference to young women at important stages in their lives. It is absolutely essential. Nutrition, one of my favourite subjects in the Department, is much underrated. It is really vital to ensure that nutrition is correctly promoted. There is a difference between feeding people and feeding them nutritiously, as I learned in my first week in DFID.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Should we not also emphasise that vaccines will not work properly on a malnourished child? We need to see these subjects as two sides of the same coin.

[Alistair Burt]

The hon. Lady is absolutely right and speaks with great experience. A child may be physically alive, but the weaker a child becomes through lack of nutrition, or through existing on the barest rations, the more prone they are to disease, and the harder it is to ensure that preventive measures work. That is absolutely correct.

I wonder whether the Minister wants to venture an opinion on the Department for International Development remaining a stand-alone Department. It might be slightly unfair to expect an answer from him on that, but I hope that this debate will leave him in no doubt of the value that we see in an independent-minded DFID. It is always part of the Government, as I occasionally had to remind officials, but it very much has its own stand- alone processes.

I hope others will cover all those points, and that I have helped to lay the ground, and made it clear how important this House feels universal health coverage is, and how proud we are of the United Kingdom’s previous contribution and its determination to keep that up. There is a clear sense that we are a world leader, through the work of our hard-working experts. The Minister should know that he has the full backing of the House in his determination to make sure that this issue remains as important to him as it has been to me and all my predecessors.

--- Later in debate ---

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

It is a pleasure to serve under you, Mr Robertson. I declare an interest in this subject, as I travelled to Ethiopia with RESULTS UK and saw the impact of setting up vaccination services as the initial building blocks towards universal healthcare. I pay tribute to the right hon. Member for North East Bedfordshire (Alistair Burt) for opening this debate and for his work as a DFID Minister. I am the chair of the all-party parliamentary group on vaccination, and I really welcome the commitment he showed in giving evidence to our inquiry on the next decade of vaccines. Our report was published in January, and I thank the team he worked with at the time.

As the right hon. Gentleman said in his introduction, universal health coverage is the idea that everyone should have access to quality healthcare without ending up in financial hardship. Half the world’s population simply does not have that, while 100 million people are thrown into extreme poverty when trying to access healthcare.

The UK has absolutely been a leader in this sphere. It is the No. 1 funder of Gavi, The Vaccine Alliance, which helps to provide affordable vaccines to low-income countries, and also helps those countries to develop their own systems to deliver vaccines. I particularly welcome the £1.4 billion commitment to the Global Fund and the fact that it was made in advance of the replenishment date. The replenishment of the polio eradication initiative is coming up this November, and the UK making a pledge in advance helps to put pressure on other countries to make similar commitments. The Global Fund is particularly involved in tuberculosis, HIV and malaria, which shows that this about not just a single thing, but a combination of vaccinations, antiretroviral drugs and malaria nets. Underneath all that, there is the need for clean water, among other things.

Vaccination itself has saved 20 million lives in the last decade. In 1988, when the polio eradication team came together, there were 350,000 cases of polio a year. Last year, there were 33 cases, in a difficult area on the border between Pakistan and Afghanistan. There is no treatment for polio. One problem when people talk “anti-vax” and say, “I don’t believe in vaccination” is that they do not remember what these illnesses look like. When I was in Ethiopia, we pulled into a garage to get petrol, and I saw a young man of about 30 standing there with the obvious deformity of flaccid paralysis from polio. The last time that I saw someone in that situation, it hit me like a boot in the face.

On Monday, we held an event in the House for polio survivors, and I thank those hon. Members who attended to hear their stories. Many of the older polio sufferers now use wheelchairs and are not therefore as recognisable as the children with polio, who used callipers or crutches. People are complacent and have forgotten the harm that polio can do and is doing elsewhere.

The Global Polio Eradication Initiative has done an incredible job using oral drops, which are critical because the gut protection a child gains from an oral vaccine protects against the further spread of the virus. The injectable form we use here protects the individual, but they can still spread the disease. It is therefore crucial that we eradicate it.

The problem is that, previously, we talked as though we would achieve eradication—obviously, we had hoped to achieve it by next year—and then look at transition. However, much of the infrastructure, staff and funding used to eradicate polio is also holding up the basic vaccination systems in low-income countries. In fact, people are now reluctant to take the oral vaccine. Some of that is because they say, “Here you are again, back in our village with your drops, but I can’t get my baby treated for another condition. We don’t have clean water. My children aren’t even fully immunised.” That is why we need the transition. Universal health coverage is now critical to achieving the eradication of polio; if there are outbreaks in Nigeria or elsewhere, it is because the routine levels of immunisation are simply not high enough.

Seth Berkley, the head of Gavi, pointed out a shocking figure to us when we set up the APPG. He said that although we think we are doing a great job, 85% of children in low-income countries are vaccinated only with DTP3—one of the very basic vaccines—and we put a tick next to them. However, only 7% of children in those countries are fully vaccinated and receive all 11 vaccines recommended by the WHO. More than 90% of children are still vulnerable to disease, and 15% have had no vaccinations at all, so we still have a lot of work to do.

I commend the UK for the 0.7% commitment to aid, which must be maintained. DFID must be maintained as a separate Department, not just for its function, but to show that commitment and drive. If our constituents say, “Charity begins at home, so why on earth are we bothering to spend money miles and miles away?” we should remember the Ebola outbreak and the fear over people arriving at Heathrow and having their temperatures taken. With air travel, the world is now a very small place, so infectious diseases threaten everyone. Vaccines will be critical to preventing antibiotic resistance, which threatens us all.

We should see our commitment both as a way to help those countries to invest in their children’s health, which helps them to develop economically and—a little selfishly—as a way to protect ourselves. Vaccination on its own will not be enough unless it is part of a system of universal health coverage that improves the health of all people, particularly the future generations of developing countries.

--- Later in debate ---

[Dr Murrison]

I was about to say that I am really comfortable to do so, because the decisions he made, and those he is associated with vicariously, are good ones. I am happy to have inherited his portfolio, but he is a difficult act to follow, that is for sure.

My right hon. Friend identified all the issues in his contribution, as I would expect him to do. He started by highlighting universal health coverage and its contribution to SDG 3, but he also made the point that universal health coverage touches on the other SDGs as well. In advance of the high-level meeting on 23 September, he was right to ask about the aims and ambitions the UK Government have for that meeting. They are encapsulated in getting more money—obviously—and getting better quality and integrated healthcare. That is something many of the contributions have touched on one way or another. I have been struck by the level of support for an holistic approach to delivering universal healthcare.

We have talked about immunisation and about the mistake we would be making if we simply imagined that going around the world offering people vaccinations and inoculations would be “job done”. It really would not be. Those interventions would be treated with a great deal of suspicion by communities, as they are at the moment, if that were all we were offering. It has to be much more than that; it truly has to be integrated. I look forward to making this point loud and clear in September in New York.

On a broader theme, as I have gone around the world, I have been struck by the roll-out of healthcare systems. Very often, there is a temptation for politicians to roll out shiny things that they can demonstrate to their constituents. That generally means hospitals, and hospitals are great things, but they may not be the right thing in low and middle-income countries.

[Dr Whitford]

In the four health systems across the UK, we are trying to address our obsession with hospitals and tertiary centres, realising we have not got enough resources in primary care, and certainly not in prevention. We need to share that knowledge with developing countries.

[Dr Murrison]

I agree with the hon. Lady. In the context of low and middle-income countries, my focus would be on primary healthcare and public healthcare, by which I understand something slightly different from public healthcare in the context introduced by the hon. Member for Birmingham, Edgbaston (Preet Kaur Gill), who speaks for the Opposition, and I will come to that in a minute. The focus needs to be on prevention and on things that deal with the problems that the poor are exposed to, first and foremost. The difficulty with shiny stuff—electorally obliging though that might be—is that it risks exacerbating health inequality; shiny things tend to be in urban centres and accessed more easily by the better-off, rather than the poor, and particularly the rural poor. We need to be very careful about that.

We need to introduce the notion that countries themselves must grow their healthcare systems, and a number of contributions touched on that. That means addressing unpleasant things such as taxation. In addressing universal health coverage, we need to ensure that we encourage Governments to establish proper mechanisms for raising taxation, so that countries can ultimately stand on their own feet. I am pleased that the UK has introduced some trailblazers in that respect—the four in Africa are Rwanda, Ethiopia, Ghana and Uganda, and the other is Pakistan—where we will be assisting Governments to build structures that will make their healthcare systems sustainable in the longer term.

A number of contributions touched on polio. I know that will be the subject of my grilling later by the hon. Member for Liverpool, West Derby (Stephen Twigg)—I will say lots of nice things about him in anticipation that he will give me an easy ride this afternoon. I am sorry that he is standing down; it will be a great loss to the House, and I urge him to think again. Polio is on the cusp of being defeated. There were 33 cases last years, from only three countries—only two countries, really. We must make sure the boot remains on the carotid, because there is a real risk that, if we are tempted to divert funds from this, we will be back to square one. That would be a tragedy because of the lives that would be lost, and because, at some point, we would have to pick up the pieces. It makes no sense, in raw economic terms, to relieve the pressure on that particular nasty at this point. I hope we will make sure in September that the pressure stays on that particular one of the “Captains of the Men of Death”.

I appreciated the comments made by right hon. and hon. Members about nutrition; they were absolutely right. The hon. Member for Central Ayrshire (Dr Whitford) rightly said in an intervention that there is no point vaccinating people if they are undernourished. It is nonsense epidemiologically and in public health terms to do so, and we must adopt an integrated, holistic approach to universal health coverage. If we can get that across to people in New York in September, we will have done the world a great service.

I am proud to be a member of a Government who are fully committed to not just the Global Fund but other funds that require replenishment. Our leadership has been salutary over many years—not just under the present Government, although I am pleased about the commitment they have made to the Global Fund—and I am confident, whoever wins in two weeks’ time, to answer the point made by the hon. Member for Dundee West (Chris Law), that that process will continue.