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Health: Disease Control (Intergovernmental Organisations Committee Report)

My Lords, in moving the Motion I want to draw attention to this report, which I think has been very well received not only in this country but in other parts of the world. It is one of a number of reports dealing with contagious diseases over a number of years. What is different about this one is that it deals essentially with the relationship between this Government and the intergovernmental organisations through which we work and which involve an enormous amount of British taxpayers’ money. A minimum of £450 million to £500 million goes into a number of these organisations, so that is an important part of the relationship. The report is also an indication of how, as some of the other reports on contagious diseases have recently suggested, the world has changed. The development of transport and trade means that we no longer have any frontiers that will stop diseases. Before there was easy movement in trade and transport, diseases tended to stay within certain geographical areas. There were exceptions to that, of course, but diseases then were largely much more constrained. The modern world means that it is much easier for contagious diseases to spread, sometimes with quite catastrophic effects, and we have seen a number of warning signs. The committee analysed four major diseases—malaria, TB, AIDS/HIV and influenza—not in detail, but to see how the intergovernmental organisations and other organisations involved were either preventing those diseases or responding to them once they happened. Although we were not involved in making judgments about other diseases, many other diseases came up during our inquiries, some of the most worrying of which were the emerging new diseases which we have yet to be alerted to. As I say, we simply used those four major diseases to highlight some aspects of the relationship within intergovernmental organisations. I put on record my thanks to the clerk of the committee, Robert Preston, who has recently retired; indeed, he retired just after the report was completed, although I hope to conclude that there was no causal effect between the two actions. He served the House a long time and deserves our thanks for that. I also thank the other members of the staff and our excellent adviser, Sandra Mounier-Jack, who gave excellent advice. I also thank, most notably, all Members from all sides of the House who served on the committee. Our inquiry discovered that the United Kingdom has a very good reputation around the world not only for the amount of finance that it puts into dealing with contagious diseases but for the professionalism with which we act through the Department for International Development and the people whom we place in the various medical bodies and intergovernmental organisations around the world. We received truly unsolicited praise. I think that every now and then we as a country have to give ourselves a pat on the back for how much we are doing, in work which is so well recognised around the world. Many of the witnesses told us, without any encouragement from me or other members of the committee, that they very much welcomed a parliamentary committee from another country coming and taking evidence from them. It had very rarely happened to any of them before and was a new experience. Yet one of them said to me in a private conversation afterwards, ““I don’t think people in Britain realise just how much money is spent in these organisations and they ought to take a little more interest””. One of the messages from this is that we need to take more evidence from people in these positions around the world. They certainly welcomed it, and I think that we ought to do it a little more often. Because of some of the recent alerts, such as SARS, and concerns about world health, there has in recent years been a dramatic increase in the funding of disease prevention and control. Alongside that, however, there has also been an increase in the number of organisations dealing with diseases. Those organisations can be split into five broad groups: intergovernmental organisations, national government organisations, public-private partnerships, non-governmental organisations, and private foundations such the Gates Foundation. It is worth noting that the Gates Foundation spends billions of pounds; it spends more than the core budget of the WHO. An enormous quantity of money is pouring into this area. This explosion of organisations obviously creates a problem: what was referred to as the ““institutional labyrinth”” of organisations. There were so many that a diagram was produced for us which would remind you of a close-up photograph of the maze at Windsor. It was impossible to find your way through or to link all the organisations. The general view, and that of the Government, is that they are not well co-ordinated. That is not a criticism; it is not meant to say that the organisations are not doing their jobs properly. It is hardly surprising. With an increase in funding of the type that we have seen, and the increase in the number of organisations, it would be quite extraordinary if the co-ordination was as good as it should be. Given the nature and seriousness of intercommunicable diseases, it is important that we work hard on that. That was one of our recommendations and I will touch on it again. One of the issues that we discussed was whether reorganisation should take place from the top down. In other words, should we try to impose a structure on this labyrinth? By and large, we felt that that would not work well, but other people felt that it might be the best way of doing it. However, we felt that an evolutionary, rather than a revolutionary, approach was needed. We were aware that several organisations were increasingly working together and linking their practices much more effectively. This is particularly important in the context of the current world economic crisis. It would be quite extraordinary if, as a result of the world economic crisis, countries generally did not try to squeeze some of the finances going into these areas. The efficient working of these organisations, and the co-operation between them, becomes a vital matter. It is also an important issue for the recipient countries. We discovered that each of the many organisations offering help to the neediest countries had its own accounting structures, administrative needs and so on. They were asking those countries to respond to them. There were many requests for a developing country to, in effect, duplicate the accountancy and administrative methods, putting a considerable burden on countries that were not well equipped to do this. One of our recommendations tries to deal with this matter. Recommendation 210 says: "““The aim should be to secure alignment of donor input to disease control programmes within the national health programme of recipient countries””." That is important because there is a problem in making sure that we do not deal with a disease without dealing with the needs of a health service structure within the developing country. We need to be able to do both. I shall return to this in a moment in the context of recommendation 192, that the Government should aim for a better balance between vertical and horizontal systems of healthcare. The vertical system, as the name implies, deals with one specific disease; for example, you would try to treat malaria in this way. An argument for a horizontal system would be trying to improve the health system of a country so that it can deal with malaria. However, if you try to put it as a question of either/or, it will not work. It is a matter of trying to get a better balance between the vertical and the horizontal. This is important. It must be recognised that if you put an enormous amount of money into one disease in one country, you may well take some of the professionals in that country—who will already be in short supply—out of the health system and into that particular disease treatment programme. That is not necessarily good for the health system. On the other hand, one could argue—as some people did in giving evidence—that if you remove the impact that a major disease has on a country, you might improve the health system simply because you have alleviated the pressure on it. It is quite a complex argument, but the balance between the vertical and the horizontal is particularly important. We need both of them; we just need to get them in balance. One of the other things to which our attention was drawn is the role of the World Bank. There was a general feeling that the World Bank could have done more and should do more in terms of the health infrastructure of a country. We tend to think of the World Bank as dealing with infrastructure such as dams, roads, railways and so on, but in fact the health structure in a country is now becoming critically important to the success or failure of that country and, as we have indicated, to the way in which disease is spread around the world. Looking at the Government’s response to recommendation 193 on the World Bank, I am still a little unsure whether they wholly agree with it, partly agree with it or are just being a bit diplomatic about what they think about the World Bank. The Minister may be able to add to that in her response. We would really like to see the World Bank taking a greater interest in the health infrastructure of countries and investing in them accordingly. Recommendation 201 emphasised the importance of the World Health Organisation, but the important area—I know that the Government agree with this, as did most people who gave evidence—is the need to reform the internal structure, as it is no longer good enough for the world that we live in and operate in. It is particularly important to get it right at the regional and country office levels. The general feeling is that the central organisation of the World Health Organisation is quite good, but because the regions are selected differently and are not necessarily directly accountable in the sense of having to have a system that responds to the WHO at the international level, the structure does not often work as well as it should do on a regional level. Therefore, there is a strong call for the regional and country offices to be restructured and made to fit in with an international structure that works. That was one of the things that the SARS outbreak drew to the attention not just of the World Health Organisation but of many countries and regions, in that what we were doing was not really working as well as it needed to. I was pleased that the Government agreed with a number of the recommendations, particularly this one. They also share our view that the new director-general of the WHO, Dr Chan, is not only doing a very good job but is very alert to this problem. It is encouraging to hear the response of many of the witnesses, who also felt that she was the right person for the job. Recommendation 194 stresses the importance of surveillance and response systems. This is where you get overtaken by the incredible acronyms of international organisations and where, if you are not careful, you can go mad. The best way is to read through them and try to remember what they stand for. Do not do that before you go to sleep because, contrary to popular opinion, it does not make you sleep; you just stay awake struggling with them. GOARN stands for the Global Outbreak Alert and Response Network. For some bizarre reason, it took me longer to remember that one than most of the others, but it is important, because it is a system that is designed for early alert and response to the outbreak of disease. I do not know whether the Government are able to tell us any more on this since their response, but my understanding is that they intend to announce their strategy in July on how to make the alert and response system work better. That is one of the key preventive arguments; it is very important. I wish to refer here to zoonoses, which is another learning curve. It is a fact that the majority of human diseases have come from animals. The word for that is zoonoses. I am sure that most noble Lords know that, but I did not know it at the time so it was educational for me. We had a good but also slightly frustrating session with the OIE, which is the World Organisation for Animal Health in Paris. I say frustrating because it came at the end of our day there and therefore the time got squeezed, which was a great pity. This organisation has a long and prestigious history going back far beyond the WHO. The director of that organisation, Dr Vallat, wrote to me that he was worried by our report, which, he felt, suggested that the WHO should, in effect, take over from the OIE the role of monitoring animal diseases. I have written back to him but I want to put it on the record that we are definitely not saying that. Indeed, the foreword of the report says that we want the WHO to take the lead in developing a strategy for dealing with disease outbreaks and problems around the world. That clearly does not mean either taking over or giving instructions to organisations, be it the OIE or any other. Dr Vallat was also slightly worried about using the new legal structure for international health regulations. Both the Government here and other organisations and individuals felt this to be an important step forward. International health regulations impose a legal duty on countries to report on diseases. As with other areas of international life, this means the development of legal structures within what would previously have been treaty agreements or arrangements between countries. One of the problems the committee had with the OIE’s position was that its code was not enforceable. That led us to the recommendation that maybe there ought to be a legally enforceable system for animal health. We acknowledge the difficulties with that. One is that the veterinary services in many developing countries do not have the ability to do it. Another important one is that countries have an enormous investment in animal trade for export and import. Therefore, they will not always be willing to sign up to a legal requirement. So I understand the arguments on both sides. My own view and that of the committee was that if we could move towards a more legal structure in the long term that would be beneficial, although I am sure that the OIE would not necessarily agree, but that does not mean taking over from the OIE. It is a difficult area because so many diseases originate with animals therefore animal welfare is a crucial factor in the spread of disease. We cannot do anything other than pay close attention to this. A number of good things are happening in this area. One of the best is the global early warning and response system, or GLEWS, designed to pick up at the earliest stage animal health problems around the world. It links the OIE with the WHO and the Food and Agricultural Organisation of the UN—three of the most important organisations in trying to spot these diseases and deal with them. I want to say more about this but time and the other things I want to mention limit me to that. Zoonoses and developing alert and response systems in developing countries for diseases that cross over from animals to human beings is an important area, one that should trouble us and that we need to get right. There are no quick fixes or easy solutions. There was some disagreement between the evidence given by the WHO and that of the OIE. I am sure that there have been one or two interesting telephone conversations between the two organisations, which I would have liked to listen in on, about who was saying what to whom. I think that has largely been resolved, but it indicates that between these very important and very good organisations there are bound to be areas of difficulty and disagreement. In the rapidly developing area of these diseases, it is important that we acknowledge that and move on. We dealt with the drug availability issue. I do not have time to deal with it now, but I note that GlaxoSmithKline has just announced a plan to try to reduce drug pricing. The Global Alliance for Vaccines and Immunization—GAVI—has developed a 10 to 20-year finance programme to provide vaccines and immunisation over a long period, which guarantees a purchase volume and a purchase price for companies. The UK was a major driver in that. We looked at the dangers of bioterrorism in some depth. I do not want to go into that in depth other than to say that the early-warning systems for a disease which is released deliberately and for one that occurs naturally are not different. We do not need to spend too much time on separate systems; the response should be the same. The International Health Partnership, which, I know, the Minister in the House of Commons, Gillian Merron, sees as very important, encouraged close co-operation between the donor countries and the recipient countries. That is important, and we want to keep an eye on it. I know that the Government place a high priority on that. The Government’s response to this has been very positive, although we have some disagreement in one or two areas, including that of the OIE. I would like some clarification at some stage on the World Bank: are we saying very clearly that it ought to invest more in health infrastructure? The committee was set up as an ad hoc committee—there is a long history to that, but I do not wish to repeat it. The development of global systems is now so rapid, so important and uses so much money from taxpayers that this House will miss the great opportunity of playing a key role in looking at the way we spend money and how these international organisations develop, particularly, as they move increasingly into the area of legal requirements, as with the international health regulations. If we do not find an alternative to the existing committee, which will now come to an end, we may regret losing such an opportunity, given the House’s specialist membership, with so much knowledge of both disease and intergovernmental organisations.