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Select Committee on Intergovernmental Organisations First Report

CHAPTER 3: INTERNATIONAL HEALTH: THE INSTITUTIONAL LABYRINTH

88.  In this chapter we review the interaction of the various actors on the international health stage, particularly those concerned with infectious disease control. We look in some detail at the role of the World Health Organisation (WHO) and then turn to address a number of the key issues which have arisen during our inquiry, including the synergy with which the various bodies are working under the existing system and the case and scope for some rationalisation of global health governance.

The Field of Players

89.  The Government wrote in evidence to us that "intergovernmental organisations, including the UN agencies, development banks, global funds and health partnerships, have a central role in health and specifically the control and spread of infectious diseases"(p 2). IGOs, however, are far from being the only players on the global health stage. Research Councils UK drew attention to NGOs, many of them (such as Stop TB) operating through partnerships, some of them including IGO representatives(p 521); and Professor David Fidler, from Indiana University School of Law, believed that recognition of the growing non-State dimension was crucial to understanding the changing nature of global health management. "The [global health] governance task", he wrote, "now extends beyond getting IGOs to function more effectively because non-State actors play significant and increasingly influential roles" (p 379).

90.  A list of the main organisations involved in controlling the global spread of infectious diseases is at Appendix 4. Figure 1 illustrates the institutional labyrinth. There may be said to be five main groups:

FIGURE 1
The Institutional Labyrinth of International Health


Source: Mbewe, WHO

91.  There has been a sharp increase in the number of such bodies in recent years and this has brought with it a major increase in aid for health programmes. But, according to Dr Tyson (DFID), it has also been driven by a perception that existing international arrangements to control specific diseases are inadequate. In many cases these organisations achieve effective ad hoc cooperation with each other. For example, Dr Lob-Levyt spoke to us of GAVI's collaboration with WHO and the World Bank (Q 801), while Dr Jorge Bermudez, Executive Secretary of UNITAID, pointed to cooperation with WHO in his organisation's purchase and supply of drugs to combat infectious diseases:

    "We rely on WHO technical expertise. We are an operational unit … WHO is not a procurement agency or a funder of products. They have a model list of potential medicines, they have a [medicines] pre-qualification scheme that works within the UN system" (Q 672).

The cooperative mode has bred a new kind of partnership organisation, including civil society representation and conferring social leverage as well as producing better information.

BOX 2
The Global Fund to fight AIDS, Tuberculosis and Malaria

The Global Fund is a worldwide Public-Private Partnership dedicated to raising and disbursing funds to combat HIV/AIDS, TB and malaria. It was founded in 2002, following a UN Special Session on HIV/AIDS. Since its creation the Global Fund has become the predominant global funder of programmes to fight AIDS, TB and malaria, with approved funding of US$ 10.1 billion covering more than 550 programmes in 136 countries.

The Global Fund does not implement programmes directly, relying instead on local practitioners, and it has created a system of grant administration and oversight in each recipient country. Global Fund grants are disbursed following needs assessments, which are carried out at country level and in which the countries themselves, often through Country Co-ordinating Mechanisms, identify the gaps in their programming and resources.

The Global Fund Board consists of 22 representatives of donor and recipient governments, of NGOs, of the private sector (businesses and foundations), and of people affected by the three diseases. The World Bank, UNAIDS, and the World Health Organization participate as non-voting members. The Board employs about 335 staff, who work at the Secretariat's headquarters in Geneva.


92.  Nonetheless, while these attempts to control infectious diseases may be justified in terms of their individual objectives, there is no doubt that, in terms of the overall picture, the fragmentation of effort results in some significant problems, including multiplication of overhead costs. Professor Walt, from the London School of Hygiene and Tropical Medicine, noted that "the [individual] donors have their own agendas, they have their own constituencies to whom they are responsible, they all want to attribute changes to their own inputs" (Q 76). As observed in the previous chapter, there has been a tendency for individual organisations to focus on bringing treatments for individual diseases rather than on addressing the problem of infectious disease control in the round. And there has also grown up a problem of in-country coordination of effort which has sometimes imposed substantial administrative burdens on recipient countries. In Dr Tyson's words, "each of them has their own structure, their own process, their own interaction with countries, and it causes large problems, not least of which is transaction costs for government" (Q 1). The Government summed up the situation by saying that "the current architecture is crowded and poorly coordinated. Within the diverse group of organisations there is no agreed vision or clarity over roles" (p 3).

93.  One of the reasons for this absence of collaboration among many of the players is their method of financing: they are competing for funds and the incentive to cooperate is often outweighed by the need to raise funds. However, the advent of institutions like the Global Fund which channel funds across more than one disease area has helped to reduce fragmentation of effort.

The World Health Organisation

94.  There was general agreement among our witnesses that WHO occupied a central position in combating the global spread of infectious diseases. There was, however, a recognition, within as well as outside WHO, that the world had changed since it was created and that these changes were now affecting WHO itself. In this section, therefore, we look in more detail at the role of WHO and how it is evolving, at the organisation's internal structure and at the interface between WHO and the newly-established European Centre for Disease Prevention and Control. We also look at funding levels.

BOX 3
The World Health Organisation

The World Health Organization (WHO) was founded in 1948 and has its headquarters in Geneva. It is the United Nations agency charged with monitoring and promoting global health.

WHO's role is to provide international leadership on global health. Its main functions are;

  • to set norms and standards for health;
  • to formulate and articulate evidence-based health policies;
  • to provide technical support to countries;
  • to monitor and assess health trends;
  • to conduct disease surveillance and alert Member States as necessary.

In addition to its Geneva-based headquarters, WHO has Regional Offices in six regions—Europe, Africa, The Americas, South East Asia, Eastern Mediterranean and Western Pacific—and over 140 Country Offices. It has an approved budget for the biennium 2008-2009 of US$4.2 billion and employs around 8,000 staff, most of them located in Regions and Member States.


THE ROLE OF WHO

95.  Founded in April 1948, WHO has just celebrated its 60th birthday. Its headquarters are in Geneva, but it has six Regional Offices[10] and 147 Country Offices. Its activities are directed and overseen by the World Health Assembly (WHA), which comprises governmental representatives from all WHO's 193 Member States and which meets annually in Geneva. The WHA appoints the Director-General (currently Dr Margaret Chan), who runs the organisation from day to day; and it formulates WHO policy, reviews and approves the programme and budget, and considers reports and proposals from the Executive Board. This latter is an expert body, comprising 34 members qualified in the field of health: its principal function is to give professional advice to the WHA and to give effect to the policies and decisions which the Assembly takes.

96.  WHO is not itself a world health service: providing health care is a national responsibility and WHO has no authority over the national health services of its members. In written evidence to us WHO described its key roles as "articulating policy options, setting norms and standards, shaping the research agenda, providing technical support to countries, assessing epidemiological trends, monitoring and evaluation, and harmonizing and aligning partner implementation strategies and goals with national health sector plans and initiatives"(p 205). Dr David Heymann, an Assistant Director-General of WHO, put it more succinctly during our visit to Geneva. "Our function for 193 Member Countries", he said, "is to set global policies, norms and standards and hope that others will work with them" (Q 514). If this seems a somewhat modest remit for an organisation employing some 8,000 staff, it should be remembered that the great majority of WHO's staff are not in Geneva; they are based in the Regions and Member States. WHO is, therefore, primarily a guiding rather than an intervening organisation. "They are not a directive organisation. They are a body to give technical advice to government" (Q 480). This description, by Paul Sommerfeld, Chair of Trustees at TB Alert, underplays WHO's role to some extent. The organisation does other things too: it analyses the non-health determinants of health, such as poverty, transport systems and education; its in-country staff work with governments in developing countries to prepare sensible health plans and it sends staff into Member States, by invitation, to help deal with health crises. But Mr Sommerfeld's statement underlines the essential point that WHO has no power to enforce the standards it sets or to intervene directly in health care in Member States.

97.  WHO is able to influence the world health scene by virtue of its position as the primary UN intergovernmental body concerned with global health. Dr Tyson, from DFID, told us:

    "WHO is the body that governments trust. They see that it is their organisation, it is the first place they will go to for a source of technical advice and they [WHO] are in a very privileged position" (Q 35)

Professor Walt referred to the perception of WHO around the world, especially by middle- and low-income countries. "It has legitimacy, it has a sense of being more neutral than any American organisation or any British or European organisation" (Q 68).

Professor Marmot, from University College London, echoed these views:

    "It is the first point of call of most developing countries' ministries of health if they have any crisis whatsoever, particularly an infectious disease crisis, they will call on the WHO local office and then on Geneva, and they [WHO] have status because they are being representative" (Q 237).

Others[11] took a similar view.

TIMES ARE CHANGING

98.  This situation is, however, changing, albeit in an evolutionary rather than a revolutionary manner. WHO may sit at the centre of global health policy-making, but it has been overshadowed in resource terms by newly-emerging funding organisations, such as the Bill and Melinda Gates Foundation, the Global Fund for AIDS, Tuberculosis and Malaria, and PEPFAR (the US President's Emergency Fund for AIDS Relief). The Gates Foundation and the Global Fund, for example, each have $2 billion-a-year budgets, which is significantly greater than WHO's own core budget. Professor Hemingway, from the Liverpool School of Tropical Medicine, felt that there was some unease in WHO about this situation:

BOX 4
The Gates Foundation

The Bill & Melinda Gates Foundation is a charitable body formed in 2000. Headquartered in Seattle, the foundation is led by CEO Patty Stonesifer and co-chair William H. Gates Sr., under the direction of co-chairs Bill and Melinda Gates, and trustee Warren Buffett. In 2006 it reorganised into three programmes: Global Development, Global Health, and United States.

The mission of the Foundation's Global Health Programme is to encourage the development of life-saving medical advances and to help ensure they reach the people who are disproportionately affected. It focuses its funding on two main areas: (1) access to existing vaccines, drugs, and other tools to fight diseases common in developing countries, and (2) research to develop health solutions that are effective, affordable, and practical.

The importance of The Gates Foundation in the global health landscape stems, in particular, from the scale of the funds it makes available for investment. For the year ended December 2007, grants paid for the global health programme totalled around $916m out of a total of some $2 billion across all programme areas. As at 31 March 2008, the Foundation had around 540 employees and supported work in more than 100 countries.


Professor Hemingway felt that at the top management level WHO was beginning to work with other powerful bodies in the global health world but that "some of those lower down the system are still intent on fighting". She cited the extension of the role of the Gates Foundation from the funding of infectious disease control into its delivery. "That is where you have seen more and more tension building", she told us, "because WHO do believe that the foundations are actually starting [to encroach] onto their territory" (Q 93).

99.  Others took a somewhat more optimistic view. Professor Ferguson, from Imperial College London, felt that WHO and The Gates Foundation "have achieved a good deal more coordination than has been seen in the past" (Q 209). Dr Lazarri, from the Global Fund, spoke of collaboration:

    "We rely on the WHO, UNAIDS and other technical partners for policy/strategy guidance, where the resources should go and what are the most appropriate interventions, what provides the best results in different conditions—because the Fund is not a technical agency. We rely on their work in providing the global guidance" (Q 635)

100.  Another important driver for change in WHO has been the emergence of new strains of highly-infectious disease, such as SARS and avian influenza, which, unless detected, identified and checked expeditiously, are capable of causing devastating pandemics. Of course, pandemics themselves are not new. But the substantial increase over recent years in international trade and travel has created a situation where, unless highly infectious diseases are quickly brought under control in the country of origin, they can spread rapidly throughout the world and create grave global health problems.

101.  There was consensus among our witnesses that the SARS and avian influenza outbreaks which had occurred during the last 10 years had focused attention on the need for an effective global disease surveillance system and on WHO as the best-placed organisation to manage it. As a result of these outbreaks, we were told by Pat Drury, of WHO's Department of Epidemic and Pandemic Alert and Response, "over the past four or five years there has been a large amount of money that has come in and been invested at a national level and in the international system because of the threat of a pandemic" (Q 538). As mentioned in the previous chapter, one of the steps taken has been to establish, under the aegis of WHO, the Global Outbreak Alert and Response Network (GOARN) and the Global Early Warning System for Major Animal Diseases (GLEWS). Another has been agreement on the first ever updating of the 1969 International Health Regulations (IHRs), which in their new form were described to us by Professor Fidler as "the most radical development in the history of the use of international law on global health problems" (p 378). Indeed, it is in the field of disease surveillance that the development of WHO's role has been most marked, and it is to this function therefore that we now turn.

SURVEILLANCE

102.  WHO's development over the last 10 years of a more up-to-date disease surveillance system rests on two main pillars—the setting up of the GOARN and the GLEWS and the negotiation and bringing into force of new IHRs. The easiest way to understand the issues is, perhaps, to approach them via an examination of the new IHRs.

103.  The new IHRs, in theory, revise those which had existed since 1969. In practice, however, they represent a step change in the way the emergence of infectious diseases is detected. Professor David Harper, of the UK Department of Health, described the 1969 regulations as "a very passive set of regulations" which required notification to WHO of only four infectious diseases—plague, yellow fever, smallpox and cholera. The new IHRs, by contrast, cover all Public Health Events of International Concern (PHEICs). Under the new IHRs each WHO Member State must create and nominate a Focal Point with responsibility for monitoring such health events nationally and, where necessary, reporting to WHO any incidents with the potential to threaten international health. The creation of National Focal Points was described to us by Pat Drury, of WHO, as "the single most significant structural change" in the way global health is being managed (Q 584). The UK's Focal Point is the Health Protection Agency.

BOX 5
The International Health Regulations

The International Health Regulations (IHR) 2005 are an international legal instrument, binding on 194 countries, including all WHO Member States. Adopted on 23 May 2005, and coming into force on 15 June 2007, they replaced the earlier IHR 1969 which had become increasingly ineffective.

The aim of the IHR 2005 is to help the international community protect against the spread of disease while avoiding unnecessary interference with global travel and trade. Whereas the IHR 1969 applied to three infectious diseases—cholera, plague and yellow fever—the IHR 2005 have a much broader scope. They apply to any diseases, irrespective or origin or source, that could present significant harm to humans.

The IHR 2005 establish a new global public health surveillance system. Under the Regulations, each State Party has obligations to prevent and control the spread of disease inside and outside its borders and to report potential "public health emergencies of international concern" to the WHO. In order to fulfil these obligations, States Parties are required to develop and maintain their disease surveillance capabilities. Recognising that, in some countries, non-governmental information sources can provide information on public health risks more rapidly than official sources, the IHR 2005 permit WHO to collect and use information from multiple sources, including the media and NGOs.


104.  Dr Silberschmidt, of the Swiss Federal Office of Public Health, agreed that the new IHRs represented a significant change in global health management. He believed that "the IHRs have really brought us into the 21st century on what disease control is". He continued: "They are binding, they are universal around the world, they are an algorithm which does not bind them to known diseases any more but makes them relevant to all diseases independent of their origin" (Q 602).

He added: "Another strength, which is quite significant for an international treaty, is that it explicitly allows the use of non-State information" (Q 602).

105.  This last point is important and calls for some clarification. Under the previous IHRs Member States had an obligation to report outbreaks of specified diseases to WHO. There was, however, no constitutional basis for WHO to challenge non-reporting if it suspected a cover-up by a Member State wishing to avoid the unwelcome consequences of disclosure for its international trade or travel. Under the new regulations, WHO is able to use other sources of information about infectious outbreaks—for example, the media or the internet—as a basis for approaching a Member State and requiring it to confirm or deny what is being alleged and, where necessary, to supply details. Though a non-declaring State might possibly continue in denial, such a situation is unlikely where the event in question is already receiving worldwide publicity. It is in the interest of the State being challenged either to come clean—and so to get international help—or to provide convincing evidence that the reports are incorrect. In this situation, though some witnesses expressed concern to us that the new IHRs remained unenforceable[12] in the sense that formal international sanctions could not be employed against a non-compliant Member State, Professor Fidler is probably right that such sanctions are not necessary. "There is not an enforcement provision", he said, "but look at the way in which the incentives and the dynamics of the rules are set up and you start to see that the enforcement of this starts to drive off the creation of reciprocal self-interest that States have to comply" (Q 965).

106.  We have referred above to the creation of the GOARN (Global Outbreak Alert and Response Network) as the other recent development in WHO's role. GOARN consists of a network of some 140 technical institutions around the world and is responsible for monitoring reports of PHEICs, assessing their significance for global health and, where necessary, taking action to help bring infections under control. The concept underlying both the IHRs and the GOARN is that Member States should themselves detect, identify and respond to emerging infections, with WHO adopting a monitoring role. But, where surveillance and diagnostic systems are weak, particularly in developing countries, it is sometimes necessary for WHO teams to be invited to investigate outbreaks and to initiate any necessary countermeasures. This reinforces our observation in the previous chapter—that global surveillance of the emergence of infectious diseases can only be as effective as its constituent parts and that it is in every country's enlightened self-interest to ensure that the surveillance infrastructure of developing countries is upgraded to an acceptable standard.

BOX 6
Global Outbreak Alert and Response Network

The Global Outbreak Alert and Response Network (GOARN) is a partnership of different institutions and networks (it has been described as a "network of networks"). Launched in April 2000 its role is to coordinate reports of and responses outbreaks of infectious disease and to provide a framework for delivering support to countries. In essence, GOARN's role is to act as a "global safety net", complementing rather than replacing national surveillance systems. Its activities are coordinated by WHO's Department of Epidemic and Pandemic Alert and Response.

There are currently around 140 GOARN partners, including scientific institutions in Member States, surveillance initiatives, networks of laboratories, IGOs and NGOs. Since 2000 GOARN has responded to around 90 events, with more than 500 experts providing field support to some 40 countries. It played a crucial role in helping to contain the SARS outbreak in 2003.



STRUCTURE

107.  We have mentioned above that WHO conducts its activities via six Regional Offices and over 140 Country Offices. In written evidence WHO described this as "a strong network which is well structured" but added that "the network is inadequately staffed, especially at country level. There are increasing demands for implementation support from governments, other technical agencies, NGOs and civil society partners, as well as donors supporting disease control at country level" (p 205).

108.  We encountered mixed views as to how well this pyramid management structure operates. We heard complaints of excessive bureaucracy in WHO's headquarters, but we also heard praise for the programme of managerial reform being undertaken by the present Director-General, Dr Margaret Chan. A number of witnesses spoke of a disconnect between WHO Headquarters and the Regional Offices, particularly the Regional Office for Africa (known as AFRO). Dr Bates, from the Royal College of Pathologists, commented that "AFRO seems to be much more autonomous somehow. Whenever you go to headquarters in Geneva and talk to them about something, it does not necessarily percolate down to AFRO and vice versa" (Q 275). Dr Conlon, from the Royal College of Physicians, concurred with this viewpoint. "There is often a disconnect", he told us, "between what is happening in Geneva and what is happening on the ground, and even on the ground the Regional Office is quite far away from where the fieldwork may be going on and where programmes are being implemented" (Q 277). And Professor Hemingway, referring to an AFRO project to set up a surveillance system for pesticide resistance, spoke of "a complete lack of understanding … as to the level of complexity of what they need to put together if they are going to properly integrate information" (Q 60).

109.  Others were more optimistic. Dr Tyson spoke to us of efforts by WHO headquarters "to bring them [the Regional Offices] more into the fold" (Q 33) and we were told of improvements, especially in the last 12 months, in the linkage between Headquarters and the Regions (QQ 13, 35). There was general agreement that some of the difficulties at least arose because the Regional Directors, like the Director-General, are elected rather than nominated and therefore saw themselves as responsible to the countries who had elected them as well as to WHO globally (QQ 513). Indeed, Dr Heymann went so far as to speculate whether WHO "spends more time collaborating internally than it does with its external partners" (Q 530) and to suggest that resolving the question of the election of Regional Directors might be "the key issue" in improving WHO's performance (Q 581). Dr Tyson believed that, "if you ask any DFID adviser in Africa, they would say the weakest link of WHO is the Regional Office" (Q 33).

110.  There was agreement that much good work took place at the Country Office level (for example, in providing technical assistance to countries in preparing disease-control programmes for funding by outside agencies and generally playing a valuable role in Country Coordinating Mechanisms[13] for external assistance), though Dr Bates felt that some of them were insufficiently independent. "Whenever you go to them", she told us, "they always refer you back to the ministry. They will not work separately from the ministry … They sit on the fence" (QQ 289, 290).

111.  Reforming WHO's internal structure is an essential, though challenging, prerequisite of improving global health governance. While it is true that some progress has been made and that the Regional and Country Offices are now more willing to cooperate following the SARS experience, a more fundamental overhaul of the relationship between headquarters and regions and a review of the current procedures by which Regional Directors are appointed seems overdue. Given the threats to global health which we face from newly emerging infectious diseases, a dysfunctional organisational structure within the world's principal policy-making, standard-setting and surveillance body simply cannot be afforded. We therefore recommend that the Government should bring its influence to bear, along with that of other like-minded Member States, to ensure that a fundamental review is initiated of the inter-relationship between WHO Headquarters and its Regional and Country Offices and of the system of appointment of Regional Directors so that WHO as a whole is better structured to meet the contemporary challenges of global health management.

RESOURCES

112.  One of the main constraints on WHO's activities is resources. The WHA approves WHO's budget in May every other year for the following biennium. The 2006-2007 budget was approved at US$3,313 million, though this was subsequently increased to US$ 3,670 million to cater for a scaling-up in the response to avian influenza. The approved budget for the 2008-2009 biennium is US$ 4,200 million. It is important to understand that WHO's budget comprises two main elements—a core budget (otherwise known as Assessed Contributions), which comprises mandatory annual subscriptions from Member States to defray the organisation's operating costs and to fund what are agreed by the whole membership to be essential programmes; and additional funding (known as Voluntary Contributions), which consist of discretionary funds made available by Member States and others earmarked to support specific programmes. Assessed Contributions account for only US$ 959 million of the current WHO budget. This means that WHO has to manage a wide range of core activities, including Epidemic and Pandemic Alert and Response and providing WHO staff to developing countries to give technical support, out of less than 25% of the total funding available. The greater part of the budget (Voluntary Contributions) tends to go on more specific objectives, such as immunisation and vaccine development, against which they have been predicated by their donors.

113.  We therefore recommend that, when budgetary negotiations for the next biennium get under way, the Government should support a re-balancing of WHO's budget in order to make more funds available for the core budget.

114.  Infectious diseases pose a major threat both to this country and to the wider world, and we believe that WHO will need additional funding if it is to be able to respond effectively to these threats on behalf of the international community. The UK is already a major funder of WHO and we are mindful of current budgetary constraints. We recommend however that the Government, in concert with other Member States, should work towards an increase in financial contributions to WHO.

WHO AND EUROPE

115.  The Stockholm-based European Centre for Disease Prevention and Control (ECDC) is not an IGO but an agency of the European Union. It was established in 2005. Its role is principally to conduct disease surveillance on behalf of the 27 EU Member States, on whose resources it draws in order to carry out its task. Its Director, Dr Zsuzsanna Jakab, told us:

116.  ECDC's remit covers the 27 Member States of the EU. All these fall within the parish of the European Regional Office of WHO (known as EURO). According to Professor Catchpole, from the Health Protection Agency, ECDC has provided added value in some areas of work, such as helping to improve the epidemiological capacities of some of the newer EU Member States. He told us:

    "If you put that question to someone from one of the smaller States in Europe, they would say they absolutely feel that they get huge value from knowing that ECDC is there. We have a tremendous resource of experts and expertise that can provide us with information and advice on how to deal with SARS or other emerging problems. They do not have that expertise and depth in other parts of Europe" (Q 152).

117.  Dr Jakab told us that "there is no overlapping in the roles and in the mandate of WHO and ECDC" (Q 893). She believed there was synergy between the two organisations and that "collaboration and partnership are absolutely vital" (Q 893), citing a Memorandum of Understanding which was signed three years ago with EURO. In addition to annual high-level meetings, there were quarterly conferences with WHO and day-to-day cooperation on operational issues between ECDC, EURO and WHO Headquarters.

118.  Dr Jakab referred to ECDC as "the European CDC in the development phase" (Q 894). Did she therefore see ECDC evolving into an organisation along the lines of the US Centers for Disease Control (CDC), which is based in Atlanta but which has outstations in many parts of the world? Dr Jakab felt that, in terms of their respective constituencies (strong national/state health structures and limited responsibilities at the federal level), "the power and the mandate of the European CDC and the US CDC do not differ too much" (Q 896). The main differences lay in their relative resources and reach.

119.  Our terms of reference exclude in-depth inquiry into the effectiveness of EU agencies or institutions, though they do permit us to examine the interface between EU and non-EU activity. Most of those who gave evidence to us took the view that there was a role for an EU agency like ECDC and that initial tensions were beginning to be resolved and synergies achieved. With just three years of experience, it is too early to judge. We believe however that it will be important that duplication and overlap does not occur and that ECDC does not become a further complicating factor in an already complex system of global disease management.

Synergy and Coordination

120.  In this section we look at some areas where there appears to us to be an absence of synergy in the way in which the various actors on the international health stage are operating and at the case for rationalisation of global health governance in order to promote better use of available resources.

HUMAN AND ANIMAL HEALTH

121.  Professor Borriello, Director of the Centre for Infections at the UK Health Protection Agency, told us that it was a mistake to think of human health as something which exists apart from that of animals. "We need to view ourselves", he said, "as part of the mammal population of the planet" (Q 163). Professor Borriello said that "we are part of a big common reservoir [of diseases], but for centuries our concentration on identifying the pathogens and/or combating them has concentrated on ourselves as a species and ignored the rest of the mammal population". New infections from animals were emerging, partly as a result of improved diagnosis but also as a result of human lifestyle changes. He explained:

122.  It is now widely accepted that increased contact with animals was probably the source of the current HIV epidemic. Professor Borriello told us that SARS may have arisen from the consumption of bush meat. Already there has been animal-to-human transmission of avian influenza found in poultry. Though as yet the virus has not developed the capability to move between humans, if and when it does the result could be an influenza pandemic of devastating proportions. Controlling the spread of infectious diseases among humans needs, therefore, to have regard to what is happening in the world of animal health. It is very important therefore for information about existing and potential animal infectious which could jeopardise human health to be known to the relevant authorities. As Professor Peter Chiodini, Head of the HPA's Parasitology Reference Laboratory put it, "synergy between the veterinary specialist and the medics is crucial to control" (Q 167).

123.  The problem is that in many countries the two disciplines operate separately rather than in an integrated manner. Professor Borriello told us:

    "The one area where interaction is not sufficiently strong is on what you would call fully integrated surveillance, where we can match patterns of human disease and newly emerging syndromes in humans to newly emerging syndromes in animals or diseases in animals and to have the two bits of intelligence in some way brought together" (Q 165).

In the UK, continued Professor Borriello, there was the National Expert Panel for Newly Emerging Infections, enabling a sharing of veterinary and medical data. Elsewhere, he said, including many European countries, "the health, the vets and the food have no linkage whatever" (Q 168).

124.  The problem is partly one of local capacity. Dr Conlon told us:

    "Most countries that I have come across in the tropics have medical schools of some sort but very few have vet schools. Again, the expertise, if it is available, tends to go to commercial farming rather than husbandry or surveillance of animal diseases. It is a real problem. If you think about most of the epidemics over the last few years that have derived from animals, it has usually been the human disease that has pointed to the problem in a retrospective analysis, finding the animal source" (Q 332).

Dr Conlon added, a propos the recent outbreaks in humans of avian flu:

    "Strengthening local vet services would have allowed people to have got onto the poultry culling and other control measures in South East Asia more quickly … Once humans get a disease, it is pretty hard for any organisation to stop it moving" (Q 339).

125.  Part of the problem also, however, is what appears to be an absence of joined-up thinking and effective coordination by the relevant international bodies. We have described above the new International Health Regulations and the much improved capability they bring to the detection and identification of emerging threats to human health. Unfortunately, the parallel international rules requiring declarations of the outbreak of zoonoses—diseases originating in animals—still follow the old regime. Dr Paul Gully, from WHO, put the contrast this way:

    "Changes to the International Health Regulations in terms of being able to respond to rumours, as opposed in the past to official notifications, have made a huge difference. We are now able to go to a country, through a region, to ask specifically what is going on, and that country realises that the world knows a particular country has a problem. Other sectors, such as agriculture, do not have that. For example, the OIE, the World Organisation for Animal Health, can only respond to a report from a country, an official report, and it does make a huge difference" (Q 530).

126.  The new IHRs, we were told, could be used to pick up indirectly the emergence of zoonoses. Dr Gully again:

    "The IHR do not relate to a specific number of diseases which are human diseases—Polio and SARS, for example. They relate to public health emergencies or events of international importance, and that would be open to interpretation as to what those applied to" (Q 552).

We were to some extent reassured to hear that, in practice, WHO works informally with the two main bodies monitoring animal health—the OIE[14] and the FAO[15]—under the auspices of the Global Early Warning System for Major Animal Diseases (GLEWS), whose role was described to us as "disease-tracking, information-sharing and multi-disciplinary action" (Q 562). Nonetheless, given that some three quarters of emerging infections in humans originate from animals, this asymmetry between the new IHRs governing threats to human health and the regulations governing the declaration of diseases in animals is worrying.

127.  We have considered whether the new IHRs should be amended so as to cover explicitly threats to human health from diseases which are detected in animals? Dr Silberschmidt (Swiss Federal Office of Public Health) thought not. "They [the IHRs] are too young", he said, "and need further strengthening and implementation to have formal revision at this point" (Q 604). Dr Heymann (WHO), on the other hand, believed that amendment was possible if the necessary political consensus was there[16]. While we take Dr Silberschmidt's point that it is preferable to allow new rules to bed down before considering amendments, we take the view that the risks arising from the present disjunction between the management of animal and human diseases are too great for it to be allowed to continue. New infections, many of them originating in animals, are appearing every year and, as things stand, are sometimes coming to notice only after they have jumped the species barrier to infect humans; and their global spread is greatly facilitated by the large and increasing volume of international travel and trade. While in many cases such transmission may not have dramatically damaging consequences, in the case of, say, a pandemic of avian influenza the time gained through detecting—or lost through failing to detect—the emergence of a virulent strain of the virus in poultry before it has had the chance to infect humans could make all the difference in averting a global disaster.

128.  We therefore recommend that the Government should pursue, as a matter of urgency, through its membership of the relevant IGOs the creation of an event-reporting system for animal diseases along the same lines as the new IHRs relating to human health and should encourage the building up of much stronger systems of cooperation between the bodies dealing with human and animal health in sharing information and handling reports of disease outbreaks.

TUBERCULOSIS AND HIV/AIDS

129.  According to UNAIDS:

The UK-based charity Results UK has written that, "despite the link between the two diseases being acknowledged as far back as the 1980s, efforts to control TB and HIV/AIDS remain largely independent of one another"[17].

130.  Others, while accepting that there had been problems of dealing with the two diseases in an integrated manner, believed that the situation was improving. Dr Coker, of the London School of Hygiene and Tropical Medicine, said:

    "Over the last 15 years or so the focus was initially on TB control and in parallel HIV control, and never the twain met and patients did fall between the gaps. I think over the last five years, admittedly belatedly, that problem has been recognised and there are efforts to try to ensure that patients do not fall between the gaps, and there are policies developed by WHO to try to address that problem" (Q 117)

Dr Alvaro Bermejo, from the International HIV/AIDS Alliance, concurred. "The intergovernmental organisations", he told us, "have played an important role in that change, particularly WHO; and the Global Fund [for AIDS, TB and Malaria], by nature of picking up funding for the three diseases, has tended to generate some greater integration" (Q 436). And we heard that the Programme Coordinating Board of UNAIDS was meeting in Thailand, with TB-HIV integration as its main agenda item (QQ 436, 728).

131.  WHO's part in this improving situation was emphasised by Dr Haileyesus Getahun, Medical Team Leader at the Stop TB Partnership. He said that "WHO took the leadership in 2004 to provide countries with clear policy and strategy clarifying what needs to be done. We have a 12-point policy which is simple and clear, and we have promoted that policy with advocacy" (Q 723). Dr Getahun told us that in Ethiopia the numbers of TB-infected patients tested for HIV had risen from 20,000 in 2002 to 700,000 in 2006 and that the emphasis now was on testing HIV-infected people for TB.

132.  We were pleased to hear of these moves towards more integrated campaigns to control the spread of TB and HIV/AIDS. Nonetheless, it is clear that some problems remain. Diana Weil, Senior Policy Adviser at the Stop TB Partnership, felt that the focus on AIDS at a political level could sometimes result in the threat from TB being relegated to a subordinate position and in a failure to give adequate recognition to the problem of TB-HIV co-infection. "In many countries", she said, "you have HIV/AIDS Commissions, which operate at a political level which is far higher than any TB programme, which is basically in communicable diseases in the public health authority … For AIDS authorities, TB is one of the many issues they are concerned about but it often gets lost in the mix" (Q 725). Ms Weil cited the UK as an example of a country which had produced AIDS strategies inadequately covering TB-HIV co-infection. We found this view echoed by Results UK [18]:

    "The UK Department for International Development (DFID) recognises the importance of coordinated planning and implementation of TB and HIV/AIDS activities in order to scale up treatment of TB among HIV-infected people and increase enrolment onto HIV treatment programmes. Despite this knowledge, neither TB nor TB/HIV co-infection is fully incorporated into DFID's current strategy on tackling HIV/AIDS".

133.  Dr Tyson, from DFID, explained that "in many countries, such as Tanzania, Uganda, Malawi, we are providing substantial resources into the budget or health budget of the country to enable the government to deliver on its priorities as reflected in the national plan. In essence, we are putting money into the Government's systems, so how governments spend that is of great interest to us, but we cannot say to them 'We want you to carve out ten per cent of it to strengthen your work on HIV/TB'" (Q 36) Dr Nils Billo, Executive Director of the International Union Against Tuberculosis and Lung Disease, recognised the rationale behind DFID's strategy but pointed out some of the problems. "Unfortunately", he told us, in many instances I would say the money sticks at the top. It maybe goes one level down but it does not trickle down to where it is really needed. That is the problem" (Q 1107). There was, Dr Billo felt, an issue of governance, commenting that "many countries have millions of dollars in the bank and are not using them, so they are not getting it to where it should be" (Q 1109).

134.  These strictures of DFID's approach to the problem of TB-HIV co-infection surprised Gillian Merron, Parliamentary Under-Secretary of State at that department. "That", she told us, "is what the updated strategy is all about". Ms Merron continued:

    "We are fully aware that we need to do more to bring services together. We are not just supporting the integration of AIDS services with other health services, including those for TB; our updated HIV/AIDS strategy sets out … a health spending target over seven years … of £6 billion".

"Please be assured", she added, "the coordination [of HIV] with TB services is very central" (Q 1160). DFID also outlined, in a supplementary note, specific projects which it was supporting to promote the integration of HIV and TB treatments (p 454).

135.  DFID's HIV/AIDS Strategy Document[19] contains the following:

    "Stronger links must be forged between TB, malaria and HIV services. In particular, in hyper-endemic countries, TB and HIV are fuelling each other, and the need for integration is made more urgent by the steep rise in drug-resistant TB infections. In places where the TB burden is high, progress has been made on screening for TB and HIV and on treating both diseases, but more needs to be done to make these services more accessible"

The Document states that "we will spend £6 billion on health systems and services up to 2015. This will help maximise progress on AIDS through closer integration of AIDS, TB, malaria and SRHR [Sexual and Reproductive Health and Rights], including maternal and child health services".

136.  We are pleased to hear that the Government's updated HIV/AIDS Strategy recognises the need for TB and HIV to be addressed in a more integrated manner and that the substantial funding which is to be provided over the next seven years for health systems and services generally will enable more attention to be paid to this problem. We remain concerned, however, by Dr Tyson's statement[20] that the UK is not in a position, as a donor, to require recipient governments to allocate a portion of funds received to addressing TB-HIV co-infection. While we recognise the need for country ownership of health programmes and for bilateral aid to be tailored to the individual needs of each recipient country, we consider that UK funding to combat HIV/AIDS in developing countries should be conditional on the adoption of an integrated approach to fighting TB-HIV co-infection.

137.  We therefore recommend that the Government should continue to encourage the development of integrated strategies for combating TB and HIV and should satisfy itself, before committing funds to fight one or both of these two diseases in developing countries, that there is adequate local recognition of the problem of TB-HIV co-infection and that there are sound programmes in place to address it.

INTER-ORGANISATIONAL COLLABORATION

138.  In an area of international activity as crowded with actors as infectious disease control, with different constituencies, objectives, management structures and funding systems, it would be surprising if there were anything approaching perfect synergy. Generally speaking, witnesses from individual organisations tend to see their own interactions with others, understandably, as collaborative, while other commentators have been more inclined to dwell on apparent non-cooperation.

139.  UNITAID is an organisation founded in 2006 by five countries—Brazil, Chile, France, Norway and the UK—but now with 27 participating countries plus the Bill and Melinda Gates Foundation. Its purpose is to fund the supply of essential drugs to people suffering from infectious diseases. UNITAID's Executive Secretary, Dr Jorge Bermudez, described his organisation's working relationship with the Global Fund for AIDS, TB and Malaria:

140.  Similarly, Louise Baker, of the Stop TB Partnership, spoke of an external evaluation which had been carried out to establish the added value of her organisation:

    "We stop our Partners doing the same thing", she told us, "we complement each other rather than do the same thing and compete. Certainly in the evaluation it appears that the added value of the Partnership has been about developing a common strategy, so that there is no counter-messaging. We are all very much in line with each other and driving in the same direction, and there is none of the squabbling that you might get if there was not a common plan" (Q 713).

141.  The general thrust of these and other comments was endorsed by Professor Ferguson of Imperial College London. "I am encouraged", he told us, "by the degree of coordination now compared with 10 or 15 years ago". Professor Ferguson continued:

    "It is a free market of different interest groups interacting. My perception is that it is a market working quite well generally at the moment … It is not perfect, but it works quite well and arguably better than the alternative, which might be a more directed approach" (Q 208).

142.  On the other hand, we heard some examples where the degree of synergy taking place was rather less than the pictures painted above. We were told by Dr Bermejo, of the International HIV/AIDS Alliance, of country-level programmes for drug treatment and drug control which appeared to be working against each other. In Dr Bermejo's words:

    "We have countries supported by UNODC [UN Office on Drugs and Crime] instituting and being given guidance and technical support around drug control for measures that really criminalise drug users and those in possession of drugs. What we see in many cases is services that need to meet their targets waiting outside some of our clinics, for example where methadone is being prescribed as substitution maintenance therapy or where drug users are coming to get their treatment and they are being detained outside the doors".

We recognise that UNODC is not a health-oriented IGO. Nonetheless, we are concerned at the tensions which the situation described by Dr Bermejo reveals between two UN bodies whose overall remits differ but who need to be mindful of each other's activities.

143.  Potentially more serious is an apparent attempt by the Atlanta-based US Centers for Diseases Control (CDC) to create a parallel global disease surveillance network to the GOARN. Dr Heymann of WHO described the position to us as follows:

    "CDC, which in the past was a very strong partner in the Global Outbreak Alert and Response Network, is now setting up its own bilateral Global Disease Detection Network. This was a vision of the CDC back in the 1990s when we set up our emerging infections programme, but we were able to convince them at that time to work multilaterally within the GOARN, and they did. Under the current Administration, however, there has been a tendency towards more bilateral relationships, not only with disease detection and response but with influenza, with HIV and malaria … It causes us very difficult problems, to the extent that many times there is difficulty in knowing who is doing what in a country when there is an outbreak of disease. It is a very difficult issue which at one time was being well coordinated by GOARN" (Q 547).

144.  We were also told that, while WHO distributes viral and bacteriological samples to competent laboratories throughout Member States for research into and development of vaccines and antibiotics, the same procedure was not followed in the case of samples obtained within the CDC's own network of Global Disease Detection (GDD) centres. "Those viruses or bacteria", we were told, "are not studied in any other laboratories" (Q 550).

145.  We had heard from CDC's Director of Global Disease Detection program, Dr Scott Dowell, that GOARN was regarded, by WHO as well as by CDC, as a 'network of networks' and that "we see ourselves as one of the networks that is part of the 'network of networks'" (Q 415) and that each of CDC's GDD centres was a collaborative project between the US and the host government (Q 404). When we put the question to Dr Dowell of whether CDC's GDD Program amounted to doing what WHO should be doing but had not sufficient resources to do, he agreed but with qualifications. He said:

    "It [WHO] is a convening and leadership function and they depend on Member States and other organisations to do a lot of the carrying out of the actual work. We hope that what we are doing fits well into the overall umbrella of what WHO is intending to accomplish and that our networks fit into the WHO-led network of networks" (Q 391).

We put WHO's concerns about parallelism to CDC. We were told that "we at CDC are very interested in seeing that the GDD Centers are part of the international infrastructure supporting IHR and functioning within GOARN". On the question of sharing virus samples, CDC wrote to us that, "when virus samples are shared and the international network functions collaboratively … the world benefits" and that CDC's collaborating laboratories "take this approach to sharing reagents, knowledge and samples as part of their daily work". CDC added that, "if there are exceptions to this collaborative approach … we would like to know about them and to help address and resolve the problems" (p 175).

146.  We are pleased to hear that cooperation between the various players on the international health stage is improving. There remain, however, instances where individual organisations appear to be pursuing their own agendas without sufficient regard to the wider picture. Separate UN bodies are following uncollaborative strategies in handling narcotics control and treatment, and the existence of parallel organisations operating in the crucial field of infectious disease surveillance is unjustifiable. On this latter issue, we have noted what CDC has said about the international role of its GDD centres and we concede that, just as the GOARN is weakened by poor surveillance infrastructures, it is also strengthened by the building up of effective ones, whether through national or international resources. We endorse therefore CDC's GDD network as an integral part of the GOARN's 'network of networks'. Our concern is that these national and international capabilities should complement each other in the way they operate.

147.  We therefore recommend that the Government should, via its representatives in the relevant UN agencies, seek to ensure that instances of non-collaborative working are highlighted and remedied. We recommend also that the Government should urge the UN Secretary-General to give WHO a clearer lead role.

Global Health Governance

THE NEED FOR IMPROVEMENT

148.  The question arises therefore of whether there should be more formal global health governance; and, if so, how that might be effected. The Government's evidence to us here was clear. "The current architecture", we were told, "is crowded and poorly coordinated. Within the diverse group of organisations there is no agreed vision or clarity over roles … In the medium term, the Government believes the large number of existing initiatives should be rationalised through mergers"(p 3). Gillian Merron, Parliamentary Under-Secretary of State at DFID, described it in oral evidence as "a situation that we know needs to be remedied". "There is", she said, "very much scope to improve the effectiveness and coherence of intergovernmental organisations that are working on health and communicable diseases" (Q 1142).

149.  In oral evidence, Dr Tyson told us:

Ms Merron endorsed this view. "We would like", she told us, "to see mergers amongst some of the international initiatives … We feel we should brainstorm around mergers—for example, the Global Fund and GAVI—and, in the future, UNAIDS". She added, however, that the Government took the realistic view that mergers were not likely to happen in the short term (QQ 1142, 1148).

Professor Chiodini, for the UK Health Protection Agency, agreed that some rationalisation of effort was called for, pointing to "parallel tracking", waste of resources and duplication of administration under the existing system. He took the view that "some rationalisation and better coordination between all these bodies with good intent and, in some cases, extremely good funding would be beneficial" (Q 194). Diana Weil, from the Stop TB Partnership, felt that that the situation was improving, that "there are more networks now of people communicating at the global and regional levels than there were before". Nonetheless, she added, "we have a long way to go because, while people say they want to combine efforts, some independent donors and governments still are funding in a very directed route because of their rules and regulations" (Q 748). Dr Lob-Levyt, from GAVI, observed that "we do need to think about respective roles and strengths in the long term and simplify the world for some of the poorest countries" (Q 830). And Professor Rubin, of the University of Pennsylvania, compared the orchestration of global disease control with designing and building an aircraft:

    "As good as the World Health Organisation is, as good as the Bill and Melinda Gates Foundation is, there is no systems integrator, and without a systems integrator the plane will not land safely" (Q 914).

150.  Nowhere is the need for rationalisation of donor effort clearer than in the recipient countries themselves, where the collective burden of large numbers of National Governments, IGOs, NGOs, Public-Private Partnerships interacting with the host government can be considerable, especially in countries with undeveloped administrative systems. Dr Tyson cited the situation in Vietnam as an example:

    "In 2005 [it] had almost 800 donor missions in one year. The combined administrative burden on countries of all these well-meaning partnerships is very significant … If we look at a typical, highly donor-dependent country, we might see 20 UN agencies, 35 bilateral agencies, 20 global or regional banks or financial institutions and 90 global health initiatives. Trying to get all these to work collectively has … been one of the greatest challenges" (Q 1).

Professor Marmot referred to "a huge bewildering variety of specific programmes, each with a demand for 'Do it this way! Account for it this way!" Recipient countries did not, he told us, have the resources to cope with this "total lack of coordination" (Q 212).

Dr Billo, from the International Union against TB and Lung Diseases, argued that:

    "If you look at a TB programme manager or an AIDS manager, one of the major tasks is to organise visits for the WHO, UNICEF, NGOs, and they have hardly any time to work because they are constantly organising visits".

Dr Billo continued:

    "Coordination is hindered a lot of times by the fact that the Global Fund, DFID or NGOs demand different ways of reporting on how money is being used in countries. That is a huge burden on countries to report on what they are doing. Also, when they have to make applications, these applications are complex. So, on a Global Fund application, for instance, they spend two or three months and the whole system is burdened by that … There are applications which demand the inclusion of certain things because at the moment the buzzwords need to be used. What happens very often is that governments hire a professional grant writer to use those words, and the buy-in is sometimes not there" (QQ 1099, 1102).

151.  The problem has been recognised for some time and there have been initiatives to ensure greater coordination. Some of the organisations which have emerged in the last few years—for example, UNAIDS, the Global Fund, the Stop TB Partnership and the Roll-Back Malaria Partnership—are themselves a recognition of the need for greater coordination and harmonisation of donor in-country efforts. The Paris Declaration of 2005 involved a commitment by over a hundred States, IGOs and NGOs to increase efforts to harmonise and align the provision of aid to developing countries. OECD reported to us that, based on a 2006 survey, "there is progress across the donor community but a lot more needs to be done" (Q 1032). One of the main objectives of the International Health Partnership[21] is to address this situation. The Global Fund has initiated Country Coordinating Mechanisms (CCMs) in a number of countries, bringing together representatives from both the public and private sectors, including governments, multilateral or bilateral agencies, non-governmental organisations, academic institutions, private businesses and people living with the diseases[22]. Diane Stewart, from the Global Fund, described CCMs this way:

    "Wherever there are players that go beyond government … the Coordinating Mechanism then takes all of those stakeholders at the country level and they discuss what the priorities will be. It is very much a joint process … Often it is chaired by the State, the Minister of Health, or in some cases the Deputy President. It is often quite a high-level organisation but it is not owned by the State and it is certainly not supposed to be. It is supposed to be a partnership" (Q 628).

How effective are CCMs? Dr Sylvia Meek, Technical Director of the Malaria Consortium, had mixed feelings. "There are efforts in most countries", she told us, "to try to have some mechanisms of coordination among the different technical agencies. They work quite well in some countries. In others they do not" (Q 478). Professor Walt expressed similar reservations (Q 98).

We were also told of Sector-Wide Approaches (SWAps), in which a number of donors agree to pool their funding in order to achieve agreed common objectives (Q 653).

HOW CAN IT BE DONE?

152.  Seeing a need for rationalisation of effort is one thing: knowing how to bring it about is another. There is a wide variety of bodies engaged in global disease control. Some are governments, others are IGOs, yet others are NGOs, Public-Private Partnerships or Private Foundations. Each has its own objectives, constitution, management structure, funding stream and reporting system. The term 'international health architecture', which we have heard used to describe the interaction of the various bodies engaged in global disease control, is perhaps a misnomer as architecture implies order and planning. The reality is more like a house which has been—and is being—continually extended in response to ad hoc pressures by individuals and groups. The fact is that, however unsatisfactory the present situation may be, the actors involved cannot be compelled to operate in a particular way or to fund specific projects which they may see as being outside their stated objectives. As Professor Borriello put it, "the bodies, many of whom are independent, need to agree that there is value in them being coordinated" (Q 194). In this section therefore we have the limited objective of sketching out, from the evidence that has been given to us, where global health governance should be going and how it might perhaps get there.

153.  A number of possible ways forward have been suggested to us, of which we shall examine just three—the formation of International Health Partnerships (IHPs), the establishment of a Global Compact for Infectious Diseases or the promotion of what has been called "networked governance" to reflect the political situation of the post-Cold War world.

International Health Partnership (IHP)

154.  The IHP was launched in London in 2007. It brings together a first wave of donor[23] and recipient[24] countries together with a wide range of health-related IGOs and NGOs[25], whose objective is to make health-related aid work better for poorer countries by:

  • focusing on improving health systems as a whole rather than on individual diseases or issues;
  • bringing about better coordination of effort among donors;
  • developing and supporting the health plans of recipient countries.

155.  Dr Tyson described the IHP as "an accelerated effort … to try and apply the principles of aid effectiveness signed up to in Paris in 2005 and to apply that to the health sector." The aim is that all the participants—donors, recipients and implementers—should sign up to mutually-compatible obligations and should align their support with the national planning processes of recipient countries in order to improve health care. Dr Tyson described the IHP as "a joint process of mutual accountability" (Q 2). He continued:

    "The International Health Partnership, we should not forget, builds on 15 years of experience in trying to get all partners, donors, civil society and the private sector working behind the national plan. It has not come out of the blue. We do have quite a lot of positive experience to build on" (Q 12)

Gillian Merron, Parliamentary Under-Secretary of State at DFID, believed that "the launch of the IHP was something of an important political milestone … It is the first time the global health community have come together with a clear signal that we cannot go on as we are" (Q 1145)

156.  The IHP may grow to encompass more donors, recipients and implementers; and, if that should happen, it may progressively take over coordination of external support to health care provision in many developing countries. In this respect it could be regarded as complementing WHO's activities by providing an implementing arm to parallel WHO's role of setting global health standards, conducting disease surveillance and providing in-country technical support. Dr Silberschmidt, while welcoming the launch of the IHP, appeared to have some reservations over its transparency and sustainability, and he drew to our attention an alternative proposal, still at an informal stage, that there might be a special committee (he referred to it as Committee C) of the World Health Assembly through which the various other players on the international health stage could be associated with the WHO. "One of the challenges of the coming years", he said, "is to find a governance mechanism which keeps the momentum, keeps the independence of the organisation, but assures coordination between all the global health players" (Q 595).

157.  Dr Lob-Levyt took a rather different view. He told us:

    "I think the World Health Organisation's strength is to its normative agendas, setting normative standards, and less on the implementation side. On the normative areas, yes. In terms of coordination, it is national governments that should be put in charge through the frameworks. There is a huge risk in putting one institution in charge of all coordination" Q832).

Professor Fidler felt that "we are in early stages with regard to seeing how many of these informal partnerships operate". He drew favourable attention to one of their notable features—namely, that they had sought to achieve their objectives, at this stage at any rate, through informal agreements rather than formal treaties. "There is a sense", he said, "particularly in this initial innovative stage of finding some new alternative approaches, that a little bit more flexibility is better at the moment than trying to walk this into international law" (Q 964).

158.  Our assessment of the International Health Partnership concept is that it represents an interesting and innovative project which has the potential for bringing about considerable improvement in the coordination of global health efforts, particularly at the all-important country level. We shall, however, have to wait and see how the concept develops—whether other countries and implementing organisations join and whether the mutual obligations which participants undertake prove sustainable and really do result in the increased efficiency of health-related aid which is envisaged. We are pleased to hear the Minister's affirmation of the importance of the IHP. We therefore recommend that the Government should throw its weight behind development of the concept in order to turn it into a reality as soon as possible. We recommend also that the IHP should be developed in a way which simplifies and avoids complicating further the already complex global health governance picture.

A Global Compact for Infectious Diseases

159.  The Global Compact concept has been advanced by Professor Harvey Rubin of the University of Pennsylvania. It is described in detail in written evidence submitted by him (pp 375-379). Briefly, Professor Rubin envisages that his Global Compact would have four main components:

The Compact would include States, who would enter into it as a treaty, and IGOs, NGOs, Academia and the private sector, who would be part of it under a system of pledges. The system would operate on the principle that the benefits of the Compact would be shared out among the players in proportion to their contributions to it. As Professor Rubin put it to us, "if you report your data, you will be high in the queue to get the vaccine; if you do this harmonisation, your scientists will be part of the governing body of the research centres" (Q 935).

160.  Professor Rubin cited a topical example of a problem which would have been avoided if a Global Compact had been in existence at the time—namely, the reluctance of Indonesia to share H5N1 virus samples to facilitate the development and manufacture of avian influenza vaccines. In Professor Rubin's view:

    "This whole Indonesia H5N1 issue, I believe, never would have come to the table if we had linked the idea of receiving vaccines and drugs as part of contributing surveillance data. If we had understood that fundamental idea from the beginning, the Indonesians' resistance to sharing sequence data, I do not believe it would ever have become a problem" (Q 918).

161.  Professor Rubin felt that a Global Compact would promote adherence to the International Health Regulations, whose enforcement he described as "a major problem" (Q 934). Under a Compact, "the IHR would be an integral part of the Compact" (Q 936).

162.  We see some potential benefits in the concept of mutuality underlying a Global Compact. If global disease control is to be effective, it must move away from the notion that it is something which developed countries do for developing ones and be seen as an activity in which each has something to give and something to gain. Thus, for example, while many of the treatment resources lie with developed countries, effective disease surveillance, let alone treatment and prevention, cannot be carried out without investment in and the cooperation of many developing ones. On the other hand, the Global Compact concept does not appear to have attracted widespread support to date among governments, IGOs or NGOs (QQ 929-933) and it is not clear to us how, even if the concept could be agreed internationally, it could be enforced. It is, however, early days and it is certainly possible that the GCID initiative may begin to attract support outside the relatively narrow circle in which it is operating at present.

Networked Governance

163.  This model was described to us in evidence by Professor Fidler, who believed that the current situation of global health governance was the result of two developments within the last 10 years—namely, the end of Cold War superpower confrontation and the growth of non-State influences on the way in which international issues are addressed. Professor Fidler suggested to us that, with the ending of the Cold War, the foreign policy of the United States—and, by extension, of many other countries—had been released from a straitjacket of East-versus-West confrontation to engage in other issues of global concern, including health. "The political prominence we have of health today", he told us, "is the result of the very specific political conditions that have developed in the post-Cold War period" (Q 986). He continued:

164.  Professor Fidler believed, however, that this situation could change if other issues of higher priority to foreign policy makers—he instanced developments in Iraq and the spread of Chinese influence in Africa—were to come to the fore. "Unless health gets embedded in all these areas of foreign policy", he warned, "and gets deeply embedded, if we have big systemic changes, where we have great power rivalries coming back to the surface again, this will disappear. We will not be talking about health as a foreign policy issue in the way we do today" (Q 986).

165.  Professor Fidler described the existing situation of global health governance as "open-source anarchy". As a result of a variety of factors, including the arrival of global information technology and the emergence of non-State actors with substantial material resources, the governance of global health could now be accessed by a wide range of players who were not susceptible to governmental or intergovernmental control. Using the analogy of computer software, he told us:

    "You have a source code that runs the software, runs the programmes for global health. That source code is now accessible and influenced by a range of actors. Via people in this networked context, they are following what is going on. The source code is open-source, it gets iteratively defined by the participation of the range of actors" (Q 979)

"The governance task", said Professor Fidler in written evidence, "now extends beyond getting IGOs to function more effectively because non-State actors play significant, and increasingly influential, roles in global health, and especially with communicable disease issues" (p 379). He cited the involvement of The Gates Foundation as an example:

    "Many people now believe that The Gates Foundation is becoming the de facto center of gravity for global health policy and funding, eclipsing the traditional lead role of the WHO and even the historically influential US CDC. This example constitutes just one feature of a rapidly changing context for addressing global health problems, a context that is increasingly posing more and more difficult challenges for IGOs" (p 379).

For this reason Professor Fidler did not believe that any rationalisation of global disease control efforts which was based on the imposition of a formal structure was likely to succeed:

    "I think architecture is the wrong model, because I do not think you are going to be able to control the behaviour of either States or the big powerful NGOs like The Gates Foundation. If you think it is hard to get the United States and George Bush to toe the line of the United Nations, try getting Bill Gates to toe the line of the WHO. He does not have to. Increasingly, The Gates Foundation is the first place people will pick up the phone to call, not the WHO" (Q 968).

166.  So, if one accepts Professor Fidler's analysis, what conclusions can we draw? He saw it as the evolution of what he called "networked governance", which he defined as "networks of State, intergovernmental and non-State actors". He regarded the new IHRs as an example of this process. "The way they build non-State actors directly into a global surveillance system is a very different model of global governance from what we saw before". It was "an innovative way of trying to integrate the new actors" (Q 962). It represented a move away from the old State-centred approach and from formal treaty-based mechanisms. What was needed, in Professor Fidler's view, was "a combination of existing mechanisms/processes but building in some of these innovative features, particularly to harness and take advantage of what non-State actors could bring to the table" (Q 963). At the moment, he believed, "we are in a political and institutional transitional period" (Q 966). What we were seeing was "a competition of ideas. The survival of the fittest is taking place right now. To some extent that is a necessary part of this transition" (Q 971). It was necessary to monitor the process, to see which ideas succeeded and which fell by the wayside and to build on the results. "You will then start to see the nodes of the networked governance become a little bit smaller, so you begin to get more coherency, and you begin to get more consensus" (Q 979).

167.  Above all, Professor Fidler believed, there was a need for States to recognise that in the globalised world of the post-Cold War era the traditional patterns of inter-State diplomacy had changed and to adjust their operating practices accordingly. "We are chasing the whirlwind of 21st century diplomacy", he wrote to us, "with an international system still tethered to 19th century patterns of State behaviour and cooperation. Caught in the middle are IGOs, such as WHO, which appreciate the disease trends but remain accountable to sovereign States and their interests" (p 375).

168.  A similar analysis was given to us by Dr Iain Gillespie from OECD. He told us:

    "There is a great demand from the individual actors, whether they be PDPs or whatever, to develop a better system. That need not necessarily be a top-down issue imposed on them. What we need is space for them to come together to develop these kinds of networks" (Q 1035).

Dr Benedicte Callan, of OECD's Directorate for Science, Technology and Industry, added:

    "We are struggling with the question of where the gaps are in the network, where do they fail and what do they fail to do. There are these multiple communities of practice. There is an incredible—and in large part this is thanks to the Bill and Melinda Gates Foundation—renaissance of ideas and groups that are trying to fill in the various gaps" (Q 1035).

Discussion

169.  We are attracted by elements of all three models. The International Health Partnership has the considerable advantage of being already in existence and of having influential participants. It is, in effect, a 'coalition of the willing' which is trying to bring greater rationality and synergy into the management of global health, especially at the all-important country level. Such self-help initiatives can often be successful where other, more top-down structures are difficult to bring about. As observed above, we believe the principle of mutuality underlying the Global Compact concept has much to commend it. It recognises that effective global control of infectious disease depends crucially on all countries, whatever their circumstances, cooperating for the common good, whether that takes the form of developing affordable vaccines and medicines, building up good disease surveillance or supplying virus samples, and that that is more likely to be achieved if each of the many actors perceives that it has a vested interest in actively participating.

170.  Networked governance, in our view, represents the most accurate analysis of the problem which global health management now faces—in particular, the rise of powerful non-State actors and the rapid dissemination of knowledge around the globe. We note Professor Fidler's view that top-down imposition of a new global health order is simply not realistic and that there is at the moment a process of natural selection taking place from which we can expect to see emerge in due course greater coherence. What concerns us is whether this process, left to itself, will necessarily lead in the direction of more synergetic and generally more effective global infectious disease control. While we recognise that a new order cannot be imposed, we cannot help feeling that the present situation cannot responsibly be left simply to work itself out in a laissez faire manner and that the future will be safer if there is a shared vision of where we are going and a body that is recognised as having responsibility for overseeing what is happening, promoting integrated or collaborative working and alerting the global community if the system shows signs of malfunctioning.

171.  In our view, and indeed in that of most of those who gave evidence to us, the natural choice of organisation to exercise such a role is WHO. Its mandated functions of health policy formulation, standard-setting and technical support have recently been enhanced by a more proactive role in the crucial field of global infectious disease surveillance and response. WHO is therefore now well-placed to prepare, with the agreement of its Member States, a strategy for the future governance of global health and to encourage the many players on the global health stage to move towards it. On the basis of the evidence we have received, there should be broad support for WHO to assume such a role.

172.  If, however, such an initiative is to succeed in bringing greater rationality and synergy to global disease control, it must be supported by resources as well as words. We have drawn attention above to WHO's budgetary structure, in which only a small proportion of total resources is available for investment in programmes which, from WHO's centrally-placed perspective, are essential to strengthen global disease control capacity. In the world in which we now live, where effective surveillance and response is crucial to disease control, we regard this situation as unacceptable and we have recommended above that WHO's budget should be re-balanced and increased. We would not wish to be misunderstood. We are not suggesting that Member States should sign a blank cheque and leave it to WHO to decide how much of its total resources should be spent on programmes to which it attached importance. What we are suggesting is that there should be some re-balancing, based on evidence of need from WHO, of the organisation's budget between Assessed and Voluntary Contributions in favour of the former. A management initiative currently being undertaken by the Department of Health in relation to funding of WHO, to which we refer below,[26] may provide a model.

173.  We therefore recommend that the Government should take the initiative, within the global health community, to promote a strengthening of WHO's role in two principal respects. First, Member States should be asked to agree, at the 2009 World Health Assembly, on a new Mission Statement which would give WHO a role of preparing a strategy for global health governance and promoting, through negotiation, an increase of collaborative working among the various actors, State and non-State, in the field of infectious disease control. Second, Member States should be asked to agree, on the basis of evidence of need presented to them by WHO, a re-balancing of the WHO budget between Assessed and Voluntary Contributions.

174.  Moving health governance forward at the global level is essential, but it is by no means the whole story. It is at the country level where the real problems of unintegrated working make themselves felt and where they have the potential to do most damage—for example, if health aid does not reach the sick people for whom it is intended or if host governments are so burdened with responding to a multiplicity of donors that they cannot do their work effectively. There was consensus among all those who gave evidence to us that the most appropriate way of promoting collaborative working among donors at country level was to align such efforts behind the health strategy and planning of the country concerned. Dr Lob-Levyt, from GAVI, told us that "the priorities should be set by the countries themselves and we should try and work behind those priorities, no question" (Q 824). Dr Getahun, from Stop TB, agreed that "an important line should be to work under the national government, under the national plan" (Q 748). We were encouraged to hear, from Diane Stewart of the Global Fund, that these principles are now being acted upon in some areas. Ms Stewart told us that "we are trying to move towards the approval of national strategies for funding, so countries will be able to develop their national strategies, say which piece of it they do not have the funds for, what is the gap, and submit that to the Global Fund for funding" (Q 641).

175.  It is important to recognise, however, that in some countries the preparation and implementation of sound national plans cannot be carried out without external support. The Centre for Global Development wrote to us that, "where a host country's plan is weak or has gaps, donors should coordinate efforts to assist the government and other country stakeholders to strengthen it"(p 470), and Dr Lob-Levyt commented that "in some areas, in order to ensure that there is informed decision-making and priority-setting, information is needed, and I think we rely on the normative role of agencies, such as WHO and others, to ensure that the correct information is available to the country to make those decisions" (Q 824). In other words, it is not enough simply for donors to align themselves with in-country health plans: they must, in many cases, support the development of sound plans which reflect real priorities and are capable of being implemented efficiently.

176.  We therefore recommend that the Government, working with other donors and with recipients, should aim to lighten the administrative burden of health aid on developing countries and to strengthen the capacity of those countries to manage health programmes. The aim should be to secure the alignment of donor inputs to disease control programmes within the national health programmes of recipient countries and to simplify the procedures for their management and reporting.

10   Africa, the Americas, South East Asia, Europe, Eastern Mediterranean and Western Pacific Back

11   See, for example, Dr Julian Lob-Levyt, Executive Secretary of GAVI (Q 825)  Back

12   See, for example, QQ 49, 560 and 934 Back

13   See Paragraph 151 below Back

14   Office International des Epizooties (World Organisation for Animal Health), based in Paris. Back

15   UN Food and Agriculture Organisation (FAO), based in Rome Back

16   See Q 569 Back

17   "An Inadequate Response", Results UK, November 2007 Back

18   "An Inadequate Response", Results UK, November 2007 Back

19   "Achieving Universal Access-The UK's Strategy for Halting and Reversing the Spread of HIV in the Developing World"  Back

20   See Paragraph 133 Back

21   See Paragraphs 154-158 below Back

22   See www.theglobalfund.org/en/apply/mechanisms Back

23   UK, Norway, Germany, Canada, Italy, The Netherlands, France and Portugal Back

24   Burundi, Cambodia, Ethiopia, Kenya, Mozambique, Nepal and Zambia Back

25   WHO, European Union, World Bank, UNAIDS, UNFPA, GAVI, UNICEF, Gates Foundation, African Development Bank and the Global fund to Fight AIDS, TB and Malaria Back

26   See Paragraph 183 Back


 
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