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Health: Disease Control (Intergovernmental Organisations Committee Report)

Volume 708: debated on Tuesday 24 February 2009

Motion to Take Note

Moved By

That this House takes note of the report of the Intergovernmental Organisations Committee, Diseases Know No Frontiers: How Effective are Intergovernmental Organisations in Controlling their Spread?

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.

My Lords, it is a pleasure to speak in this debate on Diseases Know No Frontiers, which results from the work of the committee so ably chaired by the noble Lord, Lord Soley, who has pretty well done my job for me. The committee could have chosen a great many topics for its first inquiry into intergovernmental organisations and how we are making use of our membership of them. However, examining how IGOs are tackling the global spread of infectious diseases turned out to be a complex and worthwhile exercise. We took evidence from many dedicated and experienced witnesses, who enabled us to build up a picture of how things are at present and what most urgently needs to be done to contain future threats. Following the old maxim that prevention is better than cure, we believe that preventing the spread of disease is an important factor to be pursued. I should like to say a few words on prevention of each of the four diseases that we selected for special attention, but I shall concentrate a little more on HIV and pandemic influenza than on the other two.

With malaria, control is achieved through a combination of practical measures, such as the spraying of dwellings and the provision of insecticide-impregnated nets, which kill the carrier mosquito before she reaches her victim. Unsanitary, crowded living conditions and malnutrition create a breeding ground for tuberculosis, the second of our four diseases. Therefore, prevention is linked to improving poor socio-economic conditions.

Preventing the spread of HIV is largely dependent on changing lifestyles, including, for example, sexual relations and the use of contaminated needles. However, the balance between prevention and treatment has reached a Catch-22. The evidence suggests that effective treatment through the use of antiretroviral drugs could actually increase the prevalence of the disease unless it is accompanied by effective and sustained prevention measures. The will to change behaviour may be undermined by a sense that, with the effective antiretroviral treatments available, the disease is no longer such a threat and horror. Nick Partridge, chief executive of the Terrence Higgins Trust, said that,

“good therapy … makes people healthier but it certainly does not reduce, it increases, the prevalence of HIV overall … It also creates an ongoing need for funding drug therapy which can squeeze out funding for good prevention campaigns. What is vitally important is that both go hand in hand”.

In the case of pandemic influenza, prevention is largely dependent on surveillance so that the necessary steps can be taken to prevent the virus from spreading rapidly. In order to achieve comprehensive surveillance, rather than in richer countries only, an effective global alert and response system needs to be maintained to help to identify emerging infections and deal with them at source. We understand that the University of California is carrying out research into patterns of emerging infections with a view to developing risk-based forecasts of what the next pandemic might be and where it might appear. That research is still in its infancy.

The London School of Hygiene and Tropical Medicine believes that global disease surveillance has improved markedly in the past decade. Dr Coker, reader in public health there, told us that,

“the SARS crisis forced a re-think globally on global surveillance and was really, in a sense, a dry run for pandemic flu”.

The noble Lord, Lord Soley, drew our attention to GOARN; I am sure that noble Lords will remember what those initials stand for. However, it is worth emphasising the need to invest in basic health infrastructure to provide a firm foundation on which more specific disease control initiatives can be built. That is in our national interest as well as in the interest of other countries. The committee recommended that,

“the resources which are provided through organisations of which the UK is a member”,

should bring,

“infectious disease surveillance and response systems up to an effective level”.

In their response, the Government stated that they are currently preparing their international pandemic influenza strategy, which details the direction and objectives of the UK’s international efforts on pandemic preparedness over the next three to five years.

I end by endorsing the plea made by the noble Lord, Lord Soley, for consideration of the importance of the topics still in the pipeline that could relate to our membership of IGOs. There will be many more that will be relevant. It is to be hoped that this committee or one like it will be re-established so that the good work can continue.

My Lords, this new and, to my mind, very important committee had a good start with the chairmanship of my noble friend Lord Soley and the services of our Clerk, Robert Preston, and his team. They succeeded in confining a potentially vast subject into a manageable space and enabled us to discover some alarming and relatively unknown areas of concern. They are not unknown to all; my right honourable friend the Prime Minister identified dealing with disease and global pandemics as an element in the national security strategy last March, one which required a global response. My noble friend Lord Robertson of Port Ellen and the noble Lord, Lord Ashdown, wrote in the Times last June:

“The pandemic threat is not so serious just because of the possibility of a disease outbreak but because, in a world of people moving on this scale, a disease could be upon us long before we know it is even there … This is not a temporary state of affairs but a permanent one and an interdependent world is a world of shared destinies”.

One of the most striking things that I learned was the high proportion—it is three-quarters—of new infections which come from animals by jumping the species. This is not new knowledge; it was only new to me. Most of us know that most of our common, communicable diseases began when the human race went in for agriculture and close proximity to farmed animals. Your Lordships might think, therefore, that those organisations which were set up to deal with animal health and those for human health would be aligned to share information and control measures most efficaciously. That is not what we found, as our report shows in some detail, yet the danger is greater now that animals are moved so far and so often for farming, hunting, food, laboratory and pet trades and on an increasingly globalised scale. People penetrate into the depths of the forest and the jungle more than before, and use its products more exhaustively.

As my noble friend Lord Soley said, there is no set of international health regulations to deal with animal infections, and we recommended that there should be. I regret that the Government, in this case, did not agree with us. While there are, for instance, EU directives on some of these zoonotic diseases and some general directives for agriculture and food safety, there is none to oblige disease monitoring for nature and biodiversity. Some think that the UK does not match its DfID investment in research on avian flu with full enough assessment of all future risks posed by wildlife in general. Then there is the whole area of which animal viruses, among the myriad which infect animals, will make the jump and which will turn into lethal diseases. This science, too, is in its infancy, not least because the places where these jumps happen most often are the poorest countries, in the tropics, with fewest scientific resources to identify them.

When we looked at the management of serious infections that had reached humans, we did see change and progress. Rationalisation of the complex web of organisations was being addressed by the international health partnerships launched by this Government. We saw a recognition that help with specific treatment would not, on its own, solve the systemic problems of poor health infrastructure and lack of health education which had allowed disease to flourish in the first place. The problems which poor societies have in diagnosis, in data collection and in storage were well understood, and new kinds of organisation on the international scene, which brought in all stakeholders, were achieving results. In particular, there was recognition in the Global Fund, the Global Alliance for Vaccines and Immunisation—GAVI—and others that representation from civil society was essential to achieving delivery of service and preventive education in poor countries. The arrival of a rights-based approach to health was able to break down barriers. Innovative funding mechanisms such as the International Finance Facility for Immunisation and advance market commitments, which this Government have done so much to develop and establish, have saved thousands of lives among those too poor to pay for medicine.

The word “poor” keeps cropping up in any discussion of the control of infectious diseases. It is no accident that their toll is so infinitely less in rich countries. The best way to stop the devastating mortality of AIDS, malaria and tuberculosis and the other life-threatening plagues is to eradicate the poverty, poor living conditions, malnutrition and lack of clean water which are the daily lot of those who die before their time in such large numbers. These, the non-health determinants of health, are now analysed by the WHO. They also need on-the-ground analysis by the local and national governments concerned. This is where the redistribution of resources, which is intrinsic to democratic politics, saves lives. Inequality breeds disease and early death.

Professor Sir Michael Marmot told us that if the WHO had health equity as a core value, it would be institutionally natural for the WHO to bring in the non-health causes of ill health such as education, poverty, trade, habitat and migration and to promote measures that alleviated their adverse effects. The new report of the WHO’s Commission on Social Determinants of Health, which Professor Marmot chaired, bears eloquent witness to the relationship between social justice and health. However, in our output-driven funding habits, it is hard to measure the impact of any non-health measure on any particular disease, unlike, say, immunisation, so there is a disproportionate incentive towards vertical programmes rather than improvements of the whole system. We have made recommendations to improve the focus, as well as the accountability, of both international and national health organisations through UK action.

It is important, we thought, that the World Bank’s new strategy put health in the context of its overall strategy for poverty alleviation. Perhaps the clearest lesson from our seminars was that in devising mechanisms to protect our own populations from deadly diseases from distant places, we should remember that we will do this best if we join in removing their fundamental basis: the soil of poverty in which they flourish.

Finally, as my noble friend Lord Soley said, the UK contributes sizeably to the intergovernmental organisations that we have been considering and many others. This committee is the only formal parliamentary scrutiny of that expenditure, and your Lordships might think that the taxpayer has a right to see this work continue.

My Lords, as the first speaker who has not been a member of the committee, I congratulate it on a very good report that dissected the issues, drew out the key points, and finished quite rightly on the sobering note that a pandemic is likely at some point.

I very much agree with the noble Lord, Lord Soley, that the UK’s reputation in this field is very good indeed, and it is against that background that I make some comments about how more could be done. The first point that I was going to make was made by the noble Baroness, Lady Whitaker. I therefore merely echo her remarks, with which I agree completely, about the non-health issues—the determinants of health—and the importance in that context of the World Bank playing a full role alongside the World Health Organisation and others.

Two points arise from the report and are crucial to the success in controlling the spread of communicable diseases; they are, if you like, about our vulnerability. The first point is about the UK’s interdepartmental collaboration. The report calls for more collaboration, the Government acknowledge it, and the big policy statement, Health is Global, is as good as any such broad policy document that I have ever seen on this.

How good are the Government in practice at using the strengths of the departments to reinforce each other? This is a universal issue. Three years ago, on behalf of the previous Prime Minister, I called a meeting of a number of countries to look at health and development globally. I found that every country sent two representatives—one from its equivalent of DfID and one from its equivalent of the Department of Health—apart from France, which sent three. It also sent someone from its Foreign Office. The fact that government is not totally joined up is not unique to the UK.

The important point is that the globalisation of health has implications. There is the potential for pandemics and a huge movement of staff. There is trade, drugs are sold all over the world, and above all there is an enormous movement of people around the world. We need to have a real understanding of the linkages between first-world health and development issues. The health service in the UK must act as a global player and in a global context, and when DfID deals with health it must do so with the best health knowledge available. I still do not think that I see this in practice. I know that there is good co-operation at the policy level, but is it happening in practice? The test question for the Minister is: when DfID is dealing with the development of a health system in a country, how often does it ask the Department of Health for help from its experts or ask for help from the best health experts in this country, or does it simply use its own parallel systems, processes and structures?

I am not asking this question naively. I understand that there is a difference in health issues in different countries and I absolutely recognise the expertise in DfID on the health issues in developing countries. But many things are the same in both poor and rich countries, one of which is health systems. If you are looking for support for health systems, you are more likely to find that expertise in the people who are running the health systems in, for example, this country. Another question is: how often does DfID make use of the Health Protection Agency, which is probably the best or the equal best of its kind in the world?

The parallel test question is: when the Department of Health or the Health Protection Agency is dealing with a problem originating outside this country, how often does it call on DfID for advice to make sure that it has a real understanding of what is happening in that country? This co-operation is getting better, but it is still a weak point. While I know about the relationship around health, I suspect that the same thing must be true in other areas, such as education.

My second point concerns staffing. There is a huge shortfall of health workers around the world, which is the vulnerability that underpins all others. We globally are as vulnerable as the most vulnerable point, and the most vulnerable point is likely to be in a poor country with poor health and social conditions, with very few health workers and with people who may not be able to recognise the problems as they arise. That is our big vulnerability.

I know that the UK and others are part of the innovative financing task force, which is co-chaired by the Prime Minister and the president of the World Bank. Again, I would ask the Minister for reassurances that in looking at its work, attention will be given not only to innovative funding for staffing, which is part of its terms of reference, but also to innovative approaches to staffing. My point is simple: staffing is not just about doctors and nurses. It is about all those public health professionals, public health local community workers and mid-level workers—they are called a number of names in different countries—who work in the most difficult conditions and are therefore most likely to see where the problems are. Therefore, the issue is not just about making sure that the UK supports innovative funding mechanisms in order to increase the levels of staffing in health services around the world but also about increasing the innovative structures. You do not want to have the same grades and types of staff as we have in the UK in many of these countries. We will miss an opportunity if we raise money to increase staffing, but do not use it to have the most impact on issues such as communicable diseases, which will tend to be at the most local level often with the staff who have had the least training.

Incidentally, in parenthesis, the UK has the most tremendous tradition of health education, and throughout the world it has played its part in the education of doctors, nurses and others. It has, I believe, a great opportunity, if the appropriate arrangements can be made, to support training and education internationally. That would be a very positive contribution to the globalisation of health education and would help to support poor people globally.

In summary, this excellent report has laid out the ground very well and has expressed our vulnerabilities. I believe that these two areas require more attention and more action.

My Lords, it is a great privilege to thank my noble friend Lord Soley for having initiated and having led this inquiry in a most efficient and charming manner. We finally got to grips with what is really an enormously complex subject. Before I turn to the topic of the report itself, let me reflect that today we are going through another global pandemic, a financial one. If only there were as many institutions around the world talking to each other about disease control as there are talking about financial problems, the situation might not be as bad as this. I can put it no more strongly than that. As my noble friend said, while in the report we concentrated on four major diseases, many others are no less important. We just did not have the time to deal with them. In poor countries especially, these other diseases are just as important as the four we looked at. We were also as much concerned with globalisation on the health front as with the role played by intergovernmental organisations in combating global diseases.

I want to make some points that have not yet been made because the report has been welcomed by my noble friend Lord Soley and others. We thought that we would encounter a jungle out there of overlapping jurisdictions all interfering with each other in trying to deal with the problems of the four global diseases, but instead we found a much greater degree of clarity among the people involved, especially those at the WHO. They know what they are doing and have ways of co-ordinating with other players in the field, so that while from the outside it may look messy, it is not as untidy as we thought it would be.

On the nature of structures, there is a contrast between vertical and horizontal health issues. In my view, the vertical structures are not in a sense co-ordinated enough because we have institutions such as the WHO, to which DfID contributes in a vital way, and many other similar organisations. Poor countries find themselves receiving visits from unco-ordinated groups from different nations, each bringing its own agenda and each wanting a return from the recipient country on the buck it has given. We were told that in countries such as Tanzania and Malawi, officials in the health ministries have to host as many as 340 delegations a year. I do not know when they find the time to do any proper work. We ought to worry about whether there is a way of co-ordinating this stuff so that fewer delegations visit individual countries, and those that do do not just push their own little angle. Rather they should ask about outcomes on the ground as a result of donations and worry less about whether a particular country’s dollars have resulted in a particular cure. The question should be: has a cure been achieved? Given the fragility of staffing levels in terms of both organisation and health needs in poor countries, devising some sort of co-ordinating mechanism would make a tremendous contribution. This requires on the part of taxpayers in the rich countries a bit of trust so that, although we do not quite know where the DfID dollar has actually gone, we can take it that its dollar has been properly utilised and that outcomes will show how that has been the case. The global structure needs to become slightly more co-ordinated and less nationalistic and protectionist over individual donations and the return on them.

I turn now to one or two other problems. In the case of pandemic flu, we face a problem that is not unknown in international relations: countries are often unwilling to share evidence of the occurrence of an outbreak. That happened famously in Indonesia. Countries are very often afraid of the economic impact it will have on investment, business and tourism if they admit to a problem. Again, we have to find mechanisms of compensating countries which are honest and come up with a warning that will benefit all of us. We have to tell them that if there are problems and if costs are incurred, the World Bank or some other agency such as the International Monetary Fund will compensate them, but the importance for the world at large is that they share this information and share it as quickly as possible.

Problems of sovereignty in terms of both the recipient and donor countries often get in the way of efficiently tackling the problems of disease. The matter may not be the specific responsibility of a particular government department but one about which the global leadership should think carefully what to do.

One of the lessons we would obviously like to learn from what we have done is the tremendous importance not only of the need for more resources at the vertical structures but also, as my noble friend Lady Whitaker said, of the horizontal parts of the health problem, which is the general problem of tackling poverty. It is extremely important, at a time when we are all feeling rather hard up in terms of the financial meltdown, that the global leadership—the G8 especially, and the G20—does not resile from the task of keeping up international aid so that the flow of international resources which is most needed by the poorest countries continues. Yes, we are slightly worse off, maybe by 10 per cent or 15 per cent, but even so we are still 20 to 30 times better off than those people who are really at the front line of suffering from some of these diseases. It behoves us not to fall back but to keep our commitment to helping tackle health problems in the poorest countries as far as possible.

My Lords, it is a true delight to take part in this debate. I thank the noble Lord, Lord Soley, the committee and the staff with whom he worked for producing a really excellent and interesting report. I thank him for the informative and engaging way in which he introduced a very complex report examining quite deep-seated issues. It is a very timely analysis of a really complex set of organisations with overlapping roles, multiple areas of expertise and fragmented funding streams. That is a recipe for disaster if ever there was one.

When I read the report, it was not apparent to me why a committee of your Lordships' House should have produced it. I am very glad that it did, because it brought to the subject a detachment which made its findings all the more pertinent. From looking on the web, I know that the reaction around the world has been very appreciative, and I congratulate the committee on that.

The report is timely for two reasons. To echo a point made by the noble Lord, Lord Desai, in the current financial economic situation, it is clear that there will be an ever growing need to demonstrate the efficacy and efficiency of international aid programmes. I also think that we have a golden hour in which to engage with the new US Administration in a spirit of partnership which was perhaps not possible with the previous Administration. The US Administration and their policies are one of the biggest factors in the international health scene. In addition, we have the forthcoming G8 summit. For reasons that I shall make clear later on, we have at the end of 2009 the important UN conference on climate change.

Recent events since the report was produced have demonstrated how important it is. In December 2008, cholera infected 80,000 people in Zimbabwe. As far as we know, approximately 4,000 of them died. Of that outbreak, the WHO said:

“Given the outbreak’s dynamic, in the context of a dilapidated water and sanitation infrastructure and a weak health system, the practical implementation of control measures remains a challenge”.

That was a very diplomatic way of describing a desperately sad and avoidable situation. It brought home to me the need to implement fully these international health regulations and to extend them to any disease, wherever it comes from, so that there is a global public health surveillance system, with state parties having an obligation to prevent or control the spread of disease, but in which civil society can report the true incidence of disease if a Government fail to do so. That is a tremendously important point.

I read this report in conjunction with the report from the Intergovernmental Panel on Climate Change. It announced in 2007 that projected climate change- related exposures are likely to affect the health of millions of people. Climate change will affect infectious diseases in two ways. There will be an increased risk of water- and food-borne disease, and there will be changes in vector-borne diseases. The IPCC predicted an increase in diarrhoeal disease in any place where water or food becomes contaminated—for example, after flooding—and where warmer weather leads to food poisoning due to problems with food storage. It is not possible to overestimate the extent to which climate change will have an impact on health.

Only last month in the British Medical Journal, Anthony McMichael of the Australian National University estimated that climate change could lead to an additional 20 million to 70 million people living in malarial regions in sub-Saharan Africa. He drew the clear lesson that:

“Poverty cannot be eliminated while environmental degradation exacerbates malnutrition, disease and injury … Infectious diseases cannot be stabilised in circumstances of climatic instability, refugee flows and impoverishment”.

Further, he said:

“This requires bold and far sighted policy decisions at national and international levels”,

and greater carbon emission cuts than those proposed a decade ago. To everything the noble Lord, Lord Soley, said, you have to add this extra dimension of the health impact of climate change.

I have one slight criticism of the report. In concentrating on the big three infectious diseases—HIV/AIDS, TB and malaria—the report did what in a way the noble Lord, Lord Desai, said it did. It tended to overlook what are called the neglected tropical diseases. I understand why the committee did that. Those diseases are less likely to have an impact in Britain, and that was the remit of the committee.

None the less, those neglected tropical diseases afflict an estimated 1.1 billion of the 2.7 billion people who live on less than two US dollars a day. The burden of such diseases on those people is perhaps greater than on others. In neglecting to follow those, we did perhaps miss something. I suggest to the noble Lord, Lord Soley, that, as part of his campaign—which I wholeheartedly support—to have a standing committee of the nature of his, its next report could look at those neglected tropical diseases and the work of international government organisations on them.

Having given a slight brickbat, I want to give a bouquet. The report and its recommendations about TRIPS helped to build up some of the pressure which resulted last week in that announcement from GlaxoSmithKline. I am the Liberal Democrat health spokesperson. I happen not to make a habit of congratulating drug companies, but this time we should. It was an extraordinary statement, and I add to what the noble Lord, Lord Soley, said. GSK said that it would cut prices for all drugs in the 50 least developed countries to no more than 25 per cent of UK and US levels, and less if possible. It will put any chemicals or processes over which it has intellectual property rights that are relevant to finding drugs for neglected diseases into a patent pool so that they can be explored by other researchers. It will reinvest 20 per cent of any profits it makes in the least developed countries into hospitals, clinics and staff. It will invite scientists from other companies, NGOs or Governments to join the hunt for tropical disease treatments at its dedicated institute in Spain.

Campaigners from charity organisations have understandably expressed regret that that does not include the HIV medicines. Nevertheless, they realise that it is a tremendous step forward. It will alter dramatically the whole architecture of that complex relationship of intergovernmental organisations, NGOs and private companies. I hope that there will be a compensating change on the part of other private companies, and on the part of Governments as they seek to move forward to the next stage—just as they did when the Gates Foundation came along to make its contribution.

The issue of vertical and horizontal health programmes is one of the most interesting parts of the whole report. I listened carefully to what the noble Lord, Lord Soley, said about not being able to have either a horizontal or vertical approach; that will not work, and it is a question of finding a balance. I wondered whether the Government, working with countries with which they have particularly close relationships and the NGOs and IGOs working in them, might find two countries in which it was possible to come up with models reflecting a different type of balance between them. The sticking point seems to be that national Governments do not know quite how to come up with a model that is effective for them. There are no models to which they can go.

One of the most striking pieces of testimony in the report was that of Professor Borriello about zoonomic diseases. The interesting thing he talked about was that the UK’s panel for newly emerging infections includes medical and veterinary staff, and people involved in food science. Given that 75 per cent of emerging diseases are zoonomic, I ask the Government whether we can work on that model in conjunction with a low-income country to see whether the model could be adapted to its situation, whereby it could come up with a structure enabling those with knowledge in veterinary science, food science and health to work together. It is not a matter of us exporting our models intact, because they will not necessarily be applicable, but we can take the points of models that work and enable people to adopt them. That is an important point.

I end by echoing some of the points of the noble Lord, Lord Crisp. We have in this country a wealth of experience that we would do well to export. I would go further than the noble Lord and include Defra as well as some of the other departments. We should look upon this not solely as an act of generosity on our part. I well remember, during the outbreak of foot and mouth, a colleague in the Commons, Ed Davey of Kingston, had tremendous trouble getting a refugee who was a qualified vet from Iran—a nation where foot and mouth is endemic and every vet knows exactly what it is—fast-tracked into being able to work with those dealing with the emergency here. We have a lot to receive as well as to give from such partnerships.

The four nations of the United Kingdom work jointly but in slightly different ways via the Health Protection Agency and others. The noble Lord, Lord Desai, is right: during the next few years of austerity and hardship it will be extremely difficult politically to maintain our level of international development aid. It will require courage on the part of the Government to do that and the provision of a great deal of information—this report is a welcome addition to that—to dispel some of the myths about our expenditure on international aid, to enable people to see that it constitutes investment in the health of the world, and that we are part of that world just like anybody else. If one major task needs to be carried out above all else, it is to improve co-ordination and governance, to which the committee referred. This report is an excellent basis on which to start. I very much look forward to hearing the noble Baroness’s reply to the points noble Lords have made.

My Lords, I add my thanks to the noble Lord, Lord Soley, for introducing the report so comprehensively and charmingly. There is a lot of worry about how a flu pandemic should be handled. Professor Neil Ferguson of Imperial College has described a very useful computer model to test a number of strategies to limit the spread of the disease. As there is no vaccine, they suggest anti-viral prophylaxis in order to reduce the risk of infection among approximately 20,000 people in the vicinity of the initial cluster of flu victims. He estimated that a stockpile of 3 million doses of anti-viral treatments could be needed to eliminate an outbreak. The question that springs to mind is—I have already indicated this to the noble Baroness—has the Department of Health such quantities of anti-virals available?

The report contains criticisms of the WHO, as mentioned by the noble Lord, Lord Soley. Many of us have had experience of this organisation and have found some aspects of it rather unsatisfactory. No doubt this tends to colour our judgment. It is right therefore to stress, as did the noble Lord, Lord Soley, that the present director-general, Dr Margaret Chan, has brought a very welcome breath of fresh air to Geneva, and that things have changed very much for the better in the past few years.

The report records complaints about excessive bureaucracy in the WHO headquarters but the director-general's programme of reform of the management structure has been much admired. Others have criticised what they describe as the disconnect between the headquarters in Geneva and the regional offices, especially the regional office in Africa (AFRO). Uniquely within the United Nations system, the six regional directors are elected and naturally tend to feel responsible to the countries that elected them, as well as to the WHO. In practice this federal system has worked well during the past year or so in spite of past difficulties. The director-general meets the regional directors at least three times a year; two are whole-day meetings and the third is a retreat for several days.

Concerns have been expressed that the regional governance of the WHO could get in the way of a co-ordinated and effective approach to disease outbreaks. The revised international health regulations that were adopted by all WHO member states in 2005 make it clear that authority lies with the director-general. When a serious outbreak of a disease occurs, the director-general herself does the risk assessment, has the final say and advises on any action to be taken.

There have also been recent developments in building greater coherence among the main organisations working in global health. The heads of four United Nations oganisations, UNICEF, UNFEA, UNAIDS and WHO, and the four financing organisations, the World Bank, the Gates foundation, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the GAVI Alliance, now meet every six months to align their work more closely. The last meeting was just three weeks ago. It is worth pointing out that the Global Fund to Fight AIDS, Tuberculosis and Malaria has the largest health budget in the world. It is an international financing institution investing the world’s money to save lives. To date it has committed $14.9 billion in 140 countries to support large-scale prevention and care programmes against these three diseases. Two million have been treated for HIV/AIDS, 4.6 million for tuberculosis and 70 million bed nets have been distributed.

As the noble Lord, Lord Soley, mentioned, the Gates foundation contributes more than the whole of the WHO budget. There was a feeling that the WHO was becoming rather uneasy about that. But, again the director-general has made it clear that she does not regard that as a problem. There was some controversy over the WHO announcements about leprosy some years ago but that was based on a misunderstanding over technical terms. The WHO had earlier stated that its goal was to reduce the prevalence of leprosy to less than 1 in 10,000. Its policy of recommending that the duration of treatment should be reduced from two years to one year thereby halved the prevalence which gave the impression that the WHO was claiming that it had solved the problem.

The subject of prevention, especially HIV/AIDS, is dealt with in paragraphs 47 to 49, which emphasise that prevention means changing behaviour. As my noble friend Lady Eccles stated, changing behaviour is much more difficult than treatment. What is so disturbing is that the AIDS epidemic involves more and more women worldwide, with 17.7 million women being HIV positive, which is more than ever before. In sub-Saharan Africa they constitute two-thirds of people living with HIV/AIDS. In South Africa young women are four times as likely to be HIV infected than young men.

As president of the Mildmay centre, I was involved in the establishment of the first hospice in Europe for those dying of HIV/AIDS and later the first in Africa, just outside Kampala, with enormous help from the noble Baroness, Lady Chalker, who guided us into concentrating on outpatient work and teaching. In the Mildmay centre in Uganda it was not unusual to see 100 children in a day all with AIDS, all orphans, a third of them with tuberculosis and many with malaria and the most terrible shingles and lice that I have ever seen because their immune systems were so depleted. However, I was very impressed with the HIV/AIDS prevention programme set up by the President Museveni of Uganda which reduced the incidence from 31 per cent to 5 per cent among pregnant women. Those are hard, reliable data. The ABC programme—abstinence or postponement, be faithful and condoms—has also been successful in other African countries. The WHO advocates a policy that is comprehensive and inclusive, and embraces the ABC policy, which is also supported by our Government. The Leader of your Lordships’ House stated that the Government subscribe to the successful campaigns of ABC, but not one to the exclusion of others—it is important to stress that. It is of interest that many teenagers are choosing abstinence or postponement as a safer policy. Tragically, teenage girls in many countries have no power to refuse, and face physical abuse and even death if they do not comply. In approaching the difficult subject of prevention, we need to be open to many different approaches, especially as there are such diverse cultures worldwide.

About 40 per cent of the world’s population is at risk of malaria. More than 500 million people become severely ill with malaria every year, and 1 million people die. Twenty per cent of all childhood deaths in Africa are from malaria. The Conservatives are committed to spending half a billion pounds a year tackling malaria, until the millennium development goal has been met. We will work with African countries to abolish tariffs on anti-mosquito bed nets in sub-Saharan Africa. We will establish a fund, worth £5 million a year to begin with, to help fund international placements for British health workers and support links between the NHS and health systems in poorer countries. There are many who already give generously of their time and expertise in developing countries, and we need to give them more encouragement and make it easier for them to have leave of absence from their work here. Working on Mercy ships in west African countries for most of my holidays, I have been so impressed with healthcare workers who volunteer for periods of anything between two weeks and 22 years.

The Conservatives will abandon what we believe are Labour’s plans to cut staff numbers at DfID, and we will rapidly increase its budget. British aid will be properly scrutinised for effectiveness, and results will be linked directly to independently audited evidence of real progress in these poor countries. We also plan to establish an anti-corruption hotline on the front page of the DfID website. All DfID programmes will have a designated anti-fraud officer who could be approached, anonymously if necessary, by anyone who suspects corruption. Their e-mail address and phone number would be published on the relevant pages of the DfID website, both in English and local languages. We will also consider giving some aid money directly to poor people as aid vouchers, redeemable for development services of any kind from an aid agency or supplier of choice.

The noble Lord, Lord Soley, mentioned that animal welfare is very important in the food chain, and spoke about outbreaks of infection. That reminds me of the widespread distribution of the virulent campylobacter organism, which affects 70 per cent of chickens in the United Kingdom. The chickens are killed by being stretched by the neck and feet, upside down, on a conveyor belt. They are then electrocuted, which makes the muscles contract, emptying the contents of their alimentary tract. As they are upside down, the campylobacter is sprayed all over them. They are then put in a big vat, where they become campylobacter soup. When the chickens are chopped up and put into polythene bags, they are infected with campylobacter. This is all right provided the chickens are adequately cooked. However, if they are chopped up on a board that is then used to prepare a salad, you can understand how the infection takes hold.

This report has inevitably focused on developing countries and we are often critical of the widespread infections there. However, we in the United Kingdom are not always paragons of virtue.

My Lords, it is with great humility that I answer this debate. As I read the committee’s report and evidence over the past week, I realised what a very important contribution its work has made on this vital issue. I am not surprised that this was the first subject that the committee tackled. I congratulate my noble friend Lord Soley on a truly excellent and comprehensive report and on securing this debate today. I agree with the remarks of the noble Baroness, Lady Barker, about the welcome that the report has received across the world.

My noble friend has offered me the opportunity not only to place on the record the Government’s thanks for the committee’s work but to update the House on developments since its report. I am pleased to say that progress has been made even since its publication in July. As noble Lords will know, the Government published Health is Global, the UK’s global health strategy, in September 2008. This strategy, along with the 2007 DfID health strategy, sets the framework for our work on global health between now and 2013. Health is Global highlights the links between domestic health and health beyond our shores, as well as the role of a variety of players, including intergovernmental organisations, in improving both. It includes commitments to work for better health security, including tackling infectious disease, and more effective international organisations that can help get the job done.

Since the launch of Health is Global we have seen the start of the most serious global economic crisis in decades—referred to by several noble Lords, including my noble friend Lord Desai. Finding innovative and sustainable solutions to global health challenges remains as pressing a concern as ever. Indeed, I echo my noble friend Lord Desai’s remark that this is an economic pandemic. After last year’s food and fuel crises, we now face a huge challenge to maintain the fight against global poverty. Impacts on health will vary greatly by country and context, but past downturns show common patterns. The impact on the poor will be especially serious: nutritional standards are likely to fall, as will the ability to spend on private healthcare. Given their importance in channelling resources, intergovernmental organisations will be crucial to our response.

I also agree with my noble friend about the need for coordination and for our Government and other Governments to maintain support levels in this field. It is self-evident that many health risks today require international collective action. Let us consider, for example, the threat of a worldwide influenza pandemic, mentioned by the noble Baroness, Lady Eccles, and other noble Lords.

In October 2008 the Government launched a new international pandemic influenza preparedness strategy, which aims to reduce the risk of a global pandemic through co-ordinated action at national and international level, action designed to enhance our collective ability to prevent, detect and respond to a pandemic. At the heart of this strategy are issues that the committee’s report highlighted. We recognise the need to improve infectious disease surveillance and response systems in developing nations. This is why, in addition to our share of the substantial contributions made by the European Commission, the UK has already committed more than £35 million towards the international effort to tackle avian and pandemic influenza. Much of this funding is channelled through international organisations and is being used for a wide variety of activities, including strengthening national public health surveillance systems, enhancing outbreak containment and virus eradication in animals, improving non-medical responses to pandemic flu, and strengthening health system capacity. We are also playing a leading role in developing the WHO global pandemic influenza action plan, which will increase the availability of vaccines for a pandemic, including for developing countries.

It is also vital to encourage engagement and research across veterinary and human health sectors globally, in support of what is known as a “One World, One Health” approach. A number of UN system agencies and the World Bank have launched a strategic framework, Contributing to One World, One Health. This applies the lessons learnt from avian influenza to emerging infectious diseases at the animal, human and ecosystems interface. The UK has played an active role in developing this framework and will participate in discussions to be held next month in Winnipeg, hosted by the Canadian Government. These discussions will decide which diseases should be addressed and how the strategy should be implemented. The challenge will be to apply the benefits gained in our experience of avian and pandemic influenza planning to a broader range of infectious diseases, while not losing the focus on pandemic planning.

The role and co-ordination of the work of the intergovernmental organisations is key to all this, as the report points out many times. Our view remains that there is evidence of strong liaison between the various international bodies in disease surveillance at the animal-human interface. However, global co-ordination in pandemic preparedness planning more generally could be improved. The UK’s international strategy on pandemic influenza commits us to bringing together the key international organisations working on pandemic flu preparedness in order to promote improved co-ordination and synergy. I hope this will confirm to my noble friends Lord Soley and Lady Whitaker that the Government take this very seriously indeed. We will host this meeting in June.

In June the Government published a new AIDS strategy, which underlines the UK’s commitment to continued global leadership on AIDS, and to the goal of universal access to comprehensive HIV prevention, treatment, care and support by 2010. Achieving universal access is a global commitment. Responsibility for making progress towards it lies with national Governments, supported by effective partnerships of bilateral and multilateral agencies, as well as civil society and the private sector. International agencies have played a key role in recent successes on AIDS, as already mentioned by the noble Lord, Lord McColl, but it bears repetition. For example, the Global Fund to Fight AIDS, Tuberculosis and Malaria has played a key role in a 20-fold increase in funding, from $485 million in 1997 to $10 billion in 2007, and has helped AIDS treatment increase from 100,000 people in 2001 to 3 million in 2008. There have been challenges too, but the AIDS response has helped to sharpen focus on approaches that can help. The noble Baroness, Lady Eccles, and the noble Lord, Lord McColl, quite rightly also drew our attention to the need for changes in people’s behaviour and the impact of HIV and AIDS on women and children.

The UK Government played a key role in the launch of the multi-stakeholder global malaria action plan in September. I do not apologise for using all these terms and acronyms because this report, as everybody has mentioned, is absolutely full of such terms. The UK contribution, which was announced by the Prime Minister, includes 20 million bed nets by 2010; increased funding for research and development of up to £5 million by 2010; and £40 million over two years for the affordable medicines facility to increase access to the latest and best malarial drugs. This ambitious programme needs active and co-ordinated participation by intergovernmental organisations if it is to succeed.

The committee rightly recommended that we continue to promote integrated strategies for combating TB and HIV. This Government are committed to tackling HIV and TB co-infection and recognise the need to upscale efforts to deliver universal access to TB and HIV prevention, treatment, care and support services by 2015, as well as to increase investment and facilitate research to promote the development of better tools for prevention, diagnosis and treatment of TB. DfID’s AIDS strategy supports the integration of HIV and AIDS and DfID has made a significant commitment to spend £6 billion over seven years to 2015 to strengthen health systems and services. This includes the integration of HIV and TB services.

All this must be set in the context of progress against the health-related millennium development goals. In July 2007 the United Nations Secretary-General and the Prime Minister launched the MDG “Call to Action”, encouraging the international community to accelerate progress to reach the millennium development goals. The subsequent United Nations high-level event in September 2008 saw countries, charities, foundations and businesses pledge $16 billion to help reach the goals. I am very happy to hear from the noble Lord, Lord McColl, of his party’s support for all this activity. I add one small partisan point: I welcome the turnabout of the Conservative Party in its policy on international aid, but it is slightly rich to suggest that this Government, with their record, will be reducing their commitment in any way.

We are keen to track the implementation of the actions announced at the high-level event and to maintain the momentum and focus that the event produced to get the MDGs on track. We also want to support the resolution already proposed by the UN Secretary-General and the President of the General Assembly on the MDG review summit in 2010. The high-level event also saw the launch of the Taskforce on Innovative International Financing for Health Systems, co-chaired by the Prime Minister and the president of the World Bank. The task force will explore new sources of finance to help developing countries achieve the health MDGs.

International organisations are at the heart of the response to the challenges of protecting UK health and of meeting the MDGs. But, as the report made clear, the very complexity and fragmentation of the international health architecture makes it hard for Governments, especially those in the developing world, to use these resources as effectively as possible; this is the labyrinth referred to by my noble friend. The Government are committed to help to deliver a more rational, effective and efficient health architecture, better at protecting the health of England and helping developing countries to achieve the MDGs.

In the global health strategy we commit to working with the WHO and other UN agencies to consolidate existing funding flows to the UN so that we have fewer and more effective agreements, to supporting consolidated UN country programmes in developing countries, to providing incentives to UN organisations to work together and to setting these organisations stretching targets that deliver results and value for money.

I will give three examples of how we are putting this commitment into practice. First, the International Health Partnership was launched by the Prime Minister in September 2007. It seeks to build stronger health systems by applying the Paris principles on aid effectiveness to the health sector. The International Health Partnership will play a vital role in bringing agencies together. From the developing country perspective, it is the organising framework to ensure the most effective and sustainable allocation of resources, both domestic and external.

Secondly, there is the UK WHO institutional strategy. We have now finalised our institutional strategy on the WHO; it sets out how we will work with the organisation between now and 2013. The document is on the Department of Health website. This joint strategy, which was agreed between the WHO and three government departments—the Department of Health, DfID and the FCO—takes on board many of the recommendations in the report.

For example, the strategy commits us to streamlining some of the funding that we allocate for the WHO in line with performance against agreed priorities. It sets specific indicators and targets for delivery to improve the monitoring of the agency’s performance. As part of this process, DfID is making additional funds available on a performance-related basis to the WHO at 10.3 per cent of baseline funding this year and 18.7 per cent next year. The UK gave $358 million to the WHO in 2006-07, which makes us the organisation’s second largest donor. The institutional strategy is key to holding the organisation to account for that funding and improving its performance.

The third example is our support for the WHO’s work on partnerships. A number of global health partnerships are hosted by the WHO, and it is involved in many others. This year’s World Health Assembly will consider a report on the WHO’s approach to these, including the criteria to help the organisation to decide whether to get involved in new partnerships and, if so, what the organisation’s involvement should be. We are pleased that the WHO is looking at this complex area, and we will work closely with it to get this right.

I shall now address some of the specific questions raised by noble Lords. My noble friend Lord Soley talked about vertical versus horizontal health system strengthening programmes. I thought that he explained it with great eloquence. It was new to me when I read the report, and I found it very interesting indeed. We agree with my noble friend that both vertical and horizontal support are essential; it is not a question of either/or. The World Bank has an important role to play in both, and we agree with the committee that the bank needs to invest in health infrastructure in collaboration with other players in the health field. That is our approach to the World Bank on this issue.

My noble friends Lord Soley and Lady Whitaker and the noble Baroness, Lady Barker, raised the issue of surveillance for human disease and what the OIE does in it regard. I have already said that we think the system works quite well, although we continue to push generally for improved surveillance in countries and for co-ordination internationally.

My noble friends Lady Whitaker and Lord Desai both mentioned the work of the Commission on Social Determinants of Health led by Sir Michael Marmot. The UK is very active in this area. Late last year it hosted a global conference opened by the Prime Minister in order to take this work forward. I am pleased to say that we sponsored a resolution at the recent executive board meeting of WHO member states and we are determined to see progress in this area.

The noble Lord, Lord Crisp, raised two main issues which I am pleased to be able to respond to. I thank him for his comments on using UK expertise to support health systems in developing countries. His own report in this area has been very influential. The implementation of this report’s recommendations, now being taken forward by DfID and the Department of Health, is a great example of cross-government work. The noble Lord will have direct experience of the need for this. On our global health strategy, which he mentioned, we have a commitment for the Health Protection Agency to also develop its international role along the lines he suggested. We agree with his point on innovative staffing. The key is to get the most appropriate workforce where it is needed.

My noble friend Lord Desai called for more co-ordination. His remarks echo those of most noble Lords: this is a great challenge. He also mentioned the issue of the sovereignty of resources getting in the way of preparedness. The WHO is currently taking forward an intergovernmental process to improve the system for sharing influenza viruses with more equitable access to benefits such as vaccines. The UK strongly calls for all countries to share their influenza viruses, so to speak, to enable risk assessment and to transfer this to the manufacturers of vaccines for viruses.

I agree with the analysis made by the noble Baroness, Lady Barker, of the links between climate change and health issues. She is absolutely right. She asked what we were doing to support developing countries integrating the animal and human surveillance systems. So far we have pledged £35 million to help developing countries do this, £20 million from DfID over three years channelled through multilateral agencies, such as the WHO. I have a list here of about seven other acronyms, but you get the gist. We will reprioritise DfID’s country aid programme if we are requested to do so. We aim to determine how best to contribute to improving an animal and human surveillance system for the HPAI in vulnerable areas of the world. We want to continue working with partners on virus-sharing and better distribution of benefits, and to consider further funding once the strategic framework has been agreed in Canada at the conference I referred to.

I am grateful to the noble Lord, Lord McColl, for his specific question about the quantities of antiviral available to eliminate an outbreak of flu pandemic. The UK will have enough antiviral available to treat 50 per cent of its population by the end of next month. A 50 per cent attack rate is, noble Lords will appreciate, the worst-case scenario for the next pandemic based on previous pandemics this century. The World Health Organisation has an antiviral stockpile donated by manufacturers amounting to 5 million treatment courses which can be used to contain the pandemic wherever it started, so it can be got to wherever it is needed. I think the noble Lord won the prize for the yuck factor in this debate with his very eloquent and informed description of the treatment of chickens.

As we might have anticipated, a debate led by my noble friend, with contributions from distinguished colleagues around the House, is one of the highest quality. It has taken forward the thinking on this vital issue, and I hope that my noble friend recognises from this response how seriously the Government take the issue and how grateful we are for the committee’s work. I thank all noble Lords for their excellent contributions today.

My Lords, I thank everyone who has taken part for their constructive and very supportive comments. I thank the Minister for clarifying the Government’s position on the World Bank and investment in health infrastructure and for indicating the importance which the Government attach to moving forward on the animal health/human health issue, which is so important. I thank the noble Lord, Lord McColl, for building on the comments of the noble Baroness, Lady Eccles, about prevention. He gave some figures concerning Africa of which I was not aware. I found them very useful. Like my noble friend on the Front Bench, I was struck by his comments on the treatment of chickens when they are slaughtered. For a while I thought he would do for chickens what Edwina Currie, when MP and a Minister, did for eggs with her comment on salmonella. Fortunately, he navigated those narrows quite well and he has given people like me a culinary lesson, which I shall bear in mind: I should be more careful when using a chopping board for chicken and vegetables.

The noble Baroness, Lady Barker, mentioned other diseases. The issue is how we look at intergovernmental organisations. She is absolutely right about the need to look at other diseases, but we had to take an example to fit into the key question for a committee of this type about how we use intergovernmental organisations. I am beginning to think that if we continue with such a committee in the future we may need to find a title which suggests the UK's expenditure on intergovernmental organisations. That is the key. If you end up looking too much at the disease as opposed to the intergovernmental organisation itself, you will do what many other committees could do either in the House of Commons or here, and I am anxious to avoid that. The noble Baroness’s comments are well made. I beg to move.

Motion agreed.