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Sub-Saharan Africa: Healthcare

Volume 764: debated on Thursday 16 July 2015

Question for Short Debate

Asked by

To ask Her Majesty’s Government what assessment they have made of lessons that can be learnt from the outbreak of Ebola in Sierra Leone regarding the strengthening and development of sustainable healthcare systems in Sub-Saharan Africa.

My Lords, I draw attention to the relevant entries in the Register of Members’ Interests. In particular, I am adviser to Gilead Sciences Inc, chair of Christian Aid’s In Their Lifetime Appeal and a trustee of the Planet Earth Institute. When I was fortunate enough to have my Question chosen, I had hoped that the debate would take place in the context of an end to the Ebola crisis, an end to the outbreak in Sierra Leone and that the last case would have been reported. Sadly, that is not the case and Ebola is still very much with us.

Lawrence Summers, the distinguished economist and a former Treasury Secretary in the US has described Ebola as a “stress test” on national health systems. Sierra Leone, Liberia and Guinea have clearly been found wanting. They simply could not cope. There were too few trained health professionals, too little equipment, too few supplies and too little capacity for public health surveillance and control. It is a stress test that the world cannot afford to fail, and a stress test that in some ways the WHO did fail, and the world was threatened. I suspect that if the perception of the threat had continued as it was at the outset of the crisis, more attention would be paid to the subject in our media and elsewhere today. But we are where we are.

The threat to the rest of the world is seen by all too many in the rest of the world to have passed and the circus is already beginning to move on. There is a sense that Ebola is yesterday’s story. As those who are attending today’s debate understand, that is not the case: it is still an ever-present threat and danger. This debate is particularly timely as it takes place at the same time as the world’s leaders, including our Secretary of State, are considering the future funding of development and the millennium development goals in Addis Ababa. Their considerations will have a considerable bearing on our success or otherwise in responding more effectively to the test that Ebola has presented to the health systems of west Africa and the wider world.

However, it is worth noting that a real contrast is to be drawn—Lawrence Summers draws it—between what happened in Sierra Leone, Liberia and Guinea, and what happened in Nigeria where, to a certain extent, the stress test was passed in at least one respect. Nigeria’s response to Ebola was able to be characterised by the WHO as,

“a piece of world-class epidemiological detective work”,

which it was. It was able to launch a response of aggressive, co-ordinated surveillance and control, using a system for Ebola that it already had in place for polio. That enabled Nigeria to have a response that was not able to be replicated in Sierra Leone, Liberia or Guinea where the health systems, for a variety of reasons, were already substantially degraded and underfunded. In Sierra Leone, that was most obviously because of the conflict from which it was recovering and from problems associated with that, including investment in health, healthcare and governance.

In the Lancet Lawrence Summers, building on his 2035 commission report, put the cost of health systems strengthening in the developing world at around,

“$30 bn a year for the next two decades”.

He identified this sum,

“through a combination of aid and domestic spending”,


“well under 1 per cent of the additional gross domestic product that will be available”,

from the expected growth in low and middle-income countries during the next 20 years, so that $30 billion is affordable. He goes on in the report to identify a lack of investment in public health and a lack of innovative research and development in the field of infectious diseases that affect the poor as having contributed to the crisis. We have an opportunity at this time, at the conference in Addis and the upcoming conference in New York, to do something about it.

Save the Children has estimated that the cost of dealing with the Ebola outbreak has been nearly three times the annual cost of investing in building a universal health service in all three affected countries. We have to ensure that the world learns the lessons of the crisis by a renewed focus on supporting systems of universal health coverage in the developing countries of sub-Saharan Africa. Will the Minister please tell us what steps the UK Government are taking to promote universal health coverage to give developing countries the resistance to contain this kind of outbreak in the future?

I recognise that no one-size-fits-all approach is either possible or necessary to address the issues of developing universal coverage. No one is suggesting an NHS in every country, as if one were promoting a chicken in every pot. It is much more complicated than that but there is inevitably a need for a mix of public and private, such as a role for insurance-based systems. All that has a role to play but there is at the end of the day a need for an irreducible minimum. That is, a recognition that there are some public goods the provision of which requires a role for Governments, with properly resourced departments of health, science and higher education working together with the support of ministries of finance across government to mobilise all the relevant departments in developing sustainable, effective healthcare systems that are backed up by assertive policies for public health and which tackle the root causes of the outbreak of such pandemics.

There is a need for adequate funding mechanisms and cross-sectoral work, led by finance ministries whose streams of work programmes are not dependent on the vagaries of external funding but rooted in a local set of priorities, determined locally and with a focus on value for money, local accountability and meeting the needs identified through the grassroots participation of the citizenry, who are essential to effective public health responses. All the evidence shows, as Christian Aid has shown on the ground in Sierra Leone, that you get a better response when you mobilise communities —when you work with traditional healers and leaders, alongside community healthcare workers and others, all to develop a response that is firmly rooted in communities, reflects their priorities and is capable of winning their support and confidence. It is that challenge to trust and confidence, and the lack of those now in institutions and Governments, which is one of the greatest casualties to have emerged from this crisis. It needs to be restored.

Underpinning all that work are adequate flows of revenue and resourcing which are not solely dependent on aid and development assistance from donors but rooted in the need to do better at revenue-raising locally and make sure, for instance, that we address issues and failures in the collection of revenue from extractive industries. That was a recommendation from the Select Committee of the House of Commons. There is also the need to make sure, as the Prime Minister has emphasised in a number of his interventions in this area, that we do better on illicit flows between jurisdictions and the loss to country revenues as a result of companies actively arranging their affairs and individuals to avoid tax.

So all those issues, and the response to them, need to be examined if we are to learn the lessons of this crisis. How do the Government intend to implement the Select Committee’s recommendations on improving DfID country funding and bilateral in-country assistance programmes? How do they intend to ensure that local communities are involved in that?

Finally, we need to ensure that we address an all too often neglected area of development policy—namely, the role of science and research and development. We need to make sure that diagnostic institutions and laboratories are established to build on the lessons we have learned from the Ebola crisis, and we must take account of the lack of trained personnel. The Ebola epidemic has decimated the health workforce in Sierra Leone. There are too few doctors to ensure effective recovery from the disease. The total absence of postgraduate medical training in Sierra Leone bedevils an effective response and the whole healthcare system in that country, rendering it unable to train its own doctors in-country. Will the Minister agree to receive a delegation from the Royal College of Paediatrics and Child Health, which has come forward with a proposal to address this need which it has forged, together with its partners in Sierra Leone, and other institutions in the United Kingdom, including King’s College? So we have a crisis and a problem but also an opportunity to ensure that we put in place mechanisms that not just end the present suffering but avoid the possibility of yet further suffering in the future.

My Lords, I thank the noble Lord, Lord Boateng, for introducing this very important debate. It is a pleasure for me to pay tribute to the more than 1,000 UK health workers who have volunteered to go to Sierra Leone to help combat the terrible Ebola virus. Eradication of this virulent disease presents particular cultural challenges as well as the need for rigorous medical practice. That is what makes it special.

The UK has made a tremendous contribution to the global effort due to three things: first, the willingness of so many generous skilled people to go to Africa to help others; secondly, the preparedness of the UK to help in such medical and disaster emergencies due to the training and care programmes for volunteers of the UK International Emergency Trauma Register; and, thirdly, the support for the campaign offered by DfID, the Department of Health and the NHS.

That support has been vital in providing the cash and facilities necessary to ensure that the volunteers are well trained, well supported and well cared for on their return. It is a tribute to the rigour of the systems that UK-Med and its NGO partners have put in place that only a handful of UK health workers in Sierra Leone have contracted the virus. Thanks to the quality of care that they have received, they have, thankfully, survived.

Currently, despite a small resurgence in the disease that the noble Lord mentioned, the support that the UK has given to developing local health services has meant that UK-Med and the International Emergency Medical Register are not looking for any more UK volunteers for the Ebola programme at the moment. In a way, that is encouraging, because it means that the local health services are sort of coping. Sadly, it is clear that the outbreak was so serious in the first place because the health system in Sierra Leone and the other victim countries was broken. However, local health services need to be forever vigilant, since rapid response to any small outbreak will be vital to ensuring that the outbreak is contained. So perhaps I could ask the Minister what the UK is doing to ensure that the improvements in local health services are maintained and taken even further, as the noble Lord demanded.

As for the NHS, we need to help the organisation to be geared up for releasing staff for this important work and other medical emergencies that will arise in future. We must remember that, by building a capacity to respond to health emergencies overseas, we increase our own capacity to respond nationally here at home at the same time. Following Ebola, we now have a cadre of NHS staff who have first-hand experience of treating and caring for patients with a highly contagious and lethal condition, exercising full barrier nursing and care. This will be a huge advantage when we have a major outbreak of what is likely to be an airborne infection in this country. We constantly hear about new virulent strains of influenza, for example, and the travelling habits of the world’s population make it inevitable that they will reach our shores sooner or later. Not only are these well-trained former volunteers a direct asset themselves but they can also train their colleagues wherever they work, so that these difficult cases can be managed safely and effectively.

By responding to Ebola and, indeed, earlier medical emergencies, we have built a national emergency healthcare workforce, which can quickly be mobilised to respond to emergencies overseas but is equally available for emergencies in this country, should we need it. What is to be done to ensure that we continue to have that workforce? Three initiatives have been suggested to me by Professor Tony Redmond, a trustee of UK-Med and professor at Manchester and Keele universities, to help to strengthen our response readiness.

First, on humanitarian posts, as he points out there is a great deal of altruism within the NHS and many staff wish to volunteer to help vulnerable people in other countries. However, they can find it difficult to take a break from their job, so he proposes that humanitarian posts be established in specialties and areas where it is difficult to recruit and therefore there are vacant posts. Those who take these posts will be guaranteed a period each year where they can be seconded to work overseas, either in an emergency or to help to build the capacity in vulnerable countries to which the noble Lord, Lord Boateng, has referred.

Secondly, there should be cross-trust volunteering. At present, it is difficult to work across two NHS trusts when you are not formally employed by both. The suggestion is to establish an agreement across the NHS so that volunteers who are on the register and appropriately trained and accountable can also deploy as cover across different trusts when teams are deployed overseas. This volunteering to cover for colleagues should have equal recognition with those who actually go overseas. This would also strengthen the UK’s resilience in the event of a major outbreak or mass casualty event at home.

Thirdly, volunteering needs to be incorporated into job plans and appraisals. As I have highlighted, many staff in the NHS are already engaged in volunteering to help support more vulnerable countries and also support the emergency response to disasters overseas, but this work is not recognised in training or in professional development and appraisal. Not only does volunteering help some of the most vulnerable in the world, it also increases overall job satisfaction, because healthcare workers, by and large, enjoy the opportunity to exercise their altruism. Most importantly for the UK, volunteering builds up very relevant skills and experience in managing conditions in difficult circumstances, managing resources effectively, and being exposed to a wide range of conditions and diseases that are rarely seen in the UK but which are important to recognise and to know how to deal with when they occur. The All-Party Parliamentary Group on Global Health has produced a very good document on volunteering and Professor Redmond and his colleagues would look for its recommendations to be widely supported.

I would like to ask the Minister whether the Government will consider these proposals and let your Lordships know whether they will be supported. I know that the NHS is keen to have a positive legacy from its response to the Ebola crisis. By facilitating volunteering overseas, that legacy will be strengthened. However, it is vital that, for volunteering to be safe, effective and of true benefit to the countries to which volunteers are invited, those volunteers are fully trained, insured, vaccinated, accountable and registered to practise in the relevant country. All of these things are promoted and facilitated through the International Emergency Medical Register.

Finally, I will say just a word about those left behind after the Ebola outbreak. I understand from recent research that the number of women who have been widowed by Ebola is considerable. Many have children but find themselves unable to look after themselves, let alone their families. Widows and their female children are often left in particularly vulnerable situations. Reports in the media highlight the disproportionate effect that the situation is having, as it unleashes secondary effects on economic and social development, all of which have harmful implications for women and girls. The charity Street Child reports the story of a young girl who, on the death of her father, became pregnant when she sold herself for sex in order simply to get food for her family. Widows can also face further hardship and abusive practices, such as losing their property and being shunned by society because they have no man to protect them. Therefore, I ask the Minister whether the Government are adding something to address these problems to the very significant medical programme that they have launched to eradicate this disease. Ebola will never be yesterday’s story for these people.

My Lords, I congratulate my noble friend Lord Boateng on having secured this debate and introduced it so effectively. I hope that I am not the only person present who feels distressed that there are so few contributors, as the Ebola epidemic still causes devastation across west Africa. As I discussed in a previous debate, the social and economic impact of the Ebola epidemic in Sierra Leone has been particularly severe. The country went from having one of the fastest-growing economies in the world to one that has shrunk by fully 25% of GDP. Rebuilding the healthcare system will require a great deal of direct financial aid, which can come only from the international community. In turn, a viable healthcare system cannot be built unless there is a sustained economic recovery.

The backdrop to this is not encouraging. We live in the most interdependent world ever. There was a point when people in many countries were perturbed about the Ebola outbreak. However, this is not a world that has effective global governance; the United Nations is probably at its weakest ever. In many fields one finds that pledges are made but no money is forthcoming. My great worry is that this will also be true in the case of the Ebola outbreak.

A meeting of the UN last week saw pledges of $3.2 billion to help the recovery in the three countries most directly affected by the epidemic. As the Minister will remember, I mentioned in a previous debate that the World Bank has pledged $1.62 billion. I ask, again, whether she knows whether those figures have any reality. To me, as someone who works on climate change, they sound eerily like the $100 billion a year that developed countries have pledged to the poorer counties of the world to help alleviate the effects of climate change. Virtually none of money has ever become real; this must not happen in the case of the Ebola epidemic.

Zoonotic diseases are on the increase in Africa and are in fact connected with climate change—the chief connection is deforestation. They can cause havoc and have global implications. As the noble Baroness, Lady Walmsley, mentioned, Ebola could have become a worldwide pandemic if it had happened to be an airborne virus. In Africa, the impact of the Ebola epidemic overlaps heavily with diseases that are already putting great strain on existing healthcare systems. Sub-Saharan Africa suffers from the crippling effects of HIV/AIDS, malaria and tuberculosis. Over three-quarters of total malaria cases across the world are located in Africa and over 90% of malaria deaths occur in that continent. More than 20 million Africans are living with HIV/AIDS, a staggering number, although, it has to be said, about 70% are now obtaining antiretroviral treatment.

While most attention has naturally been concentrated on the three countries that have borne the brunt of the Ebola epidemic, states not directly involved in the epidemic have also been deeply affected, again with major economic consequences. For example, a recent survey of holiday operators found a decline of up to 70% in bookings, primarily because of fear of Ebola, including for countries quite remote from those directly affected, such as Kenya, South Africa and Mozambique. The overall knock-on effect economically, morally and socially across large areas of Africa has therefore been profound—and continues to be so.

If the Minister can overcome her terrible malady, I have three further questions to ask her. First, everyone now accepts that the response of the international community to the Ebola outbreak—and especially that of the UN agencies—was too slow and fragmented. What are the main reforms that the Government would like to see put in place before the next potential global pandemic? We are in a situation where everybody is drawing lessons but the theorem that I mentioned at the beginning applies. These are mostly abstract; it is hard to see where the beef is—where the substance is. This is really dangerous, I think, for possible future pandemics. Any information that the Minister has on that point would be valuable. What would be the best reforms to produce a more effective response on the part of the international community to the next global pandemic? Any such pandemic will likely be zoonotic, as I have mentioned, but could be much more lethal.

Secondly, there has to be a step change—as I think the noble Baroness, Lady Walmsley, mentioned—in the training of medical personnel. When the epidemic started, Sierra Leone had only one doctor for every 70,000 people; compare that to Britain, where there is one doctor for every 360 people—and now they are going to have to work seven days a week. How could this process happen quickly? I cannot see any way except by the sustained involvement, again, of the international community, which means medical personnel being in the affected countries and surrounding countries for a sustained period—at least five years further. What contribution will the UK make to that and has it got that kind of timeframe? To me it seems absolutely necessary.

Thirdly, however, I think that there is a theorem of hope around. This is a period of fundamental innovation in medicine, largely because of the digital revolution. For the first time ever in human history, I think, cutting-edge technology is going directly to the poorer countries of the world. A major example is mobile phones and smartphones. The case of Nigeria, which my noble friend Lord Boateng quoted, is really interesting because Nigeria contained Ebola partly by means of text messages sent directly to millions of citizens daily to alert them to the actions needed so that the disease did not spread. This would not have been possible even 10 years ago.

We know that in Africa it has been possible to produce a kind of leapfrog effect with mobile phones—that is, African countries have gone directly to a phone system without having the stage of fixed telephone lines. It is possible that the same thing could happen with medical treatment if there is an effective response by the international community. In other words, that community should continue to bring front-line treatments, even experimental treatments that have not been fully tested, to west Africa and other parts of the continent potentially affected. It is at least conceivable that there could be a kind of breakthrough effect, because it is not just a matter of training medical personnel. If we could bring medical innovation on a large scale on that kind of model directly to poorer countries in Africa, it could be transformative in its potential impact.

My Lords, I, too, thank the noble Lord, Lord Boateng, for securing this important debate and introducing it so effectively. The last time we debated this issue in the Lords was, I think, in a debate put down by the noble Lord, Lord Fowler, at that time my noble friend, and I was fortunate to be the DfID Minster replying. In that position, I was privy to the absolutely outstanding efforts made by DfID to counter this epidemic in Sierra Leone.

Ebola illustrated, in the most appalling way, how we are all interconnected. Not only did we have a moral responsibility to respond to what was happening in Sierra Leone, a country in the development of which we played such a key role after its civil war, but it was and is in our self-interest to do so. We are all so interconnected globally that an epidemic such as this can easily move across continents, as we have heard, out of control. When that patient arrived and died in Nigeria, the world was fortunate that a nurse, in effect, gave her life ensuring that this patient was not allowed to leave the clinic, with appalling consequences for the nurse herself but astonishing protection for the people of Nigeria and the wider world. Indeed, they used the system for polio, but it was helped by the first case being received in the private clinic that it was. Too easily, the epidemic could have reached widely round the world.

We were lucky too, in my view, that we had in DfID, as Chief Scientific Officer, the outstanding Chris Whitty, from the London School of Hygiene and Tropical Medicine. There could not have been a better person to set about organising the UK’s comprehensive response to Ebola in Sierra Leone.

While the US concentrated on Liberia and France led in Guinea, work was undertaken at every level. Clinics were set up locally where patients could be identified, and those with Ebola sent to dedicated units. Lab facilities were improved to speed up diagnosis. Work with anthropologists was undertaken to work out practices which enabled those who had lost loved ones to have rites of passage which did not endanger all mourners. The development of treatments and vaccines was expedited. As my noble friend Lady Walmsley said, NHS volunteers were identified and trained to work as safely as possible in Sierra Leone. I pay tribute to them and to UK-Med.

When I answered the debate earlier this year, we seemed to be within striking distance of ending this epidemic. We seemed to have done so in Liberia. I would like to know whether the cases in the three countries are traceable to other known cases, or whether some do not fall into this category. What are the implications in either case?

The World Health Organization has rightly been criticised for its tardy response, lack of resources and inappropriate personnel in the region and elsewhere. What progress can be reported? What have we learned in terms of surveillance, early warning and response systems? How do we identify and respond to potential crises in future?

The Government of Sierra Leone were understandably keen to be supported as they rebuilt. Are we ensuring that such rebuilding is fully transparent and accountable? There was huge concern that other patients —for example, those with malaria—did not come to clinics lest they were infected with Ebola, and that vaccination and treatment for other diseases fell away. Will the noble Baroness give an estimate of the associated mortality and tell us what is being done to address this?

There has been huge concern, as others have mentioned, that children spent a long time out of school. What is being down to ensure that they make up for lost time? What is being done to support orphans, who have been mentioned? How are we best supporting women and girls, given that they are especially vulnerable, as my noble friend Lady Walmsley pointed out? The International Development Select Committee and others expressed concern about the weakness of the health systems that allowed the epidemic to take hold, and concern that these should now be strengthened. Like the noble Lord, Lord Giddens, I want to know what is being done to address that area. It is one thing to intervene in a humanitarian crisis like this, with popular support, but it is quite another to sustain long-term investment. What is the financial size of the commitment being made by DfID?

I would appreciate an update on treatments and vaccines. It was excellent that in the crisis, because of the work after 9/11, particularly by the Americans, there was some progress which could be built on. I would like to know how the vaccines from the UK, especially from the Lister Institute, have been faring. There was the proposal, of course, that we should take a shared public risk in developing these. Clearly, on the one hand, this could be an opportunity for drug companies to avoid their responsibilities. On the other hand, there could be a public good involved. The Minister’s noble friend, the noble Lord, Lord O'Neill, has discussed such public pooling of risk in relation to the development of antibiotic-resistant drugs. Where are we in relation to Ebola treatments and vaccines? How do we protect from abuse by the pharmaceutical industry in this area? Are there proposals for delivering more rapidly clinical trials in this field? How might production be scaled up and adequate delivery put in place? What work is being carried out to assess other potential disease threats which may quickly cross borders in our globalised world?

I came across one bright note in relation to Ebola. Sierra Leone has a high incidence of FGM. From what I understand, in the civil war this stopped. It re-started thereafter. I heard that it stopped again in the Ebola epidemic. It seems to me to be vital—this is what I urged and I want to know exactly what we are now doing—that we build on that change. We cannot allow things simply to return to normal. If we can change people’s burial practices, surely we can, and must, address this terrible practice as well.

I would also like to ask what lessons have been learned about the deployment of NHS staff. UK-Med seemed to do a remarkable job. Like my noble friend Lady Walmsley, I pay tribute to it. I am sure that it will be learning lessons, which we will need to apply in other humanitarian emergencies. I look forward to the Minister’s response and pay tribute again to the astonishing efforts of those right across DfID, but especially Chris Whitty, Tony Redmond from Manchester and George Turkington and their teams, for their tireless work in tackling this disease.

My Lords, I, too, would like to thank my noble friend Lord Boateng for initiating this debate. It was only a few weeks ago that we had a debate on this subject; nevertheless, I am extremely grateful that my noble friend has raised this issue again because it gives us the opportunity to focus on key priorities as we move forward. As my noble friend and all noble Lords in today’s debate have stressed, the main lessons from this outbreak relate to the strengthening of health systems, increasing the number of primary healthcare staff, improving their training, building scientific capacity in diagnostics and public health laboratories and supporting public health messaging and outreach generally. These are all topics that we touched upon in the last debate but I want to come on to some specific points.

I, too, have previously acknowledged the Government’s incredibly positive response to Ebola on the ground and the incredibly significant role of British volunteers and their bravery. In the previous debate I mentioned how much I appreciated the Government recognising their courage with a medal.

As we have heard from my noble friend, over decades Sierra Leone has had insufficient investment in its health systems. Universal health coverage can make countries more resilient to health concerns such as Ebola before they become widespread emergencies, as highlighted by my noble friend. I therefore welcome the clear commitment given in recent debates by Ministers—the noble Baroness in particular—to support universal health coverage, free at the point of access, in the language of the health goal in the SDGs. I welcome their commitment to this in the forthcoming New York negotiations in September.

Like the noble Baroness, Lady Northover, I think that we are extremely lucky to have someone like Professor Chris Whitty and I have attended many of his briefings about the crisis. In recent briefings he particularly stressed the impact of Ebola on other diseases. That is one of the key lessons for us to focus on. It is clear, as my noble friend Lord Giddens said, that gains made against malaria are at risk as health systems are pushed to breaking point and people avoid using them because they fear contracting Ebola. Many children have missed out on routine vaccination services since 2014. Modelling by the Johns Hopkins Bloomberg School of Public Health on the long-term impact of Ebola on routine immunisation suggested that as many as 1 million children could miss out on measles vaccinations as a result of the knock-on impact of Ebola.

One of the big issues affecting immunisation has been trust in the health service, another issue touched upon in today’s debate. Rumours circulating in the region have falsely claimed that childhood vaccines, such as those protecting against measles, pneumonia and diarrhoea, could be linked to Ebola. Tackling that misinformation is key. This has dealt a severe blow to immunisation coverage, with parents refusing to allow their children to be immunised against common but potentially fatal conditions, leaving hundreds of thousands of children at risk. Additionally, as we have heard from all noble Lords, hundreds of health workers in the three countries were among the 10,000 people who lost their lives to Ebola during the crisis and many were forced to abandon their posts as the epidemic took hold. As the three countries begin their return to normality, there is now a severe shortage of trained health workers to administer vaccines, let alone carry out other primary care work.

In her written response following the recent debate, which I managed to get this afternoon and which was quite helpful, the Minister outlined the immediate steps that were taken to reinstate basic healthcare as safely as possible. Picking up on the point made by the noble Baroness, Lady Northover, could the Minister set out for us today the longer- term strategy to develop more resilient and sustainable health services, particularly in Sierra Leone? What steps have been taken by the department to support the Government of Sierra Leone in developing a comprehensive strategy aimed at supporting communities to recover from the crisis and to put the country back on track to meet all the development targets that it has? Can the Minister tell the Committee whether the department, in considering the lessons of the outbreak, has examined the impact of previous changes to funding commitments to Sierra Leone? In doing so, can she tell us whether the department has reversed or rethought any planned funding cuts?

One other clear lesson on the outbreak highlighted by my noble friend Lord Boateng has been the role of community engagement—another issue that we touched on in the previous debate. I welcome the noble Baroness’s written response in relation to this, particularly on the Social Mobilisation Action Consortium, which brought together BBC Media Action, Centres for Disease Control, GOAL and Restless Development, all funded by DfID. In the debate I touched on the issue raised by the noble Baroness, Lady Northover, about the lessons in terms of FGM. I am disappointed with the written response on that. I know—I share the concern of the noble Baroness, Lady Northover—that there are huge cultural issues but if we were able to address the issue and raise awareness during such a difficult period, surely we need to ensure that we continue with that and not back away from it.

It is important that we ensure this work continues and is extended to enable civil society organisations to work with communities, to hold meetings, to brief village chiefs and, as my noble friend said, to work with religious leaders not only on basic health issues but on the importance of immunising children. We also need to ensure that there are enough trained health workers to provide the vaccines to the children.

Last week I met with Dr Seth Berkley of Gavi, the Vaccine Alliance. Unfortunately I could not attend the briefing organised by the noble Baroness, Lady Northover, but I was able to meet him separately. He made clear that as the initial Ebola epidemic recedes we face a race against time to prevent outbreaks of other dangerous diseases by ensuring that children receive the vaccines they need to protect them. That is a key element of restoring trust. Rebuilding trust among parents and carers is critical, as is ensuring that they are provided with the services they need to protect their children.

My Lords, I apologise for my coughing and spluttering throughout the debate. I tried hard to keep it under control but sadly have failed.

I join noble Lords in thanking the noble Lord, Lord Boateng, for securing this debate and I commend his long-standing commitment to international development. I thank everyone who has contributed today and pay tribute to the recognition that noble Lords have paid to DfID and its work and to the great work that volunteers and the National Health Service have also contributed.

As noble Lords are aware, we have played a major role in Sierra Leone and the region in tackling Ebola. It is good that we have come together to discuss the lessons that can be learned from the outbreak in regard to the strengthening and development of sustainable healthcare systems in sub-Saharan Africa.

There were a great number of questions. I hope that my contribution will answer some of them but I fear that time will beat me to it. I therefore undertake to write to all noble Lords by addressing a letter to the noble Lord, Lord Boateng, sending a copy to all noble Lords and placing a copy in the Library.

New cases of Ebola have reduced from 500 per week in November 2014 to around 10 to 14 per week at the last count we have been given, which was 12 July. The UK showed incredible leadership, mobilising the international community and supporting the Government of Sierra Leone to halt Ebola’s spread. I join all noble Lords in paying tribute to the British, Sierra Leonean and other health workers who tackled this disease on the front line.

There are many lessons to be drawn from this unprecedented event. We are committed to identify them and use them to inform and reform, both inside the UK and with international institutions. We have called on the World Health Organization to up its game, securing reforms at the WHO executive board in January and the World Health Assembly in May. Dame Barbara Stocking reviewed WHO’s systems for responding to health emergencies and the UK agrees with her report’s recommendations. The noble Lord, Lord Boateng, said in his very eloquent contribution that Ebola posed a real challenge and a stress test on all health systems in Sierra Leone, Liberia and Guinea. This highlighted why we need to make sure that, in response to such crises, the World Health Organization looks at its internal systems better.

We will continue to apply pressure to improve global health security at the UN General Assembly, the World Bank autumn meetings and at the G20 update in November. The pressure needs to be continued. The European Commission has been a strong supporter of health systems in all affected countries. In particular, the Commission supports countries such as Guinea, where the outbreak started, but where the UK does not provide direct support as in Sierra Leone. The UK works as a critical partner of the Commission in Brussels and in countries, pressing it to do better.

As we identify lessons, we must remember that Ebola in west Africa is unique, as was SARS and as will be the next global health emergency. We need to be committed to improving resilience in relation to all infectious diseases. In 2013, only 10 countries were below Sierra Leone in the Human Development Index. It had the lowest life expectancy in the world. Ebola highlighted how fragile its health system was. We are committed to a “health systems approach” that helps a country organise health resources—money, workforce, buildings, supplies, services and information. Ebola shone a light on all these, but surveillance, rapid response and infection control limitations allowed the outbreak to get out of control.

We have learned three particular lessons for health systems in this respect. First, good surveillance makes the most of local context. I agree with all noble Lords that in countries with limited resources we must include local communities. People and community health workers must get basic training in what to look for. Health workers must have the right incentives to engage with local people, so that communities trust and are able to communicate with them. Communities must not fear formal health facilities.

Secondly, we have learned that health systems need capacity to respond to outbreaks fast, a functioning network of health centres and rapid mobile response teams with particular skills in managing outbreaks.

Finally, we have learned that infection prevention and control needs to be at the core of any health system. In addition to these lessons from Ebola, we have learned much about how to effectively support health systems from years of supporting health in developing countries around the world. For instance, we know from our experience that effectively supporting health systems requires a long-term approach. One reason why the UK engaged so effectively in Sierra Leone was our long-standing development partnership with the country and its Government. We also know that health workers are fundamental and in short supply in the health systems of most low-income countries. We know that they must be trained, motivated, supported and held to account.

We have learned that governance is critical. Whatever kind of health system you have—mostly private or mostly public—the Government must oversee and regulate the quality of care, and ensure that the poor are protected from poor services and financial hardship in buying services. In this respect, the UK helps by advising countries on how to finance their health systems, procure and distribute essential medicines, manage payroll systems and much more. Work to help countries build health systems needs to happen at several levels—national, regional and international. This is why we continually work to ensure that the international system is better equipped to help countries build health systems and support them in responding to disease outbreaks.

In building health systems other factors outside them are critical, including access to clean water, good sanitation and hygiene. We have learned that a good public health system must engage with private clinics. Because many people in poor countries use only the private sector, private clinics need to be informed about outbreaks when they occur. In extremely fragile states where NGOs may provide most health services, NGOs also need to be part of the surveillance and response effort. More lessons need to be learnt. I assure noble Lords that we will be taking these into account as we help Sierra Leone recover from Ebola and continue to support health in developing countries around the world.

The UK is providing up to £37 million to the health pillar of President Koroma’s nine-month recovery plan. This will support health worker and patient safety in clinics through support for staff training, water and sanitation facilities, and strengthening laboratory capacity. It will also help to re-establish basic health services through the donation of drugs left over from the Ebola response. We have also committed £13 million to help countries in the region prepare for future infectious disease outbreaks. The UK has supported more than half of all beds for Ebola patients in Sierra Leone and more than 100 burial teams, trained 4,000 front-line staff, tested one-third of all samples collected nationwide and delivered more than 1 million PPE suits and 150 vehicles. Our support will not stop there as we work to help the country get to zero and stay there by rebuilding its health system.

In the two or three minutes that I have, I will try quickly to ramble through some of the questions posed by noble Lords. The noble Lord, Lord Boateng, asked about disease surveillance, what was in place and what the UK could ensure for future outbreaks of Ebola. My department and the Department of Health are seeking greater commitment from partner countries to implement the international health regulations. These regulations require countries to put in place a national system to protect, prevent and provide a public health response to the international spread of disease and other threats. The Fleming Fund is a five-year, £195 million programme, which was announced in the Budget and will be managed by the Department of Health. We are linking up with France, the United States and the Gates foundation, which have all recently announced plans to do more on disease surveillance.

The noble Lord also asked about illicit financial flows and tax evasion. At the Addis Tax Initiative in Addis Ababa, with the United States, Germany, Netherlands, Ethiopia and others, the Secretary of State launched an initiative to ensure that we commit to doubling support for tax reform in the developing world by 2020. This initiative specifically stresses the importance of tackling cross-border tax evasion and avoidance.

The noble Baroness, Lady Walmsley, and other noble Lords asked about vulnerable groups, particularly young girls and women. We know that about 10,000 children will have lost one or both parents, or their primary care givers, to Ebola. This loss of family and protection makes them absolutely vulnerable to abuse and exploitation. We are working with UNICEF and others to set up the observation interim care centres in all districts where children can be safely quarantined if they are suspected of having Ebola, families can be found if they have become separated and counselling can be received. There is a lot of ongoing work to make sure that vulnerable people, particularly children, have the right support in place.

I have a feeling that I am running fast out of time and I am struggling to breathe. Perhaps noble Lords will agree to allow me to undertake to write. I hope that at the next debate I will not be as infected as I am now. I have quite a lot of responses to get through and I fear that time and my own energy to keep upright are failing me. I thank noble Lords.

Committee adjourned at 6 pm.