[Committee name]

International Development Committee

Oral evidence: Democracy and Development in Burma, HC 821-ii
Tuesday 17 December 2013]

Ordered by the House of Commons to be published on 17 December 2013].

Written evidence from witnesses:

Members present: Rt Hon Sir Malcolm Bruce (Chair); Hugh Bayley; Fiona Bruce; Sir Tony Cunningham; Fabian Hamilton; Pauline Latham; Jeremy Lefroy; Sir Peter Luff; Mr Michael McCann; Chris White

Questions 31-107

Witnesses: Fiona Campbell, London School of Hygiene and Tropical Medicine, Mark Foster, Commissioner, the Independent Commission for Aid Impact and Charles Nelson, Chief Executive, Malaria Consortium gave evidence.

Q31 Chair: Good morning. Thanks very much for coming in. First of all, for the record, I wondered if you could just introduce yourselves.

Mark Foster: Mark Foster, one of the Commissioners for the Independent Commission for Aid Impact and the lead Commissioner for the review on Burma.

Fiona Campbell: I am Fiona Campbell. I am a DrPH student at the London School of Hygiene and Tropical Medicine. I was most recently in Myanmar with Merlin, but I am not speaking on their behalf today.

Charles Nelson: I am Charles Nelson. I am Chief Executive of Malaria Consortium and actually previously of Merlin as well, but am working in Myanmar currently on containment strategies for resistant parasites.

Q32 Chair: Thank you all very much for coming in. You will know that the Committee visited Burma last month and had an extremely interesting and informative trip. In this session, we are looking at DFID’s engagement with the health sector. I know that ICAI was reasonably complimentary about the work that was being done, but it is a major part of DFID’s budget—nearly half of their budget for the 2012‑15 period. Of £63.4 million for that period, £45.8 million is on community and maternal health, and £17.6 million on malaria. The question that was raised with us is, given spending on health in Burma has been chronically low, although DFID has been a contributor throughout the period, whether that level of commitment is at the right level. The point that has been made to us is that, if you wanted to be transformational, it may not be big enough; on the other hand, it is rather too big to be just pilot schemes. What is your take on whether or not it is balanced right and can it be transformational at that level?

Mark Foster: First of all, as you will have recognised from your visit, the needs with regard to healthcare in Burma remain incredibly high, and the overall levels of spend by the Government, for example, remain low compared to many of the other countries in the area. In terms of the need for there to be investment in the broader health sector, that need is very clearly there and all the indicators point to continuing needs in many key areas.

What we have found from our review was that, clearly, the money that DFID had been spending had been well spent and well targeted. Indeed, the programmes and the plans—the 3MDG programme is now the major focus of activity—look also to be well targeted and working on the right kinds of things. Also, it looks reasonably well set up to have a meaningful and substantive impact, higher than the impact that has been had before, primarily because there is more funding going into that programme, but also because, with the changed nature of the relationship with the Government of Burma, and particularly the Ministry of Health, there is a chance of working and leveraging that work more effectively on the ground. There is an opportunity for that piece of work to be transformational in the areas where it is focused.

It is of course focused on a subset of the townships. The question mark is: could you do more by moving out to more townships? From our assessment looking at the picture, it would be better to say, if you could really prove you could have a real impact first of all in those places, you would feel more confident of scaling and having a broader transformational effect once that had been proven.

Chair: You would need two or three years.

Mark Foster: There is probably some time to be found. Learning how to work on the ground there and to be effective, alongside an evolving governmental system, would seem to me to be worth thinking through.

Fiona Campbell: I would echo what has been said today. I would say that DFID has been very good in the way it has used its money in terms of a transformational approach, in that it has not just delivered programmes, but it has delivered them in a way that has been building the systems and the structures. The joint initiative was a very good example, where they used the opportunity in the delta to work within the system. Okay, sanctions were in place so there were restrictions, but the opportunities that were presented in supporting midwives, in supporting their transport out into villages, showed what was possible if you do invest in a certain way. They have used the money extremely well to really show how the system can work better, and that is where the transformation happens.

As has been said with 3MDG in terms of the way it is trying to approach, yes, it is only in 42 townships but, if it can show that, in those townships, it is possible to deliver services to hard‑to‑reach areas and to vulnerable populations, then that in itself shows you what is possible if you put money in, and the money will come from other places in the future.

Chair: So you think this is about the right level of funding.

Fiona Campbell: It is a massively underfunded health sector at the moment. There is room for additional funding to go in, but where the funding is going in it is having a bigger effect than just the programmes it is supporting.

Charles Nelson: I would actually agree with the other two here that, given the sort of activities that have been going on and the restraints under which we have been having to operate inside Myanmar, the money has been remarkably well spent. It has allowed the communities that need it the most to get healthcare in a way that was sustainable and engaging the communities that were there. Clearly, if there was opportunity to do more, more could be done, but that does not mean that the existing levels would not be, in their own way, transformational.

Q33 Chair: Is this likely to have an effect on the Myanmar/Burma Government? Clearly they do not have huge resources, but they have under‑spent to such an astonishing degree. Do you think that DFID might effectively persuade them that what is happening justifies their diverting some more funds? Is there any evidence they would be prepared to do that? Do any of you have a view on that?

Fiona Campbell: I have been there for two years and, certainly in terms of what has been said, there is a commitment to increase spend. They have made a commitment to universal health coverage, for instance. Universal health coverage means that everybody should have access to the healthcare they need. In order to do that, there is going to have to be a massive scale‑up in terms of infrastructure, staff, drugs and equipment getting out there. That in itself is already acknowledging that there needs to be an investment in the system. Actually what you are doing is raising the expectations within the population that they can have services. That in itself, you would hope, would ultimately put pressure on the Government to increase its allocation.

Q34 Chair: From what you have said, although it is nearly 50% of DFID’s budget, and you are a specialist in health so you are going to say that, is it justified to spend that proportion of the budget on health?

Mark Foster: Clearly one of the things that we found in the report was a sense that health had been a safe place for DFID to work during the time of the EU prohibitions on working there. Therefore, it is an area where we have been able to build up a foundational position, which allows further spend of this scale to be standing on firmer ground. There are other areas where we are just starting to think about spending money; they become the areas with regard to governance, which is another topic we may come on to talk about later on, where you will be at the very early stage of spend there. Therefore, thinking about how to put more money through those channels would be something to be questioned until the ground had been set. The sense that we had here was firm foundations had been laid; good relationships had been established with the Ministry of Health; the needs had been identified pretty well. Therefore, scaling up to a degree would make sense to be the next big focus in the early stage of the relationship with Burma.

Fiona Campbell: The other point is that, of course, there are a number of sectors that you could put money into in Myanmar at the moment but, if you look in terms of the population, out‑of‑pocket payments for health are a major contributor to people’s impoverishment. The population themselves are already making that an issue for them. If we are looking for where people would like investment, then health is a really important sector for them.

Charles Nelson: Could I add a point about the contribution that Myanmar can make to the world? If drug‑resistant parasites do get out of the Southeast Asia region, then that could be an absolute disaster for Africa. There is a contribution to be made by Myanmar to the global fight against that happening. Investment in the right type that allows them to have the surveillance necessary to do that, the health programmes in place to respond appropriately to the finding of resistant parasites, would be a huge thing that must not be missed right now, because now is the time.

Chair: We will come back to that in a minute.

Q35 Mr McCann: Good morning. Now that sanctions have been lifted against Burma, for the first time, we can provide development assistance directly through the Government of Burma. Does the Government have the capacity to provide sector support in health and what are the risks of corruption?

Mark Foster: First of all, our own perspective was that, while things have opened up, still providing money directly through the Government was something to be thought carefully about. The new programme around the 3MDG programme is still being largely managed through the fund management vehicle of UNOPS. Our overall sense is there is a stronger opportunity to work more closely with the Ministry of Health about the deployment of these funds and, indeed, to use part of these funds to strengthen their ability to manage this. One thing we were encouraged by, looking at the follow‑up from DFID to our review, was their comeback with regard to how much of this energy is going to go into building up the financial management strengths and accountability of the Government, which would then allow, in future, more funds to be put more directly through that route. The key thing here is it is still early days. We felt the fiduciary controls DFID had put in place were appropriate, even though some of the people in the chain felt that they were burdensome. Our feeling was this is still a time to be really tight; it is a time to be focused, but to deploy some of your funds towards building up capacity in the system to allow future different models.

Fiona Campbell: I agree. I think it is a very important route to go down, but it is a process. Capacity is needed at all sorts of levels. At township level, for instance, where they will be receiving funds and allocating them for services within the township, that requires people who are able to manage finances at that level. I know, just before I left, in the townships that are working, there sometimes are no people who have good financial management skills. That is one of the things that, at September time, basically they had sanctioned new positions at township level, recognising that you need to have that capacity there, but that also requires them to be skilled and to be supported. That is a process; it takes time. You need to make sure that those steps are in place before you can put money through, but I think that is definitely the way that it needs to go in country.

Charles Nelson: I would be supportive. You seem to be getting agreement across the table.

Mr McCann: Charles, I am going to start with you for the next question, so they can support your view.

Charles Nelson: We will see. There is a unique opportunity, at the moment, as the bureaucracy is opening up. Clearly there is strong bureaucracy inside Myanmar which, with the right training, actually has a platform on which it can be built. There is a time for that to be developed. Certainly in dealings with the National Malaria Control board and so on, they are very enthusiastic to find ways to grow and to get better at the task that they have in front of them, and they are being given the liberty to do it now, which they have not had until recently. The right kind of investment in capacity building through the system is going to be important, but not rushed.

Q36 Mr McCann: That is helpful, but can I press you on a couple of other points and perhaps start with yourself, Charles? When we were there, Mrs Latham, Mr White and I met with health ministers. We met with other ministers that day, and we were continually faced with an awful lot of ambition but a huge gap from the reality on the ground. How big is the skills gap within the health sector, both at administration level and at medical level? Perhaps you could maybe give some practical examples of where that gap exists.

Charles Nelson: The gap is significant, in the sense that the ability to actually control activity from end to end that you need for a good health system has not been there. They have had a very strong plan in place since 1972. The plan is clear so, within a plan, it is possible to work to build the skills. Practically, on the point that Fiona made about the townships, that is where it becomes weakest, in terms of the connectivity between the townships and the villages that those townships serve, and the facilities connecting with the communities. There are big gaps in that process, but the people there are highly capable when given the opportunity to do it. The training can be done quite fast, but it needs time to be proven. There are very practical things of getting a supply chain that works end to end and is delivering the right things to the right places, and people knowing how to use that clinically in appropriate ways. It would be the example for me of where we need to close the gap.

Mr McCann: Fiona, do you agree with Charles?

Fiona Campbell: Yes. From the experience of the delta, working with the townships quite closely and the transition to 3MDG, where we were looking at a sustainability strategy—a strategy for exit ultimately—it would also require us to identify what gaps were there in terms of skills. They are across the board. Look at all the building blocks of the health system, whether it is human resource management, whether it is supply chain, whether it is financial management, leadership and governance. How do you run good meetings at township level and make sure you have all the stakeholders at the table? How do you look at the data? Where is the data coming from? Is it reliable? Is it being used? What is it telling us about the situation within the township? What is it telling us about where we should be directing?

Those are skills that are developed through use but, if you have not had that opportunity to date or have not had the staff there—a lot of technical staff are doing managerial positions in the township—there are skill gaps across the board, at township and at regional level. At the national level, there is very good capacity in terms of technical capacity, but how is that then put into practice in terms of making decisions, developing plans, developing policies? There are gaps, yes, and there is a lot of work to be done to fill them.

Mark Foster: I would draw an analogy from my recent experiences in Kenya, where there has obviously been a recent devolution of the health management structure to the counties, which is a bit analogous to what is happening to the townships in Burma. The level of ambition you see is immediately naturally there in these new groups that, for the first time, see themselves managing a particular area, but the level of ambition clearly is out of all proportion to the reality on the ground.

I think that one of the things that is important about the focus of even the work that DFID does fund in Burma around health is to keep an eye on getting the basics right first. That is around the basics of things like the supply chain, the core skills and the delivery of basic services. You can start to think too much about structuring the whole health system. There does have to be health system strengthening activity, yes, but it is about pacing it at the right level. I would say helping the townships to set their bars at the right level, and then funding practical activities on the ground that build that base capacity, would be where I would make sure that our energies were focused.

Charles Nelson: Can I just add one other quick thought on focus? Getting the data to be able to support and evidence the progress that is being made is a clear gap and one we believe needs to be there, both short term from a surveillance point of view, to be able to respond appropriately to disease outbreaks and so on, but the other is just to provide the evidence and data to support the nature of investment going forward.

Q37 Hugh Bayley: You all know Burma quite well, it is clear from your answers, but I am missing something here. It seems you talk about the need to strengthen the system and then you talk a bit about some of the work you have done trying to strengthen township hospitals and township clinics. I am not at all clear that there is a strategic vision within the Ministry of Health that is guiding all the things you were talking about, Fiona—personnel, management training, data collection on basic health statistics and so on. To what extent can the donor community, not just DFID, create a good policy base in the sense of leadership within the Ministry of Health?

Fiona Campbell: Health system strengthening is a very misunderstood term as well. This health system strengthening idea has lots of different definitions out there about what we understand by it. There is some very good work going on right now. The World Bank has money, through 3MDG, to work with the Ministry and other partners in country to actually come to an understanding of what we mean by health system strengthening in the Myanmar context at the moment. What are the priorities? Can we get some sort of shared understanding of what we mean by it? Can we get some shared understanding about what the roadmap would be to strengthen the system? There is also a new technical co‑ordination group under the Myanmar Health Sector Coordination Committee, which is specifically around health system strengthening. The work that the World Bank under 3MDG are doing with the Ministry on that is strengthening that platform, and that is an opportunity for everybody to come together to really outline what is meant by ‘health system’.

Q38 Hugh Bayley: To do what? This is the question. Give me a couple of examples of programmes of work which this World Bank initiative is trying to do.

Fiona Campbell: They have not started yet. This is just to get an understanding. As you say, the system is huge and it is multi‑layer. It is at national level. It is at regional level. It is at township level. It is down to the community level. It is huge.

Q39 Hugh Bayley: Do you understand why I am finding it difficult to get a handle on what is going on?

Fiona Campbell: In terms of the system?

Q40 Hugh Bayley: Look at manpower, person power, planning, training of doctors of nurses and of health personnel. Does the Ministry of Health have an assessment of need in terms of personnel? Does it try to match its training of personnel to those needs? Is this the sort of thing that the World Bank programme would work with the Department to create a plan for?

Fiona Campbell: That is one element of the health system, so the human resources side of it. Back in 2012, the Ministry of Health did bring in some technical expertise, from Australia in fact, to help them think through their human resource plan for the sector. I know that the 3MDG fund has in their programme looking at the human resource side of things as well. It is there on the agenda. It is there, in that we need a plan for human resources, but you will also need one for supplies; you will also need one for—

Hugh Bayley: A lot of things—data collection, etc.

Fiona Campbell: They are all inter‑related. There are the beginnings of those discussions and of those plans taking place, at the moment.

Q41 Hugh Bayley: I suppose my question is this: you mentioned the World Bank doing some work; you mentioned consultants from Australia being brought in for a particular purpose. Is there not a danger that you have many well‑meaning donors picking apples off the tree, which they think will be good to eat, and you end up—this is a very bad simile—without an overall strategic vision of how the sector develops?

Fiona Campbell: That is back to the technical co‑ordination group around health system strengthening. That is a platform for all of those actors to come together to have those discussions.

Mark Foster: We highlighted from our review our concern that, in fact, as with Burma opening up, there would be almost a proliferation of donors suddenly looking at this area, and there would be an un‑co‑ordinated activity rushing into the country. One of the things that I have been encouraged by, again referring back to that piece of work that Fiona has just spoken about, which DFID has been focusing on, is trying to get this landscape of the health sector painted, which is a very fundamental piece of work. It also helps them think much more clearly about the role of the private sector, which is a massive part of this landscape. Again, we directed them to spend more time in thinking about how to leverage the private sector more clearly. The other key recommendation of our report was around just getting some data and putting in place, to Charles’s earlier comment, the foundational information, once you decide how many doctors to have, where to send them with what skills for what purpose. Those kinds of things are some really foundational areas.

Again I would say that DFID has a strong position of influence. It should influence these very important foundational things. Also, it should influence around getting the levels of ambition appropriately set, because the politicians will want to push the ambitions all the time. What DFID needs to play its role in doing is getting the Ministry of Health to make sure it sets the bar at the right level, in terms of what really can be done.

Q42 Hugh Bayley: Have you, with your ICAI hat on, revisited DFID’s health programme since you have done your report to see what has changed as a result of your recommendations?

Mark Foster: These are very early days. Our cycle for going back is actually more like six months to a year. It is newer than that in terms of our formal cycle. Obviously the team leader who led the work has looked back and reviewed what has been going on. First of all, we were overall very pleased they did accept all our recommendations in the first place. All of our recommendations were accepted. Particularly actions around the focus on data collection have definitely been reinforced. Some of the things around risk management of the 3MDG programme, about making sure that the right structure is in place to make sure this large and multi‑levelled programme is appropriately focused, appear to be happening. The more pragmatic planning on the township‑based activities appears to be taking place, but these are still early days. The new programme has only really been on the ground for about a year live, so these are early days.

Hugh Bayley: I have two further questions. They are unrelated, but perhaps I should pose them both.

Chair: Can you be quick, because you have taken quite a lot of time, Hugh?

Q43 Hugh Bayley: Is there a need within the Department of Health to look for one of the donors to second some key health planners and health economists to work on some of these issues? Secondly, Aung San Suu Kyi expressed to us her Yangon Hospital project. She wants to see a renovation. We will come back to that; leave that. Let us talk about secondments only.

Mark Foster: Are there any comments you have on secondments?

Charles Nelson: It is just to say there do appear to be requests coming from Ministries to organisations such as ours to provide support and input. We have made several proposals through donors and to the Ministry to put in expertise to allow these things to develop. Those are in the early stages. I would say that, of, we really are in the early stages because, until 18 months ago, we were not actually allowed to talk to the Government about what was going on and all the work was in the communities, right out on the ground, saving lives literally among communities. I do not think it is that surprising that, now that the route in is there, we are finding the gaps that need to be filled. It will be a process of finding the next priority and helping them fill, as their willingness to do that goes, within a plan that the donors can keep a good view on.

Mark Foster: More generally, I would say our experience in ICAI is the secondment model to key Ministries of key technical assistance is a very powerful way of leveraging our input.

Q44 Sir Tony Cunningham: You have touched on the Three Millennium Development Goal Fund, and obviously it is the largest fund in DFID Burma’s health portfolio, DFID expecting to spend something like £18 million between 2012 and 2016. I wonder how closely the Three Millennium Development Goal fund follows on from the Three Diseases Fund. What changes have taken place and what lessons have been learned?

Fiona Campbell: 3MDG does not build just on the 3DF; it also builds on the experience and learning from the Joint Initiative on Maternal, Newborn and Child Health in the delta. That is quite important. It does not cover just HIV, TB and malaria issues, but it also integrates those with the MNCH issues that are a major burden of disease in the country.

In addition to that, it has incorporated this health system strengthening component, so that it is working in terms of those specific disease issues and MNCH, but also in the wider system, which will hopefully have benefits for other disease and health conditions that are not covered by the direct programming under component 1 and component 2. I think it has learned and it has built on it, but not just 3DF; the joint initiative as well has been important.

Q45 Sir Tony Cunningham: I know ICAI has had some criticisms of the programme, and Save the Children and Christian Aid have also criticised the lack of flexibility. In your response, could you touch on that as well, please?

Mark Foster: Like we see across the world, actually, there obviously is a benefit in creating umbrella‑type programmes sometimes, which allows you to put a number of things together to attempt to, I would say, have a more holistic solution rather than firing in individual vertical pieces. The danger of those, of course, is either lack of focus that comes from those or inflexibility, because you are trying to move this great liner along, rather than more targeted flotillas of activity. Our concern with the 3MDG fund was it had been a long time in gestation; it was building in lots of different pieces of the jigsaw puzzle. There had been some issues with the establishment of the fund management vehicles for it as well, and what I call the nimbleness of those fund management vehicles.

Our concern was that it was well designed, appeared to have the right pieces in it, is building on the right past work, but will it be flexible enough going forward to recognise that Burma is changing so fast? You will have seen from your visit just how much it has changed in a short period of time. You might put the clock forward 18 months from now; it will be completely different again. Making sure that this very large programme with the very large funds applied to it stays nimble, manages its risks and targets itself remains our key concern.

Charles Nelson: I cannot comment on the particular design of 3MDG, but I do think that, whenever you are building a system away from something that is fundamentally infectious disease control, plus maternity, which are the basics of underdeveloped health systems, you can use approaches that gradually add things on to a system that is functioning. As you build the system to deal with malaria, TB and AIDS, you are also building the antenatal care setup, because a lot of work is done through antenatal. If you can build the strength of the antenatal care system, you can build in appropriate skilled coverage for auxiliary midwives and so on, and then midwives associated with it.

Having something to build on and building from something that you know works is actually a strong thing, not a sense of weakness, recognising that the needs will change over time, but you are building a platform, whichever mechanism you use to build it. If malaria is the primary thing, then build it off malaria. If it is maternal and child health more broadly, then you can build a wider system from it. I would not be too concerned at the moment that the focus is wrong, but you do get some very large commitments each time you take on a policy to support all HIV sufferers. You cannot stop once you start. It is critical that, as you take each of these on, it is clear what impact it has on the system, which is then able to function with the additional burden that it is given.

Q46 Sir Tony Cunningham: It is impossible to stop once it has started, or you hope it is impossible to stop.

Charles Nelson: It depends whether you contain it with what you can do and you have the skills to do. I just give the example if you go out to a village health worker. They are usually volunteers. They have their box and they deal with malaria. They do the observed treatment for TB. If they have HIV sufferers in the village, under the joint approach that was developed, they are given the antiretrovirals to oversee on behalf of the patients that they have, and that works very well. They have an auxiliary midwife who looks after the needs of the community coming through. That functions. The more you add to them, the harder it is for them to be volunteers, the harder it is for them to have the tools available to them in the village, and so you have to build a system further up to meet. The wider you get, you have to recognise that you are putting burdens on to the system that have to be managed. I think it is doable but, once you put it in, it is very hard to take back out again, as any health system knows.

Q47 Sir Tony Cunningham: Leading on from that, it is so important that these programmes are sustainable. I wonder if you could answer the question: how far past 2016 will EU funding last for 3MDG? Do you have any insight into that?

Charles Nelson: I have not, no, as I sit here.

Q48 Sir Tony Cunningham: What potentially would happen if the funding was not continued?

Mark Foster: I have no particular comment on the EU position, but we have to recognise where we are in the lifecycle of the work in Burma compared to other places, where we worry a lot about exit plans and sustainability plans. We are still in very much a building‑up of the kind of input of capability into the system here, which is going to last for a very long time. You have to be aware, as has been commented by Charles, that as you put something in you do add to the list of things that have to be kept in place to hold the system up going forward. I do believe the commitments being made around 3MDG and other programmes are setting up a trajectory that is likely to be requiring support for a long time to come, as the system is created.

Q49 Chair: The DFID team that we met there was concerned that the EU did not seem to be firmly committed beyond that 2015‑16 date, and that that would leave the system under‑funded, basically. Would you share that concern?

Fiona Campbell: I do not have any information about the EU’s longer‑term plans. They have been a major contributor.

Chair: They do not have one.

Fiona Campbell: They have been a major contributor to health over the years and for the joint initiative, as well as the 3MDG fund. Yes, I would be concerned if they were thinking of pulling out. I would want to know what was behind that, as well.

Mark Foster: Elsewhere from our travels again with ICAI, you do see all the time where something like community health workers has been put in as part of the system, through the donor structures or NGO structures, and, when that stops, that part of the system collapses very quickly. That is something to be concerned about because, in the end, that will be a part of the delivery vehicle for this stuff. How that is funded long term by the Government of Burma or other vehicles has to be part of the answer.

Charles Nelson: I do not think this is a unique challenge for Burma, however. Wherever you are investing around the world that is developing, to encourage Governments to prioritise funding where donor funding is already coming in is a hard thing to do. Conceptually it is right; in practice, if an international Government is supporting health in one area, then the Government is not going to prioritise it until such a time as it is not there.

Q50 Chair: You could have a partnership whereby you agree together.

Charles Nelson: Absolutely, if you can set that up and get agreement on what that looks like and then see it realised. Even then, the promises need to be realised once made, and that is not necessarily the case.

Q51 Sir Tony Cunningham: One final question, and it is always a difficult question in whatever country you go into where there is conflict: how will the 3MDG fund address the lack of healthcare in conflict and ceasefire areas?

Fiona Campbell: I know they have done a study. I know they have been out with their team to look at particular conflict‑affected areas in their seven states, one of which is Rakhine, and Kayin and Shan are also there; Shan and Wa were in the past. They are already looking at engaging in those conflict‑affected areas or past conflict‑affected areas.

In terms of how they engage, it is really important that the approach is sensitive to the conflict or the underlying issues of the conflict, and that requires you to have a good assessment and understand the basis of the conflict, and then ensure that your programme approach is adapted accordingly. There is that understanding within the team; they do have a conflict adviser in the 3MDG fund. That is the approach that they will take: that it is important to be sensitive and to be aware of the potential negative impact of any programme, but also the potential to do good, to be a positive and, in some ways, contribute to that peacebuilding process, whether that is by just the fact that health can be a dividend in terms of the peace process or whether it is, in fact, almost seen as a sort of neutral sector sometimes in those situations, bringing communities together and supporting that social side of it. They are aware of that within 3MDG fund and that is the approach that they will take.

Charles Nelson: I would like to say it is critical that a percentage of what goes on within 3MDG needs to be focused in those areas, because, in the harder‑to‑reach ethnic communities that have been impacted, in the border areas and so on, inappropriate treatments for infectious disease result in resistance developing. It is absolutely critical that part of the activity is focused in those areas and the exact day‑by‑day process of negotiation and having people on the ground who know the communities and are able to be there. That is more expensive than finding high‑density populations and dealing with them. We have to understand that, in that sense, good value for money is not necessarily the pounds per head spent in urban areas. We need to understand enough based on evidence gathered of what we need to do to achieve the containment of disease in those areas. It is vital that we find a way to do it. I do not think there are any easy answers.

Q52 Fiona Bruce: Good morning. When visiting health centres in developing countries, the Committee has sometimes found that the upkeep of the buildings and the cleanliness are disappointing, and that was no exception in some of our visits in Burma. The question is: bearing in mind there is only a certain amount of money, in the township areas, would you prioritise the improvement of health facilities, maintenance, sanitation, hygiene and so forth, or would you look to prioritise initially training of staff and drug provision?

Mark Foster: The particular experience in Burma matched with our experience elsewhere: in the end, there is no point in training lots of people if they are then going to work in inappropriate facilities. You need to have this whole thing moving forward on some kind of a lockstep, where the infrastructure is being kept up with the resources that are going to be working there. One of the challenges often is that it is easier to fund a training programme than it is to fund a capital programme to do the infrastructure. While there has been a mood swing away from building hospitals and building clinics as a form of aid, interestingly enough, where I have seen it on the ground, particularly again just having come back from Kenya, the infrastructure challenge, I would say, is at least as big as the skills challenge there.

Therefore, for the programme here, one of the things the townships are going to have to get their hands around is the appropriate capital spend alongside operational spend on people, the hardware and the software, to actually put in place a framework that will sustain itself. Again, as you think about health system strengthening, one of the pieces of that is core infrastructure, and we would certainly be encouraging the 3MDG programme, as it thinks about that piece, to make sure it is in the mix, because otherwise things do not stick.

Q53 Fiona Bruce: Is it also easier to fund a capital programme with an initial construction, but then not have the ongoing sustainability built in to maintain and upkeep that building?

Mark Foster: Unfortunately, it is a really common problem. In an environment where the Government is spending so little on health, the likelihood that they are going to put the operating funds in place to maintain these locations will be a challenge. There has to be a realism about that. It is also about these levels of ambition and making sure that, for example, actually you do not try to persuade a township to build a shiny new huge referral hospital, which they may well want to do. Actually, they do keep themselves focused on the art of the possible: maybe it is lower maintenance and lower cost of structures, but at least creating those basic infrastructure components.

Fiona Campbell: This was a discussion that actually came up in the delta townships in the early part of the year. Our work looking at the role of midwives and how they function was also key to this in that, yes, we have trained them and you can give them support and transport. Most of the midwives are based at the sub‑rural health centre level, which is as close as you can get to the villages but, in many cases, they do not have a facility to work from and they do not have accommodation with it. That is really critical because, if you want the midwife to go to the villages, she has to have somewhere to work from, but she also has to have somewhere she can stay overnight, as well. If that is not there, then there is a challenge for them to actually get out to the villages. If you want people to have access to services, the services also have to go to the communities, not just the communities coming to a hospital at the township. The facilities issue is a part of the mix and it is an important part. If the service itself is going to be delivered well, then that is an important part that has to be factored into that support.

Fiona Bruce: Yes, because otherwise there is a lack of aspiration in terms of the staff, attracting and retaining staff, and generally delivering well. Thank you.

Q54 Pauline Latham: When we were in Burma, we met some people with HIV/AIDS, and it appeared that you only got on the antiretroviral drugs once somebody died, because they did not have enough. One young man was being treated for TB but not HIV/AIDS, because he was too ill and his count was so low that the chances of him surviving were pretty remote. It seems that there is not a very good regime for people with HIV/AIDS; there did not seem to be people who were making sure that there was no mother‑to‑child transmission. It seemed to be very hit and miss. Was that any of your experiences or did you have a happier picture?

Fiona Campbell: I know that there was some work done and, I think in 2012, a report came out from MSF. It looked like 25% of people who should be on ARVs are actually on ARVs, so there is a gap between the need and the availability, and it is quite stark. The reality is there needs to be more investment and more people need to be put on ARVs but, as with everything, it is balancing the availability of money with the need that is there, which is huge across a number of different health issues.

Q55 Pauline Latham: If you are saying 25% were on them, were 25% on them so that they would be living with HIV/AIDS, not dying with it, because a lot of them are begin given it so late there is actually no point in having it in the first place, because they are going to die? They are just going to be too ill. The 25% who you saw who were on it regularly, were they 25% that had had it as soon as they were diagnosed, right through for the rest of their lives, or were they just 25% of people who take medicines but actually they are going to die anyway?

Fiona Campbell: The information shows that, of all the people who need to be on ARVs, only about 25% of them actually are.

Q56 Pauline Latham: They have been diagnosed so late that there is actually not much point in having it anyway, so there is a huge gap there. Actually, it is not a very good picture, when we know that in many countries you can live with HIV/AIDS. It is not a problem; it is not a big deal anymore, but there is such a big stigma there still about going for diagnosis and admitting it, so there needs to be a huge amount of work. Do you think there is a focus on moving away from HIV/AIDS in terms of the voluntary groups and development agencies in Burma, because some of the people out there do think that that is the case?

Fiona Campbell: In the past, the groups working on HIV have been very good at putting it on the agenda and keeping it on the agenda. If you look at the burden of disease in the country, it is number three, so it is a very important issue. Some of the other groups working on MNCH for instance, in the past, have not been so good at putting their issue on the agenda. What you have now is a case where other issues are coming up the agenda, so there is competition for different issues now, in terms of the discussions. I am not sure if HIV is dropping off the agenda or if it is just that there are more issues that are being discussed, and other issues that have not been so widely discussed in the past are now more so.

Q57 Pauline Latham: Such as?

Fiona Campbell: MNCH, maternal and child healthcare, which had not had such a big voice in the past, now has more of a voice, in terms of there is a TSG specifically on MNCH, which there was not before.

Pauline Latham: Sorry a TSG on MNCH? It is impossible.

Fiona Campbell: A technical co‑ordination group, so there is a technical group working on MNCH, which there was not before.

Q58 Pauline Latham: If they are doing that, surely they should be looking at mother‑to‑child transmission of HIV/AIDS. If they are not doing that, they are not really doing their job, are they?

Fiona Campbell: I am sure it is part of their discussions as well.

Q59 Pauline Latham: Are there any other examples of other competing—?

Mark Foster: The interesting thing is, having just come back from Kenya where there is a very interesting live discussion at the moment, Kenya has traditionally received a lot of focus on HIV/AIDS. In fact, if you look at the US support to Kenya, first of all, US support in general is about 50% of the total donor support and, of that, 80% is HIV/AIDS‑related. One of the interesting things there was again this question mark about the fact that not enough money had been directed towards the maternal and child health challenges. That balance was taking place in terms of how the Kenyan health authority thought about the balance of what it was doing. Several doctors we met were pleased to see that realignment taking place, in terms of covering the breadth of what they saw coming through their doors.

The interesting thing about what we saw in Burma around HIV/AIDS was that, actually, in the places we looked, we did see some very positive examples of people receiving the drugs and having the transformative effect you expect on their lives. Also, DFID does have experience, which I myself have seen in Zimbabwe, of getting ARTs out to very far‑flung rural areas, with a strong supply chain, even working in parallel alongside, not with, the Government to try to make a model work. They have experience. This needs to be a continuing focus area for their programming. It is part of the 3MDG programme. It needs to be maintained, but you are always making choices about the balance of interventions and that will carry on.

Q60 Pauline Latham: You say it needs to be maintained, but the regime that is there now does not need to be maintained; it needs to be changed completely, otherwise there is no point in doing it. Either you are going to do a programme properly or you do not bother to do it at all. You have to diagnose early. You have to make sure that there is a way of getting through the stigma, so that people can go and have counselling, so they know what they are doing, and the whole family is treated, if necessary. It is no good saying they have experience on how to do it; yes, DFID has and so have lots of NGOs, but it is not happening.

Charles Nelson: In my current organisation, it is not our primary area of expertise. It comes from other infectious disease control, but the experience from the past for me was a question of being able to guarantee sustainability of the programme when going in. If somebody has chosen to invest in more than 25% of people—and MSF did make that decision to invest constantly, having a portfolio of patients—and take on the rest of those patients, there has to be a guarantee of continuity of supply, otherwise you cannot start. That is the argument. The whole question of the total amount of resources available is actually what is driving the debate, rather than the willingness to do it right. The attempt has been to do it right for the 25% that you can do it for. That may or may not have succeeded to various degrees.

I do not have the experience on the ground, but I do know from the conversations about how you invest in any one of these commitments that you make. Unless there is some view of the future of how you continue to keep these people on ARVs once on, then people will not start, because they are then locked in for a very long time and rightly so; that is what it should be. We need to find a way to make the total community affected by HIV accessing as the commitment of the Government is, but it will take time.

Q61 Pauline Latham: As I have said, the experience we found was that you had to wait for somebody to die before you could go on it. Even if you are one of the 25%, you are actually presenting very late and the chances of survival are very low. Is it worth bothering with?

Mark Foster: The real challenge you touched on in your earlier comments is the point about removal of stigma. The main reason why people are presenting late normally in these situations, from our experience, is that there is the stigma of even going to have the test they need to have. If that says there is a particular cultural issue, which there does appear to be, different in Burma than even other countries nearby around the cultural stigma, what are the efforts you can put into that whole behavioural change side of things? Some of it is about access, supply chains, making sure the ARTs are still there and are carrying on being there, but more of it, in terms of tackling the issue you have highlighted, is around the broader education process and that is a long‑term programme of change, which again will need to be part of the picture going forward.

Q62 Jeremy Lefroy: Good morning. I want to ask about drug‑resistant malaria. Could I first of all ask whether the resistance is purely to artemisinin or to ACTs as well?

Charles Nelson: In general terms, artemisinin is now being supplied in combination and we are seeing some resistance emerging to combinations as well. It is usually caused by either monotherapies being there too long and/or inappropriate treatment regimes of any type of drug, so it is to both, worryingly, as it currently stands.

Q63 Jeremy Lefroy: We have heard about a lot of additional money that is being given, I think some from the Global Fund and from other sources, to try to tackle this problem. In your view, what needs to be done and is this enough, given that it constitutes a major threat globally and not just in Southeast Asia?

Charles Nelson: What there needs to be is a partnership with the Ministry of Health or the National Malaria Control board in Myanmar. There needs to be a focus on the at‑risk and migrant populations, which tend to be along the borders where resistance develops most easily or most readily, it seems. There needs to be constant surveillance put in and data available to be able to assure that, when cases are found, they are contained. The only way to get rid of a resistant parasite is to get rid of the parasite. It is still doable; there are still treatments available, but you have to get to the people and the amount of resistance is getting worrying. There are still options for now, but not for very long.

Q64 Jeremy Lefroy: What are those options?

Charles Nelson: The options are other treatment regimes that still work, but you have to get to people quickly enough so that they are there. The challenge is that some work done on the Bangladesh/Myanmar border showed that 70% of people with malaria were found to be non‑symptomatic, but they were carrying the parasite. Recognising that malaria is a disease of people, not a disease of mosquitoes—people and mosquitoes transmit it—if people are not symptomatic and are travelling freely, and they have a resistant parasite; that is the issue. There needs to be surveillance done. There need to be blood tests done and serology done in surveillance sites to see where these things are happening and then respond to that.

Q65 Jeremy Lefroy: Sorry, are you are saying that 70% of those tested had resistant parasites or just parasites?

Charles Nelson: Just parasites. If a resistant parasite comes through, you are not necessarily going to see it because the person is not symptomatic. They are not presenting with fever to have something done about it; you may not know that they are carrying any parasite, but it could be a resistant one. We just do not know.

Q66 Jeremy Lefroy: You said we do not have that long. How long do you think we have got?

Charles Nelson: That is honestly an unknown.

Jeremy Lefroy: Is it six months, five years, ten years?

Charles Nelson: The amount of resistant examples is growing quite rapidly at the moment. Along the borders in Cambodia, Thailand and Burma, there are a lot more incidents than we would be keen on. Of course, overall incidence is still relatively low as compared to Africa but, in the next two to three years, we have to try to be sure that nothing is travelling.

Q67 Jeremy Lefroy: How can we do that?

Charles Nelson: An investment in surveillance and just literally responding as these examples are found and finding the hot populations that have these, going in and dealing with them, with the treatments that are available—those are the tools we have at our disposal at the moment and it can be done. Whilst we have tools that still work 70% of the time, you can still deal with the parasite.

Q68 Jeremy Lefroy: Ever since I have been very interested in malaria, this problem has been known about, certainly for the last three or four years. Why has it taken so long for the international community to really get its act together on it?

Charles Nelson: That is a good question. The thing is everybody knows about it, but there is no plan B. Everybody is running to try to find a plan B because, when there was resistance to chloroquine developing, there was a plan B, which was artemisinin. There is at the moment no plan C, if you like. Plan B is running out, but there is no plan C yet. There has always been hope that the next thing would be found and that it would take a very long time for resistance to develop, but it is now coming.

Q69 Jeremy Lefroy: Does this really point to a failure in global health institutions, such as the WHO, even the Global Fund, which obviously has been aware of this for some time and only now have they decided to put a lot of resources into it, or is it the fact that there was a political block to any action because of the situation in Myanmar?

Charles Nelson: I would not put it down to a failure of any particular organisation. The thing is work has continued to try to find solutions to this and there is a lot in the pipeline. The reality of course is that, now that Myanmar has opened up, it is now possible to get in and do the kinds of activities that will allow us to bring greater control to the potential spread of the risk. It is an opportunity, rather than anything else, to really allow Myanmar to give something back to the world in this process. Where, before, we would not have had access to support them in that process, now we do. I think actually it is an exciting opportunity.

Q70 Jeremy Lefroy: At the same time, it is a pretty large threat, because we have seen that there are estimates that, if resistance goes to sub‑Saharan Africa, this could increase the number of deaths annually by something like a quarter of a million, which would roll back most of the gains made over the last 10 years.

Charles Nelson: Absolutely; that is a fact. If that is what happens, then there is a significant consequence for the people of Africa.

Mark Foster: That ought to give some thoughts for DFID around their strategies in this space. Clearly, DFID has actually been taking a pretty strong lead around innovation and focus on malaria responses around the world. Also, even in this programme here in Burma, their focus on targeting part of their activity towards this drug‑resistant malaria challenge has been something that has been on the radar screen for some time and they are planning to scale it up. A view we might take from an ICAI perspective is to make sure that, in fact, they do lesson‑learn from this more broadly across the DFID network and it does not get trapped as a piece of insight within Burma.

More generally, there is the issue about learning from it. Perhaps also, when thinking about where to deploy some of the research funding, given the challenge to this area and given DFID’s leadership role in this space, is there something more they should be doing to turbo‑charge the research to make the right connections across the international network you talk about? There could well be some added value from that.

Q71 Jeremy Lefroy: It seems to me that the contrast between the attitude to something like SARS, where we all gear up and get the vaccines produced because there is a threat to the lives of people, shall we say, in the developed world, and we really make a major impact globally, and this, which has been around for years and, actually, it is only now that people are gradually gearing up to it, is very stark, even though the potential damage to lives around the world is just as great as something like a SARS epidemic, certainly in the long term. Would you not draw that contrast? I am not pointing a finger at your organisations, which I think have generally very much taken the lead and done as much as you can on this. Overall, the global health community has been asleep on the job here, asleep at the wheel.

Mark Foster: The challenge is clearly very real. It is hard to say yes or no to that. Clearly, the reality is that the challenge you have identified is real. In fact, whether it is due to the difficulty of the task to respond to it or it has been the lack of co‑ordination and stimulus in the global community to go after it, the reality that you have outlined is a reality. The question is now what you do about it where you are now. In the case specifically of Burma, we do have an opportunity, as Charles has said, to really understand what is going on better. It does put a focus on things like data and surveillance, which we have talked about in our report, because that is not just valuable within the Burmese health system but valuable for the world. Let us make sure we are doing that and then, as I say, we need to make sure your voice and others keep everyone on the case.

Chair: I think Jeremy Lefroy has identified a strong recommendation for this Committee.

Q72 Jeremy Lefroy: If I may just say, Chairman, we have been here before. Chloroquine resistance developed in the same area, did it not? Did S/P as well? What was the other? There was a second drug—it was S/P—that developed in the same area. We are third‑time resistance‑developing. Where is the learning in the global health community that this area has a particular problem with developing resistance to malaria drugs? We seem to be not learning. I am sorry to be challenging so much, but it does seem to me that we have had the lessons. We are supposed to learn the lessons from history and we clearly have not.

Charles Nelson: There is always going to be the challenge with the particular way that this transmission occurs. A lot of the cases where this happens are extremely remote. It is along the borders and you can see the hotspots. Interestingly, there are over 500 different types of resistance that have now been identified. It is not just one that has been travelling; it has been different sorts of resistance developing along borders. It is in migrant populations and it is in the hardest‑to‑reach areas, and in the industries where people move to jobs and are put at risk in forests and so on. There are a whole lot of reasons why it occurs.

The capacity and ability to get in and deal with that on all occasions is difficult, but the overall control of malaria in those environments has actually been immensely successful. The number of deaths has dropped to near zero, so the number of deaths from malaria has dropped dramatically, and that is when these issues of resistance develop, so you combine those two things. The learnings have gone on and there is a lot more detailed surveillance activity going on now in countries where there has been access. Containment is beginning to happen in some ways. There is a lot more to do and we would encourage a lot more to be done, but I do think there is still an opportunity to win this fight. Therefore, we would be hugely supportive of efforts that do focus on containment strategies in this way, but ultimately you will only get rid of resistant parasites if you get rid of malaria, so we have to go down the elimination path.

Jeremy Lefroy: This is just the final comment I want to make on the record: I think this is almost the last chance we have got on this particular resistance. It is quite clear from the evidence that has been given that the world must take it seriously. If we are back here in two years’ time and we have not done enough, it will be too late.

Chair: The chances of that not appearing in our report seem to be remote.

Q73 Fabian Hamilton: Very briefly, if I may, I was not able to go to Burma because of malaria; I am asplenic. I wanted to ask you, following Jeremy Lefroy’s very good questions, what the economic impact of malaria is in Burma. Given that so many people are asymptomatic carriers, does it have a serious economic impact on people’s ability to be able to work or is it largely irrelevant?

Charles Nelson: Wherever malaria is endemic, and Myanmar is still the most endemic of the areas of Southeast Asia because of the access issues over time, it has an impact on people’s ability to work. As to the control mechanisms for the basics of malaria—reducing the impact of it, reducing the morbidity and certainly reducing the mortality—if you get to treat people and get to treat them quickly, then you can handle it. It does impact the economics, as any sickness does when people are unable to work. This of course is a killer of children, and adults become immune over time with exposure, or more immune over time with exposure, which is why they become asymptomatic when carrying the parasite.

Yes, it does have that impact, more so in Africa than in Myanmar, as it currently stands, but you will never have zero impact from any of this type of disease. It also is the burden on the health system, so money has to be spent by people on getting better, which means they cannot spend it on other things, so wherever it is endemic, yes.

Q74 Fabian Hamilton: Have you any idea what percentage of the total healthcare budget spent on malarial treatment, both the symptoms and the prevention, might be in Burma?

Charles Nelson: You are talking about a place where the Government commits something like £3 per head per year on health in total. In total, about £11 per person per year is spent on healthcare. I honestly do not think it is on the radar yet. It is important to the people who have to spend the money, but, in overall economic terms, I would not put it in those terms myself.

Q75 Fabian Hamilton: Would it be fair to say that malaria in Myanmar/Burma is a huge contributor towards poverty in that country?

Charles Nelson: Absolutely; there is no question about that.

Mark Foster: It is very likely that quite a high proportion of the money that is being spent by the poorest individuals on their healthcare will be in this area, will be malaria‑related. It will either be actually because of malaria or because they think they have malaria. The other thing is misdiagnosis is a massive issue. If you are in a malarial area, people think any fever is malaria, and therefore you take the malarial drugs or go to try to take them. Therefore, that also increases problems with resistance as well. The challenges are this will be a big part of the burden for these people.

Q76 Chris White: Good morning. While we were in Burma, we heard that most people had to pay to see their doctor because of the lack of public healthcare facilities. Do you think that DFID has the right balance in the amount it works with the for‑profit health sectors?

Mark Foster: We certainly identified the fact that we felt the work that had taken place historically for DFID in the health sector had not focused on the private sector. We felt there was a need to understand it better and, therefore, work out if it is actually a vehicle for doing more with. Certainly, in these emerging economies, it seems that, in fact, answers that combine the private and the public sector more effectively are probably better than trying to put in place a completely free public model, simply in that there is not the money to fund it. Secondly, you are trying to create enterprise and enterprise is part of the model here.

There is also then a question mark for DFID to think more about the role the private sector can play in their overall thinking, getting this landscape right, which will help them better target what they do. In terms of helping a township decide what it should spend its money on, fitting that around a complementary model that includes the role of the private sector would be valuable.

Q77 Chris White: ICAI identified that there was a problem. Presumably, DFID is aware of your thinking on this and I just wondered if, rather than them thinking about it, understanding it or any of those sort of words, do you think they are taking any action to address this imbalance?

Mark Foster: The first thing, which they are doing both here—and also I happen to have just come from Kenya—and in Kenya, is formally mapping it. That was a board decision, taken I think in the 3MDG board, in June of this year, to map the private sector. While that may seem fairly basic and clearly does not get you very far down the list of doing anything yet, it is a first start. Our sense is that at least we saw a reaction in terms of that degree of awareness of it.

The question is now live around what is going to happen next. How will they start to think about what that means? Does it mean they will not prioritise certain areas that the private sector is doing well? Does it mean you have to worry about—? Many of the challenges of the private sector are that people go to it to get their drugs and the drugs are of very poor quality. A lot of the issues with the private sector are the mavericks in the private sector. One of the questions might be that an area of DFID’s focus could be around the regulations that sit around a private sector health model, which again would be a recognition of its existence and add huge value to the quality of the services that people receive from those kinds of players.

Q78 Chris White: The figures we have in front of us are that 85% of the expenditure on health in Burma is on the informal or for‑profit sectors. When people are using the public health sector, they are still ending up paying for services. Do you think, with your intervention and DFID’s interventions, this trend may be reversed?

Mark Foster: You mean more free services in the public sector. I do not know the answer in terms of the specifics of whether DFID is pushing for more of that. Clearly, around the world, again, there has been a strong influencing role of DFID in targeting free services for critical points in their lifecycle, particularly maternal and child healthcare, for example, and early years healthcare. It is one of those situations where you have to be careful you do not get unintended consequences.

Again, I have just come back from Kenya, where they have just introduced free maternal healthcare. Because the capacity was not built up to respond to the increasing demand that came from making these services free, actually the quality of service everyone received went down. The outcomes have been, in some cases, quite poor. The question about free services is to make sure the system is ready to provide them in terms of the skills and the capabilities, in line with opening up that demand that you create with free services. The question would be a thoughtful approach and also, as I say, it is quite likely the final answer will be a balance, rather than one answer or the other. I do not know if others have comments on the ground.

Fiona Campbell: I guess this is a major challenge in terms of ensuring that people have access to healthcare that they need. If it is not affordable, which it is not, with people having to pay out of pocket to such an extent, then it is one of the major barriers, if not the major barrier. People are using the private sector because they are not necessarily able to access quality care in the public sector. It is also about understanding the roles and responsibilities of the public sector as well as the private sector. The private sector is very diverse; it can be public sector workers working out of hours in the private sector. Getting an understanding of how they are working together and what the incentives are for people to go to public or private is really important.

In terms of paying for services, what we are looking for is to ensure that people do not have to pay when they are sick and they need to access that service, so that they have a pre‑payment of some form or other. In the UK, we are used to it through our taxes and our insurance; there, that is not in place. We are looking at whatever the means is to have a free‑at‑point‑of‑access service for people, and to be able to pool the risk so that those who can least afford it are pooling that risk with those who can afford it better. In terms of how you go about that, I know there is work both in terms of the 3MDG fund and within the Ministry themselves looking at social protection schemes at township level to protect the poorest, but also to ensure that everybody is able to access services when they need them and that they somehow have some insurance for that in place.

Q79 Chris White: How high up the list of priorities do you think this is for the Burmese Government?

Fiona Campbell: As I said before, they have committed to universal health coverage and one of the platforms of universal health coverage is affordable access. If they are going to reach that, they are going to have to tackle this. Certainly, the Ministry of Health has had several meetings and discussions on what the best mechanism for protecting people against out‑of‑pocket payments would be. It is a challenge in that context when you do not have a well‑functioning tax system, when you do not necessarily have very high levels of people in the formal sector, so social insurance becomes challenging. It is a problem and community‑based health insurance programmes have been found not to be good in terms of scale. They have been good in terms of small programmes but, when you take them to scale, they have not necessarily been so effective. In that context, it is a really big challenge, but certainly it is something that has been on the agenda for at least a few years while I have been there.

Chair: Thank you very much. One of the things we should say that was clear to us was that at least the civilians, the parliamentarians and the politicians are in pre‑election mode, so lots of promises are being made. The questions were all about what is actually being delivered and will be delivered. Aspirations seem to be a long way above capacity, but that is politics, I guess. Can I say thank you to all three of you? I think it has been a very interesting and useful session, on the basis of which I am sure we will be able to make some very definite recommendations. Thank you very much for your evidence and for coming in.

Examination of Witnesses

Witnesses: Lord Williams of Baglan, Chatham House, Benedict Rogers, East Asia Team Leader, Christian Solidarity Worldwide, and Greg Power, Co-Founder, Global Partners Governance, gave evidence.

Q80 Chair: Can I say good morning and thank you very much for coming in? Sorry it is a little bit later than you were told, but that is the nature of evidence sessions. Thank you very much. Again, I wonder for the record if you could introduce yourselves, perhaps starting with you, Lord Williams.

Lord Williams of Baglan: I am Michael Williams, Lord Williams of Baglan.

Greg Power: I am Greg Power, Director of Global Partners Governance.

Benedict Rogers: I am Ben Rogers from Christian Solidarity Worldwide.

Q81 Chair: It is very nice to see all of you. Obviously we have described this report under the short headline of “democracy and development”. This is really focusing to some extent on the democracy bit. Our judgment was that we have potentially an emerging democracy or some form of democracy and the hope that that might give space to create development. What we are looking for from you is what your view on that is and also suggestions you may have as to how we can take advantage constructively of that opportunity. We have just come back and we all have the same questions: how is it in Burma? What is happening? It is kind of at an apparent crossroads. We have a ceasefire; I am not sure we have a peace process. We have discussions about constitutional change, but they do not seem to be very active. Perhaps the first question to ask is what your take is on what you see as the peace process and the constitutional process, both of which seem to be fairly crucial as to whether or not we have a long‑term, functioning, apparently democratic settlement.

Lord Williams of Baglan: I should have perhaps added, Chair, at the beginning, I am currently a distinguished visiting fellow at Chatham House looking at processes of transition towards reform and democracy, on the one hand in the Arab world, and on the other in Southeast Asia, which I know very well. I believe I sent a short note to the Committee last week. That reflects my view that the situation in Burma, in Myanmar, is really quite promising. It is useful to have historical and comparative frameworks. I know Indonesia well, which, like Burma, had a long period of military rule—in the case of Indonesia, 33 years—and is now one of the most robust democracies in the developing world. I am confident that Burma can eventually get to that spot.

If one reviews the past few years, one sees certain highlights. One is the relationship between President Thein Sein and Aung San Suu Kyi. I have had the privilege of chairing meetings where both of those spoke on different occasions at Chatham House, and I believe the commitment is there. It is very interesting, when the by‑elections took place in April last year, 2012, and of course the NLD virtually swept the board, 41 out of 44 seats, there was no adverse reaction from the regime, from the military, in that respect. I expect elections to go ahead in 2015. There are many major questions that hang around that, not least the question of constitutional reform.

You yourself, Chairman, referred to the meeting, I believe, on 30 October, where for the first time the 17 armed insurgency groups came together with the Government and agreed a ceasefire. Again, as I believe you referred, what we need is not just a ceasefire but political progress that can build on that, otherwise it will slip back. Finally, perhaps I would note that another 44 political prisoners were released, I believe last Friday or Saturday, so the Government does seem to be on target to release all political prisoners by the end of 2013.

Greg Power: Chair, I would start by deferring to the expertise on Burma of my colleagues on my right and left. As you will know from our submission, the focus was very much on the role of Parliament and DFID’s parliamentary strengthening, so I will defer to them.

Benedict Rogers: Chairman, good morning. Can I thank you very much firstly for the opportunity and privilege of being here this morning? I have travelled to Burma four times in the last year and a half and more than 40 times altogether, if I include the border areas, over 15 years. I would like to start certainly by acknowledging the very significant changes that all of us would see. I have witnessed them first hand. I have been able to do things in Burma that would have been inconceivable just a short time ago. I have just two brief examples that illustrate that.

Earlier this year, I travelled with Lord Alton of Liverpool and we both addressed a public gathering, organised by the National League for Democracy, in a public restaurant in Rangoon, on the theme of human rights and democracy. That would have been unimaginable previously. I was there recently in November and again organised, with the NLD, a public meeting at which the Catholic Archbishop of Rangoon gave a talk on religious harmony and peacebuilding. Again, that would have been unimaginable a short time ago. I was also able to travel recently into Chin state, which was previously part of the country that was totally closed to foreigners. I gave a three‑day workshop on human rights. Those were all extremely significant positive developments.

However, there are two dangers in the international community’s approach. One is the danger of entrenched cynicism, which would be very understandable given the past record of successive military regimes, but the other danger, which I think is more prevalent, is the danger of what I call premature euphoria. I wrote an article for the Wall Street Journal recently and I ended it by saying that “The beginning of the beginning may now have begun.” In saying that, I want to emphasise that I think, whilst the progress is encouraging in many respects, there is a very long way to go. You made remarks about the constitutional changes that are needed that we have not yet seen. Clearly, if 2015 is to be a genuine and meaningful election as part of a transition, the constitution needs to be changed before then. We may, I imagine, come back to these issues.

In addition to the ethnic peace process, and I would echo the comments about the need for that to become a peace process rather than a ceasefire, I would also like to put on record concerns about inter‑religious conflict that we have seen throughout this year. That has the potential to derail the positives. While the release of political prisoners has of course been very welcome, and the vast majority of political prisoners have now been released, at the same time, there has also been a worrying step backwards in terms of quite a significant number of arrests this year of demonstrators, not given the same kind of lengths of prison sentences that they used to be but, nevertheless, arbitrarily arrested. There are a lot of continuing cases of torture, detention and various other human rights violations. It is a very mixed picture.

I would end just by saying two things. In 15 years of working on Burma, one thing I have learned is not to make predictions and to expect the unexpected. A lot could happen between now and 2015 that we may not be able to predict. Secondly, it is unclear still what the intended destination of the regime is in this transition. That there is a transition is clear, but whether it is a transition to a genuine democracy or whether it is a transition to a more respectable kind of authoritarian regime is uncertain. We should not assume that it is definitely a transition to a democracy, at this stage. There is a lot that needs to happen for that to be secured.

Q82 Chair: Just on that point, along with Fiona Bruce, I went with the Speaker in July, as well as going in November. On the issue of constitutional reform and the potential role of Aung San Suu Kyi, the line had clearly changed between July and November. In July, it was relaxed, “Yes, we’re working on constitutional change. All things are possible.” By November, it was, “Nothing to do with me. It’s out there. There’s a constitutional review, which does not seem to meet and I only have one vote, even though I am a Minister,” and just a complete cop‑out basically.

What is your own view about that? Aung San Suu Kyi’s comment was that they were not making any hurry to change it, that their attitude was she is not eligible to be President so there is no point in voting for her. That does not seem to me a strategy that is likely to work, but nevertheless that is what she sees as their strategy. Is the most likely outcome: there will be an election; her party will do well, maybe not well enough to be absolutely in control, given there is a blocking minority from the military, and therefore there will have to be some kind of accommodation between her party and whoever represents the rest of the regime?

Lord Williams of Baglan: On the question of whether there will be an election, I believe very firmly that there will be an election. It is very difficult now for the Government to resile from that position.

Chair: That seems to be the general impression.

Lord Williams of Baglan: I would also caution that one should not see the situation simply as the regime and Aung San Suu Kyi, or the military and the National League for Democracy. There is clearly now an emerging pluralism. It is not just President Thein Sein; there is, for example, Shwe Mann, the Speaker of the Parliament, who is a very powerful figure and has different views from those of the President. Benedict issued the caution about what he termed premature euphoria. My answer to that is to stick with events and stick with the facts. Those I believe tell us a story. It is true, Chair, that there seems to be a certain inertia with regard to the issue of constitutional reform, just as there was for a long time with the question of the ceasefire meeting, which eventually took place on 30 October. In the course of 2014, they will tackle that issue.

Benedict Rogers: There has clearly been a significant change in the rhetoric on the part of the regime and members of the regime, both in terms of the possibility of constitutional change and in relation to the ethnic conflict. Government ministers are actually using the word ‘federalism’ and are willing to explore a federal future. The word ‘federalism’ was totally taboo a short time ago. The language is changing; that is very welcome. As you say, so far we have not seen a rush to change the constitution. I totally agree with Lord Williams that we must follow events and respond to events. If the constitution changes over the course of 2014 that obviously will make the 2015 elections much more credible and give us more reason for optimism. So far, I have not seen a good enough match between the language and the action.

Q83 Mr McCann: Good morning, gentlemen. Ben, could I perhaps tempt you to break your self‑denying ordinance to make a prediction? On a scale of 1 to 10, 10 being the worst, what would be your view of the risk that ethnic conflict will destabilise the progress that has been made thus far?

Benedict Rogers: If I could add to ethnic conflict the question of religious conflict as well, I think it is quite a significant risk. If I had to put it on a scale of 1 to 10, I would probably put it as a 6, as a rough guess, in that I think it is certainly a strong possibility. One of the things that DFID should be doing a lot more of is—well, there is no peace process—but movement towards a peace process on the ethnic question and investing a lot more in inter‑faith initiatives. I am told, and I am sure you would want to check this, that DFID spends currently no more than £10,000 on multi‑faith or inter‑faith initiatives, compared to the £600,000 that they gave for the startup of the Myanmar Centre for Responsible Business. Now, I am not knocking the Myanmar Centre for Responsible Business; clearly that is a necessary initiative, but a lot more needs to be done to look at inter‑faith initiatives and what can be done to prevent further violence that could derail the process.

Q84 Mr McCann: You have actually answered my second question as well. Could I perhaps put the same question to Lord Williams and the point about what you think of DFID’s work in this area, and what more they could do?

Lord Williams of Baglan: First of all, I would like to strongly echo Benedict’s remarks with regard to communal conflict. This is a real danger. A recent report by the International Crisis Group, which I am sure the Committee is familiar with, talked about the communal conflict, as distinct from the ethnic issues, being the dark side of transition. It seems to me this is something where, sadly, the danger has grown as things have opened up. I believe strongly, again as Ben said, that DFID should be doing more on this.

I have to say I find it quite difficult to get details of the DFID programme. I do not find the DFID website or, indeed, the UK embassy website in Yangon terribly helpful about this. It seems to be completely lacking in specificity. When I have made queries, too much is over on the side of business development and so on, which is very important to creating the right environment for flourishing reform, but inter‑communal conflict is the one issue in my mind that has the possibility of wrecking this process. Most of the conflict, as the Committee will be aware, has taken place in Rakhine state in western Burma or western Myanmar, but there have been signs in the last outbreak that it has actually spread to other areas in more central Burma, where there are also Muslim minorities. This should be a real priority for DFID. It is the number one danger to the reform and democratisation process, far bigger than anything else, in my assessment.

There are lessons to be learned from elsewhere. Inter‑communal problems are not new in Southeast Asia. Over 5,000 Muslims have been killed in southern Thailand in the last decade. In Indonesia, it has been a recurrent theme over the decades, so Burma is not unique in this regard. It is getting to grips with the problems and beginning to try to address them and defuse the tensions. So far, the Government has not been able to do it. I think that is a combination of a lack of determination, but also a lack of capacity. That is where DFID and other government agencies from other countries could be far more engaged.

Q85 Hugh Bayley: Lord Williams, I have two points I wanted to put to you: when we met General Aung Min, he was impressive. He appeared to have active engagement with the peace process, but the way he represented it to us made it appear as if the military would require there to be a ceasefire throughout the country before progress was made on reconciliation and DDR, perhaps devolved power on a state basis. My understanding of previous peace processes makes me feel that you should make progress where you can, when you can. To wait for the perfect negotiating situation runs a risk of the opportunity being closed off before you get to it. What would your view be on that?

Lord Williams of Baglan: I would agree with that. That is one of the lessons of the whole history of independent Burma since the British left in 1948. Ethnic insurgencies have been a recurrent problem. They have existed on and off throughout the past half century. There have often been ceasefires, either at a local level or with one group, sometimes better. The 30 October ceasefire agreement is probably the best it has ever got, but that will not hold unless we see a programme of real political engagement, what the differences are and how they are going to make progress. Progress in disarmament of the groups and so on will take some considerable time. Again, the agreement of 30 October is very welcome, but it is inherently precarious unless there is political progress.

Q86 Hugh Bayley: I suppose the second question is this: what can the UK, through diplomatic and military‑to‑military channels, as well as through the work that DFID does, do to encourage partial progress in the areas where partial progress can be made? We were told, for instance, that there were to be some top‑level military exchanges in both directions. Would this be helpful? How well do you think the UK knits together its military‑to‑military advice, its diplomatic support for a change process, with its development co‑operation?

Lord Williams of Baglan: The short answer to that is not as well as I would like to see. I say that having been a special adviser to two Foreign Secretaries and also having served many years in senior positions in the UN, including in Southeast Asia, in Cambodia for example and in Indonesia. I believe we do have a military attaché now resident in Yangon.

Hugh Bayley: We do.

Lord Williams of Baglan: I think that is an important advance. Soldiers like talking to soldiers, I suppose just as parliamentarians like talking to parliamentarians. That sort of across‑the‑piece co‑operation between DFID, FCO and MOD, all of whom have experiences that they can bring to the question of political reform, of disarmament and of moving towards peace agreements should be stronger. The weight of all three of these Ministries and Departments is not yet being brought to bear in Myanmar. That is my view.

Q87 Chair: You have already mentioned the religious conflict, and we had some engagement in that when we were visiting. First of all, we did visit IDP camps as we were driving from Naypyidaw to Mandalay, both a Muslim one and a Burmese one, and we met representatives from both the Rakhine and Rohingya community when we were in Yangon. Taking the former situation, there, although the evidence we got was that there had been external incitement, which led to burnings and some deaths, both communities felt that they had been well looked after by the authorities. Ironically in some ways, the Muslim IDP camp felt almost better looked after than the Burmese one. They were all confident that they would be able to move back and carry on. Indeed, the local representatives of the National League for Democracy were actually participating in this process of getting things back. That, whilst it was a disturbing development, gave the impression that it could be rebuilt.

Talking to the Rohingya and the Rakhine was a completely different situation, where actually both were very extreme. Obviously, the Rakhine view is that, actually, the Muslims are Jihadist subversives; they have no right to be there; they are Bengalis and their objective is to secure an Islamic state that will potentially secede from Burma. Obviously, the Rohingya say, “Actually, we are just an oppressed minority who have been here for a long time and are deprived of rights.” It is a very intractable situation. The point I am making is that, while there is concern about anti‑Muslim sentiment across Burma, how extremely worrying is that? Secondly, how can the Rakhine problem be contained, assessed and addressed?

Benedict Rogers: I have a number of thoughts in response to that. Could I first of all say how strongly I agree with Lord Williams’s remarks earlier on this subject? I would like to just add another reason why it should be a matter of deep concern to us. In addition to the potential for it to derail progress inside Burma, there is a very real risk—and we have seen evidence of this already—that what has been happening to Muslims in Burma has the potential to attract the attention of radical Islamists outside Burma and for them to use this as a recruiting issue. We have seen, particularly in Indonesia, a number of calls for Jihad against Burma.

My knowledge of both the wider Muslim community and the Rohingya community is that there is very little, if any, evidence of an extremist or a Jihadi movement among Muslims in Burma. Muslims in Burma, at least in my experience, have tended to be very moderate and not involved in extremist activity, but there is the potential both for them to be radicalised inside the country and for external radical groups to use this issue and, therefore, that is another reason why it should be of deep concern.

In terms of the solution for the Rohingya and Rakhine conflict, clearly the tensions go very deep. There are three ways forward. There are the immediate humanitarian concerns in Rakhine state. The latest figures from UN Watch are that 143,000 are internally displaced, but thousands have fled the country and are refugees outside the country. Often they leave on boats in extremely dangerous situations on the seas, and access to the camps is extremely difficult. I am sure you will have heard evidence of harassment of aid workers in Rakhine state, so there is clearly a need for DFID to do more in terms of putting pressure on the regime to open up access to the camps, protection for aid workers to make it possible to address the immediate humanitarian needs.

Two long‑term ways forward: firstly, clearly the question of citizenship of the Rohingya is at the root of this. There have been decades of the regime’s propaganda suggesting that the Rohingya are illegal immigrants from Bangladesh. The historical record shows very clearly that that is absolutely not true. As a people, they have been in Burma for generations and there is plenty of historical evidence for that. There may be a role for the British Government as a whole to do more in providing independent historical analysis that might actually counter the false propaganda in Burma and help establish the facts about the history of the Rohingya.

Linked to that is the need to maintain and increase pressure on the regime to address the question of citizenship, to amend the 1982 Citizenship Law and to move towards a citizenship law that says that whoever is born in Burma should be recognised as a citizen of Burma. The citizenship issue by itself is clearly not going to resolve the on‑the‑ground tensions between Rohingya and Rakhine. Therefore, that comes back to my point earlier about the need to invest in inter‑faith initiatives and this wider point of trying to address the question of the history and change people’s understanding, so they see the truth about the history of the Rohingya.

Lord Williams of Baglan: I agree with most of what Ben said. I have some nervousness about re‑looking at the history. As we have seen elsewhere—I served also in the Balkans—history is a dangerous terrain when it comes to finding claim to one’s land and territory, and so on, so I would be careful there. This is an inter‑communal conflict. It is being whipped up. The Jihadi element is certainly less than 1%, I would hazard a guess, but the potential is there for that growing. We saw that in Indonesia, for example, in the first decade of this century, when we had the Bali bombing and some bombings in Jakarta. The Indonesian Government has handled that and handled it well, both through security measures and through community measures. God forbid this sort of thing spreads to Myanmar, but the capacity of the Government there to address it, both in security and in community terms, would be very limited. I am worried that the borders with Bangladesh are very porous and unwelcome elements could easily come across that border.

Q88 Chair: I take from that a slight warning to the Burmese Government that, if they do not address this issue, what they claim about Jihadism will in fact become self‑fulfilling. Aung San Suu Kyi said she did not think the Government responded quickly enough when violence erupted, and she also made the point that there are no Muslims in the police force in Rakhine, which has a slight Northern Ireland familiarity.

Lord Williams of Baglan: You highlight an important point, Chair, in reference to the police force. I also mentioned this in my statement. If there are shortcomings in the army, those in the police force are multiplied tenfold. Their training, the way they handle these problems, is very bad. Some people, including the International Crisis Group, believe they have got slightly better in Rakhine state, but I am doubtful. Certainly, this is an area, as you alluded to, where we as the UK have an enormous amount of expertise and background that we could contribute, not least the transformation of the RUC into the Police Service of Northern Ireland, and the importance of that in addressing the conflict there.

Chair: That is very helpful. Greg, the next question is very much in your bailiwick, you will be relieved to know.

Q89 Hugh Bayley: Let me start with the general question: should DFID be doing more to build up formal institutions like Parliament, as opposed to or certainly in addition to its work with civil society?

Greg Power: I saw the transcript of a recent evidence session when you made this point. It is clear that DFID has historically preferred working with civil society. There are probably three reasons for reluctance to prioritise parliaments in particular. The first is that parliaments are clearly difficult, in the sense that it is politically contentious to try to involve yourself in the parliament of another sovereign nation. It involves you deeply in the politics of that country, which DFID has traditionally been nervous of. Civil society, by comparison, looks much more apolitical and much easier to do. It is a good thing.

Secondly, it is much easier to work with the executive than it is with parliaments. The executive exists to execute decisions. Parliaments do not actually implement anything. They are slow; they are laborious; they are deliberative by definition, by design. They are designed to slow down the process. There is often a tension between the desire to get things done quickly in situations like Burma and the desire to slow things down and get the legislation right. We have been working in Iraq for the last five years with the Council of Representatives there, and I remember being in a meeting in one of Saddam’s old palaces, which was substituting as the US embassy at the time, with members of the State Department and members of USAID. The State Department was very keen to get the legislation through very quickly, whilst USAID was there to slow it down to get the legislative process right. That tension exists in a lot of approaches to support to parliaments.

The third problem is parliaments are, by definition, complex. I am often asked the question, “Who is in charge of the Parliament?” It could be the Speaker; it could be the Secretary General; it could be the Chairs of Committees. There is no one person. Parliaments are unlike any other organisations. There is no one person in charge who can drive through a process of reform and change. It is a competing mass of different interests, which change over time. For those three reasons, not just DFID but donor agencies generally have much preferred to work with civil society, or with the executive at the expense of Parliament, and political parties for that matter.

Q90 Hugh Bayley: I do not know to what extent you or your colleagues are aware of the tiny bit of work, £100,000 worth of work, that DFID has started this year on parliamentary capacity building or indeed the potential for doing further work of this kind. We understand that they are planning to have a governance adviser permanently based in Naypyidaw. What skills and experience does that person need and what do you think DFID might do within the Parliament? It is planning to increase the spend from £100,000 to £1 million next year. How might that money be usefully used?

Greg Power: I do not need much prompting to criticise the whole idea of logframes, which informs most of what DFID does in terms of its governance work. As to working with the Parliament, international donor agencies have missed the opportunities to work with parliaments generally. They offer a way in to almost every single policy objective, by engaging with policy committees, by engaging with parliaments as conflict‑resolving institutions; there is a huge number of things that parliaments can potentially do, but they have been ignored because they are complex. If you are going to engage with a parliament, you need to engage at several different levels at once. You cannot go in at the top and get change to happen. You have to be engaging at many different levels. This requires a very sophisticated strategy, which is missing. This is compounded by the desire to fit everything into a logframe.

DFID quite rightly wants to ensure that there is impact in governance, but the logframe comes from development. If you are trying to build houses or get crops to grow, you have a certain number of bricks; you end up with a certain number of houses at the end. You have a certain number of seeds; you are likely to end up with a certain number of crops. Governance works completely differently. You need to be doing several different things at once to make sure that you get impact to happen, and this is missing. My one great thing would be, if you are going to engage with the Parliament, and I suggest DFID does to a much greater extent, engage at many different levels, understand the complexity of the organisation but also commit to long‑term support for the Parliament. Political change will not happen in one electoral cycle. If we think about our own parliaments and how long they took to develop, the approach in many developing countries is the assumption that you can concertina this process into three or four years and expect the whole institution to change. That will not happen.

Lord Williams of Baglan: I do not think I have much to add to that. £100,000 does not seem a big number to me. I think you are right to identify Parliament as one of the real weaknesses in Burma, and yet we are expecting so much and hoping for so much, as are the Burmese people above all, in the future in that respect. It certainly needs assistance and I would hope that DFID could do somewhat more in that regard.

Q91 Chair: Just as a practical point, what we appear to be doing is seconding staff from this House for periods of time. No disrespect to those very senior experienced people but, in some cases, they go out for a week and they go out for a couple of weeks. In fact, I am having a meeting with Oliver Bennett this afternoon; he is going for six months, but that is all we are talking about. Is the problem that you need to have permanent capacity to be able to do that and no such organisation seems to exist?

Greg Power: You certainly need continuity. I am aware of the work that Oliver is going to do, and I think there is value in trying to set up a research service and a parliamentary counsel has been seconded as well. These are good developments, but they are technical. There is this preference still for technical solutions to what are ultimately political problems. There has always been this assumption with parliamentary strengthening that, if you give a parliament enough resources, train the staff and give it enough capacity, it is bound to work. Of course, what gets in the way is politics. Most donor agencies have avoided the political incentives that cause politicians to behave in the way that they do.

The work that we do as an organisation is about understanding, firstly, why this is happening. Why are politicians behaving this way? What are the personal incentives? What are the political, institutional and party incentives that are causing this to happen? All parliamentary strengthening and all governance work is not about changing institutional structures, so much as changing the behaviour within those institutions. The reason for changing rules is to get people to behave slightly differently, both staff and members, and that element of it is often missed, because there is a desire to do something technical. While there is a merit to doing something technical, you also need to be thinking, “What is this technical intervention meant to achieve in the long run?”

Q92 Fiona Bruce: I just wanted to ask you: obviously we are interested in discussing whether DFID should have more experts to advise on parliamentary issues. Could I ask you to comment on the observations that both Benedict Rogers and Lord Williams made about the perhaps lack of capacity of experts to advise on ethnic and religious tensions as well, and whether that is an investment that needs to be made by DFID?

Greg Power: It is slightly out of my area of expertise, and I am inclined again to defer to Michael and Benedict. It seems to me that there is an absolute merit in engaging people with the Parliament to engage with some of those more deeply political issues. As I have said, most of the intention seems to be to provide technical solutions to what are political problems and you miss the sensitivities which are then shaping the politics themselves.

Lord Williams of Baglan: I was just going to say I agree very much with what Greg says. I hope I am not misjudging DFID here, but Burma is not an everyday development problem, as it were. It is politics that is holding it back. At the same time, we all recognise that there has been political progress, but they need more help in making the ultimate progress to sustaining a democracy that embraces all their peoples.

Chair: I think DFID sometimes is uncomfortable with politics but, as you say, if you want to deliver development, you cannot ignore politics.

Q93 Hugh Bayley: I wanted to ask some wider questions about the way that UK DFID in particular does political and parliamentary work. I should perhaps, for the benefit of the panel if not for anybody else, remind people that I come with some baggage as a former Chair of the Westminster Foundation for Democracy. Trying to leave that aside, I am not making a special case for the Westminster Foundation; I am concerned that DFID spends far more money on parliamentary strengthening than the relatively small grants in aid that the Foreign Office gives to the Westminster Foundation. Overwhelmingly, that money is spent with either foreign providers like NDI, a very good organisation, or multinational institutions like the UNDP, with the consequence that we fail to build in the UK a strong capacity to deal with strengthening parliamentary and political systems of our own. Although I would not for one minute suggest that the Westminster model can be packaged and dumped as a solution in other countries, there is some very special UK history and experience that, on occasion, is an appropriate part of the mix. We fail to do our job if we do not have a UK institution with the kind of firepower of the NDI, the IRI, the German Stiftungen, the Canadian Parliamentary Centre or others.

Do you think that DFID, with advice from the Foreign Office, should step back and think about how the UK could develop a national capacity to deliver help and advice on parliamentary capacity building?

Greg Power: I should start by declaring a conflict of interest in that, although we work very closely with the Westminster Foundation, we are also sometimes competing with them for work. There is certainly merit in that idea of building up that brand. The Westminster brand is incredibly strong. We have experienced this because, again, we work very closely with parliamentarians here and in different parts of the world, and the Westminster brand is a very strong one. It can work in different ways in different contexts. I was in Peru a couple of years ago, doing some stuff for International IDEA and asking about the perception of International IDEA. One of the politicians in the Peruvian Parliament said, “We didn’t like working with the NDI or IRI particularly, but we do not fear Swedish imperialism.” There is that danger: the Westminster brand is a very powerful one, a very strong one, but it can have negative connotations to some extent.

The bigger problem for DFID, in terms of commissioning this work—the Devex website has touched on this a lot recently—is that it does tend to prefer the bigger providers, the people who can run big projects for DFID, because DFID is trying to minimise its management. This does work against organisations like us or Westminster Foundation, which is smaller, to the advantage of NDI, UNDP and others. The work that the bigger organisations do is not necessarily better and, in my experience, it is definitely not better.

Q94 Chair: It is a slight chicken and egg. What you are saying is, unless you were bigger, they would not commission you, but they will not commission you to enable you to get bigger.

Greg Power: Our whole approach to parliamentary political party strengthening is that, often, the big projects that try to go in and change everything at once are based on the assumption that you can change everything at once, that you can change a parliament within five years. Actually, the smaller projects with very focused entry points tend to be much more effective. This idea that you can train politicians in new democracies to be politicians is absurd. Politicians learn by watching what other politicians do, and you build up a culture around the institution. That is what is missing in Burma and in many other places: the parliamentary culture. The rules of the game are there, but the spirit by which the game is played, the games within the rules if you like, is not there. That parliamentary culture is missing and that is a much more sophisticated and complex strategy than simply going in and trying to change the standing orders of an institution.

Q95 Hugh Bayley: Would DFID be taking some sensible steps along a path towards improving the work it does in this field by employing more people? At the moment it employs just one person in East Kilbride who has a background and expertise in parliamentary capacity building. Should it have some people in Palace Street? If so, what sort of people should it be employing to try to fashion out a strategy for work of this kind within the Department?

Greg Power: I will say one thing and then let my colleagues. The people who have been in that role, in my experience, have been exceptionally good at what they are doing and often very stretched, right across the institution. There is more interest amongst Government advisers in doing work with parliaments and political parties than is evidenced by the fact that they only have one person covering all of this. It would make complete sense to have more people trying to work out how to work with parliaments. Given that DFID was at the forefront of political economy analysis, the drivers of change stuff, trying to understand why certain reforms were not working and how you make them better, the use of political economy analysis seems to be sparsest in the most political areas, namely with parliaments and political parties. They could do well to expand their resources.

Lord Williams of Baglan: I agree with that and I am surprised by what you say that there is only one person in DFID charged with looking at these issues. Just reflecting on my own experience with the UN in Cambodia, the Middle East and the Balkans, when there are elections and parliamentary and legislative reforms, often I would be hosting visitors from NDI and other American institutions, and there would be nobody coming from the UK. There would be somebody from the local embassy, perhaps having a watching brief, but there would be nobody there really making that British commitment and contribution, which is so needed.

Q96 Jeremy Lefroy: Just picking up a point that Mr Power made, is this not a recurrent theme that DFID really does not look at smaller organisations, which are often the best, in my experience? I would say because of the need to spend money on a large scale, hopefully with value for money—I am not always 100% sure—it therefore dismisses smaller organisations.

Lord Williams of Baglan: It is partly dismissing the smaller organisations, but it is also this view of development that has become doctrinal within DFID that politics is something that must be avoided. All the Members would know that politics is key to development; that is what gets it going. As I say, from my experience in the UN and in various countries, I have not seen DFID playing the role that I would like them to play.

Q97 Jeremy Lefroy: Can I just ask? Mr Bayley referred earlier to the Stiftungen. Do the Abegg-Stiftung and the Konrad-Adenauer-Stiftung receive money from their German development agency?

Lord Williams of Baglan: I am not sure.

Greg Power: As far as I am aware, they do, yes.

Q98 Chair: Actually, that really comes to this question about the role of the Westminster Foundation. It is currently being evaluated, but should it be beefed up so that it can be much more of a part of DFID’s programme? I am deferring to someone like Greg Power. It can then presumably provide and procure on behalf of the Government, if it had an expanded capacity. I suppose we all have to declare an interest as parliamentarians, because what you are talking about is deploying more politicians to meet politicians, more often, in more circumstances. We as a Committee always try to meet parliamentarians when we are visiting countries, and we are constantly frustrated when they say to us, “We’ve got no resources, no capacity. This is great to meet you today, but where are you tomorrow?” Well, we are on the plane back home. Is the Westminster Foundation the right vehicle or is there some other model, and should it be more resourced if there is?

Greg Power: As I say, I have a slight conflict of interest in that we are occasionally competing with the WFD for work, although we do work closely with them when we can. There are several different models. The point about DFID working against smaller organisations is a very valid one. Often the smaller organisations working in the development field more generally are small because they have a very specific expertise. With us, it is parliaments and political parties. The bigger organisations, such as UNDP and NDI, try to do everything, and I would just reinforce what Michael said about the aversion to politics and the assumption that you can avoid politics and expect to get the results that you are trying to achieve. There is an awful lot of expertise in this country; there is an awful lot of expertise within Westminster, which could be much better deployed. Whether that is through WFD or letting a thousand flowers bloom and having specialist organisations that can do this work is a decision for others.

Chair: I think you just put a quote in the report there.

Q99 Chris White: Just to go a little bit further down the political change route, how important do you think political change is to achieve a greater degree of foreign investment?

Lord Williams of Baglan: That is difficult, because it is one of those yes or no questions. There has been foreign investment in the past in many dictatorships. Whether those dictatorships have actually brought enduring growth and development to their economies and societies is more problematic.

Q100 Chris White: Perhaps we could rephrase it in a different way. What do you think are the biggest barriers to economic growth in Burma?

Lord Williams of Baglan: Gosh, that is a tough one. The good news is that this is a country with an extraordinary range of resources. There has been a bidding round now with regard to oil and gas, and I think a number of British companies are involved there, including BG, which has put a bid in. The middle class is very nascent, compared, say, to the middle class in Thailand or Indonesia, let alone in Malaysia. Business skills generally are very limited, because this has been a country which, for half a century, has been dominated by the state and the growth of what one might call a capitalist class has been inhibited in that respect.

Q101 Chris White: You talk about business skills. Do you see this as an educational problem?

Lord Williams of Baglan: Partly educational but, more than education, having the environment for business to flourish and for private enterprise to play its real role. That is happening and has been happening for the last few years but, as you will know from your visit, the state still plays a huge role in the economy and society of Burma.

Q102 Chris White: Do you think DFID has a role then?

Lord Williams of Baglan: I would like to think so, yes.

Q103 Chris White: On the dark side a bit, what role do you think bribery and corruption has and how can we target that and remove some of that emergence?

Lord Williams of Baglan: That is difficult. With the absence of Singapore and Japan, I do not know an Asian country where bribery and corruption are not serious problems. One important factor to try to prevent that is the development of representative institutions. It is my belief that, where representative institutions and legislatures exist, corruption tends to be less in the Asian experience.

Benedict Rogers: Could I make a couple of points in response to this question and then, if I may, Chairman, also make a point in relation to the previous discussion about Parliament? On this issue, there are actually two crucial issues that, if they are not resolved, will make it difficult for business, in addition to the issues of corruption. One is the question of the regulatory and legislative framework in all sorts of ways, and particularly in terms of issues around land tenure and, indeed, legislation to promote responsible business. One of the concerns of civil society inside Burma regarding DFID’s funding for the Myanmar Centre for Responsible Business is that, from what I gather, it was done without very much consultation with civil society. What Burmese civil society really wants is much greater emphasis on domestic laws to promote responsible business, rather than foreign experts coming in and talking about responsible business. The legislative regulatory framework is crucial.

The other key area that I think is crucial is peacebuilding, both in the ethnic states and in relation to inter‑religious tensions. Clearly, if there is conflict, there is not stability. If society is not stable, that is not very conducive to business. It is worth noting that the ethnic states, all of which are around Burma’s borders, include some of the major trade routes into the country and are among the most resource‑rich parts of the country. If those are not at peace and the peace is not secured and stable, it will make it very difficult for investment.

Just briefly returning to the question of Parliament, there is one contribution that would be worth DFID considering. Perhaps they are doing something on this, but it would be worth looking at more. Greg talked about DFID’s tendency to work with civil society. I do not think it should be either/or and, actually, DFID could play quite an important role in helping Parliament in Burma to understand the role of civil society, and helping civil society engage more with Parliament, in the way that we do here.

Q104 Chris White: My final point is in regards to the chances of success between Burma and EITI. You have already mentioned, Lord Williams, the oil and gas sector. What potential do you think this has to change the nature of infrastructure and economics in general?

Lord Williams of Baglan: The potential is quite substantial. If gas and oil are found in the quantities that many believe are there, that is going to be a powerful input into developing the economy. Of course, as we know from elsewhere, it is not just a question of having the resources and then the capacity to extract the resources. It is how the wealth that flows from that is managed in a country and a society.

Q105 Chair: The last time the Committee did a report on Burma, which you gave evidence on then, we were only able to visit the camps on the Thai side of the border, which is what we did. Now the situation is changing. Clearly, there was almost a tension between whether the time is now for people to move from the camps back, with other people saying they are not ready to move back. What is the balance between supporting people in the camps and using the resources to help them get back? In other words, they have homes to go back to and that is possible. How practical is that?

Benedict Rogers: The time has not yet come to think of actually moving people back, but certainly work should be done in preparing for that time. The conditions at the moment are still not right for people to go back. Even in the ceasefire areas, in some areas there is actually an increased military presence. That is not going to make people feel secure about returning to their villages. Many villages have been destroyed and have not been rebuilt. There is the question of landmines and a lot of work needs to be done in landmine clearance before people can go back, and there is the whole question of livelihoods. All of those things should certainly be looked at and work should be done in those areas in preparation for people to go back.

At the same time, the refugees need to survive where they are at the moment. As a result of not only DFID but international focus shifting into Burma, I believe it is the case that rations have been cut quite a number of times and rations are now at a dangerously minimal level. Now is certainly not the time to withdraw from supporting the camps. Indeed, there is a case for looking at the level of support for the camps and rations, making sure that the refugees are supported in their survival needs, whilst preparing for the future.

Lord Williams of Baglan: I do not have anything to add to that.

Q106 Fiona Bruce: This is in connection with the judicial system. We talked about the parliamentary procedure and the creation of legislation, but it seems to me so often there is a void between that and the actual enforcement and application of it. I wondered if you would like to comment on the need to create more robust judicial institutions, right from the grassroots level of legal aid lawyers, people being able to get advocates when they are charged and local police and magistrates understanding legislation—we hear, for example, of some of the remoter regions still applying outdated legislation—and then ensuring that there is an appropriate judiciary trained up. Do you have comments on how this could happen? Should we engage the Law Society here, the Bar Council and so forth?

Lord Williams of Baglan: I do not have a lot of experience specifically on the judiciary in Burma, but what I know bears out what you are saying. Even within the institutional landscape within Myanmar, the judiciary is really one of the weakest institutions and has been denied funding and proper training of its people.

Chair: Sixty years of military dictatorship does not encourage the rule of law, does it?

Lord Williams of Baglan: No, it does not. All I can say is that I really think that this is an area where substantial reform needs to be carried out. The UK can play a role. I do not know where DFID is with regard to this, at the moment. Some of the international institutions, the UN itself, might and should be doing more in this regard. As we all know, the rule of law is so fundamental to the buttressing of democracy.

Benedict Rogers: Just to add to that if I may, I am sure you will be aware that Aung San Suu Kyi, as well as talking about the constitution, has made the rule of law virtually her mantra that she repeats.

Chair: She chairs the committee, does she not?

Benedict Rogers: Exactly. Just as there is a lot of emphasis on the goal of trying to help the military move out of politics and become a professional military under civilian control, equally, there is a real need to help the judiciary be de‑politicised after decades of dictatorship. They were used to simply making their conclusions and passing sentences according to the political instructions from the regime. Creating a sense of a truly independent judiciary is vital.

Q107 Chair: She did specifically ask for that funding, so we will take note of that. I just wanted to say that DFID is spending £69 million in the current year. We have discovered that the Japanese are spending $900 million in the current year. Do you think we could and should spend more? Is this the moment to increase that? The previous evidence was about health; 50% of that money is going into health. Virtually nothing is going into education and we have discussed parliamentary strengthening, judicial strengthening and others. I am leading you a bit, I suppose, but do you think we should increase the budget? Do you think there is capacity for increases and on what sort of scale?

Lord Williams of Baglan: From my perspective, I think two things, Chairman. Firstly, I would plead strongly for DFID and the Government to dedicate additional resources. We are now in an absolutely critical period for Burma/Myanmar’s development. The next two years will show whether we get through this, whether we have successful elections and a proper transition from military rule to constitutional government. As I said at the beginning, I am guardedly optimistic on that, but it needs as much support, including financial support, as can be marshalled, so I would like to Government and DFID in particular to dedicate more to Myanmar in the coming period.

Specifically with regard to the DFID budget and the way it is allocated in Myanmar, I am surprised that 50% of this is dedicated to health. I am trying to choose my words carefully, because I know how under‑developed the medical structures are in Burma; nevertheless, as to whether that is the right judgment, my personal view is that it is not. The next two years are going to be fundamental to the creation or not of a new Burma, and that is where I believe DFID should be targeting its resources.

Benedict Rogers: I agree very much with Lord Williams, although I think there is a necessary balance to strike between, on the one hand, preparing for the future but, on the other hand, addressing the very real humanitarian urgencies at the moment, particularly Rakhine and Kachin, which we have not discussed today. I would say certainly I think additional resources, but I would make the case for DFID to perhaps improve the way it consults with civil society over the deployment of resources, as well as looking at the institutions of government, and to see civil society not only as civil society in Rangoon, but also the groups working along the borders, which are often thought of as exiles who are not in the country. In fact, they are going back and forth across the borders all the time and very much represent their people in the ethnic states.

If I could be specific on that point, it is very welcome that the United Kingdom Foreign Secretary’s Preventing Sexual Violence Initiative is now being developed in Burma and applied to Burma, but I note with some concern that, at the moment, there is no indication that the projects that are being developed under that initiative are consulting with or working with the Women’s League of Burma, which is a major civil society organisation with a lot of on‑the‑ground experience. That would be something that I would encourage DFID and the embassy to do.

Greg Power: Just one final point: to come back to spending specifically on parliaments, it will inevitably be a very small part of the budget. My plea would be that I think the budget does need to be increased, but it is more important to spend that money wisely and shrewdly. Our experience in Iraq was that we were running a project at about £500,000 a year, which was largely security costs of getting to and from Baghdad at the time, compared with another big aid agency which was funding a project with the Council of Representatives that was $11 million a year. I would argue that we were more effective, because of the way that we approached the work itself. My final plea, if you are going to work with parliaments and the political parties, is to engage with the politics and use political economy analysis, which DFID really fought for, in the support to the Parliament itself.

Chair: Thank you very much. That is all extremely helpful. As a Committee, we have found this particular report fascinating, particularly compared to seven years ago. The point that you have made, Lord Williams, is one that the Committee feels. There is this moment of opportunity. Yes, it may all go pear‑shaped but, if you do not take the chance now, you may never get a better one. There is nowhere else in the world where we are operating where that would be the case. That is a message the Committee has got very clearly, not just from you but from our own experience. Hopefully our report will reflect that. It will certainly reflect your evidence, both what you put in writing and your oral evidence, which I found really interesting. I very much appreciate the fact you have been able to give it to us. Thanks a lot.

Oral evidence: Democracy and Development in Burma, HC 821 3