International Development Committee

Oral evidence: Responses to the Ebola crisis: Follow-up, HC 338
Monday 30 November 2015

Ordered by the House of Commons to be published on 30 November 2015.

Written evidence from witnesses:

–       Department for International Development

Watch the meeting – Monday 30 November 2015

Members present: Stephen Twigg (Chair); Fiona Bruce; Mrs Helen Grant; Fabian Hamilton; Pauline Latham; Jeremy Lefroy; Wendy Morton; Albert Owen

Questions 102-141

Witnesses: Rt Hon Justine Greening MP, Secretary of State for International Development, Marshall Elliott, Director, Joint Inter Agency Taskforce for Ebola, Department for International Development, Brigadier Tim Bevis, Head of Strategic Studies, Ministry of Defence, and Tim Baxter, Deputy Director, Health Protection Programmes, Department of Health, gave evidence. 

Q102   Good afternoon, everyone.  Welcome to the Secretary of State and to the other witnesses this afternoon.  Today’s session is part of our inquiry on responses to the Ebola crisis, following up a piece of work that the predecessor Committee did in the previous Parliament.  In a moment we will come to questions about that, but I would like, as this is the first opportunity since last week’s announcements, to invite the Secretary of State to comment on the new strategy that was set out a week ago around overseas development assistance, and the process for that going forward.

Justine Greening: Thank you very much.  Going into the spending review, it seemed like a good chance to start to pull together the various shifts that we have already seen in the Department, to assess what they meant for us but also to set them against some of the global challenges that we can very clearly see happening outside of the UK, and to start to look ahead and ask how we bring where the Department has got to together with the global challenges.

Essentially what you see us doing with this strategy is, first of all, being very clear that the UK’s engagement in international development is absolutely 100% in our national interest, and being very clear about why we say that is the case.  We are being seen as stepping up to the plate increasingly on tackling resilience and responding to humanitarian crises, and there is the role that we have increasingly played over recent years in work by the Department to support peace and security.  Particularly you will have seen this document being released against the Strategic Defence and Security Review.  Also, there is our role in driving global prosperity and recognising the fact that, frankly, for many, many countries jobs and economic development are the key routes out of long-term aid dependence and tackling poverty.  Finally, there is this core piece around tackling extreme poverty, and this issue of leaving nobody behind and making sure that that more traditional element of what DFID has done continues, and continues to sit alongside all of the newer work we have engaged in over the recent years.

Charting that forward, one of the key promises that we made was to continue our spending of 50% of our own departmental budget on particularly fragile and conflict states, and that very much reflects the fact that so much more of our work now is on key regions and countries that are increasingly fragile and in conflict, and therefore we wanted to formalise that in this strategy document too.  There were a lot of other things in it, Chair, but that possibly gives a quick synopsis.

Q103   Chair: Thank you.  How does the 50% compare with the current picture?  Is it a significant increase?

Justine Greening: When we came into office last time, we said that we would spend 30% of overall UK Government ODA.  That was just on fragile and conflict countries themselves.  What we have done is essentially made sure that we have our definition of “fragile and conflict states” right, because we want to recognise the fact that it is not just states; it is also regions.  We have been up at around 50%.  Now, rather than just having that as something that we happen to be at, we actively think that we need to be at that percentage to deliver on the strategy that we have given ourselves.  Effectively, half of the aid budget is going towards helping countries that are either in danger of or have already slipped back into conflict and are innately fragile.  Half of our work is helping other countries continue to move forward, and in doing so hopefully making sure that they themselves, when crisis hits, are better able to cope.

Q104   Chair: Does this mean, in the medium term, we are likely to see a shift towards the Middle East, for obvious reasons?

Justine Greening: It reflects the fact that that shift has taken place, and we expect that to continue.  The final bit about this that was important to me was recognising that the “how” of what DFID does has changed as well.  So we are working across Government, if you like, bringing to bear the whole of Government on our international development approach in a way that we have never really done quite so overtly before, and the evidence session today on Ebola was really an early indication of how effective we can be as a country in working with other countries on their development, and in this case a crisis response, when we are able not just to marshal DFID’s resources, but to work with the Department of Health, the MOD, increasingly with BIS on prosperity, and the Foreign Office, to really make sure that the UK Government’s international development strategy is delivered by the UK Government—led by DFID, but, where appropriate, delivered by our whole Government.  That is a really welcome shift.

Q105   Wendy Morton: First, I just wanted to go back to this 50% of ODA money, and the fragile states.  Can you clarify whether it is a formalisation of this shift from 30% to 50%, given that it appears that we have been spending that level in the last few years anyway?  The second part of the question is, given this apparent formalisation of a shift towards more emphasis on fragile states, how influential were the SDGs and the SDG process in us shifting our position?

Justine Greening: We have not always been at 50%.  This is something that we have been getting towards over the past 12 months, really.  What we are saying, though, is that we want to recognise that that is not only where we should be; we need to stay there.  It needs to be part of our strategy, rather than something that we just happen to end up spending when you tot up what we have been working on.  You asked about how it ended up getting formalised, and the link to the SDG process.  There was a bit of a push and a pull.  There was a push in the sense that, frankly, that is where we need to be.  We have, unfortunately, got what has been a growing list of fragile and conflict states in which DFID needs to do a lot of work, and we have been, but at the same with the SDG process and when you look at where countries failed on the MDGs—which ones were not making progress—it is very clear that those are the ones that suffered from instability of some sort, sometimes man-made, because of political conflicts, sometimes climate-change-related, or a country that had a tendency towards having the sort of thing that Nepal suffers, for example, an earthquake.  Essentially it was saying that if we want to leave nobody behind, which is a really important part of the next 15 years, we have to overtly be prepared to make sure we have a strategy for working in fragile and conflict states.  The key questions are about how you get development happening in the toughest places and how you stop some of the most fragile places, for whatever reason, slipping back wherever possible, so you do not lose the gains, and those are some of the areas in which we will continue to work.  This is really formalising that intent for the first time.

Q106   Fiona Bruce: Secretary of State, you talked about many different Government Departments now being responsible for applying the SDGs, led by DFID.  I was therefore quite surprised to hear, if I am correct, that the Cabinet Office is jointly responsible for co‑ordinating that.  I just wondered how that will work out in practice, and what the lines of accountability will be.

Justine Greening: The Cabinet Office’s role is perhaps more to make sure that the UK’s response to the SDGs is well co-ordinated.  The difference with the SDGs versus the MDGs is that the MDGs were really focused on developing countries.  These SDGs are universal; they apply to all countries, including our own.  The Cabinet Office role is to co‑ordinate that UK Government response to the SDGs for our own country.  Of course, what DFID is leading on is our work with other countries around the world to help them meet the SDGs too.

Q107   Fiona Bruce: And with other Departments, where they work in other countries.

Justine Greening: That is the work that DFID will lead.  Part of it, of course, is also decided at National Security Council level.  You will have seen that some of our cross-departmental funds are NSC-led, but broadly yes, it is a DFID strategy that is delivered across a number of different Departments, and we set out our key objectives in this document as well.

Chair: Thank you very much.  We will now move on to the questions on Ebola.  We are going to start with questions that relate to DFID’s response to the crisis. 

Q108   Albert Owen: Good afternoon.  First of all, in your written evidence, you accept that the outbreak exposed weakness in response and preparedness in the systems of the UN and the international community.  What has been done since last year to improve DFID’s own response and preparedness?

Justine Greening: When the Ebola outbreak took place, a fair amount of work took place within Sierra Leone itself, to initially work and provide funding for charities like Médecins Sans Frontières‎, more broadly in West Africa, and of course we can talk more this afternoon about the huge amount of work we then did.

I would like, Chair, just to take this opportunity to say very publicly a massive thank you to not only staff in the Department for International Development, of whom 250 surged to work on the Sierra Leone and the Ebola project, many of them going out to Sierra Leone, into a country that had a virus that we did not have a cure for, was more easily spread than AIDS but had no vaccine at that stage like Polio. People ran towards that and got involved, and were prepared to help us scale up in the way that we needed to in order to have any chance of working with Sierra Leone to deliver that.  Thank you to all my DFID staff, who spent months out there, many of them at incredibly short notice.  Also, though, thank you particularly to the MOD, with whom we had an unprecedentedly close working relationship in order to tackle Ebola, but also to the Department of Health and Public Health England.  We had NHS nurses out there, but we also had PHE doing a lot of our lab work and overseeing that aspect of getting to grips with Ebola.  We literally could not have tackled it unless we had worked in the way that we did.

You asked what our learnings are, quite rightly.

Q109   Albert Owen:  Yes.  By your own admission, as a Department you say that things were not quite as you would have liked them to be with the UN systems, so what have you done so that, if another outbreak came, you would not just be waiting for the WHO; you would be there ready to go?

Justine Greening: Within the UK Government, we have developed three cadres of emergency response staff, who now can respond.  One is the UK International Emergency Trauma Register, which is now continuing to be developed and is providing surgical staff.  The second is to essentially formalise the response of, in particular, NHS nurses and doctors.  The third is the equivalent for Public Health England, so we now have public health specialists who are on hand.  Internationally, we are working with the WHO, which is now putting in place a similar cadre, internationally, of healthcare staff who can respond.  Of course, all of these are mobilised through work with DFID.  We are often the team on the ground in these countries.

Alongside that, in the region, we are part of an overall WHO effort that is putting in place much better early-warning surveillance and response, and of course that sits alongside broader World Health Organization reform, which is looking at how that organisation can get better than it was at its own emergency response.  That includes the people side, which I have talked about, but also how it then responds and also critically puts contingency funding in place.

The last piece, before I finish, is also working with organisations like the World Bank, which itself is looking at how we can put in place more innovative mechanisms that give pandemic emergency funding, but also possibly looks at some kind of insurance mechanism that can be put in place to help insure against these risks and mobilise funding that can help when those risks crystallise.

Q110   Albert Owen: I have just one final remark I would like to make.  You are not waiting for the WHO; you have got all of these cadres in place, and I hear what you are saying there.  We are coming on to reform of the WHO a little later in the questions.  Do you think that the reform in itself—because it has been going on for some time—has made it frustrating for your Department so that it cannot act as quickly as it possibly could?

Justine Greening: I would not say that.  In the period that we went through, we did react quickly to the Ebola outbreak.  Our initial funding, working with people like MSF, was going on in July, and we were already looking at action on the ground in June, so we did respond quickly.  It was right for us, initially, to really push the international system to respond.  If you look at overwhelmingly the emergencies that we would be involved in, whether it is Typhoon Haiyan or, indeed, responding to the Syria crisis, that is through the UN system.  We would have liked to see the UN system step up and respond.

Q111   Albert Owen: I am glad I asked a supplementary, because that was my original question, and you are now telling me that the international systems were not in place.  What needs to be improved there?

Justine Greening: Let me just finish on that other bit, Albert.  We were pushing the system to respond.  It was very, very clear, broadly for reasons of capacity that was not going to happen.  At that point we then stood forward in August/September time to directly lead the response in Sierra Leone.  The US took a decision that they would do that with Liberia, and France with Guinea.  In August we had already set about the plans to start building Kerry Town.  Have we got into a better place now?  I think that we have.  Having said that, when I have gone back and thought about this myself, this particular crisis had a different aspect to it, because it was responding to an Ebola outbreak that was clearly spreading very rapidly.  Was it better to have a country—Britain—working hand-in-hand with the Government of Sierra Leone, and then able to provide the investable strategy that other countries like Norway, Australia, Korea were then able to put their own resourcing behind?  That streamlining did make for a more effective response. 

There is still lesson-learning to take place.  Could we have done the more consensual, multi-partner, less command-and-control structure that you often see as a feature of UN responses, where you have perhaps the World Food Programme running the food cluster or UNICEF looking after protection of children and minors on the ground?  That would have been difficult, so when I look back on this, the fact that we did step into the breach made for a stronger response full stop, and in the end a faster response.  However, this was unprecedented; it was an Ebola outbreak like no other, it turned out.  We can see that now with how long the disease stays in survivors.  In the end, yes, this was something that rapidly developed.

Q112   Albert Owen: I do have one more question because you have enlarged on it.  With regards to Sierra Leone, now, some of the issues that we have been discussing with other witnesses is whether there is a possibility that because of the Ebola crisis, all of the other good work that has been done in the area by your Department and others has been in the background and perhaps will not be looked at again when this is really over.  How would you respond to that?

Justine Greening: I do not think that will happen.  I am going to ask Marshall, as well, to respond to this, because he has led so much of the work in Sierra Leone.  The reality was that when Ebola hit we absolutely had to tackle that, because there was no getting anything back on track until we had tackled that outbreak. 

Now we face a number of new challenges that we also have to get on top of.  We had worked very hard to get girls into school in Sierra Leone, starting from a very low base, but progress was being made.  That break in children’s education that we saw over a large period of the end of last year and beginning of this year means that we have to get that back on track.  Having said that, there are other areas, actually, where in its own way Ebola unlocked some progress: for example on FGM, where we saw FGM largely stop during the Ebola crisis.  Sierra Leone has now signed the Maputo Protocol.  It is the final country in West Africa to do that, and of course we are very keen to now work with Sierra Leone to keep that progress in place. 

We want to play our role in now getting Sierra Leone back on track, and continuing to hopefully see, particularly on its economic development, that go at as fast a rate as possible.  Before Ebola hit, it was the second-fastest growing economy in the world.  Marshall, do you just want to add to that from your perspective on Ebola?

Marshall Elliott: It was incredibly hard to sustain normal development when you had the outbreak across the whole country.  I am sure that you will appreciate that.  A lot of partners left.  A lot of the private sector left.  However, I have to say that once it got to the point where it was only left in three districts, it was in three districts for several months but even at that point we worked with the Government to design an early recovery programme, which meant, even as far back as April, we were talking about being able to re-open schools and starting also to rebuild other elements of the health system—for example, putting infection prevention control into facilities all around the country, to help stop it coming back, and actually that was very successful: we managed to contain it for many months in only a certain number of districts, so the recovery piece did begin, even while we were still fighting Ebola.

Q113   Pauline Latham: How well do you think DFID’s humanitarian surge capacity operated during the crisis?

Justine Greening: I do not think that we could have asked any more of it, and that it is one of the aspects of the response of which I am most proud.  I had people in my own private office go out and be part of the team for months.  Some of them are just arriving back now.  Many of them thought that they might be there for a month or two, and ended up staying six, nine or 12 months in some cases.  We surged 250 people.  The rest of the organisation had to continue delivering on all our promises and programmes that were under way, and the Department stepped up and did that, and I am really proud of the fact that we did not have to push at all to find the surge staff.  They came forward voluntarily and did an amazing job and put themselves in a country where there was this virus, an epidemic, that had broken out, and most people would have wanted to not even go there, but my DFID staff all stepped up.  We had no challenges on that front.

Q114   Pauline Latham: They were very brave, because I went out with the Committee, and I did not feel totally secure at the beginning of it, when it was just taking off, and I honestly thought that it was a silly place for the Committee to go, and we came back and you were out there on television, so I think everybody was very brave.

Justine Greening: I should also say that we had a lot of local staff in that office, who had their own concerns for their own family, and people got on with their jobs and came into work.  In fact, more than that, they were working pretty much seven days a week and around the clock.  Ebola did not take the weekend off, and neither did any of the people involved in this response.

Q115   Pauline Latham: Did it have any impact on delivering other things through DFID?  Did it mean that it was a bit of a struggle to keep going?

Justine Greening: I think, overall, no.  We managed to juggle all the various balls.  We certainly did not take our foot off the pedal in responding to things like Syria.  So no, frankly; we had to get on with delivering everything and we did.  People worked hard over that period, and I would like to say a very public thank you to them for doing that.

Pauline Latham: This was bad enough, to have this crisis, and then there was the Nepal earthquake and Syria, so you have had a lot on your place.

Justine Greening: And, of course, over that summer we had also been dealing with the violence in Gaza, which was ongoing and had been very serious and a big issue for the Department, and also in Iraq, where we had seen ISIL suddenly start to take lots of territory.  Over the course of that summer we had also been responding to helping the Yazidis who were stranded on the mountain, and working with the RAF doing airdrops of water and vital supplies to them.

Q116   Mrs Helen Grant: Obviously with 250 great staff gone, you say that there was no real impact.  How did you manage to do that?  What measures did you put in place to cover the fact that you had lost 250 very good people?

Justine Greening: I think that there was a discussion at the Director-General level around making sure that we were managing the stresses and strains on people.  My main concern was actually with the team in Sierra Leone, who were literally working seven days a week, and there was a very structured day that would involve, for example, a meeting at 8.00 every night between a DFID team, the Foreign Office, the MOD, Public Health England and the Department of Health, who would literally go into a big hangar-style room to run through what was going on, the core stats and what was happening in the following days.  You can imagine that it was relentless, and the key thing was to make sure that we surged fast enough to enable people to keep on working.

Q117   Mrs Helen Grant: I understand the pressures there, but I am just thinking about the other crises and everything else that DFID also have to deal with.  I am almost asking how you managed back here.

Justine Greening: We had to make everything fit.  Unfortunately, like the MOD, you have to, in the end, respond to everything that comes on to your plate, so we delivered what we said that we would deliver, in terms of our results framework, and people just worked incredibly hard.

Chair: I think that it is fair to say on behalf of the whole Committee that we want to thank and put on record the Committee’s appreciation for the hard work of DFID and the other Government Departments and those working for them through that and other crises. 

Q118   Wendy Morton: The importance of community engagement in the response has been emphasised to this Committee.  How did the UK response engage with the communities in Sierra Leone?  I would be interested to know how this developed over the course of the outbreak.

Justine Greening: There were probably two or three elements.  One was about, first of all, understanding almost the anthropology behind Ebola.  With some of our core scientific leads across Government, we set up an Ebola response platform that really looked at some of the cultural issues and the epidemiology of the disease itself, and then translated that and what it would mean for our strategy.  I would say that it came out in two areas in particular.  One was the community care centres, around how we could break the chains of transmission early by actually encouraging people to come forward if they thought that that they or their relatives might have Ebola.  That involved putting in place strong community health, which had been a long-standing problem generally in Sierra Leone.  People had quite low trust in community healthcare.  It also meant what we call social mobilisation, which was often done, I should say also, Chair, by quite young people.  It was often young people.  Restless Development was one organisation that did an amazing job, literally going out to communities and talking about how this disease was spreading and how people could keep themselves safe.

The second piece it evidenced itself in was, at the end, an unfortunate piece around safe burials and working with communities to help them understand that often it was trying to bury their relatives in a dignified way that was unfortunately allowing the Ebola virus to continue to pass through families.  I would say that out of all of the pieces that we had to tackle, that was one of the hardest, because it was really asking people to change practices that they had had in place for a very, very long time and that meant a lot to them and their families.  We did that through setting up these social mobilisation teams, but then putting in place these safe burial teams that had to go and pick up bodies, make sure areas got cleaned up afterwards, and that relied on people being prepared to call a hotline at the beginning, and then as we got better organised and a more reliable process was in place, we were able to more actively go and find cases.  I would characterise the response as broadly putting in place the different elements, which were dealing with the disease, treating it, helping people to stay safe and then helping people to bury people safely.  As we got that in place, we did more chasing down of the disease and doing contact-tracing, putting in place surveillance, having a district-led approach to it that really allowed us to stop cases from infecting more people than they needed to—and, of course, treating people, which we were increasingly able to do successfully, as the six treatment centres, which we built from scratch in a pretty much record time of eight weeks, and the diagnostic work that was in place, steadily enabled us to really step up our response to Ebola.  That was when you started to see the infection rates come down.  This time last year we were probably at the peak, really.

Chair, I know that you were asking me the questions, but—

Chair: Yes, feel free to bring your colleagues in, or for your colleagues to indicate when they want to come in, of course.

Q119   Wendy Morton: I wanted a follow-up question anyway, to Brigadier Bevis, so maybe that will help broaden it out a little bit.  How well did the civilian-military partnership operate at a community level?  I would also be interested to know whether there were any issues encountered about distrust of the military in Sierra Leone, and how you were able to communicate the work that you were doing alongside DFID and get that message out into the communities.

Tim Bevis: Thank you very much.  The key point that I would make was that there was no separate activity by the military.  We delivered armed forces elements into the overall effort, and actually Marshall and his predecessor co-ordinated and sent them out.  Very early on we made the decision in the MOD that we did not want a separate chain of command in country, and therefore the JIATF, which you have probably heard of—the Joint Inter Agency Task Force—was our suggestion, and we asked for DFID to provide the lead to that, because it was the way that we could see integration happening best.  We were asked for helicopters because they wanted to get the President and other politicians out and about to engage with the local communities; we were asked to participate in some of the district co‑ordination teams and desks that went out, because that would engage with the local communities.  However, that was not an MOD effort; that, again, was a joint effort that went out there.

From our perspective, that engagement was enabled by some of the things that we could do, it was done in the context that DFID was delivering, and it got better because confidence was built by the fact that we had treatment centres and by the fact that people could actually see that they were getting results from the labs and they knew that if you went into the treatment centre you could come back out again.  The initial distrust was that if they gave someone from their family into the system, that person would never come back.  Once they could see that that was happening, all of the community solutions opened up at that point, because confidence was building.

There was one other point that I wanted to raise.  When people were asking about capacity before, certainly I can speak for the MOD in saying that the initial decisions in September and October that were made very much set us up, and then we delegated to the JIATF in country.  For us the burden on the Whitehall end came right down at that point, and then we would have little spikes where there was an inflection in the way that the campaign was to be conducted, and then there would be a briefing session, and a decision made and passed back out to theatre.  Certainly for us it was spikes of effort.

Marshall Elliott: That is a great question, actually, because that it is one of the most important issues around handling infectious diseases like this: you only win the battle against them when you have got communities completely with you.  What we saw in parts of Sierra Leone was that where communities were the strongest in unified action, could see what a terrible effect it was having on them, and also had the right local leadership of chiefs connecting up to MPs and other political leaders, they got rid of the disease really quickly.  What we saw, however—and I have talked previously about these three most difficult districts in the north of the country—is that you did not have all of those parameters in place, but we learnt as we went along where the fault lines were.  In some cases, it was practices of communities—for example, they did not want to give up certain dignified burials, so they carried on with illegal burials.  They also had a very long tradition, because they had not had a good health system, of using traditional healers, who, again, early on we did not engage but later we engaged them, so actually their practices became safer, in the context of making sure that they did not spread the disease. 

We also had problems in the north, I have to say, with some of the local leadership.  It is a stronghold of the opposition.  There were some unexpected and unhelpful messages from local political leaders, which did not help communities understand that this was really, truly a disease.  We had some very strange things go on, where they would be in denial, and some of the local chiefs would be in denial, so we engaged the President.  Actually he calls himself the chief social mobiliser of the country, going out every week.  I would go with him every week, and he would go and visit these difficult areas to get all of the local leaders to understand precisely what it was they were supposed to be doing and how to do it, engaging the communities and eventually, over time, we did make a massive change to the behaviours, and with that managed to eradicate the disease.  It was an incredibly important thing.

On the military, because I know that you asked specifically on that, our military were not there to enforce protection.  When they were part of our district teams they essentially brought skills that other civilians did not have around planning, bringing partners together and actually just organising meetings, because in each of these districts we would have sometimes 2,000 people working for maybe 100 organisations, and one of the things that I found was that the UN is not used to organising people together in a really effective manner.  Our military were great at doing this.  They brought the partners together, organised meetings at the beginnings and ends of days, and reported back.  They produced fantastic reporting and information systems in which every day every district reported up to headquarters—the National Ebola Response Centre—and this was only possible with the great skills that our military had.  They were not there to enforce protection.

Q120   Fiona Bruce: I am very pleased to hear that, because you echo the evidence given to the Committee last week from David Nabarro, who was very complimentary about the involvement of the UK military in tackling this issue, as he also was of the UK political leadership in September.  He said that that really transformed the whole situation, and talked about the military’s involvement. 

I am interested to know what lessons you learnt from the military engagement.  Secretary of State, would you use the military again?  What processes would you use to enable its use?  Brigadier, how do you feel that the military could provide support in such emergencies, from the lessons that you learnt in this event?

Justine Greening: If I can respond first, really to reinforce what Marshall has just said, it was very difficult working with communities but, in the end, we did manage to do it effectively.  The other aspect of the military response that is really easy to lose sight of was the Sierra Leonean armed forces, who of course had had huge amounts of capacity training from our own British armed forces over the years.  We were therefore able to use those relationships and that knowledge of people, frankly, in command positions to again have a pretty seamless operation between our military and the Sierra Leonean military.

The lessons learnt for me were, first of all, that when you do this sort of upstream work on relationships, it really can pay dividends when crisis hits.  We were able to work hand-in-hand with the MOD, and this is the first time ever, as far as I am aware, that the MOD’s command and control has had somebody at the top of it that was not from the MOD, but it worked highly effectively, as you have heard, and it was, in the end, one HMG team that delivered. The lesson that we have learnt there is that it absolutely can work, and although DFID staff do not wear a uniform, the culture and the professionalism sits alongside that of our armed forces.  That has then helped us put in place much stronger processes between UK military and DFID, and indeed in the SDSR and the National Security Strategy you saw us talking about a rapid response mechanism to make sure that going forward our decision-making is more streamlined.  My concern in all this was to make sure that what we were asking of our military was proportionate, but also clear-cut about what we would need if we were going to bear down on Ebola.  We very much, in the end—well, from the beginning—really had a no-regrets approach.  In other words, we had to plan for the worst-case scenario, because it was better to be able to scale back having not needed to meet it than to be behind the curve on this epidemic as it continued to rage, especially in the early days when it really had taken off and was spreading alarmingly.

Tim Bevis: Even I personally have some good experiences over the last decade, really, with the development side of DFID—as it now is; it goes right back to the ODA previously—and in particular the humanitarian side, over a very long period; we have always had excellent relationships with CHASE.  That is partly because, despite people looking slightly different, actually the outcome that you are looking for has always been exactly the same.  One of the most impressive things with DFID was how it was able to process its contracting very quickly through CHASE.  That was one of the things that we always admired.  It did not have to have classified information systems, so for us—I can remember Haiti was one of the things that I was involved with before—we always have to go through our protocols because of security and everything else.  They were able to get there and get on with it, and that came together in this particular case.

The new things that I would pick up from Sierra Leone were the way in which we had to balance tasks, because Ebola was a threat to the UK as well as being a threat out in West Africa.  As we looked through our own commitments with the National Health Service here, we, for instance, have quite a small proportion of infectious disease professionals within the military medical services, as our method is to fix the trauma out of country and then get our people back to the UK and then go to Birmingham, and actually the National Health Service infectious disease system, if you like, are the people who really then deal with the infection in, for instance, people returning from Afghanistan or wherever it might be.  Therefore, as we assisted in this case, one of our issues was that if we started drawing, for instance, reservists into the system we would have to balance out what was needed in country with PHE as to what they needed to keep back here.  We had winter approaching, as well as the possibility of Ebola coming to the UK.  That was quite a delicate co-ordination issue that we had, and through DFID and the FCO, our negotiations with other countries brought a lot of cover by talking to friends and allies elsewhere, and indeed we in the military had Canadian and Republic of Ireland military professionals who came to allow us to do the several tranches as we went forward.

The second lesson that I would take was the numbers of ways in which resources were mobilised were different in this case.  DFID always deal with NGOs and had established relationships there.  Where they were unable to achieve something, they would come to us and we would try to fill that hole.  As time went on, what they tended to do was tell us more often what they had yet to cover, so we could start warning troops, just in case.  If the NGOs did step forward, we would then relax the readiness of those people, but it meant that we were slingshotting people forward instead of being surprised by a new requirement and then going to deal with it.  So our double-planning method became more and more efficient.  We were slicker at delivering against the problems that were there.  I think that there was an issue over liability insurance, where some contracting companies have particular issues going to difficult places.  We have some expertise in that, and I think your contract department and ours talked over that.

The same happened in science; the Government science effort shared quite a lot from different experiences.  We obviously have particular biological scientific expertise, which we shared into the pool and that was used as time went on.  The integration of different levels is really a big lesson for us.

Q121   Fiona Bruce: Can I bring in Tim Baxter here for an opportunity to contribute?  Thank you very much for that.  I found that effective partnership working very interesting.  It is not something that we had heard before in such detail.  I wanted to ask you, Mr Baxter, about the Department of Health, in terms of what lessons the Department of Health has learnt in terms of its capacity to provide global leadership on health emergencies and rapid response capacity and capability.

Tim Baxter: Thank you.  I would reiterate some of the points that the Secretary of State has made about the one HMG response.  We worked very closely, with DFID in the lead, but with the FCO, MOD and others.  One of the things that we had to do was support the NHS volunteers.  I would just like to say that I think around 150 NHS staff volunteered in Sierra Leone.  Something like 10 times that volunteered, and I well remember being in Brussels with the public health Minister, Jane Ellison, and she said how many volunteers we had and, frankly, it dwarfed other countries.  That is a tremendous tribute to the NHS and also 420-odd PHE staff. 

We have learnt a lot about how best to try and approach the NHS to get volunteers.  As the Secretary of State said a lot of progress has been made in expanding what was, essentially, a trauma register—a very good trauma register.  One of my teams is also looking at rapid response, because one of the lessons from Ebola was that if we had been able to have expert epidemiologists in country early, we might have been able to spot the problems earlier and make the vital recommendations.  So one of the things that the Prime Minister announced at the G7 meeting in June was a rapid response team, and we are moving ahead with that.

In general terms we are, as the Secretary of State said, as one Government sharing the load around ODA.  My team is working around the Fleming Fund, which is around improving disease surveillance around AMR, laboratory capacity and the vaccines network.  We are trying to get ahead of the curve and put ourselves in a much better position to identify early the next outbreak and respond quickly.  We are very much learning from our colleagues, particularly DFID and their long experience in developing countries.  I would pick out those lessons.

Q122   Mrs Helen Grant: This is probably a question for everyone, but I will ask the Secretary of State first.  What would be an ideal structure of a reformed World Health Organization?

Justine Greening: There are several elements.  The first is, specifically, an improved emergency response capability of the WHO, and that has been a key feature that it has looked at since the Ebola outbreak—both in terms of people, which is why this register of surge medical professionals is important, but also processes.  We talked about early warning systems being in place and surveillance on the ground.  One of the biggest challenges we had at the beginning of this was lack of data about what was really going on on the ground, and there was actually one point where the number of cases was apparently surging, but part of that was simply because we were scaling up our operation on the ground, and were therefore capturing a bigger proportion of people actually suffering from Ebola. 

There is a people piece of this, there is a processes piece of this, and then there is a piece of it that I have talked about around the funding that is in place in order to respond quickly to this, certainly in the first one to three months of an outbreak, where stamping on things early can really stop them from getting out of control.

On broader WHO reform, my sense was there is this issue of regional co-ordinators and their power and almost their role being too much about general public health and not enough about the ability to respond to a regional health crisis that emerged.  How you change that element of the WHO to work more effectively is also incredibly important. 

Perhaps, finally, we should recognise that another issue was that it took quite some time for countries involved to themselves declare a health emergency, alongside the WHO declaration, and level 3 was not declared until August.  There is a piece of this that is getting good facts on the ground, good data and depoliticising it, so that the evidence is what the evidence is, and that is what drives the announcement of a health emergency, almost taking out of it, as far as you possibly can, the reticence that people might have in country about taking the step of saying that there is a problem that needs to be fixed.  As we have seen, failure to be clear-cut about the level of the challenge early means that it mushrooms, often, out of control, a lot more than it would have done if there had been a more transparent situation on the ground in June or July.

Q123   Mrs Helen Grant: You mentioned funding very briefly, and David Nabarro, who we saw last week, said that it needed $500 million a year more.  What do you think about that?  Is that right?

Justine Greening: I think that we certainly think it is at a level that is in terms of several hundred million.  The World Bank’s work on the pandemic emergency fund and the insurance facility is part of how we can also get that level of investment.  There is a chunk of it that needs to go into capacity-building, and the fact that, in terms of International Health Regulations, I think I am right in saying that that there are about 80 countries that still have not really complied with those regulations, but many of them are the ones who are the least able to deal with outbreaks.  Part of that needs to go into setting up the system to respond to outbreaks but also part of it needs to be better work on the ground to help countries that are most incapable become more capable, and we are involved with some of that work in Sierra Leone.

Q124   Mrs Helen Grant: So more money is needed.  Are you lobbying for it?

Justine Greening: We have been part of how some of that money is being provided.  As ever, the UK can show leadership but we need other countries to be prepared to step up to the plate.  Again, that means them getting their own houses in order, but where they do not have the wherewithal to be able to do that, the rest of the international community working to help WHO do its job, alongside smarter working and having the right people in place on the ground, as I have just talked about as well.  It is not just about the money.  Critically it is about what you are investing in, and having a better system in the first place to put that investment into.

Q125   Fiona Bruce: Just a very quick clarification, Secretary of State, because it is an important issue, this data collection one, is it not?  The witness from the WHO last week told us that it did not, if you like, shout more loudly until the autumn, because the evidence that it was getting was that the epidemic was going in waves.  Are you saying that, actually, it was the lack of accurate data that was more at fault than the fact that it was going in waves, because the data was not there to show that this epidemic was escalating?

Justine Greening: It is impossible to say in the case of Ebola; however, logically you are right.  There was a period of time when the epidemiology was not clear, and it was shifting in different directions, but the reality is that we had a poor sight of what was really going on on the ground.  Improved data and improved transparency and clearer-cut escalation procedures would have helped us get to that international emergency, that level 3, earlier.  Marshall, would you like to add to that from your perspective?

Marshall Elliott: From what I have seen and observed of the UN in action, and WHO in particular, quite clearly you do need to have better surveillance and alert systems, which would give you better information about what is actually happening, and you need, alongside that, to have a clearer system, when you are elevating it, of exactly how to do that and what additional resources to bring in.  They have regional resources; they could call up at the next level, not being able to handle it in country.  The trick will be to contain these things better in the future, but there can always be a new health emergency which, for whatever reason, is not able to be contained; if you cannot contain it, next time they will be better organised and able to bring resources more quickly.  It did take the UN system a long time to establish, for example, UNMEER and get people.  That was why the UK filled that gap, and we surged so many people—because it took the UN system so long. 

They need to be better placed, next time, for it, and they need to be able to handle certain issues that they are still not very good at and they need to be better at.  We brought in our military to build and they were fantastic at doing that.  If there is a build component to a health emergency, the UN system needs to be able to do that, to do better logistics.  Frankly, they need to be better at engaging in the politics.  Quite often, the UN has fabulous scientists and experts who give advice but do not challenge what is done with that advice.  In the case of health emergencies, sometimes they have to challenge the local authorities because they are not doing enough or doing the right thing.  There is a political level of engagement that they have learned through this, and some of the UNMEER leadership latterly have worked with us and had that political engagement, but they need to do more of that political engagement.

Q126   Jeremy Lefroy: Apologies for being late.  Secretary of State, you talked about the International Health Regulations, and the Stocking report concluded that “the global community does not take seriously its obligations under the International Health Regulations”.  I wondered what support we are giving countries, including Syria and others, to help them build those core capacities that are required to be compliant with the IHRs.

Justine Greening: We are certainly working on the ground in all of our countries where we have country programmes on strengthening health systems.  One of the lessons that comes out of this is that that work is incredibly important if countries are going to be in a better position to be able to combat Ebola themselves.  The three countries where it really took hold were countries that perhaps were most fragile and, certainly in the case of Sierra Leone and Liberia, had come out of civil war comparatively recently.  Other countries, however, like Nigeria, which had a slightly better established healthcare system, were able to really bat it off, frankly.  So there is investment in healthcare and healthcare-system strengthening matters, but we are also then working alongside the G7 and the WHO in their work in making sure that countries that have not implemented the IHR are able to do that.  As ever, we cannot do it all but we are playing a key role in that more international lobbying side too.

Q127   Jeremy Lefroy: Given that, as of November last year, only 64 countries had achieved the required capacities, 81 had reported they needed more time and 48 had not reported at all, do we need some kind of greater international oversight that ensures that countries take these legal obligations seriously?  Clearly, they have international implications.

Justine Greening: Oversight and transparency of who is meeting obligations matters but, as Marshall alluded to, really what comes out of this is that you need political will and leadership in countries, in order for them to take the genuine steps that they need to take to put in place the measures that they are going to have to in order to meet the International Health Regulations.

The key point for me is—there were many things we learned in the work that we did on Ebola in Sierra Leone—that the role that President Koroma played was absolutely pivotal.  His leadership and clear willingness to do what it was going to take to help steer his country through that crisis made the difference.  My ability to be able to phone him up regularly and talk through blockages, frankly, that we were facing in decisions being either taken or not being implemented absolutely transformed our ability to have a command-and-control structure that was there at the national level, with the National Ebola Response Centre, but then went down to the district level and could percolate very quickly through to changes on the ground.

Political leadership in all of this is key.  There is a role for us lobbying.  There is a role for us investing in healthcare systems.  In the end, however, you need leaders of those countries to want to make progress.  If that is not there, unfortunately there will be only so far that you can get.  Ebola has shown many countries that they do need to take health strengthening seriously and that they do need to make progress on it, but we should be prepared to help them do that.

Q128   Albert Owen: You will be aware of the recent report by the Independent Panel on the Global Response to Ebola, which identified its concerns around the inadequate transparency of financial flows during the crisis.  What has your Department done to ensure that money goes to where it is intended?  Moreover, how does that provide value for money, which I know is one of your priorities?

Justine Greening: One of the key conduits for channelling resources into the overall crisis response was the UN trust fund.  We were part of the steering group that oversaw how that trust fund was operated and made sure it operated effectively.  Right at the beginning of the response in Sierra Leone, the Government there carried out an audit of health and health funding, which clearly identified some risks, which we were then able to mitigate.  As ever, we worked with tried and tested partners.  This was a really different response for us because, normally, we are working through other partners; in this case, we were delivering it, so we were very close to exactly what was happening to the money—even more so than usual. 

It is probably worth me finishing, Albert, by saying that our DFID procurement team won awards for its procurement from the Chartered Institute of Procurement and Supply.

Albert Owen: Very good.  I have heard you say that in the Chamber a few times.

Justine Greening: Because we had to procure things, really, in double-quick time, like literally 1 million protection suits for people, but we did that while maintaining value for money.

Q129   Albert Owen: A serious question here: could your award-winning team supply us with a breakdown of UK spending, of where it was spent and who by?  I think it is important.  I want to raise, Chair, if I may, one of the issues that one of our witnesses, who was a frontline doctor, raised with regard to where there was small spend in isolation units, which he wanted to be done immediately.  The big money was easier to get than this small money that would have an immediate impact.  How would you respond to that, and what can be done to prevent that kind of thing in the future?

Chair: That is several questions, Albert.

Justine Greening: Yes, of course, let us make sure we get the Committee a breakdown.  It was a monumental effort, to be perfectly honest, so there was this constant addressing of a double objective, which was to get stuff procured as fast as we could but, at the same time, not compromise on value for money, often having to work with companies to make sure that they got the necessary insurance in place so that they could even get people out and able to work in country.  Just remind me of your second point, Albert.

Q130   Albert Owen: Frontline doctors could not get their hands on small amounts of money, which the professionals say could have had an impact very quickly.

Justine Greening: Yes.  I am going to let Marshall answer that.

Q131   Albert Owen: Mr Baxter might want to.

Justine Greening: Of course, I think we should allow Tim to respond to a couple of the questions that we have had on the WHO before.

Marshall Elliott: Certainly, in all the time I have been there, which goes back to March of this year, and it certainly pre-dated me, we had at least two instruments that would allow small funding to be given against the sort of things that you have asked about: the multi-donor trust fund, to which we were the major contributor for Sierra Leone; that had a small-grant facility within it, so there was an opportunity through that.  We also created, under our own funding, a similar small-grant facility, which would allow, between us, a response to any small requirement.  Every time there was, let us say, a new event, as we called it—a new case of Ebola—we sent a joint team to that location to determine exactly what was needed.  For example, sometimes you would have to build or renovate homes locally to allow high‑risk contact.

Q132   Albert Owen: I am going to push you here.  I am not clear, by the answer that you are giving, whether you are acknowledging there is a problem with the frontline getting their hands on the money.

Marshall Elliott: There was at the beginning until we established a mechanism, but once we had established a mechanism—we had multiple mechanisms, actually, and we made sure we did not—

Q133   Albert Owen: Is that not the problem?  Sorry, Chair, but I think it is important.  The witness who gave evidence to us was not a new kid on the block, if I can put it that way; he was an experienced person who had been to several difficult situations, and he found this to be a problem.  Do you feel that now it would not be a problem?  Is that what you are telling us?

Marshall Elliott: I would say that, now, it would not be a problem, but you always need to establish a proper system for being able to identify the partners who would deliver that small bit of the response.  In some cases, it was giving money, for example, to a hospital to allow it to provide some better isolation facilities.  That was the very specific issue that was raised by the case you are talking about.  It can be done, however, and we did make it happen.  Obviously, at the very beginning of it, it was not happening, until we established a system for doing it but, through the majority of the time of this response, we had that directly with DFID funding and we also ensured the UN created a similar mechanism, and then we worked together to make sure we did not duplicate.

Justine Greening: You have to bear in mind, in the beginning, the challenge was to significantly scale up to deal with an unprecedented outbreak that was threatening to take over the whole of West Africa.

Q134   Albert Owen: To be fair to our witness, he understood that, and I do not think he said it was in the beginning; he said it was ongoing.

Justine Greening: There were two challenges: one was value for money, and the second was simply making sure that we had the scale of a response that we needed.  There would have been lots of opportunity to have lots of micro projects.  That would have been excessively time-consuming at the beginning to manage.  The key challenge was getting those hospitals built, getting the lab capacity involved and getting the safe burial teams up and running.  Once those jigsaw pieces were starting to be built—and that was more a question of implementation—then there was a skeleton on which we could start to fit some of these more tailored, smaller investments that were going to make a difference.  That was our challenge the whole way through: keeping our eye on the price of what we needed to do upfront, to then be able to start to develop the strategy once those bits were being bedded down.  The whole thing was incredibly challenging from start to finish, but I think, as Marshall said, in the end we got into this and found the right mechanisms to be able to get some of those smaller contributors in place.

Q135   Jeremy Lefroy: Just following on from what Albert was saying, the case in question was before the outbreak had accelerated, and it was a matter of a few thousand pounds being requested by somebody who I knew personally and who was clearly in a position to know what he was talking about.  There did not seem to be a mechanism for providing that fairly limited amount of money for what could have saved a huge amount locally.

It is not just about this instance; it is about many instances we come across where it would be great if DFID had a bit more flexibility at local level, whereby the head of office was able to have a fund, as other people do—the Dutch, for instance, do this—where they would be backed up by senior management and Ministers and could say, “Yes, I am prepared to invest these few thousand pounds”, or £10,000 or £20,000, “because I can see the potential is there for this to save a huge amount of money.  If, however, it turns out that I was wrong, I will not be sacked for this.”  This is the kind of thing that I really think it is important that DFID looks at.  In this case, I think it could have saved an awful lot of money.

Justine Greening: That is why I think it is important in this inquiry for you to look in the round as we have got to this stage of the response.  I think all I would say is that we did provide limited funding for isolation facilities really early on in this crisis.  I suppose, logically, you are only going to hear about the things that we perhaps did not manage to get to in country, rather than the 99 things that we might have provided some quick funding for, but, as I said, that is why there is real value in this inquiry, in helping us to continue lesson-learning when you do your own broad sweep of asking people to come here and talk to you about their involvement.

Q136   Chair: Brigadier, I will take a brief response because we have several more questions and we will have to finish at 5.40.

Tim Bevis: I would just introduce the point that a number of the initiatives that have gone on in the summer caused us, in September, to look at base-lining policy.  One of the things we were bothered about was that different charities or NGOs had developed different protocols.  The World Health Organization had a different protocol from the one that we then developed in London, and one of the things we had to do was get conformity, so that people going into country had the right training against the protocol they were going to work with.  Clearly, the problem with helping people on an individual, small basis is that it brings trouble later.

Q137   Wendy Morton: During one of our evidence sessions, we were told that there is a very effective rapid diagnostic test, which was developed by the Defence Science and Technology Laboratory, but it was not deployed in Sierra Leone due to internal wrangling between Departments.  I wondered if anybody could shed any further light on that.

Justine Greening: Maybe I will ask Tim Baxter to come in but, certainly, we were involved in working to try to develop several rapid diagnostic mechanisms, mainly because that would have enabled us to have had a process whereby people could have been tested there and then, rather than having to go through a process of transporting samples back to the lab.  In the end, we were running a parallel process.  We thought we needed this so we got on with doing it, but in the end there were some issues around the testing kits being accurate all the time, so what we definitely did not want was false positives, where you send someone who has malaria and a high temperature off to an Ebola treatment centre and into the red zone when they do not have Ebola.  We got on with all of that, and Tim can talk a bit more about that, but at the same time we were getting on with the broader response.  The response started to bring the outbreak back under control, and it got to a stage where, probably, it was smarter just to keep the existing processes that were in place because, by then, we had the lab capacity and the processes to deal with the numbers of tests that we needed to deal with.

It is a good example of where we almost had to do both bits of the process, because we could have got to a stage where, frankly, it was continuing to be an outbreak at a higher level, and a higher level of incidence, and where these testing kits could have been made more accurate in time and could then have been highly useful.  As it turned out, we were bringing it back under control, so we were able to keep the process that we had in place, and it would have been quite disruptive to train a whole load of community health workers in a different process, having got them to the stage where we had got the one that was working working effectively.  Tim, do you want to add to that?

Tim Baxter: PHE were testing large numbers of samples.  They did not have backlogs.  We had, as it were, a gold-standard process that people were used to and the Secretaries of State were trained in.  Changing that in mid-stream brings with it its own risks.  This is an area where there is research continuing to be done, so it is not as if the work that has been done is wasted—not at all.  However, in the particular context of where we were, it was not quite right to introduce the tests, to my understanding.

Justine Greening: It is just a good example of how, all the way through this response, you literally got to each stage and had to broadly assess the probabilities and what the most optimal course of action from here on in was, while not unnecessarily closing off any avenues that you might need to go down—for example, this diagnostic test—that you might, in future, want to rely on, even if you thought it was quite unlikely.  There was a period when it really was not clear how far this disease would romp ahead of us before we finally brought it under control, because it was taking off so quickly at one point.  At each stage, we had scientific advice and had to respond to that, look at the different alternatives on our processes, if I can put them like that, for tackling the disease, and then try to get them improved.  You do, however, get to a stage where you have a good enough process that was working effectively, and it was riskier to change it and try to micro-improve it than it was to leave it as it was.

Q138   Wendy Morton: Can I just come back?  Just to clarify: is there a rapid diagnostic test currently available that is deemed to be effective?

Marshall Elliott: No, there is not.  I ask about this often, because it could make a big difference to the way in which you manage a response like this.  WHO has been continuing to test kits.  It is even testing some right now, and its official advice remains the same: not to try to bring a rapid test kit in at this point.  When you have a system of laboratories that is working 100%, to introduce something that still has a varying amount of uncertainty around giving false alerts—some up to 30%—would create such trauma within communities and individuals if you are wrongly diagnosing.  They are saying, “Do not use them yet”.  In the future, if they continue to get refined and better, they could potentially be used to do some early investigations in new outbreaks when you do not have labs in place.  They could be there as a backup if you did reach a situation where you did not have enough laboratory in place to keep up with the rate of the number of tests you needed to do; otherwise, they are telling us there is not a 100% test and not to use it at this point.

Tim Bevis: We believe the British test is back in testing, so it could emerge as a solution in future.

Q139   Mrs Grant: Thankfully, an Ebola vaccine is now being trialled and it looks good.  It looks as if it is effective.  I just wondered what we are doing in the UK to incentivise investment in research into these neglected tropical diseases.

Justine Greening: Of course, both the Merck and the GSK phase I trials were in part funded by DFID and, again, provided a real boost for our ability to, in the latter stages of this Ebola outbreak, really bear down on it.  We are learning scientifically the best use of ring vaccination and how to work with relatives, for example, to minimise the spread.  In terms of how we look forward, again I will ask Tim to respond from a Department of Health perspective, but in the new aid strategy that we just launched, first of all there is the Fleming Fund that is part of that, but also, critically, we established the Ross Fund.  I am very proud because Ronald Ross has connections to Putney, and we have the Ronald Ross Primary School just up the hill from where I live.  It is outstanding, Chair, and a fantastic school, and I would just like to put on record my thanks to the staff and, indeed, the head teacher, Debbie, who have done an incredible job in transforming that school to “outstanding” over the last several years.

Chair: I know it is always hard for Ministers to comment in Parliament on their constituencies—

Justine Greening: I just wanted to put that on record because they have done an incredible job.

Chair: It is on record, yes.

Justine Greening: The Ross Fund now is a funding stream that will enable us to fund not just on Ebola but, more broadly, on diseases that have the chance to become epidemics, and also neglected tropical diseases and, in addition, malaria.  It will enable us to really look at what it is going to take to do some of the underlying research to combat those diseases more readily.  That was welcomed by Bill Gates when he announced it, and what it shows and what we perhaps have not talked about is that we learnt an awful lot about how to respond to an Ebola outbreak over the past 12 months or so, but there is a piece of this that was around, “Can we do more in the future to have some of those phase 1 vaccines for some of those diseases that may well become or have the potential to become outbreaks already on the stocks, ready to go?  Is there a cadre that could be at that stage, to be then quickly developed, as we did with the Ebola vaccines, in order to be brought into use?”  That is part of the work that we hope the Ross Fund can help put in place.  Tim?

Tim Baxter: Thank you, Secretary of State.  The vaccines network brings together academia, research councils and philanthropic organisations and is very much in this space of trying to incentivise production of vaccines on those kinds of critical diseases.  With Ebola, we know that several vaccines were around.  None of them had got into phase 1 trials, and that is the sort of area where this vaccines network can really help in pulling through vaccine candidates into phase 1 trials.  The Secretary of State has talked about the Fleming Fund, which is very important.  We also have the AMR Innovation Fund, which the Prime Minister recently announced with President Xi of China.  The Chief Medical Officer, Professor Dame Sally Davies, is also going to be leading work on ODA-related research.  There is a lot of investment through the ODA strategy in terms of maintaining our global leadership in this area, so we hope to see some really concrete results in the coming years from that.

Justine Greening: This ties back to this broader issue of health-system strengthening.  If you look at the position that Sierra Leone was in before this crisis hit, getting on for 40%— 38%, to be specific—of hospital admissions were in relation to malaria alone.  It starts to get you to really see how, if we can make progress on tackling some of these massive issues like malaria—and we have seen deaths from malaria fall by two‑thirds over the last 15 years—how much money that then releases in Sierra Leone’s own healthcare-system spending to be put more broadly against improving healthcare.

Q140   Chair: That has, very neatly, brought me to the final question; we have to finish in five minutes or I am going to lose my quorum of the Committee.  The sustainable development goals place a great emphasis on universal health coverage, and the UK Government has supported that.  Secretary of State, do you think we are getting the balance right between spending on strengthening health systems versus spending on some of these vertical health programmes?

Justine Greening: Certainly from a UK perspective, we have a sensible balance now that splits between research and, if you like, upstream work: core health-system strengthening itself and then, also our work on things like making sure that treatment for malaria, etc, is there, making sure that there is family planning and all that broader public-health work that we do is in place.  We do have a good mix and, of course, we also have really supported, over recent years, the Global Fund, Gavi and these international mechanisms that have been transformational, frankly, in enabling us to get a bigger bang for the buck.

Broadly, we have got the right mix but we should continue to challenge ourselves to make sure that we never rest on our laurels, frankly.  What we are seeing is that the world is certainly changing.  We see these healthcare challenges becoming much more global in nature if we do not deal with them, and we need to continue to react as we did over the last 12 to 18 months in relation to Ebola.  As Tim has alluded to, some of the challenges that we face are changing with some of the AMR work itself—something that is now on the agenda and that would not have been maybe 10 or 15 years ago.

The last point I wanted to make in relation to this is that it is quite hard to just look at health on its own.  When you look at things like water and sanitation investment, for example, that also feeds into improving overall health outcomes.  When you look at the work on education and people’s ability to understand and read, frankly, instructions on how to improve health, it all goes together in the end.  One of things that is very clear to me and in our work in the Department is that this systemic approach on development is critical.  We should avoid falling into the trap of overly focusing on one area but not understanding, whether it is economic development or tax systems, how all of the rest of what we are doing reinforces the ability of each area in itself to do better.

Q141   Jeremy Lefroy: I must say I am very excited about the various funds—the Ross Fund, the Fleming Fund and also the work on AMR.  Forgive me if this question came up earlier, but I just wondered: we were given evidence that this crisis was really taken very seriously when it was raised to the highest political level in epidemic countries but also here.  People gave us evidence last week, and Dr Nabarro was saying that it was when you raised it to the Foreign Secretary and the Foreign Secretary raised it to the Prime Minister that things happened extremely quickly.  We are very grateful for that, but do you think that, given the timing of it and given the fact it happened during, effectively, a parliamentary recess, when parliamentarians were not around and perhaps not raising it on a regular basis, the systems within DFID are robust enough to say, “These kinds of things will be raised to my attention” whatever time of year it is, whether it is recess or when parliamentarians are asking questions?  Do you think they are robust enough?  I do not know.  It may well be that they are and, had Parliament been sitting, things would have happened at just the same time.

Justine Greening: The short answer is absolutely yes.  For the last three out of four years, I have been on a fortnight’s holiday and had to come back in order to deal with DFID‑related issues.  Irrespective of whether Parliament is sitting, or whether I am having my final two-week holiday, if there is an issue it is brought to my attention and my team’s attention, and I fix it, so no, Jeremy.

The issue, I think, we had around Ebola was a much broader international one that we have already talked about in terms of the lack of extent to which it was quickly enough picked up and the WHO’s role in this.  We were already getting on with the work of putting in place the Kerry Town facility in August, prior to that very senior-level, PM-led political involvement.  The work was already under way but, as I also said, one of the things that we have learnt here is that it took political leadership in Sierra Leone, ultimately, to fix this.  In democracy, sometimes that piece of the jigsaw puzzle does prove to be critical in really getting things motoring in the end.

Chair: Secretary of State and the other witnesses, thank you very much indeed for joining us here this afternoon.  It has been extremely helpful for our inquiry, and thank you for your responses.  Can I just finish by saying thank you to David Harrison, our Committee Clerk who is retiring today?  He kindly came out of retirement earlier in the year to rejoin us, when we had an unexpected vacancy.  It has been a pleasure, for a short period in my case but a longer period in the case of a number of colleagues, to have been working with David, and we wish him very well in his retirement.  I am sure that he will remain closely in touch with us, so, David, thank you very much.  Thank you. 

              Oral evidence: Responses to the Ebola crisis: Follow-up, HC 338                            2