Select Committee on International Development Third Report

Section 4 — Responses and Responsibilities

199. We have already made a number of recommendations as to how both DFID and other agencies should respond to the HIV/AIDS epidemic — in prevention, care and impact mitigation. In this section we attempt an overview of the responses to date of both donors and national governments, an analysis of what is needed for the international response to be coordinated and effective, a consideration of whether funding is adequate and appropriate.

Some thoughts on funding

200. It is clear from all that has gone before in this Report that the HIV/AIDS epidemic is not something which will simply go away when enough money is spent on it. But we should not then conclude that funding is irrelevant. The requirements of information and education, primary health care and STD treatment, basic palliative care and impact mitigation all require sums beyond the means of most developing countries if unassisted by donors. A number of funding issues have been brought to our attention during the course of this inquiry. We will consider how funding for HIV/AIDS is estimated; whether levels of funding are adequate; which bodies should provide funds, in what form and to whom.

201. To discuss funding of HIV/AIDS work we must first know how much is being spent and by whom. This is not, however, as straightforward a question as it might first appear. We can take as an example the various figures provided by DFID in response to questions as to its levels of expenditure on the epidemic. In oral evidence Dr Julian Lob-Levyt said, "At the moment the Government is committed to spending £100 million [over the next three years] on HIV/AIDS. We shall vastly exceed that commitment actually. At present we are spending between £20 and £30 million per year, but that spend is on a very steep rise, as a number of pledges are being transmitted, not least of which is the International Partnership Against Aids in Africa".[241] This was elaborated on in a supplementary memorandum, "Current spending is running at £20-30 million over the past four years. Anticipated to rise to over £40 million 1999/2000 and increase further year on year as projects and programmes at the early stage of development come on line".[242]

202. By the end of the inquiry the figure for DFID expenditure in 1999-2000 had increased to £54.8 million, £42.8 million for 1998-99 and £41 million for 1997-98.[243] There had thus been a considerable increase on the £15 million spent in 1992-93. These figures were for bilateral expenditure and did not include support for multilateral agencies such as UNFPA, UNICEF and UNAIDS working on HIV/AIDS and sexual and reproductive health. The figures do appear to vary and expand over time — thus in answer to a parliamentary question on 8 January 2001 DFID claimed to have spent in the previous year "over £84 million on bilateral HIV/AIDS related work — the bulk in Africa".[244]

203. It is important to note that these figures include "work in broader sexual and reproductive health which is targeted towards HIV/AIDS prevention".[245] In an answer to a parliamentary question the Secretary of State pointed out that "In many cases it is not practical to distinguish between the sexual and the reproductive health/family planning elements. There is also often no clear distinction between assisting with work in HIV/AIDS and in other sexual health issues".[246] The figures also include non-health activities where "HIV/AIDS is flagged as a significant element, for example in education and prevention, and so on".[247] Clare Short warned, "The more we mainstream our efforts the less we will be able to measure separately because it will be mainstreamed right through our programme".[248]

204. It is obviously the case that there are many facets of developmental expenditure which could have an impact on HIV/AIDS. We are worried, however, at the apparent flexibility within DFID as to what constitutes HIV/AIDS expenditure. In particular, we do not believe that sexual and reproductive health should per se be considered spending on HIV/AIDS. It is of course true, as we have maintained above, that a comprehensive provision of sexual and reproductive health services would have an enormous impact on HIV/AIDS. But it is not automatic. To give just one example, the social marketing of condoms as part of a reproductive health programme will have a different design from a social marketing programme designed to reduce HIV/AIDS and STDs. We request assurance from DFID that sexual and reproductive health expenditure is only accounted for as an aspect of HIV/AIDS spending when HIV/AIDS is explicitly and specifically addressed in the programme design.

205. Dr Peter Piot of UNAIDS confirmed that it was difficult to ascertain the amount being spent globally on HIV/AIDS. UNAIDS was attempting to collect figures so as to have a global view of "who is contributing what, so we have a base line".[249] It was not an easy task. They were taking a "double approach", gathering information from donors and from the recipient countries themselves — "You will see that it does not match, even for the same donor".[250] There were some "major discrepancies".[251] It is an obvious matter of concern when donor commitments are not realised on the ground, or at least when donors and recipients differ as to what is being spent on HIV/AIDS.

206. The mainstreaming and integration of HIV/AIDS into development work also meant that funds were more difficult to track. In their memoranda to the Committee UNAIDS expanded on the difficulties they face in assessing the level and flow of international resources for the response to HIV/AIDS. UNAIDS states, "Although the UNAIDS secretariat has made significant progress in establishing sustainable processes for the monitoring of donor country resource flows to HIV/AIDS ... some key issues remain. For example, several major DAC members including France and the European Commission continue to have major difficulties in the reporting of their official development assistance allocated to HIV/AIDS".[252]

207. Not only is it unclear how much is being spent on HIV/AIDS, information is also out of date. UNAIDS told us, "Because of administrative differences among the DAC member countries, including differences in fiscal years, there is a significant delay in reporting. It is only possible to report on donor country HIV/AIDS expenditures almost 2 years late (i.e reporting on 1998 data in mid 2000)".[253]

208. The UNAIDS secretariat is collaborating with UNFPA and the Netherlands Interdisciplinary Demographic Institute (NIDI) to collect information on official development assistance disbursed to HIV/AIDS by donor countries. UNAIDS is also working to collect and improve information on resources from UNAIDS cosponsors and from national governments.[254] UNAIDS plans to convene a meeting of donor country representatives "to agree on a common methodology for reporting on HIV/AIDS components within integrated development projects and HIV/AIDS allocations within sector wide approaches and common basket funding schemes".[255] The example of DFID shows the confusions that can arise even within one department where there is no agreed system for assessing HIV/AIDS expenditure.

209. Does it matter? We believe it does, for three reasons. First, without accurate information on funds globally dedicated to HIV/AIDS we cannot know whether sufficient sums are being spent to finance the necessary interventions. Nor can we know whether these costs are being appropriately shared. As UNAIDS put it, "What we are trying to do now is try to see what is the base line and then target who does not pay enough".[256] Secondly, at a national level it is difficult to see how effective national strategies can be designed in ignorance of the current level and breakdown of HIV/AIDS-related expenditure. Thirdly, and as importantly, uncertainty as to what constitutes HIV/AIDS expenditure is to an extent uncertainty as to whether and how expenditure has an impact on HIV/AIDS. The problems in assessing HIV/AIDS expenditure reveal a wider difficulty in knowing and agreeing on effective interventions.

210. We recommend that UNAIDS and donors reach agreement as soon as possible on how to calculate levels of expenditure on HIV/AIDS. We would expect such an agreed basis for calculation to specify, on the basis of research, the conditions necessary for mainstreamed interventions to have a real impact on HIV/AIDS.

211. Despite the difficulties in assessing levels of expenditure, UNAIDS has published information on amounts committed over time to HIV/AIDS. UNAIDS tracked HIV/AIDS funding from 10 major donors from 1987 to 1998 and discovered that it increased from about US$ 59 million in 1987 to US$ 293 million in 1998.[257] This fivefold increase is obviously encouraging, particularly when seen in the context of a decline during the same period of overall levels of ODA.

212. Further scrutiny, however, demonstrates the inadequacy even of this increased funding. UNAIDS state, "Unfortunately, as spectacular as this increase appears, it has not kept pace with the spread of the epidemic — or even the most basic requirements for HIV programmes of the most affected countries. During the same period, the number of infections has risen from 4 million to 34 million, a figure that continues to grow given the more than 5 million new infections annually. Furthermore, increases in donor support had begun to level off between 1996 and 1998, and it remains less than just 1 per cent of donor countries' total annual ODA budgets. Against the backdrop of soaring infection rates, this trend is of critical concern".[258] The point is starkly made in the UNAIDS publication 'Level and flow of national and international resources for the response to HIV/AIDS, 1996-97' where it calculates that "ODA funding per person living with HIV has therefore peaked in 1988 at approximately US$ 22 per person for the 10 ODA agencies included [in their survey]. It has since steadily dropped to its 1997 rate of under US$ 9 per person living with HIV".[259] That figure might be a somewhat crude assessment of effectiveness of expenditure but it does show that donor funding for HIV/AIDS is not matching the scale of the crisis.

213. How much money is necessary? UNAIDS have estimated a cost of US$ 1.5 billion, excluding anti-retrovirals, for an adequate response to HIV/AIDS in sub-Saharan Africa, "which includes youth-focussed interventions, interventions focussed on sexual behaviour, public sector condom provision, condom social marketing, strengthening services to treat sexually transmitted infections, voluntary counselling and testing, workplace interventions, strengthening blood transfusion services, the prevention of mother-to-child transmission, and mass media and capacity building".[260] Clare Short had a slightly different perspective on the funding issue, emphasising that "the major barrier to more effective action ... has been the unwillingness of African governments to move".[261] She went on, "so when people splash around numbers and say US$ 2 billion is needed, that sounds all very well and it sounds as though the only problem we have got is that miserable, rich donors will not provide the money. That is just untrue".[262] She said she was glad no target amount or fund had been announced at the G7 in Okinawa, "I really get fed up with demands for a fund as a cheapskate way of pretending action is being taken".[263]

214. The figures both on the decline in ODA overall to sub-Saharan Africa and of spending per HIV-positive person make appalling reading. We seem as far away as ever from the UN target of 0.7 per cent of donor countries' GNP being spent on development assistance. And we must add that the 0.7 per cent target was agreed to in an AIDS-free world. We share the Secretary of State's cynicism over headline-grabbing announcements of cash. But this fact at least is clear — not enough money is actually being spent in the response to HIV/AIDS. It is often difficult to spend wisely and effectively, that is true. Donors must as a matter of urgency devise ways of spending significant sums in less than perfect environments, at the same time strengthening national governments' policy frameworks. We believe this should be a priority for the International Partnership Against AIDS in Africa.

215. The World Bank has committed US$500 million for a three-year HIV/AIDS programme for Africa. Some witnesses, however, expressed worries over the interventions of the World Bank on HIV/AIDS. Alan Whiteside had concerns "that the Bank particularly is putting large sums of money into stuff called HIV/AIDS without necessarily having strategic or technical resources either to inform the allocation decisions or to support the implementation of those activities ... When the Bank starts loaning to governments which do not have technical capacity, the question of how to support implementation responsibly is incredibly important, and the Bank is not well structured to address that".[264] He did, however, say that the Bank did have a very important role as "the one institution which has real money outside of governments".[265] Clare Short also gave a warning with regard to the significant headline funds which the World Bank is now announcing as at the disposal of governments in the fight against HIV/AIDS. She reminded the Committee that governments "have to borrow from the World Bank".[266] She expanded on these concerns in evidence given to the Committee on the 2000 Annual Meetings of the IMF and World Bank. She expressed then some scepticism over the establishment by the World Bank of a separate fund for HIV/AIDS, which tended to create its own imperatives from dispersal "that are not always the same as how you get things moving in a country".[267]

216. The response of the World Bank and the IMF to HIV/AIDS cannot be confined to the provision of funds but must affect all aspects of their policies. Criticisms in the past of structural adjustment programmes, and the introduction of the HIPC initiative, have resulted in a more poverty-focussed approach from the IFIs to structural adjustment. To qualify for HIPC relief countries now must develop, in consultation with a range of interested parties, a Poverty Reduction Strategy Paper (PRSP), which is a requirement for the provision of funds through the Poverty Reduction and Growth Facility (PRGF), the successor to the ESAF (Enhanced Structural Adjustment Facility). Any poverty reduction strategy for countries with significant HIV/AIDS prevalence must include a clear and credible strategy on HIV/AIDS.

217. The leverage provided by the HIPC initiative could be an important impetus to effective HIV/AIDS interventions in developing countries. The PRSP approach is something the Committee has advocated since its inception and we are glad to see it introduced. In such PRSPs there is an expectation, where relevant, that the country include discussion of HIV/AIDS. Clare Short said, "absolutely HIV should be there. It is a development challenge to countries and it should be part of the programme".[268] James Wolfensohn pointed out that "The PRSP is a document of the Government, not of us, and in some countries the priorities change. In the case of Africa, at the moment, with 23 million cases of AIDS, the notion of having social programmes without dealing with the question of AIDS becomes an impossibility".[269] We welcome the introduction of Poverty Reduction Strategy Papers and in particular the insistence that HIV/AIDS is included in the strategies of all countries affected by the epidemic. The PRSP process requires adequate consultation with civil society. As we have discussed elsewhere in this Report, community groups and people living with HIV/AIDS are an essential element in an effective response to the epidemic. Therefore, every PRSP should have been preceded by consultations with community groups and NGOs working on HIV/AIDS, and, most importantly, with people living with the disease. Any strategy, to be acceptable, must take account of their views and include community participation.

218. The PRSPs are linked to the Heavily Indebted Poor Countries (HIPC) initiative. UNAIDS point out that "Across Africa, national governments pay out four times more in debt service than they spend on health and education".[270] They conclude, "By relieving debt in the poorest countries — which, often, are the ones with the highest HIV and AIDS figures — money now exported to service debt could be reinvested into AIDS prevention and care".[271] We have considered the HIPC initiative in a number of Reports and welcomed the PRSP approach, designed to ensure that funds released from debt servicing go into the social sectors. UNAIDS welcomes the inclusion of HIV/AIDS in PRSPs but warns, "a concerted effort by a coalition of interested African government officials, civil society representatives, creditor governments, and United Nations and multilateral agencies will be required to ensure that debt relief is actually used to mobilize substantially increased funding for AIDS".[272] We recommend that UNAIDS monitor the extent to which debt relief results in the mobilization of resources by national government for HIV/AIDS and reports back to the international community.

219. In the course of the inquiry it has appeared that some countries have been unhappy about taking loans from the World Bank to finance HIV/AIDS work. News articles quoted the Zambian Health Minister as refusing a loan because the country was failing to service its existing debt. Malawi had rejected a similar loan offer. South Africa has not approached the World Bank to finance HIV/AIDS programmes and it appeared that at present they have no plans to do so. Given the burden of unpayable debt and the possible costs associated with tackling HIV/AIDS, it is perhaps not surprising that there is some reluctance to receive World Bank funds on loan terms, however concessional.

220. In evidence to the Committee on the Annual Meetings of the IMF and the World Bank, James Wolfensohn, President of the World Bank, said that the Bank saw prevention as the most immediate priority for funding and they were "trying to raise money for grants; and some grants are coming, DFID itself is providing some grants in terms of AIDS. The next level is IDA lending. IDA lending is 30-year lending at no cost, at no interest; so, essentially, two-thirds of that is a grant, if you present value its value. And the third is to borrow at interest".[273] He told us that he was trying to maximise the amount of money made available on either grant or IDA terms, "and there is a move now to try to convert some of the IDA lending to grants".[274] He was very keen to see some IDA loans converted into grants but pointed out that there would be implications for IDA donors, such as the United Kingdom. The donor countries would need to contribute more to IDA in the future to compensate for the loss of funds previously due to come back in repayments. He did not, however, think that terms of repayment were an urgent issue — much more important was simply having the money available to ensure "the survivability of those countries". He thought that "the restriction on AIDS fighting is not money, the restriction is will and organisation".[275]

221. There were four conditions for World Bank assistance — "that they should have a participatory approach to HIV/AIDS ..; that there should be a coordinating body in the country, which includes both Government and people that are involved; that the Government commits to quick implementation, including channelling grant funds directly to communities, civil society and the private sector; and the use of community-based organisations and NGOs to implement the programmes".[276]

222. Clare Short, in giving evidence on the Annual Meetings of the IMF and the World Bank, warned that many developing countries had problems in debt management.[277] She was asked whether it was appropriate to provide funds for HIV/AIDS on a loan basis since there would not in the immediate future be a resulting income stream to service the debt. She responded, "It is more than a question of income stream — which is a very important question — it is also a question of foreign currency debt".[278] Loans were increasingly provided for social development rather than the traditional infrastructure projects, but such lending did not provide as readily a foreign currency income stream to repay the debt. She warned, however, against moving to a position where all such funds were on grant terms since that would "slash resources that are available".[279] Borrowing for social development was acceptable as long as the country was considering its overall borrowing capacity and managing its debts properly.

223. Clearly, as the Secretary of State and Tony Faint said, there is the potential for significant sums lent on concessional terms to be effectively used if the country concerned has control of its finances and its debt. We do, however, have concerns at IDA lending to finance the attack on HIV/AIDS in sub-Saharan Africa. The debt management capacity of many of these countries remains weak and it would be unforgiveable for the donor response to HIV/AIDS to result in an increase in their unsustainable debt burden. We must also take into account the fact that the full impact of the AIDS epidemic has yet to be felt, whatever advances might be made in the future in prevention. In other words, we question whether we should be lending into a future cataclysm, with all its effects on the civil service, infrastructure and economy of the country. We would encourage the World Bank and donors to ensure that as much as possible of the US$500 million committed by the World Bank to HIV/AIDS in sub-Saharan Africa is in grant rather than loan form.

224. Jeff O'Malley pointed out that the World Bank had come to the issue of HIV/AIDS only recently. Whilst this new commitment to fight HIV/AIDS was welcome, he was concerned that the Bank "is putting large sums of money into stuff called HIV/AIDS without necessarily having strategic or technical resources either to inform the allocation decisions or to support the implementation of those activities".[280] We are concerned that funding of HIV/AIDS is done responsibly and recommend that UNAIDS be closely involved in the provision of technical advice to the World Bank in its funding decisions.

225. Witnesses also stressed the responsibility of national governments to fund the response to HIV/AIDS. Jeff O' Malley said, "I agree with what the Secretary of State said in South Africa. Most of the resources for the response to HIV/AIDS anywhere have to come from local communities and countries in most of the world. The overall scale of development assistance ... is so small in comparison to development challenges in the world that we should not lull ourselves into thinking that a doubling or tripling of international development assistance for AIDS will solve the problem

226. Dr Peter Piot agreed, "we need an enormous increase in resources for basic prevention, for basic care. A major part of that has to come from the governments of the countries that are affected. If something is about survival or national security that is where the money has to come from. They are struggling with that".[281] A study of the breakdown of HIV/AIDS funding in 1996 suggests that "The proportion of total funds contributed by the national government was much higher in those countries of Eastern Europe (79%) and Latin America (67%) included in the study than in those countries from sub-Saharan Africa (9%) and the Caribbean (8%)".[282]

227. UNAIDS statistics suggest that many developing country governments have some way to go before they dedicate adequate funds either to the health sector or to HIV/AIDS. The study admitted that there a number of problems in such country-specific data in that it did not include cross-sectoral work and tended not to count in work in care and support. UNAIDS concluded, "The limited information on resources allocated to care is one of the weaknesses of this study ... national resource allocations are grossly underestimated".[283] Nevertheless, even when such reservations are fully noted, the UNAIDS statistics suggest that some countries with high degrees of prevalence are not as yet spending enough on HIV/AIDS. UNAIDS notes that there are variations in the ability of countries to finance a response but maintains that some of the differences in expenditure have no obvious reason, "For example, in sub-Saharan Africa, where the epidemic is the most severe, there are large differences in funding for countries with similar epidemics. Nigeria has over twice as many people infected with HIV/AIDS as Uganda (although with a lower prevalence of HIV/AIDS), yet Nigeria reported spending less than US$ 2 million in 1996, compared to the US$ 37 million reported by Uganda".[284] We are concerned that certain countries are not as yet spending enough of their own resources in the fight against HIV/AIDS. Dependence solely on donors not only limits the resources available but also demonstrates the lack of real national commitment to halting the epidemic.

228. One further aspect of funding must be considered — that is, what are the appropriate channels for HIV/AIDS expenditure. Throughout the inquiry we received a considerable amount of evidence on the need for effective action against HIV/AIDS to involve community mobilisation. Jeff O'Malley said, "many of the crucial parts of an effective response to AIDS cannot be implemented by governments ... A lot of the work has to happen outside government. Relatively few governments effectively move money from themselves out to the community sector or the private sector. In a number of countries where there have been fairly successful responses, the governments have encouraged separate streams of funding to support community action and private sector action on AIDS parallel to government".[285] He gave India as an example of a country not always successful in getting money to flow to grassroots activity. Jeff O'Malley pointed out that such non-governmental work was particularly important amongst stigmatised groups such as injecting drug users. He was concerned that DFID still viewed 'civil society' as an amorphous mass, not distinguishing the different roles that the various parts of civil society could usefully play in combatting the epidemic.[286] We recommend that DFID inform us of how they plan to encourage community involvement in the prevention of HIV/AIDS and in the care of those who are HIV-positive. We are particularly interested in how much DFID expenditure is directed at such community activity, how long-term and sustained such expenditure is, and what technical assistance is given to national governments in the funding of a community response and its replication nationwide.

241   Q.64 Back

242   Evidence, p.69 Back

243   Q.541 and Evidence, p.265 Back

244   Official Report 8 January 2001 c355W Back

245   Evidence, p.265 Back

246   Official Report 26 June 2000 c347W Back

247   Q.541 Back

248   Q.541 Back

249   Q.494 Back

250   Q.495 Back

251   Q.496 Back

252   Evidence, p.224 Back

253   Evidence, p.249 Back

254   Evidence, p.249 Back

255   Evidence, p.250 Back

256   Q.494 Back

257   Evidence, p.227 Back

258   Evidence, p.224 Back

259   'Level and flow of national and international resources for the response to HIV/AIDS, 1996-97' UNAIDS 1999 p.13 Back

260   Q.473 Back

261   Q.380 Back

262   Q.380 Back

263   Q.390 Back

264   Q.176 Back

265   Q.176 Back

266   Q.572 Back

267   Minutes of Evidence, 7 November 2000, Session 199-2000, HC 966, Q.58 Back

268   Q.572 Back

269   Minutes of Evidence 29 November 2000, Session 199-2000, HC 966, Q.72 Back

270   Evidence, p.228 Back

271   Evidence, p.228 Back

272   Evidence, p.228 Back

273   Minutes of Evidence, 29 November 2000, Session 199-2000, HC 966, Q.74 Back

274   Minutes of Evidence, 29 November 2000, Session 199-2000, HC 966, 0 Q.74 Back

275   Minutes of Evidence, 29 November 2000, Session 199-2000, HC 966, Q.74 Back

276   Minutes of Evidence, 29 November 2000, Session 199-2000, HC 966, Q.76 Back

277   Minutes of Evidence, 7 November 2000, Session 199-2000, HC 966, Q.40 Back

278   Minutes of Evidence, 7 November 2000, Session 199-2000, HC 966, Q.42 Back

279   Minutes of Evidence, 7 November 2000, Session 199-2000, HC 966, Q.43 Back

280   Q.176 Back

281   Q.470 Back

282  'Level and flow of national and international resources for the response to HIV/AIDS, 1996-97' UNAIDS 1999 p.23 Back

283  'Level and flow of national and international resources for the response to HIV/AIDS, 1996-97' UNAIDS 1999 p.22 Back

284  'Level and flow of national and international resources for the response to HIV/AIDS, 1996-97' UNAIDS 1999 p.32 Back

285   Q.167 Back

286   Q.174 Back

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