Select Committee on International Development Third Report

Section 4 — Responses and Responsibilities

The United Nations

246. We must mention the United Nations family in any section considering the international response to HIV/AIDS, although evidence did not concentrate on an assessment of the United Nations response. There has been a long-standing concern that the United Nations has too disparate and uncoordinated a structure in its handling of health issues. We have shown that HIV/AIDS not only requires coordination within the health sector but across all sectors as it has repercussions for all aspects of development. UNAIDS explained, "Starting in 1986, the World Health Organisation was assigned the lead responsibility in the UN system for assisting governments establish national HIV/AIDS programmes. By the mid-1990s, however, it became clear that the pandemic's devastating impact on all aspects of human life and on social and economic development constituted an emergency which would require an expanded United Nations effort. As a consequence, in 1996 the United Nations established an innovative joint venture, the Joint United Nations Programme on HIV/AIDS (UNAIDS), which now has seven co-sponsoring organisations: UNICEF, UNDCP, UNDP, UNFPA, UNESCO, WHO and the World Bank".[313]

247. The UNAIDS memorandum provides details of the respective activities of each of these co-sponsoring organisations. UNAIDS itself is a facilitator, aiming to help mount and support an expanded response, managing and disseminating knowledge and best practice, tracking the epidemic, advocating an expanded response to the epidemic.[314] The evidence we did receive varied in its opinion of the UN response. Students Partnership Worldwide (SPW) was critical of the failure of such multilateral bodies in the 1990s where they failed to instil in national governments a sense of urgency in setting up a cross-sectoral response to HIV/AIDS and did not produce any strategic ideas to tackle HIV/AIDS on a regional basis. They continue, "A root cause of this disjunction is that the agencies themselves do not work together. In Kampala, all five relevant UN agencies (UNAIDS, UNICEF, UNDP, UNESCO and UNFPA) have separate offices, with no established lines of communication between them".[315] In particular, the criticism was made that there was little effective interaction with grassroots organisations and community groups.[316]

248. Jeff O'Malley, however, considered UNAIDS to be a "significant success", both in advocacy, thus bringing HIV/AIDS to public attention, and in "fostering collaboration, co-operation amongst the different international organisations working on AIDS. That is particularly important as an increasing number of the international organisations become increasingly involved in AIDS".[317] We suspect that both perspectives have much truth in them. We know that for many years there has been a real problem with donor coordination, not least amongst members of the UN family. Whilst efforts are now being made to improve such coordination, we are not surprised to hear that on the ground significant problems remain. We are, however, pleased to see that the UN response to the HIV/AIDS epidemic has not been the creation of yet another agency but rather a leaner coordinating body dedicated to ensuring that HIV/AIDS is a priority across all developmental efforts. We welcome the work of UNAIDS and consider it to be making an impressive contribution to the fight against HIV/AIDS. We trust that its work will at no point be constrained by under-resourcing. We remain concerned that there is still some way to go in coordination amongst UN bodies on HIV/AIDS and believe UNAIDS should be prepared to be publicly forthright on problems and failures, if necessary shaming organisations into improvement.

249. In response to the worsening HIV/AIDS epidemic, the international community an additional development target to those listed earlier in this Report — to achieve a 25 per cent reduction in HIV infection rates among 15-24 year olds in worst affected countries by 2005 and globally by 2015. We were told that no specific strategy had been adopted to achieve this target.[318] We recommend that the forthcoming Special Session of the UN General Assembly specify the action necessary to meet the HIV/AIDS international development target. We were pleased to learn that UNAIDS is preparing a Global Strategy for the fight against HIV/AIDS. We look forward to its publication and hope it will address the main conclusions and recommendations of this Report.

Regional and multilateral organisations

250. We have not examined in any depth during this inquiry the role of regional and multilateral organisations in the fight against HIV/AIDS. We do, however, wish to note their importance in any effective response to the epidemic. It has been encouraging to observe in recent years the development of regional organisations such as the South African Development Community (SADC) and East African Community (EAC). These regional organisations have begun to take an important role in such areas as customs harmonisation, trade liberalisation, conflict resolution and regional infrastructure. We have already noted the relationship between migration and HIV/AIDS and between conflict and the disease. As movement of persons is liberalised and facilitated by such regional organisations it is important that a coherent regional HIV/AIDS strategy is in place to forestall any worsening of the epidemic. Similarly, the regional deployment of troops must be accompanied by clear policies to counteract the abuse of human rights and the spread of the disease.

251. There is obviously a danger in the multiplication of initiatives and the possible duplication of effort. We must not lose sight of the capacity of those governments and institutions we are aiming to assist. Not every organisation should necessarily work directly on HIV/AIDS. We believe UNAIDS has an important role in ensuring that the international response to HIV/AIDS is coherent and coordinated. We look forward to an analysis of HIV/AIDS coordination to date, and recommendations for the future, to be included in the forthcoming UNAIDS Global Strategy.

252. There are other organisations besides regional ones which may have a part to pay, subject to the requirements of coordination outlined above. We would mention in particular the Commonwealth. There is considerable developmental experience and a long history of mutual support in this organisation which we are sure can be usefully applied. We are pleased to see the CHOGM declaration of 1999 where the heads of government committed themselves personally to lead the national commitment against HIV/AIDS in their countries. The Commonwealth Medical Association are also active in this area. We believe the Commonwealth Parliamentary Association is also well-placed to educate and mobilise Members of Parliament in the support and advocacy of effective HIV/AIDS strategies and we look forward to greater involvement by the CPA in HIV/AIDS work.

The Department for International Development

253. We end with a consideration of the response of DFID to the HIV/AIDS epidemic. Of course in one sense the whole Report has been dealing with this issue. We turn here to a discussion of DFID's HIV/AIDS strategy. We have recommended above that every donor have a distinct HIV/AIDS strategy — we were concerned to discover that DFID does not as yet have one. Jeff O'Malley for the International HIV/AIDS Alliance wrote, "The Department for International Development (DFID) has supported some of the most important and innovative HIV activities in the developing world, but seemingly outside any overall strategy for ensuring a broad impact. DFID recently increased its commitment to HIV and began a process of improving its programmes; nevertheless, DFID is by no means a leader on this issue among bilateral agencies ... The lack of technical capacity in HIV/AIDS at both DFID and the EC has constrained the development of appropriate responses".[319]

254. The criticism was countered by Dr Julian Lob-Levyt, "We do have a clear overall strategy which is reflected in our 'Better Health for Poor People' document, which summarises that internally. We are evolving a much stronger strategy which also reflects greater regional priorities and the regional response there will be".[320] Jeff O'Malley responded, "I do not believe that DFID has had a strategy for some while. I did not mean to criticise the strategy so much as to point out its absence".[321] The lack of an explicit HIV/AIDS strategy in DFID must be remedied as soon as possible. 'Better Health for Poor People' is not adequate on its own as a framework for DFID's HIV/AIDS activities. We know that a strategy has been in preparation within DFID for a considerable time and we understand its agreement is now imminent. We look forward to the publication of DFID's HIV/AIDS strategy — it is long overdue.

255. In discussing DFID's HIV/AIDS strategy we must acknowledge that we are discussing a 'moving target'. It is clear that DFID is developing its thinking on this subject, not least as a result of our inquiry, as it acknowledged in evidence, "we have found it an extremely useful exercise being asked to produce this brief. It has helped us advance some of our own thinking, and to reinforce the message that over the last more than a year now we have really been moving out of the narrow health view of this issue and moving it out into the much broader development agenda ...".[322] Since the beginning of our inquiry there may well have been further strengthening of DFID's technical capacity on HIV/AIDS and further commitments of funds to new projects and programmes. We trust that in the final stages of preparing its HIV/AIDS strategy DFID take full account of the recommendations and conclusions contained in this Report. We also believe that the strategy should be 'owned' by all United Kingdom government departments. To the extent that the activities of a department of state have an impact on the developing world that department should take account of how such activities impinge on the epidemic.

256. In the absence of a strategy, the memorandum from DFID gives as an Appendix a helpful list of projects and programmes supported by DFID and considered to be part of their HIV/AIDS work. It is difficult, however, to know why particular activities are supported and not others, or why expenditure is high in some countries and not in others. Is it demand-led — a response to requests for assistance and effective advocacy? Does DFID have a figure that it wishes to spend on HIV/AIDS and then look for appropriate opportunities to spend such sums? Does DFID have a sense of its own 'added value' in HIV/AIDS work and concentrate on such strengths? We must examine where DFID has spent its money over the last ten years to see if there is any discernibly consistent approach. We have examined in the first instance where DFID has spent its bilateral funds, charting in a graph commitments from 1992 to 2003.

Source: DFID Memorandum

For any year the graph takes account of the value of projects being implemented. Obviously most projects last a number of years and we have simply in such cases divided the total value of the project by the number of years — thus in a three year project valued at £3 million we will for each of the three years put in a value of £1 million. This should give us a crude sense of the regional spread of DFID's HIV/AIDS work. It should be noted that further commitments from DFID may well be made. The results are nevertheless striking. DFID's bilateral HIV/AIDS expenditure in sub-Saharan Africa rose rapidly in the early 1990s to peak in 1997 but this has been followed by a considerable decline in spending in that region. Over the same period DFID's expenditure in Asia has risen more gradually but has now levelled off at fairly high amounts.

257. The Secretary of State outlined her approach in oral evidence. She warned that "we at our very best are only part of an international system ... We can try to be a leading force both in influencing the international system to operate better and to do good work from which we learn and which drives forward our understanding of what can be done. But sometimes the discussion is as though a government like ours can lead the whole world effort, and of course we cannot".[323]

258. Her second point was that up until now DFID had concentrated on prevention — "we have then driven forward programmes and efforts where we were strong and where we could get in and that has been opportunistic because you depend on governments and responses to get beyond very small interventions".[324] They were, however, now moving to a new emphasis on care, whilst also maintaining their major effort in prevention.

259. Her third point was that "the major barrier to more effective action in many countries, but particularly in Africa, where the consequences are so great, has been the unwillingness of African governments to move — with the great exception and the fine lead given by Uganda and Senegal — so when people splash around numbers and say US$ 2 billion is needed, that all sounds 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. We have not been able to spend or get in and when there are governments that will not move, that are hiding, pretending, not facing it, we cannot be a substitute for a government that will not take action".[325]

260. As was mentioned earlier, in most Asian countries prevalence rates remain low as a percentage of the population (although in a highly populated country such as India, at 0.7 per cent adult prevalence but with over 3.5 million adults HIV-positive,[326] this can nevertheless translate into appalling absolute numbers). Much can be done through effective prevention work amongst high-risk groups such as intravenous drug users and commercial sex workers and their clients. We have seen some of such work supported by DFID and consider it to be important and valuable. It appears from what Clare Short said and from the evidence provided by DFID in their memorandum that DFID is concentrating on prevention work amongst high-risk groups in Asia so as to ensure that the epidemic does not spread into the general population. This is vital work — for example, were the populations of India and China to be affected by the epidemic to the same extent as those of sub-Saharan Africa the international development targets would be utterly unachievable. We welcome the prevention work being supported by DFID in Asia.

261. Nevertheless, the recent neglect of Africa cannot continue. At the outset of our Report we claimed that there are in one sense two crises facing the international community — that the crisis in sub-Saharan Africa was on a scale which endangered all development and was threatening the very systems necessary for the fight against HIV/AIDS. For DFID expenditure on HIV/AIDS to decline to sub-Saharan Africa is unacceptable. We take the point that we cannot work everywhere nor substitute for the whole international community. It is striking, however, that it is precisely in those sub-Saharan African countries with high prevalence that DFID has a historic presence and major donor influence. DFID is one of the top three bilateral donors in nine of the ten countries with the worst HIV/AIDS prevalence in the world.

Top three donor countries in the ten countries where HIV/AIDS prevalence is highest (1999)

Prevalence (%)
Top Three Donors (ODA Net)

US$ Millions
Japan (13.9)
Germany (10.5)
UK (4.8)
UK (6.2)
Japan (4.6)
Denmark (2)
Japan (78)
Denmark (28.6)
UK (26.4)
Ireland (7.5)
Germany (5)
UK (4.4)
Germany (64.7)
UK (63.6)
Japan (59.4)
South Africa
USA (84.6)
UK (62.9)
Germany (51.1)
Germany (48.5)
USA (13.9)
Sweden (8.7)
UK (77.3)
Japan (34)
Germany (28.7)
Japan (58.6)
UK (54.1)
USA (38.9)
Central African Republic
France (30.7)
Japan (18.1)
USA (0.9)

Source: UNAIDS Report on the Global HIV/AIDS Epidemic; OECD Geographical Distribution of Financial Flows to Aid Recipients, 2001

262. We accept that there have been difficulties as a result of the unwillingness of national governments to confront the epidemic and we have already in this Report criticised such failures. Evidence suggests, however, that there is a new openness amongst Africa's political leadership to tackle HIV/AIDS. This coincides with the inclusion of HIV/AIDS strategies within the PRSPs of many of these countries. There is then an opportunity for DFID to use its long experience of working in these countries to confront the HIV/AIDS epidemic. This is surely what it means to engage in development assistance to the very poor. We recommend that DFID reverse the recent decline in its HIV/AIDS expenditure to sub-Saharan Africa and include in its HIV/AIDS strategy an account of how it plans to confront the epidemic in the region.

263. Clare Short gave one explanation for the decline in sub-Saharan African HIV/AIDS expenditure — the denial and poor policy of national governments in the region. We suspect that another reason is simply limits to the past experience and expertise of DFID in this area. The epidemic has gone beyond traditional preventive measures amongst high-risk groups, or even beyond the capacity of sexual and reproductive health measures (though both interventions remain essential). At the infection rates now seen in many sub-Saharan Africa countries any donor intervention will have to be multisectoral, promote fundamental human rights and engage with the fact that systems, including the political system, might well be profoundly weakened.

264. We have already made detailed recommendations to DFID in this Report. We have, for example, recommended that DFID continue to increase its expenditure on HIV/AIDS. We have recommended that DFID review how HIV/AIDS is affecting all its development activity, particularly in sub-Saharan Africa, and consider how development work might need to be redesigned to meet the new realities created by the epidemic. In this section we would redirect DFID's attention to sub-Saharan Africa, encouraging its new interest in the care of those living with HIV. We are pleased to note the growing seriousness with which DFID claims to be taking the HIV/AIDS epidemic. The Department should not, of course, overestimate what it can do — as Clare Short said, they are only one player in the international community. On the other hand, nor should they underestimate the impact they can have once they apply the same intellectual rigour and energy to HIV/AIDS that they have to other development issues.

313   Evidence, p.228 Back

314   Evidence, p.230 Back

315   Evidence, p.276 Back

316   Evidence, p.276 Back

317   Q.176 Back

318   Q.27 Back

319   Evidence, p.86 Back

320  Q.94 Back

321  Q.173 Back

322  Q.1 Back

323   Q.515 Back

324   Q.516 Back

325   Q.517 Back

326   UNAIDS June 2000 Report, p.128 Back

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2001
Prepared 29 March 2001