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)
| Country | HIV/AIDS
Prevalence (%)
| Top Three Donors (ODA Net)
US$ Millions
|
| Botswana | 35.8
| Japan (13.9) | Germany (10.5)
| UK (4.8) |
| Swaziland | 25.25
| UK (6.2) | Japan (4.6)
| Denmark (2) |
| Zimbabwe | 25.06
| Japan (78) | Denmark (28.6)
| UK (26.4) |
| Lesotho | 23.57
| Ireland (7.5) | Germany (5)
| UK (4.4) |
| Zambia | 19.95
| Germany (64.7) | UK (63.6)
| Japan (59.4) |
| South Africa | 19.94
| USA (84.6) | UK (62.9)
| Germany (51.1) |
| Namibia | 19.54
| Germany (48.5) | USA (13.9)
| Sweden (8.7) |
| Malawi | 15.96
| UK (77.3) | Japan (34)
| Germany (28.7) |
| Kenya | 13.95
| Japan (58.6) | UK (54.1)
| USA (38.9) |
| Central African Republic | 13.84
| 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 
