House of Commons - International Development

Select Committee on International Development Twelfth Report

4 Children

49. HIV/AIDS is having a disproportionate impact on children. Around 12 million children in sub-Saharan Africa have lost one or both of their parents to HIV/AIDS.[85] Approximately 1.8 million children are living with HIV/AIDS in the region; and the World Health Organisation found that HIV was the leading cause of death of children under five in six southern African countries.[86] Children who live with HIV/AIDS are more likely to die as a result of infection than adults: children make up 6% of the infected population but account for 14% of deaths.[87]Moreover, children are only a third as likely as adults to get access to anti-retroviral medication.[88]

Social Protection Programmes

50. Evidence from World Vision pointed out that DFID's previous AIDS Strategy Taking Action included £150 million in earmarked funding for children orphaned or made vulnerable by HIV/AIDS, which represented 10% of all the Department's AIDS expenditure during that period.[89] However, the new Strategy has moved away from this approach. Instead, DFID intends to spend £200 million over the next three years to expand social protection programmes (SPPs) in eight African countries, including the provision of cash transfers. DFID says that this funding "will provide effective and predictable support for the most vulnerable households, including those with children affected by AIDS."[90] The Strategy explains that the change of approach is intended to complement continued high levels of direct support for orphaned and vulnerable children (OVCs) from other donors, notably PEPFAR.[91]

51. We asked the Minister which eight countries DFID had selected to work with on SPPs for the first three-year period. We were told that this was still being finalised. Nor was the Minister able to tell us at that time what criteria would be used in selecting the countries.[92] However, in subsequent written evidence DFID has clarified that the criteria it will use to determine to which countries it will provide this support are "demand from countries themselves; a niche for DFID to provide this support; high HIV prevalence and high OVC burden."[93] The countries chosen for SPP support may change during the Strategy's seven-year period, "mainly due to the fact that project cycles tend to have 3-5 year time frames."[94] DFID identified 10 countries where it is already providing bilateral support for social protection for children affected by AIDS and five others where it contributes to multilateral support.[95] In separate oral evidence, DFID's Director General Policy and Research told us that DFID was funding social transfers in 20 African countries.[96]

52. DFID cited evidence from UNICEF that "well designed social cash transfer programmes could reach 80% of HIV affected households in need of assistance in low and middle income countries with high HIV prevalence".[97] Such assistance can "help secure basic subsistence, reduce poverty and protect children's access to education, health and good nutrition".[98] Children whose families receive cash transfers are less likely to need to keep their children home from school to help support their family.[99] In Zambia cash transfers have reduced school truancy by 16%.[100] DFID argues that ensuring that children get access to education is not only an important end in itself but also plays a role in preventing children becoming infected with HIV as it provides essential knowledge about HIV and helps to challenge some of the underlying factors that fuel the spread of HIV including harmful social norms around gender, sexuality and stigma.[101] Girls who complete secondary education are less likely to become infected with HIV while boys who complete their education are more likely to practise safer sex.[102]

53. The evidence we received expressed two main concerns about DFID's proposal to support social protection programmes. The first is that there is a need to ensure that social protection plans have a wider focus than just providing cash transfers. NGOs who work with orphans and vulnerable children highlighted the need for social protection programmes to include improvements in support services for vulnerable children—for example, family support services, psycho-social support, child protection services and legal assistance.[103] DFID's written evidence states that its support for social protection would not be limited to cash transfers, but no detailed information was provided about the other kinds of support it intended to provide.[104]

54. The second concern is that social protection programmes risk not reaching some of the most vulnerable children. Cash transfers will be targeted at households but many of the most vulnerable children, including orphaned children and street children, do not live in traditional households and therefore might not benefit from programmes targeted at households. Stuart Kean of the UK Consortium on AIDS told us: "There are various groups of children who are outside of the family context and cash transfers are not going to easily reach them."[105] The Consortium for Street Children reinforced the point that "home-based care programmes […] are poorly suited to reach children living and working on the streets".[106] World Vision stressed that vulnerable households with children would be only one of the groups which social protection programmes were trying to assist and that even where money reached such households, there was no guarantee that it would benefit children specifically, because of the risk of "poor intra-household distribution".[107]

55. DFID already funds social protection programmes in a number of countries. It is therefore unclear to us whether the pledge in the AIDS Strategy to spend £200 million on such programmes over a three-year period is a new commitment or a continuation of DFID's existing work in this area. We expect clarification on this. Nor is it clear to us how DFID will ensure that children affected by HIV/AIDS, specifically, are assisted through social protection programmes and cash transfers. Indicators to measure impact in this area are needed and we would expect these to be included in the Monitoring and Evaluation Framework which DFID is developing.

Paediatric care

56. The second substantial commitment that DFID has made towards dealing with the impact of HIV/AIDS on children is its plans to allocate £90 million over the next three years to improve paediatric treatment.[108]This funding will be channelled through UNITAID, which was established in 2006 as a joint initiative between the UK, France, Norway, Chile and Brazil to supply poor countries with lower cost life-saving medicines for AIDS, tuberculosis and malaria. It is administered by the World Health Organisation with a mission "to intervene in markets to lower the cost of drugs and speed up the rate at which they are made available". The DFID Strategy reports that, to date, in partnership with other donors, UNITAID has achieved a 40% reduction in the cost of paediatric anti-retroviral treatments.[109] DFID officials told us that UNITAID "has been slightly slow in starting and getting off the ground, but we feel that it has huge potential."[110]

57. In addition to improving the supply of anti-retroviral medication for children, witnesses drew to our attention the importance of treatment to prevent opportunistic infection in children with HIV. HIV weakens the ability of a child's immune system to fight off infection. Provision of the prophylaxis cotrimoxazole can reduce the number of deaths from infections such as pneumonia by 43%.[111] Stuart Kean told us that cotrimoxazole costs "one or two pence a day".[112] Yet World Vision pointed to a recent WHO report which showed that only 4% of children born to women living with HIV had received the drug despite a WHO recommendation that all children exposed to HIV should receive it until they are shown to be uninfected.[113] Malcolm McNeil, DFID's AIDS and Reproductive Health Team Leader, told us that DFID is actively promoting the use of this drug, but that the ultimate decision on whether to use it rests with national authorities.[114]

58. Children living with HIV should not be dying needlessly when a cheap and effective antibiotic is available to mitigate their vulnerability to opportunistic infections. We would encourage DFID to continue to press partner governments to ensure that cotrimoxazole is prescribed for children likely to be infected with HIV and to train their health staff to administer the drug safely.

85 Ev 103 Back

86 Ev 103 and Ev 91 Back

87 Ev 91 Back

88 UNAIDS, 2008 Global Report Back

89 Ev 103 Back

90 Achieving Universal Access, pp 5, 41 Back

91 Achieving Universal Access, p 39 Back

92 Q 93 Back

93 Ev 44 Back

94 Ev 44 Back

95 Ev 44 Back

96 Oral evidence taken on 30 October 2008 on the UN High Level Event on the MDGs, Q 140 [Mr Steer] Back