List of conclusions and recommendations
Funding
1. Should
the new US Administration decide to review its approach to development
funding, including the US President's Emergency Plan for AIDS
Relief (PEPFAR), we would urge the UK Government to take an early
opportunity to discuss with them potential areas for co-operation.
(Paragraph 13)
2. Funding for health
system strengthening is an essential part of development assistance
and we welcome the substantial sums that DFID is allocating to
it. Developing countries will never be capable of tackling HIV/AIDS
effectively unless the overall capacity of their health systems
is built up through adequate funding, including the capacity to
pursue robust prevention strategies. Our concern, however, is
that DFID has included this funding as part of its HIV/AIDS Strategy
but the specific impact that it may have on HIV/AIDS will be difficult
to measure. We recommend that, as part of its monitoring and evaluation
of the Strategy, DFID put in place indicators to assess the impact
that funding directed at health system strengthening is having
on reducing the spread of HIV/AIDS and related diseases. (Paragraph
19)
3. The Minister was
only able to give us a partial reassurance that the £6 billion
DFID has allocated for strengthening national health services
is genuinely new money, which is additional to any previous funding
announcements, rather than simply being a redirection of existing
commitments. Further clarification is required. We therefore request
a full breakdown of how this £6 billion total has been calculated
in response to this Report. Moreover, DFID has not yet spelled
out in clear terms how this substantial sum will be spent. Until
the precise allocations, and their timescales, are known, it will
be impossible to assess how much impact this apparently bold allocation
of funding is likely to have or whether it will be adequate to
meet the ambitious target of universal access by 2010. We therefore
invite DFID to provide the necessary detail in response to this
Report. (Paragraph 20)
4. We welcome DFID's
substantial funding for the Global Fund to Fight AIDS, TB and
Malaria. Disease-specific funding continues to provide vital resources
to tackle the HIV/AIDS epidemic and the Global Fund's work has
been invaluable. However, it is important that vertical funding
supports rather than conflicts with national government healthcare
systems and that it adheres fully to the principles of the Paris
Declaration on Aid Effectiveness, to which the Global Fund is
a signatory. We recommend that DFID continues to use its position
as a major donor to the Global Fund to ensure that its funding
is fully accountable to national governments and civil society
in the countries where the Fund operates. (Paragraph 26)
5. We were concerned
to learn that a substantial sum from the Global Fund has been
misappropriated by the Zimbabwean government. Zimbabwe is arguably
a unique case and it appears that the Global Fund has dealt appropriately
with this example of misuse of its money. However, the case highlights
the need for DFID to continue to press for the highest standards
of accountability and transparency in the use of funds which it
channels through multilateral organisations, particularly in countries
with weak or undemocratic governments. (Paragraph 29)
6. We believe that
a more integrated approach to HIV/AIDS funding is required. The
International Health Partnership and the Taskforce on Innovative
Financing of Health Systems are UK initiatives which feed directly
into a more integrated approach to HIV/AIDS funding. We would
encourage DFID to use the full capacity of these initiatives to
ensure that its funding streams for health systems strengthening
and disease-specific programmes are mutually reinforcing and to
press other donors to follow the UK lead towards such an integrated
approach. (Paragraph 35)
7. Targets for tackling
HIV/AIDS will not be achieved without substantial progress in
prevention and treatment in middle-income countries. The Strategy
envisages that the Foreign and Commonwealth Office will take on
an enhanced role in tackling HIV/AIDS, particularly in middle-income
countries where DFID has a minimal presence. It is vital to ensure
that FCO officials are properly equipped to carry out these duties.
We invite DFID to share with us its detailed planning for cross-departmental
working on HIV/AIDS, particularly in middle-income countries with
high prevalence levels. (Paragraph 38)
Interaction with other diseases
8. While
the funding for health systems strengthening committed by DFID
may well contribute to the treatment and diagnosis of patients
with HIV and TB, we are not convinced that DFID is taking sufficient
steps to ensure that the specific challenge of interaction between
the two diseases is tackled. Nor has DFID set out how it will
measure the effectiveness of its Strategy in addressing the interaction.
We expect to see a clearer indication of how this work will be
taken forward and measured in DFID's forthcoming Monitoring and
Evaluation Framework. (Paragraph 44)
9. The interaction
between HIV/AIDS and malaria must be tackled as part of an effective
AIDS Strategy. We welcome the commitments made by DFID in support
of the Global Malaria Action Plan. It is not clear to us, however,
how this important work on malaria will be integrated with the
HIV/AIDS Strategy. We invite DFID to provide us with further information
on this in its response to this Report. (Paragraph 48)
Children
10. 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. (Paragraph
55)
11. 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. (Paragraph 58)
Women
12. Addressing
gender inequalities should be at the heart of effective prevention
and treatment of HIV/AIDS. Specially tailored policies that focus
on education and socio-economic empowerment of women and girls
are needed to help reverse the current trend of high levels of
infection amongst women. We believe that efforts should be made
to target these strategies beyond traditional high risk groups
such as sex workers to include young people and married couples.
(Paragraph 62)
13. We support the
holistic approach towards women and HIV that DFID advocates in
its new Strategy. Addressing embedded gender inequalities will
rely on wide-ranging strategies that bring together health, education,
justice and social protection agendas. (Paragraph 63)
14. We commend the
emphasis in the new DFID Strategy on the disproportionate impact
of HIV/AIDS on women and girls. However, we are concerned by the
lack of concrete and country-specific policies within the document.
The Strategy does more to describe the impact of HIV/AIDS on women
and girls rather than to indicate how DFID will tackle it. Beyond
an important but limited set of commitments on HIV prevention
and social protection, gender-specific policies and funding pledges
are lacking. We recommend the development of a global action plan,
linked to the AIDS Strategy, which sets out the actions DFID will
take to support women-specific approaches to the epidemic over
a specified timescale. (Paragraph 66)
15. We are concerned
about DFID's lack of dedicated strategies and funding to address
gender-based violence (GBV), which is closely linked to the spread
of HIV. We highlighted successful DFID-funded approaches to addressing
GBV in Nepal, Bangladesh and South Africa in our Maternal Health
Report earlier this year and were disappointed not to see information
on scaling up or replicating these initiatives included in the
new Strategy. We recommend that, in its Response, DFID provides
us with a policy update which sets out details of the specific
approaches it will take to address GBV, including the necessary
funding commitments. (Paragraph 69)
16. We welcome DFID's
pledge to support an increase in the percentage of HIV-infected
pregnant women who receive anti-retroviral treatments (ARVs) to
80% by 2010, and thereby reduce mother-to-child transmission of
HIV. However, ARV provision is only one of a number of interventions
to prevent transmission recommended by the World Health Organisation.
We recommend that DFID works to ensure ARV provision forms one,
critical, part of a care package for HIV positive mothers that
also includes the full range of required interventions. (Paragraph
74)
17. We note the ambitious
level of percentage increase needed to meet DFID's commitment
to increasing ARV coverage for HIV-infected pregnant women: from
the current rate of 34% to 80% in just two years' time. We expect
to see a clear commitment on how progress towards this ambitious
and short-term target will be measured in DFID's Monitoring and
Evaluation Framework which is due to be published on 1 December
2008. We recommend that the Framework includes an indication of
the level of DFID's specific projected contribution to the international
efforts to reach this target. (Paragraph 75)
18. We welcome the
focus in the Strategy on closer integration of HIV/AIDS and sexual
and reproductive health services (SRH), together with maternal
and child health, TB and malaria. SRH and HIV/AIDS cannot be separated
as health issues and accordingly DFID is right to include better
integrated responses as a priority action. We believe that integration
will be more effective where it is prioritised by health systems
that are ready and willing to implement it. Accordingly, we recommend
that DFID presses both national governments and multilateral donors—particularly
the Global Fund, the World Bank and the relevant UN agencies—to
do more to support the integration of services. (Paragraph 82)
Marginalised groups
19. If
the global effort on HIV/AIDS is to achieve the goal of halting
and reversing the spread of the disease, it must be effective
in reaching marginalised people, including sex workers, intravenous
drug users, men who have sex with men and transgender individuals.
If the epidemic is not tackled in these groups it will continue
to spread to the general population and the number of people affected
will continue to increase. DFID's Strategy acknowledges this reality
but does not adequately explain how DFID will ensure that these
marginalised people are provided with the prevention, treatment
and support services they require. We would welcome further information
on DFID's plans in this area in response to this Report. (Paragraph
87)
Engagement with civil society
20. We
welcome the Minister's assurance that civil society will be fully
engaged in the implementation of the Strategy. However, further
details are needed on how DFID will pursue this engagement, including
how much funding will be allocated to support the work of civil
society on the ground in countries with a high prevalence of HIV/AIDS
and related diseases. We request that DFID provides this detailed
information in its response to this Report. (Paragraph 97)
Implementation
21. There
are many excellent examples in the Strategy of HIV/AIDS work which
DFID is undertaking with specific countries and specific groups.
What is not clear to us, however, is the extent to which DFID
intends to scale up or replicate these projects elsewhere. (Paragraph
103)
22. We agree with
our witnesses that the significant funding commitments which DFID
has made in the Strategy are impressive and that its analysis
of the current situation is excellent. However, the challenge
remains for DFID to turn the rhetoric into practical implementation
and to demonstrate much more clearly how it will achieve the targets
it has set and the commitments it has made. (Paragraph 105)
23. We will return
to this subject in our forthcoming Report on the DFID Annual Report
2008 but we are keen to reiterate our concerns, in the specific
context of the new HIV/AIDS Strategy, that staff reductions at
DFID may have reached the point where they risk adversely affecting
the Department's ability to deliver its objectives in vital fields
such as health and social care. (Paragraph 109)
Monitoring and Evaluation
24.
There are obvious similarities in the global challenges of tackling
HIV/AIDS and tackling malaria. We are impressed by the process
which DFID followed in developing the Global Malaria Action Plan
which focused on desired outcomes and used that information to
determine decisions about inputs and mechanisms. However, it is
not evident to us that DFID adopted a similarly rigorous procedure
for developing its new AIDS Strategy We believe this was a missed
opportunity and we regard the lack of specific budget allocations,
targets and outcome indicators as a significant deficiency in
the new HIV/AIDS Strategy, which we hope will be addressed in
the next stage of the process. (Paragraph 115)
25. We regret that
DFID was not able to publish the Monitoring and Evaluation Framework
at the same time as the Strategy was launched in June. All stakeholders,
including ourselves, need to understand the specific outcomes
that DFID is seeking to achieve through the funding commitments
it has announced and how it intends to measure progress towards
them. We hope that, when it is published, the Framework will provide
the answers to the important questions about implementation and
monitoring and evaluation which the Strategy itself has left open.
(Paragraph 117)
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