DFID response to the call for evidence
for the IDC Inquiry: HIV and AIDS: UK's Updated Strategy—"Achieving
Universal Access—the UK's Strategy for halting and reversing
the spread of HIV in the developing world"
THE STATE
OF THE
EPIDEMIC SINCE
2004
1. Significant progress has been made in
tackling the AIDS epidemic since Taking Action was published
in 2004. The percentage of the world's adult population living
with HIV has levelled off. Twenty times more people have access
to life-saving treatment and the price of first line AIDS drugs
has fallen considerably.
2. Despite the progress, the human cost
of the epidemic remains immense. There are still more than 33
million people living with HIV. Every day, over 6,800 people become
infected with HIV and over 5,700 people die from AIDS. In other
words, somebody dies every 15 seconds. At the end of 2007, 3 million
people were on antiretroviral therapy in low & middle income
countries, up 42% on the previous year. However, this is still
only 30% of the global need. In 2007, for every two people who
received antiretroviral treatment another five were newly infected
with HIV. This highlights the urgent need to increase efforts
on HIV prevention.
3. Currently 2 million children under the
age of 15 are estimated to be living with HIV and around 15 million
children have been orphaned and many more made vulnerable by the
epidemic. As a result of the AIDS epidemic, children and youth
are experiencing stigma and discrimination, deepening poverty
and have less access to education and parental support. The burden
of care often falls on the poorest households and communities.
Despite increasing donor resources for orphans and vulnerable
children (OVC), currently only 10-25% of affected households in
high HIV burden countries receive external support for the care
of OVC.
4. Access to AIDS services remains unacceptably
low—for example, most prevention strategies are available
to fewer than one in five people who could benefit from them.
In some high prevalence countries, AIDS is reversing decades of
progress towards better health, education and wealth.
5. "Achieving Universal Access-
the UK's strategy for halting and reversing the spread of HIV
in the developing world", the updated UK strategy (hereafter
referred to as "the Strategy") was launched on 2 June
2008. The Strategy highlights the importance of increasing effort
on comprehensive HIV prevention. It sets out the UK's commitment
to intensify prevention efforts that have proven to be effective,
such as prevention of mother-to-child transmission, family planning
and harm reduction. It also highlights the need to maintain momentum
on treatment and increase coverage of care and support. It focuses
on three main areas: responding to the needs and focussing on
the rights of those most affected by AIDS; supporting more effective
and integrated service delivery; making the money work harder
through effective partnerships.
6. The Strategy made a bold and ambitious
step by announcing a long term commitment of £6 billion to
strengthen health systems and services up to 2015. It recognises
that action is also needed outside the health sector and emphasises
the importance of a multi-sectoral response that includes action
in education, social protection and justice. The UK has already
committed significant resources to education and is now committing
to spend £200 million on social protection programmes over
three years. Evidence[1]
shows that social protection programmes, including predictable
cash transfers are an effective way to meet the needs and rights
of families and OVC.
7. DFID welcomes this IDC inquiry. Although
less than three months have passed since the publication and launch
of the UK AIDS Strategy, the inquiry provides an opportunity to
reflect on the statements and commitments made and to think about
implementation as we move forward. The UK AIDS strategy was launched
in conjunction with an evidence paper, "Achieving Universal
Access—evidence for action" which provides a summary
of the latest evidence that support the themes, actions and commitments
in the Strategy. The evidence presented in this memorandum assumes
that the IDC has had the opportunity to read both the evidence
paper and the updated strategy.
8. Below is our response to the nine issues
posed by the IDC.
Issue 1. The extent to which DFID's strategy
will be effective in tackling the disproportionate impact of HIV/AIDS
on women and children
9. The Strategy continues our attention
on the disproportionate impact on women and children developed
in Taking Action. It recognises that they are among those
most likely to be living with HIV; least able to deal with the
impacts of the epidemic; and are most likely to be failed by existing
policies, programmes, support and services.
10. The Strategy emphasises that gender
inequalities mean that women and girls' cannot always decide if,
when, how and with whom they have sex. It also acknowledges that
gender violence can significantly increase women and girls risk
of acquiring HIV infection. It emphasises the need to address
gender inequality as one of the key drivers of HIV infection.
This is an essential component of a comprehensive HIV prevention
strategy. By empowering women to negotiate safer sex, we can prevent
them from acquiring the virus.
11. The Strategy stresses the need for the
international community to work with governments and civil society
to ensure that the needs and rights of women, young people, children
and vulnerable groups are fully integrated into the AIDS response.
It also stresses the need for responses in the health sector and
beyond (especially education, social protection, justice and livelihood
sectors) in order to ensure universal access.
12. AIDS places a huge burden on children
affected by the disease, especially in sub-Saharan Africa. Social
protection, including cash transfers along with broader family
support and child protection initiatives, has been widely endorsed
by experts, including the Joint Learning Initiative on Children
and HIV/AIDS and the Inter-Agency Task Team for Children and AIDS
as an important mechanism for improving the welfare of children,
including OVC and their families. UNICEF estimates 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.[2]
At the Children and HIV/AIDS: Action Now, Action How Symposium
in early August 2008, in Mexico considerable attention was given
to the importance of social protection and cash transfers. News
of DFID's £200 million commitment to social protection was
very well received by government and non-governmental representatives.
The approach of programmes which focus only on individual orphans
and AIDS affected children as opposed to vulnerable children more
generally was strongly criticised during the XVII International
AIDS Conference in Mexico City in August 2008. There is a clear
shift in targeting towards an "AIDS conscious but not AIDS-exclusive"
approach to reaching OVC consistent with the approach taken in
the Strategy.
13. Some examples of how the Strategy will
effectively respond to the needs of women and children include:
— Over the next three years, increasing
UK spending to over £200 million to expand social protection
programmes, including cash transfers which will directly benefit
children made vulnerable by AIDS and their families. DFID will
work with governments and civil society in eight African countries
to develop social protection policies and programmes that will
provide effective and predictable support for the most vulnerable
households, including those with children affected by AIDS. The
evidence to support social protection as an effective approach
will be reviewed every two years following the Global Partners
Forum for Children Affected by AIDS.
— The updated strategy recognises the
importance of a multi-sectoral response to mitigate the impact
of the epidemic on vulnerable groups including vulnerable children.
As part of this support Ministries of social welfare will be assisted
to ensure that appropriate and well-targeted social assistance
programmes (such as old-age pensions and child support grants)
are in place. The strategy recognises that cash transfers are
only one part of a comprehensive system of care and support for
vulnerable children and their families. OVC, including those living
on the streets, also need to receive broader social support services,
accessible and affordable healthcare and education, psychosocial
support and livelihoods support. This support will be provided
both through government and NGO channels.
— We are also committed to ensuring
greater access to paediatric treatment. The UK has committed £90
million to UNITAID, from 2008-11, which will help increase access
to paediatric treatment.
— Ensuring that gender analysis is
integrated within national AIDS plans, and that targets and indicators
are developed to measure the impact of AIDS programmes on women
and girls.
— Taking action on neglected and sensitive
issues, including sex workers and adolescents' Sexual and Reproductive
Health and Rights.
— Supporting countries to develop and
implement evidence-informed and gender sensitive prevention strategies
that: promote and protect human rights; are relevant to the local
epidemic context; and promote comprehensive approaches to HIV
prevention based on the realities of people's lives.
— Working with others to intensify
international efforts to halve unmet demand for family planning
(including male and female condoms) by 2010, to achieve Universal
Access to family planning by 2015. This includes the UK's new
£100 million commitment to UNFPA for their Global Programme
to enhance Reproductive Health Commodity Security.
— Working with others to intensify
international efforts to increase to 80% by 2010 the percentage
of HIV-positive pregnant women who receive anti-retroviral treatments
(ARVs) to reduce the risk of mother to child transmission, both
in low income and high prevalence countries.
— Supporting UNAIDS to lead and advocate
for action on women, girls and vulnerable groups at the global
and country level. This includes the setting of gender guidelines
to help countries assess and mitigate against the impact of AIDS
on women, girls and sexual minorities.
14. The focus on gender in the AIDS strategy
complements DFID's `Gender Equality Action plan' that was published
in 2007. This aims to promote gender equality and to empower women
by promoting a range of interventions to achieve better outcomes
for women and girls across DFID programmes.
15. DFID is now developing a comprehensive
monitoring and evaluation framework to ensure that progress towards
the UK's priorities for action, including those focussing on women
and children, are regularly assessed and that lessons and successes
are identified and disseminated. This framework is covered in
more detail in the response to Issue 8 in this memorandum.
EXAMPLES OF
THE UK'S
SUPPORT TO
WOMEN AND
CHILDREN INCLUDE:
16. In Kenya, within the new £40
million HIV and AIDS programme, funding will be channelled to
Civil Society Organisations (CSOs) implementing HIV and AIDS programmes
for women and young people. DFID recently approved a new programme
to scale up cash transfers to 30,000 households. DFID Kenya has
also funded research on the reproductive health and HIV prevention
needs of older OVC (10-17 years) and has funded a home base care
project in Nyanza, western Kenya, serving 240,000 OVC.
17. In Zimbabwe, DFID has provided
£25 million support to a Maternal and Newborn health programme,
through UNICEF, UNFPA and a range of other partners. This will
support access to family planning services, provide emergency
obstetric care, and protect the lives of mothers and newborns,
especially those affected by HIV and AIDS. A further £23
million programme (administered by UNICEF) aims to reach 400,000
children and provides greater access to basic social services
and helps protect them from all forms of abuse.
Issue 2. (a) How HIV/AIDS interacts with
other diseases, especially TB and malaria, and (b) how effectively
this interaction is dealt with by donors and funds
18. The updated AIDS strategy emphasises
the important links between AIDS and other diseases, including
tuberculosis (TB), malaria, and with Sexual and Reproductive Health
and Rights (SRHR). It recognises the physiological interactions
between AIDS and other diseases. For example, someone living with
HIV is at greater risk of having TB. The Strategy highlights the
need for HIV and TB care to be better integrated to improve the
diagnosis of TB in HIV patients and vice versa. The Strategy recognises
the need to strengthen health systems to provide services for
individuals that address all health issues at the same time.
(a) The interaction of HIV and AIDS with other
diseases
19. TB is the most common infection among
people with HIV. In sub-Saharan Africa, for example, up to 80%
of TB patients are co-infected with HIV. In the same region, HIV
is the most important factor behind the dramatic increase in TB
in the last 10 years. Worldwide, about 13% of AIDS deaths each
year result from co-infection with TB. TB is also the most common
cause of death in people already receiving antiretroviral therapy.
TB is harder to diagnose in people living with HIV. Somebody co-infected
with HIV and TB is far more likely to become sick with TB than
someone with TB alone. So, the two diseases must be considered
together.
20. There has been major progress in the
implementation of interventions to deal with TB/HIV co-infection,
but progress has not been sufficient to reach agreed targets.
Less than 15% of TB patients are tested for HIV in Africa, despite
very high rates of co-infection. Intensified efforts to identify
TB in people with HIV are also needed. In 2008, only 42% of countries
with generalised HIV epidemics reported that they routinely screened
for TB in people with HIV. In the 63 countries that account for
97% of estimated TB cases in people living with HIV, approximately
one-third of countries have still to establish national plans
that integrate HIV and TB activities.
21. The UK government is committed to tackling
HIV and TB co-infection and to increasing investment in research
to promote the development of better tools for prevention, diagnosis
and treatment of TB. For example, DFID's research Strategy for
2008-13 outlines how DFID will double its investment in research
including health, to £220 million a year by 2010. In terms
of health, the research strategy includes a focus on developing
drugs for HIV and AIDS, TB, malaria and other diseases that affect
poor people, as well as vaccines for HIV. DFID also provides support
for research and development efforts around new TB drugs and diagnostics,
including through the World Health Organization and the Global
Alliance for TB Drug Development. DFID has been a significant
investor in Product Development Partnerships (PDPs) which have
been shown to be effective in developing new drugs and technologies
for many neglected diseases. DFID plans to increase and diversify
funding to PDPs which will include paying more attention to TB
and health technologies such as diagnostics.
22. Linkages between HIV, maternal and child
health services are also lacking. HIV increases the risk of maternal
death (with subsequent serious impact on the child and wider family)
by increasing the risk and impact of malaria and TB during pregnancy.
WHO recommends that maternal and child health services should
provide a platform for scaling up prevention of mother to child
transmission responses.
23. The UK has provided global leadership
on SRHR. The updated Strategy rightly emphasises the important
links between AIDS and SRHR. Almost 90% of HIV infections are
sexually transmitted or through mother to child transmission.
Expanding access to SRHR, including improved access to family
planning, treatment of sexually transmitted infections (STIs),
and increased condom use is an integral component of HIV prevention.
(b) How effectively is the interaction being
dealt with by donors and funds?
24. The interaction between AIDS and TB,
malaria and other diseases is dealt with by donors and funds in
different ways, with greater or lesser degrees of effectiveness.
The UK government believes that the interaction is most effectively
tackled by taking an approach that focuses on strengthening health
systems and services overall, with the aim of supporting an integrated
approach to health service delivery. An alternative way of funding
AIDS is to take a more "vertical", disease-specific
approach such as the US PEPFAR programme (the US President's Emergency
Program for AIDS Relief).
25. Whilst recognising that a vertical approach
can have certain benefits (eg ensuring that interventions prioritise
AIDS, which is particularly useful in hyper-endemic situations),
the UK's position is that interaction between AIDS and other diseases
is most effectively dealt with through investments that support
the development of well functioning, comprehensive, sustainable
and robust health systems and services. And, to ensure efficacy,
it is essential that whatever the chosen mechanism for support
that donors do not create additional burdens or transaction costs
for countries but that they honour donor commitments to the Paris
Declaration principles of country ownership; harmonisation; alignment;
managing for results; and mutual accountability.
26. One of the ways in which the UK is dealing
with the interaction between AIDS and other diseases is by making
a long term commitment of £6 billion to strengthen health
systems and services up to 2015. This echoes the recommendations
of a report published in June 2008 by WHO, UNAIDS and UNICEF,
"Toward Universal Access; scaling up priority HIV/AIDS interventions
in the health sector", in which they highlighted the need
for a focus on health systems strengthening. The UK's health systems
commitment will cover health systems, communicable diseases, maternal
and child health, and sexual and reproductive health. Stronger
health systems mean we can scale-up preventative measures, eg
Prevention of Mother to Child Transmission (PMTCT), provide anti-retrovirals
(ARVs), integrate sexual and reproductive health and rights (SRHR)
with AIDS and effectively tackle other related illnesses, such
as malaria and TB. We want to fund the health sector in its entirety
rather than individual elements of it as this will deliver the
sustainability needed in the longer term.
27. In addition to the £6 billion commitment
for health systems, the UK will provide the Global Fund for AIDS,
TB and Malaria (GFATM) with up to £1 billion to support its
global response. The GFATM is in a prime position to promote the
linkages and interaction between AIDS, TB and malaria. The UK
also remains committed to implementing the International Health
Partnership (IHP), which it founded in 2007 to support developing
country governments to improve the general health of their people,
without focusing on any one type of illness. Our comprehensive
approach to tackling AIDS and other diseases is also reflected
in our support of UNITAID (the international drugs purchasing
facility). UNITAID aims to bring down the price of drugs and diagnostics
and to increase their availability. The UK has made a 20 year
commitment to UNITAID which could see us providing as much as
£760 million up to 2027.
28. Financial support to strengthening health
systems is not the only way in which the UK is recognising the
interaction between AIDS and other diseases. We are also supporting
the technical work of UN agencies, such as the WHO, which has
developed operational guidelines on Integrated Management of Childhood/Adolescent
and Adult Illnesses. These tools support decentralisation of AIDS
related services to district hospitals, health centres and community
level and their integration with other health interventions such
as TB, substance use, pregnancy and child health.
EXAMPLES OF
HOW THE
UK AND OTHER
DONORS WILL
ADDRESS THE
INTERACTION BETWEEN
AIDS AND OTHER
DISEASES:
29. The International Health Partnership
(IHP) was launched by the UK in September 2007 to deliver,
among other things, stronger and lasting health systems to deliver
better care for the poor. It is about working together to support
developing country governments, based on the central role of health
systems in National Strategies and the coordination of funding
around these strategies. The IHP is now led by the World Health
Organisation (WHO) and World Bank, supported by the other key
international health agencies (UNICEF, UNFPA, UNAIDS, GFATM, GAVI
and Gates Foundation). Ethiopia signed its IHP country compact
on 26 August 2008. In this compact, the Government of Ethiopia
has clearly set out how it wants all development partners—bilateral
donors as well as health agencies—to support its national
health plan.
30. DFID will harness the interaction between
AIDS and other diseases by supporting research to develop
drugs, microbicides and vaccines for HIV and AIDS, TB, malaria
and other diseases that most affect poor people. These plans are
outlined in DFID's Research Strategy for 2008-13, which includes
the commitment to double investment in research, including health,
to £220 million a year by 2010. Research funding also provides
opportunities for operational research, so that researchers and
policy makers can investigate how known interventions can be scaled
up in countries, as well as research into the social and economic
contexts of HIV and AIDS in the general population and some vulnerable
groups.
31. In Southern Africa, DFID is finalising
the design of a new Regional Health and AIDS programme, providing
£55 million over five years, to address both AIDS and broader
health issues, to support countries scale up their responses to
AIDS, TB and malaria in women, children and other vulnerable groups.
Issue 3. How will the new AIDS Strategy be
incorporated into DFID's Country Programmes?
32. The Strategy recognises that while AIDS
presents a global challenge, epidemics within and across countries
and regions can and do have different characteristics. Delivery
of DFID's HIV and AIDS strategic priorities, in line with the
AIDS Strategy, is carried forward through decentralised bilateral
country programmes and also through some regional programmes,
particularly in hyper-endemic areas, or in areas where neighbouring
counties face similar challenges. Working in line with the AIDS
Strategy, country offices are responsible for the design and delivery
of HIV and AIDS responses as agreed in negotiation with the host
government and other key stakeholders, and taking into account
the local context and the constraints of DFID's overall financial
framework.
33. In all settings, DFID works in close
partnership with governments, civil society, the private sector
and other bilateral funding agencies. DFID also works with multilateral
institutions, including the World Bank, United Nations agencies
and the European Commission. The UK delivers funding through a
range of aid instruments including general budget support (often
known as poverty reduction budget support), sector budget support
(eg health or education), along with support to multilateral and
civil society actors. Decisions on which aid instruments should
be used are taken by DFID offices at a country level, depending
on what is most appropriate for the situation in that country.
34. In some settings, the priority is to
strengthen weak capacity in government or other country partners,
while supporting direct service delivery via the UN or civil society
(eg Nigeria, DRC, Zimbabwe, Burma). In other settings, DFID tends
to focus on technical support and implementation of country-led
HIV and AIDS strategies, working with governments, civil society
and international donors and agencies (eg in Ghana, Ethiopia,
Uganda, Zambia, Mozambique, India, Nepal, Pakistan, Bangladesh,Vietnam,
China, Cambodia. In hyper-endemic middle income countries, such
as Botswana, the approach is to provide technical support to unblock
political and technical barriers to scale up and promote learning
between countries. These programmes will cover a range of prevention,
treatment, care and support interventions, working with UN, state
and non state actors and vulnerable groups.
35. DFID is in the process of developing
a framework for monitoring and evaluating (M&E) the updated
AIDS Strategy. This framework, along with a baseline from which
to measure progress, will be finalised in November 2008. More
information on the M&E framework is set out in the response
to Issue 5 in this memorandum.
EXAMPLES OF
DFID COUNTRY PROGRAMMES
REFLECTING COMMITMENTS
MADE IN
THE UPDATED
AIDS STRATEGY:
36. In Africa:
— Lesotho: DFID has supported
the establishment of the National AIDS Council (NAC), including
the transparent recruitment of its CEO; establishment of its legislative
framework; and the establishment of the national People Living
with HIV (PLWH) network.
— Rwanda: DFID support to the
HIV and AIDS unit in the Ministry of Education helped achieve
the removal of primary school fees, support the piloting of alternative
education options and research on barriers to access and special
provision for Orphans and Vulnerable children (OVC).
— Zimbabwe, Lesotho, Namibia, Botswana,
South Africa, Swaziland and Angola: DFID is working closely
with UNICEF to take forward commitments on OVC including identifying
appropriate forms of social protection and child support services,
working with Ministries of social welfare to strengthen their
capacity, and providing funding through civil society organisations
to strengthen community based initiatives.
37. In South Asia:
— Pakistan: DFID has supported
the generation of evidence on HIV and AIDS and has supported the
National AIDS Control Programme to develop a new HIV and AIDS
Control Strategy. DFID plans to continue with poverty reduction
sub-sector budget support, technical assistance and encouraging
stronger political commitments on the "Three Ones".
DFID is working with the World Bank to rapidly scale up service
delivery packages for vulnerable populations and will continue
funding to increase the use of barrier contraceptives and efforts
to deal with TB and HIV co-infection and treatment for sexually
transmitted infections.
— Bangladesh: There has been
a strong focus on targeted approaches to prevent HIV and AIDS
amongst sex workers and Injecting Drug Users (IDUs). Key issues
in the new AIDS strategy, including addressing stigma, increasing
attention to the prevention of HIV infection in women and children,
and better collaboration between development partners, will be
addressed through DFID's support for a major urban health programme
(the Urban Primary Health Care Programme II, (UPHCP-II) as well
as DFID's overarching health sector support programme (the Health,
Nutrition and Population Sector Programme (HNPSP). In the UPHCP-II,
health workers and clinic managers are being given training on
the technical issues around HIV and AIDS, as well as how to reduce
the stigma associated with HIV infection. The UK is working through
the HNPSP, which includes agencies such as UNAIDS, to better address
the needs of women and children in HIV prevention through strong
collaborative efforts with government and other donor partners.
38. In the Caribbean:
— DFID is working through the regional
Pan Caribbean Partnership on HIV/AIDS (PANCAP) to ensure that
National AIDS Programmes, civil society and the private sector
develop and implement high quality national progammes to tackle
stigma and discrimination which is a major driver of the epidemic
in the region.
Issue 4: How will civil society be involved
in implementing the new strategy?
39. The updated Strategy covers a seven
year timeframe and we are therefore at an early stage in terms
of implementation. Since the public consultation closed and the
strategy was launched, officials have met with civil society representatives
on a number of occasions. One of the aims of these meetings has
been to discuss working together to implement the Strategy.
40. Civil society was actively engaged in
the consultation for the development of the strategy. A 12-week
public consultation was held between May and August 2007, coordinated
by the UK Consortium on AIDS and International Development. Strong
efforts were made to ensure that southern voices were heard in
the consultation, and to ensure that people living with HIV were
centrally involved. Considerable effort was made to take into
account the views and opinions expressed during the consultation
process.
41. The Strategy acknowledges the vital
role civil society organisations play in tackling AIDS and how
they complement the work of governments and the private sector.
It emphasises the importance of effective partnerships between
governments, bilateral and multilateral agencies, civil society
and the private sector in the AIDS response. It highlights the
need to ensure resources are channelled to where they are most
needed—including to communities and community based organisations.
42. The Strategy also acknowledges the significant
role the private sector plays through funding and research and
by influencing government. It highlights the importance of workplace
policies and programmes and the role that the private sector,
and trade unions have in this regard.
43. GFATM has been a key driver of the growth
in funding for AIDS since 2003. It now provides over one-fifth
of all international resources for AIDS. GFATM is widely acknowledged
for its strong engagement with civil society. Civil society and
NGOs represent an important part of the GFATM partnership. They
participate in the strategic planning process through their involvement
in the Partnership Forum and in specific countries through their
involvement with Country Coordinating Mechanisms. Civil Society
Organisations, from both developed and developing countries are
represented on the Board and its committees. Provisional results
from the submission of proposals to the Fund under Round 8 suggest
that some 40% of the disease specific proposals have opted to
nominate at least one Principal Recipient to receive and manage
the GFATM funds from the Government sector and one from a non
government sector, to follow the GFATM recommendation on so-called
Dual Track Financing. In October 2007, DFID committed to provide
GFATM with up to £1 billion over seven years.
44. DFID manages various funding mechanisms
specifically for civil society organisations (CSO). These include
the Civil Society Challenge Fund (CSCF), the Governance and Transparency
Fund (GTF) and the Programme Partnership Agreements (PPAs). We
have 26 PPAs with key UK and International civil society organisations.
These Agreements provide untied strategic support based on mutually
agreed objectives. DFID is committed to provide a total of £367
million over the next three years in support of these PPAs—eleven
of which have strategic objectives specifically focussing on addressing
HIV and AIDS. A number of civil society organisations (eg International
HIV and AIDS Alliance, and International Planned Parenthood Federation)
are partners in research programme consortia, funded through DFID's
Central Research Department.
45. Decisions are taken at the country level
as to the most appropriate range of aids instruments for a given
context. There are many examples of DFID funding to civil society,
including both national and international organisations, in different
countries. In addition in some contexts DFID provides funding
to a pooled funding arrangement for support to civil society organisations
for example in Mozambique and in Tanzania.
46. We are working with UN agencies such
as UNAIDS and UNICEF and directly with NGOs to find more effective
ways to get resources down to communities. For example DFID is
developing, with UNICEF, innovative mechanisms at country level
to channel resources to community based organisations in Zimbabwe
and Namibia. In Zimbabwe alone this is reaching over 130 community
based organisations and to date has reached over 180,000 children.
In Mozambique, DFID funds a UNAIDS social mobilisation officer
to enhance civil society's participation in the national AIDS
response.
47. At the biannual Global Partners Forum
for Children Affected by AIDS in October 2008 development partners,
including DFID, will be reviewing global progress on OVC commitments
including mechanisms for getting resources down to community based
initiatives. A working session will focus on learning the lessons
from existing best practices including some DFID-funded programmes
such as the Zimbabwe Programme of Support (see above in issue
3).
EXAMPLES OF
UK SUPPORT TO
CIVIL SOCIETY
IN IMPLEMENTING
THE UPDATED
STRATEGY:
— Uganda: DFID is funding civil
society and the UN to increase public involvement in policy dialogue
and to build local capacity to review and develop policy.
— Tanzania: DFID supported the
establishment of a pooled fund arrangement with the Ministry of
Finance and the Tanzania Commission for AIDS (TACAIDS). The Rapid
Funding Envelope for HIV/AIDS (RFE) was established in 2002 as
an innovative partnership between TACAIDS, the Zanzibar AIDS Commission
(ZAC), bilateral donors, and one private foundation. The RFE's
purpose is to enable civil society institutions in Tanzania to
participate fully in the national multi-sectoral response to the
AIDS epidemic. DFID sits on the RFE steering committee.
Issue 5: What is the likely effectiveness
of monitoring systems in ensuring that funding announced in the
Strategy reaches local level?
48. Monitoring and Evaluating (M&E)
activities, both at national and sub-national levels, are a central
part of DFID's management and business systems. This involves
keeping track of inputs, processes, outcomes and impacts of DFID-funded
bilateral and multilateral programmes. It is also about influencing
other donors and partners, to address gaps in performance and
to ensure transparency and accountability.
49. DFID is currently in the early stages
of reviewing budget tracking processes as well as the impact of
community level AIDS responses. This is in line with priorities
identified in the Strategy. Discussions are underway with the
Global AIDS Monitoring and Evaluation Team (GAMET) housed by the
World Bank, to lead on this work. The proposed review will assess
the impact of community interventions in 10 African countries.
The aim of the work is to track the flow of funds from national
to community level. It will answer questions such as "how
much funding has actually reached the community? What are the
obstacles hindering the flow of funds?" In so doing, it will
contribute to the overall objective outlined in the updated Strategy
of making the money work harder through an effective and coordinated
response.
50. Improved data on the volume and sector
destination of sub-national aid flows is also expected to arise
out of the International Aid Transparency Initiative (IATI), which
was launched by the Secretary of State, Douglas Alexander at the
High Level Forum on Aid Effectiveness in Accra in September 2008.
The IATI is a proposal for an international initiative to deliver
a step shift in global public availability and access to information
on aid flows, to promote increased accountability and effectiveness
of aid. The IATI seeks to secure international agreement to a
set of common information standards applicable to all aid flows.
51. In addition to general systems of M&E
and work on budget tracking processes, a framework for M&E
Achieving Universal Access is currently being developed. This
reflects the fact that the updated Strategy focuses on outcomes
and results. We aim to finalise the M&E framework and to develop
a baseline from which to measure progress by November 2008. Both
documents will be published and will be available on the DFID
website once approved by Ministers.
52. The framework is being developed in
consultation with regional divisions and country offices within
DFID and other relevant government departments, including the
Foreign and Commonwealth Office, Department of Health and the
Home Office. DFID is also consulting with key funding agencies
and with civil society organisations through the UK Consortium
on AIDS and International Development. The framework will include
a methodology to measure progress towards achieving the long term
commitment of £6 billion to strengthen health systems and
services up to 2015.
53. The effectiveness with which funds for
HIV and AIDS are achieving the desired outcomes will be assessed
when we undertake an independent review of the implementation
of the Strategy in three years time. We have also committed to
review the UK's approach to addressing the needs and rights of
OVC, including the evidence base and effectiveness of our approach
to social protection every two years following the Global Partners
forum on Children Affected by HIV and AIDS, the next meeting of
which will be held in October 2008. Plans are already underway
to review the impact of social protection. We will use the findings
of this review along with the outcomes of the biennial Global
Partners Forum, to ensure that we continue to support the most
effective ways of meeting the needs and rights of OVC.
54. In monitoring our strategy, together
with the Cross-Whitehall Working Group on AIDS, we seek to attribute
the UK's inputs through processes to outcomes and impacts in countries
and globally. The ultimate goal of the strategy is to achieve
the internationally agreed goal of Universal Access to comprehensive
HIV prevention, treatment, care and support by 2010 and the Millennium
Development Goal 6 target of halting and reversing the spread
of HIV by 2015. Indicators will be selected according to agreed
Paris Declaration principles which aim to harmonise monitoring
activities between donors and minimise the burden on country systems.
55. In Achieving Universal Access, the UK
commits to support progress towards a number of specific targets
in five key priority areas. These targets are based on a mix of
carefully chosen input, process, output and impact indicators.
The indicators cover the breadth of our work in HIV and AIDS.
However, they do not represent the sum of our work. We will also
track progress through a mix of existing and harmonised data collection
processes.
56. One such harmonised data collection
process is the routine collection and monitoring of UNGASS indicators.
This is a set of internationally agreed indicators and targets,
which is collected by UNAIDS and partner countries. In addition,
we will monitor AIDS related indicators and targets already embedded
in DFID business systems as set out in the Divisional Performance
Frameworks (DPFs) and annually collected overviews of the AIDS
response from DFID country, regional, policy and multilateral
representatives.
EXAMPLES OF
UK SUPPORT FOR
EFFORTS TO
ENSURE FUNDING
REACHES LOCAL
LEVELS INCLUDE:
57. DFID supports efforts to track how AIDS
funding is used and to ensure that resources reach community level.
For example in Mozambique, DFID has supported a National
AIDS Spending Assessment (NASA), which aims to monitor funding
for specific HIV services and interventions, at national and local
levels.
58. Monitoring trends in numbers of beneficiaries
and the quantity and quality of services is also important to
demonstrate that money is getting to where it is most needed.
For example in Vietnam, the epidemic is still concentrated
among vulnerable groups, including injecting drug users (IDUs)
and sex workers. DFID was the first donor to fund HIV prevention
and harm reduction in Vietnam. Starting in 2003, DFID provided
£17.5 million to Vietnam's first HIV prevention project,
focused on condom and needle and syringe distribution for IDUs.
DFID's pioneering work in piloting new approaches to harm reduction
helped lay the ground for high level policy change. In July 2007,
the Government of Vietnam passed a ground-breaking law on HIV
Prevention and Control, providing a legal framework of needle
and syringe exchange programmes, drug substitution therapy and
tackling stigma and discrimination. DFID is also planning a follow
up programme to finance the scale up of harm reduction. This will
join up with the World Bank programme to promote a large-scale
and coherent approach to HIV prevention.
59. It is important to ensure that government
works effectively with local NGOs so that funding reaches the
people who need it most. In Kenya, DFID will provide support
for strengthened integration and coordination between civil society
and government for implementation through capacity building, grant-making,
networking, documentation of lessons learned, and active collaboration,
through support to AMREF (African Medical and Research Foundation,
a regional NGO with headquarters in Nairobi).
Issue 6: What is the impact of vertical funds
on broader health system strengthening?
60. Vertical funds can both strengthen and
undermine broader health systems. Critics of vertical financing
highlight that these programmes operate outside of national budget
processes, largely by-pass government structures, often recruit
staff from the public sector and can weaken national systems.
61. However, in certain contexts, vertical
funding has been successful. When designed and implemented with
sensitivity to their impact on the wider health system, they can
have a positive impact. In hyper-endemic countries, the burden
of the disease is so great that existing health systems may not
have coped without a substantial boost from vertical funds. In
addition, vertical funding for AIDS can have a multi-sectoral
impact, which boosts other sectors such as education and health,
by providing teachers or health care workers with anti-retroviral
treatment. In some contexts, in the absence of vertical funds,
supporters feel that governments would have made very little progress
towards achieving universal access; for example, where political
leadership and accountability are weak and commitment to AIDS
is lacking.
62. In Haiti, a Global Fund supported
AIDS and TB scale-up led over the course of a year to a range
of improvements in primary health outcomes. Expanding capacity
for PMTCT enhanced the quality of prenatal care and all women's
health services, leading, for example, to a fourfold increase
in prenatal care visits. The comprehensive AIDS care that was
introduced improved staff morale and increased the flow of essential
medicines and vaccines, with a readily measured impact on a number
of primary health care goals including vaccination and family
planning.
63. In Ethiopia, the Global Fund
has become the major donor in training and allocating 30,000 community
health workers. These have the potential to significantly strengthen
the health sector for maternal health and immunisation as well
as for AIDS, TB and malaria.
Issue 7: What is the comparative effectiveness
in tackling HIV/AIDS of vertical funds and funding allocated to
broader health system strengthening?
64. The previous question has looked at
situations in which vertical funds can positively and negatively
impact on health system strengthening. We respond to this question
by outlining why the either vertical or horizontal
debate is one we have considered but need to move beyond. Both
approaches are needed. What is important, as the Strategy stresses,
is to ensure effective coordination, honour donor commitments
to the Paris Declaration Principles, and maximise positive impact.
65. Since Taking Action, there has
been a significant increase in vertical funding, particularly
by the USA. To compliment this increase in funding, the UK's new
Strategy has made a series of commitments which includes a long
term commitment of £6 billion for strengthening health systems
and services up to 2015. This is in recognition that major, sustained
efforts to strengthen health systems are critical to achieving
Universal Access.
66. Making UK money work harder through
an effective and coordinated response is a key aspect of the new
AIDS Strategy and in order to achieve the best possible use of
our funds, we have considered the comparative effectiveness of
vertical versus horizontal approaches. We conclude that our aim
should be to ensure that disease-specific (vertical) and health
systems (horizontal) approaches are mutually reinforcing and contribute
to achieving all of the health related MDGs. Increased funding
for AIDS should help to build stronger health systems and investments
in systems should support a sustainable AIDS response. Vertical
funds have certainly been effective in bringing AIDS treatment
to a great many people. But vertical funds are not enough. For
a country to respond effectively to AIDS, it needs a properly
functioning health system—including the health workforce
needed to make it function.
67. We are aware of the argument that earmarking
funds for AIDS can be distorting, unsustainable and can overload
fragile health systems. In addition, where AIDS funding is "off-budget",
governments can find it difficult to coordinate and fulfil the
expectations of donors. This is because vertical funds can go
through different budgeting and planning cycles, and can require
extensive and burdensome reporting requirements and donor missions.
68. For the UK, the exact mix of aid instruments
should depend on a country's state of development and capacity
to absorb development funding. This requires an understanding
of the epidemic and the required technical inputs but also the
ability and capacity of any particular country to implement programmes.
For example, a country with a well-established poverty reduction
budgetary support programme would require a different approach
to a country which was coming out of a period of unrest where
institutional capacity was weak or non-existent. The UK government
aims to tailor the choice of aid instruments to the country in
question. We remain convinced that such funding allocations for
health and the identification of priorities are best undertaken
at the country level, in discussion with the country itself and
with other donors.
69. Rather than comparing the effectiveness
of vertical versus horizontal financing, the discussion should
be more about ensuring that money is spent most efficiently and
effectively, to achieve the best results. The updated Strategy
provides details on how the UK will go about achieving value for
money.
EXAMPLE OF
UK HEALTH SYSTEM
STRENGTHENING SUPPORT
70. In four countries where the IHP overlaps
with the US PEPFAR (Ethiopia, Kenya, Mozambique and Zambia),
DFID is working with PEPFAR to support government health workforce
plans, demonstrating that it is possible to bring together complementary
financing streams for horizontal systems support and vertical
disease programmes such as HIV & AIDS to support country health
workforce priorities. By training sufficient health workers, including
community health workers, and assuring an enabling environment
for their effective retention in developing countries, we are
helping to build reliable and sustainable health systems. In this
regard, we encourage WHO to develop a voluntary code of practice
regarding ethical recruitment of health workers.
Issue 8: What are DFID's mechanisms for measuring
the impact of its funding for health service strengthening?
71. The UK government will track performance
against the delivery of DFID's 2006 White Paper commitments, which
includes strengthening health systems. We routinely monitor progress
towards our Public Service Agreement (PSA) on International Poverty
Reduction and DFID's own Department Strategic Objectives (DSOs).
Impacts of our funding are reported twice yearly in our Annual
Report and Autumn Performance Report.
72. In addition, DFID's Results Action Plan
(RAP) published in 2007 sets out to establish DFID as a model
of good practice on results and to drive reform across the international
system to realise "a world in which evidence is used effectively
to improve development and poverty outcomes". This will require
better quality statistics and information, a stronger commitment
to evidence-based policy making and robust systems for monitoring
and evaluation. It also requires strengthening the demand for
evidence of results by improving the systems which hold governments
and donors to account. The Plan is in three parts with 10 priority
actions aiming to embed results in DFID culture and systems, encourage
partner countries to monitor and account for their poverty reducing
policies and programmes and establish an international system
with a clear focus on the impact of its policies and interventions
of the poor.
73. A common monitoring and evaluation (M&E)
framework was developed for the International Health Partnership
(IHP) in February 2008 following technical and country consultations.
This will now be taken forward on a country by country basis,
linked to discussions on validation and completion of country
compacts. The M&E framework for the IHP ensures that each
of the specific health goals prioritised within the IHP (eg MDGs
4, 5 and 6) are included in a way which prioritised the health
systems components that would directly contribute to the achievement
of those goals, whilst ensuring that overall health systems in
IHP countries are not distorted.
74. Finally, the monitoring and evaluation
framework currently under development for the updated AIDS Strategy
will seek to address the question of impact of the UK funding
on health system strengthening. (See Issue 5 above).
Issue 9: Does the AIDS Strategy address issues
raised in the IDC's previous reports—Marginalised Groups;
and Maternal Health?
75. This question is answered in two parts,
the first will look at the issues raised in the IDC report from
2006 on marginalised groups, and the second will comment on the
issues raised in the IDC's maternal health inquiry from 2007,
the report of which was published on 2nd May 2008—just before
the publication and launch of the AIDS Strategy.
1. Marginalised Groups:
76. Much has happened since 2004 when DFID
launched "Taking Action". The UK has spent some
£1.5 billion on AIDS programmes. We have also taken action
to promote the needs and rights of women, young people, children
and vulnerable groups. Our updated strategy places people at the
heart of the response and shows how we will continue to promote
the needs and rights of women, young people and children, and
vulnerable groups, and how we will support countries in providing
stronger health, education and other basic services. It also includes
commitments on prevention, the "sustainability of treatment",
social protection for those made vulnerable by the disease, including
orphans and other vulnerable children, and stronger health systems.
77. A whole chapter of the updated strategy
is devoted to responding to the needs and protecting the rights
of those most affected and draws upon the recommendations made
in the previous IDC report on marginalised groups. It is accepted
that greater efforts are needed to reach those most affected by
the epidemic, including PLWH, women, young people, children and
vulnerable groups such as men who have sex with men (MSM), injecting
drug users (IDU's), sex workers and prisoners. AIDS responses
must tackle the underlying drivers of the epidemic, and again
these vary and so it is vital to use local knowledge of the epidemic
and knowledge of the drivers related to gender inequality, harmful
sexual norms, stigma and discrimination and economic need. As
set out above, the strategy has a strong focus on the needs and
rights of OVC, and informed by the strong evidence-base on social
protection, will expand this as a key strand of our strategy.
The Strategy sets out how we will support this.
78. Stigma and discrimination remain major
barriers to achieving Universal Access and require urgent attention.
National responses must also enable those most affected to participate
in the design, implementation, monitoring and evaluation of services.
79. Four priorities for action have been
identified in the updated strategy:
— Supporting the empowerment of People
Living With HIV (PLWH) and vulnerable groups to act on their own
behalf and in their own interest, and participate in all aspects
of the AIDS response.
— Ensuring that gender analysis is
integrated within national AIDS plans, and that targets and indicators
are developed to measure the impact of AIDS programmes on women
and girls.
— Promoting and taking action on neglected
and sensitive issues—including adolescents sexual and reproductive
health and rights (SRHR); the needs and rights of Men who have
Sex with Men (MSM), and harm reduction.
— Working with our partners to ensure
increased action against HIV stigma and discrimination.
EXAMPLES OF
DFID'S WORK
WITH VULNERABLE
POPULATIONS INCLUDES:
80. DFID's support in Central Asia centres
on the main drivers of the epidemic there. Central Asian countries
straddle a major heroin trafficking route. The availability of
cheap drugs, repressive laws targeting drug users, and limited
availability of HIV prevention services, have all contributed
to growing HIV prevalence. In addition, vulnerable populations
such as injecting drug users (IDUs), sex workers and ex-prisoners,
who already experience stigma and social exclusion in their communities,
find this made worse by HIV-related stigma and discrimination,
making them difficult to reach with services. In this context
DFID funds a £5.4 million Regional Central Asia HIV and AIDS
Programme (CARHAP) in Kyrgyzstan, Tajikistan and Uzbekistan. This
focuses on supporting and building the capacity of civil society
organisations to scale-up harm reduction services, including condom
distribution, needle and syringe exchange, raising awareness and
reducing stigma and discrimination. DFID also provides a £1
million contribution to the World Bank's $25 million Regional
Central Asia AIDS control project in Tajikistan, Kyrgyzstan, Uzbekistan
and Kazakhstan. This programme, hosted by the Eurasian Economic
Community, supports improving legislation and the quality of data
collection and monitoring.
81. In Zimbabwe, DFID has been working with
Population Services International to promote the use of the female
condom. This initiative has been particularly welcomed by sex
workers whose clients are often reluctant to use condoms, despite
the high risks. Through an innovative programme of interpersonal
communication and condom distribution, including through sex worker
networks and hair salons, annual sales of female condoms have
risen from 1.36 million in 2006 to around 2.8 million in 2008.
2. Maternal Health:
82. The importance of ensuring women and
girls access to education featured strongly in the IDC Maternal
Health Inquiry. Girls who are not in school have their right to
education undermined and are at an increased risk of early marriage,
domestic violence, HIV and AIDS. The AIDS Strategy places at its
heart the needs and rights of women and girls. This includes:
promoting the needs and rights of women through the integration
of sexual and reproductive health and rights and HIV; challenging
gender based violence; research into female controlled prevention
techniques such as microbicides; supporting girl's education;
and reducing the burden of care on women and children through
social protection.
83. The updated strategy recognises that
addressing gender inequality and ensuring women's rights are essential
if we are to achieve Universal Access to comprehensive HIV prevention,
treatment, care and support. DFID supports comprehensive programmes
for women that address not only their access to sexual and reproductive
health and rights but also access to education, employment and
social protection.
84. DFID shares the concern about women's
vulnerability to HIV and AIDS and the feminisation of the epidemic,
particularly in sub-Saharan Africa. Women and men face different
risks and barriers in relation to the AIDS epidemic and in accessing
services. Gender inequalities mean that women and girls cannot
always decide if, when, how and with whom they have sex, or when
to access basic services. Violence against women and girls significantly
increases their risk of HIV infection. Women and girls report
increased violence for refusing sex, requesting condom use, accessing
HIV counselling and testing, and for testing HIV-positive. Women
and girls also bear the greatest burden of care, including caring
for orphans and those that are sick.
85. DFID's overall commitment to gender
equality is set out in the 2006 White Paper and the 2007 Gender
Equity Action Plan. We will identify gender related targets in
our corporate business plan and programmes, which will be monitored
and evaluated at country level. Internationally, we are engaging
with the OECD Development Assistance Committee (DAC) on how to
improve the quality of gender statistics and we will work to ensure
that national AIDS plans integrate gender analysis and development
indicators to measure the impact of the response to women and
girls.
86. In line with the IDC recommendation,
DFID is updating its maternal health strategy. This will be consistent
with the AIDS strategy and will also reflect the issues raised
by the IDC on maternal health.
EXAMPLES OF
DFID'S MATERNAL
HEALTH RELATED
WORK INCLUDES:
87. In Nigeria, DFID has invested
£52.8 million promoting sexual and reproductive health for
HIV and AIDS reduction and behaviour change to improve sexual
and reproductive health among poor and vulnerable groups, including
women. We are also supporting the Federal Government and UNICEF
to accelerate girls' education (£26 million) and improve
their quality of life. The £12.5 million Universal Basic
Education Project also builds on this and has a specific HIV focused
component for the educationally disadvantaged (including girls).
CONCLUSION
88. The updated AIDS Strategy, as in Taking
Action, places people at the heart of the UK Government's
response. If we are to achieve Universal Access and to halt and
reverse the spread of AIDS, the evidence demonstrates we require
a long-term approach, working in partnership with others.
89. The Strategy demonstrates the UK's determination
to remain at the forefront of global efforts to achieve Universal
Access. The UK, has made a bold and ambitious step by making long-term
commitments of £6 billion to strengthen health systems and
services up to 2015, and to spend up to £1 billion supporting
the GFATM by 2015.
90. The Strategy recognises that stronger
health systems and services are critical to tackling AIDS, but
also highlights the multi-sectoral nature of the disease. The
Strategy includes a commitment to spend £200 million over
three years on social protection programmes, an approach widely
endorsed by OVC experts.
91. The updated AIDS Strategy focuses on
outcomes and results. Strong monitoring systems will be required
to ensure funding reaches the local level and in measuring the
impact of funding for health service strengthening, also in ensuring
that new and existing resources have the greatest impact.
92. We welcome the IDC interest in these
issues and look forward to working with the committee during the
seven years of strategy implementation.
BACKGROUND DOCUMENTS
Achieving Universal Access—the UK's strategy
for halting and reversing the spread of HIV in the developing
world, DFID, 2 June 2008
http://www.dfid.gov.uk/pubs/files/achieving-universal-access.pdf
Achieving Universal Access—Evidence for
Action
http://www.dfid.gov.uk/pubs/files/achieving-universal-access-evidence.pdf
Carr, Dara and Laura Nyblade, Taking
Action Against HIV Stigma and Discrimination: Guidance Document
and Supporting Resources, DFID, November 2007
http://www.aidsportal.org/repos/stigma%20guidance%20doc.pdf
1 Including from the plenary presentations by Dr Linda
Richter at the August 2008 International Conference in Mexico. Back
2
Report on the global epidemic. UNAIDS 2008. Back
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