Memorandum submitted by Interact Worldwide
1. Interact Worldwide welcomes the opportunity
to feed into the enquiry.
We are a UK based NGO working in sexual and
reproductive health and rights, HIV and AIDS with implementing
partners in Ethiopia, India, Malawi, Nicaragua, Tanzania, Uganda,
Pakistan. Our partners are engaged in efforts to scale up comprehensive
and integrated response to sexual and reproductive health, including
maternal health, and HIV services in low-level, concentrated and
generalised AIDS epidemics.
2. Interact Worldwide has concentrated its
efforts in answering three questions set by the IDC on:
— How HIV/AIDS interacts with other
diseases, especially tuberculosis and malaria and how effectively
this interaction is dealt with by donors and funds.
— The comparative effectiveness in
tackling HIV/AIDS of vertical funds and funding allocated to broader
health system strengthening.
— DFID's mechanisms for measuring the
impact of its funding for health service strengthening.
RECOMMENDATIONS
— DFID should continue their leadership
in the area of strengthening linkages between sexual and reproductive
health and HIV and AIDS as one of its key comparative advantages.
— The UK should use its leadership
on the UNITAID Board and the Reproductive Health Supply Coalition
to promote availability of the female condom.
— The UK Government should ensure the
full remit of PMTCT is considered in the commitment to expand
access within the new AIDS Strategy, including those linkages
to sexual and reproductive health and maternal responses.
3. How HIV/AIDS interacts with other diseases,
especially tuberculosis and malaria and how effectively this interaction
is dealt with by donors and funds
3.1 In order to respond to the question
how HIV/AIDS interacts with other diseases, and how effectively
this interaction is dealt with by donors and funds we must broaden
the set of cohorts to include sexual and reproductive health and
rights (SRHR). Causes of poor SRHR and HIV and AIDS are intimately
related and have common drivers: poverty, gender inequity, marginalisation
and stigma, discrimination and denial. To separate the responses
is therefore to divorce them from the reality in which sexual
and reproductive behaviour takes place and is, in turn, contributing
towards the lack of progress being made to address issues such
as maternal mortality, unintended pregnancies and HIV and AIDS.
3.2 One of Interact Worldwide's three strategic
aims is to promote responses, both within our global policy and
advocacy work as well as in our international programs, to SRHR
and HIV and AIDS that are integrated and linked so as to better
meet the needs of poor, vulnerable and marginalised people. We
endeavoured through our organizational submission to the DFID
Consultation on Updating Taking Action the UK Strategy for Tackling
AIDS in the Developing World (Annex 1) and interventions in two
joint submissions through the UK Consortium on AIDS and International
Development and the UK Sexual and Reproductive Health and Rights
to assert the importance of DFID maintaining its strong commitment
to strengthening linkages between sexual and reproductive health
and HIV and AIDS. We recommended that DFID continue leadership
on this area as one of its key comparative advantages and to work
with partners to promote a broader SHR-HIV integration agenda.
3.3 The revised strategy[10]
states as a Priority for Action: Supporting the integration of
HIV and AIDS with TB, malaria and SRHR including maternal, newborn
and child health services. The inclusion in the strategy of the
commitment to "work 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" is welcome as condoms are the only contraceptive
method which provides dual protection against unintended pregnancy
and STIs, including HIV.
3.4 UK efforts to leverage greater availability
of the female condom within DFID's leadership on the UNITAID Board
and the Reproductive Health Supply Coalition to make a market
impact would be strategic. Currently the need for the female
condom far outweighs supply given the average price of female
condoms is currently up to 33 times more expensive than male condoms.
As such not only is this commodity not prioritised on country
procurement lists but it is also largely overlooked by other bilateral
donors and UN technical agencies. Compliance with this commitment
should be measured by significant UK donations in settings where
there has been an uptake of female condoms in response to demand,
and further promoting their use by assuring sustainability.
3.5 The commitment in the Strategy to: "work
with others to intensify international efforts to increase to
80% by 2010 the percentage of HIV infected pregnant women who
receive ARV treatments to reduce the risk of mother to child transmission,
both in low income and high prevalence countries" seems not
to consider the full scope of interactions between HIV and SRH
and Maternal Health. According to the WHO comprehensive PMTCT
also includes: delivery and post-partum care; HIV treatment for
women, infants and their families as appropriate; SRH services,
including family planning; and dual protection advice for women
and their partners. Thus, it is unclear if the strategy's commitment
to promote PMTCT has considered fully this interaction and spectrum
of services.
3.6 In terms of how effectively interaction
between HIV and SRH is dealt with by other donors, given that
Interact Worldwide has been a leader in pursuing high level international
advocacy on SRH-HIV integration especially towards the Global
Fund to Fight AIDS, TB and Malaria for over two years, we have
assessed that DFID should prioritise performance on this in their
institutional strategies with UNAIDS, UNFPA and WHO which are
all currently under renegotiation. These technical partners are
committed to:[11]
— Advocate and support SRH and HIV
linkages at the policy, systems and service levels since they
are demonstrated to improve outcomes.
— Develop, adopt, modify and strengthen
relevant policies, HIV and SRH strategic plans and co-ordination
mechanisms to foster effective linkages.
— Create a supportive policy environment
to ensure the implementation of a collective human rights and
gender-sensitive approach to SRH and HIV linkages.
— Advocate for additional funding of
rigorous research to address important outcomes, such as health
cost and stigma of integrated services as well as novel approaches
to integration.
— Act on commitment made through regular
assessments of national responses to SRH and HIV linkages.
4. The comparative effectiveness in tackling
HIV/AIDS of vertical funds and funding allocated to broader health
system strengthening
4.1 The response to HIV and AIDS currently
requires both horizontal and vertical approaches. Responding
to the substantial medical impact of HIV and AIDS, including expanding
access to ART and ensuring adequate linkages to sexual and reproductive
health services, has seen limited improvements in health system.
It is now widely acknowledged that expanded support for health
systems strengthening is essential to furthering the response
to HIV and AIDS. Especially where services should be integrated
into broader responses to SRH and other diseases broader health
system strengthening is central to ensuring the ability of the
health sector to achieve this. In this light, the UK must maintain
its commitment to the Global Fund until the impact of investment
in health system strengthening pays off.
4.2 To date vertical medical interventions
have resulted in HIV services that are superior to general health
services. This disparity must be addressed. However, we cannot
allow for the standard of performance of these vertical interventions
to be reduced to the level of basic health services. All services
must be uplifted to the level of effective HIV interventions which
have for example managed procurement and distribution of ART.
This will only be achieved through broader health systems strengthening.
4.3 However, while horizontal responses
are central to furthering the response there remains a place for
vertical responses. HIV and AIDS is a societal emergency, as recognised
by the International Red Cross, as such it has both drivers and
impacts that are multi-sectoral. Any response therefore must
be multi-sectoral, as such a response that only focuses on health
systems strengthening will not respond to the whole dynamic of
HIV and AIDS. In addition, civil society organisations are
central to the provision of services in many hard to reach areas
and with hard to reach and vulnerable groups of people. Without
them high risk groups are often omitted from the response as they
are unable to access to regular health services.
4.4While horizontal funding through health systems
strengthening will be able to improve the medical response to
the epidemic vertical funds have a place in ensuring that this
response is comprehensive in its impact.
5. DFID's mechanisms for measuring the impact
of its funding for health service strengthening (HSS)
RECOMMENDATIONS:
— DFID must ensure that the allocations
of funding to health systems strengthening which allow for the
response to HIV, SRH, maternal health is transparent and accountable.
— More resources are required for the
UK to meet its fair share of ODA dedicated to ensure that the
health MDG's are achieved.
5.1 The commitment in the Strategy for fighting
AIDS in the developing world "Achieving Universal Access"
to spend £6 billion on health systems and services up to
2015 will allow for DFID to meet a commitment to integration of
HIV and AIDS services with SRHR including maternal, newborn and
child health services. This will be a major step toward having
a major impact on the overall strengthening of heath services
worldwide, as it is understood that the provision of sufficient
and adequate maternal, newborn and child health services reflects
the health of the overall health system, as these services link
from primary through to referral level services.
5.2 The main concern around how DFID will
measure the impact of its funding for HSS is that the allocation
of this funding has not been well articulated. Much of it may
already be committed to multilateral financing processes, such
as IDA replenishment. Parliamentary Under Secretary of State Gillian
Merron stated at a public consultation on the strategy on 21 June
that DFID will "fund what works". The development of
indicators for monitoring and evaluation of the Strategy are currently
being negotiated. Without a transparent split of available
of funds it will be impossible to trace the impact of this regardless
of the indicators in place.
5.3 As commitments are implied across HSS
to impact specific cohorts of HIV it is important to consider
the resources required to adequately fund these service areas.
For example: best available estimates indicate that US$ 29.8 billion
will be needed by 2010 rising to US$ 35.8 billion by 2015 globally
to achieve universal access to reproductive health services and
the SRH related aspects of HIV prevention. Based on the UK's share
of global income this equates to a UK fair share of £898.4
million in the budgeting period 2008-09 to2010-11 and £1,027.5
million between 2011-12 to 2013-14.[12]
5.4 Whether or not the spilt of the overall
HSS commitment is fairly balanced it is unlikely that £6
billion will be adequate to achieve the goal of reaching 0.1%
of ODA dedicated to health which the Commission on Macroeconomics
and Health recommended was required to meet the health MDGs. More
resources are thus required for the UK to meet its fair share
of health spending and to ensure that the health MDG's are achieved.
Annex 1
SUBMISSION TO DFID CONSULTATION ON UPDATING
TAKING ACTION THE UK STRATEGY FOR TACKLING AIDS IN THE DEVELOPING
WORLD
August 2007
Interact Worldwide is a UK based NGO working
in sexual and reproductive health and rights, HIV and AIDS with
implementing partners in Ethiopia, India, Malawi, Nicaragua, Tanzania,
Uganda, Pakistan. Our partners are engaged in efforts to scale
up comprehensive and integrated response to sexual and reproductive
health, including maternal health, and HIV services in low-level,
concentrated and generalised AIDS epidemics.
Contact: Felicity Daly, Policy and Advocacy
Manager, dalyf@interactworldwide.org, Interact Worldwide, 325
Highgate Studios, 53-79 Highgate Road, London NW5 1TL, Telephone:
+44 (0)20 7241 8513 www.interactworldwide.org
INTERACT WORLDWIDE
PARTNERS PROVIDING
CONTENT TO
THE SUBMISSION:
Mekdim and the Ethiopian Muslim Relief and Development
Association, Ethiopia; Lepra Society and collaborating partners
including Aruna, Kalinga Network of Positive People, and Udyama,
India; Uganda Protestant Medical Bureau, Uganda
Interact Worldwide county technical advisors
in Ethiopia and India engaged in facilitation this consultation
process.
1. What is the UK's comparative advantage
in changing the course of the AIDS epidemics?
What is UK's comparative advantage in relation
to the other big donors in AIDS
The UK's commitment to poverty reduction and
improving global health demonstrated by its intention to scale
up development financing and recommit itself, and other major
donors, to achieving the health Millennium Development Goals provides
comparative advantage amongst major donors in efforts to tackle
AIDS in the developing world. The UK Government has provided significant
leadership[13]
to highlight the need for scaling up basic HIV services and intends
to continue to support[14]
developing countries to achieve Universal Access to comprehensive
HIV services by 2010.
At national level DFID has demonstrated comparative
advantage technically in health systems strengthening and sexual
and reproductive health as well as a long standing commitment
health sector financing.
As the second largest bilateral donor on HIV
and AIDS the UK has demonstrated comparative advantage in pursuing
evidence based approaches to dealing with the underlying issues
of the spread of HIV infection, with particular attention to respect
of human rights and acknowledgement of harmful gender norms. This
places them in contrast to the current US administration which
sponsors the largest bilateral programme to combat AIDS but imposes
policy conditionality on developing countries which are based
on religious fundamentalism and are neither culturally relevant,
scientifically sound or in respect of rights to sexual and reproductive
choice.
The UK has demonstrated leadership in Europe
and has ensured that European development Ministers committed
to supporting comprehensive evidence-based approach to HIV prevention.[15]
The UK is well placed to ensure that EU member states set the
bar high for provide their fair share to fully finance the resources
required to provide comprehensive services for HIV and AIDS in
the developing world. It is crucial for the UK to ensure that
European Commission funding to combat HIV and AIDS, especially
to meet their share of funding for the Global Fund to Fight AIDS,
TB and Malaria, are additional as there are concerns that funds
committed for sexual and reproductive health and other development
priorities have been appropriated for HIV and AIDS resource needs.
In the Indian context DFID's comparative advantage
has been the predominant role in funding the HIV and AIDS programme,
of states including Orissa, West Bengal, Gujarat, Kerala and Andhra
Pradesh. These states have taken advantage of the technical support
unit established by DFID (RCSHA) and have had an advantage as
the Programme Support Units were established within the state.
DFID is compared favourably to other donors who have not supported
performance in states individually but have focused on supporting
the Central Indian Government.
Partners in Ethiopia remark that the UK has
also been working on addressing the root causes of the epidemic,
including poverty, lack of access to education, weak health systems,
gender inequity, and violence. They find this holistic is the
best way to secure concrete results for people living with HIV
and AIDS and at risk of HIV infection over time.
From a Ugandan perspective it is clear that
partners appreciate the leadership the UK has taken to influence
decisions in the EU and the UN regarding programming and resource
mobilization. They hope that the UK will continue to play a role
at the international level on pursuing more harmonised approaches
by donors on funding policies and priorities.
How can the UK work most effectively to ensure
the involvement of major Foundations (eg the Bill and Melinda
Gates Foundation, the Clinton Foundation HIV/AIDS initiative)?
The foundations involved in global health and
HIV and AIDS are important allies for the UK government, especially
US based foundations which are not beholden to US administration
policy conditionality. There is however growing concern that the
work of Foundations can exacerbate problems of health system coordination
at national level. When foundations donate through financing mechanisms,
eg the Global Fund to Fight AIDS, TB and Malaria, then they are
more beholden to agreed governance processes. These donors should
be encouraged to increase efforts at national harmonisation of
funding by providing resources directly through fund health SWAps
and providing support to national AIDS councils to implement national
AIDS plans.
Our partners in India note that the Foundations
have been choosing partners to support based on their own benchmarks
and feel there is greater need for Foundations to involve major
donors to avoid replication but also to develop a strong consortium
based approach in States where there civil society organizations
require greater capacity. For example, money has been given to
Catholic Relief Services in Orissa for Orphans and vulnerable
children infected and affected by AIDS by the Clinton Foundation,
however CRS does not have many civil society partners, only diocese
partners. Here it would have been more effective if there was
some mechanism amongst the donor agencies and the Foundations
to understand where resources should be put, who are the best
stakeholders who should facilitate spending.
How can the UK best influence the global and country
progress to integrate sexual and reproductive health and rights
(SRHR) within the AIDS response?
DFID's strong commitment to strengthening linkages
for sexual and reproductive health and HIV and AIDS (SRH/HIV)
integration is regarded as one of its key comparative advantages.
Interact Worldwide appreciated that there was a consistent and
wide ranging focus on reflecting on opportunities for UK leadership
on SRH/HIV integration in the Consultation document. It would
be highly useful if as part of the process of updating the AIDS
strategy, DFID re-developed its SRHR position paper to reflect
their Health Resource Center technical guidance and reflect on
opportunities and constraints faced in operationalising this approach.
DFID should continue to work with partners to
promote a broader integration agenda. Countries need to want and
to be in a position to implement integrated services such as;
antenatal care that includes HIV testing, antiretroviral treatment
for women and for PMTCT; delivery practices that take HIV into
account; support for choice in infant feeding including ART to
make breastfeeding safe; appropriate SRH services for HIV positive
women.
Southern practitioners are clear that their
clients want single points of access for a range of services wherever
possible.[16]
There is also a gap around integrated strategic health communications
in relation to sexuality, sexual behaviour and sexual health.
Additionally, integrated services for adolescents and older children
must begin with comprehensive sexuality education in schools and
be grounded in referral systems which allow them access to appropriate
services.
Our partners in India note that SRH integration
only appears in policy documents but is not operationalised at
grassroots. They call on the UK to facilitate in developing and
building the capacity of national policy makers in order to integrate
SRH within the AIDS response and ensure it is implemented. Ugandan
partners call for DFID support for integrated youth friendly SRH
services is both clinical and community based health services.
DFID has been very supportive of initiatives
to enhance support integrated SRH/HIV services in proposals funded
by the Global Fund. These efforts may ultimately make an important
contribution to address structural and policy barriers to enhancing
integrated programmes. DFID should continue and expand its support
through its role on the Board of the Global Fund. Within and in
addition to its current efforts to define the Fund's role in strengthening
health systems, the Board should be explicit in its support for
integration by approving guidelines that include SRH/HIV integration
and outline the funding opportunities for SRH/HIV integration
and for reproductive health supplies. The UK delegation to the
Board will be key in working with the Fund to create a more enabling
environment to demonstrate greater commitment to gender and enhancing
service access by women and girls.
DFID should incentivise the enabling environment
for broader integration agenda by urging expansion of integrated
programming by the World Bank. The Bank states in its Health Nutrition
and Population Strategy that it aims to, "strengthen its
capacity to support country efforts to improve health systems
integration and reduce fragmentation ... ultimately, the choice
of a path to transition toward health system integration is the
country's decision".[17]
The World Bank does not specifically address the role it might
play in ensuring SRH/HIV service integration in country programmes.
The national development policy frameworks the
World Bank requires countries to develop inadequately address
SRH/HIV integration. Poverty reduction strategies rarely provide
analysis of links between poverty, development, population, HIV
and AIDS, or address linkages between SRH and HIV in the health
section. DFID should therefore advocate with Governments for the
mainstreaming of SRH and HIV into Poverty Reduction Strategy Papers
and advocate for the World Bank to invest in research that demonstrates
the benefits, including cost, of integrated approaches to SRH
and HIV.
DFID also has an important role to play in closely
monitoring the role of the World Bank in pursuing macro-system
integration in a way that does not disable effective approaches
to provision of SRH and HIV services. Additionally given the UK's
own policy to end the support of user fees they must do more to
work with Multilateral and national partners to combat the promotion
of user fees/private sector provision of health services. DFID
must work to confront issues of exclusion based on vulnerability
and gender that underpin the poor health of poor people.
2. How can the UK best support the scale up
to universal access to comprehensive HIV prevention programmes,
treatment, care and support by 2010?
The UK Government was instrumental in gaining
global commitment to Universal Access. Determined and continuing
leadership from the UK is required to deliver on it, working with
their partners in national government, other donors and the international
community. DFID's focus on strengthening health systems is vital
to achieve Universal Access to HIV and AIDS prevention, treatment,
care and support by 2010.
Partners in Ethiopia and Uganda note that the
amount of monetary support from the UK to different development
partners in Africa is encouraging. But as the problems are deep
rooted inside the community, the need for scaling up financing
is acute and the UK ought to have a policy of guide lines of increasing
monetary support as epidemics spread.
They call on DFID for greater support to:
— Allow developing countries access
to affordable HIV and AIDS medicines.
— Provide support to countries to implement
an appropriate regulatory framework for the promotion of access
to medicines.
— Fund clinical management, antiretroviral
therapy (ART) follow up and nutritional support for those who
are enrolled on ART.
— Enlisting greater political support
in PSA countries by ensuring national plans for the response to
HIV and AIDS are comprehensive and fully financed.
— Ensuring that implementing bodies
(including civil society organisations) reduce fragmentation and
duplication of efforts.
— Encourage adequate and sustainable
mechanisms for SWAps.
— Recognition of and involvement of
civil society and non-governmental services providers.
Our partners in India argue that providing services
through the health system is important but due to stigma and discrimination
and lack of quality services client's access to services are limited.
For instance, in Orissa state there is one ART centre catering
to thirty districts which even in a low prevalence setting is
inadequate for existing clients from remote villages who can not
avail services without transportation and mobility facilities.
As the epidemic in Orissa is growing, mainly due to migration
for livelihood opportunities, partners recommend that DFID integrate
programme funding to ensure that livelihood programmes address
HIV and AIDS issues including stigma and discrimination.
3. How can the UK work within the international
system to improve the overall response to AIDS?
What role on AIDS, including integration of sexual
and reproductive health and rights (SRHR), should the UK seek
for the Global Fund, World Bank, UN, EC and Foundations working
on AIDS in different epidemics and fragile states?
DFID should continue its support for SRH/HIV
integration efforts within the Global Fund. This approach has
the potential to make a very meaningful contribution to addressing
structural and policy barriers to enhancing integrated programmes.
Countries have identified the need for increased funding for
integration through the Fund and he Global Fund indicated that
SRH integration would be supported if the impact on HIV can be
clearly demonstrated. As such SRH commodities could be funded
and proposals that include planned and costed technical support
and capacity building could be considered. Furthermore, if CCMs
do not have the capacity to undertake integration, they can request
funds through their proposals to the Global Fund to strengthen
their capacity in this regard.[18]
DFID as a participant of the Advocacy Summit[19]
was very supportive of this initiative.
It is important to highlight that countries
have identified the need for increased funding for SRH/HIV integration
through the Global Fund. At the country level, DFID can play a
stimulating demand for SRH/HIV integration among stakeholders
of the country coordinated proposals. By building the capacity
of civil society to engage with Global Fund processes at the national
level, DFID can support CCMs in becoming fully representational
of stakeholders at the national level, including SRH organisations,
which can allow for greater expertise on integration and potential
allow for more effective referral mechanisms within Global Fund
funded programmes.
The "One UN" framework which is being
piloted in selected countries provides an opportunity for increased
engagement of DFID in processes that support SRH/HIV integration
at national level. "One UN" aims to achieve faster and
more effective development operations by UN technical agencies
and accelerate progress toward the Millennium Development Goals
(MDGs) by establishing a consolidated UN presence with one programme
and one budgetary framework. SRH and HIV and AIDS, included under
MDG5 and MDG6 respectively, should be key components of a coordinated
approach that strengthens possibilities for future integration
as part of a broader development framework. Other efforts to increase
harmonisation of the AIDS response such as the (expanded) joint
UN country teams on AIDS, also provide an important opportunity
for the integration of SRH and HIV and AIDS within the broader
framework of ensuring improved and more coherent programmes.
5. How can the UK support stronger and more
effective engagement by civil society, particularly networks of
People Living with HIV and AIDS, and vulnerable groups (women,
adolescents, males who have sex with males, sex workers, injecting
drug users, and prisoners) in the global response to AIDS?
DFID could do more to support networks of people
living with HIV and AIDS and should increase funding to these
groups through the Civil Society Challenge Fund and the new Governance
and Transparency Fund as well as other means, although these are
difficult to access. DFID needs to exploit its comparative advantage
in harmonised and aligned health financing to more effectively
co-opt non state actors into national health plans and HIV responses.
Examples where DFID has already begun this include the PMO initiative
in support of NACO in India and the HAPAC initiative in Kenya.
These approaches need to be significantly scaled up.
The funding currently provided directly to southern
based networks is currently fairly modest and it is important
to recognise the role that these networks can play in terms of
advocating for their rights, reducing stigma and discrimination
and providing care and support services. DFID needs to use their
influence to encourage government to invest in creating greater
competency among non state actors in budget monitoring and overall
accountability for delivery against HIV and health targets.
The effectiveness of networks of people living
with HIV and AIDS in advocating at the national level is limited
by lack of capacity including funding for core costs. Partners
in Uganda and Ethiopia concur that broad based civil society capacity
building must be undertaken to support network organizations to
develop, contribute and implement effective AIDS policies and
programmes.
In efforts to support vulnerable groups, partners
in Africa recommended a greater focus on overall social and economic
vulnerability with efforts to identify alternative income generating
activities for the vulnerable segments of the community and programmed
for the empowerment of youth with skills, information, knowledge,
exposure and opportunities to lead and to be heard within responses
to improve SRH and combat HIV and AIDS.
Our partners in India find that more must be
done to ensure that government at Central, State and local level
need to have of people living with HIV and AIDS part of decision-making
processes in AIDS strategies. They call for DFID, and other donors,
to conduct and audit to determine how many Government Departments
have a written HIV and AIDS policy and assess how many people
living with HIV and AIDS have been hired by Government to render
services.
In sub-Saharan Africa, the recognition of Faith
Based Organisations as a critical player in clinical and community
based health service delivery (up to 60% in some countries) will
continue to be critical. Partnerships between Governments and
this sector or between DFID and this sector if HIV and AIDS is
to be seriously combated in these countries. This sector has comparative
strengths such as credibility with communities, authority to speak
and inform communities about prevention strategies and have the
strength of being viewed as having compassion for clients.
6. What should the UK do to ensure the needs
of children affected by AIDS are met?
Our partners in India find that much more must
be done by civil society organizations to fill the gap left by
the state. They note that there is a lack of professionals in
Orissa trained to provide services to Children Affected by AIDS.
They note that government is the biggest stumbling block to provide
SRHR and AIDS education and that DFID should ensure that government
not "play politics" with SRHR and AIDS education but
provide civil society with resources to ensure success of SRHR
and AIDS education.
Ethiopia and Uganda call for DFID to oversee
significant progress to:
— Increase funding and support for
treatment and research into paediatric HIV and support PMTCT scale
up.
— Address low uptake of ANC services
and address social barriers including stigma, discrimination and
gender based violence to PMTCT.
— Support legislation for the protection
of the rights of orphans, widows and other caretakers such as
grand parents.
— Delivering and encourage and supporting
community based organisations and faith based organisations to
deliver sustained care and support activities including home based
care, food and nutrition, medical access and psychological support.
— Support/assist organizations and
the government working on children living with HIV/AIDS develop.
— Support countries to develop and
implement national plans of action for the care and protection
of children affected.
7. How can the UK best contribute to addressing
AIDS related stigma and discrimination?
Within a health systems strengthening approach
the provision of integrated services, whether situating HIV services
within SRH services or situating both within basic health services,
can combat the stigma associated with access to stand alone HIV
services. Such integration efforts must maintain best practice
in HIV components. It is also important to ensure that discrimination
is not tolerated among health workers. Additionally gender-sensitive
training of health workers should be prioritized for those conducting
SRH or HIV and AIDS services.
Our partners in India were not clear that DFID
has already made combating AIDS related stigma and discrimination
a priority. In Orissa they have the impression is that DFID support
to date has been towards strengthening of service delivery and
Targeted Intervention Programme. Stigma and discrimination cases
in Orissa are rampant and have been also reported. In this low
prevalence setting HIV positive people have been ostracized and
in some cases murdered. State government has often termed the
cause of abuse as a problem over property dispute. Our partners
are dismayed that even women's commission and human rights organisations
have not condemned these cases.
They recommended that DFID support civil society
organizations to be able to track cases of HIV stigma based murders
and build up consortium to pressurize government to protect the
rights of the poor. They call for more money should be directed
through NGOs, and PLHA organizations to conduct programmes against
stigma and discrimination as the government is not sufficiently
sensitised.
Our partners in Ethiopia argued that greater
capacity for basic services for can also combat stigma. They recommended
that people living with HIV and AIDS have sufficient training
and emotional support to live positively and openly among the
community. This in turn can help on increased uptake of testing
if there is more support for countries to open voluntary counselling
and testing centre which are youth friendly.
They also call for DFID to support trainings
like "community conversations" and other efforts at
social mobilization to raise awareness of the rights of people
living with HIV and AIDS.
DFID must support civil society organisations
that are lobbying for legislative reform. National legislation
that criminalizes behaviours such as sex between males, injection
drug use and sex work, is the ultimate barrier to these groups
accessing prevention services and can also dramatically impact
work that civil society organisations (CSOs) endeavour to undertake
in support of vulnerable groups. DFID should both fund and advocate
for CSOs working to create an enabling environment for reducing
stigma and discrimination. In Uganda, our partner recommended
DFID support the implementation of national policy and legislation
to protect the rights of workers living with HIV.
8. What approaches should the UK promote for
HIV prevention? Including the social factors that drive the epidemic,
particularly amongst women and girls
DFID has and should continue to provide a counter-balance
to limited interpretations of prevention programming. The UK government
should do the following to ensure a comprehensive, evidence-based
approach to HIV prevention:
— Fund governments, multilateral institutions
and programmes that demonstrate a comprehensive, gender-sensitive
and evidence-based approach to HIV prevention.
— Prioritise funding for HIV prevention
programmes that target vulnerable groups which may not receive
funding due to other donor's restrictions.
— Fund health system strengthening
to ensure that quality, comprehensive HIV prevention services
and commodities are widely available within integrated HIV and
AIDS and SRH services.
— Support capacity building of civil
society to address rights violations in-country that have an impact
on evidence based prevention methods eg legislation which criminalises
homosexuality; legislation which bans the sale or promotion of
condoms to minors, legislation that criminalises injection drug
use and makes needle exchanges or harm reduction programmes illegal.
— Support comprehensive sexual and
reproductive health education and programmes that foster the development
of communication skills for young women and girls and channel
resources accordingly. This must go beyond comprehensive, evidence-based
information about HIV and AIDS to include sexuality education
which introduced skills around negotiation and equality within
sexual relationships, insisting the right to consent and the illegality
of physical and sexual violence and coercion.[20]
— Partners in Ethiopia and Uganda call
for enhancing the involvement of girls and women in community
based development initiatives, including income generation schemes,
as part of overall empowerment efforts.
Data from family planning programmes have shown
increasing number of prevention options increases the number of
people who choose to use at least one of those options. People
deserve more choices in HIV prevention. The UK has demonstrated
global leadership in supporting the research and development of
new prevention technologies in order to expand the range of HIV
prevention options.
As part of its long-term investment in HIV prevention
strategies, the UK needs to continue supporting research and development
until safe, effective and affordable microbicides and vaccines
are found. As these technologies are still in development a focus
on the immediate commodities gaps to address prevention needs
are crucial. DFID must continue to be a major funder of condoms
and fight increasing mythology about the inefficacy of condoms
which have been exacerbated by policy conditionality of other
major bilateral donors.
9. How can the UK support efforts to ensure
that the response to AIDS strengthens national health services
and the delivery of basic services?
Well functioning public health systems are essential
to achieve and sustain the health MDG's as well as universal access
to HIV and AIDS prevention, treatment, care and support by 2010.
Health systems in developing countries have been severely under
funded for decades and clearly need significant re-investment
over the long term. Programmes providing HIV and AIDS services
have potential to exert a positive impact on wider health systems
strengthening. Thus health system impacts should form part of
appraisal of HIV and AIDS interventions.
Opportunities in regard to this include the
following:
— PMTCT(+) as an opportunity for improving
access and quality of expanded maternal and child health services.
— Access to ART, which requires greater
investment in strengthening drug procurement, supply and management
systems.
— Integrating SRH and HIV services
to increase access, especially for women and adolescents.
DFID should lead on delivering funding support
for 10 year national health plans in PSA countries and should
increase bilateral budget support to the health sector, particularly
through SWAps, in order to resource health systems strengthening.
Partners in Ethiopia echoed a call for supporting longer-term
financing commitments for national health plans through different
aid instruments.
Inadequate numbers of health workers are a major
constraint to the rapid scaling up of the health system required
to effectively meet the challenge of HIV and AIDS. The critical
shortage of health workers in regions of the world worst affected
by HIV and AIDS has undermined possibilities of scaling-up to
ensure comprehensive HIV and AIDS services and has placed additional
burdens on already undersized and overburdened workforces providing
all health services.
DFID should facilitate the immediate and longer-term
financing of human resources as a health systems investment and
ensure that low public expenditure is not the primary constraint
to workforce expansion. They should work with developing country
governments and civil society organizations to address the fundamental
reasons for health worker migration and as a partner in Ethiopia
pointed out support capacity building of health workers. DFID
should invest in short term plans for increased salaries and improved
working conditions for health workers, building upon the support
it has provided in Malawi.
As the second largest investor in the World
Bank, the UK should work to ensure that programmes funded by the
Bank going forward overcome concerns with regard its record in
health, commitment to sexual and reproductive health, support
of fiscal conservatism and the promotion of user fees/private
sector provision of health services. DFID should also use its
leverage on the World Bank board to encourage greater monitoring
of World Bank programming and ensure their self appointed role
in leading on health systems strengthening efforts is well harmonised
with other financing instruments for global health.
How should the UK take action—at national
and international level—to ensure AIDS and SRHR services
are integrated into the delivery of basic services?
DFID has provided leadership on a growing evidence
base which emphasises integration of SRH as being critical to
the effectiveness of responses to HIV and AIDS, and the success
of HIV and AIDS programmes. They have recognised that it can be
confusing, costly and time consuming for people to visit different
facilities for HIV, STI and other SRH information and care.
DFID's Health Strategy argues that global health
initiatives should also support strengthening of health systems
that deliver health services more broadly and cites SRH and HIV
and AIDS services as key. DFID could take action to strengthen
the evidence base and use its influence to ensure adequate proportional
investment in HIV and broader SRH services within the overall
essential service mix. It is hoped that integrated delivery of
a comprehensive package of care can reduce the costs of both accessing
and providing services; improve client knowledge, confidence and
satisfaction; and ensure better service quality.
There have been significant barriers to applying
this principle within national-level SRH and HIV programmes no
less within the current state of health systems providing basic
health services. They remain independently designed, administered,
funded, and supported by different technical agencies, and are
often managed through decentralised integrated administrative
systems at the regional provincial and/or district levels. Several
departments or administrative entities need to be involved in
planning and organising integrated services, and collaboration
between these different actors is often inadequate.
DFID is a key supporter of the Partnership for
Maternal Newborn and Child Health which is promoting a "continuum
of care" model. This approach would require increased funding
for care for mothers and children from pregnancy to delivery,
the immediate postnatal period, and childhood, recognising that
safe childbirth is critical to the health of both the woman and
the newborn child.
DFID staff implementing its Health Strategy,
Maternal Health Strategy, Sexual and Reproductive Health and Rights
position paper along side the AIDS strategy must continue to advocate
with Ministries of Health and other relevant Ministries for the
coordinated and harmonised management of SRH and HIV programmes
and look for opportunities wherein these can be provided within
a strengthened health system.
DFID's support to health sector-wide processes
represents a major opportunity for developing comprehensive health
sector responses to SRH and HIV in order to fulfil the commitment
to universal access to comprehensive AIDS services by 2010 and
universal access to reproductive health by 2015. Sector strategies
provide opportunities for stronger strategic and operational integration
between various Ministry of Health programmes and coordinated
efforts to strengthen policies, human resources, procurement,
infrastructure and services.
At the international level, United Nations technical
agencies can promote and advocate for integrated programming and
services. The proposed "One UN" framework could provide
an opportunity for increased engagement of DFID in processes that
support integration at national level. UN technical agencies should
ensure faster and more effective development operations and accelerate
progress by establishing a consolidated UN presence, which will
have one programme and one budgetary framework.
While the UK pursues these efforts at UN reform,
the UNAIDS Secretariat can ensure that information on SRH integration
is provided to UNAIDS Country Coordinators (UCC) and on to the
United Nations Theme Group. Additionally DFID should continue
to support efforts for better service integration being lead by
UNFPA to influence progress to integrate SRHR within the AIDS
response by supporting ongoing efforts to improve effectiveness
and coherence of programmes and policies. Where these agencies
do not take up the approach, DFID should continue to work to get
this information out to other partners in-country.
DFID should urge for the potential expansion
of this approach by the World Bank which states in its Health
Nutrition and Population Strategy that it aims to, "strengthen
its capacity to support country efforts to improve health systems
integration and reduce fragmentation|ultimately, the choice of
a path to transition toward health system integration is the country's
decision". The Bank does not specifically address the role
it might play in incentivising SRH-HIV service integration.
The national development policy frameworks the
Bank requires countries to develop inadequately address SRH-HIV
integration. Poverty reduction strategies rarely provide analysis
of links between poverty, development, population dynamics, HIV/AIDS,
or address linkages between SRH and HIV in the health section.
DFID should advocate with Governments for the mainstreaming of
these issues into Poverty Reduction Strategy Papers.
One of our partners in Uganda added that programs
should have health system strengthening and integration component
with community based models that have been proven successful in
order to qualify for funding. DFID should support operational
research to determine models and best practices for integration
and address the lack of integration of HIV and SRHR (but mainly
HIV), which has aggravated existing human resource deficits. They
added that currently there is too much parallelism, whereas HIV
services should be routine and integrated into existing health
services.
It has been noted by African partners that enhanced
management and leadership capacity in the health sector is the
catalyst required to help these countries achieve the MDGs and
national HIV and AIDS targets. The emphasis so far has been on
in-service technical and clinical training and development of
what one partner called "more and more guidelines".
Focusing on improving the governance of both state and civil society
institutions must be addressed to ensure the response to the AIDS
pandemic and general health systems management is enhanced.
10 Achieving Universal Access-The UK's strategy for
halting and reversing the spread of HIV in the developing world.
HM Government June 2008. Back
11
Sexual & Reproductive Health and HIV Linkages: Evidence Review
and Recommendations. WHO, UNFPA, IPPF, UNAIDS, UCSF (forthcoming). Back
12
Countdown 2015 Europe (2008) Strategic Options to Ensure Greater
European Investment in Reproductive Health Supplies, 2nd Edition. Back
13
Labour Party Election Manifesto 2005, G8 2005 Gleneagles Communique,
World Summit Outcome 2005. Back
14
Gleneagles Implementation Plan for cross Whitehall action, White
Paper on International Development DFID 2006, Working Together
for Better Health DFID 2007. Back
15
2005 European Union Statement on HIV Prevention. Back
16
A discussion on http://www.aidsportal.org/Messages.aspx?ID=45
focused on "how the UK can best influence global and country
progress to integrate sexual and reproductive health and rights
with in the AIDS response". Back
17
World Bank (2007). Healthy Development. The World Bank Strategy
for Health, Nutrition and Population Results, Washington DC,
World Bank, p 50. Back
18
Interact Worldwide, Global AIDS Alliance, Population Action International,
the International HIV/AIDS Alliance, IPPF, and Advocates for Youth
(2007). Guidelines for Integrating Sexual and Reproductive
Health into the HIV/AIDS Component of Country Coordinated Proposals
to be submitted to the Global Fund to Fight AIDS, TB and Malaria
Round 7 and Beyond. Back
19
Interact Worldwide co-coordinated Advocacy Summit on Global Round
7:Integrating Sexual and Reproductive Health within the HIV and
malaria components of country coordinated proposals, Geneva, Switzerland. Back
20
International Women's Health Coalition, 2006, "Realizing
the Reproductive Health Rights and Needs of People Living with
HIV & AIDS". A panel at the XVI International AIDS Conference,
Toronto, Canada, 2006. Back
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