Memorandum submitted by the International
HIV/AIDS Alliance
1. EXECUTIVE
SUMMARY
1. The International HIV/AIDS Alliance (the
Alliance) has been working alongside ODA and then DFID since it
was established in 1993. From its inception, the Alliance has
worked to ensure that the experiences and expertise of our partner
organisations and their communities are heard by policy makers.
The Alliance supports a wide range of HIV and AIDS work in more
than 40 counties globally and our work covers all contexts of
the epidemic as classified by UNAIDS.
We will focus on five areas in this written
submission:
— The involvement of civil society
in implementing the strategy;
— Financing "Achieving Universal
Access";
— The extent to which DFID's Strategy
will be effective in tackling the disproportionate impact of HIV/AIDS
on women and children;
— To what extent does the new AIDS
strategy address the issues raised in the Committees previous
reports on Marginalised Groups?
— Monitoring systems and measuring
impact.
2. We welcome this new strategy and the
emphasis it places on achieving universal access and view this
IDC Hearing as an important moment to review the strategy and
give us confidence that HMG will play a significant role in removing
barriers to universal access and supporting other governments,
multi-laterals and civil society to do the same.
3. In the current political environment,
where AIDS is perceived to be over-funded and there is an impetus
to increase AIDS funding through budget support mechanisms, this
is an important moment to challenge some of these assumptions
and take stock of any evidence there is to ensure that the UK
governments strategy is based on sound evidence and listening
to the voices of those most affected.
4. The strategy misses an important opportunity
to clarify how DFID will ensure the full participation of civil
society in global response. To close the gap between commitments
and reality, DFID must support national governments to develop
processes that allow for meaningful engagement with civil society.
These include developing processes and frameworks with civil society
for how national governments and civil society can form effective
partnerships.
5. There is a lack of robust information
about the effectiveness of budget support for funding civil society
responses, As such there is an inherent tension in the strategy
between the frequently stated recognition of the importance of
civil society and the choice to prioritise a funding mechanism
which, without significant and rarely achieved reform to planning
and funding process, is likely to reduce civil society's ability
to participate.
6. We warmly welcome the role of the FCO
to work with national governments to advocate for the human rights
of marginalised groups. We see the recent policy advice on LGBT
populations as evidence of progress, but would like clarity of
the current structure and resources in FCO to deliver on this
important role. In 2006 the Committee raised a concern that the
FCO does not have a specific desk or unit to deal with HIV/AIDS
issues.
2. RECOMMENDATIONS
FOR AND
CHALLENGES IN
THE NEW
STRATEGY
The involvement of civil society in implementing
the strategy
DFID must support national governments to develop
processes that allow for meaningful engagement with civil society.
This includes facilitating and financing the development of processes
and frameworks, so that more robust partnerships are developed
and supported across health systems and the HIV/AIDS response.
Financing "Achieving Universal Access"
Given there is little evidence about the impact
of budget support on HIV/AIDS programmes, it is imperative that
this information is developed. This is a role that DFID should
take on if it wants to be confident that the work it is committed
to in the strategy is funded and for furthering our global knowledge
about how best to fund HIV/AIDS programming.
We welcome DFID's ongoing support for the work
of the Global Fund, who in our experience is critical for ensuring
the participation and funding of civil society at all levels of
the AIDS response, and ask the UK government to commit to a minimum
three year pledge of £703 million for the three year period.
The impact of vertical funds on broader health
system strengthening
There are numerous examples within the Alliance
network of the HIV and AIDS response contributing substantially
to building strong health systems, especially where civil society
has been involved. Therefore we recommend that DFID continues
to allocate significant resources to HIV/AIDS programmes as part
of its health system strengthening strategy.
The emphasis in the strategy on health system
strengthening is therefore a concern in that there is no financial
target for spending on HIV/AIDS, so we will not know how much
of UK government funds will be spent on HIV/AIDS programmes.
The extent to which DFID's Strategy will be effective
in tackling the disproportionate impact of HIV/AIDS on women and
children
Addressing issues of women's income, or of domestic
violence and women's autonomy in sexual decision making, requires
the broadest approach to sexual and reproductive health. As such,
the same concerns we hold in relation to key populations within
concentrated epidemics apply to the impacts of the proposed DfID
approach on women and children in generalised epidemics. Within
concentrated epidemics, the violence directed towards sex workers,
the increased vulnerability of female injecting drug users and
female partners of male injecting drug users are all examples
of challenges which general budget support is highly unlikely
to have any impact on.
To what extent does the new AIDS strategy address
the issues raised in the Committees previous reports on Marginalised
Groups?
The strategy doesn't include recent evidence
on the significance of working with MSM populations and so doesn't
give enough attention to the specific needs of this population.
Middle Income Countries with concentrated epidemics
have some of the highest incidence rates in the world. It does
not make sense for one of the leading donor governments to withdraw
its resources, including expertise at such a critical time in
the progress of the epidemic in these countries. We ask the UK
government to reconsider its position in relation to MICs.
We believe there should be a wider application
of the principle of the involvement of marginalised groups at
all levels of HIV/AIDS policy and programming work and that DFID
should reflect this value through ensuring this happens in its
own processes; and advocate for participation and more transparent
processes across other parts of Whitehall.
Monitoring systems and measuring impact
What is DIFD doing to guarantee that the funding
given to national governments will be used according to the priorities
set out in Achieving Universal Access? This includes what statistics,
data and monitoring information will they be assessing before
committing to budget support?
The financial target for strengthening health
systems and services does not indicate how much will be spent
on HIV/AIDS programmes and so it will be difficult to hold DIFD
to account for HMG's contribution towards financing the global
AIDS response.
The Alliance questions whether civil society
is involved in the National AIDS Spending Assessment (NASA) process
and the degree to which this methodology is able to measure the
impact of funds at the local level. It is possible that this is
just monitoring spend against the national plan. It is also important
to know the number of countries supported to use this methodology.
3. THE INTERNATIONAL
HIV/AIDS ALLIANCE
The International HIV/AIDS Alliance (the Alliance)
is a global partnership of national based NGOs working to prevent
HIV infection, improve access to HIV treatment, care and support,
expand communities' ability to influence the policy environment,
and lessen the impact of HIV and AIDS worldwide, particularly
among the most vulnerable and marginalised. Established in December
1993, the Alliance supports communities in developing countries
to play a full and effective role in the global response to AIDS.
Over the last 14 years, the Alliance has worked in more than 40
countries to provide grants, technical and organisational support
to an array of community-level partners to scale up HIV/AIDS prevention,
care, support, treatment and advocacy programming. The Alliance
also works closely with national governments and multilateral
partners to support the implementation of national HIV programmes
towards the achievement of universal access targets.
The Alliance has shown global leadership and
developed extensive technical expertise in key areas of HIV/AIDS
programming, including: community mobilization for ART; prevention
with most-at-risk populations; PMTCT, counselling and testing,
care and support for orphans and vulnerable children and working
with networks of people living with HIV.
DFID has funded the Alliance through a Programme
Partnership Agreement (PPA) since 2004. This relationship with
DFID enables us to engage with DFID over key policy issues. In
2006-07, the Alliance received support from the Challenge Fund
to implement an HIV/Sexual and reproductive Health (SRH) project
in India. The Alliance is currently implementing a £2 million
HIV/AIFDS programme in the Caribbean with DFID support.
The Alliance currently has an annual operating
budget over US$65 million, with a high annual growth rate. In
2007, the Alliance provided grants totalling more than $14 million
to over 754 local NGOs and CBOs—the average grant size was
$19,000.
4. THE ROLE
OF CIVIL
SOCIETY IN
THE AIDS RESPONSE
How civil society will be involved in implementing
the new Strategy
Most often, it is the people affected by HIV/AIDS
that best appreciate the causes and consequences of the epidemic
and the need for change. Yet this perspective is poorly represented
in most health programmes, national policies and global strategies.
The Alliance's programming experience consistently illustrates
that involving key populations in programme design and delivery
builds the skills and social capital necessary to reduce HIV transmission,
and to care for and support people living with HIV.
Further, these populations are among the best
monitors and advocates for a more equitable and therefore effective
response. Without organisations with the capacity to engage with
and monitor the implementation of commitments made by governments,
the goodwill, skills and capacity of the most affected communities
are often underutilised and overlooked, with consequent impacts
on the HIV epidemic. Low levels of civil society participation
in planning, coordinating and monitoring local, national and international
responses will mean policies and programmes are less likely to
be responsive, targeted and rapidly scaled up. Further, the involvement
of beneficiaries in ODA projects and programs has been shown to
have a significant impact on aid effectiveness and impact, reducing
the likelihood of project failure and increasing the chances of
success. As such, participation is essential to extracting the
most value from ODA.[21]
We warmly welcome DFID's lead on supporting the participation
of civil society in the Country Compacts of the IHP+[22]
and hope that what is learned from this work will be used more
widely to ensure meaningful Civil society involvement in the delivery
of this strategy.
In "Achieving Universal Access", the
role of civil society is recognised as critical to realising many
of the aims within the strategy, including the provision of services,
planning and budgeting and advocacy to ensure that national governments
deliver on their obligations. However there are still tremendous
gaps between the commitments made to ensure civil society engagement
and the reality on the ground. "Achieving Universal Access"
commits the government to forming partnerships with civil society
to work with IDUs and on social protection issues, but beyond
this the strategy does not clarify what DFID will do to improve
support to civil society organisations. And thus enable them to
participate in the development, monitoring and evaluation of national
AIDS strategies and plans.
Unfortunately, the text of "Achieving Universal
Access" distinguishes the work of civil society organisations
(CSOs) in health care from the work of the government led health
system. It is our belief that it is unhelpful to separate these
roles as this may lead to funding being spent in ways which undermine
an effective continuum of care and fail to reflect the reality
of how health care is delivered. In many of the countries most
heavily affected by HIV, community care and support systems are
a critical—often the only—form of care available to
mitigate the impact of HIV on people's lives, particularly in
rural areas where the poorest and most marginalised may reside.
Further, the engagement of communities and community systems with
"formal" or secondary/tertiary health sector services
will in itself enhance continuity of care as well as build civil
society participation in health system development and strengthening
Civil society's contribution to health systems
have been extensively documented and includes:
— enhancing government accountability
and transparency;
— influencing social policy through
social mobilization and promoting participatory development;
— raising, advancing and claiming rights,
including the right to health;
— advocating for equitable and pro-poor
health policies;
— acting as intermediaries between
communities and government;
— providing public goods and services
not met by the State or the private sector with a comparative
advantage in dealing with particular social issues, situations,
geographical areas and vulnerable groups.[23]
What do we think DFID should do?
Rarely do national governments and civil society
form productive partnerships without clear incentives for the
government and without support to civil society organisations
to build the knowledge and skills necessary for meaningful participation
in political processes. Therefore DFID should play a central role
in supporting and encouraging national fora which enable civil
society to take part in policy and planning decisions.
While HM government would agree with the above
conclusions, it is not clear what role DFID will play in ensuring
that the political space is created for this to happen. In this
respect the strategy misses an important opportunity to clarify
how DFID will ensure the full participation of civil society in
global response. To close the gap between commitments and reality,
DFID must support national governments to develop processes that
allow for meaningful engagement with civil society.
Our experience working with the Global Fund
has shown that putting in place processes and frameworks which
require government and civil society to work together is an important
prerequisite for enabling this to happen. The Global Fund's Dual
Track Financing requires the national Country Coordinating Mechanism
(CCM) to select two Principal Recipients, one of which should
be a non-governmental organisation. This gives both government
and civil society the framework and the incentives needed to work
together. DFID should facilitate, lead and finance the development
of such frameworks, so that these partnerships are supported across
health systems and the HIV/AIDS response.
We welcome DFID's ongoing support for the work
of the Global Fund, which in our experience is critical for ensuring
the participation and funding of civil society at all levels of
the AIDS response, However, we note recent reports that a number
of donors, in the current global economic context, may be reviewing
their commitment to the Global Fund, as well as to ODA more generally,
and urge the UK government to sustain its support for a demonstrated,
effective institution which has been shown to be unusually effective
in generating country-led, participatory, yet accountable mechanisms
for funding health system and HIV responses. An appropriate level
of support from the UK government would be to commit to a minimum
replenishment pledge of £703 million for a three year period.
It remains a concern to the Alliance that an
emphasis on "mainstreaming" HIV services, without the
meaningful participation of those whose services will be mainstreamed,
may lead to a further reduction in access to services of the most
marginalised populations affected by HIV/AIDS. In particular,
members of the most marginalised and vulnerable communities, especially
those marginalised through behaviours which are subject to legal
reprisal or social exclusion, have limited trust in government
and even some NGO providers to meet their needs. This will be
discussed in a later section of this paper.
5. FINANCING
"ACHIEVING UNIVERSAL
ACCESS"
The comparative effectiveness in tackling HIV/AIDS
by vertical funds and funding allocated to broader health system
strengthening
"Achieving Universal Access" acknowledges
that health system strengthening and AIDS specific programmes
can be "mutually reinforcing" and there are many examples
where a strengthened health system has supported health care for
positive people and where HIV/AIDS responses have led to a more
effective health system. The Alliance welcomes more financing
for health system strengthening and recognises that as well as
benefiting many health care programmes for people with HIV and
AIDS, this will also bring long-terms benefits to the health of
the nation. However we have a number of concerns about how the
comparative advantage of funding health systems and HIV/AID specific
projects is represented in the strategy.
The strategy represents a shift in DFID thinking
about how to fund the AIDS response and this has led to a much
greater emphasis on funding health systems as a way of funding
AIDS programmes.
In recent years DFID has increasingly been channelling
more aid through budget support rather than through project aid.
The amount of ODA channelled through budget support is likely
to substantially increase in the coming years, in accordance with
the Paris Declaration on Aid Effectiveness and the recently adopted
"Accra Agenda for Action", in which donors aim to: channel
50% or more of government-to-government assistance through country
fiduciary systems, including by increasing the percentage of assistance
provided through programme based approaches. The European Commission
aims to spend more than 30 percent of the
23 billion in its European Development Fund for 2008-13
through general budget support.[24]
DFID's use of budget support has increased from £268 million
to £461 million over the past five years. It now represents
nearly 20% of DFID's bilateral expenditure and is likely to increase.
There are a number of assumptions made about
budget support, namely that it results in:
— improved coordination and harmonization
among donors and alignment with partner country systems (including
budget systems) and policies;
— lower transaction costs;
— higher allocative efficiency of public
expenditures;
— greater predictability of funding;
— increased effectiveness of the state
and public administration as budget support is aligned with and
uses government allocation and financial management systems;
— improved domestic accountability
and ownership through increased focus on the government's own
accountability channels; and
— increased access to health care and
education (as it provide more funds to finance recurrent costs,
such as health workers and teachers salaries).
However, not all preconceptions about budget
support are positive:
— It can be more vulnerable to corruption
than other forms of aid, and sometimes it is crudely characterized
as "money for governments to do what they like with."
— It can only be as good as the strategy
it finances (budget support is used to support national poverty
reduction strategies), and so it reflects the strengths and weaknesses
of those strategies.
— It is not free from harmful economic
policy conditions (one of the entry conditions for both general
and sector budget support is that countries must aim for macroeconomic
stability, which is usually translated into having an IMF programme
in place).
— It has predominantly increased recipient
government accountability to donors rather than to their own citizens
(the dialogue is mainly between the recipient country's Ministry
of Finance and the donor, with often no involvement of civil society
and national parliaments and a weak negotiation position of line
ministries, such as the MoH).
— The lack of monitoring processes
to track how budget support is used prevents a comprehensive understanding
of the implications of this funding approach. This needs to be
addressed if resources for AIDS are increasingly channelled through
this mechanism.
— Budget support is given to governments
with little requirements for reporting on performance management
and the impact of the resources. This requirement has proved an
important component in other funding mechanisms to guarantee funds
achieve required outcomes.
— Populations which experience the
highest prevalence of HIV in almost all settings are often those
marginalised or excluded from wider political and social participation.
As such, general health service development may continue to fail
to meet their needs. The experience of Alliance partners is that,
even where good HIV services are available, their accessibility
to members of key populations is often compromised or restricted
by issues of stigma, discrimination or inappropriate service design
and delivery.
The benefits and challenges relating to budget
support as a funding mechanism for aid have been analysed by various
stakeholders, including DFID.[25]
While these findings relate to the use of budget support for aid
generally, analysis and evidence on its effectiveness to support
the AIDS response is limited. The assumptions above need to be
monitored and a stronger body of evidence gathered before we can
be confident that budget support is an effective way of funding
the response to the AIDS epidemic. This is a role that DFID should
take on if it wants to be confident that the work it is committed
to in the strategy is funded and for furthering our global knowledge
about how best to funds HIV/AIDS programming.
Certainly there are reasonable concerns, which
DFID shares[26]
about whether funding to government treasuries reaches the local
level, including community based organisations. These concerns
are exacerbated in the case of marginalised groups who are stigmatised,
and in many instances discriminated against in national laws which
criminalise their behaviours.
It is notable that the UN Secretary General's
Report to the 2008 UN High Level Meeting on AIDS observed that
civil society groups have access to adequate financial support
in only 19% of countries. Given that HIV funding is one of the
few sources of reliable funding for civil society in health in
many contexts, this is an alarmingly low figure.
UNAIDS stated in the 2006 Report of the Global
AIDS epidemic that "while funding for HIV programmes has
increased in recent years, many countries fail to direct financial
resources towards activities that address the HIV prevention needs
of the populations at highest risk."[27]
As such there is an inherent tension in the strategy between the
frequently stated recognition of the importance of civil society
and the choice to prioritise a funding mechanism which, without
significant and rarely achieved reform to planning and funding
process, is likely to reduce civil society's ability to participate.
The impact of vertical funds on broader health
system strengthening
There are numerous examples within the Alliance
network of the HIV and AIDS response contributing substantially
to building strong health systems, especially where civil society
has been involved. The examples cover a wide range of countries
and types of programmes, from work to access ART in the Ukraine
and Zambia, the Uganda Network Support Agents and a number of
smaller programmes in West Africa where small community-based
of civil society lead interventions have resulted in the scaling
up of services to a national level and broadening out of service
provision to more than HIV and AIDS services.
The contribution of AIDS programmes to health
system strengthening is also seen at the system level and examples
of this include:
— effective PMTCT interventions, as
a way of rescuing child health services;
— effective ART programmes, which will
reduce the number of hospital admissions and reduce the impact
of HIV on health workforce availability; and
— both the above will have a positive
effect on staff morale within the health care system.
However, on the whole, the health system/HIV
response model is not a helpful dichotomy as many countries have
unacceptably low levels of funding for AIDS work and health systems,—as
such, both need significantly higher levels of funding to achieve
universal access targets. Further, in the most highly impacted
countries where HIV accounts for a significant proportion of morbidity
and premature mortality, the distinction between strengthening
HIV responses and strengthening health systems is specious.
The emphasis in the strategy on health system
strengthening is therefore a concern in that there is no financial
target for spending on HIV/AIDS, so we will not know how much
of UK government funds will be spent on HIV/AIDS programmes. This
lack of clarity could have dire consequences in terms of guaranteeing
funds for AIDS programmes, particularly those focused on prevention
and impact mitigation and other areas of work which fall outside
of the health system. It will also be difficult for the work of
the IDC, in terms of scrutinising the degree to which DIFD is
meeting its commitments in the strategy.
One possible approach to ensure that both the
health system and AIDS programmes gain from the strategy would
be to concentrate health system work on certain components of
the health system essential in the critical pathways to tackling
the AIDS crisis such as:
— supply chain for medicines;
— the training and retention of health
workers;
— strengthening laboratory services;
and
— strengthening the role of communities
as key actors in health systems.
The Global Fund to fight AIDS, TB and Malaria
is a vertical funding mechanism committed to funding health systems.
Early on it was recognised by the Fund that as well as improving
health care for people affected by the three diseases, "the
Fund may have system-wide effects due to the sheer magnitude of
the resources it is distributing (particularly in low income countries)
and its emphasis on efficient and rapid disbursement. These effects
could be on equity, efficiency, access, quality, and sustainability
of health systems, which in turn influence the utilization and
coverage of non-focal services, and, ultimately, the burden of
diseases from sources other than the focal diseases."[28]
An evaluation framework was developed to monitor the impact of
the Funds work on strengthening health systems.
A good example of this is the grant to Rwanda
which runs from 2005-09, which has specific HSS objectives and
which was found in a mid term evaluation to have exceeded many
of its targets (2004).[29]
In addition to ensuring that health systems
are strengthened through work that focuses on the three diseases,
the Global Fund now directly funds health system strengthening
work. This includes having established a health systems strengthening
window that aims to explicitly support the strengthening of health
systems necessary to deliver results in relation to the three
diseases as well as more recent efforts to develop "National
Strategy Applications" that aim to allow the Global Fund
to provide funding to national governments in direct support of
national AIDS and national health plans.
6. THE EXTENT
TO WHICH
DFID'S STRATEGY
WILL BE
EFFECTIVE IN
TACKLING THE
DISPROPORTIONATE IMPACT
OF HIV/AIDS ON
WOMEN AND
CHILDREN
We are delighted, in the context of the current
focus on developing effective guidance on gender and on incorporating
gender into sensitive assessments and policies into national AIDS
responses, which the IDC is seeking to assess the impact of the
new DfID strategy on ensuring equitable outcomes for women and
children.
It may appear that a health systems approach
would stand a good chance of addressing the enhanced vulnerability
of women and children to HIV in generalised epidemic settings.
However, as the DfID strategy notes, many of the issues which
need to be addressed to ensure effective HIV prevention lie outside
the remit of health services. For example, while coverage of services
for the prevention of transmission from mother to child (PMTCT)
has increased substantially over recent years, the fact that a
low cost, efficacious service still only reaches 34% of those
women who may benefit from it speaks to the challenges of health
system capacity, integration of HIV and SRH services, and addressing
the stigma still attached to HIV in even hyper-endemic settings.
The structural issues—political, social,
religious and economic aspects—which make women more vulnerable
to HIV infection in the first place; and less likely to be able
to afford or access care once infected, are unlikely to be resolved
by health systems acting alone, if at all. These issues need to
be addressed at the social, cultural and political levels at which
they are manifested, and require effective social mobilisation,
the empowerment and participation of women and the engagement
of advocates for orphans and vulnerable children—all actors
historically marginalised or overlooked within mainstream health
and political settings. Addressing issues of women's income, or
of domestic violence and women's autonomy in sexual decision making,
requires the broadest approach to sexual and reproductive health.
As such, the same concerns we hold in relation to key populations
within concentrated epidemics apply to the impacts of the proposed
DfID approach on women and children in generalised epidemics.
Within concentrated epidemics, the violence directed towards sex
workers, the increased vulnerability of female injecting drug
users and female partners of male injecting drug users are all
examples of challenges which general budget support is highly
unlikely to have any impact on.
7. TO WHAT
EXTENT DOES
THE NEW
AIDS STRATEGY ADDRESS
THE ISSUES
RAISED IN
THE COMMITTEES
PREVIOUS REPORTS
ON MARGINALISED
GROUPS?
Since the IDC Hearing on marginalised groups
in 2006, there has been a lack of progress made globally in providing
the services needed by marginalised groups.
In the 2008 UN Secretary General's Report on
progress made in implementing the Declaration of Commitment 2001,
notes that:
— globally, most IDU and MSM lack meaningful
access to HIV prevention services; sex workers are somewhat more
likely to receive HIV prevention services, although access is
sharply limited in many countries;
— while 74% of countries have policies
in place to ensure equal access to HIV-related services for vulnerable
groups, 57% of these have laws or policies that impede access
to HIV services;
— in many countries, low levels of
infection in the general adult population mask higher infection
levels among populations most at risk, including sex workers,
IDU and MSM; in countries with low levels of infection, populations
most at risk are experiencing an exceptionally heavy burden of
disease;
— although nearly all countries have
national strategic frameworks addressing populations most at risk,
fewer than half have implemented HIV prevention services focused
on IDU, MSM or sex workers in all or most districts in need.
A presentation on MSM at the 2008 High Level
Meeting on HIV/AIDS showed that of those country reports analysed,
fewer than 25% included any indicators on MSM coverage or prevalence,
and fewer than 10% reported on all agreed indictors for this population.
In Africa, 3/35 reports analysed had no indicators at all for
MSM (Asia 5/22; LA 5/21). Nonetheless, where HIV prevalence surveys
are conducted, it is invariably found to be significantly higher
among MSM than among the general population, including in generalised
epidemics.
Recent data from the World Bank's Global AIDS
Program gives new insights into the degree to which the global
epidemic is far more concentrated than originally thought. However,
this evidence also `shows we are systematically under-investing
in MSM programmes... and that "Coverage of MSM programs are
lower than for sex workers or IDU"—and these are no
better than 25% for sex workers, and around 10% for IDU.
Achieving Universal Access recognises that there
are many barriers faced by marginalised groups which prevent them
from accessing services, and that much more action is needed if
this is to be redressed. The strategy says that "the UK will
play its part" to support this work, and the evidence from
our work with DFID is that the UK government has played a leadership
role in advocating for removing the barriers which prevent marginalised
groups from accessing effective interventions.
In particular, The FCO's policy position on
Lesbian, Gay, Bi-sexual and Transgender populations is an example
of the contribution the UK can make to advancing the human rights
of the LGBT community and the Alliance warmly welcomes this progress
and its implications for the human rights of stigmatised and marginalised
populations. We also welcome the commitment to "Intensify
efforts to increase the coverage of HIV and AIDS services for
Injecting Drug Users (IDUs) in countries where they are most affected.
Work in partnership with governments, multilateral agencies, civil
society and through nine bilateral programmes, to improve the
international environment on harm reduction."[30]
However, aside from the commitment to IDU, the
strategy gives inadequate attention to the challenges of meeting
the needs of key populations, including sex workers and MSM. This
is a concern in the context of Ian Pearson's observation that
"The UK has raised cases of discrimination on grounds of
sexual orientation bilaterally or in partnership with the EU with
third countries. However, I do not wish to under-play the difficulty
that we sometimes have in raising such cases with certain states.
In these instances, keeping a line of communication about human
rights issues open, and stressing their universality, is a primary
concern."[31]
Given the intensified focus on health systems
support, the FCO has been given a pivotal role in working to protect
the human rights of marginalised groups and to address the structural
aspects of HIV vulnerability. However, the transparency and accountability
of Whitehall to the international civil society HIV movement—or
to in-country civil society players—is limited. It is understood
that a cross-Whitehall group has been established to guide and
co-ordinate this work—however this group has no civil society
participation and information on its deliberations is hard to
find. In its previous report, the IDC recommended that the FCO
establish a dedicated HIV/AIDS desk—yet it remains unclear
if this has been done or how such a position would relate to the
DfID HIV/AIDS programme and to in-country HIV mechanisms such
as Global Fund CCMs. The alliance is concerned that there are
inadequate resources and structures in place at the FCO to take
on this role, and that no clear systems have been set up to enhance
policy coherence and information sharing across Whitehall.
Another concerning development in "Achieving
Universal Access" is that DFID is "withdrawing"
much of its resources from Middle Income Countries. These countries
have concentrated epidemics and include the fastest growing epidemics
in the world. It does not make sense for one of the leading donor
governments to withdraw its resources, including expertise at
such a critical time. There is enormous value to the work of DfID
in these settings, both in terms of creating enabling environments
and in supporting the work of networks of marginalised groups
key to local epidemic dynamics. We would argue that this is one
of the areas where DFID has added value and its investment in
these countries would be cost effective.
In point 22, of the IDC HIV/AIDS: Marginalise
groups report, the IDC recommends that key populations are involved
in all key areas of the programmes which DFID funds. We believe
there should be a wider application of this principle and that
DFID should reflect this value through ensuring the involvement
of marginalised groups and civil society CS in its own processes;
and insists on participation and more transparent processes across
other parts of Whitehall.
8. MONITORING
SYSTEMS AND
MEASURING IMPACT
DFID's mechanisms for measuring the impact of
its funding for health service strengthening
Achieving Universal Access marks a change in
how DFID will finance its work on HIV/AIDS. DFID has chosen to
predominantly allocate resources to government departments in
support of national plans, in alignment with the Paris Declaration
on Aid Effectiveness. This approach has inherent challenges including
transparency, accountability, fungibility and ensuring adequate
beneficiary involvement and participation.
In choosing to disburse money through financing
national government spending on health "DFID will be relying
heavily on national monitoring and evaluation systems to find
out whether outcome level indicators are being achieved. Increased
commitment to budget support should be accompanied by work to
strengthen national planning and monitoring systems. It is well
established that the financial risk for budget support is higher
than many other funding approaches. What is DIFD doing to guarantee
that the funding given to national governments will be used according
to the priorities set our in Achieving Universal Access? This
includes what statistics, data and monitoring information will
they be assessing before committing to budget support."
In the IDC report on HIV/AIDS: Marginalised
groups and emerging epidemics, the Committee raised the concern
that DFID's position on supporting nation plans and so national
monitoring processes should not prevent DFID from committing to
"transparent benchmarks" for its own contribution. In
particular the IDC noted that they do "not accept that DFID
support for national HIV/AIDS plans and transparent benchmarks
for DFID's contribution to the achievement of international `outcome
targets' are mutually exclusive".[32]
We share this view and in fact it's now greater as DFID has moved
even further away from national AIDS plans to national health
plans, while continuing to make the case that contribution to
international outcomes is unrealistic to measure.
We are also concerned about the status of the
indicators that national governments have committed to for marginalised
populations. In the original Universal Access plans which were
developed at the national level, very few countries committed
to comprehensive targets with marginalised groups. Our sense is
that there is little commitment to working with these groups...
Need to make a much bigger difference... not enough to leave it
to national governments.
Other marginalised populations are also a `Priority
for Action', however there is an unclear distinction running through
the strategy between areas of work which are priorities for action
and areas which come under the heading, "The UK will".
From the way these issues are presented it appears that work with
marginalised groups is a priority but other than IDUs does not
have very clear actions for the UK government attached to them?
The strategy contains two new financial targets.
The financial target for strengthening health systems and services
does not indicate how much will be spent on HIV/AIDS programmes
and so it will be difficult to hold DIFD to account for HMG's
contribution towards financing the global AIDS response.
DFID has recently run a consultative process
to develop indicators to measure the outcome level of the strategy.
This inclusive approach to setting an M&E plan is welcomed
by the Alliance who took part in the civil society working group.
This process was challenging as the commitments in the strategy
are sometimes vague and the distinction between priority areas
for action and the heading entitled `the UK will' is not clear.
From this work we have some observations to make about how effective
the monitoring systems are for measuring the impact of the strategy.
— The likely effectiveness of monitoring
systems in ensuring that funding announced in the strategy reaches
local level.
The strategy says that the National AIDS Spending
Assessment (NASA) tool is the chosen method to track whether funds
reach local levels. Leaving aside for the moment the question
of whether these are an effective way to track the flow of funds
to the community level, a prior concern must be that the systematic
exclusion—or lack of involvement -of those most affected
in processes of planning and allocation means that funds may be
under— or miss-allocated from the beginning. Given the data
reported earlier in this report, tracking spending in the absence
of strengthening civil society participation in planning is only
likely to give us a more accurate of the extent of systemic failure
to meet priority needs. Further, the Alliance questions the degree
to which this methodology is really able to measure the impact
of funds at the local level.
— The likelihood of being able to develop
agreed, robust indicators to demonstrate that commitments have
been implemented.
The current UK strategy identifies priority
areas and a limited number of priority actions, not always aligned
in ways that make sense to the casual reader. However, the specific
commitments made tend to be vague and non-specific, and our experience
in trying to frame indicators against these is that very few are
able to be reduced to an easily measurable output or indicator
of success. As such, there needs to be a reliance on country level
indicators in relation to HIV specific impacts eg incidence and
prevalence rates; coverage of treatment services, evidence of
increasing equity in health service provision; and for a clear
framework which links the UK's contributions to governments and
multilaterals and its policy initiatives, to HIV/AIDS outcomes.
21 Assessing Aid: What Works, What Doesn't and Why
World Bank report 1998 Ch 4 accessed at http://www.worldbank.org/aid/pdfs/ch4.pdf Back
22
DFID has been a very strong supporter of civil society engagement
in the International Health Partnership and Related Initiatives
(IHP+), working with civil society at a global level to ensure
their meaningful engagement in the Scaling up Reference Group
and, more recently, exploring how civil society engagement with
the development of country compacts can be supported and financed. Back
23
Action for global Health, Supplementary Notes on the IHP+ Civil
Society Engagement Concept Paper, 1st April 2008. Back
24
Stop AIDS Alliance, Aid Effectiveness, the Division of Labour
and Health as a Tracer Sector: Recommendations for the Alliance
and Stop AIDS Now!, 2008. The Stop AIDS Alliance is a joint partnership
between the International HIV/AIDS Alliance and Stop AIDS Now! Back
25
National Audit Office (2008). Department for International Development.
Providing budget support to developing countries. Report by the
Comptroller and auditor General. HC 6 Session 2007-08. 8 February
2008; ECDPM and Action Aid. Whither EC Aid? WECA Briefing Note:
Budget support; OECD DAC (2006). Evaluation of General Budget
Support. A Joint Evaluation of General Budget Support 1994-2004. Back
26
DFID recognises that one of the weaknesses with budget support
for health is that as donors move towards this mode of aid financing
there is a need for a strong civil society voice in order to ensure
that money is being allocated by the government according to priority
needs. A key challenge, however, is that budget support does not
include clear provisions for financing civil society, thereby
making it difficult to build the capacity of civil society organisations
to conduct advocacy work and support service delivery. Back
27
UNAIDS (2006) Report on the Global AIDS epidemic. Back
28
http://www.theglobalfund.org/en/links_resources/library/evaluation_framework/1/ Back
29
http://www.theglobalfund.org/programs/grantdetails.aspx?CountryId=RWN&compid=711&grantid=247&lang=en Back
30
P 29. Back
31
Ian Pearson MP, FCO Minister for Trade Unions and Human Rights,
TUC, LGBT Conference 2006. Back
32
House of Commons, International Development Committee, HIV/ADIS:
Marginalised groups and emerging epidemic. Second Report of Session
2006-07. Vol 1. Back
| 
