Memorandum submitted by Médecins
sans Frontières
A. EVIDENCE ON
QUESTIONS 6, 7, 8
6. The impact of vertical funds on broader
health system strengthening
7. The comparative effectiveness in tackling
HIV/AIDS of vertical funds and funding allocated to broader health
system strengthening
8. DFID's mechanisms for measuring the impact
of its funding for health service strengthening
In the current situation of providing AIDS treatment
and care, many countries, particularly those with high HIV prevalence,
face the double challenge of expanding the provision of treatment
to more people who need it while continuing to provide quality
treatment for those already on treatment. These objectives give
rise to different challenges. Continued treatment will focus on
quality of care as well as patient empowerment and treatment literacy.
Furthermore, much of the follow-up can and should be organised
outside health services. For the expansion of treatment, on the
other hand, speed of enrolment and access to services providing
AIDS treatment are key. Health system strengthening therefore
needs to focus on ensuring access to care and the inclusion capacity
of health services which initiate AIDS treatment. The role of
health services, and strengthened health systems, gains in importance
for those patients facing complications, side effects or in need
of new treatment regimens. Below we will elaborate on some of
the more important aspects.
1. Increased health care utilisation is key
for the expansion of AIDS care
In countries where expansion and scale-up is
the key challenge, health systems strengthening should focus on
measures that allow increased utilisation of health services,
building additional capacity in terms of the offer of services
and overcoming access barriers. In MSF's experience three areas
are particularly important:
1. essential services should be provided free
of charge to patients (all service-related costs, not just
medicines);
2. the supply of drugs and medical supplies
needs to be sufficient and reliable; and
3. the number, quality and productivity of health
workers needs to be increased.
We would therefore recommend that health systems
strengthening (HSS) focus on funding and supporting measures at
health service level, with a rapid and direct effect on health
service provision and access improvement. The risk of the current
HSS approach by WHO and other international agencies is that efforts
are spread broadly across the entire health system. Moreover,
the focus on long-term strengthening will not bring about the
rapid change required for improved offer of and access to health
services. We know from experience that general systems measures
take a long time to bring about improvements at the patient interface.
We therefore propose that increased utilisation of health care
and health services be the required key component and recognised
as the central indicator of success.
This could also include specific measures for
clinical health workers and support staff at clinic level (eg
improved remuneration—basic salary levels remain insufficient—non-monetary
retention incentives and recruitment of additional health workers).
These measures could be targeted at priority rural or other underserved
areas.
Additional funding for health systems strengthening
should carry the condition that the system becomes available and
accessible to patients and addresses their needs. Too many countries
still fail to link health systems to concrete output in terms
of improved access for patients and utilisation of care. We suggest
that DFID not only provide the means to strengthen services but
actually require improved access; not only increased funding and
subsidies, but actually more patients to benefit from these subsidies.
A case in point is financial accessibility—in
too many countries international subsidies for ART, malaria treatment
or other medical supplies fail to translate into reduced costs
for patients. So for example essential drugs already paid for
by international aid need to be paid for again by the patient,
while despite the provision of incentives to health staff patients
are still required to pay for consultations. The entry point to
the general health system therefore remains very limited for vulnerable
groups, including impoverished AIDS patients. Without these specific
service and utilisation-focused requirements, we fear that an
overall improvement in health systems performance will not lead
to a more effective response to patients' health needs.
We propose that DFID therefore introduce some
conditionality to the funds provided (eg not only support the
principle of free care but also introduce conditions of essential
care free of charge for patients), channel a significant portion
of funds to the health structure/clinic level and use indicators
at this level to measure progress.
Furthermore, given the lead role that DFID has
played on the removal of user fees, it is surprising that there
is no clear statement about the importance of removing financial
barriers to health care access for HIV/AIDS patients. The strategy
document mentions "universal access" 127 times, but
user fees and financial barriers only twice, including the non-committal
statement "Address barriers that prevent people from accessing
health services such as financial barriers, eg user-fees and cost
of transport for people to reach clinics" (p36). Based on
the existing evidence and DFID's commitment to helping government
partners implement free access to basic health services, we would
have liked DFID's position to be much more clearly represented
in "Achieving Universal Access". In the light of the
current policy revision of financial contributions of patients
by donors such as the EU and member states such as Denmark (see
recent statement on abolition of user fees for children and women)
as well as international agencies such as UNICEF, DFID could play
a much more proactive role in these processes.
In conclusion, therefore, HSS and AIDS care
can and should be mutually reinforcing (sometimes referred to
as "diagonalisation"). Even with a focus on HSS it is
possible to create a "win-win situation" so that efforts
on HIV/AIDS treatment and care are not put on hold while the general
health system catches up. We suggest that DFID focus on specific
elements of health systems that allow an effective platform for
service delivery to be created at periphery level, in such a way
that effective HIV/AIDS care is not compromised. As outlined above,
the priority areas for support should be the abolition of user
fees, recruitment of additional clinical staff and reliable drug
supply. These priorities should of course be reflected in specific
budgetary allocations.
2. Quality health systems for patients with
specific needs
While standard ART treatment has permitted rapid
roll-out, people with specific needs remain underserved. This
group includes children, patients with HIV-TB co-infection and
patients in need of alternative first-line or even second-line
treatment.
As time passes the subgroup of patients suffering
side effects, complications and treatment failure will grow larger.
Health systems strengthening measures need to build capacity to
respond to these needs.
Cost of ARV and OI drugs, laboratory tests
and other medical supplies
It would be a mistake to assume that the price
of AIDS drugs on the international market will continue to fall.
This may be true of the standard first-line regimen but not of
other necessary regimens. Price-reducing competition from generic
manufacturers has diminished dramatically over the last five years.
The statement in the DFID strategy on foreseen price drops through
further standardisation (thereby enabling treatment to be provided
to more people) therefore appears overly optimistic. More robust
first line regimens, specific OI drugs and second-line ART are
available on the international market only at prohibitive prices.
Specific action will be needed to fundamentally change this situation
(please refer to MSF's publication "Untangling the Web"
for more details, available on request). As a result, increased
financial resources will probably be required to ensure supply.
Paediatric treatment and PMTCT
The drugs and protocols currently available are
poorly adapted to clinic level. This is an important obstacle
to the expansion of treatment to children and mothers.
MSF's experience with children on ART has shown
that good outcomes, even with nurse-based care, depend on specific
investment in diagnostics, child-adapted treatments and specific
child-oriented counselling and social support. Nutrition supplements
are also an important factor of success for children.
B. EVIDENCE ON
QUESTIONS 3, 4, 5
3. How the new AIDS Strategy will be incorporated
into DFID's Country Programmes
4. How civil society will be involved in implementing
the new Strategy
5. Likely effectiveness of monitoring systems
in ensuring that funding announced in the Strategy reaches local
level
We have a particular concern with the universal
application of country plans and approaches. The specific characteristics
of so-called "fragile states" are particularly problematic
in this respect. Although there is considerable variation in the
definition of the term "fragile states", there is a
tendency for donors to invest a country's leadership and government
with unrealistic expectations very early on in the transition
towards "less fragility". DRC, Burundi, Cote d'Ivoire,
Sierra Leone and Chad are particularly relevant examples of this.
Even where states are recognised as barely representative of their
populations, donors and multilateral agencies still tend to engage
primarily with their governments, use standard coordination mechanisms
and, frequently, funding channels.
So called "country plans" are a particular
concern:
— The reality is that the quality and
inclusiveness of the process of building a country plan, with
the participation of all stakeholders, remains very variable.
Many authorities see government as synonymous with "country";
as a result, civil society and non-state providers like religious
health networks and PLWHA are excluded or only nominally consulted.
The experience from the Global Fund's Country Coordinating Mechanisms
(CCM) shows that even civil society representation can be manipulated,
pressured or made devoid of real significance.
— Even in International Health Partnership
(IHP) countries, there is a risk that dialogue is effectively
intergovernmental (between host country government and donors)
rather than a truly interactive and inclusive process involving
all stakeholders. The fact that the common IHP planning &
priority setting process is located at country level renders it
vulnerable to local pressures and power relations.
— Country plans often exclude vulnerable
groups. This is partly due to the generalised, one-size-fits-all
approach, which frequently neglects specific needs and gaps in
care delivery. It is also due to stigmatisation and the prejudices
of some planners. Examples include proposals for interventions
benefiting men who have sex with men (MSM), commercial sex workers
(CSW) and intravenous drug users (IDU), which have been rejected
in certain African countries, including by the CCM.
— Even with full participation and
inclusion, the quality of the country plan can be questionable.
Consensus generally does not lead to innovation and the reality
is that, in fragile states in particular, a rigid country plan
can smother or even reverse progress obtained in ensuring access
to AIDS treatment.
— Plans are not (yet) reality. Sometimes
the process of turning a plan into implementation can be very
lengthy. Populations, however, still need to be served, services
delivered and needs covered. A particular risk lies in the misconception
that progress in HIV/AIDS care should "wait" or adapt
in order to fit with plans. Equity arguments are often used to
justify this. If realism dictates that plans be implemented gradually,
this should not jeopardize progress on AIDS treatment expansion.
There are several pertinent examples here. Effective malaria treatment,
for instance, is an essential component of care for HIV infected
patients, particularly mothers and children. Many countries have
foreseen gradual implementation of the new artemisinin combination
therapy (ACT) at primary health care; however, this should not
be a reason for denying HIV/AIDS patients correct malaria diagnosis
and treatment. Similarly, governments requiring more time to implement
generalised free care and therefore using a step-by-step approach
(eg initially exempting only children) should not maintain user
fees for adult AIDS patients, for whom free care has proved to
be a significant benefit in terms of uptake of ART, adherence
and survival.
— A specific, related concern is the
emphasis on using planned improvements in primary health care
as a platform for HIV/AIDS treatment delivery and the consequent
emphasis on the integration of HIV/AIDS with other services: "AIDS
services need to be integrated with Tuberculosis (TB), malaria,
Sexual and Reproductive Health and Rights (SRHR), including Maternal,
Newborn and Child Health (MNCH) services" (p30). In principle
this is a sensible way forward, but the current reality is that
in many contexts PHC services are non-existent or of very poor
quality. Much work needs to be done before HIV/AIDS care can be
integrated without compromising on quality and access, and premature
integration could cause a setback in AIDS care delivery. The emphasis
on integration therefore needs to be handled with care. "Achieving
Universal Access" refers to service delivery that is effective
as well as integrated—in many cases these objectives will
be at cross purposes and a trade-off will be required.
The issue of funding reaching the population
and the periphery is crucial. Many countries face disbursement
problems and administrative delays through the usual government
channels. Combined with weak accountability and health systems
that are poorly accountable to their users, this can jeopardize
results and benefits for the target population and end-users.
It is therefore essential to preserve the possibility of working
with non-state providers such as civil society, PLWHA and NGOs.
This should include direct funding, in order to promote capacity
building and preserve the independence of civil society from government
funds and influence. While "Achieving Universal Access"
does refer to the possibility of "... providing flexible
resources| through international NGOs" (p6), there is far
more emphasis on non-state support being provided through multilateral
agencies (eg p6, p42, p51), particularly in "fragile states"
and always within the "country plan" logic ("Funding
multilaterals in a way that contributes to coherent implementation
of national plans at country level, promotes institutional effectiveness
and delivers results", p56). MSF would like DFID to clarify
to what extent it is prepared to fund NGOs in contexts where budget
and sector support, or in contexts like DRC, multilateral support,
is likely to be relatively ineffective.
Two final points on sustainability and budgetary
allocations:
The strategy uses the term "sustainability"
on a number of occasions. While the distinction between economic/fiscal,
political and technical sustainability is useful, DFID's view
of fiscal sustainability seems somewhat unclear, despite the backdrop
of an HIV/AIDS epidemic which will require predictable long-term
external financial support. There appears to be some incoherence
in this respect:
— "The cost of ARV therapy is
likely to be unaffordable both for individuals and the state,
and that those countries have to rely on donor funding for larger
and larger outlays. This degree of dependence may not be sustainable
in the long term". (p13)
— "Our long-term view is being
extended to an integrated package of health and AIDS commitments.
We are committing to spend £6 billion on health systems and
services over seven years to 2015". (p46)
Moreover, given that seven years will be a very
short time in the fight against HIV/AIDS, it would be good to
see clearer recognition that DFID's commitment to HIV/AIDS in
low income countries really is long-term.
Finally, while we recognise that a strategy
paper will focus on broad strategic lines rather than detailed,
costed activities, it would be very useful to have clarification
on the relative prioritisation of the different areas of focus
identified in "Achieving Universal Access". £6
billion is a substantial financial commitment—disaggregated
data on the different budget lines would be a telling indication
of the financial rather than rhetorical priorities within DFID's
overall HIV/AIDS response.
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