Memorandum submitted by Tearfund
EXECUTIVE SUMMARY
1. The Committee is aware that the new Strategy
"Achieving Universal Access—the UK's strategy for
halting and reversing the spread of HIV in the developing world"
was published on 2 June 2008. Tearfund welcomes the new Strategy
and recognises that it incorporates many of the concerns raised
by civil society organisations during the consultation period
in 2007.
2. Tearfund believes that DFID needs to
develop a robust monitoring and evaluation framework to accompany
the new Strategy. It should set out clear targets and indicators
to be reported on annually by DFID and FCO field offices. Data
from these indicators must be made publicly available and clearly
articulate the UK's contribution towards the achievement of international
targets. To this end, DFID and the FCO should strengthen national
monitoring and evaluation systems to enable them to collect sufficient
data for comprehensive reporting.
INTRODUCTION
3. Tearfund is a Christian relief and development
agency working with partners to bring help and hope to communities
in over 62 countries around the world. Tearfund currently supports
over 190 faith based organisations and church groups to respond
to HIV epidemics in Africa (generalised epidemic), Asia (concentrated
epidemic), Latin America (concentrated epidemic), Russia (concentrated
epidemic) and the Central Asian States (concentrated epidemic).
We welcome the opportunity to input our views to the International
Development Select Committee inquiry into HIV/AIDS: DFID's new
Strategy.
4. Tearfund will address the following issues
set out by the Committee:
— the extent to which DFID's Strategy
will be effective in tackling the disproportionate impact of HIV/AIDS
on women and children;
— how the new AIDS Strategy will be
incorporated into DFID's Country Programmes;
— how civil society will be involved
in implementing the new Strategy; and
— the likely effectiveness of monitoring
systems in ensuring that funding announced in the Strategy reaches
local level.
We have focused on those areas of the inquiry
where we feel our experience of working with and on behalf of
poor communities around the world enables us to make a valuable
contribution to the work of the IDC.
FACTUAL INFORMATION
The extent to which DFID's Strategy will be effective
in tackling the disproportionate impact of HIV/AIDS on women and
children
5. Tearfund will specifically address the
Prevention of Mother to Child Transmission (PMTCT) and social
protection in relation to the disproportionate impact of HIV on
women and children.
6. Mother-to-child transmission (MTCT) of
HIV, which can occur during pregnancy, delivery or breastfeeding,
is responsible for over 90% of paediatric infections. Sub-Saharan
Africa, where women represent 61% of adults living with HIV, accounted
for 90% of the 420,000 children newly infected with HIV in 2007.[45]
Without any interventions, one in three children of women living
with HIV will be infected with HIV. With interventions, the rate
of transmission of HIV from mother to child can be dramatically
reduced. While many developing countries have made significant
progress, there is an urgent need to scale up access to services
to achieve global targets for PMTCT.
7. The risk of MTCT can be reduced by taking
a comprehensive approach to PMTCT, including the engagement of
male partners. A comprehensive approach includes preventing HIV
infection in women, unintended pregnancy in women living with
HIV and providing follow-up treatment, care and support for women
who are positive, their children and families, in addition to
interventions to prevent transmission during pregnancy, delivery
and breast feeding. Antiretroviral treatment (ART) for pregnant
women living with advanced HIV can also reduce the risk of MTCT,
as well as improve the health of these women and, hence, of their
children.
8. The new Strategy highlights that HIV
disproportionately affects women and children and has an increased
focus on prevention. Tearfund welcomes DFID's statement that prevention
mechanisms must be based on the realities of people's lives. DFID
should support the development and implementation of strategies
which have increased involvement of male partners and communities
as this supports the scale-up of PMTCT.[46]
9. DFID has identified PMTCT as an effective
way to reduce the impact of HIV on women and children. Priority
1 includes a commitment to work with others to increase to 80%
by 2010 the percentage of HIV-infected pregnant women who receive
ARVs. Tearfund welcomes this reaffirmation of the commitment to
universal access[47]
to PMTCT and calls on the UK government to harness political leadership
at international and national levels to strengthen government
and donor accountability for existing commitments.
10. Tearfund welcomes the commitment to
spend £6 billion on health systems and services up to 2015,
and the Strategy's emphasis on the integration of PMTCT services
into broader Maternal, Newborn and Child health services. Higher
coverage of PMTCT has been achieved by countries that have taken
steps to strengthen health systems and maternal, neonatal and
child health services, and to integrate PMTCT interventions into
existing services. Full integration of PMTCT into services and
high coverage with antenatal care and delivery supervised by a
skilled attendant are essential for successful scale-up of PMTCT.[48]
DFID should ensure that:
— initiatives to strengthen health
systems are used as an opportunity to address requirements for
scale-up of PMTCT and paediatric care;
— maternal and child health services
have the capacity to provide HIV counselling and testing, assess
CD4 count or HIV clinical stage and offer ART or referral to nearby
facilities providing ART; and
— human resource planning is strengthened
and innovative solutions to shortages of human resources for health
are developed and implemented.
11. DFID's new Strategy contains strong
rhetoric on the rights and needs of women, but this needs to be
reflected in the monitoring and evaluation (M&E) framework.
DFID should build the capacity of national M&E systems to
capture comprehensive data on PMTCT coverage, including data on:
— women accessing PMTCT services through
the private sector and vertical programmes;
— how many pregnant women are assessed
for ART eligibility;
— the proportion of people receiving
ART who are pregnant women; and
— infant feeding and on the quality
of follow-up treatment, care and support for women and infants.
12. Tearfund welcomes the announcement of
£200 million for social protection which will help ensure
that more orphans and vulnerable children have access to better
nutrition, health and education. This demonstrates that children
are a continuing priority for the UK Government. Social protection
is an important mechanism to secure predictable support and welfare
to vulnerable children and their carers.
13. However, social protection is only part
of a comprehensive response to children affected by HIV. Children
living with HIV remain at a higher risk of mortality than adults.
A report by the World Health Organisation states that HIV has
been the leading cause of death in children under 5 in six countries
in Southern Africa. Children make up 6% of all HIV infections
but 14% of overall deaths from HIV. It is not clear from the strategy
how DFID will support the development and delivery of medicines
and diagnostics for children living with or exposed to HIV in
poor communities.
14. The Strategy includes information from
DFID-funded research from 2004 showing a 43% reduction in mortality
when children exposed to HIV are given cotrimoxazole, an affordable
and simple antibiotic. Information from the World Health Organisation
shows that four years on only 4% of children born to women living
with HIV received this. Over 90% of children born to pregnant
women in 2007 were not tested for HIV within the first two months
of their lives. As part of DFID's new Southern African regional
programme on Access to Medicines announced in the Strategy, concrete
action must be taken to ensure the rapid development of improved
infant diagnostics, increased availability of cotrimoxazole for
children and paediatric antiretroviral treatment. DFID Southern
Africa should produce an annual report on the regional Access
to Medicines programme and include progress on support for paediatric
diagnostics and paediatric treatment.
Incorporating the new AIDS Strategy into DFID's
country programmes
15. The direction and commitment in the
new Strategy is underpinned by the UK's comparative advantage
in responding to HIV epidemics and where DFID can offer leadership.
These include supporting country-led responses, building sustainable
national systems and providing flexible resources directly to
countries.
16. DFID field offices are highly decentralised,
which has many advantages including a considerable degree of flexibility
in responding to HIV. The UK's previous strategy on HIV "Taking
Action" provided a broad framework that could be used
as a guide to decision making in the national context rather than
a set of prescribed aims and objectives. Under this arrangement
there are fewer requirements to satisfy a centrally generated
policy, but nevertheless make it more difficult to appraise the
extent to which commitments are being adopted and to measure their
impact effectively. Responding to HIV epidemics must be included
in DFID Country Assistance Plans and in Director Delivery Plans.
17. The indicators in the monitoring and
evaluation framework currently being devised are those which are
already internationally agreed and are largely being reported
on via the UNGASS Declaration of Commitment or as part of national
monitoring systems. The indicators included in the final framework
need to measure the impact of specific actions DFID is taking
to contribute towards the achievement of international targets.
Related to this, DFID field offices need to report annually on
activities they have supported against each indicator.
18. Like its predecessor "Taking
Action" the new Strategy is a UK government strategy,
not a DFID strategy. Where the FCO has a presence in middle income
countries, it too must be held accountable to the monitoring and
evaluation framework and report against agreed indicators on an
annual basis. This means that responding to HIV must be included
in FCO country plans. Concentrated HIV epidemics in middle income
countries primarily affect vulnerable groups, such as IDUs, sex
workers, MSM and prisoners. These groups are less able to access
services due to discrimination, criminalisation and exclusion.
The FCO in middle income countries has a role to ensure that the
rights of vulnerable and marginalised groups are protected and
that their needs are met.
Civil society involvement in implementing the
new AIDS Strategy
19. The Strategy acknowledges the vital
role that civil society organisations play in responding to HIV
epidemics; noting their role in service provision, awareness-raising
activities and in advocacy, particularly with, and on behalf of,
those most affected by HIV. It also highlights the role and work
of faith-based organisations as a distinctive part of civil society.
Studies indicate that half of all education and health care provision
in sub-Saharan Africa are provided by faith groups.[49]
In Lesotho 40% of HIV care and treatment services are being provided
by Christian hospitals and health centres, and faith-based organisations
run almost a third of HIV treatment facilities in Zambia.[50]
20. The funding commitment of £200
million to support social protection programmes announced in the
new Strategy indicates that DFID will work with both government
and civil society organisations. It is not yet clear how DFID
intends to utilise and support the extensive experience of civil
society stakeholders in responding to the rights and needs of
vulnerable children in the planning and implementation of social
protection programmes in the eight African countries identified
in the Strategy.
21. HIV epidemics demand more than a medical
response. For example, the spread of HIV is exacerbated by ongoing
gender equity, lack of education and employment opportunities.
HIV effects the young and economically active. In hyper-epidemic
countries HIV threatens to reverse hard won development gains
and could adversely impact the achievement of the other MDGs.
The Strategy acknowledges that an effective response includes
harnessing expertise from other sectors including education, justice
and social welfare. Aside from the £6 billion for strengthening
health systems, and the £200 million for social protection
programmes, the Strategy does not articulate how DFID intends
to fund a comprehensive multi-sectoral response. Civil society
organisations provide a range of responses outside of health care
provision and are further marginalised because of the lack of
clarity on how responses to HIV outside of health will be supported
by the UK government.
22. Supporting the empowerment of people
living with HIV and vulnerable groups is the only explicit reference
to a civil society grouping under priorities for action (Priority
2: Respond to the needs and protect the rights of those most affected).
Despite the positive rhetoric in the Strategy regarding the role
of civil society, there is no clear indication of how DFID intends
to harness and support the considerable contribution of civil
society actors. This is particularly concerning as the population
groups highlighted for particular attention in the Strategy (vulnerable
groups, women and children) are supported by a vast array of civil
society programming in many low and middle income countries.
23. DFID field offices have a role to play
in improving co-ordination, collaboration and partnership between
civil society organisations, government departments and other
donors. Country-owned plans must not become a euphemism for government-owned
plans. The "Three Ones" principles provides a framework
for engagement between government, donor and civil society stakeholders,
but does not in and of itself promote better collaboration. The
"Three Ones" principles can only be effective if there
is a recognised and effective representation of all stakeholders
on the co-ordinating structures through which government operates,
and a common commitment to monitoring and evaluation.[51]
24. The interim evaluation[52]
of `Taking Action' acknowledges that HIV will require financial
support through other aid instruments alongside Poverty Reduction
Budget Support. It also highlights the need for DFID to identify
and support effective mechanisms of direct funding to civil society;
especially where civil society are providing services (including
advocacy) that may be difficult for governments to deliver effectively.
There is no clear indication in the new Strategy how DFID have
incorporated these recommendations from the interim evaluation
of "Taking Action". We would therefore recommend
that DFID needs a clear strategy for engaging with civil society,
including faith-based organisations, both here in the UK and at
country level. DFID needs to support staff to become more literate
about faith in their context to be effective in their roles.
25. A National Audit Office review in 2006[53]
indicated that DFID needs to be better at assessing within country
the roles and capacity of civil society organisations to contribute
to poverty reduction. It is critical that DFID develops indicators
in its monitoring and evaluation framework that measures the type,
amount and impact of its support to civil society groups, including
faith-based organisations. Civil society is not a homogenous group.
Data must be disaggregated to reflect the diverse range of civil
society actors involved in the response to HIV and to monitor
effectively DFID's engagement across different civil society groupings.
DFID needs to provide long overdue leadership on this issue, as
there appears to be no internationally agreed indicators on government
and donor engagement with civil society organisations.
Tracking funds to community level
26. Community-based organisations have a
significant role to play in ensuring that hard-to-reach communities
and vulnerable groups have access to health and education services,
home-based care and livelihood initiatives. Local churches are
responding to HIV. In Zimbabwe, for example, more than 20,000
local churches are running HIV programmes.[54]
They are often the focal point in communities and, importantly,
trusted by community members. Church-based programmes are mobilising
thousands of volunteers to deliver community-based services and
support with quality and compassion, motivated by their religious
conviction. In some cases, these initiatives receive external
support—but most start as a local response to need and exist
on contributions from within the community. This raises concerns
about the long-term sustainability of community-based initiatives
in the face of chronic need.[55]
Like other CBOs, local churches are struggling to meet the needs
of community members affected by HIV. They are often underfunded
and under capacity. Such groups are seldom seen or championed
by policy-makers.
27. Tearfund welcomes the commitment in
the new Strategy to track the flow of funds from national to community
level and alleviate bottlenecks under priority 4. As DFID seeks
to reduce its transaction costs by disbursing large amounts of
funding via PRBS and through multi-laterals initiatives it is
critical that funds can be effectively tracked to beneficiary
level.
28. There are clear benefits to direct budget
support including the strengthening of government capacity, increasing
harmonisation between donors and expanding service delivery. It
is designed to improve aid effectiveness by reinforcing developing
country policies and systems and to reduce transaction costs.
However, a recent report by the Committee of Public Accounts[56]
indicates that the benefits of budget support have not been quantified
and DFID has yet to establish the effectiveness of budget support
relative to other types of aid or whether it represents value
for money. DFID should support research on resource tracking and
activities to alleviate bottlenecks and this should be reported
on annually by DFID field offices. Research should focus on funds
distributed by budget support and via multilateral initiatives,
and support efforts to establish the effectiveness of budget support
in comparison to other types of aid mechanisms.
RECOMMENDATIONS FOR
ACTION
DFID should:
1. Support the development and implementation
of strategies which have increased involvement of male partners
and communities as this supports the scale-up of PMTCT.
2. Harness political leadership to strengthen
government and donor accountability for existing commitments on
PMTCT.
3. Ensure that initiatives to strengthen health
systems are used as an opportunity to address requirements for
scale-up of PMTCT and paediatric care.
4. Ensure that maternal and child health services
have the capacity to provide HIV counselling and testing, assess
CD4 count or HIV clinical stage and offer ART or referral to nearby
facilities providing ART.
5. Ensure that human resource planning is strengthened
and innovative solutions to shortages of human resources for health
are developed and implemented.
6. Build the capacity of national M&E systems
to capture comprehensive data on PMTCT coverage, including data
on:
— women accessing PMTCT services through
the private sector and vertical programmes;
— how many pregnant women are assessed
for ART eligibility;
— the proportion of people receiving
ART who are pregnant women; and
— infant feeding and on the quality
of follow-up treatment, care and support for women and infants.
7. Take concrete action to ensure the rapid development
of improved infant diagnostics, increased availability of cotrimoxazole
for children and paediatric antiretroviral treatment and produce
an annual report on the regional Access to Medicines programme
which includes progress on support for paediatric diagnostics
and paediatric treatment.
8. Develop a robust monitoring and evaluation
framework which sets out clear targets and indicators to be reported
on annually by DFID and FCO field offices; ensuring that data
from these indicators is made publically available and clearly
articulates the UK's contribution towards the achievement of international
targets.
9. Ensure that responses to HIV epidemics are
included in DFID Country Assistance Plans and in Director Delivery
Plans.
10. Develop indicators in its monitoring and
evaluation framework that measures the type, amount and impact
of its support to civil society groups, including faith-based
organisations. Civil society is not a homogenous group. Data must
be disaggregated to reflect the diverse range of civil society
actors involved in the response to HIV and to monitor effectively
DFID's engagement across different civil society groupings.
11. Develop a clear strategy for engaging with
civil society, including faith-based organisations, both here
in the UK and at country level.
12. Identify and support effective mechanisms
of direct funding to civil society organisations.
13. Set out clear plans for the involvement of
civil society stakeholders in the development and implementation
of social protection programmes in eight African countries over
the next three years.
14. Support research on resource tracking and
activities to alleviate bottlenecks. This should be reported on
annually by DFID field offices.
The FCO should:
15. Report annually against agreed indicators
in the monitoring and evaluation framework and incorporate relevant
aspects of the new Strategy into country plans.
45 UNICEF (2007) Global campaign on children and AIDS:
Unite for Children, Unite against AIDS. Stocktaking report. Back
46
Tearfund (2008) Scaling up prevention of Mother-to-child transmission
of HIV http://tilz.tearfund.org/webdocs/tilz/HIV/C8786_web.pdf Back
47
UN (2006) Resolution adopted by the general assembly 60/262. Political
Declaration on HIV/AIDS. Back
48
Tearfund (2008) Scaling up prevention of Mother-to-child transmission
of HIV http://tilz.tearfund.org/webdocs/tilz/HIV/C8786_web.pdf Back
49
African Religious Health Assets Programme, 2006. Appreciating
Assets: The contribution of Religion to Universal Access in Africa.
Report for WHO, Cape Town: ARHAP, October 2006. Back
50
ibid. Back
51
Haddad, B, Olivier J, De Gruchy, S. 2008. The potential and
perils of partnership: Christian religious entities and collaborative
stakeholders responding to HIV and AIDS in Kenya, Malawi and the
DRC. Study commissioned by Tearfund and UNAIDS. Interim report.
ARHAP. Back
52
Social & Scientific Systems, Inc. (2007) Interim Evaluation
of "Taking Action: The UK Government's Strategy for Tackling
HIV and AIDS in the Developing World": Final Report.
DFID, Glasgow, Evaluation Report 676, xxxiii + 282pp. Back
53
National Audit Office, 2006. DFID: working with Non-Governmental
Organisations and other Civil Society Organisations to promote
development. 6 July 2006. Back
54
African Religious Health Assets Programme, 2006. Appreciating
Assets: The contribution of Religion to Universal Access in Africa.
Report for WHO, Cape Town: ARHAP, October 2006. Back
55
Taylor, N. 2007. DFID, faith and AIDS: A review for the update
of "Taking Action". UK Consortium on AIDS and International
Development-Faith Working Group, July 2007. Back
56
House of Commons. Committee of Public Accounts. June 2008. Department
for International Development: Providing budget support for developing
countries. Twenty-seventh Report of Session 2007-08. Back
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