Memorandum submitted by UK Consortium
on Aids and International Development
The UK Consortium on AIDS and International
Development welcomes the opportunity to write a submission to
the International Development Committee Inquiry on "Achieving
Universal Access—the UK's strategy for halting and reversing
the spread of HIV in the developing world".
The UK Consortium on AIDS and International
Development is a group of more than 80 UK based organisations
working together to understand and develop effective approaches
to problems created by the HIV epidemic in developing countries.
It enables each agency to bring its own expertise and experience
to be shared and used to help all members improve their responses
to the epidemic, through information exchange, networking, advocacy
and campaigning. The Consortium has a number of working groups
made up of member agencies and others who meet to strengthen their
capacities through sharing good practice, exchanging information
and developing collective policy position and advocacy initiatives.
The Stop AIDS Campaign is the campaigning arm of the Consortium.
The UK Consortium's submission involves contributions
from the Children affected by AIDS Working Group, the Gender Working
Group and the Stop AIDS Campaign. The Executive Summary explains
that the two Working Groups have written submissions to IDC Question
1 on the impact on women and children and the Stop AIDS Campaign
has answered IDC Questions 6 and 7 on vertical funding and health
systems strengthening.
Sally Joss
Coordinator
26 September 2008
EXECUTIVE SUMMARY
The UK Consortium on AIDS and International
Development has answered four questions to the International Development
Committee Inquiry on "Achieving Universal Access—the
UK's strategy for halting and reversing the spread of HIV in the
developing world". Both the Children Affected by AIDS Working
Group and the Gender Working Group have answered IDC Question
1 on the impact on women and children. The Stop AIDS Campaign
has combined IDC Questions 6 and 7 on vertical funding and health
system strengthening. In this Executive Summary, the main recommendations
for each IDC Question have been listed.
IDC Question 1. The extent to which DFID's strategy
will be effective in tackling the disproportionate impact of HIV
and AIDS on women and children
Annex 1—Children affect by AIDS (CABA)
Working Group main recommendation is that DFID agree to take the
following steps:
1. Indicate what specific actions DFID will be
taking to contribute towards the accomplishment of the international
targets listed in the M&E Framework.
2. Require DFID Field Offices in each PSA country
to report annually on what activities they have supported against
each agreed indicator.
3. Strengthen the national M&E systems in
PSA countries to enable them collect the data required for comprehensive
reporting.
Annex 2—Gender Working Group main recommendations
are:
1. There is a need for greater detail and concrete
commitments on key issues.
2. Addressing gender inequality and the impact
of HIV, AIDS on women and children, requires supporting programmes
with men.
3. DFID's leadership in integrating HIV, AIDS,
sexual and reproductive health agendas and services, is essential
in ensuring that women and girls have access to comprehensive
services.
IDC Questions 6 and 7. The impact of vertical
funds on broader health system strengthening and comparative effectiveness
in tackling HIV and AIDS of vertical funds and funding allocated
to broader health system strengthening
Annex 3—Stop AIDS Campaign recommendations
are:
1. Include key AIDS specific targets and indicators
in all funding.
2. The AIDS response is multisectoral and cannot
be adequately responded to through the health sector alone.
3. Establish mechanisms to ensure the ongoing
participation and involvement of civil society in the development,
implementation and monitoring of funding allocations.
4. Investigate the possibility of using IHP+
as a model for how to effectively align, harmonise and coordinate
the various funding mechanisms—both vertical and horizontal—for
AIDS and health systems strengthening.
5. Ensure that the integration of vertical initiatives
and broader health systems strengthening is done incrementally
and methodically so that quality and results are protected.
Annex 1
CHILDREN AFFECTED BY HIV AND AIDS WORKING
GROUP[57]
IDC Question 1—The extent to which DFID's
strategy will be effective in tackling the disproportionate impact
of HIV and AIDS on women and children
INDICATORS FOR
MONITORING ISSUES
RELATED TO
CHILDREN AFFECTED
BY HIV & AIDS IN
DFID'S AIDS STRATEGY
The Children Affected by HIV & AIDS Working
Group has been advocating for targets and indicators related to
children affected by HIV & AIDS to be included in DFID's AIDS
Strategy and M&E Framework.
The indicators below relate to issues outlined
in the Strategy as priority actions and other issues that are
mentioned as requiring attention.
The indicators are those which are internationally
recognised and most are being collected by governments either
for reporting progress on the UNGASS Declaration of Commitment
or as part of national monitoring systems.
The main recommendation of the CABA Working
Group is that DFID agree to take the following steps:
1. Indicate what specific actions DFID will be
taking to contribute towards the accomplishment of the international
targets listed in the M&E Framework.
2. Require DFID Field Offices in each PSA country
to report annually on what activities they have supported against
each agreed indicator.
3. Strengthen the national M&E systems in
PSA countries to enable them collect the data required for comprehensive
reporting.
DFID PRIORITY 1:
INCREASE EFFORT
ON HIV PREVENTION;
SUSTAIN MOMENTUM
FOR TREATMENT;
INCREASE EFFORT
ON CARE
AND SUPPORT
Top line UK priorities
— Work with others to intensify international
efforts to increase to 80% by 2010 the percentage of HIV-positive
pregnant women who receive anti-retroviral treatments (ARVs) to
reduce the risk of mother to child transmission, both in low income
and high prevalence countries. (P62)
Indicator
— Number and percentage of HIV-infected
pregnant women who received antiretroviral to reduce the risk
of mother-to-child-transmission. (UNGASS, 2008)
Other issues related to children highlighted by
DFID
— Provide support to ensure that cotrimoxazole
is better utilised as a paediatric prophylaxis. (P20)
Indicator
— Number of infants born to women living
with HIV receiving cotrimoxazole within two months of birth. (WHO
& UNICEF for IATT, Report Card on PMTCT, 2008)
DFID PRIORITY 2:
RESPOND TO
THE NEEDS
AND PROTECT
THE RIGHTS
OF THOSE
MOST AFFECTED
Other issues related to children highlighted by
DFID
— National plans of action for OVC
should be supported in a long-term, predictable manner. (P27)
Indicator
— Increasing score from 59% (2007 baseline)
of the OVC Policy & Planning Effort Index in sub-Saharan Africa.
(UNICEF, 2008)
DFID PRIORITY 3:
SUPPORT MORE
EFFECTIVE AND
INTEGRATED SERVICE
DELIVERY
Top line UK priorities
— Spend over £200 million to support
social protection programmes over the next three years. Work with
governments and civil society in eight African countries to develop
social protection policies and programmes that will provide effective
and predictable support for the most vulnerable households, including
those with children affected by AIDS. (P64)
Indicators
— Percentage of orphaned and vulnerable
children aged 0-17 whose households received free basic external
support in caring for the child. (UNGASS, 2008)
— Current school attendance among orphans
and among non-orphans aged 10-14. (UNGASS, 2008)
— PROPOSED—DFID Field Offices
in the eight countries provide annual progress reports on social
protection programme.
— PROPOSED—DFID undertake evaluation
of eight-country social protection programme in two to three years,
which will include analysis of impact of cash transfers and appropriate
social protection policies and services on children.
— PROPOSED—DFID Field Offices
report annually on activities related to especially vulnerable
children eg street children and disabled children.
Other issues related to children highlighted by
DFID
1. We also need to ensure that ... provide better
diagnostics of children infected with HIV and greater access to
paediatric treatment. (P39)
2. Regularly review our approach (on vulnerable
children), including publishing a report following the biennial
Global partners Forum on Children Affected by HIV & AIDS to
ensure that the approach outlined here supports the most effective
ways of meeting the needs and rights of OVCs. (P40)
3. Supporting the development, implementation
and review of credible, ccomprehensive and costed national AIDS
plans, which are linked to national health and other sector delivery
plans. (P64)
4. Cash transfers must be part of a comprehensive
system of care and support that includes family support services,
accessible and affordable healthcare and education, psychosocial
support, and broad livelihood support. (P39)
5. A new DFID Southern African regional programme
on Access to Medicines will start in 2008. This will spend over
£10 million (in the first three year phase) to improve availability
and affordability of quality essential medicines and diagnostics
in Southern Africa Development Community (SADC) Member States.
(P45)
6. Promoting the implementation of education
programmes that help young people, both those in and out of school,
to have safe and healthy sexual relationships, free from stereotyping,
violence and exploitation.
Indicators (numbers relate to issues above)
1a. Total number of HIV-infected children (<15
years of age) receiving ART.
1b. PROPOSED—Provide progress report on
DFID support for UNITAID including activities on paediatric diagnostics
and paediatric treatment.
2. PROPOSED—Produce report analysing DFID
approach for effectively supporting OVCs, following Global Partners
Forum.
3. Increasing score from 59% (2007 baseline)
of the OVC Policy & Planning Effort Index in sub-Saharan Africa.
(UNICEF, 2007)
4. PROPOSED—DFID undertake evaluation of
8-country social protection programme in two to three years, which
will include analysis of impact of cash transfers and appropriate
social protection policies and services on children.
5. PROPOSED—DFID Southern Africa to produce
annual report on progress of Southern African regional programme
on Access to Medicines and include analysis of support for paediatric
diagnostics and paediatric treatment.
6a. Percentage of schools that provided life
skills-based HIV education in the last academic year. (UNGASS,
2008)
6b. Number of national governments that have
put in place national HIV prevention programmes for out of school
youth in most or all districts in need. (UNGASS, 2008)
DFID PRIORITY 4:
MAKING MONEY
WORK HARDER
THROUGH AN
EFFECTIVE AND
CO-ORDINATED
RESPONSE
Other issues related to children highlighted by
DFID
— Promoting efforts to track the flow
of funds from national to community level and alleviate bottlenecks.
(P65)
Indicators
— Total number of HIV-infected children
(<15 years of age) receiving ART.
— Proposed—DFID supporting research
on resource tracking and activities to alleviate bottlenecks (DFID
Field Office Annual HIV & AIDS Activity reports.
Annex 2
GENDER WORKING GROUP[58]
IDC Question 1—The extent to which DFID's
strategy will be effective in tackling the disproportionate impact
of HIV and AIDS on women and children
1.0 INTRODUCTION
The HIV and AIDS epidemic is both fuelled by
and exacerbates gender inequality. Traditional gender systems
often put men and women at a disadvantage in the face of HIV and
AIDS by restraining their ability to both stem the epidemic, and
respond to its consequences effectively. In many countries, women
are disproportionately infected and affected by HIV and AIDS.
In sub-Saharan Africa, 59% of adults living with HIV are women
and young women make up 75% of HIV positive 15-25 year olds in
the region, with the majority of new infections occurring within
heterosexual sexual relations.[59]
This is due to a complex interaction of factors including the
dependency of women and girls on men as a result of social, economic,
legal and political factors, and their survival strategies in
conditions of poverty, such as intergenerational sex, early marriage,
and sex work.[60]
Webs of historic and cultural gender traditions and contemporary
attitudes shape the sexual behaviours of men and women and have
a crucial impact on the spread of HIV. Gender norms of masculinity
and discriminatory attitudes around sex between men can also distance
and inhibit men and boys from taking responsibility for their
own and others' safety and health.[61]
In order for DFID's strategy to be effective
in addressing the impact of HIV and AIDS on women and children
and responding to gender-related issues more broadly, the GWG
suggests the following:
2.1 There is need for greater detail and concrete
commitments on key issues
There are mentions of gender throughout the
strategy and recognition of the need to address gender as a key
driver of the pandemic. However, it does not detail how this will
be achieved or what might be done differently to ensure this is
achieved. In many cases, it also does not specify the support
or resources that will be allocated to addressing the different
gender drivers of HIV. Below are some key examples of issues that
require further detail and solid commitment:
2.1.1 The strategy recommends that gender
analysis is integrated into national AIDS strategies and plans
and stresses the importance of tracking targets and indicators
to measure outcomes for men, women and sexual minorities (pages
25 and 63). What are these targets and indicators? How will DFID
ensure civil society engagement at country level? How will they
ensure that gender analysis is integrated into country plans and
how will this be measured in the implementation of the strategy?
2.1.2 We welcome the UK strategy commitment
to fund social protection programmes to reduce the vulnerability
of children and their carers through cash transfers, pensions
and child support (page 39). The strategy commits to spend over
£200 million to expand its social protection programmes in
at least eight African countries (page 40). However, it is unclear
how the eight countries will be selected, how these funds will
be allocated, which social protection mechanisms will be supported
and how the most vulnerable households will be identified. While
the strategy recognises that the greatest burden of HIV care falls
on women and girls, it makes no specific commitments regarding
the vulnerabilities of primary or secondary carers for adults
living with HIV.
2.1.3 The strategy recognises that violence
against women and girls significantly increases their risk of
HIV infection (page 24). What kind of support has been allocated
to this intersection? How will DFID promote this intersection
(violence and risk of contracting HIV) or underscore the need
for other agencies to recognise it?
2.1.4 There is a welcomed emphasis in the
strategy on the need to upscale and strengthen HIV prevention.
The participation of people living with HIV in prevention is stressed,
often to increase others' awareness or to reduce transmission
between "couples". While the importance of wider strategies
of HIV prevention for positive people is mentioned, the strategy
needs to be clear about HIV prevention within the context of both
discordant and concordant couples. Additionally, sexual and reproductive
rights and well-being of people living with HIV needs to be stressed.
2.1.5 The strategy describes DFID's support
of global and national networks of PLWH and affected communities
(page 29) but does not detail how they support the networks and
whether the support will be intensified as networks enhance their
leadership in the HIV and AIDS response.
2.1.6 How will DFID support national governance
structures such as National AIDS Councils and Country Coordinating
Mechanisms of the Global Fund?
2.1.7 The strategy addresses stigma and
discrimination throughout the document and suggests ways to address
some stigma and discrimination issues (usually by suggesting that
groups that experience stigma and discrimination are or can be
empowered to advocate for issues that affect them). What specific
interventions will DFID be supporting to address stigma and discrimination
within the context of gender?
2.1.8 The strategy builds a strong case
for new HIV prevention technologies, such as vaccines and microbicides
(page 19). They are mentioned as a key priority, alongside the
scale-up of existing technologies. The GWG welcomes the funding
commitment to this issue. However, there is no discussion about
how to engage stakeholder support for new technologies. Will DFID
support advocacy and social research to explore and promote the
potential use and uptake of new prevention technologies?
2.1.9 DFID has committed to spending up
to £1 billion on development research over the next five
years. One of their aims is to fill the gaps in our knowledge
about gender and inequality in relation to HIV and AIDS (page
58). There is also reference to the need for more research to
explore the structural drivers of the epidemic (page 15). What
measures does DFID plan to take to support social research to
gather more evidence about the impact of gender inequalities on
HIV and AIDS responses?
The GWG recommends that DFID works with civil
society organisations to establish clear and transparent mechanisms
to track how much HIV and AIDS spending in DFID programmes reaches
women and girls. We also recommend a dissagregation of data in
budget lines and programmes so that the impact on gender equality
can be measured.
2.2 Addressing gender inequality and the impact
of HIV and AIDS on women and children requires supporting programmes
with men
2.2.1 The involvement of men in discussion
and reassessments of gender norms is crucial to the building of
transformative HIV and AIDS awareness and programming.[62]
However, there are few references to working with men outside
Men who have Sex with Men (MSM). Men appear in the report in order
to highlight how many women are infected, to highlight women's
susceptibility (never their own) as deceivers or transmitters
(page 15); as bracketed additions (for example, the section on
family planning on page 17); in relation to circumcision; as having
different risks from women (but only women's vulnerabilities are
listed pages 24 and 25); or as having problem attitudes or behaviours
(page 25).
2.2.2 Although the strategy states that
"ultimately success relies on enabling people to change their
behaviour" (page 4), it neglects addressing how men might
do this. Condoms are mentioned in terms of increasing supply (pages
5 and 62). Even though the strategy states that on average, men
in Africa use only three condoms a year, condom awareness and
confidence-building or safer sex education for boys and men and
the gender issues around this are never mentioned. The strategy
speaks of it being an "urgent priority to improve strategies
controlled by women", but says nothing of urgency of educating
and enabling more men and boys to be more effective in strategies
they can control.
2.2.3 The section on the sexual and reproductive
health needs of men and MSM (page 26) fails to mention the ways
social conditions disempower many men, how traditional gender
formations of masculinity often inhibit change in boys and men,
and reproduce the behaviours that put themselves as well as others
at risk or in neglect. Additionally, while the strategy recognises
that men are also at risk of sexual abuse during armed conflict
and in prisons (page 28), the strategy recommends support systems
for women, young people, children and vulnerable groups, without
mentioning men (page 28). A gender analysis of national plans
is promoted to measure the impact on women and girls—not
boys and men too (29, 63). Men and women are listed as having
the right to a satisfying sex life and reproductive choices (page
35) but the strategy does not address the complex power dynamics
in how gender systems position men and women in relation to these.
The recognition of the burden of care on women makes no mention
of the need to challenge gender norms and stereotypes that discourage
men from caring roles. The call for stronger political leadership
makes no mention of ways male political leaders can play a crucial
role in influencing masculinity norms and inspiring (or even requiring)
men and boys to think differently about gender and act differently.
2.3 DFID's leadership in integrating HIV and
AIDS and sexual and reproductive health agendas and services is
essential in ensuring that women and girls have access to comprehensive
services
The GWG welcomes the strong support for more
effective and integrated service delivery. The strategy provides
clear arguments for linking AIDS and other health services, integrating
sexual and reproductive health rights with HIV and AIDS, and strengthening
the wider health system (pages 34 and 35)—all of which will
contribute to ensuring that individuals have a single point of
access for key services. The GWG recommends that DFID uses its
leadership position to advocate for more attention to this issue
globally and uses its influence to actively support more effective
and integrated service delivery, for example within the UN system,
the World Bank and the Global Fund to fight AIDS, Tuberculosis
and Malaria.
2.4 In-country political initiatives to change
legal frameworks and structural gender inequalities should be
supported by DFID and the FCO
The strategy raises several human rights issues
in relation to HIV and AIDS. For example, it refers to the need
for safe spaces for adolescent girls to meet and opportunities
for them to learn life skills (page 27); the need to create social,
legal and political environments to allow key populations to receive
the support and services they need (page 28); and the fact that
legal systems can be critical for tackling gender inequality,
as well as stigma and discrimination (page 38). The strategy also
states the FCO and DFID will work together to ensure broad and
effective UK support to international and national AIDS responses
that promote and protect human rights (page 58) and that the FCO
will, through representation in multilateral institutions, provide
and advocate for leadership on HIV programmes incorporating sexual
and reproductive health and rights (page 59). These commitments
are welcomed. However, in order to realise them, it is important
that DFID promotes leadership on specific issues that influence
women's rights, including the right to land and property, the
right to sexual and reproductive health rights and services, and
laws on inheritance and against gender-based violence. It is also
important that cross-Whitehall meetings regularly take place in
order to discuss and take forward these cross-cutting issues.
2.5 In order to effectively implement, monitor
and evaluate the strategy's effectiveness in addressing gender-related
issues, DFID needs to clarify its commitment to gender equality
in relation to the strategy and ensure that its staff are trained
on gender equality analysis in the implementation of the strategy
2.5.1 DFID states it is committed to gender
equality (page 25) and refers to its Gender and Equality Action
Plan (2007). However, it does not detail how the action plan relates
to the implementation of the strategy.
2.5.2 DFID commits to strengthening the
skills and competences of its staff to address gender inequality
and promote women's rights in the context of AIDS, in line with
the Gender Equality Action Plan (page 60). It is important that
both the HIV and AIDS and Reproductive Health teams receive proper
training on how to monitor and evaluate partnerships and funding
to deliver on commitments for women and girls.
Annex 3
STOP AIDS CAMPAIGN
IDC Questions 6 and 7—The impact of vertical
funds on broader health system strengthening and the comparative
effectiveness in tackling HIV/AIDS of vertical funds and funding
allocated to broader health system strengthening
1. RECOMMENDATIONS
FOR QUESTIONS
SIX AND
SEVEN ON
FUNDING
1. Include key AIDS specific targets and indicators
in all funding; including budget support and Health SWAp design,
implementation and monitoring processes. Implementing systems
such as National Health Accounts and/or National AIDS accounts,
which allow for monitoring and tracking of funds, will be crucial
as DFID move towards delivering aid through these broader health
systems strengthening mechanisms.
2. The AIDS response is multisectoral and cannot
be adequately responded to through the health sector alone. In
light of this, the government must ensure that in addition to
broader health systems strengthening, the specific resources required
to deliver an effective response to the epidemic are made available
and accessible to other sectors particularly the education and
social sectors.
3. Establish mechanisms to ensure the ongoing
participation and involvement of civil society in the development,
implementation and monitoring of funding allocations. This will
help ensure general budget support is more accountable to the
communities it is meant to serve.
4. Investigate the possibility of using IHP+
as a model for how to effectively align, harmonise and coordinate
the various funding mechanisms- both vertical and horizontal-
for AIDS and health systems strengthening.
5. Ensure that the integration of vertical initiatives
and broader health systems strengthening is done incrementally
and methodically so that quality and results are protected. An
approach that was not gradual seriously risks reversing gains
in HIV prevention, treatment, care and support, which in turn
would create additional burdens on health systems.
THE IMPACT
OF VERTICAL
FUNDS ON
BROADER HEALTH
SYSTEM STRENGTHENING
2.1 There are many examples of how HIV programmes
have strengthened health systems. A six country (Argentina, Brazil,
the Dominican Republic, Uganda, Zambia, and Zimbabwe) study describes
the following positive effects of HIV service scale up:
1. promoting integration of HIV, TB, and other
health services;
2. relieving demand for hospital beds, emergency
room services, and antibiotics that the AIDS crisis had created;
3. motivating and expanding the capacity of health
care workers;
4. increasing access to health services for marginalised
groups and the poor;
5. raising community awareness about health,
sexuality, and human rights issues;
6. making AIDS-financed clinics, laboratories,
and equipment available for other health services; and
7. improving commodity procurement and negotiation
skills with suppliers.[63]
2.2 In Ghana, AIDS programme contributes
to increasing health worker salaries across the health system.
In Cambodia, the AIDS programme has contributed to strengthening
integrated laboratory services and the supply management chain.
In Argentina, HIV services have improved health care access for
marginalised populations—sex workers, men who have sex with
men, transgender and migrant populations.[64]
Experience from Cambodia shows that the national continuum of
care programme for People Living with HIV has generated a range
of system wide benefits such as: improved staff motivation, increased
utilisation of health facilities, improved infrastructure, health
worker training, and a reinvigoration of paediatric care.[65]
Evidence from Ethiopia, shows that the Global Fund to fight AIDS
TB and Malaria (GFATM) programme has had positive impacts on human
resource management, institutional development, commodity supply,
and private/NGO sector involvement.[66]
Evidence from rural Haiti shows that an integrated HIV-TB programme
resulted in improvements in the utilisation of primary health
care services and health outcomes.[67]
All these experiences offer key opportunities to build on and
leverage for improving health care.
2.3 However, there is also a body of evidence
on how HIV programmes have weakened health systems. A report on
AIDS and health systems looked at the interactions between AIDS
and health systems in Mozambique, Uganda and Zambia. It highlighted
how certain AIDS programmes have adversely affected health systems
in terms of the health information management processes and systems,
supply management and human resources.[68]
One of the most common criticisms levelled at AIDS programmes
is that they weaken health systems by drawing away precious human
resources from the public sector. In the context of a global deficit
of 4.25 million health workers, this is particularly critical.[69]
2.4 Experience from Malawi shows that when
political commitment from donors, government and civil society
and robust national AIDS and health planning are present, both
universal access and health systems strengthening goals can be
advanced.[70]
Malawi's Emergency Human Resource Plan, a six-year programme,
funded by the Government of Malawi, GFATM and DFID, expands training
capacity by 50%, addresses re-allocation of human resources, and
increases the salaries of several cadres of health care workers.
This is an example of how vertical and funding for health systems
strengthening can be used together to achieve positive outcomes
for both HIV and AIDS and the health MDGs. A further example of
the positive synergies between disease specific funding and health
systems strengthening is provided by examining Malawi's ART programme,
the scale up of which has kept HIV-positive health workers healthy
and reduced the burden on health facilities.[71]
THE COMPARATIVE
EFFECTIVENESS IN
TACKLING HIV/AIDS OF
VERTICAL FUNDS
AND FUNDING
ALLOCATED TO
BROADER HEALTH
SYSTEM STRENGTHENING
3.1 The most important issue to highlight
in responding to this question is the fact that tackling HIV and
AIDS requires a multisectoral response and cannot be tackled through
a medical response alone. To draw on two important examples; the
empowerment of women and the provision of HIV prevention education
are key to tackling the epidemic. The funding of health systems
alone would leave these sectors under funded and reverse the important
gains made in working towards universal access to prevention,
treatment, care and support.
3.2 This submission provides evidence on
two types of broader health systems funding used by DFID; general
budget support and Health Sector Wide Approach (Health SWAp).
It argues that a mixture of both funding for health systems strengthening
and vertical programmes is required and that coordination, harmonisation
and alignment of these initiatives is crucial for tackling HIV
and AIDS and meeting the health MDGs.
BROADER HEALTH
SYSTEMS STRENGTHENING
4.1 The National Audit Office (NAO) report
on the Department for International Development's provision of
budget support to developing countries, published in February
2008 highlights the following challenges associated with the provision
of general budget support:
1. service expansion has often been at the expense
of quality;
2. progress in strengthening financial management
systems has been slower than expected;
3. budget support is expected to reduce the transaction
costs of administering aid but it is difficult to quantify this;
and
4. difficulties in monitoring utilisation of
funds and therefore in monitoring impact.[72]
4.2 A case study examining the use of general
budget support in Zambia[73]
highlighted that it only helped the government deal with regular
health problems and not the extraordinary problems such as AIDS,
TB and malaria. It is vital that in working with governments to
support the development of national health plans, DFID ensure
that the HIV response is adequately mainstreamed. In Mozambique
it was noted that even though aid delivered through budget support
has increased resources for health and underpinned a significant
improvement in service delivery and outcomes, these only benefit
selected population groups and resources for health are still
insufficient.
4.3 More significant risks identified by
the NAO report include:
1. funds being misapplied for political reasons
or because of corruption; and
2. monitoring human rights dimensions.[74]
4.4 In the context of HIV AND AIDS which
is highly stigmatised, these risks may translate into a lack of
adequate investment in appropriately targeted HIV prevention,
treatment, care and support services. The most at risk populations
such as sex workers, men who have sex with men, people who use
drugs and transgender populations typically do not access health
services in the public sector. Therefore the use of budget support
and SWAps alone are unlikely to improve their access to services.
Civil society often plays an important role in the delivery of
HIV services and the UK government must ensure that in addition
to direct budget support funding is made available to civil society
implementers.
4.5 By contrast, a recent report by the
WHO[75]
states that vertical programmes if a rapid response to a disease
is needed; to gain economies of scale; to address the needs of
target groups that are difficult to reach and to deliver certain
very complex services when a highly skilled workforce is needed.
4.6 Without clear outcome indicators in
place to monitor the achievement of important benchmarks such
as the universal access targets, it cannot be assumed that budget
support effectively contributes to poverty reduction and the achievement
of the MDGs.
THE NEED
FOR AN
INTEGRATED APPROACH
5.1 Despite the risks and challenges associated
with funding for broader health systems strengthening it is undeniable
that health systems funding and budget support is an essential
aspect of the AIDS response and critical to delivering the health
MDGs. In countries which have demonstrated significant progress
in achieving universal access targets (eg: Cambodia, Kenya), investments
in health systems strengthening—investments in laboratory
and supply chain strengthening, expansion of health work force,
training for health workforce, task shifting, involvement of civil
society, including PLHIV—were key enabling factors.
5.2 The Global Polio Eradication Initiative
(GPEI) and the African Programme for Onchocerciasus Control (APOC)
provide examples of where the activities of vertical programmes
have been integrated into the broader health systems. More than
40% of staff time funded through GPEI is devoted to provision
of health services and the APOC community treatment networks are
now being used by national health systems to deliver a range of
health services.[76]
In the context of achieving universal access, many are now suggesting
that an integrated or "diagonal" approach offers an
important solution for achieving universal access goals and expanding
primary health care for all.[77],
[78]
5.3 This submission recommends that vertical
and health systems strengthening initiatives are integrated so
that efforts are coordinated and harmonised, and the positive
synergies between vertical initiatives and systems strengthening
maximised. However, experience from the integration of TB programmes
shows that rapid integration led to a decline in quality and results.
For example, in Zambia the integration of the vertical TB programme
into the mainstream health system led to the collapse of the TB
programme.[79]
The TB experience highlights that integration of vertical programmes
into broader health systems and services requires political commitment
and careful planning and management.[80]
57 Members of The Working Group on Orphans and Vulnerable
Children: AVERT, British Red Cross, Cafod, Care International,
ChildHope, Christian Aid, Consortium for Street Children, Egmont
Trust, Healthlink Worldwide, HelpAge International, Hope HIV,
International HIV/AIDS Alliance, Learning for Life, Mildmay International,
Partnership for Child Development, Plan UK, Religions for Peace
UK, Samaritan's Purse International Relief, SOS Children's Villages,
Street Child Africa, Tearfund, Uganda AIDS Action Fund, UNICEF
UK, VSO and World Vision UK. Back
58
The Gender Working Group consists of Action Aid, African HIV Policy
Network, AMREF, CAFOD, Interact Worldwide, International Community
of Women Living with HIV/AIDS, Naz Foundation International, One
World Action, Progressio, Tearfund, VSO, Womankind, and a few
consultants with expertise in gender and HIV. Back
59
Karen Leiter, Senior Research Associate, Physicians for Human
Rights, from Epidemic of Inequality: Women's Rights and HIV/AIDS
in Botswana & Swaziland: An Evidence-based Report on Gender
Inequity, Stigma and Discrimination http://physiciansforhumanrights.org/library/news-2007-05-25.html?print=t Back
60
UNAIDS "Women and Girls" http://www.unaids.org/en/PolicyAndPractice/KeyPopulations/WomenGirls/default.asp-Accessed
19 September 2008 Back
61
UNAIDS Inter-Agency Task Team on Gender and HIV/AIDS "HIV/AIDS,
Gender and Male Participation" http://www.genderandaids.org/downloads/events/Fact%20Sheets.pdf-Accessed
19 September 2008 Back
62
World Health Organisation (2003). Review paper, "Integrating
Gender into AIDS Programmes" http://www.genderandaids.org/downloads/events/Integrating%20Gender.pdf Back
63
International Treatment Preparedness Coalition, (July 2008), "Missing
the Target 6: The HIV/AIDS response and Health Systems: Building
on Success to Achieve Health Care for All.". Back
64
Ibid. Back
65
Dhaliwal M et al, (October 2007), "Cambodia's Continuum of
Care for People Living with HIV Programme: Assessment of Quality
and Cost Effectiveness", DFID Health Resource Centre. Back
66
Banteyerga H, Kidanu A, Stillman K, (August 2006), "The system
wide effects of the Global Fund in Ethiopia: final study report". Back
67
Walton D A, Farmer P E et al, (2004), "Integrated HIV prevention
and care strengthens primary health care: lessons from rural Haiti".
J Public Health Policy 25(2):137-58. Back
68
Oomman N, Bernstein M, Rosenzwig, (2008), "Seizing the opportunity
of AIDS and health systems", The Centre for Global Development. Back
69
WHO, (2006), "Working Together for Health, The World Health
Report", http://www.who.int/whr/2006/en/ Back
70
Compernolle P, (2007), "Impact of increased aid flows for
HIV/AIDS in developing countries: working towards a sustainable
response", Royal Institute of Tropical Medicine, HEARD. Back
71
McCoy D, McPake B, Mwapasa V, (2008), "The double burden
of human resource and HIV crises: a case study of Malawi",
Human Resources for Health 6:16. Back
72
National Audit Office, (February 2008), "Department for International
Development: Providing budget support to developing countries". Back
73
Action for Global Health, (June, 2008), "Why Europe must
deliver more aid, better spent to save the health Millennium Development
Goals". Back
74
Ibid. Back
75
Atun R A, Bennett S, and Duran A, (2008), "When do vertical
(stand-alone) programmes have a place in health systems?",
World Health Organisation. Back
76
WHO, (2008), "Maximising Positive Synergies between health
systems and Global Health Initiatives". Back
77
Accessed at www.aids2008.org Back
78
Ooms et al, (25 March 2008) "The `diagonal' approach to Global
Fund financing: a cure for the borader malaise of health systems". Back
79
Action for Global Health, (June 2008), "Healthy Aid. Why
Europe must deliver more aid, better spent to save the health
Millennium Development Goals". Back
80
Uplekar M, Raviglione M, (2007), "The `vertical-horizontal'
debates: time for the pendulum to rest (in peace)?" Back
| 
