Examination of Witnesses (Questions 20-38)
DR KENT
BUSE AND
MR ALVARO
BERMEJO
28 OCTOBER 2008
Q20 Chairman: Thank you for that.
I think the point that emerged from that exchange is obviously
how best to deliver funds in ways that actually really meet the
needs. Clearly what is happening at the moment does not do it.
The debate really is about the role of direct vertical funding
targeted at specific diseases as opposed to horizontal funding
building up the capacity of the health service. In one sense it
is obvious that you need both, but the question is the priority.
DFID appears to be focusing more on the horizontal, although they
also contribute to the Global Fund. Do you have a view, both of
you, on whether they have got that balance right in terms of what
they are doing or how they should balance those two approaches?
Dr Buse: First of all, I think
that a lot of people in the last year have started to object to
those terms—the horizontal, vertical and diagonal—but
just to be clear, there are clear differences in terms of vertical
being tightly earmarked and horizontal being unearmarked. Unearmarked
being towards a budget support sort of approach or systems approaches
and looking at what is broken in the system. I just want to define
the terms so we are all talking about the same thing. Diagonal
has something to do with trying to achieve those disease-specific
outcomes with the vertical funding but also to be achieving other
kinds of health systems outcomes, whether it is more health workers
or whether it is a laboratory strengthening, or whatever. I think
DFID is trying to address or redress a past imbalance in its support.
Chairman, you talked about a balance, but actually it is not,
it is £6 billion into health system strengthening versus
£1 billion towards the Global Fund, and I think that that
is, in part, trying to rectify some of the problems that were
inherent in the tight earmarking of funds. I suppose my position
is coming through that I would see it to be a very reasonable
decision to have taken for a number of reasons, and I would be
happy to expand on those unless we want to come back to that question
but I wanted to provide some general food for thought.
Mr Bermejo: I would like to add
a couple of things. One is whether that is the right question.
I would agree that the answer we need to do both is true, but
the first big issue, I think, is to understand (and there are
lots of studies that have shown that) that the efficiency of health
systems increases proportionately to amount per capita investment
until you reach $40-60 per person per year. We are not here having
a discussion on what is the best investment in countries that
have $9-14 per year per capita. That is not the right question.
The question is how do we take it to a level where these systems
can be effective? Because if not, you can talk more about the
macro numbers, but from the communities where the HIV/AIDS Alliance
comes from, I remember in Mozambique hearing from a community
activist like Lucy who was HIV positive and had a TB infection—who
said, with the current investment we have, why do we not stop
the discussion and just invest it in cemeteries, because we are
spending much more time discussing what to do with $14 per person
per day, and money and resources and studies and meetings, than
we are seeing how we take that amount further up? How can you
really create an efficient health system? It does require more
money. So I think that is one element that we need to remember.
While I would agree that we need both—and that certainly
has been the experience in different countries who need different
balances to achieve the best health outcomes—it is a useful
discussion, but we need to remember, within $14 a day it does
not matter too much what approach you take, it just is not enough
to reach the Millennium Development Goals and the objectives that
we have set ourselves.
Q21 Mr Crabb: Given that there is
research that suggests that certain vulnerable groups, for example,
sex workers, are much less likely to access government provided
treatment and services, what does that say about the system strengthening
approach, the horizontal approach, and what should DFID be doing
to make sure that its horizontal funding still reaches these marginalised
vulnerable groups?
Mr Bermejo: That is a very good
question and one that the Alliance, because of its tradition of
working with marginalised groups, lives on a day-to-day basis.
Clearly the importance of these marginalised groups and the recognition
of the role that they have in both preventing the epidemic and
in providing solutions to the epidemic, our knowledge of how that
works has grown and the epidemiology shows that epidemics that
we thought were generalised epidemics are actually much more concentrated
on these groups than we thought in the past. So there is no doubt,
I think, in anybody's mind today that if you want to control the
HIV AIDS epidemics, you have to reach out to these groups and
involve them in the solution. As you say, health systems: first,
most of the work with these groups, the prevention work in particular,
is not a health system's work, it happens outside of the health
system, the prevention work, to a great extent. In terms of treatment
and access, clearly people living with HIV, whoever they are,
know the importance of health systems—they need the health
system to get medication on a day-to-day basis, so they do care
about health systems—but, as you have said, there are barriers
to access for these groups: whether they are transgender people,
sex workers, MSM[3]
drug users, there are very important barriers to access. So a
general budget support system that just injects money into the
public health system—because let us remember when we are
talking about budget support as a mechanism for strengthening
health systems, we are really talking about the public, government
run health systems which are in most African countries and many
other countries are a minority service provider—most of
the care is anyway provided by faith-based private sector and
other community organisations. So unless we can reach those, and
particularly those that are closer to the organisations and the
groups of people we are talking about, we will make some difference
but not all the difference we need to make to guarantee that they
have proper access to prevention, diagnostics, and treatment and
care.
Q22 Mr Crabb: Sorry to be stuck with
the horizontal and vertical jargon again, but what do you think
are the ways in which vertical funds can strengthen or undermine
health system strengthening, the health system approach?
Mr Bermejo: We have seen examples
of both, and I am sure you will want to come in. In terms of how
they can strengthen it, we have seen strengthening through, first,
reducing the burden that HIV patients put on the health system
itself. We remember those days where 60% of the beds in any southern
African hospital was occupied by people living with HIV—so
there is that burden. There is the improvement of health systems
by the fact that health workers get access to treatment. Let us
remember that the health workers crisis is one that is both produced
by people, by health workers leaving the health sector, but also
by health workers dying, particularly from HIV and TB. It also
has been shown to strengthen health systems in terms of improving
the procurement and supply management chain. When that has been
well done it has brought men and other groups to healthcare that
hardly ever visited the health clinics in these places; it has
brought young people into health clinics. There are lots of examples
where it has been done well, and many health systems were built
years ago around SRH intervention (sexual and reproductive health
services), so there is a tradition of building heath systems based
on disease specific interventions. We have also seen, I think,
examples, many of them I am sure you are aware of, where vertical
interventions have weakened health systems by paying more through
donor support, drawing resources from the primary healthcare and
from the clinics and hospitals away from the public health system
into donor-funded programmes. We have seen parallel systems for
procurement and supply management and diagnostics being set up.
So I think vertical intervention has the potential of doing both,
and it is about how we do it in an iterative manner that is well
focused, monitored and evaluated properly to see that health system
strengthening becomes an outcome of those interventions and, equally,
how we do health systems which should not be strengthening in
a way that is not a goal in itself but that really delivers health
outcomes. In many of the countries we are talking about HIV, TB
and malaria are the main killers, and we need to remember that.
Dr Buse: I would say that that
there is emerging evidence on positive and negative externalities,
if you want to use that language, and that there is a process
going on that is led by WHO[4]
right now, that is trying to collect and analyse that evidence
systematically, WHO it is part of a large network working on this
and I am not sure if DFID is part of that process, but the aim
is to develop guidance for next summer so as to ensure that all
opportunities to identify and address not only the negative impacts,
the unintended negative impacts from the past but also to identify
where positive synergies can be grasped so if funding is put through
a vertical system then automatically some non disease-specific
health systems outcomes will be generated. Labs will be strengthened
and shared, for example, between AIDS programmes and non-HIV programmes,
that x-ray machines will be shared, that the staff will be shared.
But I think one of the dangers is that the vertifical financing
mechanisms create certain kinds of incentives as well that are
not necessarily at the service delivery level but are more at
the stewardship and governance level of the health sector. So
if you have quite well funded programmes, there can often be an
incentive for that programme manager to report back to their funders—be
it the Global Fund, be it the World Bank, be it PEPFAR, be it
DFID, if DFID were going down that route—as opposed to programme
managers reporting up the chain of command within the health system
to their parliament, for example. So DFID has, over the past 15
years, supported sector-wide approaches for more rational allocation
of funds across the sector based on the burden of disease and
the cost-effectiveness of various interventions, and one of the
things that the financing of vertical programmes seems to have
often done is remove the incentive for those programme managers
to participate in wider sector dialogue and, therefore, to share
and to look for where those positive synergies can be obtained.
But to answer your question, there is a process going on, a lot
of the large agencies are a part of it, and then it becomes more
a political question how does DFID as a donor, with its billion
dollars that it has given to the Global Fund, demand that the
Global Fund take a more systems and holistic approach to its investments.
I just want to come back to the question raised by my fellow witness.
I would agree that we should be asking for $60 or $80 per capita
for health, but the reality is right now we have $15, so it behoves
us to use $15 or $20 in the most judicious way possible. I think
there are a lot of cost-effective interventions addressing a number
of health problems that are not HIV that deliver more health outcomes
for every pound spent. There is a methodology and, again, a global
process that has taken place, and it is on-going, it is called
CHOICE at WHO, which looks at how much health is delivered per
unit of spend, and a number of the HIV spends are not terribly
cost-effective. In other words, it is not that those HIV/AIDS
programmes are not having a profound effect, they are having an
effect on a lot of people's lives, but more effect in terms of
health impact could be had from spending the same amount of money.
There are obviously really good reasons for spending on HIV/AIDS,
and there is a huge amount of momentum now behind efforts to get
money onto the table for HIV/AIDS. So I see this as quite an historic
opportunity to use the AIDS funding and to use the profile that
AIDS has garnered to reorient health systems so that they take
advantage of those positive synergies and they reorient from simply
delivering maternal and child health services in many low-income
countries, to dealing with chronic and non-communicable diseases,
as well HIV/AIDS is going to increasingly become a chronic condition
and chronic problem, so that this opportunity is used not to say
that "AIDS has been over funded" but that we need more
funding for HIV/AIDS but it should be used in such a way as to
strengthen health systems, I think that there are a number of
global health initiatives that have revolutionised the AIDS business,
the Global Fund being one of them, UNITAID, GAVI,[5]
and so on. They have a lot of strengths to bring to the table,
but their remit should be focused on making sure that they use
vertical financing mechanisms to achieve these positive synergies
and positive externalities from the AIDS funding.
Q23 Richard Burden: Thank you. You have
given some very helpful comments about how we can achieve greater
synergies and strengthen health systems from the position of vertical
funding. Could I perhaps ask you to look at it the other way round
though? DFID is putting £6 billion worth of its money into
strengthening health systems. As well as seeing how vertical funding
can be used to strengthen health systems, do you think enough
emphasis is put by DFID on working out the impact of the funding
it puts behind strengthening health systems on making tangible
contributions to combating HIV/AIDS?
Dr Buse: I would say that there
certainly is a lot less evidence. I have not done a study on this,
and there is not a lot of money around to do studies on it, but
I think it will be difficult, to answer your question, because
we do not really know what is happening at country level because
the emphasis over the past number of years has not really been
on health system strengthening and this is a relatively new commitment
that DFID has made in terms of the £6 billion. I notice in
their strategy that they talk about one health system strengthening
outcome measure that I could see by looking at it briefly, and
it was 2.3 health workers per thousand population. I do not know
if we want to go down having a conversation in terms of how you
would measure health systems strengthening progress and what sort
of indicators should we be looking to have.
Q24 Richard Burden: That is what
I was getting at in a way. Would you think that that 2.3 health
professionals per thousand people living with HIV/AIDS would be
a meaningful indicator, or is it barking up the wrong tree?
Dr Buse: I think that the AIDS
world has brought us very good outcome indicators in relation
to universal access to prevention and care. The problem with a
global target like 2.3 is that it ignores a lot of national specificity
and differences and that one can have 2.3 health workers in one
geographical area and not in another. That kind of global target
is actually quite difficult to work with. I think a much better
approach is to take a country-specific approach and look at what
is broken in their national system and to identify which parts
of the heath system require strengthening, and that might be around
subcontracting NGOs to provide services to hard-to-reach populations.
It might be around health workers, it might be around surveillance,
it might be around procurement or the kind of diagnostics that
you were asking Lucy about. But the point is to see it from a
country perspective what needs fixing and developing a plan; that
way you get the variety of stakeholders involved in owning whatever
kinds of outcomes or targets you are trying to achieve. Coming
back to why I think universal access is a reasonable ambition,
or one possible approach, is that it is very equity oriented;
that one can go through the healthcare system and say what sort
of services do we think on the basis of economics or other preferences
in terms of what everyone should have access to. Should everyone
have access to essential drugs within two and a half kilometres?
Should everyone have access to a package of health services? Does
the surveillance system work? Is there a fair financing system?
I know those are very challenging things to try to define and
measure, but I think it is more useful than saying in five years
are there 2.3 healthcare workers in Nigeria per thousand people.
Mr Bermejo: Can I add also to
your question? I think there is an issue about the hard evidence,
even in countries like the UK. To think that Kenya is going to
be able to collect data as to how many sex workers, MSM or drug
users are accessing the health services—it is not going
to happen. If you can get age and gender disaggregation, you are
pretty lucky; you are certainly not going to get that other type
of information, so we will probably not have that hard data for
a long time. But I can tell you of a study that has just been
done trying to look at the HIV epidemic amongst transgender population,
and this is the sub-group that has the highest HIV prevalence
in the world. In many cases, like Mumbai, Latin America, 40% of
these groups are living with HIV. 40% is a very high rate, hardly
found in any other community. There has been a study to see access
to healthcare services by the transgender population. It is appallingly
low, because, firstly, if they are hospitalised they feel uncomfortable
being sent to the male ward, which is where they are sent because
their names have not changed. They are still registered as a man,
so they are sent to the men's ward, where they are difficult to
hide. They do not look like most of the other men that are in
that ward and they do not relate to them; they see themselves
as women. Most of them, a great majority of them, die without
accessing treatment or even having a diagnosis. No amount of health
system strengthening, of horizontal funding to a SWAp[6]
is going to change that, and if we believe, as the Alliance does,
and I think most people do, that containing the HIV epidemic requires
stopping the fastest growing epidemics, many of which are outside
sub-Saharan Africa, many of them are in middle income countries,
and many of them are fuelled by key populations, by marginalised
groups, then it is clear, I think, that if our focus is on containing
the HIV epidemic in addition to health system strengthening that
we need to do we also need targeted interventions that will reach
these groups. I think there is no denying of that. I think DFID
recognises that in its strategy, I do not think it is clear in
the way it funds, and I think there is an issue here of: if you
recognise it in a strategy do you have specific targets as to
how much money you are actually going to target to these groups
and what are the funding mechanisms you are going to use? That
is the question, I think.
Q25 Sir Robert Smith: Is there anything
we can look at just to assess whether DFID's strategy, predominantly
health system strengthening, provides better value for money than
going down a vertical route? Is there any way we can assess?
Mr Bermejo: Better value for money
in terms of containing HIV?
Q26 Sir Robert Smith: Yes.
Mr Bermejo: That is the question.
Will it contain HIV better than any other strategy? Not will it
improve health better than any other strategy? It depends what
the question is, and it is hard, I think, to respond because I
think we would support 80 or 85% of what DFID is doing on the
ground. I think the HIV strategy still is not specific enough
to see what the outcomes that are expected to be achieved from
DFID's investment is, so it is very hard to measure the outcome.
The strategy does not say it, at least not in those clear terms,
but if we are saying those £6 billion are going to be for
health system strengthening through budget support and sector-wide
support, if that is what we are saying, then I would say that
is not the best investment to contain HIV, and I think most people
would agree with that. You need a combination of health system
strengthening and vertical interventions that reach marginalised
groups. DFID would say we are doing that too, but that is not
clear from the strategy and what the balance of those two things
is not reflected in the strategy.
Dr Buse: I would have to agree
that different approaches are needed in different contexts. I
suppose I would like to know what any specific epidemic looks
like. If we consider what is really going on in diverse epidemics,
particularly with some of the fast emerging epidemics in places
like Pakistan, amongst highly stigmatised groups, I think we need
to put this in the context that there are six or seven thousand
new infections every day. That is what we should have our eye
on: how to prevent the future burden of this disease and think
about sustainability. We should be thinking about prevention and
what do we know works in prevention. I think I would agree that
there are certain things that strengthening the health system
probably cannot achieve in terms of dealing with the human rights
abuses that lead to the new HIV infections in the populations
that my fellow witness were just mentioning. Having said that,
I do see within the DFID strategy quite a bit of emphasis placed
on prevention amongst marginalised groups. But that is not talking
about value for money necessarily. It is difficult to answer that
question. To deal with HIV from a human rights perspective, let
us say, and to talk about the way transgender persons or men who
have sex with men are treated in society is a question that, if
one were going to study, would take time-series analysis or data
over quite a long period to see the human right intervention to
be implemented and to have an effect on HIV transmission. So I
do not think you are ever going to get a very neat comparison
there in terms of value for money analysis, but I would say, from
my perspective, that certainly prevention needs to be a very large
part of the picture. In addition to which is dealing with a number
of the social and structural determinants which drive why people
are vulnerable to HIV, and part of that then becomes DFID finding
ways of supporting groups in countries who wish to deal with the
political realities, dealing with small politics, if you will,
of addressing the human rights of transgenders for example or
men who sell sex. I agree that budget support probably is not
the way that that is going to happen, to understand the political
and social obstacle to support human rights, or social determinants
interventions because there has to be very creative support to
groups that are trying to change the policy environment within
which people live and the legal framework and for example the
way that police forces treat people once they arrest them, and
so on and so forth. So I would defy an economist to give you a
very simple answer to whether or not a human rights intervention
delivered by NGOs is a cost effective way to avert a death or
not. It is quite a difficult question to answer.
Q27 John Battle: In a sense I am
pressing for an overview and a very generalist question: because
the debate on HIV/AIDS seems to me to have changed over time.
The Zambia example was highlighted for many years as a successful
example of an African country that tackled it, but then—the
problems with TB that we are now discussing—for 10 years
we discussed access to antiretrovirals, for example, as treatment,
and now that debate has slipped into the background. If you could
just outline for me, and I like, I think, to have the kind of
theoretics (and I do not use that term pejoratively) of the analysis,
but in terms of the context, where do you see the epidemic rising?
Which are the key marginal groups that we should be addressing?
Which are the key places that we should be focusing on? I am not
sure that I have got that clear in my mind. I have got this structure:
is it clinics and holistic healthcare, is it prevention or is
it treatment, but where are the real pressure points in the world?
In the past we said: "Go to Zambia, see how they have done
it and use that as the template." Now we know that there
are problems with that template. Then we went to an antiretrovirals
campaign. Is it second generation or third generation? Where are
we now?
Mr Bermejo: It is a very difficult
question, where are we now. I think one of the things we have
realised, and I know I am just paraphrasing Peter Peart on this,
the only thing we know is that there is not a magic bullet, so
every time somebody says, "If we just did this we would contain
the epidemic", before they even tell you what this is, you
know that is wrong. We know we need a combined effort. I think
what we have come to realise is that the prevention benefits that
we thought would come out of scaling up treatment—there
was all this talk about the synergy between the two and how, if
we only managed to get all these people on treatment, prevention
would take care of itself—that has also proven to, unfortunately,
not be true. As you were saying Kent, in DFID's strategy and in
PEPFAR too there is a great opportunity, while maintaining the
scale-up of treatment, to focus and refocus on prevention. I think
that is one place where we know we are. In terms of prevention
though the situation is we know pretty well what can be done and
what works to reduce the epidemic amongst key populations is focused
prevention. There are a lot of studies and lots of countries such
as India, Cambodia, Thailand and Brazil which can show we know
what works there; it is political will that is needed in those
places and sufficient investment. We need to understand that prevention,
just as treatment, is a lifelong thing. It is not something you
do once and then you say, "We already did prevention in this
country." You need dosage, you need lifelong the same, and
multiple drugs and multiple prevention interventions; we know
that. I think the good thing is that for concentrated epidemics
we know that a focus on prevention will close the tap and at the
same time we have got an obligation to keep people alive. In the
generalised epidemics I would say that what to do is much more
complex and I would not claim to know. I wish I did! I think we
need to continue focusing on treatment. When you have one-third
of your adult population infected, to decide that you are not
going to provide treatment is a pretty difficult decision, whether
or not it is the most cost-effective intervention, but at the
same time we need to realise that that is unsustainable and we
need to reduce the incidence. We are beginning to see, even at
country level and particularly at city level, a reduction in new
infections in generalised epidemics. I think it is still unclear
as to what is the most cost-effective combination of interventions
in those countries. I really think more research is needed in
that area and that is something that we need to be investing in.
We need to be investing, which I think is your issue about Zambia,
in not just HIV itself but HIV-related health issues, and certainly
TB and sexual and reproductive health are important considerations.
When we know 30% of women in many of these southern African countries
are HIV infected it is clear that the most cost-effective way
of preventing mother-to-child transmission is investing in preventing
unwanted pregnancies and making sure that the general population
has access to good sexual and reproductive health services. I
think it is a difficult answer but that is more or less where
we are. I do not know, Kent, if you want to add anything.
Dr Buse: The only thing I would
add is one of the positive things I have seen in the last few
years is not only a mantra around "know your epidemic and
respond accordingly" but increasingly a number of the organisations
that were, unfortunately, funding AIDS programmes that were not
based on much science are being pushed into a direction of being
slightly more reasonable in terms of where they are putting their
funding. So know your epidemic but I would also say know your
politics, know what prevents you from being able to spend the
money on the things that the evidence suggests you should be spending
it on. That has not been happening enough and there need to be
more brave voices who say, "Why are we spending our money
on this? We could be spending our money in a more cost-effective
way". One of the big things is going to be looking in a very
realistic way at what are we going to do about sustainability,
how are we going to generate these resources, what sort of new
resource-generation mechanisms will we need to keep people on
antiretrovirals, and how are we going to make them affordable,
and what sort of new deals can we come up with, with PhRMA[7]
for example?
Q28 Daniel Kawczynski: Do you agree that
a more diagonal or integrated approach to funding for HIV/AIDS
is likely to be more effective than horizontal or vertical approaches?
If you could make your answer as jargon-free as possible I would
be grateful.
Mr Bermejo: I certainly will not
use the "diagonal" word because I hate it, because I
think it is very ill-defined. With a more integrated approach,
yes, I think it is certainly integrated in the sense that when
we are programming HIV vertical funds, in terms of raising funds,
in terms of mobilising public opinion and political capital we
need to see specific interventions. You do not get the UK public
and your constituents enthused about health system strengthening
and you will not; you get them enthused about making a difference
on HIV, TB, malaria, and sexual and reproductive health, so I
still think from that perspective of mobilising public opinion
and funds we need disease-specific mobilisation, vertical if you
want in that sense. In terms of how we use those resources best
you do need a combination and that is a combination that does
not just say we have these vertical programmes running on one
side and then health systems in parallel track; that is not integration,
that is a balance of two investments but it does not integrate.
I think there is a lot that we can do to ensure that those two
tracks integrate more together, which I think is your question,
and certainly the growing attention and political oversight now
on looking at whether that integration is truly happening. That
means, as we have seen in many countries still, for example if
you go to Ukraine, where we have one of our largest problems,
the HIV and the TB people in the Ministry of Health continue not
to talk to each other and continue to have resources spent in
parallel. I have to say that one of the benefits of the Global
Fund's intervention (they are funding HIV but they are as yet
to fund TB because of the approach that they are following) has
been at least to get that dialogue started and get civil society
involved in health services that were extremely vertical and had
no civil society and community participation, so you can see the
effect of vertical interventions making that more horizontal.
Does that make it more effective? There is no doubt in our mind
that it does. It is equally important that health systems strengthening
has specific health outcomes in mind and that we do not fall into
this thing of we are strengthening health systems so our only
targets are going to be number of health workers per population,
number of beds, number of nurses, or the speed with which a pill
gets to a clinic out in the field. We need to retain that focus
on health outcomes and if it is not improving health outcomes
then it is not good health system strengthening. Yes, I believe
that there is value in integration if we do it well and carefully.
Q29 Daniel Kawczynski: In terms of
DFID, if you could clarify a little bit what do you see the main
challenges that DFID faces in pursuing this integration?
Mr Bermejo: There is the fact
that their strategy is not specific enough. It is not clear as
to what resources are going to go where and what health outcomes
and specifically what HIV outcomes are to be expected, so it makes
monitoring very, very difficult. There is also the challenge that
at country levels the developing countries where sector-wide or
budget support has been provided they do not have the monitoring
and evaluation plans and systems to be able to track whether their
resources are being effectively utilised. So I think there are
several challenges along the chain for DFID which are not easy
to resolve. You have already highlighted some of them in your
report of last year when you were calling for a stronger outcome
target for DFID. I have to say I think this current strategy instead
of taking it a step in the direction this Committee had highlighted,
in that sense it has taken it a step further backwards. Your complaint
was that it only had a spending target for HIV and it did not
have other outcome targets. This one does not even have a spending
target for HIV, so in terms of the strategy there is still more
specificity needed and more ability to measure. Those things are
getting in the way not just of DFID being able to contribute to
implementation but all of us being able to truly monitor progress.
Q30 Chairman: As a final point we
might look at civil society because that arises somewhat out of
that. DFID says it wants to engage civil society but then says
it is putting most of its money into building health services,
so what is the balance?
Mr Bermejo: This is one area where
we have a lot of discussions with DFID. I always say that we agree
with DFID 80% and there is 20% we do not agree, and this is amongst
the 20% we do not agree. We are seeing a greater emphasis on multilateral
and bilateral government-to-government support and the proportion
of DFID funds going to that increasing. We do not think that that
is a good HIV strategy. We think it is a strategy that is driven
by some constraints that they have like the reduction in personnel
overseas in DFID offices which make mechanisms like multilaterals
or SWApS more attractive because they have lower transactional
costs in terms of the human resources required for DFID, but that
should not be what is driving the strategy. We know and DFID knows,
that if we are going to reach these hard-to-reach populations,
and particularly if we are going to reach them in their bedroom
or where they inject drugs, which is where HIV transmission occurs,
then we need civil society, and I mean the local civil society,
to get involved in service delivery, as well as having the capacity
to monitor the difficult decisions that politicians and governments
have to make. I always say—and you will know better than
I do—that I have yet to meet an MP who got elected because
of the great job they did with sex workers in their constituency
and because of how close and supportive they were to drug users.
You do not get elected on that basis. I have always said we will
move the Alliance to the first constituency that proves that to
me! That has yet to happen. If you acknowledge that and that is
the case, then you need to have an AIDS system that acknowledges
that and that acknowledges that it is very difficult for government
services to reach these populations which are critical. We need
civil society both in terms of service delivery as well as holding
their own governments to account for the resources that come into
the government and for the outcomes of those programmes.
Chairman: Can I go to Marsha Singh because
I pre-empted his question.
Q31 Mr Singh: Just to follow up on
that point, DFID's strategy gives a general commitment to increasing
participation with civil society but only gives a couple of examples
of doing so. Is that a sign of mistrust of civil society or is
it a sign of no experience of engaging with civil society? Secondly,
coming to the point of sustainability, is working through civil
society sustainable rather than working through a public health
system, which whether it is good or bad should be there for a
long, long time whereas civil society might not be there for a
long time? Finally, you have talked about the accountability of
government which I think most certainly does play and should play
a role, but what about the accountability of civil society for
the resources that it might wish to put into them to deliver services,
how are they accountable?
Mr Bermejo: There were several
questions there. Firstly, it is certainly not the case that DFID
does not have experience in working with civil society. DFID has
been over the years one of the donor agencies that has worked
more and better through civil society in the world, I would say,
and has been a leading example of that. Clearly I would say that
every one of the civil servants working in DFID that we have encountered
has had a lot of willingness and openness to working with civil
society. Is it an issue around at a particular point in time in
the AIDS strategy a lack of political will? I think there was
an element of that and we need to remember that this current strategy
comes in the middle of changing ministers, changing governments,
and the strategy gets caught in the middle of that, gets delayed,
there is then talk that there is not going to be a strategy. Civil
society's participation in designing that strategy, which had
been from the beginning very intense, suddenly disappears. We
hear that there is not going to be a strategy and then a strategy
does in the end emerge. Part of the lack of civil society participation
at some part of that process had an impact. I also think, as I
said, that part of the lower willingness to work with civil society
is really driven by the fact that there are fewer staff available
from DFID so it is clear that engaging with civil society, whether
it is here in the UK or in India or in South Africa, is resource
intensive. You need people to do this and when you are being cut
back in terms of the people that are available, you tend to cut
those things that are more resource intensive, and I think civil
society engagement is suffering from that. I think that is probably
more the explanation as to why it is happening and it certainly
is not good news for HIV, that is for sure. In terms of the accountability
issue, I think there is a very interesting discussion now which
I was hearing quite recently where suddenly the Global Fund is
being characterised as an undemocratic, non-accountable mechanism
of funding and IMF and the World Bank and others are suddenly
portrayed as the most democratic funding mechanisms, which was
a shock for me to hear. I know where it came from. It came from
the fact that because of the vertical nature of the Global Fund
in many countries it does not come into the national budget and
it does not have parliamentary oversight. I think that certainly
is unacceptable. I really think that that does not need to happen
just because it is disease-specific. We should still have a policy
dialogue that brings in those accounts and whether they go to
civil society or to anybody they should be integrated in the national
budget and under parliamentary oversight, and that would be a
way of holding the NGOs to account, too. I realise that the issue
of NGO accountability that you are raising is a real issue. I
think civil society has taken some steps towards self-regulating
codes of conduct and other things but I think that is still not
enough and we need to do more; I agree.
Q32 Mr Singh: And sustainability?
Mr Bermejo: The sustainability
issue is one where I have shifted my own thinking. I would have
agreed with you because I used to think that civil society was
less sustainable than the public health system. My time in the
Alliance has shown me that that is not true in a way. If I give
you the example of Ukraine, where we are implementing a multi-million
dollar, nationwide programme, that was first implemented by the
government but then because of corruption taken away from the
government and given to an NGO to implement. During that time—and
that was 2004—there have been four different governments
and seven different health ministers in Ukraine. The national
AIDS programme has changed leadership at least half a dozen times
and has been for months without leadership. The civil society
programme—and it is run by a national NGO—has continued
operating regardless. I think we are making assumptions partly
around sustainability. Of course the sustainability of funding
requires a commitment from the Government to include it in the
budget, that I would agree, but it is not more sustainable because
it is run through a government delivery system than because it
is run through a civil society delivery system, provided the Government
has it in the budget and it remains the overall steward. The implementation
mechanism that it chooses does not necessarily impact the sustainability
is what I have seen from that experience.
Mr Singh: I tend to agree with you because
in May I went to Bangladesh to see their programme against TB
which a weak government could not sustain and yet civil society
is sustaining that programme.
Q33 John Battle: I think it is in
a sense a response to the comment you made about politics and
whether people could campaign on the basis of tackling HIV and
drugs. I would encourage you and say that I do believe it is possible
for politicians to change the perception. I represent a constituency
which has a huge prison, and we tackle drugs and it is one of
the most popular campaigns because everybody could be affected
by people taking heroin and cocaine, so I just want to say it
can be turned round which brings me to the political question
that I would put to Dr Buse. In countries where there is political
resistance to taking HIV/AIDS seriously, we have a bigger problem
there, I am thinking of the issues around South Africa and maybe
the issues I am very conscious of at the moment in some of the
Caribbean countries. How do we tackle those and does DFID put
them on the agenda or is that for us as politicians to do? Who
addresses the really deep political resistance to tackling this
challenge?
Dr Buse: I would like to see all
this start with evidence in terms of what are the drivers of the
epidemic and what do we think the solutions are. That is very
country-specific and it depends on which bit of the epidemic we
are discussing. In every country you will find constituencies,
maybe not geographically as you were just discussing, but various
groups that would like to see the problem addressed in one way
or another. Often you will find allies inside and outside of government.
I think that around the top five interventions, let us say, in
any one country in terms of those interventions that are going
to make the biggest amount of difference, that an organisation
like DFID could usefully support groups—advocacy coalitions
if you want to call them that—to undertake analysis on a
long-term basis that did try to understand which groups are opposed
to this and why, and seeing if it is an issue simply of framing
the palatability of it, as you were suggesting, or taking care
of a local problem. I do see a useful role for an external agency
like DFID to provide money, and we are talking small amounts of
money, although of course there is a human resource issue in terms
of a lot of country offices are not necessarily set up for doing
that, and that would help groups to understand the politics and
to come up with strategies and tactics for dealing with them,
because at the end of the day we can make commitments to getting
2.3 health workers or whatever, but I think we have an obligation
to help countries also to meet the Millennium Development Goals
or the targets around HIV/AIDS. If they are blocked because certain
interest groups find it difficult to deal with the fact that certain
men have sex with men, for example, DFID should use its creative
powers to change the way that that political problem is perceived,
and I think it is very context-specific challenge. You cannot
sit here in London and suggest how that might work in Dhaka.
Q34 Chairman: I think we saw a good
example of that when we were in Hanoi where DFID had worked with
civil society both with intravenous drug users and the sex trade
and actually persuaded the Government of Vietnam to go somewhere
it did not think it wanted to go when it saw how it could be done.
Mr Bermejo: You were mentioning
South Africa and one thing is clear—that the treatment action
campaign in South Africa has been a big influence on a reluctant
government who have installed prevention of mother-to-child transmission
programmes and treatment programmes, and that has really been
the most effective way of making sure that the new health minister
and the new Government takes a different view on HIV. In the Caribbean
where civil society is much weaker I think we have seen that we
really need to find additional ways to try and change a very homophobic
culture and government where it is more challenging.
Q35 Daniel Kawczynski: I just want
to very briefly ask Mr Bermejo to go back to what he said before
about politicians. I did not fully understand what you said. You
said you had never come across a politician who has campaigned
on—
Mr Bermejo: Not who has campaigned,
who got elected on the basis of having worked closely with sex
workers and drug users to minimise the health risks that they
are exposed to. If you are the first one let me know! Honestly
I am saying it because it is not a popular thing, it is something
we know we need to do. Many of the politicians' and governments'
values are there but we need to acknowledge that it is a difficult
issue usually to work with and most people say "yes but not
in my backyard" or "not in my neighbourhood" or
whatever, so harm reduction programmes, programmes that tend to
empower sex workers or drug users to take care of their own health
and minimise the risks that they are putting are usually not particularly
popular and their access to services is usually limited I think
the best public health approach and human rights approach is to,
in a way, acknowledge that these are difficult to reach for government
service delivery and to find alternative mechanisms to reach them.
That is where I was going.
Q36 Daniel Kawczynski: You seem to
be giving me the impression that you feel that therefore politicians
are not interested in helping these—
Mr Bermejo: That is not what I
am saying. What I am saying is that in trying to think of which
ways to help them you need to acknowledge that it is not a popular
subject and find alternative ways of reaching those populations.
I think many politicians in this country and Spain, where I come
from, and in many other countries have established very strong
harm reduction programmes in prisons, which you were talking about,
and of course that requires politicians to support it, to establish
it, to care about it and to make it happen. It still is not a
popular intervention. I spend a lot of time in my country explaining
to people why it makes sense to give needles in prisons. Most
people, most of my colleagues, friends that I went to university
with, still think it is not a good idea, and you are faced with
that challenge. I am not saying people do not care. I am just
saying we need to acknowledge that and find ways of reaching them
that are specifically designed for that and that a mainstream
approach will probably not take us there. That is what I mean.
Q37 Chairman: Part of our role as
a Committee is to be prepared to say these things so we will look
forward to your amendments, Daniel!
Dr Buse: Obviously we do not need
to lecture you on what political interests politicians and political
leaders fact but there have been a number of leaders in southern
Africa who faced political incentives to act on HIV/AIDS when
they came into power. For example Museveni, with no tourist industry
at stake and therefore nothing really to lose by coming to the
international community and saying, "We have got a serious
problem, can you help us solve it?" In other cases the political
incentives have not necessarily been just around stigmatised groups
but also some leaders have openly said, "Our workforce is
small and specialised", or, "Our workforce is of a certain
nature and we do not need to deal with this problem, it does not
matter", so political incentives obviously do speak to whether
or not leaders at all levels take action on HIV/AIDS.
Daniel Kawczynski: I think what you are
proposing is a very progressive agenda and I think it will take
politicians a certain amount of courage to do what you are doing.
I very much hope that future generations of politicians will be
more courageous in this regard.
Chairman: Thank you very much. We have
probably overrun on that but I think it has been an extremely
useful exchange. However, I want to be fair to our last group
of witnesses to ensure they have an opportunity too, so thank
you very much to both of you.
Q38 Chairman: Thank you very much for
coming in and for being so patient. Obviously this last session
is particularly important looking at the impact of HIV and AIDS
on women and children. Before we start perhaps you could introduce
yourselves and who you represent.
Ms Murphy: Good morning everyone.
My name is Fionnuala Murphy and I have been working for five years
as a campaigner and advocate on HIV and AIDS issues. Most recently
I work in ActionAid where I have been running a campaign called
Invisible Woman where the objective is to get DFID to put women's
rights at the heart of their work on HIV and AIDS.
Ms Bradford: I am Carol Bradford,
and I am representing the Indicators Working Group of the UK Consortium
on HIV/AIDS. We have been working with DFID to monitor and evaluate
the strategy.
Dr Kean: Good morning. I am Stuart
Kean and I am Senior HIV and AIDS Policy Adviser with World Vision
but I also co-chair the Children and AIDS Working Group of the
UK AIDS Consortium.
3 3 Men who have sex with men Back
4
4 World Health Organisation. Back
5
5 UNITAID is an international drug purchase facility for HIV/AIDS,
TB and malaria administered by WHO, The GAVI Alliance (GAVI) (formerly
The Global Alliance for Vaccines and Immunization) is an alliance
between different stakeholders, in both the private and public
sectors, committed to the mission of saving children's lives and
protecting people's health through the worldwide expansion of
childhood vaccination programs. Back
6 6
Sector wide approach. Back
7
Pharmaceutical Research and Manufacturers of America. Back
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