Examination of Witnesses (Questions 40-58)
MS FIONNUALA
MURPHY, DR
STUART KEAN
AND MS
CAROL BRADFORD
28 OCTOBER 2008
Q40 Chairman: And in relation to
children?
Mr Kean: In relation to the indicators
at this time, I think there really are questions to be asked about
the targets and I think that, as with so much within the strategy,
it is a matter of if you were sitting in Lusaka or in Nairobi
what would you be doing and how would you interpret it. A high
level of interpretation is going to be required. For example,
on the prevention of mother-to-child transmission goal, which
is one of the very specific goals, to support the international
target, we need to ask what is DFID going to contribute and what
is going to be the system for trying to track that across even
the PSA[8]
countries. I recall DFID saying that they had 126 targets in the
previous strategy and there was a concern to move the other way.
I believe they have probably gone too far the other way and now
it is very difficult to see what are the specific targets that
individual civil servants are going to be trying to implement.
Picking up on some of the discussion we have already heard this
morning, one of my concerns is about how we get the policy dialogue
because particularly in relation to direct budget support if you
are working, say, in Zambia and you are putting money in through
the budget, things will happen if those issues for example around
children are in the national AIDS strategies which are then funded
by the budget, but it does mean that you have got to have staff
in the Lusaka office engaging on policy discussions, to ensure
that those policy issues or those priorities that we are concerned
about on mothers and children are actually included in national
documents. I think there is a whole set of processes that requires
targets and with the direct budget support being the main instrument
for delivery, I do have concerns.
Chairman: I think we have made the point
on a number of occasions that budget support is not necessarily
a low staffing option.
Q41 Mr Singh: There are many, many
shocking statistics in this field of HIV and AIDS but I think
the most shocking one is the fact that 60% of all adults suffering
from HIV and AIDS are women and 75% of young people suffering
from HIV and AIDS are women. Given that context—and you
did say earlier that women's rights should be at the centre of
DFID policy and then you reeled off a list of commitments—do
you think that those commitments (and I know you had reservations
about how to implement them) represent DFID putting women's rights
at the centre of their policy?
Ms Murphy: As I said, a lot of
this is about implementation and I believe that if DFID implements
all the pledges that they have made, in addition to doing some
extra work around treatment accessibility for women and involvement
of women, DFID could make really meaningful progress for women
and girls. As far as ActionAid is concerned, in our written submissions
we have listed specifics that we feel DFID should be doing that
could really take this work forward but in terms of key things
that we think need to happen in order to ensure the kind of progress
we want, we have narrowed it down to four top things. The first
of these is that DFID needs to create budget lines that allocate
money for the intersection of women's rights and HIV and AIDS,
including a specific budget line on the intersection of violence
against women and HIV. At the moment we have been told that £6
billion has been allocated for health. We have no idea how much
of that will go to support women. We have no idea how much money
will come from other budgets such as education, because a big
part of the issue of women's low status is the fact that more
than 10 million more young girls than young boys still are not
in education and three-quarters of the world's illiterate people
are women, and that has an impact on how women later become vulnerable
to HIV infection, so will money come out of education and how
much money will go to these things, we do not know. That is one
point. The second point is that we feel DFID need to be stepping
up to the mark and showing more international leadership on issues
around the feminisation of HIV and AIDS. They have made a number
of pledges around championing evidence-based prevention, scaling
up access to family planning, taking action on violence against
women, but what we would really like to see is a long-term global
advocacy plan that identifies key moments and key opportunities
to influence these issues, and pinpoints the institutions where
DFID will be pushing these issues and sets out strategic activities
that DFID will undertake on them. Some of the outputs that we
see coming from this are DFID visibly challenging female-unfriendly
prevention strategies, increased momentum around access to sexual
and reproductive health care, increased investment in microbicides
and post-exposure prophylaxis, DFID really championing the fight
against violence against women in international fora, and also
DFID working with other donors and developing country governments
to improve the economic status of women. The third thing that
we think is really important is the training of staff because
in ActionAid we have made women's rights our cross-organisational
priority and we have recognised that if we really want to do that
in our international work and in our community level work and
everywhere in between then the first thing we do need to do is
train our staff. I do not think that it is that different in DFID.
I think they need to set aside money and time for a comprehensive
programme, training their staff to understand and act on the linkages
between women's rights and HIV. Finally, we would really like
to see DFID commit to a concerted action plan on violence against
women itself because we think this is an area where there is a
really urgent need for action. If you look at countries like South
Africa, a young girl at birth in South Africa has a higher chance
of being raped than of learning to read and write and that is
a really shocking statistic. I have come back from Nigeria recently
where I have met young women who are forced into marriage at the
age of 12 before many of them even know what sex is, and you can
imagine what happens to them when they are taken home by their
older husbands. There really is a need for concerted action on
physical and sexual violence, which is a daily reality for many
women around the world. Again some of the things we would like
to see from DFID are funding streams for this, international leadership,
pushing to get indicators on violence against women in fora like
the Global Fund, IHP+,[9]
the Education Fast Track Initiative and also making sure that
there are indicators of violence against women and girls in national
AIDS and health and education plans as well. Of course we feel
that there is a strong role for DFID to work with the FCO in terms
of spearheading political and legislative reform ensuring that
perpetrators of violence can be prosecuted and women have access
to justice and that things like marital rape and sexual abuse
in schools are prevented through law and through prosecution.
We feel that if DFID would take action in these four key areas
then we could see a real change.
Chairman: That is a very long list and
DFID will very often say they are not the governments of these
countries.
Q42 Mr Singh: I was just coming to
that point, Chairman, in terms of action on the ground, in terms
of violence against women because it is obviously an issue of
culture, law and order and enforcement, so what could DFID practically
do in an in-country situation to prevent that violence, short
of saying to these governments to whom we give money, "This
is what we expect you to conform to in terms of international
law in terms of women's rights, and if you do not conform to those
practices then we will not be giving you money in terms of aid"?
Is that the approach that you would like to see?
Ms Murphy: I think that would
probably be going a bit too far for us from the point of view
of country ownership, but what I will say is that this is not
an idea that we have plucked out of our values in the UK and are
trying to transport over to other countries; ActionAid is part
of an international campaign called Women Won't Wait which is
made up of women's movements in about 40 countries who are working
against violence against women and HIV, so there are voices for
change in these countries. Obviously part of it is about the fact
that these voices are not being factored into civil society consultations
and international AIDS plans and that even where these voices
are heard, there is not always the political leadership to make
sure that the demands of women who face violence trickle down
into the health system and the education system and through the
programmes of multilateral institutions, so it is partly about
making sure that those voices really come through. I would just
add that you pointed to international agreements. This is nothing
that most governments have not signed up to in the numerous human
rights accords and women's rights accords that have been signed
over my lifetime and well before. We have to bear in mind that
this is not something that we are importing; this is something
that has been agreed to.
Q43 Mr Singh: But if we can suspend
aid because of corruption in elections, why can we not suspend
aid if they do not respect women's rights?
Ms Murphy: I think it is partly
about making sure that aid is spent in a way that does respect
women's rights instead of saying let us stop the aid and see what
happens because women, who are most often dependent on the meagre
state support that there is, would be the first to suffer from
that. One of the things that we have looked at a lot is, how could
DFID money be used to train health workers to understand the issues
that women face, to recognise the signs and symptoms of violence
and to understand what support and care and referrals they can
offer to women to enable women to get out of a dangerous situation
or to enable women to deal with violence in their lives. The same
can be said of money that we give to education. How can we ensure
that part of that money is spent on creating safe schools for
girls, and making sure that girls have safe toilet facilities
and making sure that their schools are near to girls so they are
not at risk of violence on their way home and making sure there
are systems within schools that enable girls that are the victims
of sexual assault in schools to hold the perpetrators of those
assaults to account. I think there is a lot that could be done
to create positive change through aid rather than necessarily
saying we should stop aid if we think that it is not respecting
women's rights.
Q44 Mr Singh: Is there any point
at all in engaging men in programmes that change their behaviour
in terms of women's rights? Is there any mileage in that at all?
Ms Murphy: Absolutely and that
is certainly mentioned in DFID's strategy both in terms of tackling
violence against women and also in terms of challenging broader
gender stereotypes and gender norms which are harmful and helping
young men to resist peer pressure to be unfaithful to their girlfriends
or to be violent towards women. Whilst women's rights are about
women, gender is about everyone. We all have a gender and that
is not necessarily set as one thing throughout our lifetime. I
think there is a really important role to be played in educating
young men, and supporting young men to consider their behaviour
and to be brave enough to stand out from the crowd and say, "I
do not think it is a brave man who beats up his girlfriend. I
think it is a brave man who respects his girlfriend and is willing
to think of her as an equal," so I think that is really important.
Chairman: I can testify to the fact that
Marsha Singh took President Karzai head on on this particular
issue when we met with him.
Q45 Mr Kawczynski: Very briefly,
Ms Murphy, following on from what Mr Singh was saying to you.
You mentioned that you were working with 40 women's organisations
around the world, I presume from 40 different countries?
Ms Murphy: It was women's organisations
in 40 countries so a lot of them are national coalitions made
up of smaller organisations, like the Stop AIDS Campaign.
Q46 Mr Kawczynski: Obviously you
are collating information from them. Do you make a quarterly or
yearly assessment of the progress that is being made in those
40 countries with regards to rights for women and do you publish
that in any way?
Ms Murphy: Personally we do not.
It is not being run by ActionAid UK because ActionAid UK is not
our head office as such. Women Won't Wait is a global coalition
which ActionAid helped to get off the ground but we are not the
secretariat. We do regularly gather evidence and success stories
and we have a woman coming over from Sierra Leone around World
AIDS Day, who has headed up a national coalition which has managed
to bring in two laws, one on domestic violence and one on marital
rape, so criminalising both of those things and creating accountability
mechanisms. Similarly in Ethiopia, a coalition there has been
campaigning against a practice where a young girl will be abducted
and then the abduction will be the precursor to marriage as such
so the family will either barter to have the child returned or
they will agree that the child will marry into the family. The
coalition there has been very effective in getting that issue
on to the Government's agenda and is hopefully moving towards
legislative reform. I can certainly dig out some other success
stories and send them to you if that would be useful.
Q47 Mr Kawczynski: It would be very
useful because I think sometimes we tend to focus on being critical
of these countries and beating them up. It would be very helpful
to have some positive information that you can give us on specific
legislative changes that Sierra Leone or Ethiopia have made following
on from the campaigns that have been run. I would very much appreciate
that information.
Ms Murphy: Absolutely and also,
as I said, this lady is coming over from Sierra Leone for World
AIDS Day, and will be speaking at an event we are hosting on the
evening of World AIDS Day. We are hoping that Ivan Lewis will
come along so it would be great if anybody on the panel is interested
in that would come and join us as well.
Q48 Chairman: I was going to address
the issue of children and mother-to-child transmission because
clearly children in this context have done nothing, they are absolutely
innocent victims. The DFID strategy is to reduce that transmission
and to increase to 80% the number of women who receive antiretroviral
treatment, yet when you look at the causes of transmission, that
does not on the face of it appear to be a comprehensive approach.
Is that adequate as a target?
Dr Kean: About 90% of children
who acquire infection are infected vertically as a result of transmission
through the mother. If it was an HIV-positive mother in the UK
she would have full services including antiretroviral treatment
and her chances of passing on the virus would be 1 to 2%, but
in many developing countries it would be about 35 or 36%. By having
access to comprehensive prevention of mother-to-child transmission
services you can significantly reduce the number of HIV positive
children. I think that improving the services is critical and
having that as a top line action that DFID is going to support
is great. The question, as I said before, is what will that mean
they will be doing to contribute to that?
Q49 Chairman: That is my point, they
are saying let us give mothers antiretroviral drugs and that has
kind of dealt with it, but that does not seem to be the answer.
Are you saying that DFID needs to take a rather broader approach?
Dr Kean: I think what they need
to do is be able to strengthen support. When I was visiting Zambia
two or three months ago I met the director responsible for prevention
of mother-to-child transmission treatment and he said that the
support that donors provide in a sense as external voices (but
providing support on a number of things that I was raising that
I would also like to bring to your attention) but certainly generally
prevention of mother-to-child transmission treatment is critical
because it does mean that more resources will be allocated particularly
because they are coming through direct budget support. "Just
having greater scrutiny" was how it was described to me by
the director, having a score card that has prevention of mother-to-child
transmission treatment (PMTCT) and a number of other child-related
issues I think is critical. On the question of what will DFID
be doing, I think they need to be identifying the best practices
that have been working in a number of countries where now those
coverage rates are up to 60 or 70%. They need to be able to document
those, understand what has happened in successful countries and
be able to try and ensure that those are passed to colleagues
working in other DFID countries. If I could just mention one of
the other issues in our submission which is around cotrimoxazole,
which is a very cheap antibiotic that has been widely known about.
In 2004 DFID funded with the HRSC research which identified that
it could reduce infant mortality by 43%. If children were able
to get this then the potential deaths from opportunistic infections
such as pneumonia could be significantly lowered. The latest UNAIDS
figures the access to cotrimoxazole, show only 4% and even in
Zambia it is 16% coverage, and that is in a country where DFID
has done this research and found that this drug has these amazing
results. We are talking about one or two pence a day.
Q50 Chairman: It is not an expensive
drug.
Dr Kean: It is just an antibiotic
and yet it can have a very significant impact. I think it highlights
the more general issue of how when a piece of research has been
done how do you make sure that that moves on into development
and how do you scale up a piece of best practice. Something that
has had a major success, funded by the UK Government, actually
needs to be celebrated but then needs to be taken up further.
This was the kind of issue that again the director of PMTCT in
Zambia was saying we need to be doing much more on that. Certainly
from civil society's point of view that is what we are trying
to get but it needs to be policy.
Q51 Chairman: You would like DFID
to be more specific on that?
Dr Kean: Very much so. That particular
research finding was alluded to in the previous strategy when
it had just been undertaken. It is again alluded to in the latest
strategy but there is nothing being said about how that is going
to be scaled up. I am aware that UNICEF is conducting some analysis
at the moment to try and identify what the best practice is but
I am really hoping that DFID will learn from that and be able
to encourage it. The question is how through this strategy, can
we ensure that steps are taken to get targets around such good
practice.
Q52 Chairman: We will have an opportunity
to question the Minister later this week so we might take that
up.
Dr Kean: That would be a very
helpful one.
Q53 John Battle: Can I sharpen the
focus on children with HIV. Children make up 6% of the infected
population and 14% die so their death rate is higher. I just wanted
to ask about DFID's strategy because they focus on social protection
if not social transfers—handing money over basically to
traditional families and hoping that cash transfer helps. Do you
think it does and do you think other services are needed instead
to supplement that approach?
Mr Kean: There are two issues
I would want to raise about that. One in a sense is the whole
issue of paediatric treatment and what is needed to be done to
try and scale that up because clearly at the moment barely 10%
of the children are getting access to antiretroviral therapy.
Clearly with two million children who are HIV positive you need
to be doing something, so the question then is why is not that
more prominent within the strategy, so from that point of view
I really share your concern. There is a range of things that need
to be done to do that. In terms of social protection it is not
going to answer that issue. I think the social protection issue
is there because increasingly in relation to the care and protection
of orphans and vulnerable children, which was very much the focus
of the child work in the Taking Action strategy, there was an
assumption that resources would go to communities and that community-based
organisations would provide the services needed. I still think
that is very important. In the intervening time the role of cash
transfers as part of social protection has clearly been an area
that DFID together with ILO[10]
has taken a lead role on. It is clear that cash transfers in a
number of countries are showing promise, as a means of providing
care and protection for many vulnerable children and clearly not
just children affected by AIDS, and that can only be a good thing,
but I think our concern certainly as the Children and AIDS Working
Group is that it has got to be broader than just cash. The ministries
that are responsible for providing social welfare, providing child
protection, providing legal protection and providing birth registration,
are the "Cinderella" ministries, the ones that do not
have the resources, so you can put resources into the community
but if in turn there are no child protection services, indeed
if there is not the investment in education and health as well,
then the services are not there to be bought into.
Q54 John Battle: I would have thought
particularly in post-conflict countries that the number of children
that are abandoned, orphaned or indeed are street children in
cities would not be reached by social transfer and protection
at all. Is that a group we should be concerned about?
Dr Kean: Absolutely, it is indeed,
and there are various groups of children who are outside of the
family context and cash transfers are not going to easily reach
them and alternative methods have to be found. We have heard there
are no such things as magic bullets, but I think whilst it is
important to pursue the social protection work that is going on
and the pilots and the long-term studies that are going on, we
must not throw out the baby with the bath water and the various
community-based organisations and faith-based organisations that
are protecting and providing services to street children, to disabled
children, to communities looking after orphans, you need to have
those structures in place to be able to provide them with care
and protection. That is not going to come from $10 delivered on
a monthly basis.
Q55 Sir Robert Smith: You touched
in quite a lot of the evidence on the emphasis in the DFID strategy
which is firmly on health system strengthening, but how can funding
allocated in this way be effectively monitored and evaluated?
When it is reviewed in three years' time what do you think should
be the key elements we are looking at to evaluate if it has been
a success?
Ms Bradford: That is one tough
question because, as has already been mentioned, the AIDS strategy
has no budget for specifics. Let me step back just one second
and explain a little bit about the process we just had with DFID.
It was fairly ground-breaking in that civil society was invited
by DFID to come in, and a small group of us went in and worked
with them on their Monitoring and Evaluation Framework for their
AIDS strategy. The process went very well. It began a bit stiffly,
a bit formal, but it became very collaborative, and I would say
that there was give and take on both sides. But, it did bring
up many limitations to properly measuring, and many of them have
already been brought up at the hearing already, and showed that
without spending targets or budgets it is very difficult to track.
The health systems measures and indicators are not very good and
they need further developing as the evidence base is not really
there nor the indicators with which to measure it. Also we ran
into many problems with the harmonisation agenda, which is meant
to make things simpler in measuring work across donors, and it
does make things simpler at the country level to have a similar
monitoring and evaluation framework, so the whole harmonisation
agenda is basically positive but it does have a catch, in attribution:
what has DFID done and what have other donors done is very difficult.
Indeed the deal with harmonisation is not to get too much into
attribution. We were trying to work with DFID to say how can you
look at what your programmes have done. We were working under
Chatham House Rules, so I am not able to give too many details,
but we were able to work out some qualitative reporting that will
be monitored. There will be a baseline, a mid-term and final evaluation
that will begin to look at some of the things that DFID has actually
done.
Q56 Sir Robert Smith: I understand
they will be publishing the strategy for monitoring in November.
Do you think in a way that is coming up with a strategy before
you have worked out how to monitor it? Would it have made more
sense to integrate the developments so that the monitoring and
the strategy came together?
Ms Bradford: Let me just say that
we are making real progress. Remember the last strategy did not
have a framework at all and it was worked on towards the end,
so this is definite improvement. An additional thing to say, and
again this has been touched on here already, a problem we found
was staffing limitations within DFID made it continually difficult
to collect as much data. If you are already overworked, additional
reporting requirements are always complicated. That is not meant
to be a criticism, it is just the current set-up.
Q57 Chairman: Do the others have
a comment on what they think should be in it?
Ms Murphy: I think I have already
said quite enough in terms of the specifics of what we would like
to see there.
Ms Bradford: May I make a comment
quickly on gender just so you feel better. We had a gender expert
in our group and DFID is very open to working on gender. I agree
with Fionnuala that training within DFID might help more DFID
people understand gender. It is a very complicated issue and it
has got to be done more than gender champions. Some groups within
DFID understand the concept very well, so training may help, but
there is good give and take with bringing in gender aspects to
the Monitoring and Evaluation Framework.
Dr Kean: We have as the Working
Group submitted the indicators that we suggested that DFID should
include in its M&E framework and in a sense I think it is
trying to put the onus on a DFID field office to be able to say
what they have contributed in a number of key areas. I have mention
cotrimoxazole, paediatric treatment, prevention of mother-to-child
transmission and indeed what they are doing for children outside
of care, like street children and disabled children. It comes
back to the first point I was making about the lack of targets.
The best we are going to get is people saying what activities
have you undertaken to be able to contribute towards this international
goal. I will not read all the specifics but they are in the evidence
that we have submitted.
Q58 Chairman: Thank you for that.
Obviously across the whole piece monitoring what works and how
effective it is is difficult but absolutely essential, partly
to demonstrate that money is being spent in a way that delivers
positive results and to keep on board the taxpayers who are funding
it. It is difficult but it is obviously necessary and at the same
time as the aid budget and the development budget raises (and
one hopes in the circumstances that may still be possible) then
to carry the public with you it is more important than ever that
you show that the money is being spent effectively, so I think
it is very helpful to have those kinds of suggestions.
Dr Kean: The other element to
allude to is the point about trying to identify what are the best
practices, what are the achievements, so it is not just a matter
of being able to report back to the taxpayer but because there
is good practice, if you are working in Malawi or Botswana next
to Zambia, and Zambia has just found this fantastic research result,
then surely it makes good sense to share that, so documenting
good findings and good practice, asking what works and hearing
the success stories. It is important that this monitoring framework
does pick up this much more qualitative approach so that we can
get that and share information as much within DFID as well as
being able to publicise to the taxpayer that there has been some
real success achieved.
Chairman: Thank you all very much. I
think it has been a very helpful exchange. Obviously it is going
to help us to question the Minister and also to formulate our
report, so thank you for coming in and sharing those thoughts
with us.
8 Public Service Agreement. Back
9
International Health Partnerhip Plus. Back
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International Labour Organisation. Back
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