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CORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 1068-i House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE INTERNATIONAL DEVELOPMENT COMMITTEE
HIV/AIDS: DIFID'S NEW STRATEGY
MS LUCY CHESIRE DR KENT BUSE and MR ALVARO BERMEJO MS
FIONNUALA MURPHY, DR STUART KEAN and MS CAROL Evidence heard in Public Questions 1 - 58
USE OF THE TRANSCRIPT Oral Evidence Taken before the International Development Committee on Members present Malcolm Bruce, in the Chair John Battle Hugh Bayley Richard Burden Mr Stephen Crabb Daniel Kawczynski Mr Marsha Singh Sir Robert Smith ________________ Memorandum submitted by Lucy Chesire
Examination of Witnesses
Witness: Ms Lucy Chesire, Kenyan HIV-TB Advocate,
ACTION Project Q1 Chairman: Good morning, Lucy. Can you hear and see us? Ms Chesire: Yes, I can hear you loud and clear. Can you hear me? Q2 Chairman: Yes, we can hear you. That is fine. Thank you very much. First of all, can I say thank you very much for coming into the DFID office to talk to us. Some of us met you when you were in London in June and, obviously, we felt that you would be a very good person to share your experiences with us. I just wondered if you would perhaps start by saying, as somebody who has been living with HIV and TB, what are the biggest challenges that you face, and feel free to express what you think are the most important issues for you? Ms Chesire: Okay. Thank you very much. It is excellent of you. First of all, the challenges and experiences of people living with HIV are very clear. Are you able to hear me? Q3 Chairman: Yes, we can hear you now. There was a slight scramble, but carry on. Ms Chesire: Okay; cool. What I wanted to say was that some of the challenges that people with HIV face in relation to TB/HIV co-infection, is the issue around the main diagnosis. The challenges are around diagnosis because, if I can give my own experience, what basically happened is that I was already living with HIV and I went for a chest x-ray but the truth was that none of them were actually showing that I had TB. So that is the biggest one. The kind of techniques that are being used should actually be updated. If you look at the chest x-ray, it has been used for over 100 years (inaudible), and that technically means that if you want to see a diagnosis for having HIV, for TB, it means, despite being in an area of (inaudible) it becomes very difficult for the patient to be able to survive. Q4 Chairman: It is very difficult; I do not know whether we can get a better sound quality. While that is being done, can I say I certainly understood the main point you were making, which is that you believe that the diagnosis for TB is inadequate and outdated. I can perhaps ask you the question, if you can understand me, to follow that up: are you, therefore, saying that you would like to see priority given to improving the diagnosis and then also giving people with HIV routine screening with better techniques? Ms Chesire: In relation to that, I think it is pretty clear what the demand for interaction activities is. When you look at the TB and HIV collaborative activities (inaudible) it states very clearly what programmes are supposed to do. Something that they need to do is establish mechanisms for co-infection, because here we have a reasonable ambition and, therefore, the programmes need to cognate together. The issue is around decreasing the burden of TB among people living with HIV/AIDS and, of course, decreasing the burden of HIV among TB patients. What basically programmes are supposed to do is be able to create each and every part. When you look at TB/HIV co-infection--- Q5 Chairman: Lucy, can I stop you? Ms Chesire: Yes. Q6 Chairman: The sound quality is variable and what they are suggesting is it might be better if we redial and see if we can establish a better connection. We are getting quite a lot of what you say, but it is very difficult to get a complete record. So if we can stop and see if we can re-establish the connection, I think it would be better for all of us. Ms Chesire: That is fine. Q7 Chairman: Hopefully we will see and hear you more clearly in a minute or two. Ms Chesire: Okay. Chairman: I am sorry about this, but I am assuming that people are all having difficulty with the sound. The Committee paused whilst a new video link connection was established Q8 Chairman: Hello, can you hear us? Ms Chesire: Yes, we can. Q9 Chairman: Okay. I think that is better. We will certainly try. I am sorry about that. Technology is great when it works but it is a problem when it does not. You were saying to us that you find the techniques for diagnosing TB are primitive. Perhaps you would just say it again. Are you really saying more should be invested in improving the techniques for diagnosing and are there particular problems with people who are HIV positive? Do they require dedicated diagnosis? Ms Chesire: I do not think they necessarily require dedicated diagnosis. The issue is that the diagnoses that are currently available are not all sufficient to be able to detect micro-bacterial problems with HIV, and what that basically means is that it calls for more research into TB/HIV co-infection with regard to diagnostic provision and co-ordinating bodies. Now, on reflection (inaudible) whereby it takes over six hours to be able to get a conclusive test. Of course, the challenge here is that the current diagnosis is not able to pick up the micro-bacteria and that is why we have to look at the global TB side. They are trying to see what can be done in relation to advancing the diagnostics for TB/HIV so that every person who has HIV is screened for TB, but, equally, antiretroviral therapy is continuing. When you look at the three basic donors for HIV, which is PEPFAR,[1] Global Fund and the World Bank, none of them are actually charting how many people living with HIV are being screened, and to me that is a crisis, because we cannot have over seven or eight hundred thousand people who are already infected and only less than 2% of them are being screened, and that shows that even the global donors are not really able to adopt and address co-infection as being a problem. Q10 John Battle: I wonder if I could ask whether the problem in detection of TB is an issue of screening personnel staff and clinics, or is it a scientific problem that once a person has HIV scientifically the bacterial infections make it more difficult for even the best doctors to detect TB? What is the basic issue here? Is it scientific detection or is it lack of staff, medical personnel actually physically screening people? Ms Chesire: The problem is actually both. It is both scientific and also it is medical. Why I say it is both scientific and medical is because all the TB/HIV programmes that are currently implementing the co-infection activity, only less than 1% of persons living with HIV around the world are actually being screened for TB, which to me is a disaster. We cannot afford to delay diagnostics. Programmes are not even doing the actual screening and at the same time, not even for the very few that are doing it, like in Kenya, Malawi and Rwanda, they are recording and reporting a problem, and that is why when you look at the countries' plans they do not even have a specific indicator for TB/HIV, which to me is a disaster. Q11 John Battle: Could I follow that up? Are the health authorities screening for TB for people who are not yet diagnosed as HIV positive? In other words, is there a general anti TB campaign and screening running? Ms Chesire: Absolutely. For those who are symptomatic, they are being screened, but the screening is not done for the generalised population. That is one thing we need to understand. What I am also trying to say is that when you look at the TB/HIV co-infection activities, when it comes to decreasing the volume of TB among people living with HIV, one requirement is each of us, for example, living with HIV should be screened for TB. Currently that is not happening. That is why I was trying to give examples of countries that are even implementing co-infection activities, we still see that it is just not happening. Q12 Chairman: DFID are targeting a lot of their funding over the next few years to strengthening health services. Do you think this will help or do you think the HIV/TB at-risk patients will kind of get lost in the general service? In other words, do you think you need to continue to have a targeted service, and, if you have a targeted service, can you deliver it if you do not have an effective health service? Ms Chesire: That is very interesting, because I always look at it as you have to do both - you cannot have one and not have the other - and so, at the end of the day, what we have seen in the past is that because of the burden of TB, HIV and malaria actually this whole area is a symptom of our current healthcare standards, and it shows everybody it means how do each work together so that at the end of the day even specific programmes are actually contributing to health system strengthening. If you look at the health system strategy, screening states that one of the clear components is the issue around the whole of the health strategy. How do we look at the six blocks in relation to that? You are talking about healthcare workers having adequate healthcare providers, healthcare financing, monitoring and evaluation in place - all these components are really significant, so we know that we cannot have one without the other because we have got to have both of them working in tandem so that at the end of the day the strengthening means that we have an efficient service so that at the end of the day somebody is able to actually get adequate services. Q13 Sir Robert Smith: On that point, how do you think DFID should measure the effectiveness of its strategy? What sort of outcome should it be looking for to see if it has made a difference? Ms Chesire: One of the things that DFID needs to do is that when you look at the current AIDS strategy there is not really much on what they are going to do specifically on TB/HIV, and that provides an opportunity, so it is important that it is clear-cut in terms of how much of DFID's money is actually going even to contribute to addressing the issue of the co-infection alongside the health system. Then, of course, the issue of monitoring, which is really critical. It is pretty clear that if DFID wanted to go that way, one of the indicators we will be looking at is how many persons are being screened for TB? How many TB/HIV co-infected patients are benefiting from prophylactics, which is Isoniazid preventive therapy, and then at the same time, how many of these are being started on HIV antiretroviral therapy? So these are inherently difficult to look out for, and I think they are pretty well spelt out when you look at the TB/HIV co-infection activities, but it is important that through the AIDS strategy, which is lacking currently, there is no allocation of funding that is going to address the co-infection, despite (inaudible), or people living with HIV around the world, and then, of course, the issue of monitoring and evaluating to see what progress is being made at the country level and within the country plan. Q14 Chairman: Is the problem that not only are you not screening and diagnosing people who are vulnerable to TB and are HIV positive, but if you do not actually have the health infrastructure, you cannot treat it? It is almost worse to be told you have got TB but there is no valid treatment available. So is access to treatment at least as big or bigger a problem than diagnosis? Ms Chesire: I think we have seen the issue of access to treatment being much more available to many people. It was a big challenge actually when starting antiretroviral therapy for many people, and today we have over 280,000 people who have been started on treatment. So we have come a long way in relation to that, but the thing is we have also got to be able to address the challenges that are coming up today, and that is why TB/HIV co-infection as a challenge has been very, very important in one area where we are having multi-drug resistant TB and also XDR,[2] and so, with resistance to most of the drugs, it becomes much more scary because it is becoming more expensive to be able to treat it. The cost is $5,000 to treat one person for multi-drug resistant TB, over a period of two years, and this is something where we have drawn on the South African experience whereby the very first people who were diagnosed to have MDR-TB, were actually people living with HIV, and so it means that we have got to look back and say what are the challenges and the plusses, think where (inaudible) has exposed the takeover healthcare and what can be done in order to be able to bring progress so that we are actually able to contribute to a period where we can offer our services, which will become an impediment if the challenges that are coming along are not being addressed as we go by. Q15 Chairman: If I am right, the incidence of multi-drug resistant TB has got a lot to do with not having early diagnosis. So clearly for a developing country finding $5,000 for a patient is extremely challenging, but presumably you can find a(lot) smaller amount of money to actually catch them before they develop multi-drug resistant TB. Am I right in that judgment, and is that really one of the things you are focusing on? Ms Chesire: You are pretty right in that, but I do not think your figure is right because when it comes to multi-drug resistant TB, the issue of making the difference becomes also another greater challenge, because when you look at XDR and MDR, most countries do not even have the laboratory facility to be able to screen that, and that is why now the World Health Organisation has been trying to see if it can set up a laboratory within Africa, so that patients can get better services with the screening being done so that it does not become an impediment. Q16 Chairman: I was going to ask you, because really this is an opportunity for you to provide from your experience your thoughts, as to how DFID could better deliver on HIV/TB; so do you have a specific point or points that you would like DFID to take on board if they are spending, as they are, or offering, substantial amounts of money that would meet your concerns and objectives? In other words, if you were writing DFID policy, what would your priority be? Ms Chesire: I think my priority would be one of accommodation in terms of a financial commitment within the HIV strategy to be able to address the co-infection, and then, of course, secondly, the opportunity for DFID to be able to track the amount of money that it is spending on some of the diseases, which is currently not happening, and then, of course, most importantly, the issue of monitoring and evaluation. Q17 Chairman: Do you have a view, then, about the Global Fund, because that clearly is designed to try and deliver that, but you feel that it is falling short? Ms Chesire: The Global Fund has played its role, but it has also had its challenges along the way. I was going through some of the proposals from the first round of funding to the seventh round. It is pretty sad, as much as it is either the fault of the countries. When they are putting in either HIV or TB proposals, they should be able to incorporate a TB/HIV indicator. Most countries actually do not do that. So we are seeing HIV proposals falling to the ground, particularly TB/HIV co-infection not being addressed, and I think in the up and coming Global Fund meeting, which is taking place on the seventh and the eighth, part of the recommendation is to make sure that when they have a net core of proposals which are coming up, one of the requirements would be that all countries when submitting HIV proposals should specifically have a dedicated allocation for TB/HIV and also specify the type of activities that should be undertaken to be able to address that. Q18 Chairman: Thank you very much. I am sorry we had a problem with the line and the sound. It was actually much better the second time. We are very grateful to you. I think it would have been nice for you to be here, because I think you are a very good witness, and the technology has slightly got in the way of us. Nevertheless, I think we have had a useful exchange and you have had an opportunity, I think, to give us some food for thought. I sincerely hope our report will reflect some of the things you have said. DFID, of course, are listening, both given that you are in the DFID offices in Kenya they are listening, but here as well. Can I thank you very much indeed for coming in and can I wish you very well with your campaign and your own personal health too. Ms Chesire: Okay. Thank you. Memorandum
submitted by International HIV/AIDS
Examination of Witnesses Witnesses: Dr Kent Buse, Health Policy Analyst and Mr Alvara Bermejo, Executive Director of the International HIV/AIDS Alliance, gave evidence. Q19 Chairman: We can resume on our second set of witnesses. Just to comment on the last session, I think Lucy Chesire is a real campaigner. Those of us who have met her in person know what kind of personality she has got and I do not think the technology completely communicated that, although I do think she said some very important and useful points. I wonder, first of all, if I could ask you both to introduce yourselves for the record and, obviously, for the benefit of the whole committee? Dr Buse: Certainly. My name is Kent Buse, I am a political economist, I taught at Yale for a number of years and taught at the London School of Hygiene and Tropical Medicine. I have worked for a number of UN organisations. For the past three years I have been with the Overseas Development Institute here in London and I am about to join UNAIDS next week. I have done a fair amount of work on global health initiatives, but my real interest is in the politics of decision-making in the health sector. Mr Bermejo: My name is Alvaro Bermejo; I
am the Executive Director of the International HIV AIDS 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 that 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 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 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 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 vertical financing mechanisms they 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 that 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 heath 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 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 differ contexts. I suppose I would like to know what any
specific epidemic looks like. If we
consider what is really going in diverse epidemics, particularly with some of
the fast emerging epidemics in places like 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 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 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 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 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 Mr Singh:
I tend to agree with you because in May I
went to 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 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 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 face but there have been a number of leaders in southern 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. Memoranda submitted by ActionAid and the
Examination of Witnesses Witnesses: Ms Fionnuala Murphy, Campaigns and Policy Officer, ActionAid; Dr Stuart Kean, Chair of the Working Group on Children Affected by AIDS, and Ms Carol Bradford, Chair of the UK Network for Sexual and Reproductive Health Rights, UK Consortium on AIDS, gave evidence. 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. Q39 Chairman: Even in the introduction you have slightly anticipated the first question which is: to what extent do you think that DFID's approach does actually pay sufficient attention to the impact of their strategy on the needs of women and children in terms of HIV/AIDS? You will be aware that last year we did a report on maternal health which raised the AIDS dimension so as a Committee we have covered it but we are anxious to hear from your point of view whether DFID is doing enough and what more it could do. Ms Murphy: If you look at achieving universal access, there are a lot of really important first steps in the strategy in terms of tackling the ways in which women and girls are affected by HIV and AIDS. ActionAid was really pleased to see a number of commitments in there and I have just made a list here. For example, there is a pledge to continue UK leadership on comprehensive HIV prevention that is evidence-based especially for vulnerable groups; a commitment to train DFID staff on women's rights; pledges to take action to stop violence against women and girls; a recognition of the importance of integrating HIV with sexual and reproductive health services which reflect the reality of women's lives; promises to include a gender analysis in HIV prevention strategies; moves to increase access to contraception and female-controlled HIV prevention such as female condoms and microbicides, and to work with other countries to increase access to those commodities; greater attention to the burden of care on women and a pledge of £200 million to be spent over the next eight years on social protection for carers; and broader pledges to address structural inequalities that keep women poor and that put women at risk of HIV infection. I am sure Carol will have a lot more to say about this. I think those are really important first steps but for us the real challenge is about how these pledges are going to be implemented because they are very top-line promises but they are actually talking about very complex cultural and structural issues, so the real challenge is what action does DFID propose to take, and how will DFID measure success and make sure that we have got there and that we have delivered real benefits for women and girls. Ms Bradford: I am going to just speak very briefly. I am here more to talk about the monitoring and evaluation aspects, but I also represent the International Partnership for Microbicides which is a product in development that will help women prevent HIV. DFID as part of its monitoring has agreed to up its research spend on both microbicides and vaccines, so these will both be very beneficial to women. Obviously it is prevention work in the future. 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 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 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 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 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 four % and even in 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 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 six % 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. [1] US President's Emergency Plan for AIDS Relief [2] Extensive Drug Resistant TB [3] Men who have sex with men [4] World Health Organisation [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.
[6] Sector wide approach [7] Pharmaceutical Research and Manufacturers of [8] Public Service Agreement [9] International Health Partnership Plus [10] International Labour Organisation |