Written evidence submitted by the International HIV/AIDS Alliance

 

September 2009

 

The International HIV/AIDS Alliance (the Alliance) welcomes this opportunity provided by the International Development Committee to contribute to the review of the Department for International Development's Strategy 'Achieving Universal Access'. This submission will draw on the Alliance's global experience of working with populations key to the HIV epidemic, and as a civil society organisation active in service delivery, capacity building and advocacy at both national and international levels. The Alliance will address in this submission all six areas of focus identified by the Committee for this enquiry.

 

I. The International HIV/AIDS Alliance

1. Established in 1993, the International HIV/AIDS Alliance (the Alliance) is a global partnership of nationally-based organisations supporting community action on AIDS. Currently working in over 40 countries - those threatened by emerging epidemics, as well as those already heavily affected - the Alliance emphasises the importance of working with people who are most likely to affect, or be affected by, the spread of HIV. DFID has funded the Alliance through a Programme Partnership Agreement (PPA) since 2004. In the Caribbean, the Alliance is currently implementing a HIV/AIDS programme with DFID support of £2million.

 

II. The process established by DFID for monitoring the performance and evaluating the impact of the Strategy

2. As noted in previous submissions to this Committee in 2008, dividing the process of Strategy development from the development of a monitoring, evaluation and accountability strategy posed challenges. The development of 'Achieving Universal Access' Strategy ('the Strategy') would have benefitted from an integrated process of indicator selection to ensure that the Strategy from the outset was committing to measurable deliverables and commitments.

 

3. In many ways, the process established by DFID to develop the M&E framework presented a groundbreaking approach in engaging civil society in the monitoring process of the Strategy and in making the framework more relevant for those involved in the implementation of the Strategy. Following DFID's request for civil society involvement in the development of its M&E framework, the UK Consortium on AIDS and Development set up an 'Indicators' Working Group' (IWG), of which the Alliance was a member. Whilst the IWG was asked to focus the development of indicators, it was able to provide support and expertise to inform other parts of the framework. DFID's commitment to the process and the IWG was clearly shown through the continued engagement of staff and the openness and honesty with which meetings were conducted.

4. Based on the Alliance's assessment of the process, the discussion between the IWG and DFID led to a more balanced approach to monitoring and evaluation of the Strategy. It allowed DFID's efforts to be informed by recognized good practice and the direct experiences of monitoring HIV responses. The discussion and joint inputs have resulted in more requests for qualitative information within the data collection tools, which will facilitate documentation of good practice for knowledge sharing and learning.

 

5. The short timeframes for review of draft documents and provision of feedback, and the application of Chatham House rules to the IWG proceedings, limited the ability of the IWG to consult and engage the stakeholders it was representing. From the outset there appeared to be lack of clarity of the purpose of the group, with no efforts to agree on Terms of Reference for the IWG or to clarify its role in the final decisions related to the selection of indicators. IWG members were not assured endorsement of the final product.

 

6. So despite DFID's commitment to an inclusive approach, the methodology and nature of the process limited the extent to which civil society engagement was meaningful due to several factors. Collectively, these elements of the process presented challenges to the ability of the IWG to be fully representative. We hope very much that as this work progresses that this process will be improved and that the M&E strategy will benefit from a more rigorous consultation process.

 

7. Recommendation:

· Future efforts to engage civil society should adopt an approach that allows for more thorough engagement of all partners in the development of the M&E framework. Recommendations for good practice from HM Government COP on consultations[1] should inform consultation efforts across HM government's departments.

 

III. Progress on health systems strengthening and on an integrated approach to HIV/AIDS funding

Progress on Health Systems Strengthening

8. Since the launch of 'Achieving Universal Access' and the announcement of the UK government's plans to spend £6 billion on strengthening health systems and services, there has been limited information available on the use of these funds. Since the launch of the Strategy, the UK government has made the following commitments:

· an estimated £450 million until 2011 to support national health plans for eight IHP+ countries at the UN High Level Event on the Millennium Development Goals in September 2008;

· £40 million to the Affordable Medicines Facility for malaria and an increase in malaria research spending to at least £5million per year by 2010;

· £50 million to fighting neglected tropical diseases[2].

Despite the Committee's request[3], it remains unclear how these commitments and the £6 billion committed under 'Achieving Universal Access' will contribute to strengthening health systems and services to support the achievement of universal access.

 

9. The International Health Partnership and Related Initiatives (IHP+) presents an opportunity to DFID to allocate resources to health systems strengthening, however implementation progress has been slow. While the IHP+ aims to improve the effectiveness of health aid delivery, the IHP+ has not been able to address the initial key concern of financing gaps for health in its focus countries. In Ethiopia, the first country to sign a compact, a funding gap of between US$1.56 billion to US$2.84 billion was identified[4]. However, in response, donors, including DFID, allocated just a fraction of what was required.

 

Threatening universal access to HIV prevention

10. DFID's focus on health systems strengthening potentially undermines DFID's own commitment to HIV prevention, as there is a limit to how much of a role health services can play in HIV prevention. Universal access to HIV prevention cannot be achieved solely by investing in health systems and services and is often an area that formal health systems ignore. Given the urgent need to increase investment in HIV prevention if the spread of the virus is to be halted and reversed by 2015, it is essential that DFID supports more immediate investments to maintain progress and inject support into urgent preventative measures that may need to be addressed outside the formal health system.

 

11. An area where the UK has been taking a lead is through its role in the EU Action Team on Prevention, under the European Programme for Action to confront HIV/AIDS, Tuberculosis and Malaria in External Action.

 

12. The Alliance notes the Committee's finding in point 14 of the 12^th report of session 2007/08. The Alliance fully agrees with the principle that health service access should always be seen as an opportunity to support prevention efforts and that in the case of prevention of mother to child transmission and TB prevention and management this is especially critical.

 

Supporting an integrated approach

13. The Alliance is concerned about the adopted position that 'parallel systems' are inherently inefficient or more likely to result in lack of co-ordination than HIV services integrated into broader health systems - usually interpreted as systems run only by the state. Much of health systems strengthening does not refer to a broad system which integrates community level systems into the continuum of care in an effective and sustainable way.

 

14. Community level systems play a critical role in ensuring access for and involvement of marginalised populations in HIV services. In many places, 'stand alone' ARV treatment programmes have been developed or implemented due a lack of capacity in the broader health system, and in response to the high levels of stigma and discrimination experienced by people with HIV in health services. Addressing stigma and discrimination in broader health systems is critical to ensuring successful integration or a broader health system role in HIV treatment and care. However there is little evidence of overt plans to address this in many health systems integration plans or discussion documents. This is something that needs to be addressed before integration is attempted, not after evidence of systematic discrimination becomes known.

 

15. It is simplistic to imagine that a parallel system is inherently less effective and efficient than a large, multi-departmental system, as 'parallel' systems with effective communication and co-ordination mechanisms could provide a more effective and integrated service than administratively 'integrated' systems with poor internal communication and co-ordination. In Ukraine, where ARV procurement, supply and distribution has recently been 'integrated' into the health system after many years of effective delivery through community organizations, evidence shows that it has resulted in significant problems in continuity of supply due to inefficient systems and a lack of commitment within the state agencies.

 

16. Evidence suggests that integration of the community level systems can result in reductions of hospital readmissions of chronically ill patients, better co-ordination of care, and increased access to services through the delivery of high quality, cost-effective home based care. In Uganda, health workers identified the referral system operated by the Alliance's Network Support Agents (people living with HIV providing support and services linked to the formal health system) helped increase the number of people living with HIV served and also made reporting more efficient and effective.

 

17. Recommendation:

· DFID should publish the breakdown of its spending on health systems strengthening along with mechanisms to collect evidence of impact on health and HIV indicators.

· Through its leadership role in the IHP+, DFID needs to ensure more rapid implementation at the country level, which includes efforts to fill financing gaps for health in the IHP+ focus countries.

· DFID should demonstrate how it is meeting its commitment to universal access to prevention, including by urgently exploring and supporting immediate investments into HIV prevention measures that may need to be addressed outside the formal health system.

· DFID should ensure that gains in the HIV response are not lost through its focus on HSS, by addressing stigma and discrimination before integration of HIV responses into public health systems is attempted.

· DFID's approach to integrated funding for AIDS should recognize the role of community systems and through its funding and policies ensure adequate support to this sector.

 

IV. Integration of HIV prevention, treatment and care with other disease programmes, particularly tuberculosis and malaria

18. The continued lack of concrete strategies and approaches for integration of HIV with other disease programmes from DFID gives rise to concerns that support for integration may not be nuanced enough to take into account the complexities of HIV. While the benefits of integrating HIV with other disease may provide gains from the funding and policy perspective, this may not always be the case at the level of service access and delivery. Furthermore, a nuanced and well-developed approach to integration is required to avoid any compromise on quality and access, and setbacks in the delivery of HIV-related services.

 

19. While the Strategy clearly recognises the need for linkages and integration between SRHR and HIV, it still remains unclear how DFID intends to support integration. Beyond the promise to intensify efforts to halve unmet need for family planning by 2010, neither the Strategy nor the M&E framework include a target related to universal access to comprehensive reproductive health, as articulated in the MDG target 5b, or to sexual health, and the realisation of sexual and reproductive rights as a critical component of HIV responses.

 

20. The Maternal Health and SRHR strategy, initially planned for mid-2009, has been postponed indefinitely and therefore this opportunity in the last year to concretise DFID's actions in this area was not realized. Upgrading the 2004 SRHR Position Paper to the level of a strategy to guide the UK's support for maternal health and SRHR, with its accompanying targets and M&E framework, will reinforce and supported the operationalisation of the emphasis on linkages with HIV outlined in the Strategy.

 

21. The Committee recommended in its 12^th report of session 2007/08 that DFID presses particularly the Global Fund to do more to support the integration of services. DFID staff from the AIDS and Reproductive Health Team expressed interest in the Alliance's experience of securing Global Fund resources for integrated services. However, this has not yet translated into an increase in resources for the Global Fund to support its scale up of integrated programmes.

 

22. The Alliance notes that neither DFID's strategy nor the Committee's review last year highlighted the urgent need for greater integration between Hepatitis C and HIV responses among people who use drugs. HIV and HCV co-infection affects large numbers of injecting drug users and the two diseases interact to produce more rapid disease progression and higher rates of mortality and morbidity. While the same proven interventions for HIV prevention among drug users also prevent transmission for HCV, diagnostic and treatment outcomes for both could be significantly enhanced with greater integration of mostly lacking responses to HCV and HIV. Rates of HCV testing are low, and despite being increasingly successful, access to treatment for HCV is very poor due to the high cost of patented drugs and the lacking capacity in health systems and community organisations to manage HCV treatment.

 

23. Recommendations:

· Specific approaches to ensure integration of HIV with other disease programmes need to be developed and published as part of the Strategy and its M&E Framework

· DFID's approach to integration needs to be more nuanced, taking into account the particularities of the HIV response, the strength of health systems and the social and legal context, to avoid any compromise on quality and access, and setbacks in the delivery of HIV-related services.

· DFID should ensure that integration and linkages between SRHR and HIV address SRHR comprehensively, and are not limited to family planning. These efforts should be guided by and clearly defined within the overdue Maternal Health and SRHR Strategy.

· Efforts to address HCV infection need to be incorporated into HIV responses for people who use drugs to ensure more impact of DFID support on health outcomes for these communities.

 

V. The effectiveness of DFID's Strategy in ensuring that marginalised and vulnerable groups receive prevention, treatment, care and support services

24. Effective programmes for marginalised groups are central part of the Strategy. The Alliance looks forward to continue supporting DFID's work in this area and strongly recommends that DFID develops clear plans for how the UK Government will act on the commitments it has made in its Strategy to marginalised populations.

 

25. The Alliance has had productive meetings with the FCO in relation to their role in the implementation of the Strategy. However we are unclear about how the FCO and DFID are taking this work forward as there has been limited communication with UK stakeholders. This may have resulted in missed opportunities for synergies and collaborative advocacy.

 

26. The Alliance also welcomes DFID's ongoing support for the International Harm Reduction Association and for DFID's excellent advocacy work in support of HIV prevention at the UNGASS High Level Meeting on Narcotic Drugs held in Vienna in June 2009. DFID has made a new commitment to supporting the work of the Global Forum on HIV and MSM. The Alliance applauds this commitment as a significant step in ensuring strengthened advocacy and commitment globally to meeting the HIV prevention needs of this critically important and underserved population.

 

27. In a number of countries, including Senegal, the work of DFID and the FCO in supporting local advocacy has also helped to protect the rights of this highly vulnerable population. Conversely, the withdrawal of DFID staff and offices from some countries, such as Nepal, presents risks to the continuity of important programmatic interventions targeting vulnerable populations, and threatens to undermine universal access commitments.

 

28. Recommendations:

· That the FCO and DFID develop and publish plans to address the needs of marginalised groups, which includes predictable and sustainable financing for community responses most effective at reaching marginalised groups.

 

VI. The effectiveness of social protection programmes within the Strategy

29. Based on the Alliance's programming experience supporting children affected by HIV and AIDS, children who are the most vulnerable to HIV infection and also to the impact of HIV on their lives are most likely not to benefit from development interventions. These include children with disabilities, street and working children and those most rarely mentioned, children of people who use drugs and of sex workers.

 

30. Social protection programmes in general, and those programmes that promote community targeting of vulnerable families, an important positive approach in social protection programmes, are in danger of excluding these families due to stigma and discrimination by community members and institutions. Criminalization of sex work, of drug use and of these communities contribute to the difficulties in identifying children and families in need and ultimately excludes them from services because of fear of police harassment, legal action and separation of children from their families.

 

31. The success of DFID's commitment to cash transfer and social protection programmes will depend on DFID's efforts to address the underlying structural causes of children's and their families' vulnerabilities, such as criminalisation, stigma and discrimination and broader human rights violations. In addition to ensuring the participation of affected and marginalised communities in the development of social protection programmes, social protection programmes must be provided in an environment that ensures the realisation of these communities' rights.

 

32. Recommendations:

· As social protection programmes, including cash transfers, are at risk of not reaching the most marginalised children affected by AIDS there is a need for direct support for efforts to address underlying structural causes of children's and their families' vulnerabilities to complement.

 

VII. Progress towards the commitment to universal access to anti-retroviral treatment and its impact on the effectiveness of care and treatment, particularly for women

33. Despite DFID's commitment to universal access in the Strategy, the leadership in this area shown by DFID in the past appears to be waning. DFID's contributions to the HIV response are increasingly tied to improvements in health services and systems, rather than targeted HIV-related outcomes. If this is the case, then DFID's approach risks undermining and reversing the hard-won progress made to date towards universal access to treatment. The Global Fund to Fight AIDS, TB and Malaria, for example, faces a severe funding shortfall of approximately $4 billion for the 2008-2010[5], despite providing ARVs to more than 2 million people living with HIV. We welcome DFID's long-term commitment to the Global Fund, however £1 billion over 7 years, does not represent the UK's fair share to support the Global Fund's efforts to, among other things, sustain and increase access to ARV treatment.

 

34. There has been tremendous progress made on increasing the number of HIV positive people who receive treatment. There is an urgent need to maintain a focus on these gains to ensure uninterrupted access to ARV treatment, and consistent drug supply chains to reduce the frequency of drug stock-outs, to not only save the lives of those already on treatment and those in need in future - but also to reduce the likelihood of drug resistant HIV. In order to make progress on this important issue, we welcome DFID's strong support for UNITAID's patent pool, which has enabled the cost of treatment for HIV, TB and malaria to be reduced at the country level.

 

35. Recommendations:

· DFID should ensure that its focus on health systems strengthening does not undermine progress to universal access to HIV treatment and provide its fair share to the Global Fund by increasing on its current pledge by £183.5 million for the period 2009-2010 to enable ongoing and future treatment programmes.

 

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[1] http://www.berr.gov.uk/files/file47158.pdf

[2] 'Health in Crisis: Why in a time of economic crisis Europe must do more to achieve the health MDGs'; Action for Global Health; 2009; (http://www.actionforglobalhealth.eu/media_publications/afgh_policy_reports/policy_report_health_in_crisis/policy_report_health_in_crisis)

[3] Point 20 of the 12^th report of session 2007/08

[4] Compact between the Government of the Federal Democratic Republic of Ethiopia and the Development Partners on Scaling Up For Reaching the Health MDGs through the Health Sector Development Programme in the framework of the International Health Partnership; Ethiopian Federal Ministry of Health; August 2008 (http://www.internationalhealthpartnership.net/CMS_files/documents/ethiopia_country_compact_EN.pdf)

[5] Updated Demand Estimate 2008-2010; Global Fund to Fight AIDS, TB & Malaria; Caceres, Spain, 30 March-April 1 2009; (http://www.theglobalfund.org/documents/publications/replenishment/caceres/Resource_Needs_2008-2010_en.pdf)