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Written evidence submitted by VSO
Introduction
VSO is an international development agency that works through
volunteers overseas, and also on return to their country of recruitment. It
works in more than 40 developing countries in Africa, Asia and
VSO
has HIV and AIDS programmes in 18 countries across Africa,
In
1. The process established by DFID for monitoring the performance and evaluating the impact of the strategy
1.1 The omission of an M&E plan from the strategy when it was launched led to considerable skepticism about how and whether DFID would be able to deliver it's ambitious and wide-ranging strategy. 1.2 We would like to praise DFID for actively involving civil society (in the form of the UK Consortium on AIDS and International Development) from the start of the development of their M&E processes for their HIV and AIDS strategy. VSO fed substantially into the care and support and gender indicators that the Consortium M&E working group suggested to DFID. 1.3 The resulting M&E plan "Monitoring performance and evaluating impact", launched in December 2008, established a process of producing "a baseline position from which to review progress" to be "published in the first half of 2009". Unfortunately this has not yet appeared. The first planned review of progress is December 2010. Therefore a proper analysis of DFID's implementation of its strategy is impossible at this time. This submission is based therefore on our organizational awareness of DFID's HIV work over the last year. 1.4 It is unclear to external organizations the extent to which DFID country offices use the strategy to guide their decision making or the development of their own country strategies and interventions. A document similar to the "Gender Equality Action Plan: Africa Division 2009-2012" for the HIV strategy would be most welcome. 1.5 The M&E plan also makes no mention of the role of PPA implementing partners in delivering DFID's HIV strategy. We recommend that the work of PPA implementing partners is also taken into account in the M&E for the HIV strategy. 1.6 We also recommend that DFID country offices work with partners in-country to agree on a common co-ordinated M&E system to significantly reduce the burden of multiple reporting processes, and harmonise in line with the principle of the Three Ones[1]. In some sectors DFID country offices are already attempting to do this with (e.g. DFID Sierra Leone). VSO has recently developed one M&E process model across our 18 HIV country programmes to report to DFID and this could be shared and co-ordinated with other partners. It assesses three work streams - 1) the scale and significance of our programmes 2) the use of inclusion as a proxy to measure the system strength of service delivery and 3) focus group discussions and surveys to better understand beneficiaries' definitions of quality services and whether they are receiving them. 1.7 We applaud the fact that DFID has linked its strategy to global targets and indicators, although clearly challenges of attribution remain. This year DFID has actively engaged and led on the process of improving and fostering coherence of internationally agreed indicators. DFID currently co-chairs the interagency Indicators Working Group of the UNAIDS Monitoring and Evaluation Reference Group. It is working closely with the Care and Support Working Group of the UK Consortium on AIDS and International Development, which VSO co-chairs, to review global care and support indicators to input into the upcoming review of UNGASS indicators. Together, DFID and the UK Consortium on AIDS and International Development have modeled a new independent review process for global indicators that the Indicators Working Group of UNAIDS Monitoring and Evaluation Reference Group has now endorsed. 1.8 Sufficient funding for and meaningful review of these global targets needs continued commitment at the highest level. This is particularly true of the target of Universal Access to Treatment, Prevention, Care and Support by 2010 proposed and led by the UK Government at the G8 in 2005. We urge the Minister for International Development and the Prime Minister to lead on this again next year to ensure a sober review of progress on this target is undertaken at the 2010 G8 and UN MDG review and that clear new achievable commitments are made.
2. Progress on health systems strengthening and on an integrated approach to HIV/AIDS funding
Progress on health system strengthening 2.1 There is no doubt among health and HIV professionals globally that health system strengthening is critically under-funded in most developing countries and that health and HIV funding and programming needs to be more closely integrated. 2.2 VSO applauds DFID and the UK Government's
strong leadership globally over the last few years on health system
strengthening. This has been demonstrated, for example, through their
championing of the International Health Partnership (IHP) and most recently by
announcing at the UN that the 2.3 We welcome DFID's adherence to the
An integrated approach to HIV/AIDS funding 2.4 In the context of the need for a global focus on health system strengthening and better integration between HIV and health responses, DFID's commitment to £6 billion for health in the HIV strategy makes sense. However, it remains controversial that there was no commitment to what percentage of that will be spent on HIV and that there were very few HIV-specific funding targets. This sends a worrying message that broader health system strengthening should be promoted at the expense of funding for HIV. We ask that DFID openly counters this message by highlighting the importance of addressing HIV[2] and, crucially, committing the needed funds to those bodies that have a proven track record of both addressing HIV and building the health system at the same time. 2.5 The need for getting the funding balance
right between horizontal and vertical funding is an ongoing challenge. In
mid December 2007 Douglas Alexander announced the 2.6 This setting of the funding balance should
also be based on an honest evaluation of how effectively the money is being
spent. This was demonstrated clearly by
a comparison of the evaluation reports of the World Bank Independent Evaluation
Group and that of the Global Fund for AIDS, TB and Malaria. The World Bank's report states that only 18% of their HIV
projects in 2.7 We are pleased to see that DFID has responded by collaborating with the World Bank to start to address these issues by conducting an ambitious evaluation of the community response to HIV and AIDS with a view to increase resource allocation. They have enlisted the support of the UK Consortium on AIDS and International Development to facilitate full civil society engagement and VSO is actively involved. 2.8 Finally, there is a sense that DFID may be de-prioritising HIV, evidenced by the reduction of clear funding commitments to HIV in the strategy, their strong criticism of vertical funding programmes and a serious reduction of the number of staff in the AIDS and Reproductive Health Team. This has a big impact on the capacity to drive the strategy forward within DFID or to continue to play a leading role in global HIV policy discussions.
4 The effectiveness of DFID's Strategy in ensuring that marginalised and vulnerable groups receive prevention, treatment, care and support services:
4.1 It is essential that DFID continues to find and increase direct and numerous ways to deliver significant funding, training and capacity building support to community-based responses delivered by civil society. This is vital because there remain significant concerns over the extent to which government strengthening of public health systems will actually increase access to services for the most disadvantaged or excluded in society. Public health services are often not accessible due to factors such as distance, cost, discrimination or cultural dynamics. For example, injecting drug users often cannot access government health services because drug use is illegal and people living with HIV sometimes do not access public health services due to discrimination from staff. In the short to medium term, and until public health systems are dramatically improved, civil society organizations often target and provide services more quickly and effectively to the hardest to reach communities. 4.2 DFID's commitment to gender equality in the strategy was very welcome and responded to many of the issues and recommendations VSO and Action Aid highlighted in our joint 2007 policy report on women's access to HIV services Walking The Talk. In research from 13 countries we found that systemic gender inequality means that poor rural women are among those hardest hit by the HIV pandemic and have minimal access to publicly funded HIV services[4]. As noted earlier, there is limited evidence of DFID's implementation of the strategy but it has made some case studies available on the DFID website and in the Gender Equality Action Plan Africa Division document. The projects cited are primarily in the two areas where women's access is most limited and under-resourced - prevention and care and support. Of those listed that focused on prevention, we highlight DFID Nigeria's work training women as peer educators to improve understanding of sexual and reproductive health and make condom use more acceptable[5]. This is key work in a continent where 75% of those infected between the age of 15 and 24 are women. Of those listed on care and support, DFID Zimbabwe and DFID Zambia's work on care for the carers stands out as essential work because most carers for people living with HIV are women, often older women, who seldom receive any recognition, support, training, or equipment to help them do their amazing work[6]. 4.3 We note also that DFID has funded a national survey on
prevalence of HIV and sexually transmitted infections among male and
transgender sex workers in 4.4 A particularly vulnerable group whose needs have largely been sidelined in HIV policy at national and global level are persons with disabilities (PWDs). We were encouraged to see the reference to PWDs in the DFID strategy and DFID's funding of ZAFOD (Zambian Federation of the Disabled). Direct and focused support is essential to enable disabled persons' organisations to participate in the development and evaluation of guidelines for HIV service delivery, national strategic and operational plans, and national AIDS councils. The need to mainstream the HIV needs of PWDs into national policies for effective handling is urgent. Governments and donors should seek to support innovative projects initiated by PWDs that are deemed to address their specific health needs. At regional level, DFID should actively consider supporting advocacy networks such as The African Campaign on HIV/AIDS and Disability. The Campaign aims to reduce the vulnerability of disabled people to the impact of HIV by promoting HIV policies, programmes, information and services that genuinely include them.
5 The effectiveness of social protection programmes within the Strategy:
5.1 VSO believes that social protection is an essential contribution to providing a safety net for the poorest, including those who are infected and affected by HIV. 5.2 One of the clear and welcomed funding commitments in the HIV strategy was for £200 million for supporting social protection programmes over next three years in at least 8 African countries. Unfortunately, DFID have still not defined which countries these are and so monitoring progress remains impossible. We eagerly await more news on how this funding has been distributed and to which countries.
6 Progress towards the commitment to universal access to anti-retroviral (ARV) treatment and its impact on the effectiveness of care and treatment, particularly for women:
6.1 Globally good progress has been made to get ARVs to those who need them, with more than 4 million now on ARV treatment[8]. However, there is still much work to be done to make ARVs cheaper and accessible to the remaining two thirds who still do not have access to treatment. In this regard DFID's continued and increased support to The Global Fund is critical with the Fund now supporting 2.3 milion people on ARVs (as of June 09). We also particularly welcome DFID's support of the UNITAID patent pool and call for pharmaceuticals to get involved. 6.2 The challenge of ARV access is even greater for children living with HIV who, in Sub-Saharan Africa, "are about one third as likely to receive antiretroviral therapy as adults"[9]. A renewed focus from DFID on the rollout of paediatric ARVs is an imperative. 6.3 UNAIDS/WHO 2007 statistics gathered in 25 low and middle income countries in 2007 showed that although women accounted for 51% of people living with HIV, 57% of those receiving treatment were women. This shows that women are accessing treatment more effectively than men. However concerns remain around women's adherence to treatment due to stigma and fear of revealing their status and there is still no consistent global collection of data on adherence to treatment. 6.4 Shocking statistics also remain regarding HIV positive pregnant women's access to anti-retroviral treatment to avoid mother to child HIV transmission. As of 2007, only 33% of pregnant women were receiving PMTCT[10]. DFID's HIV strategy commited to work with others to intensify international efforts to increase coverage of PMTCT to 80% by 2010. To this end, DFID organised a workshop on PMTCT with the UK Consortium in May 09 and produced concrete recommendations on scale up. 6.5 As mentioned in section 1, DFID and the UK Government's commitment at the 2005 G8 and at the UN General Assembly in 2006 was Universal Access to comprehensive prevention, treatment, care and support by 2010. While certainly essential, access to anti-retroviral treatment is not enough on its own. As Alan Whiteside comments, delivering treatment without prevention is like mopping the floor with the tap running[11]. Prevention and care and support have received the least focus of funds and support and now require serious attention by the international donor community. 6.6 It is widely accepted globally that work on prevention is in crisis. The WHO 2009 progress report noted that an estimated 2.7 million people were newly infected with HIV in 2007[12] - which means that for every two people placed on treatment, 5 more become infected. DFID has led on prevention globally and should continue to do so. For example, DFID have taken on leadership of the EC Task Team on Prevention. 6.7 HIV care and support is the often forgotten pillar of Universal Access, largely because donors and national governments have left it to poor communities to provide often without support. Strengthening health systems must include direct resources and support for community-based responses, home-based care organisations and carers - particularly women who provide the majority of care and support in the family and community. As mentioned above, DFID is supporting some excellent in-country home-based care, and therefore should take advantage of this to play a much stronger role raising the profile of care and support in global HIV policy discussions. The proposed DFID funded conference with the UK Consortium on AIDS and International Development on Care and Support in 2010 would be an important opportunity to move forward in this area.
[1] The "Three Ones" principles, agreed in 2004, aim to achieve the most effective and efficient use of resources, and to ensure rapid action and results-based management: One agreed HIV/AIDS Action Framework that provides the basis for coordinating the work of all partners; One National AIDS Coordinating Authority, with a broad-based multisectoral mandate; One agreed country-level Monitoring and Evaluation System.
[2]
HIV prevalence globally may have leveled off but there are still 33 million
people living with HIV (UNAIDS 2008 figures) and the HIV prevalence rates in
some of the world's poorest countries are nothing short of national emergencies
(e.g. 26.1% in [3] World Bank Independent Evaluation Group, 2009 Improving Effectivess and Outcomes for the Poor in Health, Nutrition and Population (p.xvi). The Global Fund for AIDS, TB and Malaria, 2009, ScalingUp For Impact: Results Report, P.55 [4] VSO and Action Aid, Walking The Talk: Putting women's rights at the heart of the HIV and AIDS response, 2007 [5] The DFID Nigeria case study and a DFID Uganda case study of DFID's work on raising awareness of domestic violence with the police force can be found in Gender Equality Action Plan Africa Division 2009-2012, p.6 & 8 [6]
DFID case studies on care for the carers are on the DFID web site - Caring for
the carers in [7]
DFID website case study 'AIDS Survey
highlights at-risk groups in [8] WHO, UNAIDS & UNICEF, Towards universal access: Scaling up priority HIV/AIDS interventions in the health sector, September 2009 progress report http://www.who.int/hiv/en/ [9] UNAIDS Global Facts and Figures 2008, p.2 [10] IBID [11]
Presentation to [12] WHO, UNAIDS & UNICEF, Towards universal access: Scaling up priority HIV/AIDS interventions in the health sector, September 2009 progress report http://www.who.int/hiv/en/ |