UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 1053-iHouse of COMMONSMINUTES OF EVIDENCETAKEN BEFOREINTERNATIONAL DEVELOPMENT COMMITTEE
PROGRESS IN IMPLEMENTING DFID'S HIV/AIDS STRATEGY
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Transcribed by the Official Shorthand Writers to the Houses of Parliament: W B Gurney & Sons LLP, Hope House, Telephone Number: 020 7233 1935 |
Oral Evidence
Taken before the International Development Committee
on
Members present
Malcolm Bruce, in the Chair
John Battle
Hugh Bayley
Mr Mark Lancaster
Andrew Stunell
________________
Witnesses: Ms Fionnuala Murphy, Interact Worldwide, Mr Alvaro Bermejo, International HIV/AIDS Alliance, Ms Sally Joss and Mr Mike Podmore, UK Consortium on AIDS and International Development, gave evidence.
Q1 Chairman: Good morning and thank you very much for coming to help with this annual inquiry on HIV/AIDS progress. I wonder for the record if you could introduce yourselves.
Mr Podmore: My name is Mike Podmore and I am HIV and AIDS Policy and Advocacy Adviser at the VSO (Voluntary Service Overseas). I have been asked by the Consortium, according to Sally, to join her in representing the UK Consortium on AIDS and International Development because VSO has been very active in the Consortium for many years. We currently co-chair the Consortium and co-chair the Care and Support Working Group and we are active members of the Gender and Prevention Working Groups.
Ms Joss: Hello. I am Sally Joss, Co-ordinator of the UK Consortium on AIDS and International Development. The UK Consortium has over 18 members and we have made a collective submission to this Committee on this inquiry.
Mr Bermejo: My name is Alvaro
Bermejo. I am the Executive Director of
the International HIV/AIDS
Ms Murphy: Good morning. My name is Fionnuala Murphy and I am from Interact Worldwide and I am an Advocacy Manager working on universal applicants.
Q2 Chairman: Thank you. You know how we operate on this Committee and, as I said, we do an annual review of progress which we have done for the last three or four years. Can I also say that there are four of you. I do not want to inhibit any of you. At the same time you do not need to comment on every question because we might overstay our time frame. Starting with you, Alvaro, you probably share some of the views of the Committee that, yes, you welcome the department's monitoring and evaluation framework but we are still left wondering how you quantify and evaluate what is going on and you obviously made a criticism of that and also the cross-Whitehall working. How do you think we could do it better?
Mr Bermejo: We certainly welcomed the initiative at the beginning in the sense that it was very innovative, it was one of the first times that DFID was really involving civil society in setting up the indicators they were going to use. That was very positive, but both from civil society and from the DFID side I think we were unable to see that translated into the final product and many things slipped in that path. The one thing we did not really achieve was to get a clear definition of what success would look like, so there are two different issues. One is the ability to measure progress, in which I think there are some advances and we certainly welcome the baseline as it has been produced but we will comment on it in a minute, but I think we also need to remember it is not just an issue of indicators; it is also a lack of definition of what success will look like. Once we invest all this money what is the outcome we expect to see at the very end? Measuring that and having that defined properly I think is something that still remains to be done. I would say it is better than before. For the previous one we did not have a baseline. Now we have a baseline. It can still be improved along the way. We do not just have to say, "Okay, that is what there is". It can be improved, for example, by ensuring that the civil society engagement that there was at the beginning in designing the process continues. What we have had for this baseline right now is DFID country offices sending country reports back to DFID that nobody has seen. Then DFID collates them and produces this baseline which you cannot really track back to any particular country, so it really does not enable a discussion to happen at country level where civil society and other players, government, et cetera, could get engaged in contributing to that feedback from the country, and it also limits our ability here to provide anything for oversight and contributions. I think there are opportunities there to improve but I would say it still is a step forward from where we were when it was the previous strategy, that by the time we got to the mid-term evaluation review we really had no baseline to compare with.
Q3 Chairman: Thank you for that. That somewhat bears out what we were saying before you came in the room, and I wondered if others would wish to comment on that. What it seems to us, when you look at their report, is that when you ask for it you get some quite useful information which is quantified and yet it is not aggregated and it is not generally available. It does rather give the impression that if they were simply to publish their country programmes on the website we would be three-quarters of the way where we want to be and I just wonder whether anybody else wants to comment on that or add to what Alvaro said about it.
Ms Joss: I think it is very difficult also to know how much country offices use the strategy to plan what they are going to do as far as programmes, et cetera, are concerned. The Consortium very much would want to commend DFID for the introduction of the baseline. This is a massive move forward from the previous AIDS strategy where there was no baseline and not really a monitoring and evaluation framework to even start to measure what is happening. I think also one of the difficulties with a lot of the present AIDS strategy is that it is going to be very difficult to attribute what DFID has done in the harmonised international efforts to tackle HIV and AIDS and I think it will be very difficult to work out exactly what DFID has contributed to the general battle against AIDS.
Mr Podmore: I would like to concur with all that has been said. We also applaud the fact that DFID has linked its strategy to these global targets and indicators. As Sally said, there are challenges of attribution. DFID has actively engaged in and led on the process of improving and fostering coherence internationally of agreed indicators, and so I would like to applaud DFID for leading in some of those areas, particularly co-chairing the Indicators Technical Working Group of the UNAIDS Monitoring and Evaluation Reference Group. They have been working with the Care and Support Working Group of the Consortium to model a process of independently reviewing HIV and AIDS indicators for that working group, so, with all the challenges that DFID has with its own monitoring and evaluation, it has made some steps forward but is leading well at the international level in terms of global indicators.
Q4 Andrew Stunell: I think it leads on from that that DFID has allocated £6 billion to strengthen health services and there is clearly a tension, maybe even a conflict, about how that feeds back into AIDS services. Even some of your evidence comments on that. Do you believe that DFID has got the mechanisms in place to support the AIDS programmes you would want to see?
Mr Bermejo: This was one of the questions
last year, I remember, as well. As I
said then, I think it still has proven to be the case that it is a good
strategy to strengthen health systems.
In terms of the impact it is going to have on HIV/AIDS, it is going
hopefully to increase the coverage of treatment programmes and it is going to
deal with one element of prevention, which is the bigger prevention that can be
done within the health service, the prevention of mother-to-child transmission
and blood safety, but it is not going to curb the epidemic. To do that we need to work beyond the health
system to really prevent new sexually transmitted infections and new infections
transmitted through the sharing of injecting equipment. We clearly need a strategy that strengthens
health systems but goes beyond that. To
the extent that DFID has that it certainly has declared that that is the
intention. The money is not
following. The money is going very much
to health systems and I think you can see other efforts outside of health
systems strengthening suffering from that focus, and it will be important to
remind DFID, I think, that there is much more to a strategy that can curb the
epidemic than just health systems. We
have known for ages that healthcare services alone cannot do that. We need to get to the other prevention
activities. In terms of how health
systems will affect treatment and allow us to sustain treatment programmes,
there is a second issue which I would highlight, which is that we are still
seeing evidence of enormous stigma and discrimination within the healthcare
workforce and the healthcare system preventing access for people living with
HIV. There is a very interesting
indicator that I would use to illustrate that.
For example, if one looks at Latin America, probably
Q5 Andrew Stunell: Can I just ask you to follow through on that? Year on year, and you said we asked the same question last year, is what you are reporting to us now anecdotal or would you say that there is clear evidence that there is this discontinuity between the two programmes or the two steams of work?
Mr Bermejo: I would say there is clear evidence. This is happening. It is not just a phenomenon that is DFID related. It is happening with other players as well but I think we see more and more recapturing of the response by the medical establishment, this feeling that the health service can deal with the HIV epidemic now. We see that, in spite of the rhetoric, as money gets tighter what countries tend to do, because it is the reasonable political response, is to make sure that people at least that are on treatment continue getting treatment and if the resources are narrowing that means that prevention suffers even more. I think we are going to see in the next two or three years the tendency started two years ago of a more reductionist approach in which the HIV/AIDS response is seen just in terms of healthcare systems and it will not be enough, it will not curb the epidemic.
Q6 Chairman: There is also slight discontinuity in any case in that DFID says that, and that was really the thrust of our inquiry last time, how you can measure that, but quite often in the country programmes they tell you what they are doing about prevention though that is not part of their declared strategy.
Mr Podmore: Can I just build on what
Alvaro said because he talked, quite rightly, about prevention but, in
particular with the focus on treatment there, care and support is basically the
often-forgotten pillar of universal access and it is also something that
suffers a great deal as a result of a focus on health system strengthening that
is about just public health systems, hospitals and clinics. Often in countries such as sub-Saharan
Ms Murphy: I would also like to pick up on this point. I think we all know here, and it has been discussed, that outside of the health system, outside of even a focus on HIV, if we want to tackle HIV there is need for a focus on poverty eradication, on education, on women's rights and lots of other areas. My colleagues have talked already about the important role that non-state actors play in those responses. What I have understood from DFID is that there is money from other budget lines which is going towards initiatives which link, for example, violence against women with HIV, which link education and HIV, and that is good news, but what is concerning is that we have now seen this framework that will measure how the £6 billion is being spent in relation to HIV; will that also encompass these other pots of money from other budget lines? Also, in terms of money that is going to civil society organisations, for example, through PPAs, some of that money is used to deliver HIV services and HIV programmes, so will there also be a counting on that as part of the reports on this strategy? The other point that I would like to make, and it links into the question that you asked in the written submission process around integrated funding, is that the health system strengthening and integrated funding work together and I know that what we found interacted, in a study that we did in Ethiopia a while ago when we looked at the national health plan, was that, while there was an acknowledgement that reproductive health, which is an area that links very closely with HIV, was an important area and needed prioritisation in Ethiopia, when it came to the targets and indicators there were not appropriate targets other than maternal health. There were no targets on other integrated health issues. What we know about health system strengthening is that while, of course, a strong health system is critical to delivering an effective HIV response, it is not a given that just because you have a strong health system you will therefore deliver on some of these neglected areas. That links with Alvaro's point about the fact that in Chile, because of stigmatisation towards men who have sex with men, services are not reaching the people, so I think we need to go further in this promotion of health strengthening and really think how can we make sure that the health planning process includes targets and indicators but also goes on to deliver in terms of access to HIV services.
Q7 Mr Lancaster: That takes us on really nicely to the next question, which is about the integration with other programmes. There is an acceptance that effective AIDS strategy should be integrated with other disease programmes, TB and malaria. I am asking you to comment on how effective you think DFID's approach to this is and whether or not those who need it most are getting the support.
Ms Joss: I would like to reiterate what came in in a separate submission and was also included in the Consortium submission from a member of the Consortium, Results UK. They were saying how they feel that both DFID and the International Development Committee should be acknowledged for recognising the importance of integrating the response of HIV services with TB and malaria and other disease programmes. In March 2009, earlier this year, Results UK did a survey of the DFID offices to see whether there was a level of collaboration and integration in these programmes, and half the DFID offices surveyed said that they first of all expected the co-infection rates of TB and HIV to rise considerably over the next five years, and half the offices also agreed that there was insufficient collaboration on TB and HIV programmes in the countries where they were working. However, stating that there was insufficient collaboration does actually indicate that there is a recognition that there is a need for integration and that that integration of programmes has already started, so I think that that is a real advance. It is insufficient at this present time and there is room for improvement, obviously, but there is that recognition and there is that acknowledgement that this needs to happen between programmes. Unfortunately, the M&E framework which has been set up for the new AIDS strategy does not require DFID offices to measure progress on TB and HIV integrated programmes and there is no indication of how much of the £6 billion that is to be spent on health systems will actually go to those programmes as well. Results UK were very keen that DFID should review their practice paper, The Challenges of TB and Malaria Control, and that this TB strategy should be run in parallel with achieving universal access so that the strategies are intertwined and that there should be clear monitoring and evaluation targets for HIV and TB integration. They also feel that DFID's future support for HIV in research and development should be looking at faster and more effective diagnostic tools for detecting TB because often current tests miss TB in people living with HIV, which means that there is a very high death rate. They also feel that there should be research done into new drug regimes. I think it is very important to realise that it is not just TB and malaria but that there are also co-infections like hepatitis that need to have an integrated programme of HIV services.
Q8 Mr Lancaster: So, having pointed out the shortcomings, how in practice should DFID improve the effectiveness of tracking?
Ms Joss: I think the answer is that there needs to be something added into the monitoring and evaluation framework which does track the integration of programmes of co-infections and other diseases like TB and malaria.
Q9 Chairman: The areas that we have already touched on are the marginalised groups, and indeed two years ago, I think it was, we focused particularly on that in our report. Again, anecdotally in different countries we know that DFID does take these issues on, but do you think that they could do more in a more co-ordinated way, and do you think there is a strategy or is it just that in some countries they decide that is the way to go and in others they do not? What could be done to make dealing with those problems, so the drivers of the epidemic in most places, more attractive?
Mr Bermejo: There are two things. One, this is a particular question where we need to look across Whitehall and not just at DFID because I really think that on these issues of raising the case and supporting the case for marginalised and vulnerable groups in many of the countries the FCO should have and does have a role as well, and a little bit of that is included in the report, but we need to realise that if we are looking at controlling the global epidemic there are a number of countries that are middle-income countries that are critical for that - the Russias, the Ukraines, the Chinas, Brazils, South Africa. Those are critical for the response, with the exception of South Africa, but even there it is particularly the most at-risk populations, and certainly in all the other countries it is men who have sex with men and drug users, that are the main drivers of the epidemic who are always going to be unpopular from a political point of view and where we need the FCO, where DFID is no longer there in any of these countries, to play a role. We really need to look at the role that they can play in creating a policy environment where these groups can access services and are empowered to take prevention measures and, funnily enough, and that is in a way the irony of it, from a scientific technical point of view, in terms of knowing what to do to control those epidemics that are concentrated in particularly vulnerable groups, we know what needs to be done. What we still have not succeeded in doing is in creating the policy space for those things to happen, and in that effort to create policy space DFID can be important but FCO can be even more critical.
Q10 Chairman: On that point have any of you done any evaluation of what the FCO is doing? As far as we are aware the FCO does not even have a budget for this, it does not appear to have any expertise, so do you have any indication of whether the FCO, apart from having the responsibility, is doing anything?
Mr Bermejo: We have done a little bit of
work with FCO, but in cases where there was blatant violation of human rights
hitting the media we have liaised with FCO and FCO has supported measures to
try and address the issue of MSM jailed in
Q11 Chairman: We are going to ask you about that but can I ask the question from the other end? I take exactly the point you are making but do you have any practical evidence - you mentioned Senegal where the FCO are doing something, or at least did do something, or perhaps the other way round - where they should be doing something and are not?
Mr Bermejo: Senegal was one case where they were detained, where we were in contact with the FCO, the FCO was in contact with their French partners, where was a strategy to release these people from prison and re-integrate them back in the community, where the FCO was active. We have seen some other statements in eastern European countries, in particular around Gay Pride and some other activities there, but I would say that we have also seen some work done with UNODC and at the international level with some of the agencies from the FCO to try and create a policy environment, but at country level there are only a few cases, the ones I have mentioned - eastern Europe and Senegal, that I am aware of. There probably are others.
Q12 John Battle: Just to follow through the case of reaching marginalised peoples, we have just done a report, and I am massively exercised by urbanisation, and Mike is dead right in one sense - can we get beyond the healthcare systems, and I think he used the phrase "from hospital to home". I like the idea of that, getting down to reach the parts that never get reached, but the trouble is that ten per cent of the world have not got a home in formal settlements, and for those in shanty towns, you have not got an address so you are not registered. I just wonder, internationally as well as DFID, and I am not taking the focus off DFID, whether there are any strategies to gauge the need at that level and bring them in to rebuild it from the street level to the hospital rather than the other way round?
Mr Podmore: Yes, I think there very much are opportunities there. Firstly, it is obviously about having a very clear strategy about how you are building your community response, which obviously DFID is leading in some part by being such a significant donor to the Global Fund and the Global Fund is providing significant funds to community-based responses, so that is really important, but there needs to be more. One of the great problems is that it is just not known what is happening largely at community level, partly because donors, international institutions largely, are not funding research into that area. We just do not know. For example, in terms of M&E, of care givers, we have no international nor many national stats about how many volunteer care givers there are at national level and people just have no idea about what the cost of care is to people in communities, so until we start funding that sort of work we are not going to be able to know how we can best do that. A lot of our NGOs are really trying to build that work and be able to bring care givers, for example, to international platforms to speak for themselves and raise it as an issue. I am harping on about care and support but it is equally about community based prevention. I think people just are not aware of what is happening.
Q13 Chairman: Does the Foreign Office actually have a proactive strategy? I think the impression I am getting is you are saying no.
Ms Murphy: I wanted to raise the issue of women and girls. Women and girls are not a minority but they are vulnerable and they are marginalised in many parts of the world. In African countries people have a picture of those under the age of 25 and three-quarters of them are young women so it gives an indication of women's vulnerability. The DFID White Paper has recently pledged to triple funding for services to tackle gender-based violence up to £120 million per year, and I think that is a really exciting development, but there is obviously much more that needs to be done. The DFID strategy talked a lot about the vulnerability of women and girls and the evaluation framework pledged that detailed targets and indicators on progress made for women and girls would be included in national plans. We have not seen those national baseline reports. Maybe there is more about that in there but it is important that those are developed so that we can really see exactly what is being done for women and girls. The reason that this is important is that it really links with women's access to services and from the baseline we know that access to PMTCT is still much too low. I think it is about a third of women who need PMTCT services. One of the reasons for this is the simple fact of what happens to women in many communities when they are diagnosed as HIV positive. A woman can be thrown out of her home and have her children and her property taken away from her. She will be accused of bringing the virus into her family. She will face violence from her husband and her in-laws. In terms of a woman who is pregnant and already physically and emotionally vulnerable because of that, plus a HIV positive diagnosis, to put those two things together and expect women to cope with no backup is really impossible and it is no surprise that many women will refuse HIV tests in an antenatal care setting or where they think that those tests will be pushed on them, and ICW have documented cases of women being tested without their consent. It is not a surprise that women will just avoid antenatal care altogether and that is very worrying as well. The DFID strategy talks about PMTCT in terms of the delivery of anti-retrovirals to prevent onward transmission of the virus to babies and that is a really important part of PMTCT, but we also need to think about all the other parts, such as meeting the mother's health needs beyond pregnancy and birth but also meeting all of the mother's needs and making sure that women get the counselling they need and also have the backup services so that if they do face violence and eviction they have somewhere to go.
Q14 John
Battle: Thank you for that approach as well because my
instincts tell me that you have to build systems from the base up and not the
top down, and sometimes measuring from the top means they never reach the parts
they are supposed to reach. One of the
groups that we were drawn to the attention of by World Vision was people with
disabilities who are really written off.
Women, children and adults with disabilities are out of the frame when
it comes to this agenda. If I am abusive
about the Foreign Office, they used the term "in the field" when I was a
minister there. That meant going to an
embassy somewhere. At least in DFID
going "into the field" means leaving the embassy and going somewhere, so we are
making some progress. If I remember
rightly I think it was
Ms Joss: You are right in mentioning
World Vision because World Vision, as one of the members of the Consortium, has
written about social protection. I do
not know if I can answer your question fully but I think what World Vision is
saying is that they notice very clearly that social protection and cash
transfers do a lot to help households.
It means quite often that nutrition is immediately improved, that
children's health is immediately improved and girls go to school, for example,
but there are many groups, which is exactly what you are indicating, which are
left out of those because they are not in households, street children, for
example, often children with disabilities.
One of the biggest issues around all of the social protection is that
cash transfers are not enough and that there need to be on the ground welfare
support services that are supporting vulnerable households, vulnerable
groups. We are looking at family support,
child protection, getting children out of orphanages and into the community
where they can be looked after by families.
One of the main points that World Vision was making in its submission
was that there have to be welfare support services along with the cash transfer
schemes, and they are very much asking what has happened to the enormous
momentum that there was around the announcements of cash transfers and then the
extra announcements and the further £200 million that was announced at the G20
London Summit. Somehow, between
Mr Podmore: Can I add very briefly to that? We emphasise the fact that we need to have and DFID needs to be promoting a really broad conception of social protection. In UNAIDS currently one of the nine priority areas that they identified for their outcome framework over the next few years was social protection and they threw in a whole range of different things, but one of the things that was not particularly mentioned was the community response, and so as well as welfare systems, pensions, food and nutrition support and, of course, cash transfer and a whole range of different services, and including in that free or subsidised health and education, we need to really be talking about this broad conception so we are not limiting it to channelling funds just through government. I thought it was great that you brought up people who were living with disabilities. It is a particular area that I think is forgotten in the international policy discussions. I am encouraged to see that DFID mentioned people with disabilities in the strategy and they mentioned one funding of ZAFOD, the Zambian Federation of the Disabled, but I think there really needs to be increased and directly focused support for disabled persons' organisations in-country so that they can influence policy dialogue and also for DFID to support innovative projects that disabled people's organisations are trying to promote so that they can participate in the planning and delivery of HIV services, because often, even in the community, in people's homes it is people with disabilities who are left behind when everyone else goes to the HIV prevention talk in the community. They are just left behind so we would also recommend that DFID actively supports advocacy networks such as the African campaign on HIV and AIDS and disability and other national networks like that.
Q15 John Battle: Sometimes, and I am smiling now, the word "community" can be a kind of portmanteau word and everybody is hidden underneath that umbrella. In our report last year we emphasised the need to get to civil society, another great umbrella. In my neighbourhood when I was first elected in 1987 we had seven inner city local community groups. We have now got 700, so what I suggest is a great myriad reach of civil society there, but has DFID got a strategy to get to those civil society organisations, because otherwise what you find is that those that catch a bit of media attention, the bigger ones, hoover up the money and the ones we need to get to, who are actually on the ground floor level or in the hidden-away corners, are not the ones that are being reached and supported? Have DFID got a strategy to get into the complexity and depth of civil society where the most marginalised are?
Mr Bermejo: I would say no, and let me explain a little bit why. I think our logical reaction is to a situation where they have less and less staff both on the ground and here and thus are looking to reduce their transactional costs, the amount of time that it takes to mobilise resources and support. These groups, which are very diversified, which are small, take up a lot of time of people and so their strategy in a way logically is to go more towards budget support, multilateral where you can, with one contract, get hundreds of millions of dollars out rather than having to deal with small community groups. I think that is the driver that is behind what is happening in DFID. I think there are other solutions to this issue, which is a bigger issue than DFID, so they are not going to be able to solve it. We have seen in some countries the creation by a number of donors of civil society funds where they all pool their resources and then they hire a technical management agent, whether it is KPMG or Deloittes or some other organisation, to manage that process in Uganda or in Kenya in the south to support those southern NGOs, and that and PPAs here might be a strategy but it is difficult to see how it could be done. I think it is a good question to DFID. I think their only reaction is this natural one, "You know what? We do not have the staff any more to be able to do this", and we need to address that issue.
Mr Podmore: I think also DFID's funding through PPAs should be forgotten. It is not actually something that is mentioned in the M&E or in the strategy, the funding that it gives to organisations like ours, who in some ways really specialise in building capacity of those organisations on the ground, whether it be through volunteers, through funding capacity support, a whole range of interventions.
Q16 John Battle: PPAs being the partnership agreements?
Mr Podmore: Yes.
Q17 Mr Lancaster: I am tempted to pick up on Sally's comments about World Vision. I have the honour of having their headquarters in my constituency and Stuart Kean and others constantly make that point. I thought it was worth putting that on the record.
Ms Joss: Oh, you know him?
Q18 Mr Lancaster: I certainly got that message. We have already touched on it slightly with Ms Murphy's comments but I just wanted to move on slightly to access to anti-retroviral treatment. Great progress has been made but we are clearly still going to miss the 2010 target. You have answered partly why that is going to be but can you expand on that and say what more we could be doing to try and push that issue forward?
Ms Joss: I will start and I am sure we
are probably all wanting to comment on this.
Yes, we are going to miss the target but I think it needs to be said
that there has been a massive increase in the numbers of people on treatment. There is a 30 per cent increase in one year
and there has been a ten-fold increase over five years, but that is still not
enough to curb the epidemic. I think the
report that came out from the All Parliamentary Group on AIDS called The Treatment Time Bomb explains very
clearly what is going to be happening, which is that as people become resistant
to drugs they will have to move on to the more expensive drugs and the Global
Fund work on a basis that there will probably be a five per cent migration from
first generation to second generation drugs per year, so ultimately this is
going to mean that the drugs that are cheaper now will go out of use and that
more expensive drugs will have to come in and countries will find it
extraordinarily difficult to sustain the level of treatment that they presently
have and particularly if they want more.
We really commend that the Government and DFID are taking this issue so
seriously and recognising the threat that countries have, and we really welcome
most definitely the UK Government's and particularly DFID's financial and moral
support for UNITAID and the idea of patent pools. We believe very strongly that the idea of a
patent pool and handing over the patent rights to UNITAID and allowing others
who need access to those patents to be able to use them in exchange for a
royalty payment is a definite step forward.
This means that the pharmaceutical companies do not lose out completely
because they still get their royalty payments and it also means that there is a
chance of generic production. Very
clearly, in figure 2 of The Treatment
Time Bomb, it shows that until there is generic competition the branded
companies do not drop their prices. What
we would very much like to see is the International Development Committee
adding its voice to the call for a patent pool. We feel also that we would like
not only for you to add your voice to the call for a patent pool but it is
absolutely key to involve pharmaceutical companies. There needs to be increased pressure on
pharmaceutical companies. They do not
make much of a profit on drugs that are sold to poor developing countries; the
profits are made here, so we really ask for a real push and pressure to be put
on pharmaceutical companies to put people before profits and to exhibit some
sort of social responsibility, and already Gilead, which is one of the
pharmaceutical companies that makes HIV drugs, has publicly endorsed the idea
of patent pools, so it is not impossible.
It is also key that the
Mr Bermejo: I will not repeat the patent
pool issue but it is a really important one where we think the International
Development Committee should make a contribution as well. I would like to come back to the bigger
picture of treatment and the sort of feeling that to some extent the view from
the
Q19 Chairman: I think you have answered some of the questions we were going to ask anyway, so that is absolutely fine. One of the concerns I have is just what you have just mentioned, stopping treating people. You are saying we cannot afford to treat them and what happens when the money runs out unless you bring the prices down, but I have also heard that the side effects of some of these drugs will create a whole range of other problems. I happen to have a particular interest in deafness and I know that some of the cheapest antibiotics being prescribed in developing countries are the prime cause of the rising incidence of deafness in those communities. You are raising a whole can of worms here, that they are not getting cheap effective drugs; in other words, they are getting the junk dumped on them. We are not solving the problem; we are creating more problems. That is essentially what you are saying.
Mr Bermejo: Yes. I would not call them junk, I think that is a bit excessive, just in the sense that they are still saving lives, but at an added cost that they should not be paying in terms of their own health and the side effects, in that sense they are junk, yes.
Q20 John Battle: In a sense my question follows on not just the Global Fund but DFID published its White Paper, Eliminating Poverty; Building our Common Purpose in July, and there is a shift in that to support from multilateral sources, more money would go through the fund, there would be more emphasis on fragile states. How will that affect DFID's programmes for HIV/AIDS, as you would see it?
Ms Murphy: This is something that we
talked about a little in our submission under the second question on approaches
to health system strengthening. Interact
Worldwide flagged up some concerns about funding the interactive tools of the
World Bank which I know some of my colleagues on the Panel would share. The World Bank's own evaluation of this
produced a report earlier this year looking at the World Bank's health,
nutrition and population programmes and that report found that something like a
third of all the funds that had been dispersed had been spent ineffectively,
and when it came to HIV programmes in Africa the toll was much higher. We would question the
Q21 John Battle: It is a White Paper and submissions can go in to respond to it now.
Ms Joss: Can I just back what
Fionnuala was saying with some of the statistics? It is said that over the past decade, over an
evaluation of World Bank's health projects, that only two-thirds showed
satisfactory outcomes, and in
Mr Podmore: We do strongly believe that there needs to be a re-evaluation of the balance of how money is being spent. We recognise that DFID is going to fund the World Bank but we want them to proactively, as they are doing, work with the World Bank to ensure that they address those really clear issues. One of the ways that DFID is doing that with the Consortium is by conducting an ambitious evaluation of the community response to HIV and AIDS which is already welcome considering what we were talking about before. It is that sort of work that I think is really critical, that DFID puts the same critical eye on the World Bank that it seems to be placing on the Global Fund.
Ms Joss: Just to say a bit more about the project that the Consortium on AIDS is involved in with the World Bank and DFID, the World Bank is evaluating over the next couple of years the community responses to HIV and AIDS programmes. We are like a conduit which can enable the World Bank and DFID (although not quite so much) to be able to access people who are working on the front line and people who are working in community and grassroots organisations.
Chairman: Thank you very much indeed. That is extremely helpful. I think you have given us some ammunition, if you like, to put to the Minister immediately. Obviously, this is something which not only have you helped us with in the past and which we will continue to do and have undertaken to do, certainly till next year when we get to the end of the five-year programme. I do not know what we will do after that. Thank you very much; it has been very helpful to us.
Memorandum submitted by the Department for International Development
Examination of Witnesses
Witnesses: Mr Michael Foster MP, Parliamentary Under-Secretary of State, Mr Jerry Ash, Team Leader, AIDS and Reproductive Health, and Mr Alastair Robb, Senior MDG Results Adviser, Department for International Development, gave evidence.
Q22 Chairman: Good morning, Minister, and thank you very much indeed for coming to help us with this single session on our annual report on progress on tackling HIV/AIDS. For the record, could you introduce your team.
Mr Foster: Of course, and thank you, Mr Chairman. It is always good to appear before the Committee. I am obviously Mike Foster, Parliamentary Under-Secretary at the Department for International Development.
Mr Robb: I am Alastair Robb and I have just finished working as a DFID adviser in DFID Uganda.
Mr Ash: And I am Jerry Ash. I am acting Team Leader for AIDS and Reproductive Health in the Policy Division of DFID.
Q23 Chairman: First of all, you will know from past reports that the Committee recognises that the Department does a lot of very good work in tackling HIV/AIDS, but we have a problem in evaluating it and measuring it and the way that DFID presents it. Certainly, in the evidence session we have just had, that has been reinforced by the witnesses who have said that the tracking mechanisms, the evaluation and the quantification really of what is being done is still imperfect, so, first of all, do you accept that is the case and, if so, how do you think you can improve it so that you demonstrate effectively in more identifiable terms really what the Department are doing to tackle this epidemic?
Mr Foster: Certainly, we appreciate that monitoring and evaluation is not an easy task to do and that complexity does provide us with a test. If then that is also matched up with wanting to have a rigorous evaluation to make sure that what is published does reflect as closely as possible what is going on on the ground. In terms of the detail, clearly what we have done with our AIDS Strategy and then the baseline assessment, it is very much geared at the strategic end rather than at a sort of more operational level, but there are projects and the DFID-based projects are on the website so that people can actually see what the outcomes are and they are available on the website, but we are keen to listen to the views of others who think we can do more, mindful of course that we do not want to spend valuable resource just measuring for no benefit and mindful of course of the arguments of aid effectiveness and trying to balance the need for detailed measurements against using numbers and data that are already available.
Q24 Chairman: I think the Committee accepts that we spend too much on trying to produce statistics and that is not the prime purpose, but I think there are some concerns as to indeed how the allocation is determined between prevention, treatment and care, and also quite often in your publications you give good examples by country, but you do not aggregate them across the piece, so you say, "Well, that's very practical. Why do you not just add them all up?" and we say, "Well, we're able to say we have done that much on prevention, that much on care", and so on, so I completely accept your strictures and the Committee does not wish you to waste resources simply producing statistics, but it seems to me there is quite a lot of information inside the Department which is not simply being collated in a way which would actually reinforce the case that you wish to make and which the Committee wants you to make.
Mr Foster: Certainly, in terms of the country-led examples, what we try and do is make sure, when we are dealing with HIV/AIDS, that each country is treated very much in its own individual right. We have to look at the epidemic in-country, so our approach to, let us say, a country in Asia might be different from a country in Africa because of the nature of the epidemic being different in those particular countries, and that addresses why we tailor different methods in each country, but on the point about measurement, if the Committee were to recommend something that is feasible and we could do without additional resource going on just a compilation of statistics, then we will listen of course, Chairman.
Q25 Mr Lancaster: Minister, you have already published the template which country offices and regional divisions will report on their performance against commitments in the AIDS Strategy, so, when those templates are filled in, will you publish them in full?
Mr Foster: I am not sure whether the approach is to publish them all in full. We certainly do it on a project basis. Jerry, do we plan to do it?
Mr Ash: Well, we will certainly listen to the Committee's recommendations. As you acknowledged, we published a fairly detailed template in the M&E Framework on the last World AIDS Day and we will be using that to kick off the process of the first of the series of two-yearly reports, the first of which will be due to be published on World AIDS Day 2010, and we will seriously consider publishing the country returns in full.
Q26 Mr Lancaster: If I may, I am going to press you on it. Judging from what the Minister has just said, there is no extra money being spent on these because these templates are going to be filled in and the information will be there, so what have you got to hide?
Mr Foster: Mr Lancaster, I do not think anyone is hiding information. It is literally just a matter that it will require extra work to be done even if material is available in the template as somebody has got to put it all together in a format that people want to see. That said, if that were a recommendation from the Committee, of course we would look at it seriously. If it is addressing a concern that is out there amongst civil society or amongst committee members, then I am very much open to looking at it.
Q27 Mr Lancaster: I think many of us feel strongly, "Let's look at the wider issue". All three parties are committed to 0.7 per cent, but I think in the current climate we have to do everything we can, do we not, to explain to British taxpayers how their money is being spent. As we have seen through the processes here in Parliament, transparency must be the best possible thing, so it just strikes me that, if you have a document which is going to be filled in anyway, why would it not be published?
Mr Ash: Exactly.
Mr Foster: I am not going to go down the road of the 0.7 ----
Q28 Mr Lancaster: No, but it just as to why.
Mr Foster: I understand what you are saying and you could have a debate on that, but I do agree entirely with you, particularly in the current climate, about making sure that the UK taxpayer knows exactly what they are getting for their money, and that is an important buy-in from them to enable DFID to actually do the work that it does, and it is something which certainly officials right across the board are aware of and there is ministerial interest in this particular matter as well.
Mr Robb: I would maybe just say from a country perspective that we would be very happy for the returns to be used in any way that they are needed both to ensure the transparency, but also to make the point clear of what we are doing at country level. I think your point also about aggregating data is a very good one so that we have a bigger story to tell rather than just single country stories, and that would make quite a strong impact with the public.
Q29 Chairman: Well, as I say, when you look at the aggregate, there is quite a lot of quite good information, but it does not give you the whole picture. Minister, if I could say it on a general basis, having chaired this Committee for the last four years and having done quite a number of visits, whenever we go to a particular country as a committee, we usually get a first-class briefing from DFID in detail as to how the money is being spent, what the priorities are and where it is going, so it is given to us, but that is not on the website of the country situation, so it seems to me that there is a lot to be said for putting that kind of information. It also helps, if I may say, the civic society groups and the politicians in those countries because that information is something they can then engage their own governments and their own ministers with, so I am not necessarily asking you for immediate responses to that, but I would really commend to you that I think there is quite a lot that the Department could do within the resources you have got which would make it open and more transparent to everybody's benefit, particularly on this issue. Just to finish on this point, you also in your White Paper are putting more money through the multilateral agencies, which different members of the Committee may have different views about, but I think collectively we do not fundamentally disagree with and we recognise the role of these agencies. However, we have just had evidence on health, for example, that the World Bank outcomes, particularly in Africa, have been somewhat disappointing in a number of areas, so how, if you are putting more money through an organisation like the World Bank, can you ensure that you are able to monitor it effectively and also to influence the World Bank to ensure that some of the DFID approaches may improve the outcomes?
Mr Foster: Our perspective, Mr Chairman, is that money channelled through the multilateral route gives us the ability to influence what decisions are made because we are a major funder of organisations like the World Bank and in other multilaterals, where we will have a seat on the board, it gives us clear direction as well, and the prize for us is that, if we make the changes that, we believe, are necessary to improve the effectiveness of the multilaterals, and that is, as you say, in the White Paper a very key theme for DFID to pursue, the real prize is the bigger bang that you get from just doing stuff bilaterally. We can have the most fantastic practice as DFID with our bilateral money, but, if we can make the change multilaterally, the benefits are far greater, and that is the direction of travel for us.
Q30 Chairman: I think yes, Minister, the Committee would accept that, and this Committee has a good relationship with the World Bank and I have met with them on more than one occasion.
Mr Robb: Just to highlight the point that the Minister has made, DFID often at country level does not have the same level of resources in terms of money, but also in terms of human resource, so our way of dealing with the multilaterals is to lift the game of these partners at country level. For example, in Kenya at the moment we have been involved in the latest World Bank project by helping to develop the project, but also to review the project in-country, and with the UN there is a huge capacity, in fact I think it is about 400 people working in the UN on AIDS within the Eastern, Central and Southern Africa region, and we are looking at getting them to lift their game so that that capacity can be most maximised, so it is about the fact that we do not have all the resources and how we influence them, particularly at country level, which allows us to have more ability to achieve results.
Chairman: And we have seen some good examples of that on our visits.
Q31 Mr Lancaster: Can I just pick up on the Minister's comments about the multilaterals. Two days ago, we had the replenishment of the Caribbean Development Bank and a reception here upstairs, but it was the seventh replenishment, and what was clear from that was that some of the conditions that we had applied to the sixth replenishment had not been met, and they were only minor conditions. For example, when we had the replenishment of the Asian Development Bank, some of the money was (?), so, whilst I accept and agree exactly with what the Minister is saying, it does seem sometimes that, as you move forward through replenishments of these multilaterals, the regional banks especially, we seem to be forgetting what has happened in the past and, whilst we make an agreement at the time, when we move on to the next replenishment, we are not really holding these banks to account to the degree that we should and applying these conditions, so I was really interested in the Minister's comments on that.
Mr Foster: I am not sure that I agree with that, Mr Lancaster, having been involved in the discussions prior to agreement of the replenishments, and very much in terms of the decision that is taken as to whether we replenished the Caribbean Development Bank, being one of the ones that I had responsibility for, what you have highlighted is exactly the type of conversation that we have with the bank and it is because we have a relatively large shareholding within the Caribbean Development Bank that it enables us to have that leverage over change. By and large, if memory serves me, I think they did comply with nearly all we asked of them at the sixth replenishment and then for the seventh one we put fresh conditions for change on them, and I think that is a very useful carrot to offer a multilateral like that.
Q32 John Battle: If I may, without dismissing the banks, switch from the banks to the people really and ask about what are sometimes referred to as the most marginalised people, but who, I think, are the poorest of the poor which some of the strategies never ever reach. I think that, particularly on this agenda, DFID has made a big commitment to strengthening the health systems, but, as one of our witnesses said, the health systems need to be worked right through from the hospital to the home, and that was the expression. Now, my own caveat there would be that ten per cent of the world's population do not have what we would recognise as a home and they are live effectively on the street or in these informal communities. People with disabilities, adults and children, street children, child labourers, child workers, sex workers; there are whole groups of people that the strategies never seem to get down to and among, other than some vague attempt to get through, perhaps if I said, prominent or attractive civil society organisations. I just want to ask, understanding that we have to get into the complexity of civil society organisations, what progress is DFID making to get the strategies to reach the parts that no one is yet really reaching or even analysing to assess the need?
Mr Foster: First of all, Mr Battle, there is a recognition with marginal groups that, by their very nature, it does mean that society is putting them to one side and it is more difficult to do and approach them in a more general manner. In some cases, it is because of the illegal nature of their activities which also adds an obstacle to ----
Q33 John Battle: Sometimes they just have not got an address because they live in a informal settlement, a shanty town or a favela.
Mr Foster: We recognise that there is a real problem which we have to pay particular attention to. Perhaps I can give a couple of examples where we know our work has proved that we can make a difference. I think you and I and the Chairman went to see the Chengdu treatment centre where there was methadone treatment and commercial sex workers were also treated there, and that was an example where DFID had had a pilot project that has actually proved so successful that the Chinese authorities have actually taken it on board to mainstream it, so, in effect, we were recognising with our particular project work that there was a problem, we highlighted it, showing the authorities that it could be done and then enabled that to become mainstream. We have also done the same in India where we are providing budget support, but channelled through key civil society organisations that can deliver on the ground because it is not always easy to go through the government machinery, as you quite rightly pointed out, Mr Battle, and then there are other areas where we have highlighted particular problems, and I know Alastair would want to talk about this. African lorry routes, transport routes, have a particularly high incidence of HIV/AIDS because of the nature of the lifestyles that are led. Now, we have recognised that in terms of some of the work that we have pinpointed on them, and perhaps, Alastair, you would want to say a bit more.
Mr Robb: Just, first of all, to agree fully with your concerns about marginalised people who do not access health services, and DFID's approach to that is not just a singular approach. We are building the health system, making it more accessible through the abolition of user fees, but also improving the quality because everybody who accesses that care needs that quality care. At the same time, we recognise that those services are not sufficient, particularly in terms of access, for the poorest and most marginalised, and in enabling those people, not only are we providing support to civil society organisations that can outreach, but we are also doing work with social protection, including cash transfers to the most needy so that they are more able to access healthcare, education, et cetera. On the issue about AIDS and truckers and knowing that some of these people are particularly at risk to the disease, this is part of knowing our epidemic and knowing both the people who are more at risk of becoming infected or of transmitting the disease, but also the people who are more likely to suffer the consequences of becoming infected so that our response, the national response that we are supporting, can be better suited to addressing those people.
Q34 John Battle: I think what I am pressing you on is that I am looking for a much stronger marginalised participation strategy right across development and then, if am going at it from the angle of HIV/AIDS, there are whole swathes of people at the bottom written off, frankly, in the systems. I would even argue with you that social protection is okay, but it does not reach the parts it needs to, that you need an address and a home, and I go back to that point again of people who are out on the street, so are you confident, and I am thinking of the White Paper, I did not, frankly, good though it is, feel that there was a strong enough dynamic coming through and a strategy to move, not that DFID staff should all become outreach workers, but to have a strategy to build connections to get the people to go to meet the people. Without that happening, and it is hard work, it is costly work, it is time-consuming work, but I am not yet confident that I am seeing the outline of a strategy there. Am I being unfair?
Mr Foster: I would say yes. Very much the core work on tackling poverty means that the most vulnerable, and you mentioned the street children as a good example, are excluded from all sorts of links to their society because of the fact that they are living in the street. I think that, if you saw some of the work, and I think you are going to Bangladesh shortly and I am hoping that you will go to see some of the work that we do with street children in Dhaka, you will see the project that DFID runs which not only is primarily about education, but actually that is used as a taster, as a vehicle to getting wider access to do with health concerns.
Q35 John Battle: I think that is my exact point, and it just does not apply to DFID. What I worry about is governments, including our own and including in my own inner-city neighbourhood, where we have pilot projects and then we snuff out the pilot, good though it might be, before the full oven has got going, so I am looking to see how you see, and I have seen good projects, like in Vietnam, how these projects become developed. You mentioned the phrase that they become, I think you said, mainstreamed, so how do they do that? Have we got a strategy to get from those beacon projects to a full-blown one and one which pushes other international organisations as well? I just do not quite think we are there yet, but I need it to be a stronger theme.
Mr Foster: I think by what you have said yourself, Mr Battle, it is a fact that the UK and in your constituency, we are not there yet, and we are clearly not going to be there yet in terms of the sorts of countries that we are working with, but very much the direction for us about supporting health systems in the broadest sense rather than just vertical funding streams, the argument that I know you went through last year in a similar inquiry, that is exactly why we want to have the investment in broad health systems so that we can get to reach people by means of employing more health visitors, more health workers, reaching targets that were laid out in our strategy of 2.3 per thousand. That enables us to have a better chance of reaching the very people that you describe.
Q36 Chairman: I should say that our Report on Urban Poverty is published today and it covers quite a lot of the point about how you serve the millions of people who are out of reach of quite a lot of these systems, which actually brings me on to another question which was raised in the context of this, that you were making commitments for £200 million for social protection across eight African countries, but you have not identified, or you have identified, but you have not given the information as to which countries they are, so are you able to tell us now? I think that, when the Secretary of State initially mentioned it to us, he said there was an objective evaluation process and he could not at that point tell us which countries, although he had a number in mind, but surely, 15 months on, you should be able to.
Mr Ash: I think I am right in saying that it is not a fixed or static number that we intend to work, and believe we are working, in of at least eight countries across Africa. They may change certainly over the seven-year long-term implementation time-frame of the Strategy, but I believe that at the present time we are working in Zimbabwe, Kenya, Zambia, Malawi, South Africa, Sierra Leone and Rwanda, and that, as programmes are developed, more may be added and as programmes come to an end.
Q37 Chairman: Are you going to be able to give us, and I am not asking for it now, any detailed information on that? It is, after all, £200 million over three years and that is quite a lot of money and we need to have some indication of how it is being spent and also whether this is additional money or whether it is within the existing programme, but targeted in this particular way.
Mr Foster: We can give you examples, Mr Chairman, of the nature of the work that we do with social protection at the country level and that might help describe how the system works. Alastair, can you talk about some African stuff?
Mr Robb: I can. In terms of actually what we do on social protection, in addition to the monies that we provide, we have been at the forefront of creating social protection policies with countries, including in Uganda where most recently the Vice President, as a result of DFID's lobbying, has ensured that social protection is now part of the National Development Plan, so it is an important part of our work, not just the monies that we bring to the table, but also the policy dialogue. A lot of the work that we are doing at the moment is looking at cash transfers and ensuring that money goes to the poorest, and the people that you are talking about, I agree with you, those people that are really out of reach of the whole system are not going to be the ones that necessarily benefit from this, but there are a huge number of very poor people who will benefit from cash transfers, and over time we will be doing analysis to assess how that impacts on their lives, including how it impacts on children, orphans and vulnerable children, and people with HIV.
Q38 Chairman: I am sure the Committee would be very supportive of the objectives, and I think we would just like more information. The Consortium on AIDS and International Development, I think it was the VSO member, said in their submission to us, related to this and the eight countries and I thank you for the answer there, "Unfortunately, DFID have still not defined which countries these are", well, you have partially answered that question, "so monitoring progress remains impossible. We eagerly await more news on how this funding has been distributed and to which countries", so it seems to me in your interests to make a little bit more information available about that so that people can make a judgment as to how effective it is. I do not think we are disputing that it is a good idea, but we would like some indication of what the outcomes are.
Mr Foster: It is a fair point and it goes back to where we started the session from about information which, I know, civil society is keen to see and, as I say, we will look at what we can do.
Q39 Mr Lancaster: Sticking with money, the Global Fund in July announced a $3 billion deficit for their programme in 2010. What assessment have you made as to why this has happened and what impact is it going to have on the HIV/AIDS Strategy?
Mr Foster: Obviously, we are aware of
the figure that you have just described.
In terms of the
Q40 Mr Lancaster: A couple of years ago, the UK led by doubling its replenishment of the African Development Bank to £116 million and other countries followed, so, given the deficit, is the UK going to lead again by helping to fill this deficit?
Mr Foster: Well, in terms of our contribution, I think we set the direction that we would like others to follow by setting out a long-term commitment, so we were not looking at just annual change, we were saying, "Look, here is a seven-year programme for £1 billion". In terms of an example of what the UK's individual contributions are year on year, last year, 2008, we put £50 million into the Global Fund and this summer we have just handed over £115 million, so our contribution has indeed doubled year on year, but it is part of a £1 billion long-term commitment, and I think it is the long-term commitment, Mr Lancaster, that people need to make to make sure that the Global Fund has the predictability of finance to enable them to plan their work. Without that predictability, it makes it very difficult to do proper work on the ground.
Q41 Mr Lancaster: I think that is absolutely right and I agree with the Minister wholeheartedly on that, but it does not answer the question of how we are going to plug this gap, so how does the Minister anticipate that the $3 billion deficit will be filled?
Mr Foster: Well, I think that there are discussions that we can have with the G8, as leading funders of the scheme, to try and leverage in more support from them, I think there are other avenues to support the work of the Global Fund perhaps through innovative health financing options which can make up some shortfall in the cash, and I think we have to also try to make what money is in and has been pledged work better, to make it more effective on the ground. I think there is a job for us to do with others on that front as well, but it is a lobbying exercise, Mr Lancaster, and it is very difficult. We are not in a position to tell others to pay their fair share. There are opportunities, I am sure, for CSOs internationally to make and to do their lobbying, which is perhaps another direction of travel, and they have been highlighted in the public as a route that they can follow to put pressure on their governments to fulfil the payment of what is only seen as a fair share towards the Global Fund.
Q42 John Battle: I would like to ask about the Cross-Whitehall Strategy Group. We would all agree generally with joining up government and there is a strategy to pull together the Home Office and the FCO and they have got a clear remit. The remit says, "The Home Office, FCO and DFID will work together to improve the international environment for harm reduction" by increasing the coverage of HIV prevention, and the rest of it. I sometimes think, whether at ministerial level or department level, one department, rightly, is taking the lead and trying to get the others and corale them together, but ends up doing all the work and the others are not quite joining in, so my question comes in the most friendly way to say: is DFID getting enough support from the other departments, are they taking it seriously and are there enough personnel gathering round it, and is there a budget? Could you tell us a bit about the Cross-Whitehall Working Group.
Mr Foster: It is an informal group. It is a meeting of officials and not ministers.
Q43 John Battle: It meets how often?
Mr Foster: It meets on a quarterly basis. The last meeting was on 7 October and the meeting before that was on 15 July, but it is an informal meeting of officials. In terms of what it discusses, Jerry?
Mr Ash: Well, it was very useful in both developing the Strategy and in helping develop the Monitoring and Evaluation Framework and the subsequent baseline. I believe that the other government departments represented on it are committed to it and the issues that we deal with, but I am not sure I could go very much further than that in committing colleagues in other departments to do more or to commit more resources.
Q44 John Battle: I assume you and your section are the secretariat of it, that you keep the notes of the meetings and you run it and organise it and they come along?
Mr Ash: That is correct, yes.
Q45 John Battle: I am just pressing on the depth of their commitment to it really. Do you publish the notes of the meetings? I know they are informal, but are they shared around?
Mr Ash: No, we have not published the minutes of the meetings as yet, but we are happy to consider doing so, if the Committee would want it.
Q46 John Battle: Harm reduction in fact is a massive issue and to take, as with everything, the myopic world which operates around my constituency, we have a huge prison, so the Home Office might well need to be there. Am I daft to ask why the Health Department are not on the group?
Mr Ash: They are.
Q47 John Battle: Are they? I thought it was just the Home Office, DFID and FCO.
Mr Ash: No, certainly not.
Q48 John Battle: So it is Health as well?
Mr Ash: The Department of Health are fully represented.
Q49 John Battle: Good. Do they make any contribution in funding and support then?
Mr Ash: I am not aware of the Department of Health putting official development assistance into AIDS. On a domestic basis, research and issues like that, I am sure they are fully active, but they play a full part in the group.
Q50 John Battle: Do not get me wrong, I am encouraged you get together, but I am just stating it and make sure DFID does not carry all the work of it, that we share the work and perhaps other bigger departments can make a bigger contribution, and we might learn, and hopefully internationally, from what is going on by sharing the information and knowledge through that group. That could be quite an exciting, pioneering development actually.
Mr Foster: What I can do, Mr Battle, is perhaps write to you with some more information about the Cross-Whitehall Group, who is on the group and how it is funded so that it enables the Committee to then make an informed decision as to what they make ask of us.
Q51 John Battle: Okay, but I think you know where I am coming from on that.
Mr Foster: Yes, I understand fully.
Q52 John Battle: As a second question, DFID, rightly, in the last ten years has been promoting whole programmes to the poor, poor countries, fragile states, so there was some withdrawal, rightly, from middle-income countries. Then there is a bit of a gap and I am now picking up that the Foreign Office seems to have been invited to take the lead role, particularly in HIV/AIDS, in middle-income countries. I wonder what that means. Have they got expertise? Do they have people in the field that can work on HIV/AIDS, have they a budget, or are they just keeping a watching brief on it? I am just interested in what the Foreign Office is doing in middle-income countries.
Mr Foster: First of all, just to explain again, Mr Battle, exactly why we have moved DFID offices out of middle-income countries, it is because they have graduated to middle-income status and 90 per cent of our spend is on the low-income. I know it is well-rehearsed, but that is why those decisions have been taken. Then it is left with the Foreign and Commonwealth Office having a watching brief over the work on HIV/AIDS, and, Alastair, you have got some examples.
Mr Robb: I was going to give examples
of countries where we do work together and maybe Jerry would like to talk about
the middle-income. In the countries
where we work together because we still have a presence, for example, Burma,
the Foreign Office were really important in enabling us to enter into Burma to
do the important bits of work on HIV, so DFID, with the Foreign Office, led the
way in tapping an epidemic in a very fragile state through a joint UN
programme, which has grown with others now working on that, but we are at all
times keeping the EU common position and, with the advice of the Foreign
Office, ensuring that we are working in that politically sensitive environment
in the best way. The
John Battle: Burma is a good case and actually, if I may say, a brilliant example of absolutely excellent work by Foreign Office staff and ambassadors there working with DFID together in a very difficult situation, if I can put it that way.
Chairman: We put on record, John, also that the increase in the funding was as a direct result of the recommendation of this Committee!
Q53 John
Battle: Indeed!
Could you give me any examples and, for example, one which we ought to
keep an eye on big time,
Mr Ash: I do not have an example of
how the FCO is supporting the implementation strategy in
Mr Foster: Obviously, Jerry mentioned it is in the baseline, but also what the Foreign Office do and what they do in middle-income countries will of course be a feature of the biennial reports that we publish as well in terms of what we are committed to on that.
John Battle: It is just that in this area of public policy perhaps more than others, the integration across income countries might be slightly more important than in other areas that I might emphasise where there is a strong emphasis on poverty and poor policies, and I am totally behind that, but in HIV you might find it does not simply cut across the poverty bracket, as it were, and, without taking into account middle-income countries, the whole strategy could be undermined as well. I think I have made my point clear.
Q54 Chairman: The Gleneagles Summit, which was now four years ago, secured very substantial commitments from the international community and a very specific pledge to achieve universal access to HIV/AIDS treatment by 2010. I think we know that that target is not going to be hit, but the question I want to ask first is: to what extent has the economic downturn affected the commitment of those other G8 countries specifically in this area? We know of countries that have cut their aid, but are you able to evaluate where they have specifically cut their commitment to achieving this target?
Mr Foster: Certainly, it is on the
record, Mr Chairman, our position on the long-term commitment to aid, and Mr
Lancaster recommitted his side to it as well, the 0.7 per cent. As you know from events earlier in the
autumn, the Prime Minister said that we will be looking to legislate for that
as well, so the
Q55 Chairman: But, given that there are people who have cut back, our previous witnesses gave testimony to the fact that a great deal has been achieved, in other words, an awful lot of people are getting treatment that were not getting treatment and, had that commitment not been made, that presumably would not have happened, but it is not going to achieve the target, so you are left with two problems. What happens in 2010 when you miss the target, what are the implications, and also of course, having achieved the target, how do you sustain it? The worst of all idiocies would be to get to 2010 and say, "Ah well, we've achieved 80 per cent", or 70 per cent, "and now we're going to stop funding".
Mr Foster: I think again that justifies the logic of our approach on health system financing rather than perhaps whole-project or vertical-led financing in that, if you have achieved a target, you pat yourself on the back and psychologically you just sort of move on to work out what the next target is you want to aim for, whereas, if we have got health systems generally being funded, it needs some mainstreaming before it does make it easier to cement and build in as a permanent feature of healthcare in particular countries so that we do not fall foul of the idiocy that you have just described. It also, I think, from what you said, reinforces our argument about prevention being the focus of our work on HIV/AIDS because that tends to be the area that can be cut if there are limits on spending. It is easier to cut prevention work than it might be treatments that people are already being given and are embarked on, so our focus on prevention, I think, will help deal with some of the unintended consequences of cuts in funding.
Q56 Chairman: We had again in the previous evidence session some indications that some governments in developing countries are saying, "Well, we're going to stop adding people to the treatment list", so one of their responses for not having funding is to say, "Well, we have enough difficulty treating the people we have got and we are not going to add any more", which clearly means that you have got a growing problem.
Mr Foster: And again, from what they have said, the best course of action in the longer term is to focus more and more on the prevention. In preparation for this hearing, Mr Chairman, we have been looking at the prevention bit and there is a phrase which has cropped up which I was determined to get on the record in this particular committee hearing, and I think it comes from Uganda, Alastair, and it is, "You can't mop the floor properly until you've turned the tap off", and that is very much central to the message about prevention being the direction for us to make the most impact in dealing with HIV/AIDS.
Mr Robb: I just want to add a very quick comment from a country perspective where I think there is a level of complacency about HIV that, by not hitting this target, it will further highlight the actual problem in-country where we are seeing rising numbers of new infections. In Uganda, a country that was once stated as a success, even during the time when prevalence was coming down in the mid-1990s, there was a rising number of new infections per annum, and it does give us a bit more momentum behind why prevention matters, the focus that DFID is putting on prevention.
Q57 Chairman: Perhaps a separate question comes in there which I did not anticipate, but are we in a better environment for the prevention mechanisms? Are we in a better across-the-piece acceptance that some of the more difficult issues can be addressed?
Mr Robb: I think we are in a much better position than we were and I think that, in part, that is due to DFID working with the UN to bring the evidence to the table about why prevention matters, knowing your epidemic and knowing where we are in an epidemic and understanding that it is not about a single prevention strategy, it is about, in the same way as you have combination treatment, having combination prevention.
Chairman: I think John Battle might want to come to that in a minute.
Q58 Mr Lancaster: Building on that in a way and the implications of the DFID White Paper published in July where we saw a move towards multilateral funding rather than bilateral funding, and we have talked about that already, there was a feeling really from witnesses that perhaps DFID is de-prioritising HIV/AIDS, quoting a reduction in the number of staff, so I guess, Minister, we are really after not just reassurance that that is not the case, but also perhaps some form of evidence that demonstrates that the Department's commitment to this is strong and will continue.
Mr Foster: I would have argued that the fact that we had the AIDS Strategy, that we have had that baseline assessment, that we are doing the biennial reports, against that baseline, it would reinforce the fact that actually DFID is as committed as ever to working on HIV/AIDS, and the fact that we have this £6 billion commitment to health systems on top of the £1 billion to the Global Fund would suggest that the resources are also being put in to deal with HIV/AIDS. Health systems, we think, are the right direction for us to go and we believe that other donors are in agreement with that, so I would counter any argument which says we were de-prioritising HIV/AIDS; I do not think we are at all.
Q59 Mr Lancaster: But there certainly was a consistent theme that this is the perception, so why then do you think this perception has been allowed to grow? Is that the fault of the Department? Have you felt engaged or what? It is definitely there.
Mr Foster: I do not hold the view, so it is difficult for me to work out why that perception is there. I can only envisage that it is because other health issues have perhaps come more to the fore as a concern, so, if you take maternal health as an issue, suddenly it has become more important in terms of the public eye perhaps. That is not to say that we are de-prioritising our HIV work or spending more attention now on maternal health, it is just that, in terms of lobbying, in terms of perhaps press attention, maternal health is perhaps getting a greater share of the attention than HIV/AIDS did, or perhaps it is taking some of the attention away from HIV/AIDS, but it is not taking away resource and it is not taking away our commitment.
Q60 Chairman: I just want to pursue the question on fragile states because the change in the priority in the White Paper does raise the question as to whether or not the countries that have a significant AIDS incidence, but are not decreed as fragile, might actually suffer from a reprioritisation, or at least how can you assure us that they will not?
Mr Foster: In terms of what we said about the White Paper and the movement to this greater emphasis on fragile states, what we said is that it was 50 per cent of new money, new bilateral spend, which will go on fragile states, so the core funding that we have announced already, the £6 billion and the £1 billion to the Global Fund, that is not going to be diverted to work in fragile states. In terms of the need in fragile states, there is still a need there to deal with HIV/AIDS and it is perhaps different from what you might have in Sub-Saharan Africa and it requires us to look very much at a country-specific problem, but, for example, in a post-conflict situation you are often coming to terms with the poor treatment of women and violence against women which can often be a particular bad transmitter of HIV/AIDS in a sort of particular segment. That is an area where perhaps our work on fragile states would deal with an issue on HIV/AIDS which would not have cropped up, but which I think is important that we deal with.
Q61 John Battle: The American strategy, the President's Emergency Plan for AIDS Relief, as it is sometimes referred to under its acronym of PEPFAR, means that there have been some changes both in American policy, but also in budget. I just wonder what is our relationship with that strategy now, our conversations with the Americans, and how you feel that the PEPFAR changes are helpful and whether the budget change is in the right direction.
Mr Foster: We very much welcome the change, not just in this, but perhaps other areas of policy as well from the Obama Administration. Certainly, their budget commitments on global health and what they said on sexual reproductive health and rights we have welcomed, the focus on broader health issues is perhaps more in line with what DFID has been doing itself, including child and maternal health and family planning which clearly have some benefits on HIV/AIDS as well, and the robust funding mechanisms that they are looking to bring in, again we welcome that, so we think that actually, by the changes that President Obama has made in his Administration, it enables us to have perhaps an even closer working relationship between DFID and USAID actually on the ground.
Q62 John Battle: In terms, say, of policy, fine, but, if it stretches the budget from five years to six, we might be worse off, which is what they have done.
Mr Foster: We think they are making some
very positive noise about the amount of money that they are putting into the
system about how it is going to be spread.
Perhaps as an example in-country,
Mr Robb: Yes, I think we are getting very good working relationships at country level, and PEPFAR, working less vertically through its own initiative and working with us and co-operating with national governments, so setting up partnership agreements so that it is consistent with the overall AIDS or health strategy, indicates their commitment to working better and achieving wider sets of outcome.
Q63 John Battle: So there is an in-country discussion with the Americans where you are working together?
Mr Robb: Yes.
Q64 John
Battle: Which is good, and at the policy level, is
there a discussion at the
Mr Ash: Yes, there certainly is. At the policy level, we talk to the
Q65 Chairman: Certainly, the Committee had an early meeting with USAID representatives very shortly after President Obama was elected, and indeed no doubt they were visiting other departments as well, in which they were openly saying, "We can now work alongside DFID", whereas previously we were not doing so, so are you telling us that this is really happening on the ground?
Mr Foster: Yes, and the advantage is that, under their old way of running it, it would have been very much project-led with no incentive to have the partnerships and collaborative working that they are now free to have, and obviously some of the restrictions they used to have about where they worked, with those disappearing, it just gives them more freedom to work with us and others.
Chairman: They certainly appear to be liberated in their approach.
John Battle: May I suggest that we might also need to keep an eye on the budgets to make sure that they are not reduced so that the impact is that less people get assistance, if we are not careful, which is difficult perhaps.
Q66 Chairman: Well, thank you. There are one or two issues you have said you will write to us to give us more information.
Mr Foster: Of course, Chairman.
Q67 Chairman: May I just make the usual point that we have a very tight timescale on this one.
Mr Foster: Because you are reporting on World AIDS Day.
Q68 Chairman: That is our objective, so obviously anything you can give us, the quicker you can give it to us, the better. Perhaps I can also repeat the point that I think there is a lot you could do from the data you have in the Department to publicise it more effectively on your website and in other ways which would actually be in everybody's interests, and we may come back to that.
Mr Foster: That has come across loud and clear.
Chairman: We are obviously going to be doing a report on your annual report and we may repeat that then. Thank you very much indeed; it has been very helpful.