3 HEALTH SYSTEM STRENGTHENING
16. One of the central pillars of DFID's
HIV/AIDS Strategy is the commitment to spend £6 billion in
the period to 2015 on health system strengthening. This includes:
increasing the number of health staff in developing countries;
funding for more and better hospitals and clinics, improving the
supply of drugs and equipment; increasing access to services;
and improving the management and co-ordination of health services.[29]
17. In our Report last year, we welcomed this substantial
funding and emphasised that "developing countries will never
be capable of tackling HIV/AIDS effectively unless the overall
capacity of their health systems is built up through adequate
funding." We expressed concern, however, "that DFID
has included this funding as part of its HIV/AIDS Strategy but
the specific impact that it may have on HIV/AIDS will be difficult
to measure". We recommended that the monitoring and evaluation
framework included mechanisms to track the impact of funding for
health systems strengthening specifically on HIV/AIDS treatment
and care. We also asked for much greater detail on how this sum
would be spent, including precise allocations and timescales.[30]
18. In its response to our Report, DFID failed to
provide the information that we had requested. It said that "specific
decisions about spending and allocations to programmes, including
on AIDS, are taken at country level. These programming choices
are made according to specific national and regional profiles."
It was emphatic in telling us that "it is not feasible, practical
or desirable to set out detailed multi-country plans in a 7-year
Strategy."[31] Despite
our recommendation on the need for indicators to track the impact
specifically on HIV/AIDS of health systems funding, the only provision
in the M&E framework in relation to health systems funding
is that:
DFID corporate performance systems will be used
to report on progress against the strategy's £6 billion health
systems and services commitment. This will be derived from bilateral
expenditure identified as targeting the health sector as well
as an imputed share of core contributions to multilateral organisations,
civil society organisations and DFID's provision of debt relief.[32]
19. The UK Consortium told us that there is consensus
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".[33]
However, witnesses shared our concern that, a year on, it
remains unclear how the £6 billion would contribute to supporting
the achievement of universal access to HIV/AIDS care.[34]
Whilst welcoming DFID's substantial funding, VSO said that "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." It considered that this sent a "worrying
message" that broader health system strengthening would be
promoted at the expense of funding for HIV programmes.[35]
20. Witnesses emphasised that an effective response
to HIV requires activities beyond public health systems. In particular,
some commentators were concerned that, while strengthening health
systems was necessary to improve HIV/AIDS treatment,
there was a risk that it would not contribute effectively
to HIV prevention. The Alliance told us that:
DFID's focus on health systems strengthening
potentially undermines DFID's own commitment to HIV prevention,
as there is a limit to how much of a role health services can
play in HIV prevention. […] Given the urgent need to increase
investment in HIV prevention if the spread of the virus is to
be halted and reversed by 2015, it is essential that DFID supports
more immediate investments to maintain progress and inject support
into urgent preventative measures that may need to be addressed
outside the formal health system.[36]
In our 2006 Report on marginalised groups affected
by HIV/AIDS, we said:
[…] programmes which address the drivers
of epidemics, rather than generalised programmes, will be most
successful in combating the spread of HIV/AIDS. Social and legal
barriers to effective prevention and treatment programmes for
key groups need to be addressed in some countries to ensure successful
implementation of national HIV/AIDS strategies.[37]
Targeted prevention programmes aimed at high-risk
marginalised groups have the potential to be a much more effective
intervention than generalised treatment programmes offered by
public health services. Where such prevention programmes are successful
in reaching the marginalised groups which are the "drivers"
of epidemics, this may reduce the rate at which the disease spreads
into the general population. Fewer resources would then need to
be devoted to treating large numbers of infected people in public
hospitals and clinics.
21. Alvaro Bermejo stressed that there is a "need
to work beyond the health system to really prevent new sexually
transmitted infections and new infections transmitted through
the sharing of injecting equipment". He added:
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. [38]
He raised the issue of stigma and discrimination
in the healthcare system and workforce which may prevent people
in high-prevalence groups seeking or gaining access to treatment
and care. He called for DFID, and other donors, to ensure that
indicators are put in place to enable the tracking of the impact
of health system strengthening initiatives on vulnerable groups.[39]
(We will examine the issue of marginalised groups in more detail
in Chapter 6.)
22. Mr Bermejo was also concerned that prevention
programmes might suffer as a result of the global economic downturn
reducing the funding available for HIV/AIDS work. He believed
that as "money gets tighter" the political response
would be to concentrate on people who are currently receiving
treatment at the expense of prevention programmes:
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.[40]
23. Evidence from UNICEF highlighted that it remains
unclear how HIV/AIDS prevention programmes would be funded, particularly
programmes to improve life skills education for young people and
"initiatives to address the underlying drivers of HIV infection,
such as gender norms, multiple concurrent partnerships and age
disparate relationships, which increase young people's vulnerability
to HIV infection."[41]
24. In addition to the risk of HIV prevention receiving
insufficient funding and attention, Mike Podmore of VSO pointed
out that care and support was the "often-forgotten pillar
of universal access". Health system strengthening focused
on hospitals and clinics and ignored the important aspects of
care and support provided in the community. As people with HIV
and AIDS live longer, due to the increased provision of anti-retroviral
treatment, there was a growing need for more long-term care and
support services. He stressed that it was most often poor women
and children in communities who were providing the necessary support.
Their contribution was largely unrecognised, nor were they being
provided with the resources they needed. He believed that DFID
should ensure that health system strengthening encompassed "hospitals
all the way to the home" and recognised that it "is
not just about channelling money through governments because it
is the community-based responses that are really delivering care
and support on the ground and a lot of prevention interventions."[42]
25. We strongly support the substantial funding
which DFID is providing to strengthen health systems in developing
countries and fully accept that capable and well-resourced health
services are an integral part of an effective HIV/AIDS strategy.
We remain seriously concerned, however, that DFID has no mechanisms
in place to track the impact which its £6 billion funding
for health systems will have specifically on HIV/AIDS care, despite
this being one of the key elements of its Strategy. We reject
DFID's assertion that it is not "feasible, practical or desirable"
to specify how its £6 billion in health systems funding will
be allocated. We recommend that, in response to this Report, the
Department provide us with a meaningful breakdown of its spending
plans for this funding package, at least over the next two to
three years, including an indication of how HIV/AIDS programmes
are likely to benefit.
26. The focus on health systems also ignores that
fact that some of the essential components of universal access,
particularly prevention and long-term care in the community, may
not benefit from health systems funding. We recommend that, in
response to this Report, DFID sets out how it will ensure that
its HIV/AIDS Strategy promotes an holistic approach which includes
prevention, treatment, care and support for all people living
with HIV/AIDS, including those vulnerable to discrimination and
stigmatisation. This approach must also recognise that prevention
and care services are frequently provided outside the public health
sector, by family members and community groups, and that targeted
prevention programmes aimed at marginalised groups are often one
of the most effective HIV interventions.
29 See DFID, Achieving Universal Access-the UK's Strategy
for halting and reversing the spread of HIV in the developing
world, June 2008, pp 35-36 and Achieving Universal Access-Monitoring
performance and evaluating impact, p 13 Back
30
Twelfth Report of Session 2007-08, HIV/AIDS: DFID's New Strategy,
HC 1068-I, paras 19-20 Back
31
First Special Report of Session 2008-09, HIV/AIDS: DFID's New
Strategy: Government Response to the Committee's Twelfth Report
of Session 2007-08, HC235, pp 2-3 Back
32
Achieving Universal Access-Monitoring performance and evaluating
impact, p 9 Back
33
Ev 73 Back
34
Ev 52 Back
35
Ev 82 Back
36
Ev 52 Back
37
Second Report of Session 2006-07, HIV/AIDS: Marginalised Groups
and Emerging Epidemics, HC 46-I, para 18 Back
38
Q 4 Back
39
Q 4 Back
40
Q 5 Back
41
Ev 80 Back
42
Q 6 [Mike Podmore] Back
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