6 MARGINALISED AND VULNERABLE
GROUPS
43. In our Report last year we said:
If the global effort on HIV/AIDS is to achieve
the goal of halting and reversing the spread of the disease, it
must be effective in reaching marginalised people, including sex
workers, intravenous drug users, men who have sex with men and
transgender individuals. If the epidemic is not tackled in these
groups it will continue to spread to the general population and
the number of people affected will continue to increase. DFID's
Strategy acknowledges this reality but does not adequately explain
how DFID will ensure that these marginalised people are provided
with the prevention, treatment and support services they require.[76]
We asked DFID to provide us with more information
about its plans for reaching marginalised groups. DFID's response
was that "it is not possible to provide this level of detail
in a global strategy", although it did provide some specific
examples of its work with high risk groups in India, Kenya and
Vietnam.[77] In China,
we saw for ourselves the significant impact which DFID's work
with marginalised groups was having. An independent external review
of the initial project, which was focused on the poor western
provinces, concluded that it had led to a range of positive outcomes,
including: increased condom use; reduction in needle-sharing amongst
IDUs; sex workers being empowered to negotiate 100% condom use;
and a decrease in stigma. DFID subsequently committed £30
million to its HIV/AIDS programme in China over five years to
build on this successful work.[78]
44. DFID's Strategy recognises the need to create
programmes specifically aimed at disadvantaged and marginalised
groups. It notes that the groups most affected by AIDS are women,
young people, children, men who have sex with men (MSM), injecting
drug users (IDUs), sex workers and prisoners. They are:
- more likely to be living with HIV than the general
population;
- less able to deal with the impact of the epidemic;
and
- most likely to be failed by existing policies,
programmes, support and services.
The Strategy emphasises the need to "address
the underlying drivers of their susceptibility and vulnerability.
Thus, tackling AIDS means addressing social exclusion and safeguarding
human rights."[79]
45. Witnesses agreed that IDUs, sex workers, MSM,
other sexual minorities and prisoners are among the most marginalised
groups in society and suffer the most discrimination. In many
countries the authorities deny the existence of these groups or
their behaviour is classified as illegal. Access to public health
services is often difficult, due to distance, cost, stigmatisation
or cultural factors. For example, where drug use is illegal, injecting
drug users often do not use government health services for fear
of prosecution or because they are subjected to discrimination
by health staff.[80]
46. Mike Podmore of VSO identified people with disabilities
as a particularly vulnerable group who were frequently forgotten
in international policy discussions. He believed that there was
a need for "increased and directly focused support for disabled
persons' organisations in-country" to enable them to influence
policy dialogue. He said that DFID should support innovative projects
that disabled people's organisations were trying to promote to
enable them to participate in the planning and delivery of HIV
services. He told us that "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." He called for DFID to support advocacy networks
such as the African campaign on HIV and AIDS and disability, and
other similar national networks.[81]
47. Similarly, World Vision highlighted that:
Children and adults with disabilities are routinely
ignored and marginalised because of fear and misunderstanding
around disability. This includes exclusion from HIV prevention
and support services. Less than 10% of disabled children in sub-Saharan
Africa receive an education and therefore more than 90% miss out
on school-based HIV-education programmes. Literacy rates are very
low amongst people with disabilities.[82]
It said that there is a "mistaken belief that
disabled people are not sexually active and are not at risk from
HIV infection" and that "this misapprehension is doubly
damaging and dangerous as children and adults with disabilities
are 2-3 times more likely to face sexual abuse and violence."
Street children were also identified as:
[…] one of the most marginalised groups
when it comes to accessing HIV-related services and support. Care
for orphans and vulnerable children often evolves from home-based
care programmes—which by their very nature are poorly suited
to reaching children who live or work on the street. Street children
are more likely to be sexually active at a younger age. They are
unlikely to use testing and counselling or treatment services,
access to which often depends on consent from a parent or guardian
and a stable, supportive home life. Street children are in great
need of HIV prevention services, but rarely receive them.[83]
Role of civil society in providing
HIV/AIDS services
48. In our 2008 Report, we emphasised that "civil
society is particularly important in reaching marginalised groups
who are much less likely to use services provided by the state."
However, it was not clear to us from the Strategy how DFID would
support civil society organisations to undertake HIV/AIDS work
and we requested further information. The Government's Response
acknowledged "the important role that civil society has within
an effective AIDS response" and provided us with examples
of DFID support for civil society interventions in a number of
countries. These included DFID funding in Nepal for a Challenge
Fund managed by the National Association of People Living with
HIV/AIDS which worked with 70 community-based organisations providing
nutrition support, treatment, care homes and referrals for 5,000
people living with HIV/AIDS.[84]
49. The UK Consortium told us that "in the short
to medium term, and until public health systems are improved,
civil society organisations can often target and provide services
more quickly and effectively to the hardest to reach communities".[85]
However, Alvaro Bermejo of the Alliance believed that DFID's ability
to use civil society to reach marginalised groups effectively
was hampered by the need to reduce administrative costs. He said
"they have less and less staff both on the ground and here
[in London] and thus are looking to reduce their transactional
costs [and] the amount of time it takes to mobilise resources
and support". He said that many of the civil society organisations
working in HIV/AIDS were small and "very diversified"
and partnership with them took up a lot of time. He felt that
efficiency savings were driving DFID towards budget support for
multilateral programmes where "hundreds of millions of dollars"
could be disbursed without having to deal with small community
groups. He suggested that one solution to the current problem
of interacting with smaller groups would be for a number of donors
to pool their funds and hire a technical management agency to
disburse funds to small civil society groups.[86]
50. The impact of a reducing staff headcount on DFID's
work has featured in a number of our reports. Specifically in
relation to HIV/AIDS, our 2008 Report noted that "staff reductions
at DFID may have reached the point where they risk adversely affecting
the Department's ability to deliver its objectives in vital fields
such as health and social care."[87]
In response, DFID said that the balance of posts in the organisation
would move away from general administrative roles to a "greater
concentration on professional skills" and that "we expect
to employ more staff with political and institutional knowledge
about our stakeholders; and with skills enabling them to build
relationships and communicate effectively."[88]
We will return to the question of the impact of efficiency savings
on DFID's wider operations in our forthcoming inquiry into the
DFID Annual Report 2009.
51. Reaching the most marginalised people and
those excluded from society with effective HIV/AIDS interventions
can often best be achieved by small civil society organisations
who understand the needs of specific groups of disadvantaged people.
Engaging with such organisations requires adequate staff time
and expertise. We remain concerned that DFID staff reductions
mean that the Department is less well-equipped to do this necessary
work than previously.
52. DFID has given us some impressive examples
of how it is using Challenge Funds channelled through umbrella
organisations to support community-based organisations. We are
not, however, convinced that DFID yet has a comprehensive strategy
for working through civil society and community groups to reach
the people most in need of HIV/AIDS services. We recommend that
DFID, in response to this Report, provide us with further information
on how it will use its monitoring and evaluation mechanisms to
measure the effectiveness of its funding for HIV/AIDS civil society
groups.
Gender-based violence
53. In our 2008 Report on Maternal Health we noted
that "gender-based violence has a powerful impact on women's
health, and contributes to unplanned pregnancies, abortions and
the spread of sexually transmitted infections, including HIV and
syphilis."[89] In
our 2008 AIDS Report we expressed concern about "DFID's lack
of dedicated strategies and funding to address gender-based violence
which is closely linked to the spread of HIV."[90]
In its response, DFID told us that it would address the issue
of gender-based violence through its existing Gender Equality
Action Plan and through its country programmes. It said that it
was "reviewing the level of our work on violence against
women, to evaluate where, and how, we can do more on this important
issue."[91]
54. DFID announced in its recent White Paper a commitment
to include, within its new security and access to justice programmes,
measures to support women and girls affected by violence.[92]
We were also encouraged to see that one of the priorities for
action in the M&E Framework is: "ensuring that gender
analysis is integrated within national AIDS plans, and that targets
and indicators are developed to measure the impact of AIDS programmes
on women and girls."[93]
However, the problem of gender-based violence against women and
girls and its interaction with HIV/AIDS is still not being addressed
directly.
55. Gender-based violence is an abuse of women's
human rights and is a significant contributory factor in the spread
of HIV. In its new White Paper, DFID has given a commitment to
support women and girls affected by violence and its HIV/AIDS
Monitoring and Evaluation Framework includes a provision for gender
analysis of AIDS programmes. Although welcome, neither of these
measures directly tackles the impact of gender-based violence
on women and its links with HIV. DFID told us last year that it
was reviewing its work on violence against women to assess where
and how it could do more to tackle it. We recommend that it shares
the results of that review with us, in response to this Report.
76 Twelfth Report of Session 2007-08, HIV/AIDS:
DFID's New Strategy, HC 1068-I, para 87 Back
77
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, HC 235, p 16 Back
78
Third Report of Session 2008-09, DFID and China, HC 180-I,
paras 48-49 Back
79
Achieving Universal Access, p 23 Back
80
Ev 75 Back
81
Q 14 [Mike Podmore] Back
82
Ev 86 Back
83
Ev 86 Back
84
Twelfth Report of Session 2007-08, HIV/AIDS: DFID's New Strategy,
HC 1068-I, paras 88-97; 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, HC 235, pp 16-17 Back
85
Ev 75 Back
86
Q 15 [Alvaro Bermejo] Back
87
Twelfth Report of Session 2007-08, HIV/AIDS: DFID's New Strategy,
HC 1068-I, p 109 Back
88
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, HC 235, p 19 Back
89
International Development Committee, Fifth Report of Session 2007-08,
Maternal Health, HC 66-I, para 25 Back
90
Twelfth Report of Session 2007-08, HIV/AIDS: DFID's New Strategy,
HC 1068-I, paras 67-69 Back
91
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, HC 235, p 13 Back
92
DFID, Eliminating World Poverty: Building our Common Future, Cm
7656, July 2009, p 75 Back
93
Achieving Universal Access- Monitoring performance and evaluating
impact, p 13 Back
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