Written evidence submitted by Interact
Worldwide
1. Interact Worldwide welcomes the opportunity
to feed into the inquiry. We are a UK based NGO working in sexual
and reproductive health and rights and HIV and AIDS with implementing
partners in developing countries including Ethiopia, India, Malawi,
Uganda and Pakistan. Our partners are engaged in efforts to scale
up a comprehensive and integrated response to sexual and reproductive
health, including maternal health and HIV services.
2. Interact Worldwide will comment on the
following questions raised by the IDC:
— the process established by DFID for monitoring
the performance and evaluating the impact of the Strategy;
— progress on health systems strengthening
and on an integrated approach to HIV/AIDS funding;
— integration of HIV/AIDS prevention, treatment
and care with other programmes;
— the effectiveness of DFID's Strategy
in ensuring that marginalised and vulnerable groups receive prevention,
treatment, care and support services; and
— progress towards the commitment to universal
access to anti-retroviral treatment and its impact on the effectiveness
of care and treatment, particularly for women.
The process established by DFID for monitoring
the performance and evaluating the impact of the strategy
3. As members of the IDC are aware, last
November DFID released a document setting out the process they
will use to evaluate the impact of their HIV and AIDS strategy
Achieving Universal Access. In it DFID commits to producing a
report every two years, with the first one due at the end of 2010,
as well as a mid-term evaluation to take place in 2011. Below,
we give some comments on the technical details of the process
and on our concerns in relation to what exactly is to be monitored.
4. The biennial reports which DFID propose
will give an overview of their work at country, regional and multilateral
level and will highlight successes, challenges and areas for future
action. Progress will be assessed against the priorities identified
in Achieving Universal Access, as well as against the DFID Corporate
Performance Systems and international targets such as the MDGs,
UNGASS targets etc.
5. While limiting reporting to every two
years will make it difficult for civil society to gain an up to
date understanding of what progress DFID is making, given DFID's
limited staff capacity on HIV and AIDS Interact Worldwide is broadly
supportive of this proposal. We would emphasise the need for open
communication between DFID staff and civil society in the period
between reports, so that an accurate understanding of DFID's commitments
is possible, leading to more fruitful dialogue in national and
international forums and deepened partnerships in developing countries.
6. As mentioned above, DFID is also proposing
a mid-term evaluation to take place in 2011. They have suggested
that a representative of civil society with expertise in monitoring
and evaluation will be included in the evaluation team. Interact
Worldwide would like to make some basic points concerning this
evaluation:
— The evaluation should focus on lessons
learnt from the first stage of the strategy's implementation,
and the follow up process needs to ensure that these lessons are
translated into changes in the second stage. It is particularly
important that any evaluation be completed and a follow up action
plan drawn up and implemented early in the strategy's lifetime.
— There appears to be some overlap between
the functions of the mid-term evaluation and the biennial reports,
with both appearing to include a monitoring and an evaluation
component. It may be more strategic for DFID, given limited resources,
to focus on making the most of the biennial reports and ensuring
that recommendations from these are followed through.
— Civil society involvement in any monitoring
and evaluation process needs to be as open and transparent as
possible. To this end, civil society should be able to select
its own representative (according to skills criteria set out by
DFID) and where possible civil society representatives should
be able to engage in dialogue with their colleagues in the wider
NGO community.
7. Beyond the technical process, Interact
Worldwide also has some concerns relating to the criteria against
which DFID's work will be evaluated. The priorities and some of
the key actions proposed in the monitoring and evaluation framework
are open to broad interpretation. For example, by pointing to
relatively general activities many country offices will be able
to say they have met targets to "support the empowerment
of people living with HIV and vulnerable groups" and "promote
and take action on neglected and sensitive issues including adolescents'
sexual and reproductive rights". Interact Worldwide would
have liked the monitoring and evaluation framework to be based
on more specific and measurable targets, as this would have provided
for a more robust assessment framework. The vagueness of the DFID
priorities makes it all the more important that country offices
are encouraged to develop their own detailed targets and indicators,
and that the reporting and evaluation processes focus on outcomes.
8. This point links in to the issue of data
collection. In the past, DFID have had difficulty tracing exactly
where their money is going and particularly whether it is bringing
benefit to vulnerable and marginalised groups. It is important
that DFID reporting systems can establish where money has gone
and who has benefitted.
Progress on health systems strengthening and on
an integrated approach to HIV/AIDS funding
9. Interact Worldwide would first like to
make a general comment on integrated funding. During last year's
IDC enquiry many organisations raised concerns about the use of
a single funding target for health systems including the HIV response.
While a strong health system is a key component of the AIDS response,
other sectors including education, legal reform, women's empowerment
and poverty alleviation all have a role to play, as do non state
actors such as NGOs, social movements and community based organisations.
While we have been assured by DFID staff that these sectors are
continuing to receive DFID funding it is unclear what funding
commitments have been made with in other sectoral lines of the
DFID budget and whether these are sufficient for the project cycle
of the HIV and AIDS strategy.
10. Until DFID's first progress report is
released it will be difficult to comment in detail on their efforts
in terms of health systems strengthening and funding, and whether
this has led to improvements in service delivery and access. However,
we can comment on DFID's work with bodies including the International
Health Partnership, the World Bank and the Global Fund for AIDS,
TB and Malaria.
The International Health Partnership and related
initiatives (IHP+)
11. The IHP+ was launched in 2007 and aims
to improve the way international agencies, donors and developing
countries work together to develop and implement national health
plans. It aims to harmonize funding around a single national health
strategy, thus reducing the administrative burden for country
governments and promoting long term planning. While development
of the national health plan is country-led, donors including DFID
play a role in inputting into this process.
12. While Interact Worldwide supports the
IHP+ goals in terms of harmonization and improving effectiveness,
we are concerned that in some cases the IHP+ has led to a marginalisation
of sexual and reproductive health, an area that links closely
to HIV and AIDS. For example a study completed by Interact Worldwide
in Ethiopia earlier this year (attached) found that scaling up
reproductive health services had not received sufficient attention
in the IHP+ country compact. Moreover, the national health plan
had not linked with existing reproductive health initiatives including
the UNFPA Global Programme on Reproductive Health Commodity Security.
13. While focusing on health systems strengthening,
it is critical that health planning efforts (including through
initiatives like the IHP+) lead to gains in specific health areas
such as HIV, sexual health, family planning etc. This is in line
with the fifth Paris Principle—managing for results.
14. Within the IHP+ system basic criteria
already exist against which national plans are assessed, and better
results could be assured through the inclusion of criteria on
reproductive health and its integration with HIV services, as
well as on ensuring access to services for vulnerable and marginalised
groups. As DFID sit on the board of the IHP+ this is something
that they could push for at international level.
The World Bank
15. A recent study by its own evaluation
office (EIG) found that up to one third of funds that went to
the World Bank's Health, Nutrition and Population Programme had
been spent ineffectively. The EIG report highlighted major blockages
around performance, ensuring outcomes that benefit the poor, monitoring,
accountability, risk assessment, efficiency and coordination with
other sectors. The study recommended that the Bank take the following
measures in order to improve its performance:
— Intensify efforts to improve its performance.
— Renew its commitment to delivering results
for the poor, including greater attention to reducing high fertility
and malnutrition.
— Build its own capacity to help countries
make health systems more efficient.
— Enhance the contribution of other sectors
to HNP outcomes.
— Improve evaluation and governance.
16. As a major donor to the World Bank,
DFID should take action to ensure these recommendations are followed
up. Moreover, given these findings we would urge the UK government
to reconsider its reliance on the World Bank to deliver for the
health sector overall and for SRH.
The Global Fund for AIDS, TB and Malaria (GFATM)
17. The GFATM has played a vital role in
generating increased ODA targeted towards meeting MDG 6. To date,
the GFATM has approved funding of US $11.4 billion for 550 programmes
in 140 countries. It provides a quarter of all international financing
for AIDS, two-thirds for TB and three quarters for malaria. In
addition, the GFATM has developed a range of policy initiatives
to enhance country-led efforts to address the target diseases
and benefit other health indicators, including:
— Explicit recognition and funding opportunities
to support the strengthening of public, private and community
health systems. Funding can support strengthening of systems where
weaknesses and gaps constrain the achievement of improved disease
outcomes.
— Adoption of a strategy for Gender Equality
which guides Global Fund efforts to encourage a positive bias
in funding programs and activities that address gender inequalities
and strengthen the response for women and girls.
— An explicit recognition of the importance
of linking sexual and reproductive health and rights and the three
diseases. The Gender Equality Strategy and materials supporting
proposal development highlight the importance of increased linkages.
They state that funding can be requested to provide access to
HIV prevention through integrated health services, especially
for women and adolescents through reproductive health care. More
funding has been secured in recent Rounds for RH commodities including
contraceptives.
— A separate but complementary strategy
on Sexual Orientation and Gender Identities was approved and should
support community organisations targeting HIV prevention within
vulnerable communities.
— Explicit recognition of and funding to
support community systems involved in the responses to the three
diseases. Scaling up the response to the three diseases will not
be successful without strengthened community systems.
18. A key challenge for the GFATM at present
is a severe funding shortfall, which will impact on the amount
of grants that can be fully funded. This sends a worrying message
to countries looking to the Global Fund to provide sustainable
funding for life-saving interventions. Donors must help to fill
the gap by paying their fair share.
19. The Secretary of State has indicated
that there will not be an additional UK pledge beyond the £1
billion announced at the launch of the strategy to cover the period
2008-15. Interact Worldwide and colleagues have called on the
UK to increase its pledge for the period up to 2010 by £183
million, on top of our current pledge of £360 million for
that period. This is the UK's fair share based on our share of
total donor income (5.7%).
20. Alongside considering increases to their
financial contribution, the UK can provide key technical assistance
to civil society and ministries in their country level roles in
order to ensure they are requesting GFATM funds for programmes
which integrate HIV, reproductive health and gender.
Integration of HIV/AIDS prevention, treatment
and care with other disease programmes, particularly tuberculosis
and malaria
21. On the question of how HIV and AIDS
responses are being integrated with other health services, we
must broaden the set of cohorts to include sexual and reproductive
health and rights (SRHR). Causes of poor SRHR and HIV and AIDS
are intimately related and have common drivers: poverty, gender
inequity, marginalisation, stigma, discrimination and denial.
To separate the responses divorces them from the reality in which
sexual and reproductive behaviour takes place and is, in turn,
contributing towards the lack of progress being made to address
issues such as maternal death, unintended pregnancy and HIV and
AIDS. Indeed, the revised strategy states as a priority "supporting
the integration of HIV and AIDS with TB, malaria and SRHR including
maternal, newborn and child health services".
22. While limited information will be available
until next year's report, Interact Worldwide has some concerns
around the declining emphasis placed on SRHR services in the context
of health systems strengthening. As set out above, evidence from
an Interact Worldwide study in Ethiopia found that SRHR services
had been marginalised in the national health plan and harmonisation
between reproductive health initiatives and the IHP+ country compact
had not taken place. Furthermore, the commitment in DFID's Strategy
to "work with others to intensify international efforts to
increase to 80% by 2010 the percentage of HIV infected pregnant
women who receive ARV treatments to reduce the risk of mother
to child transmission" seems to construe PMTCT narrowly as
the provision of drugs to prevent vertical transmission and does
not consider the full scope of interactions between HIV and sexual,
reproductive and maternal health.
23. WHO guidelines state that comprehensive
PMTCT also includes delivery and post-partum care, HIV treatment
for women, infants and their families as appropriate, SRH services
including family planning and dual protection advice for women
and their partners. PMTCT services should also recognise the high
levels of violence faced by women in some countries and adapt
the way they work accordingly.
24. Services which meet a wide range of
needs are more likely to be taken up by women, leading to better
health outcomes for women, their partners and children. By limiting
its approach to a narrow definition of PMTCT services the UK is
failing to reach vulnerable women. This is worrying given that
the UK is leading an EU wide action team on HIV prevention, focussed
on PMTCT. Interact Worldwide and others raised these issues at
a recent Open Space Day on PMTCT at DFID but there has been little
communication on how discussions from that day will influence
DFID policy going forward.
The effectiveness of DFID's strategy in ensuring
that marginalised and vulnerable groups receive prevention, treatment,
care and support services
Women and girls
25. The recent DFID White Paper announced
a tripling of funding for security and justice, with an emphasis
on preventing gender based violence, to £120 million per
year. This is a welcome announcement which we hope will lead to
a reduction in all forms of sexual and gender based violence.
26. DFID's strategy acknowledged that women
and girls increasingly bear the brunt of HIV and AIDS and recognised
that this was largely due to the denial of women's rights. Violence
against women was flagged as a particular concern.
27. The implementation framework accompanying
the strategy pledged to ensure inclusion of targets and indicators
on women and girls in national AIDS plans. While this commitment
was made over a year ago, we have no information on whether countries
have developed these targets and indicators. We believe that DFID
should be leading by example by ensuring these indicators are
speedily developed and then showcasing them in order to encourage
other countries to follow suit.
28. DFID also pledged to work with others
to halve the unmet need for family planning including male and
female condoms by 2010, and to achieve universal access to contraception
by 2015. This target has the potential to yield considerable results
in improving the status and health of women and girls. Yet currently
DFID has an outdated position paper on sexual and reproductive
health and rights which is not considered a comprehensive approach
to fulfilling the International Conference on Population and Development
Programme of Action. A new maternal health strategy was due this
year—which may have dealt with family planning and a range
of SRHR interventions—but Ministerial approval to postpone
this strategy until 2010, most likely after the next general election,
has now been given.
29. In this context, it is unclear how DFID
plan to meet their commitment on family planning and indeed what
they have done so far on this target. In fact, many organisations
working on SRHR are hearing from partners in developing countries
that the growing emphasis on health systems strengthening on the
part of donors is actually leading to reduced investment in vital
services such as family planning.
30. Increasing access to female condoms—the
only female-initiated method which protects against both STIs
and unintended pregnancy—is particularly important. Currently
demand for the female condom far outweighs supply yet this commodity
is not prioritised on country procurement lists and is largely
overlooked by donors and UN technical agencies. One obstacle is
cost; the average price of a female condom is 40 pence—up
to 30 times more expensive than a male condom.
31. The UK could take a number of steps
in order to comply with its commitment on female condoms including:
— Working with others to bring down the
cost of female condoms and to assure supply sustainability through
UNITAID and Access RH, an initiative of the Reproductive Health
Supplies Coalition which DFID now chairs.
— Providing sustainable funding for female
condom programmes both in terms of helping to create demand and
in funding supplies.
Men who have sex with men
32. Receptive anal sex is a sexual behaviour
that increases risk of HIV transmission exponentially. Yet in
many societies, discrimination and social marginalisation prevents
men who have sex with men (and other sexual minorities) from accessing
the services they need within the health system. Criminalisation
of same sex relations can also deter men who have sex with men
from being open with health workers about their sexual behaviours
and health needs. The resulting lack of information can lead to
increased risk of infection with HIV and STIs and also to reduced
likelihood of diagnosis and effective treatment.
33. Gender-based violence against sexual
minorities who are seen as deviating from gender norms is widespread
and often legitimised by discriminatory laws against same sex
relations (currently in place in more than 70 countries). The
recent DFID White Paper announced plans to tackle gender based
violence and ensure access to justice for survivors. This is a
welcome announcement which we hope will lead to a reduction in
all forms of sexual and gender based violence.
34. Wider promotion of the rights of sexual
minorities is also important in order to ensure their health,
livelihoods and life satisfaction. The FCO has already stated
"we do not think that democratic governance and sustainable
development can take place where groups of people are excluded
from enjoying their human rights" and has developed a programme
for promoting the human rights of LGBT people. We hope that going
forward DFID can work with the FCO to implement this programme
and promote the health and rights of sexual minorities around
the world.
Progress towards the commitment to universal access
to Anti-retroviral Treatment and its impact on the effectiveness
of care and treatment, particularly for women
35. While the number of people accessing
HIV treatment has now grown to at least 4 million, until the first
DFID report next year we will not know what role UK funding is
playing in this nor what impact it has had on women's access to
treatment.
36. In developing countries women are often
diagnosed with HIV during pregnancy. Care at this stage may focus
on preventing onward transmission to her baby while neglecting
the woman's wider health and psychosocial needs. It is vital that
PMTCT services cater to women's wider needs in line with WHO guidelines.
This will increase uptake and ensure better health outcomes for
women and children.
37. In addition, women are often unable
to take time away from work or family responsibilities and may
lack the resources to travel to hospital. Where HIV treatment
is integrated with other services (such as family planning, nutrition
counselling, and treatment for opportunistic infections) and provided
at primary care level, it is more likely that women will be able
to access and adhere to it. Health care workers should also be
trained in gender so they are able to understand the issues faced
by women and offer them appropriate treatment and services accordingly.
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