Written evidence submitted by the International
HIV/AIDS Alliance
September 2009
The International HIV/AIDS Alliance (the Alliance)
welcomes this opportunity provided by the International Development
Committee to contribute to the review of the Department for International
Development's Strategy "Achieving Universal Access".
This submission will draw on the Alliance's global experience
of working with populations key to the HIV epidemic, and as a
civil society organisation active in service delivery, capacity
building and advocacy at both national and international levels.
The Alliance will address in this submission all six areas of
focus identified by the Committee for this enquiry.
I. THE INTERNATIONAL
HIV/AIDS ALLIANCE
1. Established in 1993, the International
HIV/AIDS Alliance (the Alliance) is a global partnership of nationally-based
organisations supporting community action on AIDS. Currently working
in over 40 countries—those threatened by emerging epidemics,
as well as those already heavily affected—the Alliance emphasises
the importance of working with people who are most likely to affect,
or be affected by, the spread of HIV. DFID has funded the Alliance
through a Programme Partnership Agreement (PPA) since 2004. In
the Caribbean, the Alliance is currently implementing a HIV/AIDS
programme with DFID support of £2 million.
II. THE PROCESS
ESTABLISHED BY
DFID FOR MONITORING
THE PERFORMANCE
AND EVALUATING
THE IMPACT
OF THE
STRATEGY
2. As noted in previous submissions to this
Committee in 2008, dividing the process of Strategy development
from the development of a monitoring, evaluation and accountability
strategy posed challenges. The development of "Achieving
Universal Access" Strategy ("the Strategy")
would have benefitted from an integrated process of indicator
selection to ensure that the Strategy from the outset was committing
to measurable deliverables and commitments.
3. In many ways, the process established
by DFID to develop the M&E framework presented a groundbreaking
approach in engaging civil society in the monitoring process of
the Strategy and in making the framework more relevant for those
involved in the implementation of the Strategy. Following DFID's
request for civil society involvement in the development of its
M&E framework, the UK Consortium on AIDS and Development set
up an "Indicators" Working Group' (IWG), of which the
Alliance was a member. Whilst the IWG was asked to focus the development
of indicators, it was able to provide support and expertise to
inform other parts of the framework. DFID's commitment to the
process and the IWG was clearly shown through the continued engagement
of staff and the openness and honesty with which meetings were
conducted.
4. Based on the Alliance's assessment of
the process, the discussion between the IWG and DFID led to a
more balanced approach to monitoring and evaluation of the Strategy.
It allowed DFID's efforts to be informed by recognised good practice
and the direct experiences of monitoring HIV responses. The discussion
and joint inputs have resulted in more requests for qualitative
information within the data collection tools, which will facilitate
documentation of good practice for knowledge sharing and learning.
5. The short timeframes for review of draft
documents and provision of feedback, and the application of Chatham
House rules to the IWG proceedings, limited the ability of the
IWG to consult and engage the stakeholders it was representing.
From the outset there appeared to be lack of clarity of the purpose
of the group, with no efforts to agree on Terms of Reference for
the IWG or to clarify its role in the final decisions related
to the selection of indicators. IWG members were not assured endorsement
of the final product.
6. So despite DFID's commitment to an inclusive
approach, the methodology and nature of the process limited the
extent to which civil society engagement was meaningful due to
several factors. Collectively, these elements of the process presented
challenges to the ability of the IWG to be fully representative.
We hope very much that as this work progresses that this process
will be improved and that the M&E strategy will benefit from
a more rigorous consultation process.
7. Recommendation:
— Future efforts to engage civil society
should adopt an approach that allows for more thorough engagement
of all partners in the development of the M&E framework. Recommendations
for good practice from HM Government COP on consultations[25]
should inform consultation efforts across HM government's departments.
III. PROGRESS
ON HEALTH
SYSTEMS STRENGTHENING
AND ON
AN INTEGRATED
APPROACH TO
HIV/AIDS FUNDING
Progress on Health Systems Strengthening
8. Since the launch of "Achieving
Universal Access" and the announcement of the UK government's
plans to spend £6 billion on strengthening health systems
and services, there has been limited information available on
the use of these funds. Since the launch of the Strategy, the
UK government has made the following commitments:
— an estimated £450 million until
2011 to support national health plans for eight IHP+ countries
at the UN High Level Event on the Millennium Development Goals
in September 2008;
— £40 million to the Affordable Medicines
Facility for malaria and an increase in malaria research spending
to at least £5million per year by 2010; and
— £50 million to fighting neglected
tropical diseases.[26]
Despite the Committee's request,[27]
it remains unclear how these commitments and the £6 billion
committed under "Achieving Universal Access"
will contribute to strengthening health systems and services to
support the achievement of universal access.
9. The International Health Partnership
and Related Initiatives (IHP+) presents an opportunity to DFID
to allocate resources to health systems strengthening, however
implementation progress has been slow. While the IHP+ aims to
improve the effectiveness of health aid delivery, the IHP+ has
not been able to address the initial key concern of financing
gaps for health in its focus countries. In Ethiopia, the first
country to sign a compact, a funding gap of between US$1.56 billion
to US$2.84 billion was identified.[28]
However, in response, donors, including DFID, allocated just a
fraction of what was required.
Threatening universal access to HIV prevention
10. 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. Universal access to HIV prevention cannot
be achieved solely by investing in health systems and services
and is often an area that formal health systems ignore. 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.
11. An area where the UK has been taking
a lead is through its role in the EU Action Team on Prevention,
under the European Programme for Action to confront HIV/AIDS,
Tuberculosis and Malaria in External Action.
12. The Alliance notes the Committee's finding
in point 14 of the 12th report of session 2007-08. The Alliance
fully agrees with the principle that health service access should
always be seen as an opportunity to support prevention efforts
and that in the case of prevention of mother to child transmission
and TB prevention and management this is especially critical.
Supporting an integrated approach
13. The Alliance is concerned about the
adopted position that "parallel systems" are inherently
inefficient or more likely to result in lack of co-ordination
than HIV services integrated into broader health systems—usually
interpreted as systems run only by the state. Much of health systems
strengthening does not refer to a broad system which integrates
community level systems into the continuum of care in an effective
and sustainable way.
14. Community level systems play a critical
role in ensuring access for and involvement of marginalised populations
in HIV services. In many places, "stand alone" ARV treatment
programmes have been developed or implemented due a lack of capacity
in the broader health system, and in response to the high levels
of stigma and discrimination experienced by people with HIV in
health services. Addressing stigma and discrimination in broader
health systems is critical to ensuring successful integration
or a broader health system role in HIV treatment and care. However
there is little evidence of overt plans to address this in many
health systems integration plans or discussion documents. This
is something that needs to be addressed before integration is
attempted, not after evidence of systematic discrimination becomes
known.
15. It is simplistic to imagine that a parallel
system is inherently less effective and efficient than a large,
multi-departmental system, as "parallel" systems with
effective communication and co-ordination mechanisms could provide
a more effective and integrated service than administratively
"integrated" systems with poor internal communication
and co-ordination. In Ukraine, where ARV procurement, supply and
distribution has recently been "integrated" into the
health system after many years of effective delivery through community
organisations, evidence shows that it has resulted in significant
problems in continuity of supply due to inefficient systems and
a lack of commitment within the state agencies.
16. Evidence suggests that integration of
the community level systems can result in reductions of hospital
readmissions of chronically ill patients, better co-ordination
of care, and increased access to services through the delivery
of high quality, cost-effective home based care. In Uganda, health
workers identified the referral system operated by the Alliance's
Network Support Agents (people living with HIV providing support
and services linked to the formal health system) helped increase
the number of people living with HIV served and also made reporting
more efficient and effective.
17. Recommendation:
— DFID should publish the breakdown of
its spending on health systems strengthening along with mechanisms
to collect evidence of impact on health and HIV indicators.
— Through its leadership role in the IHP+,
DFID needs to ensure more rapid implementation at the country
level, which includes efforts to fill financing gaps for health
in the IHP+ focus countries.
— DFID should demonstrate how it is meeting
its commitment to universal access to prevention, including by
urgently exploring and supporting immediate investments into HIV
prevention measures that may need to be addressed outside the
formal health system.
— DFID should ensure that gains in the
HIV response are not lost through its focus on HSS, by addressing
stigma and discrimination before integration of HIV responses
into public health systems is attempted.
— DFID's approach to integrated funding
for AIDS should recognise the role of community systems and through
its funding and policies ensure adequate support to this sector.
IV. INTEGRATION
OF HIV PREVENTION,
TREATMENT AND
CARE WITH
OTHER DISEASE
PROGRAMMES, PARTICULARLY
TUBERCULOSIS AND
MALARIA
18. The continued lack of concrete strategies
and approaches for integration of HIV with other disease programmes
from DFID gives rise to concerns that support for integration
may not be nuanced enough to take into account the complexities
of HIV. While the benefits of integrating HIV with other disease
may provide gains from the funding and policy perspective, this
may not always be the case at the level of service access and
delivery. Furthermore, a nuanced and well-developed approach to
integration is required to avoid any compromise on quality and
access, and setbacks in the delivery of HIV-related services.
19. While the Strategy clearly recognises
the need for linkages and integration between SRHR and HIV, it
still remains unclear how DFID intends to support integration.
Beyond the promise to intensify efforts to halve unmet need for
family planning by 2010, neither the Strategy nor the M&E
framework include a target related to universal access to comprehensive
reproductive health, as articulated in the MDG target 5b, or to
sexual health, and the realisation of sexual and reproductive
rights as a critical component of HIV responses.
20. The Maternal Health and SRHR strategy,
initially planned for mid-2009, has been postponed indefinitely
and therefore this opportunity in the last year to concretise
DFID's actions in this area was not realised. Upgrading the 2004
SRHR Position Paper to the level of a strategy to guide the UK's
support for maternal health and SRHR, with its accompanying targets
and M&E framework, will reinforce and supported the operationalisation
of the emphasis on linkages with HIV outlined in the Strategy.
21. The Committee recommended in its 12th
report of session 2007-08 that DFID presses particularly the Global
Fund to do more to support the integration of services. DFID staff
from the AIDS and Reproductive Health Team expressed interest
in the Alliance's experience of securing Global Fund resources
for integrated services. However, this has not yet translated
into an increase in resources for the Global Fund to support its
scale up of integrated programmes.
22. The Alliance notes that neither DFID's
strategy nor the Committee's review last year highlighted the
urgent need for greater integration between Hepatitis C and HIV
responses among people who use drugs. HIV and HCV co-infection
affects large numbers of injecting drug users and the two diseases
interact to produce more rapid disease progression and higher
rates of mortality and morbidity. While the same proven interventions
for HIV prevention among drug users also prevent transmission
for HCV, diagnostic and treatment outcomes for both could be significantly
enhanced with greater integration of mostly lacking responses
to HCV and HIV. Rates of HCV testing are low, and despite being
increasingly successful, access to treatment for HCV is very poor
due to the high cost of patented drugs and the lacking capacity
in health systems and community organisations to manage HCV treatment.
23. Recommendations:
— Specific approaches to ensure integration
of HIV with other disease programmes need to be developed and
published as part of the Strategy and its M&E Framework.
— DFID's approach to integration needs
to be more nuanced, taking into account the particularities of
the HIV response, the strength of health systems and the social
and legal context, to avoid any compromise on quality and access,
and setbacks in the delivery of HIV-related services.
— DFID should ensure that integration and
linkages between SRHR and HIV address SRHR comprehensively, and
are not limited to family planning. These efforts should be guided
by and clearly defined within the overdue Maternal Health and
SRHR Strategy.
— Efforts to address HCV infection need
to be incorporated into HIV responses for people who use drugs
to ensure more impact of DFID support on health outcomes for these
communities.
V. THE EFFECTIVENESS
OF DFID'S
STRATEGY IN
ENSURING THAT
MARGINALISED AND
VULNERABLE GROUPS
RECEIVE PREVENTION,
TREATMENT, CARE
AND SUPPORT
SERVICES
24. Effective programmes for marginalised
groups are central part of the Strategy. The Alliance looks forward
to continue supporting DFID's work in this area and strongly recommends
that DFID develops clear plans for how the UK Government will
act on the commitments it has made in its Strategy to marginalised
populations.
25. The Alliance has had productive meetings
with the FCO in relation to their role in the implementation of
the Strategy. However we are unclear about how the FCO and DFID
are taking this work forward as there has been limited communication
with UK stakeholders. This may have resulted in missed opportunities
for synergies and collaborative advocacy.
26. The Alliance also welcomes DFID's ongoing
support for the International Harm Reduction Association and for
DFID's excellent advocacy work in support of HIV prevention at
the UNGASS High Level Meeting on Narcotic Drugs held in Vienna
in June 2009. DFID has made a new commitment to supporting the
work of the Global Forum on HIV and MSM. The Alliance applauds
this commitment as a significant step in ensuring strengthened
advocacy and commitment globally to meeting the HIV prevention
needs of this critically important and underserved population.
27. In a number of countries, including
Senegal, the work of DFID and the FCO in supporting local advocacy
has also helped to protect the rights of this highly vulnerable
population. Conversely, the withdrawal of DFID staff and offices
from some countries, such as Nepal, presents risks to the continuity
of important programmatic interventions targeting vulnerable populations,
and threatens to undermine universal access commitments.
28. Recommendations:
— That the FCO and DFID develop and publish
plans to address the needs of marginalised groups, which includes
predictable and sustainable financing for community responses
most effective at reaching marginalised groups.
VI. THE EFFECTIVENESS
OF SOCIAL
PROTECTION PROGRAMMES
WITHIN THE
STRATEGY
29. Based on the Alliance's programming
experience supporting children affected by HIV and AIDS, children
who are the most vulnerable to HIV infection and also to the impact
of HIV on their lives are most likely not to benefit from development
interventions. These include children with disabilities, street
and working children and those most rarely mentioned, children
of people who use drugs and of sex workers.
30. Social protection programmes in general,
and those programmes that promote community targeting of vulnerable
families, an important positive approach in social protection
programmes, are in danger of excluding these families due to stigma
and discrimination by community members and institutions. Criminalisation
of sex work, of drug use and of these communities contribute to
the difficulties in identifying children and families in need
and ultimately excludes them from services because of fear of
police harassment, legal action and separation of children from
their families.
31. The success of DFID's commitment to
cash transfer and social protection programmes will depend on
DFID's efforts to address the underlying structural causes of
children's and their families' vulnerabilities, such as criminalisation,
stigma and discrimination and broader human rights violations.
In addition to ensuring the participation of affected and marginalised
communities in the development of social protection programmes,
social protection programmes must be provided in an environment
that ensures the realisation of these communities' rights.
32. Recommendations:
— As social protection programmes, including
cash transfers, are at risk of not reaching the most marginalised
children affected by AIDS there is a need for direct support for
efforts to address underlying structural causes of children's
and their families' vulnerabilities to complement.
VII. PROGRESS
TOWARDS THE
COMMITMENT TO
UNIVERSAL ACCESS
TO ANTI-RETROVIRAL
TREATMENT AND
ITS IMPACT
ON THE
EFFECTIVENESS OF
CARE AND
TREATMENT, PARTICULARLY
FOR WOMEN
33. Despite DFID's commitment to universal
access in the Strategy, the leadership in this area shown by DFID
in the past appears to be waning. DFID's contributions to the
HIV response are increasingly tied to improvements in health services
and systems, rather than targeted HIV-related outcomes. If this
is the case, then DFID's approach risks undermining and reversing
the hard-won progress made to date towards universal access to
treatment. The Global Fund to Fight AIDS, TB and Malaria, for
example, faces a severe funding shortfall of approximately $4
billion for the 2008-2010,[29]
despite providing ARVs to more than 2 million people living with
HIV. We welcome DFID's long-term commitment to the Global Fund,
however £1 billion over seven years, does not represent the
UK's fair share to support the Global Fund's efforts to, among
other things, sustain and increase access to ARV treatment.
34. There has been tremendous progress made
on increasing the number of HIV positive people who receive treatment.
There is an urgent need to maintain a focus on these gains to
ensure uninterrupted access to ARV treatment, and consistent drug
supply chains to reduce the frequency of drug stock-outs, to not
only save the lives of those already on treatment and those in
need in future—but also to reduce the likelihood of drug
resistant HIV. In order to make progress on this important issue,
we welcome DFID's strong support for UNITAID's patent pool, which
has enabled the cost of treatment for HIV, TB and malaria to be
reduced at the country level.
35. Recommendations:
— DFID should ensure that its focus on
health systems strengthening does not undermine progress to universal
access to HIV treatment and provide its fair share to the Global
Fund by increasing on its current pledge by £183.5 million
for the period 2009-10 to enable ongoing and future treatment
programmes.
25 http://www.berr.gov.uk/files/file47158.pdf Back
26
"Health in Crisis: Why in a time of economic crisis Europe
must do more to achieve the health MDGs"; Action for Global
Health; 2009;
(http://www.actionforglobalhealth.eu/media_publications/afgh_policy_reports/policy_report_health_in_crisis/policy_report_health_in_crisis) Back
27
Point 20 of the 12th report of session 2007-08. Back
28
Compact between the Government of the Federal Democratic Republic
of Ethiopia and the Development Partners on Scaling Up For Reaching
the Health MDGs through the Health Sector Development Programme
in the framework of the International Health Partnership; Ethiopian
Federal Ministry of Health; August 2008
(http://www.internationalhealthpartnership.net/CMS_files/documents/ethiopia_country_compact_EN.pdf) Back
29
Updated Demand Estimate 2008-10; Global Fund to Fight AIDS, TB
and Malaria; Caceres, Spain, 30 March to 1 April 2009; (http://www.theglobalfund.org/documents/publications/replenishment/caceres/Resource_Needs_2008-2010_en.pdf) Back
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