House of Commons - International Development Committee

Progress on the Implementation of DFID's HIV/AIDS Strategy - International Development Committee Contents

Written evidence submitted by RESULTS UK

30 September 2009

ABOUT RESULTS UK

Part of a global movement, RESULTS UK is a non-profit advocacy organisation which works internationally to generate the public and political will to end poverty. Currently, our work focuses particularly on education, health, microfinance and water and sanitation.

We currently lead a network of more than 30 organisations in the UK Coalition to Stop TB provide the secretariat to the APPG on Global Tuberculosis, and belong to the Advocacy to Control TB Internationally (ACTION) network and the Stop TB Partnership. We also belong to the Action for Global Health Network, the UK AIDS Consortium and the British Overseas NGOs for Development network (BOND).

SUMMARY

RESULTS UK welcomes the International Development Committee Inquiry into progress on implementation of DFID's HIV/AIDS Strategy "Achieving Universal Access". It is encouraging that the IDC are maintaining their commitment to examine HIV/AIDS issues annually.

It is very positive that the need for HIV-TB integration was incorporated into the HIV/AIDS strategy, and DFID has worked to apply this priority through central policy and in many partner countries. There are still gaps to be filled, but we believe this strategy will achieve long term benefits, not only in addressing the co-epidemic of HIV and TB, but in strengthening the global health sector.

We are however concerned at this early stage to ensure that there be stronger provisions for monitoring and evaluation. This is elaborated upon in the following submission.

Structurally, we are hopeful that DFID will continue to enhance the efficacy of its support, both bilateral and multilateral. It is, moreover, important that the international community continue to scale-up its response to HIV and HIV-TB.

KEY RECOMMENDATIONS

To DFID

Achieving Universal Access

all

— In cooperation with partner governments, record bilateral investment in HIV and HIV-TB as an input indicator.

The Challenge of TB and Malaria Control

— Continue to share best practice between DFID country offices and with donor partners, in line with the Paris Declaration on Aid Effectiveness and the Accra Agenda for Action.

— Specify how the Government's commitment to spend £6 billion on health services and systems by 2015, (announced at the launch of DFID's revised strategy for tackling HIV/AIDS in 2008) will be spent.

— Continue to emphasise improved health systems through national HIV-TB programming.

To the IDSC

— Investigate ways DFID and the Treasury can better foster policy reform at the IMF.

The challenge of TB and Malaria Control

The following submission addresses in detail the specific focus areas outlined in the call for evidence.

1. The process established by DFID for monitoring the performance and evaluating the impact of the strategy

1.1 Given that DFID's HIV/AIDS Strategy was launched in 2008, the timing of this inquiry presents challenges in evaluating the impact of implementation over this short time frame. It is clear that the monitoring and evaluation framework complementing the HIV/AIDS Strategy will be crucial to measure the longer-term performance and impact, and we hope that the Committee continues to track this M&E framework closely.

1.2 DFID have stated that addressing HIV-TB co-infection is a priority and have committed to do more to support the integration of HIV/AIDS and TB Services.[44] However, despite ongoing recommendations for the need for specific targets to address HIV-TB co-infection, along with clear steps outlining how these targets will be achieved, these were not incorporated within the HIV/AIDS Strategy Monitoring and Evaluation framework. DFID's overall Public Service Agreement (PSA) targets (as detailed in the 2008 DFID Annual Report), include no HIV-TB indicators and no TB indicators for Africa where the burden of TB is greatest.

1.3 It is therefore crucial that the Monitoring and Evaluation Framework be reviewed to include HIV-TB targets in order to have some way of assessing the outcomes of DFID's efforts in this area. Due to the lack of specific measurables for each country office on HIV-TB integration (as well as integration of HIV with other services such as Malaria, maternal, newborn and child health) it may not be possible to attribute outcomes to DFID and to evaluate the impact of the strategy.

1.4 Individual country offices are not required to provide comprehensive and equivalent data on HIV-TB activities. Qualitative evidence collected by RESULTS UK from five DFID offices in Africa,[45] all of which stated in 2008 that there was "insufficient collaboration" between HIV and TB programmes,[46] suggest there have been positive steps toward implementing integrated services, and improvements on the ground. This is, however, not true across the board. One office stated DFID itself had not made progress toward integration in their country, and the feedback suggested there was variance in progress.

1.5 We noted that DFID's work in some countries is as facilitator, encouraging collaboration and the exchange of best practice between national health services, and other actors such as the WHO, USAID and the US President's Emergency Plan for AIDS Relief (PEPFAR). This is a positive and encouraging role for DFID and this type of work will no doubt effect a greater paradigm shift toward better HIV-TB integration. However the impact of this cannot be audited without proper outcome indicators.

1.6 Suggestions for targets that could be used to monitor the progress of a DFID supported country in achieving HIV-TB collaboration have been provided to DFID previously, and are once again attached as Appendix A.

1.7 We strongly urge that DFID also specifically record how much bilateral funding will be devoted to HIV and HIV-TB. This should include funds incorporated within the £6 billion commitment to strengthening health systems, and should be broken down by year and on a country to country basis. This will further transparency, and help civil society gauge the priority given to HIV-TB. Solely measuring financial input is not the same as measuring progress. However, by eliciting this data, DFID will be able to evaluate mechanisms and monitor progress in HIV-TB integration where it ought to have been made (based on financial investment), as well as convey to country partners the importance of HIV-TB integration to the success of the strategy. This a repetition of a recommendation made by the ACTION network in March 2009.[47]

1.8 DFID should also demand a clear strategy for HIV-TB integration, as well as routine monitoring and evaluation of HIV-TB indicators, from multilateral organisations with considerable HIV programme investment. Priority should be given to the World Bank, who recently stated that the aim of their new Health, Nutrition and Population Strategy is to ensure that all health sector operations (including HIV/AIDS projects) incorporate TB control and prevention strategies to the extent possible.[48] Although the Bank identified a number of projects in Sub-Saharan Africa that incorporate TB control, they have still not identified mandatory monitoring and evaluation indicators to track and assess efforts against TB-HIV co-infection. We feel that this is an area which demands attention from the Select Committee.

2. Integration of HIV/AIDS prevention, treatment and care with other disease programmes, particularly tuberculosis and malaria

2.1 Data published in March 2009 reported that 12 of 24 DFID country offices felt "insufficient TB-HIV collaboration" is a challenge to addressing the TB epidemic. Over half of these offices also expected rates of TB-HIV co-infection to rise over the next five years.[49]

2.2 At present, the integration of HIV-TB services appears to have been unevenly prioritised in DFID's work in the last 12 months.[50] While progress has been made, there is still a lack of integration in a number of high burden countries. Acknowledging that the epidemic has country specific characteristics, RESULTS UK urges DFID to re-emphasise the need for tailored integrated service delivery, and that a framework for such be incorporated into all Country Assistance Plans.

2.3 We were pleased to note that Health Advisors were briefed in HIV-TB[51] and discussed best practice during their 2009 retreat, suggesting DFID centrally are giving integration some priority. Where progress has been seen at country level, RESULTS UK commends DFID's policy work facilitating enhanced integration of HIV and TB services in the succeeding twelve months. In particular, a strong dialogue with PEPFAR in both Uganda and Kenya, seems to have translated its commitment to lead a "global response to fully integrate HIV prevention, treatment and care with TB services at the country level"[52] into practice. There were also several examples of DFID consulting on national HIV-TB strategy, and some instances where enhanced policy was being successfully practised on the ground, as in Northern Uganda.

2.4 In Malawi, a history of HIV-TB coordination was built on with the formulation of a national strategy to integrate HIV and TB services using shared sites for HIV-TB clinics, the effective screening and cross-referral of patients and the efficient use of ART. Even though this is not functioning perfectly, robust evaluation is in place.[53]

2.5 The advanced integration and concurrent evaluative monitoring in Malawi provides a model, and we would urge the sharing of this best practice from the in-country DFID staff and partners, such as Lighthouse Malawi, to other national offices and partners.

2.6 The strategy commits to increase funding for research into an AIDS vaccine and microbicides. However, it does not make any similar commitment to increase funding for new tools for TB which will be crucial to reducing morbidity and mortality among people living with HIV/AIDS. A new regimen of drugs is required that can combat TB in a shorter time period and that are compatible with ART. New diagnostics that can detect all forms of TB in people living with HIV/AIDS (PLWHA) and that can be used in low resource settings are urgently needed. However, as reported by the APPG on AIDS in July 2009, TB (and Malaria) R&D is particularly neglected due to low commercial value.[54]

2.7 DFID have clearly acknowledged through Achieving Universal Access the need for disease specific strategies to tackle global epidemics, and that integration of these strategies can play an important role in the strengthening of broader health systems. We acknowledge and support DFID's work on broader systemic health challenges- challenges that may otherwise harm the efficacy of any disease focused programming- and encourage the promotion of HIV-TB integration as a benchmark of national health system strengthening.

2.8 RESULTS UK acknowledges that "vertical" disease-focused programmes can be problematic if improperly imposed on existing healthcare structures, as happened in Uganda, where healthcare professionals were precipitately diverted from mainline services to HIV work.[55]

2.9 However, it should be noted that recent research shows that health systems can substantially benefit from a well-planned national disease response.[56] Through national programmes, newly trained health workers can develop transferrable skills; infrastructure can be improved with renovation and new building; distribution networks can be grown; monitoring practice can be enhanced and useful data collected; all these benefits are transferrable to the health system at large. These broader outcomes can be treated as goals for national HIV-TB programmes in accordance with WHO guidelines,[57] and DFID should seek to facilitate these benefits.

2.10 Due to the changing face of the TB epidemic, with an increasing threat of drug resistant strains and the impact of TB on PLWHA, there is a clear need for a DFID strategy outlining the UK's response to Tuberculosis. RESULTS UK strongly urge the Select Committee to recommend that DFID review their practice paper The challenges of TB and Malaria control (December 2005) and develop a comprehensive strategy on TB which fully integrates with DFID's overarching health related goals. This TB Strategy should run in parallel to Achieving Universal Access and identify clear monitoring and evaluation targets for HIV-TB integration. DFID's HIV/AIDS Strategy will save many more lives if it is coupled with a clear strategy to address TB in all high burden countries.

3. Progress on health systems strengthening and on an integrated approach to HIV/AIDS funding

3.1 Achieving Universal Access recognises that "the availability of sufficient numbers of trained and motivated health workers, who are adequately paid and located where they are most needed" is crucial to the effective building of health systems and a pre-requisite for scaling up the provision of HIV/AIDS services.

3.2 A recent review of strategies to promote health systems strengthening (HSS) found that the majority of donor programmes for HSS (with the notable exception of Malawi) "consist ... mainly of training approaches as part of different programmes to strengthen the health sector. In general there is relatively little focus on more comprehensive responses to [Human Resources for Health] development." Even in Malawi the review notes that "support for national salary reforms still appears to be regarded as a government domain where donor contributions may be problematic if not sustained".[58]

3.3 In much of the world there remains a "health workforce crisis"; numbers of health workers have not increased at the rates needed to be able to provide universal access to HIV/AIDS and HIV-TB services. There are many reasons behind this issue, including emigration and the impact of HIV/AIDS on health workers themselves, but fundamentally the main barrier is governments' inability to employ sufficient workers due to budget restrictions that lead to too few health workers being employed by the government and low remuneration offers for those who are employed. In Uganda, the DFID office reported that 50% health worker absenteeism is a primary retardant to progress. Comprehensive reform of the government's ability to employ health workers, including of national salary systems, is therefore crucial to solving the crisis.

3.4 To a large extent the crisis is simply a question of lack of resources, and in order to tackle this DFID should look into increasing its funding, encouraging other donors to do the same (and to provide this extra aid as long-term flexible financing that can meet requirements to be spent on recurrent costs) and developing innovative financing streams for health such as a currency transaction levy.

3.5 However, external restrictions on governments' macroeconomic choices also impact resources available for healthcare. Over the past few decades the restrictive macroeconomic policies promoted by the IMF have been increasingly recognised as a constraint to scaling up the response to health crises in the developing world. Historically, the IMF has directly restricted the ability of governments to hire additional health workers through imposing "wage bill ceilings" which restrict the amount that a government can spend on public sector workers. In 2007 the IMF recognised that wage bill ceilings had in many cases been damaging, and agreed to use them only in exceptional circumstances. However, this has not led to a big enough change in the ability of developing countries to hire adequate numbers of health workers. In many countries wage bill ceilings remain a government policy, despite the evidence that many more health workers are needed to reach the MDGs in the majority of developing countries. Part of the reason for this remains the IMF's stance.

3.6 The IMF promotes very low inflation and fiscal deficits, restricting the choices that developing countries can take about what macroeconomic policies to follow. Evidence shows that investments in health and education lead to high economic growth, but despite this the IMF's insistence on low fiscal deficits can prevent countries from making investments that pay off. The basic issue is that the IMF assesses returns on investments in a short time-frame—typically three to five years—because it is a short-term actor, whereas the returns from health and education investments are seen properly only in a much longer time-frame. There also remain concerns over the diversion of aid to build foreign currency reserves, which similarly restricts the level of resources that can be spent on healthcare.

3.7 As an example, Kenya's health sector, although not one of the most under-staffed in the continent, has a significant worker shortage. The most recent figures available show that the country has 1 physician and 12 nursing or midwifery personnel per 10,000 population, against a WHO recommended minimum of 23 healthcare professionals per 10,000 population.[59] This in a country with an HIV prevalence of between 7.1 and 8.3%, and therefore a severe HIV-related strain on the health system.

3.8 Kenya's severe health worker shortage has its roots in the country's IMF restructuring programmes over the past few decades. The IMF imposed a hiring freeze to reduce the size of the civil service, which preventing sufficient hiring of health staff between 1993 and 2005. An interview in 2009 with a key respondent at the Division of TB and Leprosy (DTLP) within the Ministry of Health revealed that one of the factors limiting the testing and diagnosis of TB (the biggest killer of HIV-positive people) in Kenya remains the shortage of laboratory technicians.[60]

3.9 Between 1999 and 2007 Kenya had a PRGF arrangement with the IMF, under which the country borrowed SDR 112.5 million (about US$170.4 million). During the 2008 Article IV consultation a disagreement arose between the IMF and the Kenyan Government over the appropriate level for the fiscal deficit. The Government set the budget deficit at 5.3%, but were urged by the IMF staff team to reduce this to 4.5%. In order to do this, the IMF suggested that "foreign-financed investment spending [be] executed in line with rates of the recent past (rather than the 100% execution rate assumed in the budget). This would still allow for real spending growth of some 2% (versus 5% in the budget)."[61] In effect this would mean that foreign aid continued to be diverted into paying down the fiscal deficit rather than expansion of pro-poor spending. This is a recent discussion, and raises concerns that the IMF continues to negatively impact on social sector spending in developing countries, lessening the impact of donor attempts to strengthen health systems through its advice to member country governments, even in the absence of a financial programme.

3.10 In response to recent macroeconomic shocks (drought, food, fuel, and financial) Kenya applied in March 2009 for funding from the IMF's Exogenous Shocks Facility. A freeze on recruitment has once again been instigated, and it is unclear how long this is intended to be in place. Under the ESF agreement there will be a temporary increase in borrowing rates, allowing the fiscal deficit to increase to 5.2%. However, this remains below the deficit originally budgeted by the Kenyan Government before the impact of the exogenous shocks was felt, meaning that anticipated public investment (which was to be financed under the original budget) will have been squeezed out by the impact of the shocks. Even more concerning, the fiscal deficit is projected to be smaller than average over the medium term in order to make up for the temporary increase, which will squeeze limited health budgets even further.[62]

3.11 In fact, the swift rebound of fiscal deficits to normal or even lower than normal levels in 2010 is a feature of many of the recent crisis agreements with low-income countries. To deal with the greater-than-expected impact of the financial crisis on government revenues, 79% of the low-income countries that reached an agreement with the IMF between April and August 2009 saw their fiscal deficit limits increased by an average of 1.4% between the two reviews conducted 2009. However, 70% of these countries are expected to decrease their fiscal deficits again by an average of 1.3% in 2010 (meaning that the 2010 agreements almost wipe out the temporary increases seen in 2009), while 80% of these countries will have to reduce their deficit by an average of 1.7% of GDP between 2009 and 2011, meaning that in the short to medium term countries are being told to reduce their deficits in the face of recession. This is in stark contrast with the IMF's advice to G20 nations not to end the "fiscal stimulus" too soon. In addition, of the nine countries in this set that had sufficient data to track projections for spending on priority social sectors, at their mid 2009 reviews five were planning to spend less on social sectors such as health in 2008 and 2009 than they were 6 months earlier.[63]

3.12 In 2007 the Kenyan Government agreed that the Clinton Foundation, the Global Fund, and PEPFAR will fund the salaries of more than 2,000 additional health workers for a limited period, after which the government will take over.[64] This is an extremely positive move, but it remains to be seen what effect the new lower fiscal deficit in the medium-term will have on the ability of the government to take on these new staff. Donors should ensure that pressure is applied to the IMF to allow Kenya the fiscal space to absorb these additional health workers into the national budget.

3.13 Kenya's case illustrates that although the IMF has made adjustments to its short-term policy to address the unprecedented global economic crisis, in the long-run its policies remain a barrier to scaling up investments in key workforces, and will prove a significant impediment to achieving the health systems strengthening goals of "Achieving Universal Access". The IMF is not a development agency, and takes a very short-term approach to macroeconomic policy. There is an urgent need to better integrate IMF programmes with longer term development work, to ensure that needs for investment in social sectors are accommodated in short-term budgetary and macroeconomic decisions.

3.14 At a recent meeting Christian Mumssen, Division Chief for the Strategy, Policy and Review Department at the IMF, admitted to RESULTS that the linkages between investment, growth and fiscal balance are not the IMF's expertise. Mr Mumssen called on other development partners to assist the IMF in this area.[65] It seems clear from this comment that DFID should take a greater role in IMF negotiations—including at country level—to provide evidence to support the returns on investments in health and education and to help determine suitable levels of financing for key social and development sectors. Currently there is an evident disconnect between development policy and the IMF, with the IMF restraining the effectiveness of donors' attempts to support health systems strengthening.

3.15 RESULTS recommends that the International Development Select Committee investigate this issue further, ideally through a joint inquiry with the Treasury Select Committee to look into the coherence between DFID's work and the representation of the UK on the IMF Board, which is managed through HM Treasury.

43 In April 2009, the World Bank's Independent Evaluation Group (IEG) issued an evaluation of the Bank's entire Health, Nutrition and Population (HNP) lending portfolio from 1997 to 2007:
http://lnweb90.worldbank.org/oed/oeddoclib.nsf/DocUNIDViewForJavaSearch/2DDDEC31CBF08D36852575B5006B34ED/$file/hnp_full_eval.pdf Back

44 Most recently reiterated in a letter from Ivan Lewis to the UK Coalition to Stop TB (18 May 2009). Back

45 DFID Offices in the Democratic Republic of Congo, Kenya, Malawi, Uganda, Zambia (September 2009). Back

46 ACTION, Living With HIV, Dying of TB, March 2009:Table 12, (March 2009). Back

47 Advocacy to Control TB Internationally (ACTION): Living with HIV, Dying of TB, (March 2009) Page 41. Back

48 Letter to the APPG on Global Tuberculosis from Ajay Tandon, Acting Director, HNP, The World Bank (August 2009). Back

49 Advocacy to Control TB Internationally (ACTION): Living with HIV, dying of TB (March 2009) Page 26. Back

50 Based on RESULTS UK feedback from DFID offices in Malawi, the DRC, Zambia, Kenya and Uganda (September 2009), when asked "In your country of work, have DFID been able to move forward with integration of HIV-TB services in accordance with Achieving Universal Access?" Back

51 Mark Rotich, DFID Kenya (September 2009). Back

52 PEPFAR: Tuberculosis and HIV/AIDS, http://www.pepfar.gov/documents/organization/114192.pdf Back

53 Lighthouse Malawi: Integrated TB and HIV services at Martin Preuss Centre-Initial Findings
http://www.mwlighthouse.org/index.php?searchword=hiv+tb&ordering=&searchphrase=all&Itemid=1&option= com_search Back

54 APPG on AIDS: The Treatment Timebomb (July 2009) Page 29. Back