Written evidence submitted by VSO
INTRODUCTION
VSO is an international development agency that
works through volunteers overseas, and also on return to their
country of recruitment. It works in more than 40 developing countries
in Africa, Asia and Latin America, recruiting skilled women and
men from North and South, and from a range of professions. VSO
groups its work under six goal areas: education, secure livelihoods,
participation and governance, disability, Health and HIV and AIDS.
VSO has HIV and AIDS programmes in 18 countries
across Africa, Asia and the Pacific. Our objective is to combat
stigma, support prevention and increase the availability of treatment,
care and support for those infected and affected by HIV and AIDS.
We tackle the impact of HIV and AIDS through volunteer placements;
advocacy initiatives to encourage policy change; networking activity
to build links between communities and governments; small grants
to support awareness-raising and income generation activities;
training events, international conferences and learning exchanges.
The focus of our global HIV advocacy work AIDS Agenda is
on the key intersection between HIV and gender. Inequality between
women and men continues to be a major driver of the HIV and AIDS
pandemic and we advocate for three key approaches: direct empowerment
of women; the constructive involvement of men; and addressing
the immediate needs of women infected and affected by HIV and
AIDS.
In Africa, where HIV and AIDS are widespread
and have a devastating impact on the lives of millions of people,
a strong feature of our work is supporting HIV prevention and
home-based care services for people and children infected and
affected by HIV. In Asia and the Pacific, where HIV and AIDS is
not yet as widespread, VSO works with groups vulnerable to infection
to raise awareness about how to prevent the spread of HIV. We
also work to increase public understanding about the stigma some
groups face and how this affects their ability to access the information
and healthcare advice they are entitled to.
1. The process established by DFID for monitoring
the performance and evaluating the impact of the strategy
1.1 The omission of an M&E plan from
the strategy when it was launched led to considerable skepticism
about how and whether DFID would be able to deliver it's ambitious
and wide-ranging strategy.
1.2 We would like to praise DFID for actively
involving civil society (in the form of the UK Consortium on AIDS
and International Development) from the start of the development
of their M&E processes for their HIV and AIDS strategy. VSO
fed substantially into the care and support and gender indicators
that the Consortium M&E working group suggested to DFID.
1.3 The resulting M&E plan "Monitoring
performance and evaluating impact", launched in December
2008, established a process of producing "a baseline position
from which to review progress" to be "published in the
first half of 2009". Unfortunately this has not yet appeared.
The first planned review of progress is December 2010. Therefore
a proper analysis of DFID's implementation of its strategy is
impossible at this time. This submission is based therefore on
our organizational awareness of DFID's HIV work over the last
year.
1.4 It is unclear to external organizations
the extent to which DFID country offices use the strategy to guide
their decision making or the development of their own country
strategies and interventions. A document similar to the "Gender
Equality Action Plan: Africa Division 2009-12" for the HIV
strategy would be most welcome.
1.5 The M&E plan also makes no mention
of the role of PPA implementing partners in delivering DFID's
HIV strategy. We recommend that the work of PPA implementing partners
is also taken into account in the M&E for the HIV strategy.
1.6 We also recommend that DFID country
offices work with partners in-country to agree on a common co-ordinated
M&E system to significantly reduce the burden of multiple
reporting processes, and harmonise in line with the principle
of the Three Ones.[88]
In some sectors DFID country offices are already attempting to
do this with (eg DFID Sierra Leone). VSO has recently developed
one M&E process model across our 18 HIV country programmes
to report to DFID and this could be shared and co-ordinated with
other partners. It assesses three work streams—(1) the scale
and significance of our programmes, (2) the use of inclusion as
a proxy to measure the system strength of service delivery and
(3) focus group discussions and surveys to better understand beneficiaries'
definitions of quality services and whether they are receiving
them.
1.7 We applaud the fact that DFID has linked
its strategy to global targets and indicators, although clearly
challenges of attribution remain. This year DFID has actively
engaged and led on the process of improving and fostering coherence
of internationally agreed indicators. DFID currently co-chairs
the interagency Indicators Working Group of the UNAIDS Monitoring
and Evaluation Reference Group. It is working closely with the
Care and Support Working Group of the UK Consortium on AIDS and
International Development, which VSO co-chairs, to review global
care and support indicators to input into the upcoming review
of UNGASS indicators. Together, DFID and the UK Consortium on
AIDS and International Development have modeled a new independent
review process for global indicators that the Indicators Working
Group of UNAIDS Monitoring and Evaluation Reference Group has
now endorsed.
1.8 Sufficient funding for and meaningful
review of these global targets needs continued commitment at the
highest level. This is particularly true of the target of Universal
Access to Treatment, Prevention, Care and Support by 2010 proposed
and led by the UK Government at the G8 in 2005. We urge the Minister
for International Development and the Prime Minister to lead on
this again next year to ensure a sober review of progress on this
target is undertaken at the 2010 G8 and UN MDG review and that
clear new achievable commitments are made.
2. Progress on health systems strengthening
and on an integrated approach to HIV/AIDS funding
Progress on health system strengthening
2.1 There is no doubt 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.
2.2 VSO applauds DFID and the UK Government's
strong leadership globally over the last few years on health system
strengthening. This has been demonstrated, for example, through
their championing of the International Health Partnership (IHP)
and most recently by announcing at the UN that the UK chaired
Taskforce on Innovative International Financing for Health Systems
has access to an additional $5.3 billion for health systems. This
would grant over 10 million people access to free services.
2.3 We welcome DFID's adherence to the Paris
principles of country ownership by channeling significant funding
for health through Direct Budget Support (DBS). However, we remain
unclear how DFID will specifically monitor the use and effectiveness
of this money for health systems strengthening. There is a strong
need for the development of clear DBS indicators.
An integrated approach to HIV/AIDS funding
2.4 In the context of the need for a global
focus on health system strengthening and better integration between
HIV and health responses, DFID's commitment to £6 billion
for health in the HIV strategy makes sense. However, 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. This sends a worrying message that broader health
system strengthening should be promoted at the expense of funding
for HIV. We ask that DFID openly counters this message by highlighting
the importance of addressing HIV[89]
and, crucially, committing the needed funds to those bodies that
have a proven track record of both addressing HIV and building
the health system at the same time.
2.5 The need for getting the funding balance
right between horizontal and vertical funding is an ongoing challenge.
In mid December 2007 Douglas Alexander announced the UK will contribute
£2.134 billion to the World Bank over the next three years.
This contribution makes the UK the largest donor to the World
Bank over this funding period. The announced commitment of DFID
to the Global Fund on AIDS TB and Malaria was £1 billion
until 2015, which is substantial but insufficient considering
the fact that the Global Fund announced in July a budget shortfall
of about $3 billion in order to simply maintain and finance programs
planned for 2010. DFID should be congratulated as a leading donor
but encouraged also to re-analyse this funding balance as well
as to push other donors to commit more funds.
2.6 This setting of the funding balance
should also be based on an honest evaluation of how effectively
the money is being spent. This was demonstrated clearly by a comparison
of the evaluation reports of the World Bank Independent Evaluation
Group and that of the Global Fund for AIDS, TB and Malaria. The
World Bank's report states that only 18% of their HIV projects
in Africa were satisfactory. The Global Fund report stated however
that 69% of their projects met the highest rating.[90]
2.7 We are pleased to see that DFID has
responded by collaborating with the World Bank to start to address
these issues by conducting an ambitious evaluation of the community
response to HIV and AIDS with a view to increase resource allocation.
They have enlisted the support of the UK Consortium on AIDS and
International Development to facilitate full civil society engagement
and VSO is actively involved.
2.8 Finally, there is a sense that DFID
may be de-prioritising HIV, evidenced by the reduction of clear
funding commitments to HIV in the strategy, their strong criticism
of vertical funding programmes and a serious reduction of the
number of staff in the AIDS and Reproductive Health Team. This
has a big impact on the capacity to drive the strategy forward
within DFID or to continue to play a leading role in global HIV
policy discussions.
4. The effectiveness of DFID's Strategy in
ensuring that marginalised and vulnerable groups receive prevention,
treatment, care and support services
4.1 It is essential that DFID continues
to find and increase direct and numerous ways to deliver significant
funding, training and capacity building support to community-based
responses delivered by civil society. This is vital because there
remain significant concerns over the extent to which government
strengthening of public health systems will actually increase
access to services for the most disadvantaged or excluded in society.
Public health services are often not accessible due to factors
such as distance, cost, discrimination or cultural dynamics. For
example, injecting drug users often cannot access government health
services because drug use is illegal and people living with HIV
sometimes do not access public health services due to discrimination
from staff. In the short to medium term, and until public health
systems are dramatically improved, civil society organizations
often target and provide services more quickly and effectively
to the hardest to reach communities.
4.2 DFID's commitment to gender equality
in the strategy was very welcome and responded to many of the
issues and recommendations VSO and Action Aid highlighted in our
joint 2007 policy report on women's access to HIV services Walking
The Talk. In research from 13 countries we found that systemic
gender inequality means that poor rural women are among those
hardest hit by the HIV pandemic and have minimal access to publicly
funded HIV services.[91]
As noted earlier, there is limited evidence of DFID's implementation
of the strategy but it has made some case studies available on
the DFID website and in the Gender Equality Action Plan Africa
Division document. The projects cited are primarily in the two
areas where women's access is most limited and under-resourced—prevention
and care and support. Of those listed that focused on prevention,
we highlight DFID Nigeria's work training women as peer educators
to improve understanding of sexual and reproductive health and
make condom use more acceptable.[92]
This is key work in a continent where 75% of those infected between
the age of 15 and 24 are women. Of those listed on care and support,
DFID Zimbabwe and DFID Zambia's work on care for the carers stands
out as essential work because most carers for people living with
HIV are women, often older women, who seldom receive any recognition,
support, training, or equipment to help them do their amazing
work.[93]
4.3 We note also that DFID has funded a
national survey on prevalence of HIV and sexually transmitted
infections among male and transgender sex workers in Pakistan.[94]
We hope that DFID will continue to fund such work so that there
is more awareness of the existence and needs of these groups and
they have greater access to health and HIV services. This applies
particularly to IDUs, sex workers, males who have sex with males,
transgender and intersex. We would also be interested to hear
the extent to which DFID is working with the Foreign and Commonwealth
Office to institute and defend the rights of these groups.
4.4 A particularly vulnerable group whose
needs have largely been sidelined in HIV policy at national and
global level are persons with disabilities (PWDs). We were encouraged
to see the reference to PWDs in the DFID strategy and DFID's funding
of ZAFOD (Zambian Federation of the Disabled). Direct and focused
support is essential to enable disabled persons' organisations
to participate in the development and evaluation of guidelines
for HIV service delivery, national strategic and operational plans,
and national AIDS councils. The need to mainstream the HIV needs
of PWDs into national policies for effective handling is urgent.
Governments and donors should seek to support innovative projects
initiated by PWDs that are deemed to address their specific health
needs. At regional level, DFID should actively consider supporting
advocacy networks such as The African Campaign on HIV/AIDS and
Disability. The Campaign aims to reduce the vulnerability of disabled
people to the impact of HIV by promoting HIV policies, programmes,
information and services that genuinely include them.
5. The effectiveness of social protection
programmes within the Strategy
5.1 VSO believes that social protection
is an essential contribution to providing a safety net for the
poorest, including those who are infected and affected by HIV.
5.2 One of the clear and welcomed funding
commitments in the HIV strategy was for £200 million for
supporting social protection programmes over next three years
in at least 8 African countries. Unfortunately, DFID have still
not defined which countries these are and so monitoring progress
remains impossible. We eagerly await more news on how this funding
has been distributed and to which countries.
6. Progress towards the commitment to universal
access to anti-retroviral (ARV) treatment and its impact on the
effectiveness of care and treatment, particularly for women
6.1 Globally good progress has been made
to get ARVs to those who need them, with more than 4 million now
on ARV treatment.[95]
However, there is still much work to be done to make ARVs cheaper
and accessible to the remaining two thirds who still do not have
access to treatment. In this regard DFID's continued and increased
support to The Global Fund is critical with the Fund now supporting
2.3 milion people on ARVs (as of June 09). We also particularly
welcome DFID's support of the UNITAID patent pool and call for
pharmaceuticals to get involved.
6.2 The challenge of ARV access is even
greater for children living with HIV who, in Sub-Saharan Africa,
"are about one third as likely to receive antiretroviral
therapy as adults".[96]
A renewed focus from DFID on the rollout of paediatric ARVs is
an imperative.
6.3 UNAIDS/WHO 2007 statistics gathered
in 25 low and middle income countries in 2007 showed that although
women accounted for 51% of people living with HIV, 57% of those
receiving treatment were women. This shows that women are accessing
treatment more effectively than men. However concerns remain around
women's adherence to treatment due to stigma and fear of revealing
their status and there is still no consistent global collection
of data on adherence to treatment.
6.4 Shocking statistics also remain regarding
HIV positive pregnant women's access to anti-retroviral treatment
to avoid mother to child HIV transmission. As of 2007, only 33%
of pregnant women were receiving PMTCT.[97]
DFID's HIV strategy commited to work with others to intensify
international efforts to increase coverage of PMTCT to 80% by
2010. To this end, DFID organised a workshop on PMTCT with the
UK Consortium in May 09 and produced concrete recommendations
on scale up.
6.5 As mentioned in section 1, DFID and
the UK Government's commitment at the 2005 G8 and at the UN General
Assembly in 2006 was Universal Access to comprehensive prevention,
treatment, care and support by 2010. While certainly essential,
access to anti-retroviral treatment is not enough on its own.
As Alan Whiteside comments, delivering treatment without prevention
is like mopping the floor with the tap running.[98]
Prevention and care and support have received the least focus
of funds and support and now require serious attention by the
international donor community.
6.6 It is widely accepted globally that
work on prevention is in crisis. The WHO 2009 progress report
noted that an estimated 2.7 million people were newly infected
with HIV in 2007[99]—which
means that for every two people placed on treatment, five more
become infected. DFID has led on prevention globally and should
continue to do so. For example, DFID have taken on leadership
of the EC Task Team on Prevention.
6.7 HIV care and support is the often forgotten
pillar of Universal Access, largely because donors and national
governments have left it to poor communities to provide often
without support. Strengthening health systems must include direct
resources and support for community-based responses, home-based
care organisations and carers—particularly women who provide
the majority of care and support in the family and community.
As mentioned above, DFID is supporting some excellent in-country
home-based care, and therefore should take advantage of this to
play a much stronger role raising the profile of care and support
in global HIV policy discussions. The proposed DFID funded conference
with the UK Consortium on AIDS and International Development on
Care and Support in 2010 would be an important opportunity to
move forward in this area.
88 The "Three Ones" principles, agreed in
2004, aim to achieve the most effective and efficient use of resources,
and to ensure rapid action and results-based management: One agreed
HIV/AIDS Action Framework that provides the basis for coordinating
the work of all partners; One National AIDS Coordinating Authority,
with a broad-based multisectoral mandate; One agreed country-level
Monitoring and Evaluation System. Back
89
HIV prevalence globally may have leveled off but there are still
33 million people living with HIV (UNAIDS 2008 figures) and the
HIV prevalence rates in some of the world's poorest countries
are nothing short of national emergencies (eg 26.1% in Swaziland).
This has been exacerbated by the financial crisis that has forced
many poor countries to reduce treatment and prevention budgets
(eg Tanzania announced a reduction of national HIV prevention
budgets by 25%). Back
90
World Bank Independent Evaluation Group, 2009 Improving Effectivess
and Outcomes for the Poor in Health, Nutrition and Population
(p xvi). The Global Fund for AIDS, TB and Malaria, 2009, ScalingUp
For Impact: Results Report, P 55. Back
91
VSO and Action Aid, Walking The Talk: Putting women's rights at
the heart of the HIV and AIDS response, 2007. Back
92
The DFID Nigeria case study and a DFID Uganda case study of DFID's
work on raising awareness of domestic violence with the police
force can be found in Gender Equality Action Plan Africa Division
2009-12, p 6 and 8. Back
93
DFID case studies on care for the carers are on the DFID web site-Caring
for the carers in Zambia 21 November 2008; New Dawn of Hope for
HIV help in Zimbabwe; HIV no barrier to doing business in Zimbabwe
29 July 2009. Back
94
DFID website case study `AIDS Survey highlights at-risk groups
in Pakistan, 28 November 2008. Back
95
WHO, UNAIDS & UNICEF, Towards universal access: Scaling up
priority HIV/AIDS interventions in the health sector, September
2009 progress report http://www.who.int/hiv/en/ Back
96
UNAIDS Global Facts and Figures 2008, p 2. Back
97
Ibid. Back
98
Presentation to UK Consortium on AIDS and International Development
AGM, 16 Sept 2009. Back
99
WHO, UNAIDS & UNICEF, Towards universal access: Scaling up
priority HIV/AIDS interventions in the health sector, September
2009 progress report http://www.who.int/hiv/en/ Back
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