Examination of Witnesses (Questions 1
- 19)
THURSDAY 22 OCTOBER 2009
MS FIONNUALA
MURPHY, MR
ALVARO BERMEJO,
MS SALLY
JOSS AND
MR MIKE
PODMORE
Q1 Chairman: Good morning and thank
you very much for coming to help with this annual inquiry on HIV/AIDS
progress. I wonder for the record if you could introduce yourselves.
Mr Podmore: My name is Mike Podmore
and I am HIV and AIDS Policy and Advocacy Adviser at the VSO (Voluntary
Service Overseas). I have been asked by the Consortium, according
to Sally, to join her in representing the UK Consortium on AIDS
and International Development because VSO has been very active
in the Consortium for many years. We currently Chairs the Consortium
and co-chair the Care and Support Working Group and we are active
members of the Gender and Prevention Working Groups.
Ms Joss: Hello. I am Sally Joss,
Co-ordinator of the UK Consortium on AIDS and International Development.
The UK Consortium has over 80 members and we have made a collective
submission to this Committee on this inquiry.
Mr Bermejo: My name is Alvaro
Bermejo. I am the Executive Director of the International HIV/AIDS
Alliance.
Ms Murphy: Good morning. My name
is Fionnuala Murphy and I am from Interact Worldwide and I am
an Advocacy Manager working on universal access.
Q2 Chairman: Thank you. You know
how we operate on this Committee and, as I said, we do an annual
review of progress which we have done for the last three or four
years. Can I also say that there are four of you. I do not want
to inhibit any of you. At the same time you do not need to comment
on every question because we might overstay our time frame. Starting
with you, Alvaro, you probably share some of the views of the
Committee that, yes, you welcome the department's monitoring and
evaluation framework but we are still left wondering how you quantify
and evaluate what is going on and you obviously made a criticism
of that and also the cross-Whitehall working. How do you think
we could do it better?
Mr Bermejo: We certainly welcomed
the initiative at the beginning in the sense that it was very
innovative, it was one of the first times that DFID was really
involving civil society in setting up the indicators they were
going to use. That was very positive, but both from civil society
and from the DFID side I think we were unable to see that translated
into the final product and many things slipped in that path. The
one thing we did not really achieve was to get a clear definition
of what success would look like, so there are two different issues.
One is the ability to measure progress, in which I think there
are some advances and we certainly welcome the baseline as it
has been produced but we will comment on it in a minute, but I
think we also need to remember it is not just an issue of indicators;
it is also a lack of definition of what success will look like.
Once we invest all this money what is the outcome we expect to
see at the very end? Measuring that and having that defined properly
I think is something that still remains to be done. I would say
it is better than before. For the previous one we did not have
a baseline. Now we have a baseline. It can still be improved along
the way. We do not just have to say, "Okay, that is what
there is". It can be improved, for example, by ensuring that
the civil society engagement that there was at the beginning in
designing the process continues. What we have had for this baseline
right now is DFID country offices sending country reports back
to DFID that nobody has seen. Then DFID collates them and produces
this baseline which you cannot really track back to any particular
country, so it really does not enable a discussion to happen at
country level where civil society and other players, government,
et cetera, could get engaged in contributing to that feedback
from the country, and it also limits our ability here to provide
anything for oversight and contributions. I think there are opportunities
there to improve but I would say it still is a step forward from
where we were when it was the previous strategy, that by the time
we got to the mid-term evaluation review we really had no baseline
to compare with.
Q3 Chairman: Thank you for that.
That somewhat bears out what we were saying before you came in
the room, and I wondered if others would wish to comment on that.
What it seems to us, when you look at their report, is that when
you ask for it you get some quite useful information which is
quantified and yet it is not aggregated and it is not generally
available. It does rather give the impression that if they were
simply to publish their country programmes on the website we would
be three-quarters of the way where we want to be and I just wonder
whether anybody else wants to comment on that or add to what Alvaro
said about it.
Ms Joss: I think it is very difficult
also to know how much DFID country offices use the AIDS strategy
to plan what they are going to do as far as programmes, et cetera,
are concerned. The Consortium very much would want to commend
DFID for the introduction of the baseline. This is a massive move
forward from the previous AIDS strategy where there was no baseline
and not really a monitoring and evaluation framework to even start
to measure what is happening. I think also one of the difficulties
with a lot of the present AIDS strategy is that it is going to
be very difficult to attribute what DFID has done in the harmonised
international efforts to tackle HIV and AIDS and I think it will
be very difficult to work out exactly what DFID has contributed
to the general battle against AIDS.
Mr Podmore: I would like to concur
with all that has been said. We also applaud the fact that DFID
has linked its strategy to these global targets and indicators.
As Sally said, there are challenges of attribution. DFID has actively
engaged in and led on the process of improving and fostering coherence
internationally of agreed indicators, and so I would like to applaud
DFID for leading in some of those areas, particularly co-chairing
the Indicators Technical Working Group of the UNAIDS Monitoring
and Evaluation Reference Group. They have been working with the
Care and Support Working Group of the Consortium to model a process
of independently reviewing HIV and AIDS indicators for that working
group, so, with all the challenges that DFID has with its own
monitoring and evaluation, it has made some steps forward but
is leading well at the international level in terms of global
indicators.
Q4 Andrew Stunell: I think it leads
on from that that DFID has allocated £6 billion to strengthen
health services and there is clearly a tension, maybe even a conflict,
about how that feeds back into AIDS services. Even some of your
evidence comments on that. Do you believe that DFID has got the
mechanisms in place to support the AIDS programmes you would want
to see?
Mr Bermejo: This was one of the
questions last year, I remember, as well. As I said then, I think
it still has proven to be the case that it is a good strategy
to strengthen health systems. In terms of the impact it is going
to have on HIV/AIDS, it is going hopefully to increase the coverage
of treatment programmes and it is going to deal with one element
of prevention, which is the bigger prevention that can be done
within the health service, the prevention of mother-to-child transmission
and blood safety, but it is not going to curb the epidemic. To
do that we need to work beyond the health system to really prevent
new sexually transmitted infections and new infections transmitted
through the sharing of injecting equipment. We clearly need a
strategy that strengthens health systems but goes beyond that.
To the extent that DFID has that it certainly has declared that
that is the intention. The money is not following. The money is
going very much to health systems and I think you can see other
efforts outside of health systems strengthening suffering from
that focus, and it will be important to remind DFID, I think,
that there is much more to a strategy that can curb the epidemic
than just health systems. We have known for ages that healthcare
services alone cannot do that. We need to get to the other prevention
activities. In terms of how health systems will affect treatment
and allow us to sustain treatment programmes, there is a second
issue which I would highlight, which is that we are still seeing
evidence of enormous stigma and discrimination within the healthcare
workforce and the healthcare system preventing access for people
living with HIV. There is a very interesting indicator that I
would use to illustrate that. For example, if one looks at Latin
America, probably Chile is one of the countries that has the best
health systems in South America. That is an epidemic that is mostly
affecting men who have sex with men, as it is in the whole southern
cone, and injecting drug users, mostly male, so it is a country
where most of the doctors, the health services, tend to suspect
HIV infection in men. Women are diagnosed later and in many cases
missed because doctors do not tend to think of women as being
affected by HIV. But then when one looks at who is on treatment
one sees that 90 % of the women who need treatment are on treatment
but only 40 or 50 % of the men are on treatment that need it,
and that is a reflection of what is happening in that healthcare
system, which is that these males, who are mostly gay men and
other men who have sex with men or injecting drug users, are not
wanting to access that health system because of stigma and discrimination
and they are dying as a consequence. We really need therefore
to acknowledge that there is work to be done and I think the main
thing we need to push DFID and other players to do is to make
sure that as we focus on strengthening health systems we put in
indicators that allow us to track what impact this is having on
access to services from vulnerable groups and that does not exist
right now. We need to build that in because, if not, this mainstreaming
might come at a big cost for the HIV epidemic.
Q5 Andrew Stunell: Can I just ask
you to follow through on that? Year on year, and you said we asked
the same question last year, is what you are reporting to us now
anecdotal or would you say that there is clear evidence that there
is this discontinuity between the two programmes or the two steams
of work?
Mr Bermejo: I would say there
is clear evidence. This is happening. It is not just a phenomenon
that is DFID related. It is happening with other players as well
but I think we see more and more recapturing of the response by
the medical establishment, this feeling that the health service
can deal with the HIV epidemic now. We see that, in spite of the
rhetoric, as money gets tighter what countries tend to do, because
it is the reasonable political response, is to make sure that
people at least that are on treatment continue getting treatment
and if the resources are narrowing that means that prevention
suffers even more. I think we are going to see in the next two
or three years the tendency started two years ago of a more reductionist
approach in which the HIV/AIDS response is seen just in terms
of healthcare systems and it will not be enough, it will not curb
the epidemic.
Q6 Chairman: There is also slight
discontinuity in any case in that DFID says that, and that was
really the thrust of our inquiry last time, how you can measure
that, but quite often in the country programmes they tell you
what they are doing about prevention though that is not part of
their declared strategy.
Mr Podmore: Can I just build on
what Alvaro said because he talked, quite rightly, about prevention
but, in particular with the focus on treatment there, care and
support is basically the often-forgotten pillar of universal access
and it is also something that suffers a great deal as a result
of a focus on health system strengthening that is about just public
health systems, hospitals and clinics. Often in sub-Saharan Africa
in particular, where health systems are struggling and not reaching
the poorest communities, the result is, because of the success
of treatment, more and more people living longer, needing a broader
range of long-term care and support services, who is delivering
those services? It is poor women and children in communities,
and currently, through health system strengthening with a narrow
conception, those people are not being recognised and given the
resources they need, so we very much urge DFID to have a broad
conception of health system strengthening that stretches from
hospitals all the way to the home. They have emphasised social
protection as being maybe one important way that they can support
care and support in communities but we really urge DFID to have
a very broad conception of social protection that is not just
about channelling money through governments because it is the
community-based responses that are really delivering care and
support on the ground and a lot of prevention interventions.
Ms Murphy: I would also like to
pick up on this point. I think we all know here, and it has been
discussed, that outside of the health system, outside of even
a focus on HIV, if we want to tackle HIV there is need for a focus
on poverty eradication, on education, on women's rights and lots
of other areas. My colleagues have talked already about the important
role that non-state actors play in those responses. What I have
understood from DFID is that there is money from other budget
lines which is going towards initiatives which link, for example,
violence against women with HIV, which link education and HIV,
and that is good news, but what is concerning is that we have
now seen this framework that will measure how the £6 billion
is being spent in relation to HIV; will that also encompass these
other pots of money from other budget lines? Also, in terms of
money that is going to civil society organisations, for example,
through PPAs[1],
some of that money is used to deliver HIV services and HIV programmes,
so will there also be a counting on that as part of the reports
on this strategy? The other point that I would like to make, and
it links into the question that you asked in the written submission
process around integrated funding, is that the health system strengthening
and integrated funding work together and I know that what we found
interacted, in a study that we did in Ethiopia a while ago when
we looked at the national health plan, was that, while there was
an acknowledgement that reproductive health, which is an area
that links very closely with HIV, was an important area and needed
prioritisation in Ethiopia, when it came to the targets and indicators
there were not appropriate targets other than maternal health.
There were no targets on other integrated health issues. What
we know about health system strengthening is that while, of course,
a strong health system is critical to delivering an effective
HIV response, it is not a given that just because you have a strong
health system you will therefore deliver on some of these neglected
areas. That links with Alvaro's point about the fact that in Chile,
because of stigmatisation towards men who have sex with men, services
are not reaching the people, so I think we need to go further
in this promotion of health strengthening and really think how
can we make sure that the health planning process includes targets
and indicators but also goes on to deliver in terms of access
to HIV services.
Q7 Mr Lancaster: That takes us on
really nicely to the next question, which is about the integration
with other programmes. There is an acceptance that effective AIDS
strategy should be integrated with other disease programmes, TB
and malaria. I am asking you to comment on how effective you think
DFID's approach to this is and whether or not those who need it
most are getting the support.
Ms Joss: I would like to reiterate
what came in in a separate submission and was also included in
the Consortium submission from a member of the Consortium, Results
UK. They were saying how they feel that both DFID and the International
Development Committee should be acknowledged for recognising the
importance of integrating the response of HIV services with TB
and malaria and other disease programmes. In March 2009, earlier
this year, Results UK did a survey of the DFID country offices
to see whether there was a level of collaboration and integration
in these programmes, and half the DFID offices surveyed said that
first of all they expected the co-infection rates of TB and HIV
to rise considerably over the next five years, and half the offices
also agreed that there was insufficient collaboration on TB and
HIV programmes in the countries where they were working. However,
stating that there was insufficient collaboration does actually
indicate that there is a recognition that there is a need for
integration and that that integration of programmes has already
started, so I think that that is a real advance. It is insufficient
at this present time and there is room for improvement, obviously,
but there is that recognition and there is that acknowledgement
that this needs to happen between programmes. Unfortunately, the
M&E[2]
framework which has been set up for the new AIDS strategy does
not require DFID offices to measure progress on TB and HIV integrated
programmes and there is no indication of how much of the £6
billion that is to be spent on health systems will actually go
to those programmes as well. Results UK are very keen that DFID
should review their practice paper, The Challenges of TB and
Malaria Control, and that this TB strategy should be run in
parallel with achieving universal access so that the strategies
are intertwined and that there should be clear monitoring and
evaluation targets for HIV and TB integration. They also feel
that DFID's future support for HIV in research and development
should be looking at faster and more effective diagnostic tools
for detecting TB because often current tests miss TB in people
living with HIV, which means that there is a very high death rate.
They also feel that there should be research done into new drug
regimes. I think it is very important to realise that it is not
just TB and malaria but that there are also co-infections like
hepatitis that need to have an integrated programme with HIV services.
Q8 Mr Lancaster: So, having pointed
out the shortcomings, how in practice should DFID improve the
effectiveness of tracking?
Ms Joss: I think the answer is
that there needs to be something added into the monitoring and
evaluation framework which does track the integration of programmes
of co-infections and other diseases like TB and malaria.
Q9 Chairman: The areas that we have
already touched on are the marginalised groups, and indeed two
years ago, I think it was, we focused particularly on that in
our report. Again, anecdotally in different countries we know
that DFID does take these issues on, but do you think that they
could do more in a more co-ordinated way, and do you think there
is a strategy or is it just that in some countries they decide
that is the way to go and in others they do not? What could be
done to make dealing with those problems, so the drivers of the
epidemic in most places, more attractive?
Mr Bermejo: There are two things.
One, this is a particular question where we need to look across
Whitehall and not just at DFID because I really think that on
these issues of raising the case and supporting the case for marginalised
and vulnerable groups in many of the countries the FCO should
have and does have a role as well, and a little bit of that is
included in the report, but we need to realise that if we are
looking at controlling the global epidemic there are a number
of countries that are middle-income countries that are critical
for that—the Russias, the Ukraines, the Chinas, Brazils,
South Africa. Those are critical for the response, with the exception
of South Africa, but even there it is particularly the most at-risk
populations, and certainly in all the other countries it is men
who have sex with men and drug users, that are the main drivers
of the epidemic who are always going to be unpopular from a political
point of view and where we need the FCO, where DFID is no longer
there in any of these countries, to play a role. We really need
to look at the role that they can play in creating a policy environment
where these groups can access services and are empowered to take
prevention measures and, funnily enough, and that is in a way
the irony of it, from a scientific technical point of view, in
terms of knowing what to do to control those epidemics that are
concentrated in particularly vulnerable groups, we know what needs
to be done. What we still have not succeeded in doing is in creating
the policy space for those things to happen, and in that effort
to create policy space DFID can be important but FCO can be even
more critical.
Q10 Chairman: On that point have
any of you done any evaluation of what the FCO is doing? As far
as we are aware the FCO does not even have a budget for this,
it does not appear to have any expertise, so do you have any indication
of whether the FCO, apart from having the responsibility, is doing
anything?
Mr Bermejo: We have done a little
bit of work with the FCO, but in cases where there was blatant
violation of human rights hitting the media we have liaised with
the FCO and the FCO has supported measures to try and address
the issue of MSM jailed in Senegal or in a number of other countries.
What we have not seen is a systematic approach to the issue or
any strategy but then it would be difficult for us to see it,
partly because the cross-Whitehall group that meets here does
not make public any of its minutes or its agenda or anything.
Q11 Chairman: We are going to ask
you about that but can I ask the question from the other end?
I take exactly the point you are making but do you have any practical
evidence—you mentioned Senegal where the FCO are doing something,
or at least did do something, or perhaps the other way round—where
they should be doing something and are not?
Mr Bermejo: Senegal was one case
where they were detained, where we were in contact with the FCO,
the FCO was in contact with their French partners, where was a
strategy to release these people from prison and re-integrate
them back in the community, where the FCO was active. We have
seen some other statements in eastern European countries, in particular
around Gay Pride and some other activities there, but I would
say that we have also seen some work done with UNODC[3]
and at the international level with some of the agencies from
the FCO to try and create a policy environment, but at country
level there are only a few cases, the ones I have mentioned—eastern
Europe and Senegal, that I am aware of. There probably are others.
Q12 John Battle: Just to follow through
the case of reaching marginalised peoples, we have just done a
report, and I am massively exercised by urbanisation, and Mike
is dead right in one sense—can we get beyond the healthcare
systems, and I think he used the phrase "from hospital to
home". I like the idea of that, getting down to reach the
parts that never get reached, but the trouble is that 10 % of
the world have not got a home in formal settlements, and for those
in shanty towns, you have not got an address so you are not registered.
I just wonder, internationally as well as DFID, and I am not taking
the focus off DFID, whether there are any strategies to gauge
the need at that level and bring them in to rebuild it from the
street level to the hospital rather than the other way round?
Mr Podmore: Yes, I think there
very much are opportunities there. Firstly, it is obviously about
having a very clear strategy about how you are building your community
response, which obviously DFID is leading in some part by being
such a significant donor to the Global Fund and the Global Fund
is providing significant funds to community-based responses, so
that is really important, but there needs to be more. One of the
great problems is that it is just not known what is happening
largely at community level, partly because donors, international
institutions largely, are not funding research into that area.
We just do not know. For example, in terms of M&E, of care
givers, we have no international nor many national stats about
how many volunteer care givers there are at national level and
people just have no idea about what the cost of care is to people
in communities, so until we start funding that sort of work we
are not going to be able to know how we can best do that. A lot
of our NGOs are really trying to build that work and be able to
bring care givers, for example, to international platforms to
speak for themselves and raise it as an issue. I am harping on
about care and support but it is equally about community based
prevention. I think people just are not aware of what is happening.
Q13 Chairman: Does the Foreign Office
actually have a proactive strategy? I think the impression I am
getting is you are saying no.
Ms Murphy: I wanted to raise the
issue of women and girls. Women and girls are not a minority but
they are vulnerable and they are marginalised in many parts of
the world. In African countries people have a picture of those
under the age of 25, but three-quarters of them are young women
so it gives an indication of women's vulnerability. The DFID White
Paper has recently pledged triple funding for services to tackle
gender-based violence up to £120 million per year, and I
think that is a really exciting development, but there is obviously
much more that needs to be done. The DFID strategy talked a lot
about the vulnerability of women and girls and the evaluation
framework pledged that detailed targets and indicators on progress
made for women and girls would be included in national plans.
We have not seen those national baseline reports. Maybe there
is more about that in there but it is important that those are
developed so that we can really see exactly what is being done
for women and girls. The reason that this is important is that
it really links with women's access to services and from the baseline
we know that access to PMTCT[4]
is still much too low. I think it is about a third of women who
need PMTCT services. One of the reasons for this is the simple
fact of what happens to women in many communities when they are
diagnosed as HIV positive. A woman can be thrown out of her home
and have her children and her property taken away from her. She
will be accused of bringing the virus into her family. She will
face violence from her husband and her in-laws. In terms of a
woman who is pregnant and already physically and emotionally vulnerable
because of that, plus a HIV positive diagnosis, to put those two
things together and expect women to cope with no backup is really
impossible and it is no surprise that many women will refuse HIV
tests in an antenatal care setting or where they think that those
tests will be pushed on them, and ICW have documented cases of
women being tested without their consent. It is not a surprise
that women will just avoid antenatal care altogether and that
is very worrying as well. The DFID strategy talks about PMTCT
in terms of the delivery of anti-retrovirals to prevent onward
transmission of the virus to babies and that is a really important
part of PMTCT, but we also need to think about all the other parts,
such as meeting the mother's health needs beyond pregnancy and
birth but also meeting all of the mother's needs and making sure
that women get the counselling they need and also have the backup
services so that if they do face violence and eviction they have
somewhere to go.
Q14 John Battle: Thank you for that
approach as well because my instincts tell me that you have to
build systems from the base up and not the top down, and sometimes
measuring from the top means they never reach the parts they are
supposed to reach. One of the groups that we were drawn to the
attention of by World Vision was people with disabilities who
are really written off. Women, children and adults with disabilities
are out of the frame when it comes to this agenda. If I am abusive
about the Foreign Office, they used the term "in the field"
when I was a minister there. That meant going to an embassy somewhere.
At least in DFID going "into the field" means leaving
the embassy and going somewhere, so we are making some progress.
If I remember rightly I think it was Vietnam and Hanoi where we
saw a project where the Foreign Office and DFID were working well
together and had gone into a local project in the centre of the
city, the downtown part of the city. I am just wondering, with
the social protection schemes, do those programmes reach the parts
that we need to be getting to? Are they geared to them? It is
social protection but, if you like, the poorest of the poor are
not included in them. What is your view about reaching some of
the groups and the people? I am thinking of street children, the
way you articulated the needs of women who are written off. How
many people are we writing out of the frame and not even getting
the research done? I know it is not just a DFID question but is
DFID's social protection programme geared in the right direction?
Ms Joss: You are right in mentioning
World Vision because World Vision, as one of the members of the
Consortium, has written about social protection. I do not know
if I can answer your question fully but I think what World Vision
is saying is that they notice very clearly that social protection
and cash transfers do a lot to help households. It means quite
often that nutrition is immediately improved, that children's
health is immediately improved and girls go to school, for example,
but there are many groups, which is exactly what you are indicating,
which are left out of those because they are not in households,
street children, for example, often children with disabilities.
One of the biggest issues around all of the social protection
is that cash transfers are not enough and that there need to be
on the ground welfare support services that are supporting vulnerable
households, vulnerable groups. We are looking at family support,
child protection, getting children out of orphanages and into
the community where they can be looked after by families. One
of the main points that World Vision was making in its submission
was that there have to be welfare support services along with
the cash transfer schemes, and they are very much asking what
has happened to the enormous momentum that there was around the
announcements of cash transfers and then the extra announcements
and the further £200 million that was announced at the G20
London Summit. Somehow, between London and Pittsburgh that has
got lost and the momentum has gone, so the questions that World
Vision want to ask are what is happening on social protection
cash transfers and what is DFID doing for welfare support services?
Mr Podmore: Can I add very briefly
to that? We emphasise the fact that we need to have and DFID needs
to be promoting a really broad conception of social protection.
In UNAIDS currently one of the nine priority areas that they identified
for their outcome framework over the next few years was social
protection and they threw in a whole range of different things,
but one of the things that was not particularly mentioned was
the community response, and so as well as welfare systems, pensions,
food and nutrition support and, of course, cash transfer and a
whole range of different services, and including in that free
or subsidised health and education, we need to really be talking
about this broad conception so we are not limiting it to channelling
funds just through government. I thought it was great that you
brought up people who were living with disabilities. It is a particular
area that I think is forgotten in the international policy discussions.
I am encouraged to see that DFID mentioned people with disabilities
in the strategy and they mentioned one funding of ZAFOD, the Zambian
Federation of the Disabled, but I think there really needs to
be increased and directly focused support for disabled persons'
organisations in-country so that they can influence policy dialogue
and also for DFID to support innovative projects that disabled
people's organisations are trying to promote so that they can
participate in the planning and delivery of HIV services, because
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. They are just left behind
so we would also recommend that DFID actively supports advocacy
networks such as the African campaign on HIV and AIDS and disability
and other national networks like that.
Q15 John Battle: Sometimes, and I
am smiling now, the word "community" can be a kind of
portmanteau word and everybody is hidden underneath that umbrella.
In our report last year we emphasised the need to get to civil
society, another great umbrella. In my neighbourhood when I was
first elected in 1987 we had seven inner city local community
groups. We have now got 700, so what I suggest is a great myriad
reach of civil society there, but has DFID got a strategy to get
to those civil society organisations, because otherwise what you
find is that those that catch a bit of media attention, the bigger
ones, hoover up the money and the ones we need to get to, who
are actually on the ground floor level or in the hidden-away corners,
are not the ones that are being reached and supported? Have DFID
got a strategy to get into the complexity and depth of civil society
where the most marginalised are?
Mr Bermejo: I would say no, and
let me explain a little bit why. I think our logical reaction
is to a situation where they have less and less staff both on
the ground and here and thus are looking to reduce their transactional
costs, the amount of time that it takes to mobilise resources
and support. These groups, which are very diversified, which are
small, take up a lot of time of people and so their strategy in
a way logically is to go more towards budget support, multilateral
where you can, with one contract, get hundreds of millions of
dollars out rather than having to deal with small community groups.
I think that is the driver that is behind what is happening in
DFID. I think there are other solutions to this issue, which is
a bigger issue than DFID, so they are not going to be able to
solve it. We have seen in some countries the creation by a number
of donors of civil society funds where they all pool their resources
and then they hire a technical management agent, whether it is
KPMG or Deloittes or some other organisation, to manage that process
in Uganda or in Kenya in the south to support those southern NGOs,
and that and PPAs here might be a strategy but it is difficult
to see how it could be done. I think it is a good question to
DFID. I think their only reaction is this natural one, "You
know what? We do not have the staff any more to be able to do
this", and we need to address that issue.
Mr Podmore: I think also DFID's
funding through PPAs should not be forgotten. It is not actually
something that is mentioned in the M&E or in the strategy,
the funding that it gives to organisations like ours, who in some
ways really specialise in building capacity of those organisations
on the ground, whether it be through volunteers, through funding
capacity support, a whole range of interventions.
Q16 John Battle: PPAs being the partnership
agreements?
Mr Podmore: Yes.
Q17 Mr Lancaster: I am tempted to
pick up on Sally's comments about World Vision. I have the honour
of having their headquarters in my constituency and Stuart Kean
and others constantly make that point. I thought it was worth
putting that on the record.
Ms Joss: Oh, you know him?
Q18 Mr Lancaster: I certainly got
that message. We have already touched on it slightly with Ms Murphy's
comments but I just wanted to move on slightly to access to anti-retroviral
treatment. Great progress has been made but we are clearly still
going to miss the 2010 target. You have answered partly why that
is going to be but can you expand on that and say what more we
could be doing to try and push that issue forward?
Ms Joss: I will start and I am
sure we are probably all wanting to comment on this. Yes, we are
going to miss the target but I think it needs to be said that
there has been a massive increase in the numbers of people on
treatment. There is a 30 % increase in one year and there has
been a ten-fold increase over five years, but that is still not
enough to curb the epidemic. I think the report that came out
from the All Parliamentary Group on AIDS called The Treatment
Time Bomb explains very clearly what is going to be happening,
which is that as people become resistant to drugs they will have
to move on to the more expensive drugs, for example the Global
Fund work on a basis that there will probably be a 5 % migration
from first generation to second generation drugs per year, so
ultimately this is going to mean that the drugs that are cheaper
now will go out of use and that more expensive drugs will have
to come in and countries will find it extraordinarily difficult
to sustain the level of treatment that they presently have and
particularly if they want more. We really commend that the Government
and DFID are taking this issue so seriously and recognising the
threat that countries have, and we really welcome most definitely
the UK Government's and particularly DFID's financial and moral
support for UNITAID and the idea of patent pools. We believe very
strongly that the idea of a patent pool and handing over the patent
rights to UNITAID and allowing others who need access to those
patents to be able to use them in exchange for a royalty payment
is a definite step forward. This means that the pharmaceutical
companies do not lose out completely because they still get their
royalty payments and it also means that there is a chance of generic
production. Very clearly, in figure 2 of The Treatment Time
Bomb, it shows that until there is generic competition the
branded companies do not drop their prices. What we would very
much like to see is the International Development Committee adding
its voice to the call for a patent pool. We feel also that we
would like not only for you to add your voice to the call for
a patent pool but it is absolutely key to involve pharmaceutical
companies. There needs to be increased pressure on pharmaceutical
companies. They do not make much of a profit on drugs that are
sold to poor developing countries; the profits are made here,
so we really ask for a real push and pressure to be put on pharmaceutical
companies to put people before profits and to exhibit some sort
of social responsibility. Already Gilead, which is one of the
pharmaceutical companies that makes HIV drugs, has publicly endorsed
the idea of patent pools, so it is not impossible. It is also
key that the UK maintains its support because at present the patent
pool is an idea but it is very likely that the business case for
the patent pool will be put to UNITAID board this December and
so it is key that the UK Government maintains its support for
the use of patent pools.
Mr Bermejo: I will not repeat
the patent pool issue but it is a really important one where we
think the International Development Committee should make a contribution
as well. I would like to come back to the bigger picture of treatment
and the sort of feeling that to some extent the view from the
UK has been that the Global Fund and the Americans are dealing
with this so let us leave it to them. They have got much more
money and they are supporting most of the people on treatment
in the world, which was (and still is) the case, but clearly the
Americans are also looking at how to offload what they are now
calling the treatment mortgage for these toxic assets, as sometimes
you hear in Washington these days. I think it is really important
that we have a concerted effort and collaboration on how that
happens. You can see why the Americans are thinking like this.
You can see what the Global Fund can do, but it is really important
that the UK engages in that dialogue and does not just leave it
for others to deal with because there is the issue that Sally
has mentioned of second-line drugs but there are other issues
there as well. First, WHO[5]
in the next few weeks will issue new guidelines lowering the time
in which you have to start treatment, so asking for people to
start treatment with higher CD4 counts because that has been seen
to be the most productive approach. That will immediately put
millions of people onto our list of those in need of treatment.
We have equally a situation where one of the drugs that we call
first-line is only first-line in developing countries. Here it
is seen as too toxic and with too many side effects to be able
to prescribe it but we call it first-line for developing countries
just because it is cheap. However, we should not be using it in
developing countries either so we can clearly see a future scenario
where, even if you do not continue increasing the number of people
on treatment, there is not the money to afford the current people
on treatment as they move towards more expensive drugs. We are
convinced that that and the current economic and financial crisis
and the opportunities that that provides make a strong case to
be pushing for something like a currency transaction levy that
would allow billions more to be available for the health MDGs[6],
including the HIV response and the Global Fund. If not, we are
going to see more and more of what we are seeing already and the
truth is that there are already a number of countries which are
saying, "We do not put a single person more on treatment".
That is the situation we are confronted with right now.
Q19 Chairman: I think you have answered
some of the questions we were going to ask anyway, so that is
absolutely fine. One of the concerns I have is just what you have
just mentioned, stopping treating people. You are saying we cannot
afford to treat them and what happens when the money runs out
unless you bring the prices down, but I have also heard that the
side effects of some of these drugs will create a whole range
of other problems. I happen to have a particular interest in deafness
and I know that some of the cheapest antibiotics being prescribed
in developing countries are the prime cause of the rising incidence
of deafness in those communities. You are raising a whole can
of worms here, that they are not getting cheap effective drugs;
in other words, they are getting the junk dumped on them. We are
not solving the problem; we are creating more problems. That is
essentially what you are saying.
Mr Bermejo: Yes. I would not call
them junk, I think that is a bit excessive, just in the sense
that they are still saving lives, but at an added cost that they
should not be paying in terms of their own health and the side
effects, in that sense they are junk, yes.
1 Partnership Programme Agreements Back
2
Monitoring and Evaluation Back
3
United Nations Office on Drugs and Crime Back
4
Preventing Mother to Child Transmission Back
5
World Health Organisation. Back
6
Millennium Development Goals. Back
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