International Development CommitteeWritten evidence submitted by RESULTS UK and the International HIV/AIDS Alliance

Background on Submission Contributors

International HIV/AIDS Alliance—Established in 1993, the International HIV/AIDS Alliance (“the Alliance”) is a global partnership of nationally-based linking organisations working in over 40 countries, to support community action on AIDS in developing countries.

The Alliance opened a Country Office in Zambia in 1999. This office is currently in the process of becoming a Linking Organisation—an independent national NGO to be known as Alliance for Community Action on HIV and AIDS in Zambia (“Alliance Zambia”). Over the last 10 years, Alliance Zambia has mobilised community responses on HIV by providing technical support, training, mentoring and funding community-based organisations (CBOs). The key focus of its work is community and government health systems strengthening. It has developed significant experience in the following programme areas: promotion of comprehensive treatment access and adherence and positive living, stigma reduction, orphan and vulnerable children protection and youth prevention. More recently, Alliance Zambia has developed policy experience in broader health issues.

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.

The following documents are supporting evidence to this application and are attached the email:

Zambian CSO Petition to the Minister of Health Honourable Kasonde on the 10th Anniversary of the Global Fund; and

“Don’t Stop Now: How underfunding the Global Fund to fight AIDS, TB and Malaria impacts on the HIV response (2011).”

Summary

1. Despite progress made towards child mortality and HIV in Zambia, significant challenges remain in reaching the MDGs.1

2. Tuberculosis (TB) and HIV place huge social and economic burden on communities in Zambia and affect human and social development investments. The impact of TB and HIV on women and children in Zambia has to date not been adequately addressed, and unless there is emphasis placed on this area within domestic and donor policy, the effect of these diseases will continue to hamper progress towards MDGs 4 and 5.

3. Zambia is currently on track to meet the MDGs on HIV and TB, and recent advances in HIV prevention and treatment and progress towards better diagnosis of TB offer the opportunity to scale up the response to these diseases, saving thousands more lives.

4. However, the Global Fund to Fight AIDS, TB and Malaria (GFATM), which is the principle mechanism for delivery of UK commitments on TB, HIV and Malaria, and whose funds are critical to addressing these diseases and strengthening health systems in Zambia, is in crisis.

5. Lack of funding and increasing demands on scarce resources put Civil Society Organisations (CSOs), central to the disease response, at risk of closure; leading to thousands of people not able to access essential life saving treatment and basic support services. Strategies to address barriers to health care, particularly for women and at risk populations will also be threatened.

6. The Zambian Government, multilateral and bilateral donors and CSOs need to urgently work together ensure that funding is made available to meet the needs of affected populations. As gaps in services are identified, money will need to be channeled directly to affected communities and CSOs who play an important role in their delivery.

7. Recommendations to DFID Zambia and the International Development Committee (IDC) need to be urgently addressed if the UK and Zambian Government are to fulfill their commitments on TB, HIV and malaria.

Recommendations

DFID Zambia

8. Safeguard against funding shortages for TB, HIV and malaria

8.1 Support the Zambian GFATM Country Coordinating Mechanism (CCM), and Zambian Government, in urgently identifying the impact of the cancellation of round 11 on current and future TB, HIV and malaria programming and the national health system.

8.2 Work with other donors and the Zambian Government to ensure that current and planned scale up of disease programming is achievable.

8.3 Support the Zambian government to protect budgets for strategies to address social and economic determinants increasing vulnerablity to TB, HIV and malaria, such as anti-stigma programmes, nutritional support and community care givers renumeration. In some cases DFID bilateral support might be necessary.

9. Strengthen civil society organisations

9.1 Assess opportunities to provide urgent funding and support to CSOs in Zambia, safeguarding innovative projects aimed at reaching the most vulnerable and at risk populations.

9.2 Provide support to CSOs to strengthen capacity to oversee implementation of national policy and use of funds. For example, through DFID’s planned “strengthening civil society voice” Project.

9.3 Monitor projects supported in Zambia through DFID’s Civil Society Challenge Fund and Global Poverty Action Fund. Assess at country level the potential for expansion.

10. Integration of TB and HIV in current and future programming on maternal and child health

10.1 Ensure that current international guidelines on TB/HIV integration are adhered to in all their existing and future bilateral programming on HIV, maternal and child health.2

10.2 Support the Zambian government to ensure that strategies to address TB/HIV co-infection are a routine component of reproductive and maternal and child health policy and programming.

10.3 Ensure appropriate indicators on TB, HIV and maternal health integration are included within domestic and DFID policy, with associated monitoring and evaluation to assess progress and impact.

IDC

11. Task DFID to assess the implications of the cancellation of Global Fund round 11 on UK goals and objectives relating to TB, HIV, and malaria and maternal and child health. This should include individual country level investigation of where gaps in services may occur and the role DFID should play in meeting current and future funding needs.

HIV and TB in Zambia

12. The Zambian HIV response has improved greatly including; a reduction in mother-to-child transmission, increase in ART coverage and an increase in HIV screening from 29.7% in 2006 to 50% in 2009. 39% of TB/HIV co-infected persons now receive treatment, and 15% of women and men aged 15–49 received an HIV test and results in the last 12 months.3

13. Despite these accomplishments, huge gaps remain. HIV prevalence in Zambia remains at 14.3%4 among adults; one million people are living with HIV (PLHIV). At least 53,634 adults and 5,516 children still do not have access to treatment. Thousands of PLHIV do not have access to good-quality home-based care and palliative care and support that they need.

14. Zambia has a high prevalence of TB with notification rates of 425 per 100,000 people in 2009.5 TB remains the leading cause of morbidity and mortality for PLHIV. The high burden of TB reduces productivity, affecting people in the prime of their working life.

15. To date, Zambia has achieved success in TB control, increased its TB treatment success from 86% in 2008 to 88% in 2010,6 the highest rate in sub-Saharan Africa. However, Zambia is only able to detect 80% of their cases annually, due mainly to geographically dispersed populations, poor infrastructure, and lack of adequate diagnosis tools for use in low resource settings and amongst PLHIV.7

HIV and TB in Women

16. Women are disproportionately affected by HIV and TB. 60%8 of PLHIV in Zambia are women. Among young people aged 15–24, nearly four times as many women are living with HIV than men.9 Women often delay access to treatment, having fewer resources to access care and facing greater disease related stigma.10 In addition to being more vulnerable to disease, women also carry the biggest burden of TB and HIV care in the household.11

17. Recent efforts to reduce maternal mortality in Zambia have achieved notable success.12 Internationally, there is increasing recognition of the need for TB integration to be a core component of national HIV and maternal health (MH) programming and donor policy.13 However, there still remains a gap in policy at country level.14 Zambia will not reach the MDGs on MH unless the effects of TB and HIV on women are more directly addressed within donor and country policy and programming strategies.

Policy in Zambia on TB and HIV

18. The Ministry of Health implements TB control activities through the NTP through the Sixth National Development Plan, National Health Strategic Plan and the National TB Strategic Plan 2011–15. The National HIV/AIDS Strategic Framework (NASF) 2011–15 aims to provide a multi-sectoral, multi-layer and decentralised response to HIV and AIDS in Zambia.15

DFID Policy

19. In “Towards Zero Infections: The UK’s position paper on HIV in the developing world” DFID state that bilateral support for HIV will be provided in fewer countries, with a focus on prevention, key populations and integrated services.16 The GFATM is cited as the principle mechanism the UK uses to drive its response to TB and HIV, signaling a shift from investment in bilateral programming on TB and HIV to channeling more funds through multilateral organisations.

20. The DFID Zambia Operational Plan, states that they will be “shifting funding from the National AIDS Council to focus on AIDS prevention programmes”, without giving details of where funding will be directed in future. Budget lines for HIV/AIDS and Reproductive, Maternal and Newborn Health are included (TB is completely absent), but there is little indication about how bilateral investment will be maximised through integration. Nor is there a mention of how bilateral and multilateral funding and programmes for health in Zambia will be coordinated. DFID Zambia are currently in the process of developing a Gender Strategy, it is not clear whether the effects of TB and HIV on women will be addressed through this policy.

21. In line with DFID’s aid reviews and AIDS position paper, the principle mechanism for UK support for the national HIV and TB response in Zambia is through the GFATM.

The Global Fund to Fight AID, TB and Malaria (GFATM)

22. Zambia is a recipient of five GFATM grants, a total of $613,391,092 of approved funding ($399,932,893 dispersed).17 GFATM money is critical to the delivery of TB, HIV and malaria services and the strengthening of core health systems in Zambia.18

23. Following the identification of fraud by the GFATM Office of the Inspector General in October 2010, the Ministry of Health, Ministry of Finance and National Planning, and the Zambian National AIDS Network were barred from being GFATM Principal Recipients (PRs) and country funds were frozen. Although alternative PRs have now been found, impact has already been felt on services.

24. In November 2011 the GFATM board announced the cancellation of round 11 due to financial constraints.

25. Zambia’s CCM had been relying on round 11 to strengthen drug suppy and supply management to ensure uninterrupted treatments for the three diseases. To date this management process is weak, and DFID (in partnership with USAID) are providng bilateral funding to avoid stock outs of malaria commodities. The government has already had to respond three times with an emergency procurement to fill the gap. Gaps in drug supply affect treatment adherance for patients and increase the risk of drug resistance.

26. The Zambian CCM were also depending on round 11 funding to strengthen intensified TB case finding; TB diagnostic capacity in facilities; quality assurance of TB microscopy training; the scale-up of remote diagnosis of TB using mobile technology; improve accuracy in monitoring of TB cases;19 ^, 20 and increased scale-up of isoniazid preventive therapy.21 This round was seen as critical to achieving increased community involvement, better coordination of civil society, and the engagement of private sector stakeholders in the national HIV response.22

27. The affects of the cancellation (and previous freeze on funding) have already impacted CSOs in Zambia. A number of hospices that provide palliative care and ARVs will be closing in the next few months. CSOs in Zambia are calling on the government to develop policy to protect these hospices and in the interim provide ART, TB treatments and social support to clients to avoid treatment default.23 Existing services are already under threat, before the Zambian Government can even consider scaling up programmes to utilise recent advances in treatment, diagnosis and prevention for TB and HIV.

The Transitional Funding Mechanism

28. As an emergency measure the GFATM have announced a Transitional Funding Mechanism, (TFM) which, they state, will support current GFATM grants facing significant program disruption between now and March 2014. The TFM will only account for continuation of essential prevention, treatment and/or care services, with no scale up of services beyond the existing levels of patients, geographic areas or populations. Countries that decide to maintain existing scale of early diagnosis should demonstrate how alternate sources of funding, (domestic or from other donors) will be deployed to cover the costs of placing additional people on treatment.

29. Applications are only for a period of two years and applicants must demonstrate that there are no alternative sources of funding available. Countries are also required to adhere to counter-part financing, with the Zambian government required to reach 20%.

30. In-country partners report that the Government has strong political commitment to funding work on health and there is to be a 46% increase in the health budget for 2012 (compared to 2011). This is encouraging momentum towards increased domestic financing, but the Government still face significant challenges to meet the needs of the population.

31. The Zambian government currently provides only 2% of the resources put towards the National AIDS Strategic Framework between 2011 and 2015 and is now under pressure to increase its budget allocation to health (still below the desired 15%).

32. The cancellation of round 11 and the restrictive conditions of the TFM come at a time when significant advances provide the promise of a scaled up response to the three diseases.24 Below outlines only some of the potential implications in Zambia.

32.1 There is an estimated gap of $13,587,379 for malaria commodities between 2013–15.

32.2 The restriction on scale up of services threatens integration of TB/HIV services within MH programmes.

32.3 In addition to current resource constraints, the Zambian government will be placed under even more financial strain to implement new ART guidelines.

32.4 Zambia will struggle to take advantage of new technologies for better diagnosis of TB within high risk groups.

32.5 The provision of nutritional support and initiatives such as cash transfer programmes to patients may no longer be possible.

32.6 There will be an impact on strengthening health systems such as infrastructure development, vehicle procurement etc. which is essential to servicing hard to reach groups and rural communities in Zambia.

32.7 Funding will not be available for generalised/untargeted training, which may result in the loss of community health workers.

33. Zambia is eligible, and has intention to apply to the TFM for both TB and Malaria (they are not eligible for HIV funding due to current grants). TFM applications close on 21 March; until the results are known it is difficult to determine the full implications of funding constraints and where gaps in service provision and scale up will be. It is clear that the cancellation of round 11 and the restrictive conditions of the TFM will have a profound effect on the ability of Zambia to deliver on the National Health Strategic Plan 2011–015. The Zambian Government along with bilateral donors need to urgently identify a contingency plan for gaps in future services, whether or not Zambia receive funds through the TFM.

34. To mark the 10th anniversary of the GFATM, CSOs in Zambia called on the Government25 to put in place mechanisms for local resources to protect HIV services through the establishment of a National AIDS Trust Fund which needs to safeguard against treatment shortages across the three diseases, not just HIV.

Role of Civil Society

35. CSOs and affected communities in Zambia are critical to the country’s ability to meet the health MDGs. In-country partners stress that the success of national plans on TB and HIV and the new National Health Strategic Plan (2011–2015) will depend on CSO capacity to hold government to account on commitments made and use of funds.

36. CSOs and community caregivers are critical to de-centralised TB, HIV and malaria services. In addition to mobilising communities to access services, they strengthen linkages between community-based interventions and health facilities, including client follow-up.

37. DFID identify CSOs as crucial to delivering policy change, and DFID Zambia’s country operational plan commits to “involve beneficiaries in the design, monitoring and evaluation of our programmes […] Specifically in the health sector, we will provide support to civil society to conduct “voices of the poor” user surveys to assess whether health services are meeting the needs of beneficiaries on the ground”.

March 2012