Keynote Speaker:

Ivan Lewis MP - Parliamentary under secretary of state for DFID

Speakers:

Rifat Atun - Director Strategy Policy & Performance Cluster, GFATM

Kevin Osborne - Senior HIV adviser, IPPF

Elizabeth Mkame - Muthande Society for the Aged, South Africa  

Paul Bernstein - Managing Director, ARK  

Chair:

Simon Maxwell - Director, ODI

Ivan Lewis MP (Parliamentary under secretary of state for DFID)

Lewis was delighted to have the opportunity, on World Aids Day 2008, to discuss the UKs role in the fight against HIV/AIDS.

Listen, learn and lead: Although he is new to the job, he brings experience from previous ministerial positions he has held – specifically, the best approach dealing with challenges is to listen, learn and lead. Listen to those who use DFID services as well as the front-line workers; learn about what works and what doesn’t; and finally provide clear and coherent leadership.

Opportunities in 2008: Financial crisis and new leadership

This year, 2008, has been marked by two historic moments; the financial crisis and new leadership in the US and South Africa. No doubt the commitment to international development has been threatened by the former; the UKs commitment is as strong as ever.

Tackling development is morally right, but equally it is a matter of self interest – we are interdependent.  Now is not the time to retreat from international development, it is an opportunity to step up. Reforms of international organisation must be in the interest of the developing countries.

We must have a narrative that enables us to clearly demonstrate the benefits of our cumulative efforts. Questions donors should ask are whether we are getting value for money, whether aid is adding value and helping people? The development community should focus less on inputs and dollars, and should talk about outcomes and impact - specifically the contributions that it can bring to development.

This new leadershipin the USA may mark a philosophical change. Although there has been a genuine commitment from the Bush administration to invest in the fight against HIV and AIDS, Lewis hopes that Obama will bring a change in the ideology of PEPFAR.

In South Africa, 2.5 million people have died of AIDS, 1500 become infected each day with HIV. It is therefore frightening to think about the implications of a state that is in denial about the epidemic.

Lewis, who only recently had returned from a visit to South Africa, supports the new leadership in South Africa.  DFID provide £15 million to the new health minister to help her deliver real change and to provide coherent leadership.  Benefits of addressing HIV/AIDS in South Africa will go way beyond the borders.

However, DFID cannot supersede the government. Rather it intends to collaborate with the private sector, international foundations, civil society and donors to harness a new political leadership in South Africa, and to create a new partnership to wage a positive change in AIDS. 

There has been rapid progress in South Africa, and that can have positive externalities on the rest of sub-Saharan Africa.  Lewis challenged the development community to identify other risks, in particular HIV-TB co-infection, that are causing significant concerns.  An agent of positive change in South Africa is the national network of buddies who do drama, presentations, and debates to get younger people to think differently about HIV/AIDS. Getting young people into the debate is crucial. But there are also challenges, of stigma, political leadership makes a different (both at national and local levels), as well as the.

UK’s strategy to address the HIV/AIDS epidemic entails:

• achieving universal ARV access is part of the new UK strategy
• a focus both on treatment and  prevention
• a 7 year strategy and commitment to sustainable and predictable funding
• an emphasis to support systems which will promote sustainability and long term change
• a country specific strategy, since the effectiveness of AIDS interventions varies across countries.  Such a choice is not between programmes or health systems. 

How will DFID measure its impact? How will DFID be held to account?

Today DFID published a Monitoring and Evaluation document  for the updated AIDS strategy. Every 2 years a report will be produced to asses whether this new DFID approach is good.

Mkame, who is from South Africa, spoke as an elderly person who is a carer, a member of Muthande and someone who has been impacted by the HIV/AIDS epidemic. 

She spoke about the plight of the elderly.  Millions of children in South Africa have been orphaned. These orphans are cared for by grandparents. However, the global AIDS discourse does not focus on the role of older people – the focus is mostly on the 15 to 49 year old age group.  There is little data on the prevalence of HIV/AIDS among the elderly, on who is providing care and what kind of support should be provided to carers. Older people are often not included in programmes and projects.

Mkame’s niece passed away in 2005 and left seven children, who often look to her for support. She finds it very difficult to meet all their needs. Grandparents, like Mkame, often have to provide care and support for grandchildren and people living with HIV and AIDS.  This has a major impact on older person’s lives. Impacts include:

• Aggravating ill-health: older people may already be ill, and caring for another will aggravate their health status. They are also exposed to opportunistic infections (e.g. drug resistant tuberculosis)
• Stigma and discrimination: older people are also experiencing stigma and discrimination by members of their own communities
• Economic challenges: caring for someone entails buying more food, covering medical expenses, and therefore finding additional money for these is difficult. Prices increases especially impact older people who do not have an income and have many people who depend on them. Cost of funerals also place financial burdens on the elderly. Older people in South Africa have access to pensions, but it is usually not enough to support a family.  They also face problems of corruption.
• Increased emotional burden: they become parents again to a new generation of children

Mkame called on the South African and UK government, as well as other funding agencies to consider the needs of older people so that grandparents like her will be able to provide adequate care for themselves and their families. 

Atun’s presentation was organised around three key topics:

1. Global fund guided principles

The Global Fund is international partnership that operates as a financing entity.  It emphasises country ownership & inclusiveness, and provides performance based funding

1. Funding overview

The Global Fund has a total of US$ 19.1 billion pledges available through 2010, and approximately $11.9 billion has been transferred.  The total grant funding that has been approved on 2-year budgets is $ 8.9 billion, and on 5-year budgets is $ 21.9 billion. The amount disbursed thus far is $6.7 billion.  Approximately 61% of funding goes to AIDS, while 25 % goes to malaria and the remaining 15% goes to TB. Global Funds investments are targeted to correspond to match disease burdens by region.

1. Challenges ahead

The Global Fund aims to mitigating adverse effects of the crisis by:

•         creating a buffer to provide predictable programmatic financing

•         providing innovative financing approaches (Debt2Health)

•         driving towards sustainability by strengthen health systems and community systems

It is also promoting an architectural review of national strategy applications to improve efficiency and alignment, and is putting systems in place to manage future needs and demands.

What does the credit crunch mean for people on the ground?

Osborne opened his speech with a Dickens quote to show that there are opportunities in these tough financial times: “It was the best of times, it was the worst of times”

IPPF’s primary focus includes sexual and reproductive health and rights, AIDS and HIV, adolescents, access, abortion, advocacy and it is funded by core donors, foundations and the private sector.

The impact of global financial conditions on IPPF theshort run will result from exchange rate volatility. IPPF receives majority of income in Euros, and reports and expends in US dollars.  A strong dollar means less immediate resources available

In the medium-to-long-term the impacts will be seen if the economic constraints on governments and foundations result in downward pressure on agreed funding profiles. Nonetheless, the election of new US President offers opportunities for increased funding to sexual and reproductive health and fewer restrictions on HIV funding – regardless of the downturn.

Reduced funding for sexual and reproductive health means:

• service providers will decrease the range of services provided, and that IPPF will have to cut back their services (e.g. home-based care/mobile clinics).
• decreased advocacy for vulnerable, under reached groups. If spending on advocacy is cut, short term impacts will probably not be noticeable, but may mean that public health interests will be damaged in the long term
• cuts in other funding to other ‘development sectors’ such as road building, water and sanitation, housing etc. will have a knock-on effect on public health outcomes

Therefore the funding squeeze will cause IPPF to take the following actions:

• “Back to Basics” – returning to core business, and remain true to providing the essential services, away from all the nice add-ons
• “Going local” – need to increase volunteer base in order to maintain services at the Member Association, grass-roots level after a cut in funding.
• Refocusing on what the essential services are, and the rationale for providing them (i.e. the services that make people human, not the things that are nice) will hone the strategic direction if IPPF. This should re-energise and refocus IPPFs desire to help meet the sexual and reproductive health right needs of all and especially those most in need

Osborne closed his presentation with a quote from Abraham Lincoln: “The best thing about the future is that it comes only one day at a time.”

Paul Bernstein’s presentation began with a background on Absolute Return for Kids (ARK). ARK is an organisation founded in 2002 by leaders in the alternative investment industry (hedge funds) with a shared vision of collective philanthropy.  It is a direct implementer, and aims to maximise impact and ensure measurability and accountability.  Pre-defined strategic areas include HIV/AIDS (South Africa, Mozambique), education (UK, India) and children in care (Romania, Bulgaria).  ARK is one of the UK’s top fundraising children’s charities.

Antiretroviral Therapy (ART) Programme prevents children from being prematurely orphaned by keeping their HIV+ mothers and caregivers alive. The Programme ensures that these mothers as well as children infected with HIV receive life saving drugs, support and care. It also partners with government to enable rapid and large scale delivery through local clinics, and ensures sustainable exit strategies. 

In South Africa ARK had enrolled 32,963 HIV+ carers and children onto treatment at the end of June 2008. In Mozambique ARK aims to enrol 4,500 mothers and carers and 500 children onto treatment over the next four years.

In this financial downturn, the funding impact is expected to include an inevitable drop in funding from private foundations, a likely shortage of ARVs (for example the Free State is already experiencing a shortage of drugs), and service cuts.

Hope or Despair? This financial downturn poses major challenges in the face of existing shortfall.  It will stretch the ability of governments and NGOs to deliver where needed. Pressure for efficiency, accountability and innovation will increase. An opportunity may be that resources be targeted where impact is highest.

DFID was congratulated for it track record in the fight against HIV/AIDS.

Questions addressed during the discussion:

• Will lack of earmarked funding make tracking money more difficult?

• How will DFIDs new strategy address the drivers of the epidemic that go beyond the health system (e.g. poverty, food security, stigma, and gender)?
• Faith based organisations (FBOs) are the largest providers of care in sub-Saharan Africa and in conflict torn areas. How will DFIDs new strategy integrate FBOs to achieve universal access?
• DFID has been a sustainable funder, what we really need to do is convince other governments to do the same. How do we do this?
• We are winning some of the battles – there has been significant increase in access to treatment. What next? What safety nets and opportunities are out there for people on treatment? 
• Strategy making is about making choices. Where to we put HIV/AIDS on the agenda, and are there any trade-offs to prioritising or de-prioritising HIV/AIDS?  Are we making choices about the aid-architecture? 
• What about the community based approach? Communities partnering to deal with HIV/AIDS place emphasis on drugs, testing and health systems.
• As budgets for HIV/AIDS are reduced, an emphasis may shift to easily quantifiable outputs, and a de-emphasis on qualitative and structural change. How will DFID address this?

Simon Maxwell closed the meeting reminding the audience that 7-8 years ago there was little money for HIV/AIDS and much fewer people on treatment. Every step along the way there are tough choices.  It is important for HIV/AIDS community to keep its eye on hard choices.