The 2005 Commitments to Africa: HIV/AIDS & the Delivery on the MDGs
Hilde F. Johnson, Former Minister for Internatioanl Development, Norway
Baroness Janet Whitaker, Vice-Chair, APGOOD
Hilde F. Johnson opened the sixth meeting in the ODI & APGGOOD 'What's Next in International Development?' series by noting how much progress on the international development agenda had been achieved over the last few years, and in particular the rallying of the world community behind the Millennium Development Goals (MDGs).
However, she noted that much progress on delivery of commitments is needed, in particular with regard to Africa. Africa could overtake Asia as the continent with the greatest absolute number of people in poverty by 2015. Even if the 2005 G8 commitments are delivered, it will not reach its MDG targets.
She argued that HIV/AIDS is one of the most important factors influencing Africa’s capacity to reduce poverty, and will be a long-term problem. Reversing the pandemic is not only an MDG in itself but crucial for meeting others. Just as the virus increases vulnerability and destroys core functions of the human body, so it does to human society.
There are currently 26 million people in Sub-Saharan Africa living with HIV/AIDS – some 60% of the global total (40 million people). AIDS-related deaths are devastating the private and public sector workforces across Africa – e.g. almost 20% of health service workers have been lost to AIDS.
She said that therefore fighting HIV/AIDS must be part of the core development agenda; this will require reforms in:
aid deliverypolicies and governance
sustainability and predictability of aid
policy coherence and
She argued that we know the basics of what needs to be delivered: a combined programme of prevention, treatment and care. These need to be combined in high-profile national campaigns, with political and religious leaders courageously fighting stigma and discrimination.
For prevention, ABC is the most well-known strategy, and condoms are an essential part of this approach. But for women it is clear that ABC does not work: their husband may be unfaithful; and they often lack the power to enforce condom use. She suggested that improved femidoms, microbicides and an eventual AIDS vaccine are crucial for women. Universal access to treatment must mean no one is discriminated against – including women, young people, rural people etc.
She described national ownership of programmes and the mobilisation of society at all levels, as a precondition of success. There is a job for African governments in providing leadership; some have performed well, others less so. But donors must also be disciplined and allow national governments to take the driver's seat.
Looking at policy reforms, lack of coordination and complementarity, she said, may – in the case of HIV/AIDS - be devastating. Development actors have committed themselves to the “3 Ones” at country level (one AIDS action framework; one coordinating authority; and one monitoring and evaluation system). This is a breakthrough. But in her experience, implementation is uneven and must improve. Adding a fourth “One” – one financing mechanism – has been agreed in Mozambique and should be strived for when countries ask for it.
Looking at the predictability and sustainability of funds, she called on donors to commit themselves to binding and multi-year aid agreements, although she recognised this would prove challenging for some donors – with parliamentary constraints. Creative approaches such as the airline tickets levy or the IFF could provide topping-up money, but will not deliver the necessary long-term reliable funding.
In terms of policy coherence, she highlighted particularly that:
The loss of system capacity to OECD countries must be stopped: 1 in 4 doctors who qualify in Africa work in the OECD. National codes of conduct have proved too weak: she proposed either an international code or more creative or tougher measures;
Donors should pool resources at country level to build system capacity, and avoid stand alone “fly in” consultancy models.
Post-conflict or “fragile” states pose particular challenges: however they are defined or labelled, there are c20 countries in Africa where high levels of instability, migration, inequality, disunity and the collapse of public institutions all increase the risk of high levels of HIV/AIDS prevalence. Some donors had governance criteria attached to their aid that effectively excluded these countries from funds – but this conflicts with the goal of universal access to treatment. She suggested, first, that how to address this was a major knowledge gap; but secondly, that progress might be made through harnessing the “total capacity” of these societies. Grassroots capacity is often invisible to donors; key people need to be found and supported.
She addressed volume of aid last, remarking that systems are essential for money to be effectively spent. However, more funding is crucial. It is estimated that an additional US $22bn will be needed by 2008; there is an urgent need to significantly increase funding.
She finished by expressing the hope that the very urgency and brutality of the pandemic could help push reform in the areas she outlined above, which would benefit not only the struggle against HIV/AIDS but many other areas of development. HIV/AIDS could go from being the killer of development to a catalyst for positive change. But this will require people mobilising and holding politicians to account for their commitments.
In the discussion, a particular focus was resource constraints, in particular:
the risk that AIDS work will be funded by diverting money from other important programmes
whether to focus on countries where success was most likely, and
prioritising AIDS above all the many other serious problems facing Africa.
Other points concerned:
How to maintain political will
What should the UK government prioritise to prevent new infections?
The expense and uncertainty of the current ARV testing regime
the role of political and religious leadership, especially with regard to condom distribution
TRIPS as an obstacle to treatment
the role of the private sector in delivery
the concept of “total societal capacity” and the real leaders of change, particularly women.
Responding on resource issues, she noted that:
vertical interventions that don’t consider the wider health system may be damaging; external agencies must work with Ministries of Health and others to prevent distortion
a uniform approach to distribution has already been chosen – universal access; but publicising success stories is still possible within this, and important
more generally, in LDCs resource constraints will always be an issue. Prioritising within the HIV/AIDS strategy is not possible – the whole package is necessary. Prioritising between HIV/AIDS and other serious concerns would have to be done on a case-by-case basis: but she repeated her hope that HIV/AIDS responses could act as a catalyst for wider progress in development.
On the other points, she said that:
Political accountability is crucial, including of the G8 – unfortunately there was no official monitoring mechanism for the 2005 commitments. Public and media pressure would be important
She suggested that the UK government should focus strongly on the feminisation of the pandemic, addressing young women and girls, who are the most vulnerable for a number of medical and social reasons
Regarding testing, she was most concerned about the lack of progress on preventative products such as microbicides. She feared that large pharmaceutical companies were targeting the market of people who already had AIDS, and not prioritising the poor women with little buying power who would be the greatest beneficiaries of microbicides
On leadership, there was encouraging progress, although she felt there has been a worrying shift in President Museveni’s position in Uganda. Regarding religion, US aid and condoms, she noted that President Bush’s PEPFAR fund actually distributes substantial amounts of condoms, although it does not highlight this in its publicity.
On TRIPS, she said that she had been assured that the Doha ARV agreement was in practice sufficient – but if this was not the case then that would be crucial.
She regretted the lack of private sector involvement so far, particularly in funding. Companies operating in high-prevalence areas could also play a leadership role in running ARV programmes for their employees.
She agreed that total capacity has been neglected and mobilising it is crucial to drive positive change. NGOs have experience on working locally at the grassroots but much potential remains untapped. She concluded that there is a limit to what external actors can do: what is crucial is providing support for communities and people at grassroots to achieve change.
NB: with regard to testing ARVs, one discussant highlighted the IBM World Community Grid initiative, which allows anyone with an internet-connected computer to make it available for online mathematical testing of new treatments.
In the sixth meeting in the ODI & APGGOOD 'What's Next in International Development?' Hilde F. Johnson discussed Africa, HIV/AIDS & the MDGs.