Select Committee on International Development Minutes of Evidence

Examination of Witness (Questions 160 - 180)



Mr Worthington

  160. On the stigma attached to HIV/AIDS and the willingness or otherwise to discuss sexual matters, in this country we have seen AIDS through the prism of who does it affect? It affects drug addicts and homosexuals, two stigmatised groups. We are not used to seeing this issue in relation to heterosexual couples. What is the form of the difficulty that people have in talking about these sexual matters in African society? We tend to talk about Africa and not to take into account that Africa consists of very different countries. Can you help us to understand why people find it difficult to get community activity going, given the stigma associated with this subject?
  (Mr O'Malley) In one way or another I have been involved in responses to AIDS in about 20 countries and there is no country to which I have gone where people have not sat me down and said, "One thing you have to understand is that it is very hard for us to talk about sex here". That is not even talking about AIDS. I am from Canada, but other than in the United States, where people are quite proud of their ability to talk about sex in some ways, it is a fairly common assumption that in almost every culture people do not talk about sex very well. Only an outsider can see, but that appears to be the case everywhere. However, it varies a lot and I do not think that talking about sex per se is necessarily a barrier because, if you will excuse the broad generalisation, many countries in Asia seem to have more difficulty, at least with the public discussion of sexuality, than many countries in Africa and Latin America. I know generalisations are dangerous but I think there is something in that. How people talk about sex, with whom they talk about sex, and what they say varies a lot and creates problems. There are a couple of particular problems with AIDS. One is the early association of homosexuality—more than injection drug use—and the amount of fear and discrimination and hatred of homosexual behaviour around the world is quite remarkable. President Museveni, not excepted, in one of his less helpful remarks, has contributed in that regard. That association is slowly fading away now, but it is remarkable how long it has persisted. It is absolutely remarkable how long the association between homosexual sex and AIDS has persisted. That is not just among political leaders, but at a really broad level. Even more than sex, a big taboo in most societies is talking about death. In many parts of the world, there is a taboo about talking about death and a strong persistence of influence around ideas about things like witchcraft. It is important not to dismiss that out of hand. It is also important not to exaggerate it. When you put together homosexuality, sex and death in one equation and add to it the suspicion that supernatural forces may be at work, that is a difficult combination. I think that is where political leadership is so important, not community response. Recently, in Mozambique the president talked about a member of his family dying of AIDS and by connection he was talking about sex. In 1988 or 1989 President Kaunda of Zambia talked about his son dying of AIDS. Those are incredibly important opportunities. Unfortunately, recently in Zambia a woman was arrested, charged and for a short time jailed for possession of a vibrator as a sex toy. The fact that people are not able to own and talk about sex in that way does not cause AIDS but it reflects something in the society. Any discussion about using a vibrator being safer than having sex with men cannot happen if you can be put in jail for it. Does that help?

  161. It helps enormously. You are saying that for some people in Africa now AIDS may be associated with the fact that that person has been associated with homosexual activity or that there is a witchcraft issue and that person has been picked out as morally inferior or as having done something wrong. Can you take that a little further? In order to turn things around, these points are enormously important.
  (Mr O'Malley) The homosexual association is slowly fading. It has been incredibly disruptive over time, but it is slowly fading. The only way in which to do something about that is to talk openly about sex. Even though the vast majority of infections around the world are caused by heterosexual sex, talking about homosexual sex is part of the way in which to talk about heterosexual sex. If we cannot talk about sex we shall not be able to talk about changing behaviour that puts people at risk. The association with witchcraft is patchy and I do not want to exaggerate it, but it is particularly dangerous now because often it also causes enormous harm to children and survivors of those who have died of AIDS. It is not necessarily just the negative association with an individual, but it can also be seen as a negative association with the family or household. Again, there is concern about the surviving partners or children. I do not believe that there is an easy answer. We have some political leaders, but far too few, who talk about people in their families dying of AIDS. We still do not have political leaders who talk about the fact that they are living with HIV. We have far too few sports or entertainment figures who talk about it. The brother of one of the members of my board of directors was one of the most famous musicians in Nigeria. He knew he had AIDS for several years and despite the fact that his brother was a former minister of health and was on the board of directors of an AIDS charity, Fela Ransone-Kuti while living did not come out publicly and say that he had AIDS. After he died his family made a decision to say to the public that Fela Ransone-Kuti died of AIDS. Every Nigerian you talk to will point to that as the turning point of public discussion about AIDS in Nigeria. A musician, whom everyone knew, whom not everyone loved — the government did not like him — but many people loved him, died of AIDS. If we can get to the point where those people say they have HIV while they are living, then we shall really start to see some success. But in relation to things like human rights, people are not willing to do that. If there is not an environment that protects people when they talk about having HIV and which encourages them to be involved, of course they will stay discreet about it.

Mr Khabra

  162. Would you agree that various communities in the world have different attitudes because of their traditions, cultures and religions? You will find it difficult to get co-operation in some communities—Asia in particular. How do you overcome such difficulties and convince those communities to participate in your programme?
  (Mr O'Malley) Everywhere it is a challenge. In Tanzania a catholic diocese developed a simple education intervention that has spread around the world. It is called the "three boats". Essentially it is a message that there is a sea of risk out there and there is a boat for "mutual fidelity", a boat for "celibacy" and a boat for "condom use". They say that in their religion they believe that people should stay in one of the first two boats, but the most important thing is not to fall into the sea and that they would rather people did not use condoms but it is better that people are in the condom boat than in the sea. At a grass roots level that approach has spread to places like Burkina Faso and Senegal. Outside Christian communities, that approach has been developed for use in an Islamic context, as in Bangladesh. That very simple logic tends to be very powerful at a grass roots level. I believe that there are problems in the hierarchies of certain denominations, particularly around condom use and it is very important to challenge that. It is not just the hierarchies in religious organisations, but there are hierarchies in institutions around the world that do not mention condoms enough. I am concerned that UNICEF does not pay nearly enough attention to condom promotion. As Carol Bellamy is to come before your Committee, you may want to explore that point.

  163. In that situation do you consider the intervention or the co-operation of the government to be essential?
  (Mr O'Malley) If you are to have an effective impact at a national level all stakeholders need to be involved: the Government, religious leaders, community groups, the private sector, the media and others. That does not mean that you cannot do anything in the absence of one of those sectors. There is good work going on where religious authorities are hostile and government authorities are indifferent, but turning to the evidence that we have, when there is clear hostility and indifference from an important stakeholder, we do not see the kind of impact at a national level that we see otherwise. That goes for most of the world.


  164. Is the morale of communities affected by HIV/AIDS in such a way that it makes it more difficult for the community to respond because of their low morale?
  (Mr O'Malley) Yes. Morale is being undermined in certain places where the epidemic is far advanced.

  165. That is when AIDS has set in and there are deaths?
  (Mr O'Malley) Yes, large numbers of deaths. Even there, there is an incredible potential around the issue of children affected by AIDS to renew community concern and action. You may have heard from other testimony or in your reading that often links are made between prevention and care in the sense that there is a wide consensus now among professionals responding to AIDS that if you do not provide any care you will not be effective in preventing HIV. If you would like, I can talk about that later. I would go one step further and say that there are tremendous opportunities to make individuals and communities concerned about children. People will mobilise and do something about what will happen to their children and their neighbours' children but it is much harder to mobilise them around an abstract virus that may make them sick or kill them in many years' time. Not only do they do something for the children, but once people become involved in something like that that allows you to explore why the families are falling apart. That is an important opportunity. I also think that your question points to talking about hope and creating hope. The particular data that Alan talked about are in cities or states. Even in the worst affected countries 60 or 70 per cent of the population do not have HIV. Of course, we have to be concerned about the people who do have it, but in many places people are now convinced that they have HIV because they have heard so much about how badly infected their country is, so they say, "Why bother using condoms? We are all going to die anyway". If that is their attitude how will you change behaviour? We have to emphasise that even in the worst affected countries most people do not have HIV. Another point is that most of the world has nowhere near these infection levels. Even in Africa the extremes are that there are about 15 countries with very severe epidemics and that is less than half of the countries of Africa. The risks of more severe epidemics elsewhere in Africa, in Asia and in parts of Latin America are very real, but there the challenge is not the despondency of the impact, but the challenge is, "This is not my issue". That is the challenge for most of the world today.

  166. The message must be that this can be and should be managed?
  (Mr O'Malley) Yes.

  Chairman: Mr Worthington, would you like to ask the question on funding?

Mr Worthington

  167. There is a general issue around more money being needed. There is no question about the fact that community interventions will take a lot more money to be effective. Have you thought about the most effective ways of doing that funding? Obviously, there is central government, local government, NGOs, direct community involvement and so on. Have you any thoughts on that?
  (Mr O'Malley) Yes, on a few different levels. I agree with what the Secretary of State said at South Africa House. Most of the resources for the response to AIDS anywhere have to come from local communities and countries in most of the world. The overall scale of development assistance, as this Committee knows full well, is so small in comparison to development challenges in the world that we should not lull ourselves into thinking that a doubling or tripling of international development assistance for AIDS will solve the problem. We have to reinforce that message. That does not mean that I do not think that international development assistance has a key role to play. I believe it has a key role; I believe that it should be increased and we have to talk about what it is spent on and how it is spent. I expect we shall get back to that. Within a country I believe very strongly, and evidence of association points to the importance of multiple channels of dispersement. Even the strongest governments can play important key roles, but many of the crucial parts of an effective response to AIDS cannot be implemented by governments. Governments with a functioning health service can offer health services. Politicians can, for free, make a tremendous impact. Governments through the education sector and a whole range of other sectors can do very important work. A lot of the work has to happen outside government. Relatively few governments effectively move money from themselves out to the community sector or the private sector. In a number of countries where there have been fairly successful responses, the governments have encouraged separate streams of funding to support community action and private sector action on AIDS parallel to government. My big concern about India—I am disappointed that your colleague has left—was that DFID has perhaps put too much faith in the ability of the government of India to put money in at the top that will flow down through many levels and get out to the communities. There are states in India where that is happening—Andhra Pradesh and Tamil Nadu are good examples—but in more states that does not happen effectively. Even where that does happen, governments will never be very good, for example, in funding projects for injection drug users. In Asia injection drug users are a very important flashpoint in the epidemic. The most effective work with those populations will always be funded outside government.

  168. On the Indian point, we concentrate on particular states, instead of the whole of India. It is an act of faith that the other states are picked up by other countries. I think at South Africa House you said that you have had enough pilots?
  (Mr O'Malley) Yes.

  169. And that what we now need is replications. Have you written down a list of principles for replication?
  (Mr O'Malley) I have not written those down at the moment. I have some notes and I could go on at length about it. At the moment we are involved in a multi-centre project that is attempting to consolidate all the evidence. In the United Kingdom in September we shall be having a seminar to put all that together. There are some simple ideas that are obvious. One is to focus on what works. The second is not to have a gold standard. When the evidence points strongly towards something, we should not wait for everything to be wrong before we improve it; we should not have all our eggs in that particular basket. Another point is that there is an association between scale and quality and if you bring something to a large scale and replicate broadly, you will see a decline in quality so you should expect that and do not point to the fact that one or two things have collapsed or that, as Alan said, 10 per cent of the money has been diverted. That will happen. What matters is whether, overall, 80 or 90 per cent is effective, whether it is getting to where its supposed to go and whether it is happening? It is much easier in a small pilot project to pay attention to everything so that not a penny will be misspent and the quality of everything will be very high. We will not bring things to scale that way so we have to be willing to make some compromises.


  170. Is it sensible of DFID to concentrate some of their effort in the brothels of India and Bangladesh?
  (Mr O'Malley) Absolutely. Most countries in Asia have either what you would call a concentrated epidemic or a low epidemic. India has a concentrated epidemic; Bangladesh has virtually no epidemic at all. In places where the epidemic is not generalised, there is a strong argument that most resources should be focussed on the populations that are most vulnerable, but also the populations that are most likely not only to be infected, but to play a role in infecting others. In large parts of Asia that brings us back to the stigma question. It means that efforts in brothels, with people who exchange sex for money or drugs outside brothels, drug injectors and indeed men who have sex with men in much of Asia are very important. Those are all politically and socially sensitive areas. I commend a number of governments in Asia for discreetly allowing and encouraging such actions, including in Bangladesh where the political risk of working on issues like men who have sex with men, drug users and sex is probably quite high. At this point the government is being remarkably open to not paying close attention, knowing that somebody needs to do that work.

   Chairman: I shall ask Mr Khabra to ask the question on international community.

Mr Khabra

  171. In your opinion, in what area should the international community concentrate research funding?
  (Mr O'Malley) I think that different international institutions and international funders have different value added aspects in terms of where to invest their research funding. I believe that by and large it is important to have an approach that looks at the needs for today, tomorrow and the day after. That is not my line—it is someone else's—but it is a good line. In the past few years I have welcomed the increased attention to the development of an HIV preventive vaccine, but I fear that the sexiness of a magic bullet is such that perhaps there has been inadequate attention paid to funding what can make a difference today and tomorrow. I point to a couple of particular points. On the technological side, we need better diagnostics, both for the infections that people with HIV are susceptible to and die from, but importantly for sexually transmitted diseases. I am sure that you all now know of the association between sexually transmitted diseases and HIV. The diagnostics that exist are difficult to use outside laboratory settings and expensive. An easy to use and cheap STD diagnostics system would make a huge difference and would be easy to develop. Technologically for tomorrow, we should look at things like microbicides, at better condoms, condoms that men are happier to use and condoms that women are happier to use. There is something called an invisible condom, which is a gel that can turn into something like a condom-like substance that is under development. Those are all very important things. That is not to say that we should not invest in a vaccine, but these things are more likely to come on stream sooner. Finally, I believe that there is a lot of important research outside the realm of technology. I shall point to two examples. Right now in Thailand an insurance company is involved in a scheme where it lowers group premiums for companies that are willing to implement HIV prevention and care activities in the workplace. They have a graduated steps system, where the more the company will do in the workplace, the lower the group premium goes. That is a very innovative response, which is obviously driven by profit, but if it works it is the kind of thing that probably should be promoted all over the world. Somebody should be—and indeed in that example someone is—assessing whether that is working and promoting the results of that research to other insurance companies. Similarly, there is a lot of rhetoric about involving people with AIDS in the response. It is important to look at how to do that most effectively and to promote those results so that people can do it more effectively. That is what we call operations research. I think different people have different labels for it. It is important not to focus just on technology. We have to look at how to do a better job with what we have.

  172. Do you consider that there should be an international forum for such work?
  (Mr O'Malley) That may be a good idea. I have not thought about it. Creating a new fund with a new bureaucracy and administration is not necessarily the highest priority. A lot of mechanisms already exist. Critical thinking about how to invest those resources and having some kind of forum whereby international actors can better share information about what they are doing would be useful. In recent years the UK and the US have improved their sharing of information and within the EU there is a reasonable amount of sharing. So the UK is actually a very important bridge between Europe and the United States. Nevertheless, there is a remarkable lack of attention to research efforts, for example, in South Africa, Japan, Brazil or India, in that type of sharing of information.

  Chairman: Barbara Follett will now ask about DFID's programmes.

Barbara Follett

  173. In your work you have criticised DFID's strategy. Would you like to respond with details of your reservations about the strategy?
  (Mr O'Malley) I do not believe that DFID has had a strategy for some while. I did not mean to criticise the strategy so much as to point out its absence.

  174. That is why I hesitated over the word.
  (Mr O'Malley) Certainly I attempted in my submission to note that DFID has been involved in funding some very important work. I believe that. I also believe that within the past couple of years DFID has improved remarkably. I shall come to that in a moment. Overall, for most of the past decade, from my perspective—you may hear different things from officials in the department—DFID's functional strategy has come out of the Cairo conference on population development about six or seven years ago in which there was an attitude that HIV should be integrated into other sexual and reproductive health concerns and that in addressing other sexual and reproductive health concerns somehow HIV would take care of itself. That, as far as I know, was never put out in a strategy paper, but if I look at where funds went and where staff resources went, that seemed to be the functional strategy. I believe very strongly that that is an important part of any strategy, but I also believe very strongly—and what has happened in the epidemic backs me up—that that is clearly inadequate. Even now, in 2000, 17 years into the epidemic, DFID is now preparing a draft AIDS strategy. I am pleased. I am pleased they are preparing it. I do not know where it has been. Although there has not been a formal and public consultation process, I have informally seen drafts of the paper which is under preparation. I continue to have concerns that within that draft strategy some of the shortcomings of the Better Health for Poor People paper which came out earlier in the year are reflected again in the HIV/AIDS strategy. As I noted in my submission, I am particularly concerned that DFID seems to refer to civil society as an amorphous mass. If DFID chooses to use a definition of "civil society" which includes everything from the media to the for-profit private sector, to NGOs, to community groups, that is fine, but it is essential, with limited resources, to say "What roles do different parts of society play?" and, with limited resources and limited administrative and human resources, "Where do we invest our funds to make the most difference?" I believe strongly that there has been too much generalisation within civil society. If I were to reduce it to a soundbite, I believe that its informed thinking seems to be informed by contracting-out culture, in the sense that there is an acknowledgement that governments may wish—and, indeed, it may be a good idea for governments—to contract out certain elements of governmental responsibility to an NGO, or a for-profit firm or a church. I agree with that, I think that might be a responsible thing for a government to do, but I strongly believe that there is a role for different parts of civil society and a need for a strategy for different parts of civil society beyond contracting out. I shall give two examples, if I may (and I know I am going on at length here). First, private sector providers. In Cambodia poor people—not people with AIDS, poor people in general—spend over 25 per cent of their disposable income on healthcare. A large part of that expenditure is on a mixture of things—on traditional remedies and on "Western" and modern medicine, often drugs. People with AIDS and households affected by AIDS spend much more than that. Clearly that can put the family that is on the borderline of poverty into destitution. Much of that spending is bad spending; people are buying drugs or buying products which do not even help them. There is a need in Cambodia and most of the world to educate people about how to invest their own private resources rationally, about why not to buy products which do not work and about why they should concentrate on products which work and which are cheap. That is just a very small part, but that is part of what one has to think about in talking about civil society and AIDS. Quite separately, back to this question of community mobilisation, NGOs, international NGOs, capital city NGOs and capital city consultant firms, donors, governments can have a role in supporting community organisations and churches, but none of us outsiders are effectively going to be able to change community norms. As our role—and here I would lump together people like me, an international NGO, from a consulting firm, from somebody at DFID—all we can do is that we can encourage and support effective responses within the community, but if we go in directly as outsiders we are not going to be able to change those norms. If you lump all NGOs together and act as if the local farmers association or youth group is the same as an NGO like the International HIV/AIDS Alliance, you are not going to have a very good strategy.

  Chairman: Now Mr Colman wants to ask about the European Community.

Mr Colman

  175. Yes, I want to ask about that and the UN. In your written evidence to us you made a statement saying that "the Commission"—that is, the European Commission—"seems to lack the necessary political will, bureaucratic structures and technical expertise to effectively support community and civil society responses to AIDS." That is a direct quote from your submission to us. What exactly is the problem which is causing this?
  (Mr O'Malley) It has changed over time. I should underline that the European Commission has individuals with strong technical capacity in AIDS. However, if you look at the entire Brussels machinery, there are a couple of people whose full-time responsibility—it is not even their full-time responsibility—whose primary responsibility includes technical advice on AIDS. This is from one of the largest donor agencies in the world, which draws on a couple of individuals who have responsibilities including AIDS, but other things as well. There was a period of several years where one of those individuals who has been there a long time was supported by something called an AIDS task force. That helped to some degree, because although officially it showed up in the accounts as grant-giving, basically it was a grant to an organisation to set up an office in Brussels and provide her with support, but at least it meant that there were half a dozen people — I must say, I do not know how many people, but there was a little team of people—who could critique proposals, provide technical advice, provide insight and also do some advocacy about why to pay attention to HIV and how to pay attention to HIV. There is no way that one or two people are going to be able properly to advocate for, and advise on, how to spend the amount of resources which the EU should be spending on AIDS, and that is with a very narrow definition of the spending which is called AIDS spending. Again, to go back to Professor Whiteside's testimony, if you then want to talk about how to make agriculture, education and health sector reform more appropriate in the context of AIDS, those one or two individuals do not have a chance. At a country level, there are a different set of problems—which again I expect you are largely familiar with—which are not necessarily problems about AIDS but they affect AIDS, but they are problems which are broader problems of how the Commission administers and manages its development assistance budget. Those problems affect AIDS as they affect other things.

  176. We are, of course, going to Brussels on 6 July. Obviously we shall be following up these points at that time. Perhaps I can then take you on to the wider situation. Do you have any comments you wish to make about the response of the multilaterals, particularly the UN family and the international financial institutions, and whether their work could be improved? You may want to talk about UNAIDS, as you are part of that network.
  (Mr O'Malley) Yes. I believe that UNAIDS, which was created three or three-and-a-half years or so ago, maybe four now, has, in a couple of ways, in a fairly short period of time, I believe, been a significant success. The two ways in which I believe it has been a significant success are that I believe that the fact that you are having these hearings, the fact that there has been so much attention to AIDS recently, after a period of many years of lull, reflects the success of UNAIDS in its advocacy role. Again, in terms of causality and evidence, I cannot prove that UNAIDS has contributed to AIDS going up the public agenda, but what I do see is that UNAIDS has been at many levels trying to engage in advocacy work, and that there is now more public discussion in many fora about AIDS. I believe that UNAIDS has contributed to that. I also believe that UNAIDS in many countries is beginning to have real success at fostering collaboration, co-operation amongst the different international organisations working on AIDS. That is particularly important as an increasing number of the international organisations become increasingly involved in AIDS. The two which I would point to, which in the last three or four years have really dramatically increased their engagement, are the World Bank and UNICEF. UNICEF has had some involvement in AIDS from the mid 1980s, but it was a very, very small level of involvement until very recently. The World Bank, as far as I know, had very little involvement even in financing health until 1993, and only a very small number of loans associated with AIDS or reproductive health since then, but of course the President of the Bank has made many proclamations recently about AIDS being on the Bank's agenda and, indeed, is obviously encouraging further at least lending for AIDS. I am not sure what the mix between IDA funds and other funds is. I think it is incredibly important that UNAIDS helps to co-ordinate and provide technical backup to those efforts. I have a concern that the Bank particularly is putting large sums of money into stuff called HIV/AIDS without necessarily having strategic or technical resources either to inform the allocation decisions or to support the implementation of those activities. There are places where different mechanisms have been developed, and which seem to be working, but I would say that they are few and far between, with Brazil being a notable success story for the Bank, but that is largely because the Brazilian Government had such large and impressive existing capacity. When the Bank starts loaning to governments which do not have technical capacity, the question of how to support implementation responsibly is incredibly important, and the Bank is not well structured to address that. Overall, I think that the UN family and other international institutions do have a very, very important role; the Bank because they are the one institution which has real money outside of governments, and several of the others because of their fully co-ordinated role and their technical capacity.

  177. We asked Professor Whiteside a question in terms of the extent to which HIV/AIDS had affected the internationally agreed development targets. The Social Summit Copenhagen plus 5 is next week. Is UNAIDS going to be represented there? Will the concerns about the effects of HIV/AIDS be taken into account, just as an example of how the UN family should be seeing HIV/AIDS as something which is affecting everything that they are doing?
  (Mr O'Malley) The draft text going to Copenhagen has a great deal—

  178. To Geneva.
  (Mr O'Malley) Yes, for the Copenhagen plus 5 activity. The draft text has a great deal of language about AIDS. Indeed, that is a big change from five years ago. ICPD plus 5—Cairo plus 5—which happened in New York (I am not very good with dates) a year-and-a-half or so ago, similarly saw an increase in attention to AIDS. I was on the UNAIDS delegation to ICPD plus 5. I am not going to Copenhagen plus 5. So I do think that that has been taken into account to some degree. On the question about whether the targets have to be revised, you have heard from Alan, you have heard from others and, no doubt, DFID. Certainly in many countries who are worst affected by AIDS the broad international development targets are no longer realistic. In other parts of the world they are. I also want to point to the importance reflected from Copenhagen plus 5 and Cairo plus 5 of some kind of specialist HIV advocacy and technical capacity. Effective responses to AIDS are not going to be implemented around the world at community level by AIDS organisations and AIDS programmes. AIDS has to be connected to people's lives in other ways. Similarly, again government welfare systems, healthcare systems, education systems have had broad remits. There is a need for specialist HIV action to make sure that community organisations, churches, government departments are paying attention to AIDS and to help them to figure out how to do it. Most of the implementation—whether that is an implementation of community responses or delivery of services or government policy—should be integrated. I actually think that one of the weaknesses of the Southern African response has been that the NGO response has been predominantly led by what are called AIDS service organisations which are specialist AIDS NGOs. That has meant that the women's groups, the youth groups and the family planning groups have said, "Okay, that's their business. We do something else." As long as that segregation is there, it is not going to work and the AIDS specialist groups are never going to reach many people. They might provide a very good service to a very small number of people. One of the things that excites me so much in Uganda is that TASO went from being an AIDS service organisation to becoming really an international intermediary organisation which is a training and advocacy service to both local government and local community organisations and other civil society organisations.

  179. UNAIDS were involved in that transformation?
  (Mr O'Malley) I think that particular transformation really pre-dated UNAIDS, but it just points, I think, to the problem with any discussion which says that AIDS should be integrated or AIDS should be specialised. We need both. We need those specialist AIDS organisations, including UNAIDS, doing that advocacy, but UNAIDS is not, I think, doing a very good job of implementing anything. I think UNAIDS strengthens the advocacy and that technical backup to other people who can implement it. In the NGO sector I believe the same; I believe that those of us who are essentially AIDS specialists must concentrate on advocating for, and supporting, integration, rather than setting up a bunch of vertical specialised AIDS interventions.


  180. You would not be in favour of just putting money for AIDS into the Department of Health in Uganda, though, would you?
  (Mr O'Malley) Absolutely not. Once again, to give credit to the Department of Health in Uganda, something which is interesting is that they themselves started to call for funding to go to more than themselves. Again, having some specialist AIDS resources, but also funding elsewhere, absolutely. There are additional costs associated with making your programme, whether that is an education programme, or an economic development programme or a broad primary healthcare programme; there are additional marginal costs associated with making those programmes AIDS-responsive. Somehow we have to figure out how those marginal costs will be met, but I tell you, it is a lot more efficient to pay the marginal costs of making those programmes responsive to AIDS than it is to set up stand-alone AIDS services.

  Chairman: That is very clear. I think we would like to thank you very much indeed for coming this morning and talking to us on this subject about which we have heard from you before. We value your written evidence, but it has been most important actually to talk through these questions, and I think we have gained considerably from it. Thank you very much indeed.

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