Post 2015 Development Goals

Written evidence submitted by the International HIV/AIDS Alliance

Background

1. The International HIV/AIDS Alliance (‘the Alliance’), established in 1993, is a global partnership of nationally-based linking organisations working in over 40 countries, to support community action on AIDS. In pursuit of Millennium Development Goal (MDG) 6 : combat HIV/AIDS, malaria and other diseases, with a specific focus on HIV and AIDS, the Alliance experience has demonstrated that in order to adequately address the HIV-related needs of people living with and affected by HIV a broader approach is needed which spans across all of the MDGs.

2. We welcome this opportunity to provide a submission to the International Development Committee (IDC) inquiry for the post-MDG development goals. The Alliance as a member of the BOND Beyond 2015 UK Group and as one of the coordinators of Action for Global Health (AfGH) UK supports their submissions from the broader development and global health perspectives. This submission by the Alliance responds specifically on the HIV issue.

3. Key recommendations

· Human rights and equality need to underpin the post-2015 development goals to ensure that the poorest and most vulnerable and marginalised groups are not left out.

· The MDGs which have not been met must not be dropped. Global and national targets around MDG 6 have driven unprecedented progress in addressing HIV by galvanising political leadership and accountability. This needs to be built upon in the post-MDG framework.

· The unprecedented response to HIV before and since the MDGs were set has demonstrated that the participation of the most vulnerable and marginalised in governance structures improve quality, effectiveness, value for money and accountability.

· Multi-sectoral responses are key. The corporate sector needs to share the responsibility to improve public health and access to affordable goods and services.

Question 1: Lessons learned from the adoption of the International Development Targets and the Millennium Development Goals: in particular how effective has the MDG process been to date

4. The MDGs have provided a global framework for development, which has been effective in increasing political and financial commitment for programmes benefitting the poorest and most vulnerable groups and have provided a framework to hold governments and donors accountable on progress made. The three health-related MDGs [1] have created a focus on health within broader development, resulting in health becoming a key objective of development cooperation and policies. The specific focus on HIV in MDG 6 has led to HIV-specific commitments and funding:

a. In 2001, the United Nations General Assembly (GA) held its first ever health-related Special Session on HIV and AIDS (UNGASS). As a result the GA endorsed the 2001 Declaration of Commitment on HIV/AIDS [2] . The 2001 Declaration provided the political momentum necessary to catalyse the HIV response at national, regional and global levels. Governments have re-affirmed their commitments to HIV and AIDS in 2006 and 2011.

b. A regular reporting cycle was established for countries to report progress made in two-year intervals to the Joint United Nations Programme on HIV/AIDS (UNAIDS) and then synthesised into a biennial global report. These global targets and reporting mechanisms provide a straightforward segmented approach for governments to formulate corresponding policies and guide national development planning. By placing a spotlight on both success and failure, they have acted as a strong driver for dramatic scale-up of national HIV responses in many countries.

c. In response to these commitments, two notable funding flows were established, the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM) in 2002 and the US President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003. The GFATM has disbursed more than $22 billion in a decade and has saved more than 7.7 million lives. PEPFAR is the largest commitment by any nation for an international health initiative dedicated to a single disease.

d. At the national level, the MDGs and subsequent HIV-related policies increased country ownership of the HIV response. In 2002, the first generation of National HIV Strategic Plans (NSP) were established, which helped define how countries respond to HIV based on their own context. According to the UNAIDS report "Together we will end AIDS" (2012), 81 countries increased their domestic investments for AIDS by more than 50% between 2006 and 2011.

e. Leadership at the regional level has also emerged in recent years. In 2012, the African Union launched the "Roadmap for shared responsibility and global solidarity for AIDS, Tuberculosis and Malaria in Africa" which charts a course for more diversified, balanced and sustainable financing for the HIV response by 2015 and demonstrates Africa’s new leadership and voice in the global AIDS architecture.

5. The global response to AIDS has demonstrated tangible progress towards the achievement of MDG 6 [3] (and contributed to progress towards MDGs 1, 2, 3, 4 and 5 and strengthening of health systems) [4] .

a. Target 6a: Have halted by 2015 and begun to reverse the spread of HIV/AIDS. New infections among children have declined dramatically, with 57% of an estimated 1.5 million pregnant women living with HIV in low- and middle-income countries in 2011 having received effective antiretroviral drugs to prevent transmission of HIV to their children.  The UNAIDS 2012 Global Report cites that the number of adults (15 and over) newly infected with HIV continues to decline globally, with 2.2 million acquiring HIV infection in 2011 (500,000 fewer than in 2001). They write that ‘nevertheless, the rate of decline is not sufficient to reach the goals of reducing the number of people acquiring HIV infection by 50% by 2015’. Substantial gaps and obstacles exist for accessing HIV prevention, treatment, care and support; especially for populations at higher risk of HIV infection. Punitive laws, gender inequality, violence against women and other human rights violations continue to undermine national responses to HIV/AIDS.

b. Target 6b: Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it. This target (defined as coverage of at least 80 per cent of the population in need) was not reached [5] . Despite this, having the target and commitments has led to the more than 8 million people in low- and middle-income countries being on antiretroviral therapy (ART), up 20% from 2010 [6] . An immense achievement considering in 2000 it was thought large scale treatment access was not financially viable. At this rate, less than 14 million people will be receiving ART at the end of 2015. With the same concerted effort the gap could be closed to reach the 15 million target [7] .

Challenges in the current MDG framework

6. The current framework does not capture the vast inequity and inequalities which impact overall progress. Often, there is an uneven distribution of health services or resources between men and women, poor and rich, general population and marginalised groups and urban and rural areas. The general indicators in the current framework are not detailed enough to give a realistic view of those inequalities, something that should be addressed in the new framework.

7. There was little attention given to coordination and synergies among the health-related MDGs as well as MDGs from different sectors. These are lost opportunities for maximising investments and efficiencies to achieve improved health and development outcomes. For example: most HIV infections are sexually transmitted or are associated with pregnancy, childbirth and breastfeeding; lack of sexual and reproductive wellbeing and HIV share root causes; HIV is the leading cause of death among women of childbearing age [8]  ; food insecurity increases HIV risk and people living with HIV on ART are able to improve their food security [9] .

8. A human rights-based approach is clearly missing in the current MDGs. Human rights should underpin the new framework with minimum standards as a measure. For instance, placing human rights at the core of addressing HIV ensures meaningful participation by affected communities and improved public health outcomes. Respecting, promoting and protecting human rights, including the right to life, the right to health, the right to freedom of association, the right to privacy and the right to self-determination need to be at the centre of the response to HIV and broader development.

9. Southern governments and civil society organisations were not engaged as equal partners in the development of the MDGs. This has consequently led to a lack of inclusive ownership among some countries. The next framework should therefore be more in line with the aid effectiveness principles and be based on national needs, with appropriate financial and technical support available to ensure meaningful and inclusive participation.

Question 2: How should the ‘Sustainable Development Goals’  be established following Rio +20 relate to the ‘Development Goals’ being considered by the High-Level  Panel?

10. The Alliance is in agreement with Action for Global Health and BOND Beyond 2015 UK that the Development Goals following Rio+20 and the work by the High Level Panel should be a single unified set of development goals. There is already a sense of ‘commitment fatigue’ amongst the international community from the myriad of development related initiatives. Having parallel processes and frameworks will create disparate approaches and splinter political and financial commitments. The post-MDG framework should be a force to revitalise and empower national, regional and global collaboration for cohesive and sustainable development.

Question 3: The coverage of future goals: should they be for developing countries only or should progress be monitored in all countries?

11. Progress should be monitored in all countries irrespective of their economic or development status. High-income countries have not all necessarily met or will continue to meet all global targets. Where they have met a particular MDG goal (or post MDG goal) it is essential that they continue to monitor their progress, be held to account globally, or even set higher targets. A Post-MDG framework must be global to foster equality and solidarity. The future development framework should have overarching global goals and targets which can be contextualised at the national level.

12. The current MDG framework is heavily focused on low-income countries rather than on poor and marginalised people. Internationally we are seeing a shift towards focussing development cooperation in low-income countries (LICs) and withdrawal of investments in middle-income countries (MICs). Using country income categories as the main criterion for allocating development funding to countries is counterproductive. Income alone is not indicative of countries’ ability to pay for the costs of their disease responses. This approach also makes the assumption that all individuals living in MICs have the same ability and opportunity to access services. Where there is capacity and willingness among countries to provide more public funds for their HIV and health responses, the money is often targeted at building and paying for biomedical interventions and commodities rather than for often controversial or unpopular interventions for communities most affected by HIV and AIDS.

13. Moreover, this approach ignores other factors including the fact that many countries will transition from LIC to MIC status over the next few years. Even when this transition happens, poverty in MICs will remain high and exacerbated by rising income inequality. Two-thirds of the world’s poor live in MICs. In fact, 60% of the world’s poor live in five populous MICs: Pakistan, India, Nigeria, China and Indonesia [10] .

Question 4: The process: are the right voices being heard? What are the opportunities for and constraints to global consensus?

14. The current MDG framework was developed using a ‘top-down’ approach that was UN and donor-driven. Lack of country engagement led to weak country ownership and a global framework that did not build on national plans. The next framework should be inclusive of all stakeholders (governments, private-sector, donors, non-state actors and communities) and driven by the voices and experience of people most affected by poverty, and in particular, the most vulnerable and marginalised populations. We can truly say that the next chapter of development will be a success if the most underprivileged individuals can access the same comprehensive quality services as the general population without stigma and discrimination. What the future framework contains is as important as how it is developed and who is involved in the process.

15. Although national governments should bear the prime responsibility for the development, implementation and monitoring of the new framework, icivil society organisations are key actors for ensuring quality and sustainability of programmes and should participate in the definition of any framework to ensure the needs of the most vulnerable are taken into account. They should also have a strong role in monitoring progress of the new framework and the national strategies based on it in order toenhance political will and accountability.

16. There are examples from the global HIV architecture which can provide models for inclusion of most vulnerable and marginalised groups. Biennial national level UNGASS reporting includes the National Composite Index (also known as the National Commitments and Policies Instrument - NCPI), which tracks indicators related to policy and human rights components of national HIV responses. It is mandatory that governments include civil society consultation for the formulation of this index. The UNAIDS Programme Coordinating Board, UNITAID and the GFATM all have civil society constituencies as part of their governance structures. At the country level, GFATM Country Coordinating Mechanisms ‘include representatives from both the public and private sectors, including governments, multilateral or bilateral agencies, non-governmental organizations, academic institutions, private businesses and people living with the diseases [11] . The post-MDG process and ultimately the resulting framework would be strengthened by drawing on these examples.

Question 5: Targets: was the MDG ‘target-based’ approach a success? Should it be retained? How should progress be measured?

17. The concrete, measurable and time-bound goals, targets and indicators of the MDGs were crucial in creating broad support among the public, civil society, governments and even the private sector. They were clear and easy to communicate, realistic and achievable. However, the new framework goals should be adapted to the current development agenda.

18. The overarching post-MDG ‘goals’ (at the level of the MDG1, 2, 3 etc) should have sub outcomes and impact targets that can be consolidated to measure progress and contribution to achieving the overarching goals. Both qualitative and quantitative measures should also be used. For example, qualitative approaches will help capture progress on quality of health services, empowerment and human rights. Additionally, measures should also be developed to capture cross-sectoral working and how it contributes to achieving the overall goals.

Question 6: Financing global goals: are new mechanisms needed?

19. In order for the post-MDG development goals to be met, long-term sustainable and predictable funding must be identified and secured. No goal set in the future development framework should go unfunded.

20. Firstly, development financing should leverage existing effective funding mechanisms and commitments. The new framework should hold to account both donors and countries to their current spending commitments. At the international level, donors who have pledged funds to multilateral mechanisms like the GFATM should be held to account to fulfil their pledges and contribute their fair share. At the national level, governments should be made accountable for commitments not fulfilled such as the Abuja Declaration in which African governments promised to spend 15% of their budget on health.

21. Secondly, donor countries like the UK should support innovative financing mechanisms to raise the funds needed to fill the financing gaps for development. An example of this is the Financial Transaction Tax (FTT) which would put a tiny tax of about 0.05% on financial products traded by the financial sector, in order to raise around £216 billion for development. A small proportion of this, £6.2 billion could provide free health care to nearly 227 million of the poorest.

22. The new development framework needs to ensure that the investment of existing and new resources maximises efficiency and value for money. A good example of how this can be done is the UNAIDS led Strategic Investment Framework for the HIV response [12] , designed to promote efficiency while maximizing results. The Investment framework is a planning tool that identifies the most effective evidence-proven interventions and ensures they are targeted where they are most needed based on the national context. According to the modelling exercises, improving the strategic use of resources according to the principles of the investment framework would avert 12.2 million new infections and 7.4 million AIDS-related deaths by 2020, with optimized investment leading to rapid declines in new HIV infections globally. This approach can be applied more generally to the broader post-MDG framework.

Question 7: The role of the private sector and other non-state organisations

23. The private (corporate) sector and civil society should both be meaningfully involved in measuring and guiding progress in the new framework.

24. The private sector should contribute financially to the new agenda in accordance with its capacity. The corporate sector should go beyond the concept of corporate social responsibility to working with national governments to develop programmes that are aligned with national development strategies and plans. The corporate sector must share responsibility and adjust behaviour and business models to support equitable economic growth, reduce poverty and improve health. An example of this is Gilead Sciences’ participation in the Medicines Patent Pool permitting generic manufacture of ARV-related compounds.

Question 8: Timescale: what period should the new framework cover? Was the 15-year timescale for the MDGs right?

25. The 15-year timescale for the MDGs gave an achievable time-bound target which was practical and helped to facilitate long-term planning. Within 15 years progress can be measured and individuals contributing to these efforts will be able to celebrate these achievements within their lifetimes.

Question 9: The content of future goals: what would be a good set of global goals? What continuity should there be with the MDGs, and how should the unfulfilled MDGs be taken forward?

26. Within the post-MDG framework the Alliance would like to see improved health outcomes of the poorest and most marginalised communities globally through the provision of universal coverage and access to high quality health care services via a rights-based approach. The strengths of having a specific development goal must not be lost but strengthened.

27. While developing integration between HIV/AIDS and other health and development sectors is essential for improved health outcomes, HIV and AIDS can only continue to make progress if it is included in the new development framework as an independent priority area for action [13] . The achievements in tackling the HIV pandemic have in large part been made possible by the international focus made possible by MDG6 but there is still much to do. For the first time we are able to contemplate ‘ending AIDS in a generation’ but this will only be possible through a last focused push of resources and retargeting of interventions. Losing a specific HIV goal/target now will seriously undercut our efforts at a crucial time.

28. The HIV/AIDS and related global health post-MDGs goals and targets should:

· Include the existing MDG targets. The MDGs that have not yet been met must not be dropped - we need to build on the momentum and progress that has been achieved to date. Whichever new health indicators are chosen, we must ensure that we set the bar for global health ever higher and strive ever harder to reach it. The indicators that measure the progress on HIV and AIDS should not be weakened.

· Be based on the principles of equity, social determinants of health, universality and measurability.

· Realise the right to health, particularly for poorest and most vulnerable groups. It is important to place human rights as an integral dimension of the design, implementation, monitoring and evaluation of health and other related policies and programmes, including political, economic and social.

· Include a balance of intermediary and end-point results (for example, measuring health systems strengthening as well as increased life expectancy and reduced excess mortality). Potential health impact targets could include: Global burden of disease, including HIV and AIDS prevalence; Life expectancy; Child and maternal mortality. Potential intermediary targets (for example, around health systems and preventative health) should include universal health access and coverage progress, e.g. Universal access to treatment for HIV and AIDS; Condom use at last high-risk sex; Proportion of population aged 15-24 years with comprehensive correct knowledge of HIV and AIDS.

October 2012


[1] Goal 4: Reduce Child Mortality, Goal 5: Improve Maternal Health, Goal 6: Combat HIV/AIDS, Malaria and other diseases.

[2] UN General Assembly Special Session on HIV/AIDS (June 2001). Declaration of Commitment on HIV/AIDS. Available at: http://www.unaids.org/en/media/unaids/contentassets/dataimport/publications/irc-pub03/aidsdeclaration_en.pdf

[3] UN Department of Public Information (2010). Goal 6 : Combat HIV/AIDS, Malaria and Other Diseases Fact sheet. Available at: http://www.un.org/millenniumgoals/pdf/MDG_FS_6_EN.pdf

[4] UK Consortium on AIDS and International Development (2012). Policy Briefing: Posotive Gains: Promoting Greater Impact on Health Through HIV and AIDS Programming. Available at: http://aidsconsortium.org.uk/wp-content/uploads/2012/10/Policy-briefing-Positive-Gains-01.10.2012-smaller.pdf

[5] UN Department of Public Information (2010). Goal 6: Combat HIV/AIDS, Malaria and Other Diseases Fact sheet. Available at: http://www.un.org/millenniumgoals/pdf/MDG_FS_6_EN.pdf

[6] UNAIDS. Together We Will End AIDS: Global Report 2012. Available at: http://www.unaids.org/en/media/unaids/contentassets/documents/epidemiology/2012/20120718_togetherwewillendaids_en.pdf

[7] Ibid.

[8] Defined as aged between 15 and 44.

[9] University of California San Francisco (2012). Starting Antiretroviral Therapy Improves HIV-Infected Africans’ Nutrition. Available at: http://www.ucsf.edu/news/2012/10/12862/starting-antiretroviral-therapy-improves-hiv-infected-africans-nutrition

[10] Amanda Glassman, Denizhan Duran, and Andy Sumner ( 2011 ) . Global Health and the New Botton Billion: What do Shifts in Global Poverty and the Global Disease Burden Mean for GAVI and the Global Fund? CGD Working Paper 270. Washington, D.C.: Ce ntre for Global Development .

[11] Global Fund to fight AIDS, Tuberculosis, and Malaria. Country Coordinating Mechanisms (CCM). Available at: http://www.theglobalfund.org/en/about/structures/ccm/

[12] Towards an improved investment approach for an effective response to HIV/AIDS. The Lancet, Volume 377, Issue 9782, Pages 2031 - 2041, 11 June 2011 .

[13] Institute of Development Studies (2012). MDGs 2.0: What Goals, Targets and Timeframe. IDS Working Paper. Vol. 2012 No 398. Available at: http://bit.ly/QeqXw0

Prepared 16th October 2012