Written evidence for the International Development Committee’s inquiry into Extreme Poverty and the Sustainable Development Goals.

This written submission was compiled by the UK Civil Society Global Fund Working Group. Organisations supporting the submission: STOPAIDS, Frontline AIDS, Malaria No More UK, ONE Campaign, RESULTS UK and Youth Stop AIDS.

How well is UK Official Development Assistance (ODA) targeted towards tackling extreme poverty and how effectively do the FCDO policies and programmes contribute to the achievement of Target 1.1 of SDG 1?

Through the UK Government’s role as a critical contributor to the fights against HIV, TB and malaria, it is playing a leading role in combating both the causes of extreme poverty and supporting people to transition out of it.

Ending AIDS, TB and malaria is part of a broader health goal (SDG 3): Ensure healthy lives and promote wellbeing for all at all ages. Target 3.3 within SDG 3 commits to “end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases” by 2030. The SDGs are interdependent. Agenda 2030 acknowledges that efforts to achieve the goals to reduce poverty or ensure gender equality will help promote better health, while in turn improving health outcomes is key to the success of other SDGs. Evidence suggests that the interconnectivity across the SDGs - including SDG  1 -  is critical to the goal of ending these infectious diseases.

Individuals and households affected by poverty are likely to be hit harder by the impacts of HIV & AIDS, TB and malaria. For example, without adequate HIV care, services and treatment, people become unwell and quickly become unable to work. This both deprives individuals of an income and reduces a country’s gross national product.[1]

Discrimination against people living with HIV can also reduce livelihood opportunities by adversely affecting social networks and employment opportunities.[2] Insufficient income can also be a factor in a person’s decision to sell sex (sex work) or exchange sex for goods (transactional sex). However it should be noted that many sex workers may choose the occupation as a form of economic empowerment rather than as a ‘last resort’. However, people who sell sex or transact sex are disproportionately impacted by HIV.[3]

As diseases highly linked to poverty, income-based inequalities also affect outcomes in the fight against malaria and TB. As well as affecting individual and household finances, failure to combat the three diseases also inhibits wider economic growth. For example, work absences necessitated by drug-resistant TB treatment were estimated to have resulted in a loss to global GDP (PPP) of at least US$3 billion in 2018 alone.[4] 

Considering the interconnections between infectious diseases and poverty, the FCDO’s long standing support for the Global Fund To Fight AIDS, TB and Malaria (Global Fund) should be highlighted as an impactful investment that contributes to the achievement of Target 1.1 of SDG 1. The Global Fund is the leading multilateral organisation investing in the three diseases and health systems. It is the single most important mechanism for donors, recipient countries, civil society, the private sector and other stakeholders to unite in their response to these epidemics and has repeatedly proven to deliver high value for money.

Global Fund partnership has turned the tide against infectious diseases, built health systems and saved more that 44 million lives. In countries where the Global Fund invests, AIDS-related deaths have dropped by 65 per cent, malaria deaths by 45 per cent and TB deaths by 28 per cent since 2002.

Given that discrimination against people living with HIV can also reduce livelihood opportunities, the Global Fund’s important work on maximising health equity, gender equality and human rights should be highlighted. In the Global Fund’s newly adopted 2023-2028 Strategy, it proposes an even greater determined action to tackle human rights and gender-related barriers.[5] This includes scaling up comprehensive programs and approaches to remove human rights and gender-related barriers across the portfolio. Within this it includes a partnership-wide commitment to confront the criminalization of communities most affected by the three diseases and support enabling legal and policy environments.

The Global Fund’s work is all the more important given the devastating secondary impacts of the COVID-19 pandemic on HIV, TB and malaria services. It’s estimated that the pandemic has set back progress on TB by 12 years[6], while 2020 saw declines in testing and prevention services for HIV, a decline in the number of TB cases notified to health services, a decline in the number of people treated for TB as well as disruptions to key diagnostic tools for malaria[7]. As such, investment in the Global Fund going forward will be critical to win back the  progress that has been lost since the start of the pandemic.  

Given the Global Fund’s critical role in reducing disease incidence and building health systems, these investments also support countries’ economic development and response to crises like COVID-19.  Subsequently these investments support Global Fund implementing countries to expand their social expenditure, public services and other country-driven interventions that can tackle extreme poverty and create further opportunities for economic growth.

The UK Government was a co-founder of the Global Fund and has remained front and centre in supporting the Global Fund to achieve these amazing results, contributing approximately GBP 4 billion to date. It is estimated that the UK’s investments into the Global Fund have saved over three million lives. The UK’s £1.4 billion pledge to our 6th Replenishment in 2019 was the 2nd largest contribution overall. Similarly strong support will be critical for the success of the Global Fund’s upcoming 7th Replenishment in 2022.

Recommendations:

-          The UK Government should make an ambitious pledge for the Global Fund’s seventh replenishment in line with the resource needs identified in the forthcoming investment case.

-          The UK Government should use their funding and representation on the board of the Global Fund to ensure effective implementation of the Fund’s 2023-2028 Strategy, including associated targets that would support the achievement of Target 1.1 of SDG 1.

●       How might the FCDO’s strategy, policies and programmes need to change as the number of people in extreme poverty grows due to the global pandemic or the effects of climate change?

Large inequities in the coverage of services and health outcomes are often linked to the amount people have to pay for care, with women, children and adolescents worst affected.[8] It is encouraging that the FCDO’s recently published “Ending the Preventable Deaths of Mothers, Babies and Children by 2030: Approach Paper” recognises that these “vulnerabilities often compound one another in a cycle of poverty, disability and ill health”.[9]

Given this and how we are likely to see the number of people in extreme poverty grow due to the global pandemic and effects of climate change, it’s critical that the FCDO redoubles their commitment to achieving Universal Health Coverage (UHC), Health System Strengthening and working through programmes to ensure that people are not pushed into poverty because of out of pocket  costs for health services.

With the Global Fund’s close partnership approach with Governments, civil society and other key stakeholders and their extensive funding to advance health system strengthening, they play a key role in delivering Universal Health Coverage. The Global Fund is the largest multilateral provider of grant support to strengthen health systems. It invests over $1 billion a year to improve supply chains, disease surveillance, lab systems and data systems; train health care  workers; and build stronger community responses. Through these investments and supporting countries to achieve Universal Health Coverage, the Global Fund builds resilient systems for health that also helps prepare countries in responding to increasing numbers of people in poverty and removes barriers from people accessing the services they need.

As explored above, given that HIV, TB and malaria are highly linked to poverty and income-based inequalities, if the international community can reduce disease incidence rates and improve health outcomes, it will limit the number of people driven into poverty.

The FCDO can also better respond to the increasing poverty rates and the interconnectedness between disease and poverty within their international development strategies. The FCDO is currently developing its international development and Global Health strategies. These strategies should connect with and build upon the commitments within the FCDO’s “Ending the Preventable Deaths of Mothers, Babies and Children by 2030: Approach Paper” and their “Health systems strengthening for global health security and universal health coverage: FCDO” position paper and should be guided by saving lives, rather than by trade or economic incentives. The Ending Preventable Deaths paper states the Government will continue its support for the prevention and treatment of HIV, TB and malaria through the Global Fund.[10] To ensure the FCDO plays a leading role in limiting the extent and impact of extreme poverty, this commitment to continuing to support the Global Fund should also be reflected within the FCDO’s International Development and Global Health strategies.

Recommendations:

-          The FCDO should increase support to national strategies advancing UHC and secure this commitment within the UK's planned International Development and Global Health strategies.

●       How effectively do the FCDO’s strategy, policies and programmes address the needs of women and girls in extreme poverty?

Given that HIV, TB and malaria are also highly linked to poverty and disproportionately affect women and girls, the FCDO’s long-standing support for the Global Fund should be highlighted.

Women and girls continue to be disproportionately affected by HIV, TB and malaria. In 2020, 1.5 million people were newly infected with HIV, of which women and girls accounted for 50 per cent globally. Adolescent girls and young women (ages 15-24) continue to be disproportionately affected by HIV. In Sub-Saharan Africa, women and girls made up 63 per cent of all new HIV infections in the region in 2020.[11] And AIDS related illnesses continue to be the leading cause of death amongst women of a reproductive age globally.

Whilst TB generally affects more men than women, it remains among the top five causes of death for women aged between 15 and 44 in low-and middle income countries[12].  As for malaria, pregnant women are particularly susceptible to the disease. Potentially fatal for the woman, it can also cause miscarriage, low birth weight or premature births.

The Global Fund is one of the most impactful investments that the FCDO makes in supporting women and girls. Since being founded 20 years ago, the Global Fund has saved 44 million lives. Adolescent girls and young women (AGYW) are a mainstay focus for the Global Fund. In 13 priority countries shouldering the highest HIV burden, new HIV infections have now fallen by 41% among AGYW since 2010. The Global Fund supported 11.5 million pregnant women to receive preventive therapy for malaria in 2020. There are also numerous TB programmes from The Global Fund that specifically support women and girls in poverty. This includes the Global Fund’s investments in Afghanistan to fund female community health nurses, supporting them to deliver TB prevention and care to women in remote communities who otherwise cannot visit health facilities without the escort of a male relative[13].

Recommendations

-          The UK’s continued strong and ambitious investment in the Global Fund is wholly aligned with its strategic focus on supporting women and girls. As the FCDO seeks to increase its aid spending targeted to supporting women and girls, it should protect funding pledged at the 6th replenishment and make another ambitious pledge to the Global Fund at the 7th replenishment conference as a proven, impactful mechanism.

●       How effectively does the FCDO review the outcomes of the projects and programmes it funds that tackle extreme poverty? What evidence is there that UK aid is being used to build pathways from extreme poverty to sustainable livelihoods?

The Global Fund is an excellent FCDO investment that delivers value for money, transparency and effective monitoring of outcomes of the projects it funds. The 2020 AID Transparency Index rated the Global Fund as ‘very good’ for overall transparency, underlining the Global Fund’s commitment to tracking health investments and providing quality data.[14] This tracking of health investments comes through both the Global Fund’s annual Results Report and the own reporting from their donors, including the UK Government’s annual reports that can be seen on DevTracker in which they score “A”s for programme scoring.

The 2021 Global Fund Results Report shows that despite operating in very difficult circumstances owing to COVID-19, the Fund supported 21.9 million to access antiretroviral therapy for HIV in 2020; 4.7m people with TB treated in 2020; and 188 million mosquito nets distributed in 2020.[15] The UK Government sets demanding performance targets onto their investments for the Global Fund. It is estimated that health programs supported by the Global Fund partnership had saved 44 million lives as of the end of 2020. STOPAIDS estimates that more than 3 million of these lives were saved thanks to UK Aid contributed to the Global Fund and that in 2020, the UK’s investments supported over 1.5 million people to access ARV therapy.[16] Given the aforementioned linkages between health outcomes and extreme poverty, these impressive results are a clear example of how UK aid is being used to build pathways from extreme poverty to sustainable livelihoods.

●       What effect have the cuts in UK ODA had on the FCDO’s ability to address extreme poverty? What evidence is there to suggest poverty was a key consideration in deciding where the cuts should fall?

Despite making significant cuts across the Government’s wider portfolio of HIV, TB and Malaria ODA spending, it’s welcome that the UK Government has maintained the funding commitment it made at the Global Fund’s Sixth Replenishment. FCDO Minister Amanda Milling has also recently stated that the FCDO is on track to fulfil our 6th replenishment pledge.[17] Given the Global Fund’s critical role in fighting the three diseases and proven impact in other cross-cutting areas such as health system strengthening and pandemic preparedness, having this funding protected is saving countless lives and addressing extreme poverty.

With the UK’s long-standing partnership and the Global Fund’s critical role in delivering on multiple of the FCDO’s development priorities, it’s understandable why the Government chose to protect the funding committed at the Sixth Replenishment. But to ensure an effective response against infectious diseases and maximise value for money for UK Aid spending, the UK Government should be cautious about investing its resources solely into the Global Fund at the expense of other critical multilateral and bilateral investments that support the eco-system for where the Global Fund can be at its most effective.

Despite being a strategic priority, global health has still seen dramatic and devastating cuts of up to 40% overall. For example, for 2021-2022, UNAIDS had their annual funding cut by over 80%, from £15 million a year to just £2.5 million. With difficult decisions being made on the aid budget, investments which are small, but which have a large catalytic impact are particularly high value for money. Because UNAIDS plays a critical role in helping countries reform policies (for example, ensuring that pregnant girls are not dismissed from school and LGBTQI+ people are not criminalised) and helping countries secure and spend other resources effectively (including supporting countries to successfully use grants from the Global Fund), this small investment is an exemplar of value for money. The 2016 DFID business case for UNAIDS funding recognises that “with much of DFID’s support for the HIV response allocated to the Global Fund, UNAIDS’ role in improving the effectiveness and efficiency of the Global Fund is particularly important for delivering value for money for UK aid.[18]

Other examples of the UK Government’s ODA cuts that will affect the effectiveness of the Global Fund include the reduction of funding to UNITAID, UNFPA,  UNDP, the closure of several bilateral programmes and the significant reduction in biomedical Research & Development funding.

Recommendations

-          The UK Government should continue to ensure it disperses the full amount pledged to the Global Fund from its sixth replenishment without delays.

-          FCDO business planning in 2022 should allocate additional resources to the crucial organisations that support the effectiveness of the Global Fund that experienced significant ODA cuts in 2021.

-          The UK Government should urgently return to the 0.7% ODA of GNI spending commitment.

●       How the FCDO can play a more effective part in the eradication of poverty as a convener, thought leader and investor.

With the UK Government’s position as a Board Member of the Global Fund, they are well positioned to drive implementation of the Fund’s 2023-2028 Strategy, including associated targets that would support the achievement of Target 1.1 of SDG 1.

And given the significant resources that will be required at the Fund’s seventh replenishment, whilst ensuring their own ambitious pledge, the UK Government should actively use their bilateral relationships and engagement with international bodies (including the G7, G20 and Commonwealth) to leverage increased contributions from other Government donors and the private sector. The upcoming UK Government hosted “Global Pandemic Preparedness Summit” provides a key opportunity for the Government to mobilise other donors and highlight the Global Fund’s critical cotrinhitions to global health and pandemic preparedness & response. Likewise, the UK Government hosted “Safe To Be Me Conference” in June gives a key opportunity to rally other donors and highlight how the Global Fund is an impactful investment that ensures inclusive access to healthcare and advances marginalised communities’ human rights - both key factors that support the eradication of poverty.