Call for evidence opened on impact of UK aid cuts

Introduction

We are STOPAIDS, a network of 70 UK agencies fighting to secure an effective response to HIV and AIDS since 1986. We are submitting evidence to this inquiry to set out our concerns around the impact of the aid cuts on the international HIV response, the Covid-19 response and future pandemic preparedness. We also highlight how a lack of systemic analysis to development challenges and solutions within the Integrated Review risks further entrenching inequity in global health and other interrelated socio-economic issues.

Strategy

●      The strategic targeting of UK aid spending, including the focus areas set out by the FCDO’s seven global challenges and their alignment with the conclusions of the Integrated Review

The FCDO’s seven strategic challenges and the conclusions of the Integrated Review, although broad in scope, miss a more systemic analysis of the nature of each of these challenges and how they are interrelated. From a global health and specifically Covid-19 perspective, without analysing the root causes of what has led to the global inequity we see in access to Covid-19 tools today we will not effectively strengthen global health resilience.

Whilst it’s important that the UK are focusing on the One Health approach, which recognises the close connection between the health of people, animals and the environment, the Integrated Review fails to see how equity in the next pandemic could be secured. When referring to the aim to ‘accelerate equitable access to COVID-19 vaccines, therapeutics and diagnostics (VTDs) worldwide’ the solution is to donate surplus doses to COVAX. Donating surplus doses to COVAX in the short term is an urgent and laudable aim (though we have no evidence of when and how much the UK Government intend to give) but we must look at what has caused the vast inequity we see now where we currently with a handful of HIC having access to 85% of vaccine doses and 0.3% to the lowest income countries.[1]

The reality is that HIC’s were able to act quickly, enabled by their resourcing, to secure the lion’s share of available doses. Scaling up manufacturing of vaccines hasn’t been made possible to the levels we need because the pharmaceutical industry has not been open to sharing the vaccine production know-how, and agreeing to open licensing, which would allow manufacturers who have the capabilities to produce to start manufacturing. We know that no-one is safe until everyone is safe, and we implore the UK Government to realise that it is an act of enlightened self-interest to put pressure on industry to share IP and technology know-how. Companies can do this through the WHO Covid-19-Technology Access Pool (C-TAP), which has recently been re-launched, a facility where intellectual property, research, data and technology know-how can be shared to ensure the Covid-19 response is a public common good.[2]

To support the operationalisation of C-TAP the UK Government should also follow the example of the USA, New Zealand and now Japan in not blocking countries from using the option to Waive parts of the TRIPS (Trade Related Aspects of Intellectual Property Rights) Agreement which relate to Covid-19 vaccines, therapeutics, diagnostics and other equipment. This, coupled with transfer of know-how, would remove the barriers that companies in South Africa, Bangladesh, Indonesia, Australia and Canada currently face in being able to start producing vaccines for their countries and regions.[3]

By not addressing the seeds of global health inequality, it means that other development priorities will also be negatively affected. For example, cuts to health will directly inhibit the UK Government’s goal of improving girls’ education, as lack of access to health services increases poverty and results in more girls leaving school.

On top of this issue of what is lost by not applying a more systemic analysis to challenges and their solutions is the fact that, due to the cuts to ODA, progress towards meeting these priorities (as they currently stand) will be significantly stalled. Global Health has received a 40% cut in funding, which will impact both current objectives as well as risking an undoing of much of the progress that has been made in the HIV response and in other areas.

Meeting the 2030 target of ending AIDS as a public health threat was already at risk with approximately 690,000 people annually still dying from an AIDS related illness despite is being preventable. Furthermore the Covid-19 pandemic has led to massive disruptions in the HIV response. Across facilities surveyed by the Global Fund, HIV testing fell by over 40 per cent in 2020.[4] This is not the time to be scaling back but scaling up on the commitments if we want to stand a chance of reaching the 2030 goal and not undoing the progress that has been made to date.

●      Whether these focus areas address the most pressing global development challenges

We are encouraged to see that global health is a stated priority for the FCDO but we are concerned with the framing around ‘securitisation’ for two main reasons. Firstly, referring to something as a ‘security threat’ has been predominantly pushed from HICs in the West. The language implies a ‘protecting the West from the rest’ conceptualisation which is the complete antithesis of the kind of global collaboration required to have strong pandemic preparedness and resilience.[5] This coupled with the trend in naming Covid-19 variants after places e.g ‘The India Variant’ has led to villainisation, stigmatisation and racial discrimination.[6]

Another criticism is that this kind of approach can lead to a militarisation of the response and giving more powers to police. We’ve seen an abuse of power of policing in the UK, in Kenya, Ghana, Nigeria and South Africa under the guise of enforcing Covid-19 restrictions.[7] We would advise the UK Government to reframe this language and focus more on ‘International cooperation to support global health and pandemic preparedness’.

We are also concerned around the framing of some of the additional priorities outlined in the Integrated Review and their impact on global health. For example, one of the priorities states:

As a maritime trading nation, the UK will be a global champion of free and fair trade. The openness of the UK’s economy will be protected from corruption, manipulation, exploitation and the theft of intellectual property.

The framing of intellectual property (IP) in terms of protecting it from theft clearly indicates the strength of the UK’s resolve that IP is a crucial part of the UK’s wealth creation. The issue when it comes to intellectual property on health technologies is that, more often than not, decreases their public health value. This is through the fact that exclusive IP rights create monopolies and monopolies drive up prices by reducing competition and artificially restrict supply by curtailing who can produce. As a result, many health technologies from cancer drugs to Covid-19 vaccines are inaccessible due to their price or their small volumes. In our paper The People’s Perception: Re-imagining Health Innovation To Deliver Public Value [8] we explore the impact of IP on health further and put forward a recommendation for the UK Government to use other approaches to incentivise innovation.

●      The effectiveness of the Government’s policy to focus ODA spending on countries where UK economic, security and development interests align

We would strongly argue that ODA spending needs to go to the regions, countries, and groups that need it most, wherever they are. Rather than according to where the UK can make strategic alliances to fulfil commercial agendas. This position around the ODA allocation has been outlined in more depth in STOPAIDS’ additional submission to this inquiry.

It’s important to state that from a global health and particularly an HIV response perspective, evidence shows that the community-led HIV response has been effective at increasing knowledge of HIV, promoting social empowerment, increasing access to and use of HIV services, and even decreasing HIV incidence, all through the effective mobilization of limited resources. It is now widely agreed that to end the AIDS epidemic, community responses to HIV must be integrated into national HIV & AIDS plans, from the planning and budgeting phases to the implementation, monitoring and evaluation phases. However, the community response has been continuously underfunded.  An ODI study into the barriers to community organisation receiving funding shows that UN agencies and a number of larger INGOs dominate the humanitarian landscape, as they have (or are perceived to have) the systems and capacity to absorb fluctuating – and often considerable – funds and risks.[9]

The UK Government should investigate the extent to which ODA  is concentrated in or channeled through organisations based in high income countries and investigate alternative models for delivering finance directly to community groups. This might profile models such as the approach taken by the organisation Thousand Currents.[10] Through their grantmaking program, Thousand Currents partners with grassroots groups and movements — led by women, youth, and Indigenous Peoples in the Global South — to create lasting solutions to our shared global challenges. They build long, trusting relationships with their grantees but with minimal strings attached - an approach that has delivered impressive outcomes. They also have a Philanthropic Partnerships program; Thousand Currents works with donors and impact investors to adopt transformative practices that can dismantle injustice and inequity. It could also consider existing FCDO funded mechanisms to support civil society organisations such as the Robert Carr Fund (RCF). The RCF for civil society networks is the first international pooled funding mechanism that aims to strengthen global and regional HIV civil society and community networks. One of their strategic focuses is on movement leadership which looks to assure a stronger, continuous, community-led and rights-based response to HIV.

Administration

●      Changes to the administration of UK ODA, including the FCDO assuming responsibility for deciding the final departmental allocation of ODA and administering the majority of UK ODA

●      The split between bilateral and multilateral ODA spending, and the effectiveness of these channels for the delivery of UK aid

Going forward a cross government approach to global health is essential. The governance structures and arrangements of the approach should include maintaining and strengthening the current Global Health Oversight Group, creating and implementing a cross-government Global Health Strategy and assigning a Government Minister responsible for delivering the government’s manifesto commitment of Ending Preventable Deaths. The creation of a cross-government Global Health Strategy which articulates the UK’s role in supporting the achievement of SDG3 globally would allow the UK to crystalise its vision of its role in global health and to ensure that the multitude of global health investments and programmes the UK is involved in are all pulling in the same united direction. 

Process

●      The FCDO’s approach to the process of implementing in-year changes to the aid budget during the 2020-21 financial year, including its communication with stakeholders

●      The FCDO’s approach to setting ODA budget allocations for the 2021-22 financial year, including its communication with stakeholders

It is critical that the UK Government meaningfully engages stakeholders in the process of implementing in-year changes to the aid budget, and in setting ODA budget allocations. Currently there is an inconsistent approach by the UK Government regarding consultation with the UK public and key stakeholders in the countries where ODA is spent. There is no document that describes the UK Government’s approach to consultation. In order to ensure diverse and quality scrutiny, UK civil society should be recognised as a key development partner by the Government and engaged regularly and systematically for feedback. Additionally, UK Aid must be accountable to communities that it serves and create opportunities for feedback through country programmes and spending where these do not already exist. Any government department spending UK Aid should include information on citizen needs and preferences as a systematic requirement for portfolio and programme design and management.

In the approach to implementing in-year changes to 2020-2021 there is a lack of information around how these funding allocations align with FCDO’s strategic objectives and the decision-making process given FCDO’s own evaluation of organisations such as UNAIDS receiving an A for their performance in 2020. We are also concerned by the lack of impact assessments undertaken prior to the decision-making process and allocation.[11]

Impact of the changes

●      Impact upon communities in lower income countries

●      Impact upon organisations implementing UK ODA programmes

Analysis from Action For Global Health highlights that the cuts will impact every area of global health and interconnecting issues, and result in a decades-long, catastrophic rollback on a myriad of health issues, to which the UK had previously contributed so significantly and laudably. [12] Organisations, including BOND, have also highlighted the wider impact the cuts will have on other UK ODA programmes, lower-income countries and our ability to play a leading role in achieving the Sustainable Development Goals.

There have been significant cuts made to the UK Government’s support for the global HIV response. These cuts couldn’t have come at a worse time for the HIV pandemic. Even before COVID-19, the HIV response was in a precarious position. AIDS remains the number one killer of women of reproductive age and 1.7 million people acquired HIV in 2019. COVID-19 is now threatening to reverse years of progress and increase deaths.

Within this context, there is a very real threat of hard-won progress on HIV and AIDS going into reverse. These cuts by the UK Government will actively increase that risk, setting the stage for a resurgence in HIV acquisitions and AIDS related deaths across many countries. One such organisation that has seen their funding cut significantly is UNAIDS, the Joint United Nations Programme on HIV & AIDS. The UK, which has provided £15 million a year for the past five years, plans to provide only £2.5 million this year – a more than 80% cut.[13]

These proposed UNAIDS cuts risk jeopardising their work supporting some of the most marginalised people; hurt its work to help girls’ education and empowerment; and lessen its ability to help countries, including the UK, to end HIV & AIDS. Whilst all other donors are maintaining their support for UNAIDS, the UK’s cuts are at odds with the UK’s strong support for UNAIDS’ new strategy and its own development priorities. The new UNAIDS strategy connects strongly with realising the UK’s Strategic Priorities for ODA including global health security; girls’ education; science, research, and technology; and open societies and human rights.

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 (so that pregnant girls are not dismissed from school and LGBTQ people are not criminalised) and helping countries secure and spend effectively other resources (including supporting countries to effectively use grants from the Global Fund To Fight AIDS, TB and Malaria), this small investment is an exemplar of value for money. For the past 3 years, the UK’s own evaluation has rated UNAIDS as A for their performance. [14] Given UNAIDS’ critical work, it’s catalytic impact and relatively small amounts of funding involved, the UK Government should mitigate the earlier decision by making a supplementary allocation to this low-cost high-impact agency.

Another UN Agency that does important work for the HIV response, and Sexual Reproductive Health and Rights (SRHR) more broadly, is the United Nations Population Fund (UNFPA). The UK has announced plans to cut 85% of its funding given to the UNFPA. These cuts will be devastating for communities’ access to contraceptives and reproductive health supplies.

There have also been significant cuts to the UK’s funding for global health Research & Development (R&D) which plays a critical role in developing new effective health technologies and advances the HIV response. For example, the Government has unilaterally withdrawn over £150M to programmes that protect communities against neglected tropical diseases (NTDs), and to research and development in NTDs.[15]

There have also been significant cuts to the UK Government’s bilateral HIV funding. This is partly due to how the UK cancelled several funds supporting small and medium sized civil society organisations including the Aid Connect, Aid Direct Impact and Community Partnership grants streams.

These projects were effective in reaching and supporting marginalised communities. Key populations and their partners account for more than half of all new HIV acquisitions globally. Despite this, it is estimated that only 2% of HIV funding globally goes to key-population led responses. The significant cuts to the UK’s bilateral HIV funding and closure of programs that were effectively reaching communities, is likely to further heighten the barriers these communities face in realising their right to health.

Through the cuts to UK Aid Connect, programs implemented by STOPAIDS members Frontline AIDS and IPPF have been forced to close. These programmes were on track to pilot new SRH services and support Community Based Organisations (CBO)  to develop new data systems to build evidence to influence wider civil society and authorities, across 7 countries. The impact of cutting the programmes at this point is not only the loss of potential future results, but also losses in staff at implementing organisations and the risk of damage to relationships between partner organisations, many of whom operate in extremely fragile and politically challenging environments.

One of the programs is ‘ACCESS’, a consortium-led programme aimed at producing evidence-based, sustainable approaches to under-represented SRHR issues for marginalised and hard-to-reach populations, including LGBT+ people and refugees. The programme was scrapped 6 months into implementation.

Without additional funding, IPPF have noted that they will be forced to close services in Afghanistan, Bangladesh, Zambia, Mozambique, Zimbabwe, Cote D’Ivoire, Cameroon, Uganda, Nepal and Lebanon and may be forced to close services in an additional 9 countries. IPPF have highlighted that this will withdraw support for SRH services from approximately 4,500 service delivery points globally.

The Evidence and Collaboration for Inclusive Development (‘ECID’) was another consortium-led programme that had their funding removed. The project aims to contribute to poverty reduction, the realisation of rights and improved well-being of over three million people. It had a focus on the most marginalised people, including women and girls, LGBTI people, ethnic minorities and people living with HIV.

Given the Global Fund’s critical role for the responses against HIV, TB and Malaria; it’s welcome that the UK has committed to maintaining funding given at its last replenishment. However, there is a risk that there could be changes to the timing to the dispersal of the funding. To prevent disruption, it’s critical that the Sixth Replenishment pledge is dispersed as planned. And to help mitigate against the impact of this year’s funding cuts from the UK Government to the broader HIV response and to get the HIV response back on track; it’s critical that the Government works to ensure that the Global Fund is fully resourced at next year’s replenishment.