Panel discussion on linking HIV and SRHR

Taking the linking agenda forward

Money and Switzerland's political will are also necessary in order to create youth-friendly services in the field of HIV and sexual and reproductive health that are accessible to all and affordable. Extracts from a panel discussion on the subject.

According to Jeffrey Sachs, the UN special adviser on the Millennium Development Goals, most countries are not giving enough to reach the Millennium Development Goals (MDGs), particularly in terms of HIV and sexual and reproductive health. Eveline Herfkens, one of the founders of the millennium campaign, recently made quite a strong statement about Switzerland in particular not providing enough funding. How much is Switzerland actually spending on HIV and reproductive health?

Helena Zweifel: I can present you with some very new data, which the OECD released yesterday, collected and analysed by our expert Joachim Rüppel from the Medical Mission Institute in Würzburg. In 2010, Switzerland's official ODA amounted to 0.41% of gross national income (GNI). If we exclude spending within Switzerland for refugees and exclude debt relief, the real transfer was only 0.31% of GNI. Joachim Rüppel's task was to look at how much Switzerland spends internationally on health promotion, on HIV and on reproductive health. There is not much information on reproductive health in the OECD data, but he found quite a bit on HIV. This might be seen as an indicator of what seems to be important or not to the international community. In 2009, Switzerland's total contribution for international health was CHF 140 million, that is 0.025% of GNI, or 7.9% of total ODA. This contribution has been more or less stagnant in the last five years.

Comparing Switzerland's ODA disbursements for health promotion in relation to GNI with other European countries, we find Switzerland at the bottom. This year Italy is lower for the reason that Italy has not disbursed the money committed to the Global Fund so far. But when Italy pays - and it will - Switzerland will definitely be ranked last.

Concerning the HIV response, Joachim Rüppel looked into specific HIV interventions as well as sector-wide programmes and general budget support. He used a special key based on estimates used for other country analyses. In 2009, Switzerland spent USD 9.9 million for HIV in bilateral cooperation. Switzerland also contributes to the World Bank, the World Health Organisation, UNAIDS and other multilateral organisations. The contribution to the Global Fund to fight AIDS, Tuberculosis and Malaria was USD 6.3 million in total, of which USD 3 million was on HIV. Which is very little. The result: Switzerland spent a total of CHF 36 million for the HIV response in 2009, that is a mere 0.006% of GNI.

This data shows that Switzerland's spending on international health cooperation and on HIV is stagnating at a low level. There is a need for Switzerland to raise its contribution on international health, on HIV and on reproductive health. Therefore, aidsfocus.ch and the Network Medicus Mundi Switzerland are advocating a rise in Switzerland’s contribution in international cooperation to 0.7% of GNI, and a rise in its share in international health promotion, in the HIV response and in sexual and reproductive health and rights.

What can Switzerland do to raise its contribution, and how can it raise its effectiveness through linking sexual and reproductive health and HIV?

Nathalie Vesco: If SDC spends – according to the figures of your study – roughly 25% of the total contribution for international health towards the control of HIV/AIDS, this represents a substantial part. Switzerland has international commitments to finance and contribute to UN organisations and international organisations, and it has bilateral commitments. Therefore, SDC, as approved by the Swiss parliament, has to allocate resources within a defined framework, which is not too flexible. In that sense, one of the challenges would be to look for more impact with the same amount of money.

We have been discussing all day about raising the effectiveness through linking sexual and reproductive health and HIV, and we were discussing in the working groups the role of the different actors. But the issue is not only financing, we also have to look into the way SDC actually works, the way we choose our partners and negotiate with them, and the way we can for example contribute through the policy dialogue with UNAIDS, or with global health initiatives such as GFATM, to reach most efficiently men, women, adolescents, the ones who are most in need. I think that for SDC, there is still space for improvement in communicating what we do, what we have reached, who are our partners...

The other point is, with a link to the data that Helena presented: How can we improve the synergies and complementarities between the actors present in this room? It is easy to show a specific contribution while co-financing aidsfocus or IPPF. There you can define exactly what goes for HIV/AIDS or what goes for the linkages of HIV and sexual and reproductive health. But what about the projects where we are working in Tajikistan or Moldova or in Tanzania? The sector-wide approach has been mentioned, but we also need to speak about health system strengthening. Our hypothesis is that for instance in Central Asia there are a lot of problems as mothers are dying because they do not have access to health care when they are pregnant or have complications during giving birth or after. Our focus is on training the medical staff in order to make sure that services required are available, that there is infrastructure and equipment. We might first need to finance or to contribute to the equipment or to the training. This is an important contribution for building linkages with sexual and reproductive health, even if it does not appear in the OECD data as prevention of HIV. But in the end, it is part of it. How do we quantify this?

This brings us back to the discussion we had during the day about the linkages which go beyond the vertical funding. SDC has for example strengthened, in its bilateral as well as multilateral engagement, the promotion of adolescent sexual and reproductive health services. Beside working with women and girls, SDC emphasized the need to include men and boys as agents of change in sexual and reproductive health. Evidence shows that this strategy can be effective in bringing down infection rates and can bring better health for poor and vulnerable populations.

Yvonne Gilli: I will try to speak with the voice of an average parliamentarian and not with my personal voice, because this would not be representative. For a parliamentarian it actually matters how much money we have spent on OECD activities and how effective this money is spent. It matters where we stand in comparison to others, and what impact this has for Switzerland. We do not want to lose in comparison to other countries, but like everybody else, we want to be influential in an integrated way.

We all have to be aware right now that we succeeded in increasing ODA recently to 0.5% of GNI. This is not corrected the way Helena said, but we are aware that all countries have the same problems concerning this sort of “cheating”. We have do be aware that we don't have a majority in parliament for 0.5% of GNI for ODA. This is important to know because, and that is a question which got raised before, who is the decision maker? The fact that we did increase ODA was a simple deal in parliament, and the pressure group for this deal were the NGOs in the field of developmental cooperation. The pressure groups which we are counting on in parliament are the population and the pressure groups coming from ODA. We need to maintain all the efforts. We actually do need answers concerning how effective our money is invested and how our position is in comparison to other countries. On an international level, at least, I would like to have disaggregated figures. I would like to know why SDC distributes the money the way it does and what actually is best practice. We do not have the figures from these organisations concerning sexual and reproductive health right now, and that makes it more difficult to work in parliament.

What I also would like to have is more linkage and more awareness about the parliamentarians engaged in this work. There are quite a lot of different all-party groups, such as the group working with the Red Cross, the groups working on sexual and reproductive health and advisory groups on fighting HIV and AIDS. They have common fields, and if we do not speak with a united voice - a kind of umbrella voice from different NGOs - we will not be effective. There is too much fragmentation also within parliament, which makes it difficult to get majorities. Much is possible if you address the different party groups with an united voice and show in your field of work which money goes into sexual and reproductive health, what is best practice and where can you show a good effect. More cross-sectional work is important.

For the work in parliament, I need more information and at the same time I am overloaded with information. This is a question of using synergies. With every sort of information I get from NGOs I would like to get information on sexual and reproductive health as a cross-sectional topic. I need the information in an integrated way, and when we hear it all the time, it sort of it gets in my mind and it has consequences in shaping the parliamentarians' mind and willingness to spend on ODA.

Let us discuss and crystallize the second issue that we have been working on today: what are the roles of the different stakeholders to take the agenda of linking sexual and reproductive health and HIV forward?

Kevin Osborne: There are three things: Point one is that we must not fool ourselves and attempt to establish another ‘linkages’ sector. Linkages is a modality, and if we accept that it is bi-directional, it means that the HIV community has to do work on sexual health and the sexual health community has to do work on HIV.

The second point: It is a moving field. There is a lot of good practice happening in the field on all levels – policy and programmes. On the global political level, people are talking about it, and on the ground level, people are doing it. It seems to be at the country level a lot more work on integration is happening ‘de facto’ on the operational level. Where are some of the current gaps? The first one is around policy: There is an absence of policy at the country level between the sexual and reproductive health units and the HIV units. Let us try and get those synergies. I think within the donor community there is a large political commitment to it. The question comes up now and I think we should have a donor conversation, or better ‘donor integration’ among and between various donors. The donors, the foundations and the private sector should get together and say this is an important area and discuss how can we get together. There are all parts of different pieces of the same pie. The second gap is about what linkages looks like in different HIV contexts. What is happening at the moment is that people are focussing around issues of maternal health. But maybe linkages and maternal health do not really affect people who inject drugs; their ‘linkages’ issue may be sexual rights.

The third point is that the SRH and HIV research communities should come out with a common agenda so that the research really takes us to new territories and addresses some of the current gaps (e.g. around cost effectiveness, linkages in concentrated epidemics, etc.). And in two years time when we meet again we could have a new conversation.

Let us move on to the third topic that we discussed, to the challenges and opportunities of linking HIV and sexual and reproductive health and creating youth-friendly services. Could you please crystallize the challenges and opportunities as you see it from your perspective?

Beatrice Savadye: A first main challenge is donor conditions. Some donors are funding only HIV programmes and others are funding sexual and reproductive health. This creates parallel structures and promotes territorialism.

The other point is that this issue of parallel structures and policies affects communication. On the one hand we have the HIV policy and on the other hand the reproductive health policy. Actually it should be integrated into policies and strategies that promote the linkages of sexual and reproductive health and HIV.

A major factor is the need for advocating youth-friendly and integrated services. Many of the political leaders and policy makers are not aware of the issues that are affecting young people. The politicians really need to be sensitised on such issues and interact with each other. As mentioned before, the reproductive units and the HIV units should work together.

Chandra-Mouli: One message that I heard from several people is that we need constantly to be aware that adolescents and young people are a heterogeneous group. A boy of ten is very different from a young man of nineteen, a boy of fourteen is very different from a girl of the same age, and two boys of the same age growing up in different circumstances develop very differently. So they have very different needs and evolving needs - needs that can change from one day to the next.

People also reiterated the need to be aware of the cultural context. For example in Chad or in rural India, a girl who starts her menstrual periods is seen as an adult woman. She may be kept out of school and be asked to follow all the rules of an adult woman. So the cultural construct that we use in Switzerland cannot be used in rural India, although one can say urban areas of Delhi or Lagos are not so different from Geneva or London in some aspects.

I lived in Zambia for ten years and still feel a strong connection with that country. Listening to Beatrice today almost brought tears to my eyes to think about the challenges young people in Zambia face today. Putting myself in the shoes of a fourteen or fifteen year old girl in Zambia or Zimbabwe: my father is struggling to feed the family in a very difficult time; I have done well in school and am getting ready to go to university; my father says to me - I have supported you so far, now you have to take care of yourself. I have responsibilities with the younger children. So, these young people - who have been cared for through childhood illnesses, fed and nourished and educated - are left on their own at a crucial stage of their lives. They are not able to get contraception, including emergency contraception or a safe abortion. The result is a disaster, a tragedy for these young people, their families and society as a whole.

If there is one thing I would like to add to what Kevin said, it is that alongside efforts to strengthen HIV and SRH, we need concerted efforts to make existing HIV and SRH programmes more responsive to young people. Further, we need responsive programmes and ones that are both sustained and large in scale. Monica, Sybil and Beate described good programmes, but they all said that they were concerned about their sustainability. There are small - even micro-projects in many places, and they are often of a short time frame. They meet the needs of some adolescents, but we need to do better and we need to do more, much more.

Three pressing and largely neglected issues came up within the discussions. Firstly, unsafe abortion: 2.5 million adolescents are estimated to have unsafe abortions every year. Half of all maternal deaths in Africa are due to unsafe abortion. Secondly violence: Several people said when girls or young women are beaten or coerced into having sex, we don't know what to do. Thirdly, boys and young men: What are we doing to reach them and what approaches are we using. Three important and neglected issues.

I think we all heard the real need for adolescents to be on the public health agenda. Many of you are already addressing adolescents. If you are please step up your work. If you are not, please try to do something, however small, to meet the needs and fulfil the rights of adolescents in the communities you serve/work with.

Helena Zweifel: To take the linking agenda forward and advocate youth-friendly services in sexual and reproductive health and HIV for all, Switzerland has to do more. I agree with Yvonne Gilli that for lobbying and advocacy we need concrete data on how much Switzerland is spending internationally on sexual and reproductive health. We will have to conduct another study to fill the gap and share and discuss the results with SDC, interested parliamentarians and the wider network.

Another point that I picked up in the discussion is the fragmentation of voices, or rather, overcoming this fragmentation and to speak with one voice on HIV and SRHR linkages and promotion of health for all. This is what the aidsfocus.ch platform already is working on, in close collaboration with the members of the Network Medicus Mundi Switzerland. It will intensify its efforts in this regard.
The next aidsfocus.ch conference will take place one year from now. An interesting topic, which was inspired by Chandra’s remark, could be “Where are the boys and men in the AIDS response?”, or “boys, men and sexual health”. Some of our partners have experience in working with boys and men and would like to share them with us. The partner organisations of aidsfocus.ch will decide on next year’s topic this fall.

Helena Zweifel is the executive director of the Network Medicus Mundi Switzerland and aidsfocus.ch. Nathalie Vesco is in charge of HIV and reproductive health at the Swiss Agency for Development and Cooperation (SDC). Yvonne Gilli is member of the national parliament, Beatrice Savadye is advocacy officer of SAYWHAT, a Zimbabwean NGO. Kevin Osborne is the Senior HIV advisor at the International Planned Parenthood Federation (IPPF) in London. Venkatraman Chandra-Mouli is the Coordinator of the Adolescent Health and Development unit in the World Health Organization (WHO) in Geneva. The panel discussion was moderated by Kate Molesworth, Swiss TPH.