ODE TALKS PODCAST
TRANSCRIPT OF INTERVIEW WITH BEN DAVID
Dereck Rooken-Smith (Office of Development Effectiveness, AusAID):
Hello and welcome to ODE Talks. I’m Dereck Rooken-Smith.
‘Responding to Crisis’ is the title of ODE’s recent evaluation of Australia’s contribution to the national
response to the HIV epidemic in Papua New Guinea. The report found that AusAID had been a major
driver of the national HIV response in PNG. However it also found, that the relevance and
effectiveness of AusAID’s interventions has been mixed. The evaluation makes several
recommendations for AusAID’s management of the program in future, including that it moves to an
integrated health approach, with HIV activities managed as part of the broader, sexual and
reproductive health activities.
With me today is Ben David. Ben is AusAID’s Principal Health Advisor, and he joins me to talk about
the evaluation and its implications for AusAID. Ben welcome to ODE Talks.
Ben David:
Thank you.
Dereck Rooken-Smith:
Let’s start off Ben just by asking, from your point of view, what aspects of the evaluation did you
think were most important for the PNG program?
Ben David:
It’s a really good question, and from my perspective this is a really welcome evaluation. I think I
would make four points here.
I think the first is the importance of independent evaluation like this for our programs, particularly
for HIV and AIDS. It’s rapidly changing our understanding of HIV and AIDS, not only in PNG but
globally, and that we need to maintain rigour around how we invest in the evidence and
understanding of these epidemics in different contexts. So the importance of this type of evaluation
which informs our program and informs the quality of our thinking and our investment through
AusAID, but also the PNG Government’s investments, is critical.
In relation to the specific recommendations, I think there are three key areas. The first is the
importance of political leadership and ownership and accountability, and I think the evaluation
really brought that point home. And the implication for our program is that we don’t just think about
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the service delivery to vulnerable groups – the sex workers, men who have sex with men and the
IDUs, but we think about the implications for influencing government leadership, because ultimately
they are critical in sustaining the response to HIV and AIDS epidemics in PNG. So what that means is
basically that we need to engage in policy dialogue; we need to think about how we structure our
program to engage and influence government policy and prioritisation of its resources; and we need
to use things like our partnership agreements to really encourage that dialogue with our
counterparts. My second point is around integration. Integration with HIV and AIDS services within
the broader sexual and reproductive health services, whilst we maintain the integrity of targeting
like these vulnerable groups which often find it hard to access formal services. So my message is it’s
very much around a balancing between integration into formal government services, but also
ensuring that we are targeting these vulnerable groups and working with civil society to do that.
And I think my final point and priority is around monitoring and evaluation. I think the point about...
that came from the evaluation around the critical importance of data and data quality in
understanding the nature of the epidemic – that is critical. That’s an issue we see globally in Africa, in
generalised epidemics, but also in these key epidemics amongst marginalised groups, these
concentrated epidemics in places like PNG and East Asia. So we have to invest more in data quality
and information for decision making.
Dereck Rooken-Smith:
A lot of the media coverage of the evaluation really highlighted perhaps that aspect, by showing that
there was not much comprehensive data at the beginning of the exercise, and drawing on that the
evaluators were saying that there was really no strong evidence that AusAID interventions had led to
a reduction of new HIV infections. How would you respond to that?
Ben David:
The point I would make is that’s a common issue. Measuring impact on incidence is quite a tricky
issue because you need a baseline, and you need to have comprehensive regular widespread testing
to allow you to actually get the data sets to be able to see whether there’s an improvement or a
decrease in incidence in annual rates of infection.
I think the second point around this is the challenge of information and data systems that I
mentioned earlier. I think the evaluation rightly raises the point that we, and the PNG Government,
need to really invest heavily in better quality data and monitoring and evaluation. But having said
that, the point I think that’s really important to get across is that the program has made a difference,
and has made a difference to people living with HIV or vulnerable to HIV. We’ve got some very good
examples. In 2011 our support provided treatment for over 10,000 people and testing for 72,000...
people. Some of our targeted programs have achieved over 75% coverage of condom use amongst
sex workers. And some recent modelling of the PNG program as a whole has said the collective
efforts have prevented over 4,000 new infections and prevented almost 5,000 HIV/AIDS related
deaths.
Dereck Rooken-Smith:
Yes. I think the evaluation did actually recommend that we do use more research and evidence in
planning the program going ahead. From what you’re saying and also reading the report, it appears
that most of the evidence about HIV/AIDS in Papua New Guinea was actually collected over the last
few years as part of the project. In fact, we have, through project activities really created quite a large
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database and a better understanding for all concerned about the epidemic. Can you give us some
more examples though of what we’re doing now in terms of using the research and evidence for
program design going forward?
Ben David:
Yes well I think this is a really important issue. I mean a good example, is actually what happened in
PNG a few years ago we thought this was a generalised epidemic. What a generalised epidemic
means that you have HIV prevalence in over 1% of the population. So in 2005 we thought it was up
to 2%, and there was huge concern that this was an accelerating epidemic that was going to start to
look like an Africa type generalised epidemic covering maybe 10, 20%, 30% of the population. We
now know as we’ve invested in good surveillance and further research that that’s not actually the
case. Actually the current figure makes this a concentrated epidemic, so well below 1% of the
population, and primarily in high risk and vulnerable groups such as sex workers and men who have
sex with men. So what that has meant is that the program has adjusted, and adjusted its targeting
and focus. In terms of what we’re doing now and the program is doing now, there’s I suppose two
elements. There’s investing in new research. For example, there’s support... joint support with the
World Bank for a bio-behavioural study which is going to inform the Government’s understanding
and our understanding of HIV prevalence across PNG, which will be really critical to future national
and provincial planning and then our program support. There’s other aspects. There’s actually
building the capacity of government in civil society groups to actually use and utilise evidence, and
the evidence base, which is a really critical point. It often gets lost in this discussion. We can provide
lots of smart papers and facts and figures but unless people are actually utilising them and applying
them for programs then that’s a problem.
So the PNG Program is actually investing in building up capacity of civil society, organisations
involved in service delivery to better use and utilise evidence for impact. One of the things I would
like to sort of push for myself is more systematic approach to building in research, and particularly
longitudinal evaluations within programs as they are designed. That’s when you need to invest in it,
and that will help us and governments and country partners to better understand the relationships
between our inputs and process, and eventually impacts.
Dereck Rooken-Smith
You mentioned at the outset too, the recommendation that to some extent may be considered
controversial – I know there’s a big international debate really about this question of integration or
separate focus on HIV/AIDS. This report has come up with a recommendation that our program be
more integrated with the overall health programs in PNG. Could you just comment? You started
earlier on talking about this, but perhaps you could just flesh those thoughts out a bit more.
Ben David:
I think the first point is that we and the PNG Program absolutely accept that recommendation for the
program. I mean my view is that we need to take a fairly balanced approach to this, and the
important point is it’s got to be context specific and based on a good understanding of one, the
rationale, and what aspect of the response needs to be integrated. I’ll just give you an example,
financing of ART – of anti-retroviral treatment. That’s critical that that gets integrated within to
government planning and budget and financing to sustain treatment for the life time of people living
with HIV. And we know now that that’s a long time. We see HIV increasingly as a chronic disease
which is for the life time of a person, so you need to sustain financing for treatment, for a lifetime,
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and that implies sustainability and predictability, and you need procurement systems to do that and
budgets to do that.
And one of the positive moves that the government of PNG have made is actually to recently put...
allocate 15 million Kina to ART treatment on budget, and that is as a result of some of our policy
engagement with government.
But in terms of the debate about integration, there are obviously big advantages for vertical
approach to HIV, especially when you’re dealing with marginalised groups that are often suffer from
stigma and discrimination and there are sensitivities accessing formal health services.
But what we’ve seen in the past is that has often gone too far in that direction, and there’s a real issue
about sustainability, and then overall quality and effectiveness of services, because often people
living with HIV and AIDS may have TB – tuberculosis, they may have other health conditions, so they
need to access a holistic healthcare system that can provide for all those needs. Yet we know the
costs of large vertical programs just focussing on one disease is not sustainable in many cases and
problematic and creates inefficiencies.
So my point: there’s a trade-off on both sides here, and we need to think about the different aspects
of the response and look at what needs to be integrated and what’s not. I think there’s a strong
argument in PNG that there’s a stronger link to sexual and reproductive health services. I think the
important thing we have to keep sight of is that we maintain a relationship with those key civil
society organisations that have that ability to outreach to these communities.
Dereck Rooken-Smith:
I think you’ve answered my last question a little bit already about the... I wanted to know what
particular aspects of this evaluation, which is of course context specific – PNG. But are there things
that are applicable to the HIV response more generally. You’ve touched on a lot of those I think, but
perhaps just to sum up if you could pull out a couple of the main messages that you think have a
broader applicability to our HIV/AIDS Program more generally.
Ben David:
I think the really key message that comes out of the evaluation is know your epidemic, and invest in
knowing your epidemic. It’s shifting, it’s changing our understanding of the epidemiology and the
appropriate program response is evolving. So for all our country programs and regional programs
involved in HIV and AIDS, the first port of call is, do you know your epidemic or epidemics? Often
they’re different epidemics within a specific country. So that’s really important and that implies of
course investing in that, and working with national country counterparts to do that.
I think within that, recognising that this is context specific is very important, and that we need to be
prepared to be flexible and to shift and change our approach according to the evidence that emerges.
Again, it’s not static. You don’t design a program like a windup toy and just let it go. You are
constantly evaluating, and for HIV and AIDS programs that’s particularly important to do that given
the nature of the epidemiology.
My second point is the importance of understanding the political economy of HIV and AIDS and the
broader context within a country to respond appropriately to the epidemics in these countries. The
importance of political leadership is critical to any sustainable response here, and of course we’re
dealing with some very sensitive issues, it’s about sexual and reproductive health behaviours, it’s
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about cultural norms and standards, it’s about intravenous drug use, so some of these are some of
the most sensitive issues in many of the countries and societies in where we live, and therefore
highly political in nature. So we have to understand that and we need to think about the implications
for our own policy dialogue and influence.
Third point is the importance of data, and data quality for decision making and investment in good
surveillance and good monitoring and evaluation. It’s critical, and I think it needs to be almost one of
the mandatory parts of all our health programs is that you know, we should not be moving forward
without extremely robust M&E frameworks, and money behind them, resources behind them, to
actually make them work.
And that brings me I suppose to my final point about integration, where we urge caution to have not
an overly simplistic view of integration, or to take some global template. It’s got to be context specific
and based on the understanding of what’s the best, most effective approach within a different
country context. I think it’s a really key issue, but it’s something that we have to take seriously and is
ultimately going to be about sustaining these programs.
Dereck Rooken-Smith:
Well that’s great. Thanks for making the time to come and speak to us today, Ben. That’s a very long
report. It’s a very complicated report. I think 10 minutes of listening to you sum it up will save us a
lot of time reading. Thank you very much.
Ben David:
Thank you.
Dereck Rooken-Smith (outro):
You’ve been listening to ODE Talks, produced by the Office of Development Effectiveness at AusAID,
the Australian Government’s aid agency. For more information go to www.ode.ausaid.gov.au
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