Meeting the Challenge: Canada's Foreign Policy on HIV/AIDS - With a Particular Focus on Africa

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Section 4.0 - Demonstrating Leadership

This section discusses the importance of leadership and explores how Canada can play a leading role in the global response to HIV/AIDS. It provides examples of multilateral fora within which Canada can have influence, and examines two bilateral relationships of importance: those with South Africa and the United States. The section explores what Canada can do to promote the United Nations General Assembly Special Session (UNGASS) Declaration of Commitment on HIV/AIDS. The section then examines the need for collaboration within Canada among the federal departments and agencies that play a significant role in the global response. Finally, the section outlines how DFAIT can demonstrate leadership within its own department.

The HIV/AIDS pandemic desperately needs a voice among industrial nations, and... Canada is uniquely positioned to be that voice. [We call] on the government to make a substantial and public commitment to the political and moral leadership role needed to fight the HIV/AIDS pandemic in sub-Saharan Africa.

- HIV/AIDS and the Humanitarian Catastrophe in Sub-Saharan Africa³⁵

Canadians emphasize that they expect leadership from the Government in defining clear policies and in ensuring adequate capacities and coordination to support these policies.

- A Dialogue on Foreign Policy: Report to Canadians³⁶

Effective leadership in response to HIV/AIDS in Africa and globally requires dealing with four obstacles in particular:

• the lack of access to affordable treatment for the mass of people affected by HIV/AIDS;
• inadequate support for health systems which are instrumental in the prevention, care and sustainable treatment of HIV/AIDS;
• continuing and, in many cases, worsening poverty, persistent discrimination against women and girls and other socio-economic determinants of vulnerability; and
• inadequate resources for responding to the pandemic.

These continue to be obstacles because of lack of political will. Canada can play a decisive role in leadership to concentrate political will on the challenge, while contributing to solutions to these obstacles.

Potential for achievement: saving and extending lives

There is clear evidence with respect to HIV/AIDS that coherent action can save lives, dramatically lower new infection rates and even lead to long-term reductions in health costs as well as other costs. Coherent action requires leadership. Leadership is being demonstrated on the world stage, as the following examples attest:

• Brazil accounts for one-third of the people living with HIV/AIDS in developing countries who receive satisfactory treatment.³⁷ The Brazilian program provides antiretroviral treatment for about 125,000 people. The Joint United Nations Programme on HIV/AIDS (UNAIDS) has said that "the success of the Brazilian programme is due to investment in prevention campaigns (among young people and sex professionals, in particular); the production of generic antiretroviral drugs and also the mobilization of civilians in pressuring the government to adopt new policies, as well as working with the public sector."³⁸ Brazil has also proven that investing in treatment not only saves lives, but reduces costs to the health system over time. According to a Brazilian impact study, the per patient costs of treatment in 2001 were 50 percent lower than in 1997, due in part to the reduction in price of generic products and negotiated reductions in imported drug prices. The study also found that an estimated 358,000 hospital admissions were avoided in the period 1997-2001, representing a saving of $US 1 billion.³⁹ A further study demonstrated that universal free access to triple antiretroviral treatment in a developing country like Brazil can produce benefits on the same scale as in richer countries.⁴⁰

• In Uganda, HIV prevalence among pregnant women in major urban antenatal clinics shot up to 31 percent in the 1980s. As a result of concerted action by the government and by others, rates have now been reduced by more than half. Among teenage mothers, they fell from 28 percent in 1991 to six percent in 1998. Prevalence in the general adult population has declined from 14 percent a decade ago to eight percent in 2000.

• In Thailand, an explosive rise in seroprevalence among injecting drug users, female sex workers, pregnant women and men attending STD clinics was identified in the 1980s. Aggressive government action, including STD treatment, condom use and a national campaign has checked the epidemic, keeping HIV seroprevalence rates among pregnant women and blood donors below three and two percent respectively. Spending by the government and by donors jumped from US$684,000 in 1987 to US$10 million in 1991. Government spending alone on HIV/AIDS programs was US$82 million in 1997.

This is not to suggest that these countries have a perfect record in terms of their responses to HIV/AIDS. On the contrary, authorities in both Uganda and Thailand have been criticized for their human rights records, both with respect to HIV/AIDS and more generally.

As a wealthy country with a history of internationalism, Canada is well positioned to play a leading role in the global response to HIV/AIDS. DFAIT, in cooperation with other relevant federal government departments and agencies, can begin the process of establishing Canada's political and moral leadership by championing a significantly increased level of material and political support from industrialized nations for the response to HIV/AIDS. To this end, DFAIT should develop a comprehensive HIV/AIDS strategy, and should involve other HIV/AIDS stakeholders, including the NGO sector, in the elaboration of this strategy.

Because of its size and relative wealth, South Africa is a leader on the African continent. In the courts and on the streets of South Africa, a tremendous battle is being fought to convince the national government to adopt a plan for the provision of antiretroviral therapies and other HIV-related medications to people living with HIV/AIDS. The government has been slow to respond and has offered up a number of excuses for not proceeding. It even maintained for several years that HIV does not cause AIDS, despite irrefutable scientific evidence to the contrary. There were opportunities during this struggle for Canada, through its bilateral relationship and through the Commonwealth, to communicate to the Government of South Africa the importance of developing a national HIV treatment plan. Only recently, after considerable pressure, the government committed to developing and implementing such a plan. However, it is already threatening to backtrack on this commitment, citing budgetary and other difficulties. Now, more than ever, Canada needs to lend its voice to efforts to convince the Government of South Africa to follow through on its commitments. Attention to this particular bilateral relationship could be crucial because South Africa is currently the country with the single largest number of people living with HIV/AIDS, and because its role on the continent it such that the policy directions it takes have an influence elsewhere in sub-Saharan Africa.

Working through coalitions: the Canadian way

Canada's foreign policy has broken new ground through the formation of groups of like-minded countries, coalitions of the committed. The creation of the International Criminal Court and the campaign to ban land mines are two examples of where Canada has successfully adopted this approach. Given the scale of the global response required to address HIV/AIDS, it makes sense for Canada to work with other countries to shape particular elements of that response.

Coalitions of countries are required to scale up the global response to HIV/AIDS and to break some particular log-jams, such as the failure to eliminate barriers to providing access to affordable medicines, and the failure to commit adequate funds to the global response in general, and the Global Fund in particular.

Canada could seek to form a "leadership coalition" which could take action on a series of inter-related issues. Alternatively, Canada might take the lead in building different coalitions depending on the issue - coalitions, for example, with sister donor countries (e.g., Norway); with countries that have had path-breaking positive experiences (e.g., Brazil, Senegal, Uganda); with countries that have been successful in providing affordable generic drugs (e.g., Brazil); and with the countries most seriously affected (e.g., virtually any southern African country).

Where Canada can have an influence

Canada can influence the global response to HIV/AIDS through its bilateral relationships and through multilateral fora. The multilateral avenues through which Canadian policy can be brought to bear include:

• The United Nations (UN), which continues to play a vital role in setting global policy. The General Assembly, through its Special Session (UNGASS) on HIV/AIDS and regular agenda items; the Security Council; the Economic and Social Council and a number of subsidiary bodies; the follow-up mechanisms for UN conferences (such as Population and Development [Cairo], Women [Beijing], Social Development [Copenhagen], Financing for Development [Monterrey] and Sustainable Development [Rio de Janeiro and Johannesburg]) - are all engaged to some extent in responding to the HIV/AIDS challenge. Not least of these policy-setting fora was the Millennium General Assembly and the resulting Millennium Declaration, from which the Millennium Development Goals (MDGs) derived.

• The High-Level Session on Financing for Development of the UN General Assembly (October 28-30, 2003), which can be utilized to highlight the development challenge of HIV/AIDS as a cross-cutting issue, to ensure that evidence of the impact of HIV/AIDS is thoroughly integrated in UN economic and development reporting and analysis, and that the challenge is adequately addressed in further plans of action. Events organized to discuss follow-up to other UN Conferences as well as to the review of the Millennium Declaration in 2005 may offer similar opportunities.

• Key UN agencies - UNAIDS, the World Health Organization, the United Nations Development Programme, the United Nations Children's Fund, the United Nations Development Fund for Women, the United Nations Population Fund - which all offer opportunities for Canadian contribution and leadership. They have capacity for sector-specific policy development and are experienced multilateral funding channels.

• The Bretton Woods Institutions - the World Bank and the International Monetary Fund (IMF) - which play decisive roles. The Bank has considerable influence on developing countries, as a leading funder and holder of debt, in the field of health and development in general; and has an important, and on occasion, negative influence on national policy in debtor governments. The IMF is also instrumental, in terms of the impact of its policies and its influence on national budgetary and monetary policy, and on shaping the response of the governments of developing countries to HIV/AIDS and health systems challenges.

• The World Trade Organization, which has had a powerful influence on the nature and speed of the response to HIV/AIDS, particularly in the area of access to treatment. It has significant impact on health and HIV/AIDS through the implications of existing agreements, and through current negotiations in such fields as intellectual property, services, investment and government procurement.

• The Commonwealth and La Francophonie, which are useful meeting places for representatives of many of the most seriously affected countries in Africa, the Caribbean and Asia. For example, the Commonwealth Finance Ministers' Meetings, and the Heads of Government Meetings (CHOGM), including the upcoming CHOGM in Abuja, Nigeria in December 2003, offer the opportunity, on the one hand, to influence ministers attending the annual meetings of the World Bank and the IMF and, on the other, to coalesce with governments at the highest level.⁴¹ The Abuja meeting, in particular, could be an excellent opportunity for reinforcing joint commitments and increased resources for the effort against HIV/AIDS and for announcing Canadian initiatives.

• The G8, which has already raised expectations concerning the priority of dealing with HIV/AIDS and concerning funding for AIDS and other major diseases. Relations with Africa, the New Partnership for Africa's Development (NEPAD), and the G8's own Plan of Action regarding Africa offer windows for engagement and the exercise of leadership. While the G8 is a less formal, and accountable, body than the others mentioned above, it can set the tone on key issues, and it provides occasions for informal bilateral influence at the highest levels.

Regional associations and initiatives are also important fora. In the case of Africa, the African Union and the NEPAD development initiative have both received significant attention from Canada. This attention must be sustained and developed.

Of Canada's many bilateral relationships, the one with its closest neighbour must be given close consideration. Because of its size, wealth and influence, the United States (US) has played and must continue to play an important role in the global response to HIV/AIDS. The US can be an agent for positive change though, regrettably, it does not always fulfill this role. For a number of reasons, including the fact that the two countries share a common border, Canada has had a special relationship with the US and is thus well-placed to influence its policies with respect to HIV/AIDS. Canada can support progressive US policies - such as the recent decision to increase funding for HIV/AIDS for a number of (mostly African) countries and for the Global Fund to Fight AIDS, Tuberculosis and Malaria - while proposing and implementing alternative policies in areas where our respective policies may differ - such as reproductive rights, public delivery of health services, condom use, and needle exchanges and other harm reduction programs. By exercising its full share of responsibility in resource provision, Canada may be able to encourage or trigger greater proportionality by the US. Further, by clearly articulating an overall policy orientation in fundamental human rights terms, Canada would be encouraging the US to do the same.

UNGASS

One of the most important mechanisms for responding to HIV/AIDS globally is the implementation of the UNGASS Declaration of Commitment on HIV/AIDS.

The majority of the commitments in the Declaration of Commitment are domestic, and DFAIT can play a role in encouraging other countries to live up to these commitments. Some of the commitments, however, are international in nature. DFAIT should consult with relevant stakeholders in Canada to identify actions that Canada can take to support the international commitments.

There are concerns in the international NGO community about how the implementation of the commitments in the Declaration will be monitored, at both the national and global levels. UNAIDS is trying to promote the involvement of civil society in critiquing the annual UNGASS progress report prepared by the UN Secretary-General. DFAIT should support the UNAIDS efforts.

Finally, when the Declaration of Commitment on HIV/AIDS was negotiated, there was considerable discussion about whether certain vulnerable groups should be listed. Canada championed the inclusion of men who have sex with men, sex trade workers, injection drug users and indigenous peoples. Canada articulated the fundamental importance of recognizing, respecting and protecting the human rights of these groups as part of the response to HIV/AIDS. Unfortunately, compromises had to be made to secure agreement on the entire text of the Declaration of Commitment. As a result, these four vulnerable groups were not included. To counter this omission, DFAIT, in its bilateral and multilateral relations, should advocate for national strategies that address the needs of men who have sex with men, sex trade workers, injection drug users and indigenous peoples.

Leadership within Canada

Participants in the recent Dialogue on Foreign Policy recommended"improved policy coherence among the many departments and agencies that support Canada's affairs abroad."⁴² They also encouraged cultivation of partnerships with other levels of government and with civil society organizations. Participants said that "more coordination of these multiple instruments is seen as integral to strengthening Canada's ability to speak with a unified voice and carry weight internationally."⁴³

If Canada is to exercise leadership in global affairs, an increased measure of coordination and coherence within the federal government is required. This emphasis on policy coherence has been cited by the Canadian International Development Agency (CIDA), in its publication Canada Making a Difference in the World: A policy statement on strengthening aid effectiveness,⁴⁴ and elsewhere. As CIDA points out, it is also "widely supported within the OECD [Organization for Economic Cooperation and Development], the G-8, the World Bank, the IMF and the UN system."⁴⁵ In its Development Co-operation Review: Canada (2003), the Development Assistance Committee (DAC) of the OECD devoted a full chapter to the issue of policy coherence for development. The DAC commented positively on two decisions by Canada - to grant free market access to the least developed countries, and to untie some official development assistance - saying that these decisions indicated a "turnaround" in Canadian policies, "requiring political leadership from the top." Citing increased evidence of Cabinet coordination in development policy as well as working level communication between departments (and a "strong interdepartmental culture"), the DAC suggested that a more structured approach "needs to be taken further as some of the complex development-related issues in today's world require a more systematic and forward-looking approach and more active monitoring of relevant domestic policies."⁴⁶

Prime Minister Jean Chrétien spoke of the need for policy coherence in the context of development challenges in his address to the Monterrey International Conference on Financing for Development (2002). The Minister of International Cooperation, the Honourable Susan Whelan, met with representatives of Canadian NGOs at Monterrey, and agreed to undertake a process of inter-departmental consultation, with the aim of developing an inter-departmental process of dialogue with NGOs on cross-cutting development issues, including HIV/AIDS. The first such dialogue is scheduled for mid-October 2003.

The need to develop and support international leadership for Canada in confronting HIV/AIDS is precisely the sort of complex development issue that requires a coherent inter-departmental approach. The Minister of Foreign Affairs, in his request for this study, engaged sister departments. Coherent and effective implementation of the recommendations in this study must involve the collaboration of DFAIT, Health Canada, the Department of Finance, CIDA, and potentially other departments and agencies, as well as the Office of the Prime Minister. Such an approach should also be characterized by collaboration with NGOs in Canada and with governments and civil society organizations abroad. This collaboration would be timely given that the Canadian Strategy on HIV/AIDS, which contains a global component, is in the process of being renewed.

Leadership within government employ

For DFAIT, an integral part of a coherent policy is the application of principles that it supports to the day-to-day operations of the Department. The Treasury Board has an HIV/AIDS human resources policy that covers all employees of the federal government. At this time, it does not mention HIV treatment. In line with the overall objectives of policy on HIV/AIDS, and in support of coherence and credibility, DFAIT, CIDA and other government departments with personnel abroad and with locally-engaged staff need to be covered and supported by up-to-date personnel policies on HIV/AIDS.

A number of governments, including the United Kingdom (UK) and the Netherlands, have policies, governing their foreign and/or their development agencies that deal with the supports provided for HIV positive locally engaged staff and their HIV positive dependants. A number of other governments have policies in development. Several non-governmental development agencies have developed policies as well.

These workplace policies address HIV/AIDS specific issues including discrimination, confidentiality and survivor benefits, and cover all workplaces (at home or abroad) of the agencies involved. The UK government, through its Department for International Development and its Foreign and Commonwealth Office, covers the costs of treatment for HIV positive locally engaged staff and their HIV positive partners.

A reasonable foundation for comprehensive workplace policies is found in the ILO Code of Practice on HIV/AIDS and the World of Work,⁴⁷ which deals with such issues as gender equality, screening and continuing the employment relationship. (See also Section 7.0 [Canadian Businesses Operating Abroad].)

DFAIT should adopt a comprehensive HIV/AIDS workplace policy for all of its staff abroad based, at a minimum, on the ILO Code. DFAIT should also cover the costs of HIV-related treatments for HIV positive locally engaged staff, their partners and dependents.

Recommendations

2.	We recommend that DFAIT, in cooperation with other relevant federal government departments and agencies, take the necessary steps to establish Canada's political and moral leadership in the global response to HIV/AIDS by championing a significantly increased level of material and political support from industrialized nations.
3.	To this end, we recommend that DFAIT develop a comprehensive HIV/AIDS strategy, and that DFAIT involve other HIV/AIDS stakeholders, including the NGO sector, in the elaboration of this strategy.
4.	We recommend that DFAIT develop coalitions of like-minded governments to implement specific aspects of its HIV/AIDS strategy.
5.	We recommend that the Canadian Government ensure effective interdepartmental collaboration on Canada's global response to HIV/AIDS, involving all federal departments and agencies that are significantly involved in the global response; and that DFAIT work with these departments and agencies to develop the structures that would support this collaboration.
6.	We recommend that DFAIT work with other relevant departments and agencies to ensure that there is an advisory body, made up of people with expertise in global HIV/AIDS issues from various sectors, including the NGO and development sectors, to provide advice to these departments and agencies on Canada's global response.
7.	We recommend that in its bilateral relationship with the United States, DFAIT support United States policies in response to the HIV/AIDS pandemic that are guided by, and consistent with, international human rights norms and principles, while actively promoting alternative policies in areas where the approaches of the two countries differ.
8.	We recommend that DFAIT, in its bilateral relationships, encourage other countries to honour the commitments they made in the United Nations General Assembly Special Session (UNGASS) Declaration of Commitment on HIV/AIDS; and that in multilateral fora, DFAIT promote the Declaration of Commitment on HIV/AIDS.
9.	We recommend that DFAIT enter into discussions with relevant stakeholders in Canada, such as Health Canada, the Canadian International Development Agency and NGOs working on global AIDS issues, to review the international commitments containing in the Declaration of Commitment, and to identify actions that DFAIT can take in support of these commitments.
10.	We recommend that in multilateral fora and in its bilateral relationships, DFAIT promote the need for national HIV/AIDS strategies to include programs for men who have sex with men, sex trade workers, injection drug users and indigenous peoples.
11.	We recommend that DFAIT adopt a comprehensive HIV/AIDS workplace policy for all of its offices abroad, embodying, at a minimum, the principles and policies established in the ILO Code of Practice on HIV/AIDS and the World of Work; and that its workplace policy cover locally engaged staff as well as employees of the Government of Canada.
12.	While it is ultimately the responsibility of government to provide treatments for people living with HIV/AIDS , we recommend that until such time as governments are able to provide treatment, DFAIT should demonstrate strong leadership by covering the costs of treatments to HIV positive locally engaged staff, their partners and dependents.

Notes

35. SCFAIT. Report. 2003.
36. DFAIT. A Dialogue. 2003: p. 20.
37. da Costa, Mariana Timoteo. BBC Brazilian Service. "Brazil's pioneering Aids programme." BBC News. 14 July 2003. news.bbc.co.uk/go/pr/fr/-/hi/world/amercas/3065397.stm. Accessed 27 July 2003.
38. Ibid.
39. Teixeira, Paulo et al. The impact of antiretroviral therapy in Brazil (1996-2001). International AIDS Conference 2002. 7-12 July 2002. Abstract No. MoOrB1098. International AIDS Society. www.aegis.com/conferences/14wac/MoOrB1098-eng.php. Accessed 13 August 2003.
40. Marins, J.R.P. et al. "Dramatic improvement in Survival Among Adult Brazilian AIDS Patients". AIDS 2003;17 (11): 1675-1682.
41. See, for example: The recommendations to the Commonwealth Finance Ministers with regard to HIV/AIDS in the Commonwealth Civil Society Statement on Financing for Development. Prepared for the Commonwealth Finance Ministers Meeting. 24-26 September 2002. (London, The Commonwealth Foundation, 2002).
42. DFAIT. A Dialogue. 2003: p. 20.
43. Ibid: p. 20.
44. Canada. Canadian International Development Agency (hereafter CIDA). Canada Making a Difference in the World: A policy statement on strengthening aid effectiveness. (Ottawa, CIDA, September, 2002): p.12/22. www.acdi-cida.gc.ca/. Accessed 13 August 2003.
45. Weston, Ann and Daniel Pierre-Antoine. Poverty and Policy Coherence: A Case Study of Canada's Relations with Developing Countries. (Ottawa, The North-South Institute, February 2003): p.3.
46. Organization for Economic Cooperation and Development (hereafter OECD). Development Assistance Committee (hereafter DAC).Development Co-operation Review: Canada (2003). (Paris, OECD, 2003): p. 15.
47. International Labour Organization (hereafter ILO). The ILO Code of Practice on HIV/AIDS and the World of Work. Available on the ILO website via www.ilo.org/public/english/protection/trav/aids/code/codemain.htm. Accessed 23 August 2003

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