Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694818770518.pdf (Australia)
Inquiry into the strategic effectiveness and outcomes of Australia’s aid program in the Indo-Pacific and its role in supporting Australia’s regional interests.
June 2018 Scott McGill International Program Division Manager Nikki Teggelove International Program Adviser Inquiry into the strategic effectiveness and outcomes of Australia's aid program in the Indo-Pacific and its role insupporting Australia’s regional interestsSubmission 23 ASHM International Submission Inquiry into the strategic effectiveness and outcomes of Australia’s aid program in the Indo-Pacific and its role in supporting Australia’s regional interests.
ASHM International (ASHMIP) are technical experts in clinical workforce development for HIV, viral hepatitis and sexual health.

Our specialist team engages with governments, non-government organisations, professional societies, community and faith-based organisations, and academic institutions to strengthen health systems through clinical workforce development.
We build the capacity of health personnel to provide high quality clinical management of blood-borne viruses and sexually transmissible infections.

ASHM International’s experience is global, but with specific focus on the Asia and Pacific regions.

We are currently providing services to projects in Papua New Guinea (PNG), Timor-Leste, Fiji, Solomon Islands, Cook Islands, Vanuatu, Samoa, Kingdom of Tonga, Niue, Palau, Nauru, Federated States of Micronesia, Republic of Marshall Islands, Tuvalu and Kiribati.
ASHM International advocates for Australia to demonstrate full commitment to a robust aid program.

ASHM International advocates for commitment by Australia to a robust aid program that builds trust with neighbouring nations, strengthens regional partnerships, enhances regional stability and security, promotes universal access to health and wellbeing, and ensures the effective execution of foreign policy within in an increasingly competitive region.
Australia’s aid policies and strategies, including Australian aid: promoting prosperity, reducing poverty, enhancing stability (2014) and Making Performance Count: enhancing the accountability and effectiveness of Australian Aid (2014), along with international commitments to the 2030 Agenda for Sustainable Development and the Sustainable Development Goals, provide strong frameworks for delivery of effective aid.
We believe, however, that implementation is compromised by a lack of political commitment demonstrated by budget allocation.

0.22% of gross national income1 apportioned to foreign aid is inadequate to achieve these essential objectives and maintain Australia’s status as a trusted development partner within the Indo-Pacific region.

Addressing sexual and reproductive health and rights is a key component of improving outcomes for women and girls.
Relevant to this Parliamentary Inquiry Terms of Reference, ASHM International’s work within the Indo-Pacific region prioritises improving outcomes for women and girls.

Specifically, ASHMIP works with local partners across Asia and the Pacific to deliver sexual and reproductive health trainings that aim towards the virtual elimination of HIV, viral hepatitis and significant reductions in sexually transmissible infections (STIs).

Over 60% of ultimate beneficiaries of our projects are female.
Women and girls remain extremely vulnerable within the region to physical and sexual violence2, and sexually transmissible diseases (including HIV)3.

At 71-66-83%4, there is still much work to be done to achieve the UNAIDS 90-90-90% targets within the region that would demonstrate effective clinical management of People Living with HIV and create a greater environment of protection from HIV acquisition for all women and girls.

1 Lowy Institute.

(2018).

Australian Foreign Aid.


Available at www.lowyinstitute.org/issues/australian-foreign-aid.

2 DFAT.

Pacific Women Shaping Pacific Development.

(2017).

Ending Violence Against Women.

Available at www.pacificwomen.org/our-work/focus-areas/ending-violence-against-women/.

3 Avert.

(2018).

HIV and AIDS, Women and Girls.

Available at www.avert.org/professionals/hiv-social-issues/key-affected- populations/women.

4 Avert.

(2018).

HIV and AIDS in Asia & the Pacific Regional Overview.
Available at www.avert.org/professionals/hiv- around-world/asia-pacific/overview.
ASHM International | 2 Inquiry into the strategic effectiveness and outcomes of Australia's aid program in the Indo-Pacific and its role insupporting Australia’s regional interestsSubmission 23 Pivotal to improving outcomes for women and girls is ensuring their sexual and reproductive health and rights5 including absence of disease, protection from sexual violence, clinically responsive services following violence, and access to a comprehensive package of high-quality reproductive health services (incorporating family planning).
To enable, and promote, the inclusion and participation of women and girls in education, productivity and engagement with family and community6 there needs to be continued investment in: Strengthening the competence and confidence of the health workforce to respond to existing and emerging threats in sexual health • • Addressing menstrual hygiene management • • • Ensuring family planning and reproductive health services are accessible and available Enabling responsive sexual and reproductive health programming in humanitarian response Establishing clinical and community partnerships that address prevention and response to sexual and gender-based violence • Reducing barriers to sexual health and wellbeing including stigma and discrimination, and harmful traditional and cultural practices.
Effective aid must demand and deliver high quality, consistent programming and be driven by structured exit planning for sustainability.

Trust in health services is a key element for success in managing diseases that require long-term (or life-long) medication adherence.

In the absence of confidence within the system, individuals are less likely to seek testing and treatment, or to adhere to treatment regimes once commenced7.
Defaulting on medication and follow up creates risk for the emergence of drug resistant infections, which then require more expensive medications and often, longer treatment times.

ASHMIP’s experience was that the withdrawal of funding from HIV programs in Papua New Guinea during 2016 and 2017 created significant instability for individuals, organisations, programs and the PNG national HIV agenda.
The rapid rollout of cuts left little time for assessment and transfer of patients (on antiretroviral and other long-term medications) to operational services, and placed immense burden on remaining health practitioners to service increased patient loads.

Furthermore, patient confidence in services was placed at risk and, under the Treatment as Prevention model, prevention efforts within the country were jeopardised.
ASHM International believes the sexual and reproductive health of women and girls during these significant funding amendments was compromised.

Planned implementation of budget changes could have reduced clinical and programmatic turmoil, and improved outcomes for women and girls in PNG.

Effective aid must deliver high quality, consistent programming - especially in health service delivery - and be driven by formal exit planning for sustainability.
Tackling emerging threats in sexually transmissible infections for national and regional health security.

The global emergence of multi-drug resistant sexually transmitted infections including gonorrhoea, mycoplasma genitalia, syphilis and chlamydia, poses a tangible threat to Australia8.

This is evidenced by the recent identification of super-gonorrhoea among two Australian citizens, acquired whilst travelling within the 5 World Bank Group.

(2014).
(2014).

Advancing Women’s Sexual and Reproductive Health: Lessons from World Bank Group Gender Impact Evaluations.

6 Burnet Institute, Susu Mamas, IWDA, WaterAid & Plan.

(2017).

The Last Taboo: Research on menstrual hygiene management in the Pacific.

7 Shubber, Z., Mills, E., Nachega, J., Vreeman, R., Freitas, M., Bock, P., Nsanzimana, S., Penazzato, M., Appolo, T., Doherty, M. & Ford, N. (2016).

Patient-Reported Barriers to Adherence to Antiretroviral Therapy: A Systematic Review and Meta- Analysis.
doi.org/10.1371/journal.pmed.1002183 8 WHO.

(2017).

Gonococcal antimicrobial resistance in the Western Pacific Region.

ASHM International | 3 Inquiry into the strategic effectiveness and outcomes of Australia's aid program in the Indo-Pacific and its role insupporting Australia’s regional interestsSubmission 23 Indo-Pacific region9.
ASHM International believes that an ongoing commitment is required by Australia’s aid program to address emerging drug-resistant sexually transmissible infections within the region, to reduce the border crossing of super-bacteria with little to no treatment options.

The Western Pacific is disproportionately affected by viral hepatitis, with an estimated 40% of global deaths caused by hepatitis occurring in the region - over 1500 deaths per day10.
Funding for viral hepatitis is extremely limited globally, and a lack of programmatic and clinical response continues to result in escalating epidemics, especially of Hepatitis B.

Improving outcomes for women and girls, who are most vulnerable to sexually transmitted infections, requires focus on emerging disease trends and responsive funding mechanisms that enable localised and regional responses to outbreaks and epidemics.
Enhance the effectiveness, efficiency and relevancy of aid delivery through the establishment of structured funding mechanisms from project establishment.

ASHM International projects work across bilateral, multilateral and private funding mechanisms, with significant benefits in leverage and linkage, and identifies local partners (or assists in development of professional networks) for project implementation - a ‘mentoring the mentor’ model.
This approach presents both opportunities and challenges with the obvious benefits of community determined project planning, and the measures of performance-based funding being incongruous with local capacity and delivery.

ASHMIP are extremely supportive of performance-based funding frameworks, but our experience in project implementation has been that the process is unclear, tedious and administratively heavy.

This conflicts with broader DFAT funding demands for outcome and impact focussed projects.
Effectiveness, efficiency and relevance of project operations could be enhanced, especially during the establishment phase, through provision of clear and timely guidance on requirements for project budgeting, monitoring and evaluation, performance-based funding, reporting and sustainability planning.

We experienced definite improvement in delivery of these during the recent PNG Partnership Fund rounds.
Australia’s aid program should maintain focus on building peace and prosperity within the Indo-Pacific region, and its commitment to international health and development goals.

In summary, ASHM International respects the immense and positive strategic role of Australia’s aid program in building of peace and prosperity within the Indo-Pacific region.
With ever-changing global dynamics, it is an essential time for Australia to continue execution of foreign policy objectives in partnership with its regional neighbours and to strengthen its commitment to improving universal health and livelihood, especially for women and girls.

We encourage DFAT to maintain the government target of 80% of investments effectively addressing gender issues in implementation11.
We also recommend that creative new approaches are explored to reaching most vulnerable women and girls including those living with HIV, STIs, viral hepatitis and broader sexual and reproductive health challenges (such as sexual and physical violence, and poor access to family planning).
A focus on gender equality and women’s empowerment, through continued support for sexual and reproductive health and rights, is essential to achieve Australia’s commitment to the Sustainable Development Goals, and for maintaining Australia’s position as a trusted and trustworthy development partner within the Indo-Pacific region.

9 Health.Vic.

(2018).

Multi-drug resistant gonorrhoea detected in Australia.

10 WHO Western Pacific Region.

(2016).


Regional Action Plan for Viral Hepatitis in the Western Pacific 2016–2020.

11 DFAT.

(2016).

Gender Equality Strategy.

ASHM International | 4 Inquiry into the strategic effectiveness and outcomes of Australia's aid program in the Indo-Pacific and its role insupporting Australia’s regional interestsSubmission 23