Prepared by Muhammad Yussuf
EXECUTIVE SUMMARY
Review of the progress made by the United Nations system organizations in achieving the Millennium Development Goal 6 – target 7 – to combat HIV/AIDS
JIU/REP/2007/12
Objective: To assess the progress made in the achievement of Goal 6, target 7, to have halted by 2015 and begun to reverse the spread of HIV/AIDS, and to provide Member States with an objective assessment of the efficiency and effectiveness of the policies and programmes implemented and the bottlenecks in achieving this target.
Key issues, main findings and conclusions
By the end of 2006, more than 25 million people had lost their lives to AIDS, and an estimated 39.5 million were living with HIV/AIDS. In 2006 alone, there were 4.3 million new infections and 2.9 million deaths due to AIDS. There is an upward trend in the prevalence of HIV infections since the adoption of the target. There has been an increase of approximately 28 per cent in the number of people living with HIV in 2006 as compared to the 2000 estimates. The future course of the disease and its real magnitude remain unknown.
The most important factor that limits the effective functioning of the joint United Nations Programme on HIV/AIDS (UNAIDS) is its weak and outdated mandate. The Economic and Social Council established the mandate in 1994 when the pandemic was viewed as a health problem with limited impact. Thirteen years later, the situation has drastically changed. UNAIDS now has a broad, dynamic and challenging responsibility with greater accountability to its stakeholders. UNAIDS progress depends on actions taken by other entities/actors, such as national Governments, international donors and civil society over whom it has no institutional authority. The mandate of UNAIDS needs to be enhanced and reinforced. The authority of the UNAIDS secretariat needs to be enhanced for effective coordination.
The existing partnership of ten Cosponsors is too many. Neither the UNAIDS secretariat nor the Programme Coordinating Board (PCB) has any controlling organizational authority over the Cosponsors. Consequently, little can be done to exert pressure on the Cosponsors to become effective partners within UNAIDS. There is a certain degree of overlapping and duplication of activities among the Cosponsors at the country level. Prevention of mother-to-child transmission, which is a major prevention activity, is a vivid example of such a duplication of efforts.
Since its inception in July 1995, the UNAIDS PCB has held twenty meetings and has provided meaningful guidance and direction to UNAIDS. However, the effectiveness of the PCB is limited by several factors. In the existing institutional framework, the decisions of the PCB are not automatically binding on the Cosponsors. PCB decisions need to be endorsed by the governing bodies of all the Cosponsors before they can be implemented. This is a time-consuming process, which at times has a detrimental effect on issues that need to be acted upon immediately.
The Committee of Cosponsoring Organizations has only limited authority. It is neither an executive nor a monitoring body and only endorses the budget and the workplan of UNAIDS. Moreover, it has authority only for activities financed from the UNAIDS Unified Budget and Workplan (UBW) and has no authority over the individual Cosponsors’ programmes on HIV and AIDS.
With regard to the division of labour, there is clearly a lack of awareness and clarity among the various stakeholders at the country level, particularly among the various government departments and civil society partners on the division of labour and its modalities. The lead agency concept among the United Nations country teams also lacks clarity due to the overlapping mandate of the Cosponsors. There are overlapping issues in the division of labour, such as the prevention of mother-to-child transmission, women and children, youth and prevention efforts that have remained unresolved among the Cosponsors.
Only limited progress has been made with regard to the joint programming as a result of the inability of country teams to allocate adequate time for developing joint programmes due to overlapping priorities, such as the United Nations Development Assistance Framework and country planning cycles, which provide the support for the joint programmes. The main challenges facing joint programming include the continued development of joint plans based on individual United Nations agency imperatives and priorities, rather than the development of integrated joint plans that are based on national needs and priorities.
The application of the “three ones” principles is central to the coordination efforts at the country level. A key challenge for the effective implementation of the “three ones” principles at the country level is the existence of many coordination structures with overlap in membership and focus, often without linking consultation and decision-making structures and processes. The typical example of overlap is between the National AIDS Councils (NACs) and the country coordinating mechanisms (CCMs) of the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM).
About 85 per cent of affected countries have national AIDS action frameworks or national strategic plans (NSPs). In order to be useful, NSPs have to be fully costed, with workplans translated into practical plans suitable for regional/grass roots implementation, and budgets that specify sources and allocation of funds. Many of the frameworks are not translated into workplans and budgets; it is estimated that only 60 per cent of the frameworks are costed and budgeted. Similarly, only 52 per cent have been translated into an operational plan and/or annual priority action plan. Many Member States have difficulty in translating national plans into actionable regional/grass root-level plans.
The establishment and maintenance of a broad-based NAC, with the involvement of diverse stakeholders, is a political as well as a technical issue with its related problems. It would be too ambitious to create a completely new multi-sectoral mechanism and give it a remit to lead and coordinate the response of a wide range of well-established and powerful stakeholders. Often, the high-profile launching of an infant mechanism into a complex and highly politicized national AIDS response has caused tensions and frustrations among the various stakeholders, and in some cases has lost their support.
A significant number of countries still do not have a funded, functioning monitoring and evaluation (M&E) system, which has been developed through partner coordination. Shortcomings in M&E systems represent one of the most pressing challenges standing in the way of achieving the target set by this Millennium Development Goal (MDG). The challenges include weak collaboration among stakeholders, shortage of M&E skills, insufficient financial and other resources for M&E, and the absence of well-functioning systems for collecting, analysing and reporting on the data needed for M&E.
The “3 by 5” initiative has achieved only a limited amount. It was estimated that by December 2005, only 1.3 million people were under antiretroviral therapy or antiretroviral treatment (ART) as opposed to the targeted 3 million. The major achievement of the initiative was that it showed that with significant mobilization of resources and efforts from various stakeholders, antiretroviral therapy could be provided in even the most resource-constrained settings like, for example, in sub-Saharan Africa.
However, the striking differences between regions in the percentage of ART coverage of the needy population underscore the fact that many countries are far from containing their growing AIDS pandemic.
Universal access to care and treatment for all those who are in need by 2010 is an ambitious goal that provides lifelong support. The scaling-up towards universal access should be equitable, accessible, affordable, comprehensive and sustainable. In other words, it faces many challenges. The national health systems in most of the affected Member States are increasingly facing an unprecedented challenge due to a lack of investment in health services and the rapid scale-up of ART. The national health systems that are delivering maternal and child health services are under enormous strain, catering for large numbers of people living with HIV in need of lifelong care for chronic disease.
Inadequate numbers of health workers are a major constraint to the rapid scaling-up of ART programmes. The expansion in labour markets has intensified professional concentration in urban areas and migration within regions and from developing to developed countries. There is an exodus of skilled health workers from the public to the private sector due to attractive pay and working conditions. Most of the public health services suffer from low pay, poor occupational health and safety conditions, lack of training and prospects for career advancement, poorly supplied medical facilities, an acute shortage of staff, and poor management and overall health system governance.
The scaling-up of ART has shifted the focus onto treatment and considerably weakened prevention efforts. The challenges posed by universal access to treatment are formidable and need resources. As a result, many of the civil society partners that were traditionally involved in community mobilization and prevention have shifted their focus to treatment support activities, resulting in greater reduction in the scaling-up of prevention activities. Furthermore, a major part of donor funding is earmarked for treatment and the affected Member States are not able to allocate a matching share of domestic funding to prevention efforts.
The financial resources needed for HIV/AIDS show an increasing trend due to the increase in the numbers of people living with HIV and the expansion in HIV/AIDS programmes to serve more of those in need. The financial resources available for HIV/ AIDS fall far short of what is needed to scale up towards universal access. UNAIDS estimates that the amount needed for an expanded response in low and middle income countries will be US$ 18.1 billion in 2007, US$ 22.1 billion in 2008 and US$ 30.2 billion in 2009. Against this, the money received, the existing pledges, commitments and trends indicate that the available funds are US$ 10 billion for 2007, i.e. a resource gap of US$ 8 billion in 2007. To meet the goal of universal access by 2010, available financial resources for HIV must quadruple by 2010 compared to 2007 – up to US$ 42.2 billion and continue to rise to US$ 54.0 billion by 2015.
The World Health Organization (WHO) Commission on Macroeconomics and Health estimate that an additional US$ 27 billion per annum in aid is needed to strengthen the capacity of health systems so that they can deliver basic health-care packages effectively. Meeting this target would require a five-fold increase in donor spending on health that does not include free access to ART for everyone in clinical need.
The role of civil society is pivotal in the implementation of this target. The proliferation in the number of civil society partners, particularly the non-governmental organizations (NGOs) dealing with HIV/AIDS both at national and international level is a major concern. In the last ten years there has been a considerable increase in the number and range of NGOs specialising in HIV/AIDS work. By one reliable estimate, there are now more than 60,000 AIDS-related NGOs globally. The proliferation of AIDS-related NGOs has, at times, occurred at the expense of accountability and credibility. The existence of the so-called “briefcase NGOs” in many countries undermines the credibility of the genuine NGOs.
The role of the Department of Public Information (DPI) in creating public awareness on the issue of HIV/AIDS is pivotal in the fight against the HIV/AIDS pandemic worldwide. DPI has been involved in high-profile events aimed at mobilizing the media industry globally in the fight against HIV/AIDS. It is estimated that 5 to 10 per cent of the total coverage of DPI is devoted to HIV/AIDS-related activities. However, DPI does not have a clear-cut strategic framework and/or guidelines related to the dissemination of information on HIV/AIDS, despite the fact that formal meetings between the former Head of DPI and the Executive Director of UNAIDS have been conducted in the past with a view to reaching some kind of understanding on the modalities for cooperation between the two entities in the area of HIV/AIDS-related information coverage.
In countries like Brazil, India, South Africa, Russia, Poland and Botswana that have plenty of financial resources of their own devoted to the fight against the HIV/AIDS pandemic, the only thing that the authorities in such countries would want to hear are excellent innovative ideas from the United Nations family that could assist them in making the fight against HIV/AIDS much more effective, efficient and sustainable in the long run. On the other hand, unfortunately, a good number of poorer developing countries continue to depend heavily on foreign bilateral donors as a reliable means of funding in support of the national response to HIV/AIDS. If unchecked, this will be an extremely dangerous trend in the long-term sustainability of the implementation of HIV/AIDS mandated programmes and activities.
The international community and more particularly the United Nations system organizations seem to be increasingly optimistic about the future prospects for the fight against HIV/AIDS. However, after more than 100 meetings with representatives of Governments, NGOs, civil society, and with various officials from the United Nations system organizations in the countries visited, there is every reason to believe that the world is currently losing the battle against the HIV/AIDS pandemic. In other words, as new infections continue to outpace the global effort to prevent and treat patients, the need for an AIDS vaccine is more compelling today than at any time in the history of the pandemic.
Listed below are the recommendations for consideration by the legislative bodies of the relevant United Nations system organizations. Other recommendations (recommendations 3, 4, 5, 6, 7, 8, 9, 10 and 11), proposed for the consideration of the executive heads, can be found in the main text of the report.
Recommendations for consideration by legislative organs
The Economic and Social Council should review and strengthen the mandate of UNAIDS, including enhancing the authority of the secretariat, in order to effectively lead, coordinate and monitor the fight against HIV/AIDS and to ensure proper accountability of the Cosponsors to the joint programme. As part of the review, the number of Cosponsors should be restricted to the six original organizations/Cosponsors, namely, the United Nations Development Programme, WHO, the United Nations Population Fund, the United Nations Children’s Fund, the United Nations Educational, Scientific and Cultural Organization and the World Bank. Other organizations could participate through the Cosponsors on the basis of a memorandum of understanding.
The Economic and Social Council should review and revise the authority, role and responsibility of the UNAIDS Programme Coordinating Board, to enable it to have supervisory responsibility over the UNAIDS secretariat and the Cosponsors in relation to the joint programme on HIV/AIDS.
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