Report to the Chairman, Subcommittee

on African Affairs, Committee on

Foreign Relations, U.S. Senate

United States General Accounting Office

GAO

May 2001 GLOBAL HEALTH

Joint U.N. Programme

on HIV/AIDS Needs to

Strengthen CountryLevel Efforts and

Measure Results

GAO-01-625
Page i GAO-01-625 Global Health

Letter 1

Appendix I Status of the International Partnership Against

AIDS in Africa 28

Appendix II Objectives, Scope, and Methodology 32

Appendix III Cosponsors’ HIV/AIDS Programs and Activities 35

Appendix IV Comments From the Department of State 40

Appendix V Comments From the U.S. Agency for International

Development 43

Appendix VI Comments From the Joint United Nations

Programme on HIV/AIDS 48

Appendix VII GAO Contact and Staff Acknowledgments 64

Table

Table 1: UNAIDS Cosponsors' Estimated Spending for HIV/AIDS,

1996–1999 12

Figure

Figure 1: Structure of UNAIDS 6

Contents
Page ii GAO-01-625 Global Health

Abbreviations

HIV/AIDS Human Immunodeficiency Virus/Acquired

Immunodeficiency Syndrome

U.N. United Nations

UNAIDS Joint United Nations Programme on HIV/AIDS

UNESCO U.N. Educational, Scientific, and Cultural Organization

UNICEF U.N. Children’s Fund

USAID U.S. Agency for International Development

WHO World Health Organization
Page 1 GAO-01-625 Global Health

May 25, 2001

The Honorable Bill Frist

Chairman, Subcommittee on African Affairs

Committee on Foreign Relations

United States Senate

Dear Mr. Chairman:

Despite efforts by the international community to reduce the spread of

Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome

(HIV/AIDS), AIDS is now the fourth leading cause of death in the world

and the primary cause of death in sub-Saharan Africa. According to the

Joint United Nations Programme on HIV/AIDS (UNAIDS), more than 36

million people are living with the virus worldwide, and more than 21

million have died since 1980. Furthermore, given the scale of the

pandemic, HIV/AIDS has grown beyond a public health problem to become

a humanitarian and developmental crisis. For example, the U.S. National

Intelligence Council1

 concluded that the persistence and spread of

infectious diseases, such as HIV/AIDS, are likely to aggravate and, in some

cases, provoke economic decline, social fragmentation, and political

destabilization. In 2000, the United States classified HIV/AIDS as a threat

to national security, and the Congress approved approximately $466

million for international HIV/AIDS efforts in 2001.

UNAIDS, funded in part by the United States, is one important

international effort against HIV/AIDS. UNAIDS was established by the U.N.

in 1996 to provide coordinated U.N. action and to lead and promote an

expanded global response to the worldwide epidemic. The organization

was charged with providing technical support and information, including

best practices, epidemiological data, and other information on the national

and international response to HIV/AIDS. UNAIDS was also expected to

evaluate the progress made toward achieving its mission. UNAIDS is made

 1

The Global Infectious Disease Threat and Its Implications for the United States, No. NIED

99-17 of the National Intelligence Estimates (Washington, D.C.: National Intelligence

Council, Jan. 2000).

United States General Accounting Office

Washington, DC 20548
Page 2 GAO-01-625 Global Health

up of a Secretariat and seven U.N. cosponsors2 with individual

responsibilities that are to work together to achieve UNAIDS’ mission. We

reported in 1998 that UNAIDS had made limited progress toward achieving

its mission.3

 We found that U.N. cosponsors had not increased funding to

integrate HIV/AIDS into their programs as expected and that UNAIDS had

not been effective in coordinating the U.N. response at the country level or

in helping developing countries respond to the worldwide epidemic. In

January 1999, UNAIDS launched the International Partnership Against

AIDS in Africa to enhance national and international efforts against the

epidemic in Africa.

This letter responds to your request that we examine UNAIDS’ progress in

achieving its mission since we last reported in 1998. In this report, we (1)

assess UNAIDS’ progress, especially at the country level, toward

increasing the coordination and commitment of the U.N. and global

community; (2) assess UNAIDS’ progress in providing technical support

and information and in developing a monitoring and evaluation plan to

measure results; and (3) identify factors that may have affected UNAIDS’

progress. In addition, you asked us to provide information on the status of

the International Partnership Against AIDS in Africa. (See appendix I for

the status of this Partnership.)

To examine UNAIDS’ progress, we interviewed key Secretariat, cosponsor,

and U.S. officials. We reviewed extensive UNAIDS’ documentation,

including progress reports, governing board documents, annual surveys of

country-level operations, external evaluations of several of UNAIDS'

functions, and a UNAIDS survey of 12 of its leading bilateral donors

published in 2000. We also conducted a survey of U.S. Agency for

International Development missions, which are key partners in the global

response, to obtain perspectives on UNAIDS' HIV/AIDS efforts at the

country level. Appendix II provides a more detailed description of our

objectives, scope, and methods.

 2

The seven cosponsors are the United Nations Children’s Fund; United Nations

Development Programme; United Nations Population Fund; United Nations International

Drug Control Programme; United Nations Educational, Scientific, and Cultural

Organization; World Health Organization; and the World Bank.

3

HIV/AIDS: USAID and U.N. Response to the Epidemic in the Developing World

(GAO/NSIAD-98-202, July 1998).
Page 3 GAO-01-625 Global Health

Since we last reported in 1998, UNAIDS has made progress in increasing

U.N. coordination and enhancing the global response to the worldwide

HIV/AIDS epidemic; however, its efforts at the country level need

strengthening. UNAIDS is developing a strategic plan for coordinating the

U.N.’s overall response to the HIV/AIDS problem and has helped shift the

global community’s response to HIV/AIDS from an exclusively healthoriented perspective to a multisectoral approach that addresses the

various ramifications of high rates of HIV/AIDS on a country’s

development. Most importantly, U.N. and bilateral donors have increased

their funding for HIV/AIDS. However, these successes have been partly

offset by the inability of UNAIDS’ cosponsors to fully integrate HIV/AIDS

into their programs and activities and by UNAIDS’ weak efforts at the

country level. The in-country representatives of the seven UNAIDS

cosponsors have not been sufficiently effective in coordinating the U.N.’s

response or assisting host countries in combating the HIV/AIDS crisis.

UNAIDS’ donors have indicated that future funding increases may depend

on UNAIDS’ ability to demonstrate that it is achieving results at the

country level.

UNAIDS has provided financial and technical support to about 50

HIV/AIDS technical networks worldwide since1998 that link local

communities and regions to HIV/AIDS-related resources from universities,

health organizations, and private consultants. In addition, UNAIDS has

successfully developed a series of best practices in the form of reports and

case studies on a comprehensive set of issues, including improving the

safety of blood products, caring for individuals infected by HIV and

tuberculosis, and increasing access to HIV-related drugs. Users of the

series found the reports to be authoritative, high quality, and

comprehensive. However, UNAIDS has not been as successful in tracking

the funding and actions host governments and others have taken to

address the AIDS problem at the country level. Further, 5 years after its

creation, the Secretariat has yet to implement a monitoring and evaluation

plan that would enable UNAIDS to determine the important results of its

overall efforts and measure progress toward achieving its objectives,

especially at the country level.

Several factors, some of them external to UNAIDS, have impeded UNAIDS’

progress in achieving its multiple goals. UNAIDS was intended to be a

model of U.N. reform whereby a single Secretariat together with several

U.N. agencies would marshal the U.N. and global community’s resources

to address the AIDS pandemic. However, the critical monetary and human

resources UNAIDS Secretariat and cosponsors were expected to marshal

are controlled by other U.N. agencies, as well as bilateral donors, national

Results in Brief
Page 4 GAO-01-625 Global Health

governments, and the private sector. UNAIDS’ influence is thus dependent

on how effectively it can advocate AIDS causes to others. UNAIDS also

began with a weak political mandate from the U.N. and the international

community. This affected UNAIDS’ initial efforts to find resources to

address the worldwide HIV/AIDS problem and to pressure UNAIDS’

cosponsors to integrate AIDS into their development agendas. Finally,

UNAIDS has not always responded to the pandemic in a consistent

manner. It has not always followed through sufficiently on specific efforts,

such as developing regional initiatives, that it undertook to address

HIV/AIDS problems.

This report makes recommendations to help UNAIDS improve the

integration of HIV/AIDS into the cosponsors’ strategies, programs, and

activities; to hold UNAIDS’ cosponsor representatives more accountable at

the country level; and to improve UNAIDS’ monitoring and evaluation

efforts. In written comments on a draft of this report, the Department of

State, U.S. Agency for International Development, and UNAIDS generally

agreed that the program improvements we recommended were needed

and that in some cases, action is under way. However, UNAIDS

commented that the report focused too much on program shortcomings

and that the report did not fully recognize the positive steps that have been

taken by the Secretariat, cosponsors, and others since our 1998 report. We

believe that the report showed progress in a number of areas since our last

report, including increased U.N., national, and international commitment

and funding to HIV/AIDS causes, improved technical support and best

practices, and increased U.N. coordination. Where appropriate, we have

modified our report to include additional information to address UNAIDS’

concerns.

The World Health Organization (WHO) established the U.N.’s first program

to respond to HIV/AIDS in 1987. Later that same year, the U.N. General

Assembly encouraged WHO to continue its efforts and urged all

appropriate U.N. system organizations to support AIDS control efforts. In

the early 1990s, U.N. officials and bilateral donors increasingly recognized

the need for a multisectoral response to the complex challenges of the

HIV/AIDS pandemic, including the social, economic, and development

Background
Page 5 GAO-01-625 Global Health

issues contributing to the spread of the virus.4 They realized that WHO’s

medically based approach was insufficient to effectively combat the virus.

In response, the United Nation’s Economic and Social Council5 established

the Joint United Nations Programme on HIV/AIDS and operations started

in 1996. The mission of UNAIDS is to strengthen and support an expanded

response to HIV/AIDS aimed at preventing the transmission of HIV,

providing care and support, reducing the vulnerability of individuals and

communities to the worldwide epidemic, and alleviating its impact.

UNAIDS was not expected to fund the efforts of the global community.

Intended to be a model of U.N. reform, UNAIDS is the United Nations’ first

joint, cosponsored program of its type.6

 UNAIDS is comprised of a

Secretariat and seven U.N. cosponsors that act at the global, regional, and

country levels. UNAIDS’ Programme Coordinating Board7

 is the governing

body for all programmatic issues concerning policy, strategy, finance, and

monitoring and evaluation of UNAIDS. Through the Committee of

Cosponsoring Organizations, the cosponsors’ executive heads or their

representatives meet twice a year to consider matters concerning UNAIDS

and to provide input into UNAIDS' policies and strategies. The UNAIDS

Secretariat, headquartered in Geneva, Switzerland, and acting primarily at

the global level, is in charge of the overall coordination and management

of UNAIDS and leads the International Partnership Against AIDS in Africa.

The seven cosponsors are independent U.N. agencies that have programs

in regions and countries worldwide. By joining the UNAIDS partnership,

they committed to joint planning and action against HIV/AIDS. Cosponsors

 4

A multisectoral approach involves all government sectors, including education, defense,

and finance. It also involves sectors outside the government such as the media; the private

sector, including business, labor, and foundations; and nongovernmental organizations

such as religious groups.

5

The U.N. Economic and Social Council was established to promote economic and social

progress; human rights; and solutions to international economic, social, and health

problems. The Council reviews work on HIV/AIDS every 2 years and selects the

membership for UNAIDS’ governing board.

6

UNAIDS is the first joint, U.N. cosponsored program to organize around common

objectives, to have a fully constituted governing board, and to have a secretariat that does

not have direct authority over its cosponsors.

7

The membership of the Program Coordinating Board includes representatives from 22

countries; 5 representatives of nongovernmental organizations, including people living with

HIV/AIDS; and the 7 cosponsors. It is the only U.N. agency to include representatives of

nongovernmental organizations and people living with HIV/AIDS on its governing board.
Page 6 GAO-01-625 Global Health

are charged with integrating HIV/AIDS-related strategies, policies,

programs, and activities into the work of their respective agencies. Figure

1 shows the organizational structure of UNAIDS.

Figure 1: Structure of UNAIDS

Source: GAO based on UNAIDS documentation.

UN Economic

and Social

Council

U.N. Economic

and Social

Council

UNAIDS Program Coordinating Board UNAIDS Program Coordinating Board

Secretariat

UNICEF

UNDP

UNFPA

UNESCO

UNDCP

WHO

World

Bank

UNAIDS Committee of

Cosponsoring

Organizations

UNAIDS Committee of

Cosponsoring

Organizations

UNAIDS
Page 7 GAO-01-625 Global Health

The United Nations creates U.N. “theme groups” on specific issues to

facilitate its efforts at the country level and to promote a more coherent

U.N. response to national priorities. For example, one type of theme group

focuses on the environment and sustainable development, and another on

the empowerment of women. The U.N. has 132 theme groups on HIV/AIDS

that serve as UNAIDS’ primary mechanism for assisting developing

countries. They are composed primarily of the senior staff of UNAIDS’

cosponsors and are located in-country. The theme groups’ principal

objectives are to coordinate the U.N. response at the country level and to

support national governments and others in their efforts to mount an

effective and comprehensive response to HIV/AIDS. Theme groups are

expected to share information, plan, and monitor coordinated actions with

their U.N. partners and, in some cases, jointly finance major AIDS-related

activities in support of host governments and national partners, such as

nongovernmental organizations. In priority countries,8

 the theme group

may be supported by a Country Programme Advisor, a country-based

Secretariat staff member. In addition to supporting the broader U.N.

system, to build national commitment to HIV/AIDS action, this advisor is

expected to provide information and guidance to a range of host country

partners including government departments, nongovernmental and

community-based organizations, and people living with HIV/AIDS.

UNAIDS is funded through voluntary contributions from national

governments, cosponsors’ cash contributions, and private donations. None

of its funds comes from the U.N. budget or from U.N. member states’

assessed contributions. UNAIDS' biennium budgets (including the

Secretariat’s and cosponsors’ activities at the global and regional levels)

were $120 million for both the 1996-1997 biennium and the 1998-1999

biennium. The budget for 2000-2001 is $140 million. Cosponsors also

provide funding for their HIV/AIDS-related activities from their core

budgets and solicit supplemental funding for their country-level activities

from bilateral donors and other sources, such as foundations. The United

States is the largest contributor to UNAIDS, providing $34 million for the

1996-1997 biennium, $31 million for the 1998-1999 biennium, and

approximately $32 million for the 2000-2001 biennium. The State

Department is the United States’ liaison with multilateral organizations

 8

To more efficiently use its resources, UNAIDS Secretariat focuses on countries that have

the highest HIV prevalence, the fewest financial resources, and the potential for the

greatest impact, among other criteria.
Page 8 GAO-01-625 Global Health

such as the United Nations, and the U.S. Agency for International

Development (USAID) manages U.S. funding to UNAIDS and coordinates

and participates in the U.S. delegation to UNAIDS’ governing board.

UNAIDS has made progress toward increasing global coordination and

commitment to HIV/AIDS since we last reported in 1998. UNAIDS is

developing a U.N. system strategic plan that will help coordinate the U.N.’s

HIV/AIDS-related programs and activities. In addition, UNAIDS’

cosponsors have increased their commitment and efforts to integrate

HIV/AIDS into the work of their agencies; however, progress varies from

cosponsor to cosponsor. UNAIDS’ advocacy efforts, especially those of the

UNAIDS Secretariat, have helped increase national and international

commitment and approaches to the worldwide epidemic. Funding by U.N.

and bilateral donors has also increased. However, UNAIDS’ efforts at the

country level are weak. UNAIDS’ theme groups continue to have difficulty

organizing a unified U.N. response and helping host countries combat

HIV/AIDS. Country Programme Advisors—the Secretariat’s country-based

staff—also have not been as effective as expected in supporting HIV/AIDS

efforts of the theme groups and host countries.

According to the UNAIDS governing board, the success of UNAIDS is

highly dependent on collaboration within the U.N. system. However, half

of UNAIDS’ donors9

 surveyed did not believe that the Secretariat had been

as successful as originally expected in facilitating the coordination of U.N.

actions on HIV/AIDS. According to USAID officials, the Secretariat’s lack

of clear guidance and coordination produced, in part, confusion within the

U.N. system about the roles of the Secretariat and cosponsors. In

response, the Secretariat is facilitating the development of the U.N. System

Strategic Plan for HIV/AIDS for 2001-2005. The plan is designed to provide

a more coherent U.N. response to HIV/AIDS, documenting the efforts of

the Secretariat, 7 U.N. cosponsors, and 21 other U.N. agencies, such as the

International Labour Organization and the Food and Agriculture

Organization. The Secretariat stated the plan will be presented to UNAIDS’

 9

The UNAIDS Financing Study, an independent survey of 12 of UNAIDS’ leading bilateral

donors commissioned by UNAIDS’ governing board and issued in September 2000, solicited

donors’ perspectives on several issues, including the extent to which UNAIDS has been

successful in its roles and responsibilities.

UNAIDS Has Made

Progress Toward

Increasing

Coordination and

Commitment to

HIV/AIDS, but

Country-Level Efforts

Need Strengthening

UNAIDS Has Worked to

Improve U.N. Coordination

and the International

Community’s Commitment

and Approach to HIV/AIDS
Page 9 GAO-01-625 Global Health

governing board by June 2001. In addition, the Secretariat and cosponsors

began conducting detailed reviews of each of the cosponsors’ HIV/AIDS

programs in March 2000. These reviews profile each cosponsor’s mandate,

structure, operations and budget, and HIV/AIDS-related work. The reviews

are intended to improve UNAIDS’ strategic planning and collaboration and

to increase understanding within UNAIDS about each of the cosponsors’

roles and responsibilities.

UNAIDS cosponsors’ commitment to HIV/AIDS has increased since we last

reported. Over the past 2 years, the executive boards of several

cosponsors have issued statements to strengthen agency action on

HIV/AIDS. For example, in January 2000, WHO’s Executive Board

requested that the Director General strengthen the agency’s involvement

in the UNAIDS effort and give HIV/AIDS priority in its budget. All UNAIDS

cosponsors’ executive directors now speak at major international

meetings and events, advocating for increased attention and activities to

combat HIV/AIDS. Some cosponsors also have elevated the position of the

HIV/AIDS unit or focal point organizationally to highlight the visibility and

importance of the issue within the agency. For example, in 1999, to focus

on its HIV/AIDS efforts in sub-Saharan Africa, the World Bank created a

new office that reports to the agency’s Office of the Regional Vice

Presidents. The same year, the U.N. Children’s Fund established a seniorlevel post and unit at their headquarters.

On the other hand, the cosponsors’ progress toward integrating HIV/AIDS

into their agency strategies, programs, and activities has varied and

continues to evolve. For example, an external evaluation of the U.N.

Development Programme’s HIV/AIDS program, prepared in 2000, found

that HIV/AIDS had not been fully integrated into the agency’s work. In

response, the Development Programme made HIV/AIDS one of its top

priorities and launched a resource mobilization campaign to support

country-level activities, among other efforts. The U.N. Population Fund

also evaluated its HIV/AIDS programs and concluded in its 1999 report that

many of the agency’s efforts to integrate HIV/AIDS were superficial. In

response, the Population Fund made HIV/AIDS a top priority as part of its

2001 agency realignment process—an action that the agency expects will

accelerate efforts to integrate HIV/AIDS into its existing programs. The

Executive Director of UNAIDS said that further strengthening cosponsor

commitment and integration of HIV/AIDS is a top internal challenge for

UNAIDS. Appendix III briefly describes the HIV/AIDS programs and key

activities of each of UNAIDS’ cosponsors.
Page 10 GAO-01-625 Global Health

UNAIDS’ major donors, U.S. government officials, cosponsor officials, and

others credit UNAIDS, especially the Secretariat, with contributing to the

national and international communities’ increased awareness of and

commitment to the fight against HIV/AIDS. They also credit UNAIDS and

the Secretariat with helping to reframe HIV/AIDS as an issue involving all

sectors rather than an issue involving only the health sector. Many

national governments around the world were slow to respond to the

HIV/AIDS epidemic, even those in the most affected areas in sub-Saharan

Africa. In response, UNAIDS’ Executive Director visited 21 developing

countries in 1999 and 2000, including 14 African countries. In those

countries, the Executive Director stressed the importance of mobilizing

efforts to combat HIV/AIDS and taking a multisectoral approach to the

countries’ presidents and other high-level national leaders. For example,

UNAIDS’ Executive Director met with the Prime Minister of Ethiopia in

September 1999 to advocate for a high-level, expanded, and multisectoral

response. In April 2000, the President of Ethiopia launched the National

Council on AIDS, supported by a National Secretariat in the Office of the

Prime Minister and composed of multisectoral subcommittees. With

assistance from the Secretariat and the World Bank, some countries are

incorporating responses to HIV/AIDS into their country’s long-term

multisectoral development plans.

UNAIDS also has worked with the international community, including the

private sector, to broaden and increase efforts to combat HIV/AIDS. In

December 2000, the Secretariat, several cosponsors, and the Japanese

government collaborated to develop detailed strategies, goals, and targets

for the Group of Eight’s10 plan to address HIV/AIDS and other infectious

diseases. In addition, in September 2000, the Secretariat, WHO, and the

European Commission conducted a high-level meeting to explore

additional multisectoral actions that the European Union could take

against poverty and communicable diseases such as HIV. UNAIDS also

worked to get the private sector more involved in international efforts to

combat HIV/AIDS. The Secretariat and the World Bank, together with

USAID and several U.S. foundations, convened 15 major U.S. foundations

in January 2000 and presented data on the foundations’ limited

expenditures on HIV/AIDS. According to the Secretariat, the foundations

subsequently committed to providing more funding. In April 2000, one

 10The Group of Eight consists of the heads of state of the United States, Great Britain,

Canada, France, Germany, Italy, Japan, and Russia. The Group meets annually to address

the major economic and political issues facing their nations and the international

community.
Page 11 GAO-01-625 Global Health

attendee the Bill and Melinda Gates Foundation--announced a $57 million

grant to expand national HIV/AIDS programs for youth in Botswana,

Ghana, Uganda, and Tanzania. The Secretariat also has helped cultivate

the involvement of the U.N. Foundation in global efforts against

HIV/AIDS.11 Since 1998, the U.N. Foundation has allocated at least $25

million for HIV/AIDS-related activities implemented by UNAIDS’

cosponsors in southern Africa and Ukraine.

Cosponsors reported that estimated spending for HIV/AIDS programs has

increased significantly in the past 2 years. However, most of the increased

spending came from the World Bank, which provides loans to national

governments for specific HIV/AIDS-related projects. Bilateral donor

funding increased slightly in 1998 over previous years, but funding has

increased considerably among some donors since then. Despite these

efforts, total funding for HIV/AIDS efforts is well below what experts

estimate is needed to effectively combat HIV/AIDS around the world.

Table 1 shows estimated spending for HIV/AIDS by UNAIDS’ cosponsors

from 1996 to 1999. Overall, UNAIDS’ cosponsors have increased spending

for HIV/AIDS programs and activities from $296.9 million in the 1996-1997

biennium to $658.1 million in the 1998-1999 biennium. Most of this

increase (96 percent) came from the World Bank. Four other cosponsors

increased spending for HIV/AIDS-related activities, although some did so

only slightly. The U.N. Development Programme decreased its spending

for HIV/AIDS.

 11The U.N. Foundation was established in 1997 to oversee the administration of a gift made

by Ted Turner in support of U.N. causes.

U.N. and Bilateral Donor

Funding for HIV/AIDS Has

Increased
Page 12 GAO-01-625 Global Health

Table 1: UNAIDS Cosponsors' Estimated Spending for HIV/AIDS, 1996–1999

In millions of U.S. dollars

Spending for HIV/AIDS

UNAIDS Cosponsors 1996–1997 1998-1999

U.N. Children’s Fund $61.0 $65.0

U.N. Development Programme 95.8 91.9

U.N. Population Fund 42.5 45.0

U.N. International Drug Control Programme n/aan/aa

U.N. Education, Scientific, and Cultural Organization 4.1 6.6

World Health Organization 27.6 38.9

World Bank 65.9 410.7

Total $296.9 $658.1

a

 The U.N. International Drug Control Programme was unable to provide information on its

spending for HIV/AIDS activities. Although it estimates that it spent approximately $11

million over the past several years, it could not isolate HIV/AIDS spending within its

demand reduction program. Other cosponsors also reported difficulty in tracking HIV/AIDS

spending.

Source: U.N. cosponsors’ estimates of HIV/AIDS spending.

Cosponsor officials cited several reasons that affected their ability to

increase HIV/AIDS spending. First, several cosponsors’ budgets have

either declined or remained stable over the past few years. For example,

the U.N. Population Fund’s overall budget declined from $628.7 million in

the 1996-1997 biennium to $581.7 million in the 1998-1999 biennium.

Second, earmarked funds12 for activities other than HIV/AIDS have

increased. For example, although the U.N. Development Programme’s

overall agency budget has increased from $4.3 billion in the 1996-1997

biennium to $4.8 billion in the 1998-1999 biennium, the percentage of its

budget that was earmarked for specific efforts increased from 62 percent

to 70 percent. Finally, the strength of the U.S. dollar has led to poor

exchange rates with other countries, reducing the value of bilateral donor

contributions to overall agency budgets. For example, according to U.N.

Population Fund officials, some bilateral donors made substantial

 12Bilateral agencies sometimes specify the issue or activity for which their contribution can

be used.
Page 13 GAO-01-625 Global Health

increases in contributions to the agency from 1999 to 2000, but these

increases were neutralized by the exchange rate.13

According to the UNAIDS Secretariat, while bilateral donors maintained

their spending for HIV/AIDS in 1996 and 1997 at $273 million each year,

funding increased slightly in 1998 to $293 million.14 As of May 2001, the

Secretariat could not provide us with more current data, but evidence

from specific countries suggests that funding has increased further. For

example, the United States committed approximately $466 million in 2001

compared with the $293 million spent by all bilateral donors, including the

United States, in 1998. Canada announced in June 2000 that, over the next

3 years, it would increase its international HIV/AIDS spending from $20

million to $60 million per year. According to the Secretariat, most major

bilateral donors have increased their HIV/AIDS funding for Africa since

2000. However, these increases are much less than the minimum of $3

billion that UNAIDS estimates may be needed annually for basic HIV/AIDS

prevention, treatment, and care in the sub-Saharan Africa region alone.

The U.N. Secretary-General is currently advocating for the creation and

funding of a global AIDS fund that would support HIV/AIDS activities in

developing countries. The U.S. Administration pledged $200 million to the

fund in May 2001.

One of UNAIDS’ primary functions is to strengthen host nations’ capacities

to plan, coordinate, implement, and monitor the overall response to

HIV/AIDS. However, UNAIDS’ governing board, donors, and senior

officials do not believe that UNAIDS has been as effective as expected at

the country level. The performance of UNAIDS’ theme groups varies

widely, and their overall performance in facilitating the U.N. response at

the country level and in providing effective assistance to host countries’

efforts to combat HIV/AIDS has been weak. In addition, UNAIDS

cosponsors and the Secretariat do not hold theme groups sufficiently

 13For example, in 1999, Denmark gave to the U.N. Population Fund 200 million Danish

Krone (U.S. $27.9 million). Denmark gave the same amount in 2000, but the exchange rates

reduced the value of the donation to U.S. $25 million.

14The Secretariat’s data on bilateral donor spending reflects 1997 prices and exchange rates

and tracks 10 bilateral donors for which data are available over time. The bilateral donors

are Australia, Canada, Denmark, Germany, Japan, the Netherlands, Norway, Sweden, the

United Kingdom, and the United States.

UNAIDS’ Country-Level

Efforts Need

Strengthening
Page 14 GAO-01-625 Global Health

accountable for their efforts. The Secretariat’s Country Programme

Advisors have not been as effective as expected in supporting the theme

groups’ and host countries’ HIV/AIDS efforts. The Secretariat has not

provided the advisors with sufficient guidance and training and initially

did not hire individuals with the right mix of skills.

According to UNAIDS’ 2000 survey of its donors, UNAIDS has not been as

successful as they expected in strengthening governments’ HIV/AIDS

activities and ensuring that appropriate and effective policies and

strategies are implemented to address HIV/AIDS. In addition, the survey

said that donors believe UNAIDS has been weak in promoting broad-based

political and social commitment and action to prevent and respond to

HIV/AIDS at the country level. According to the survey, donors’ perception

of UNAIDS’ lack of sufficient relevance at the country level could be a

threat to future funding. UNAIDS’ governing board said that the ultimate

test of UNAIDS’ success lies in the degree to which it successfully helps

host countries combat HIV/AIDS. However, at the latest meeting of

UNAIDS’ governing board in December 2000, both the governing board

and UNAIDS’ Executive Director noted that UNAIDS needed to improve

its country-level response. The governing board emphasized that a

coordinated, consistent U.N. response was needed and that improving the

performance of UNAIDS’ theme groups required urgent attention.

UNAIDS’ Executive Director concurred with the board’s assessment,

saying that these tasks are a formidable challenge and that strengthening

UNAIDS’ country-level efforts is one of UNAIDS’ top internal challenges.

UNAIDS’ 132 theme groups on HIV/AIDS—composed primarily of

cosponsors’ senior in-country staff—are UNAIDS’ primary mechanism at

the country level to coordinate the U.N. response and support host

countries’ efforts against HIV/AIDS. However, overall theme group

performance varies considerably. For example, in surveying 36 USAID

missions worldwide, we asked about the extent to which the theme groups

were strengthening the overall national government response to HIV/AIDS.

Of the 24 missions responding, 8 said to a very or great extent, 7 said to a

moderate extent, and 9 said to some, little, or no extent.15 In addition,

UNAIDS’ annual surveys of its theme groups from 1996-1999 indicate that

they have made little progress in key areas, including developing an

 15USAID has a total of 82 missions worldwide. We surveyed 36 missions representing those

that had been involved in HIV/AIDS activities for at least 2 years at the time of our survey.

UNAIDS’ Donors and Senior

Officials Believe Country-Level

Efforts Are Weak

Theme Groups’ Performance

Varies and Accountability for

Results is Limited
Page 15 GAO-01-625 Global Health

advocacy plan, mobilizing resources, and developing a U.N. system

integrated plan on HIV/AIDS.

• According to the UNAIDS Secretariat, theme groups are expected to

develop joint advocacy action plans to plan and manage joint advocacy

work on HIV/AIDS and to clarify what the theme group is advocating and

by whom and how. UNAIDS’ annual surveys show that, in 1997, 31 percent

of theme groups surveyed had developed a systematic approach to

advocacy in the form of a strategy or plan. In 1999, 37 percent of theme

groups had developed an advocacy plan or strategy.16

• Since UNAIDS is not a funding agency, mobilizing resources to support

country-level efforts against the epidemic is another key role of the theme

group. According to UNAIDS, in 1997, under one-half of UNAIDS’ theme

groups were mobilizing resources for HIV/AIDS activities, a figure that

increased to about one-half in 1999. Most resource mobilization efforts

were ad hoc, with only one-quarter of theme groups having developed a

systematic approach to resource mobilization as expected.

• According to the UNAIDS Secretariat, a U.N. system integrated plan on

HIV/AIDS is the basis for coordinated U.N. support to the national

response and is the single most valuable indicator of the U.N.’s

commitment at the country level. However, according to UNAIDS, as of

February 2000, only 18 out of 86 theme groups surveyed had completed an

integrated plan and one-half had yet to take any steps to begin the process

of completing one.

In 1998, we found that UNAIDS’ theme groups were ineffective for a

number of reasons. The UNAIDS Secretariat did not provide timely

guidance about operations or responsibilities. In addition, UNAIDS’

cosponsor staff at the country level were not committed to the UNAIDS

mandate, nor were they held accountable by their respective agencies for

their participation in the theme groups or for the theme groups’ results in

supporting national HIV/AIDS efforts.

In our most recent work, we found that some of the cosponsors and the

Secretariat still do not hold theme group members accountable for results.

For example, while the Director-General of WHO directed their country

directors to participate in theme groups, WHO does not assess their

involvement as part of their annual performance review. Neither the World

 16In 1997, the Secretariat surveyed a total of 126 theme groups and received 64 responses.

In 1999, the Secretariat surveyed a total of 129 theme groups and received 86 responses.
Page 16 GAO-01-625 Global Health

Bank nor the U.N. International Drug Control Programme requires theme

group involvement or includes it as a required element in annual

performance reviews of senior country-level staff. The UNAIDS

Secretariat also does not hold theme groups accountable for results.

While the Secretariat has no organizational authority over the cosponsors’

country-level representatives, the theme groups are expected to undertake

a number of activities, including developing advocacy and resource

mobilization plans. The Secretariat’s annual surveys of theme groups are

one way that UNAIDS obtains information on theme group operations.

However, these surveys currently focus only on the internal operations

and management of the theme group rather than the implementation of

these plans or the extent to which theme groups are successful in their

other efforts to support host countries’ HIV/AIDS efforts. The Secretariat

said that it is improving the annual surveys to allow for tracking of theme

group results. Also, in recognition of the continuing challenges with

theme groups, UNAIDS created the Interagency Task Team on Theme

Group Operations, and the Secretariat created a new Theme Group

Support Unit.

According to U.S. officials and officials from both the UNAIDS Secretariat

and cosponsors, Country Programme Advisors—the Secretariat’s countrybased staff—have not been effective as expected in supporting HIV/AIDS

efforts of the theme groups and host countries. For example, guidance

provided by the UNAIDS Secretariat instructs the advisors to advocate to

national governments for expanded efforts on HIV/AIDS but provides no

guidance on what to do or how to do it. Without adequate guidance or

training, an advisor’s success is dependent on his or her personal talents

and skills. According to the Secretariat, many advisors have not been

successful because they lack crucial diplomatic skills and were not hired

at a rank high enough to successfully interact with and influence U.N. and

host country government officials. In some instances, the Secretariat has

increased the grade level at which these advisors are hired and is in the

process of hiring new advisors with the right skills. UNAIDS also held a

meeting on developing a plan of action to better focus their recruiting

efforts and support the advisors in their work.

While the UNAIDS Secretariat was not intended to fund or implement

HIV/AIDS activities, it does provide small amounts of funding to support

theme group proposals for projects to stimulate national HIV/AIDS efforts.

These funds are also expected to help theme groups leverage funds from

other sources. These funds could be used, for example, to support

activities to design and develop national strategic plans or to support the

development of major grants or loans to address HIV/AIDS. UNAIDS

UNAIDS’ Country Programme

Advisors Have Not Been as

Effective as Expected

Theme Groups and Advisors

Are Not Actively Submitting

Funding Proposals for CountryLevel Activities
Page 17 GAO-01-625 Global Health

provided $22.9 million in these funds for the 1998-1999 biennium and

allocated about $23.5 million for the 2000-2001 biennium. After an

evaluation of the funding process in June 1999,17 UNAIDS found that 65

percent of projects receiving such funds succeeded in leveraging

additional funds and, in some cases, in involving new sectors and partners.

However, the evaluation also found that theme groups generally were not

committed to submitting proposal requests, were not adequately involved

in the proposal process, and did not always possess the technical

expertise needed to develop a quality proposal. In addition, the evaluation

found that the Country Programme Advisors had not assisted theme

groups in preparing proposals to the extent that the Secretariat had

expected. According to UNAIDS' Secretariat, the proposal process has

been streamlined for the current biennium.

UNAIDS is charged with developing and providing information to enhance

the U.N. and global response to the HIV/AIDS worldwide epidemic. The

UNAIDS Secretariat has continued to improve its technical support and

best practice materials since we last reported, but the best practice

materials have not been sufficiently distributed. The Secretariat also has

made progress in tracking the pandemic but has encountered difficulties

in tracking the national and international response to the pandemic with

regard to funding and activities. In addition, the Secretariat’s monitoring

and evaluation efforts have various weaknesses, and UNAIDS still cannot

report overall results or measure progress towards its objectives,

especially at the country level. As a result, UNAIDS is constrained in its

ability to make management decisions based on data or to ensure its

donors that it is using program resources productively.

A key function of the UNAIDS Secretariat is to arrange for and provide

selected technical support and to identify, develop, and disseminate best

practices. In our 1998 report, we said that the Secretariat had not

adequately mobilized regional resources to provide technical support.

Since then, the UNAIDS Secretariat has established and supported

Technical Resource Networks to help arrange the technical support

needed by U.N. organizations and others working on HIV/AIDS activities.

 17The evaluation, Findings From an Analysis of the Strategic Planning and Development

Fund Process, was completed by the Resource Group International Sarl, Geneva,

Switzerland, and issued July 1999.

UNAIDS Has Made

Mixed Progress in

Improving Technical

Support, Best

Practices, and Other

Information to

Enhance the

Response to the

Pandemic

UNAIDS Has Made Some

Progress Improving

Technical Support and

Best Practices Materials
Page 18 GAO-01-625 Global Health

These networks consist of groups of individuals, communities, and

institutions that are expected to share information, provide peer support,

and help identify sources of technical information and assistance to those

working on HIV/AIDS issues. The Secretariat has facilitated the creation of

13 networks since 1998 and has provided financial and technical support—

such as facilitating discussions on technical issues related to HIV/AIDS—

to 49 networks worldwide. For example, the Secretariat initiated the

Forum of Condom Social Marketing network in 1998 and, with the

cosponsors, has supported groups such as the Asian and European Harm

Reduction Networks and the Religious Alliance Against AIDS in Africa.

To help improve the technical capacity of U.N. cosponsors and others

working on HIV/AIDS-related activities in a number of geographic regions,

in 1996, the Secretariat and cosponsors began establishing regional

technical teams to serve groups of countries. These intercountry teams—

locate in Abidjan, Cote d’Ivoire (western and central Africa); Pretoria,

South Africa (eastern and southern Africa); and Bangkok, Thailand (Asia

and the Pacific)—are expected to facilitate existing intercountry initiatives

or networks and develop new mechanisms of exchange and collaboration;

help arrange for technical assistance from other organizations,

universities, and private consultants; and mobilize additional resources for

subregional HIV/AIDS efforts. To help determine whether these teams

were meeting their objectives, the Secretariat commissioned an evaluation

of the Inter-country Team for Western and Central Africa, published in

January 2001, which assessed the team’s relevance, effectiveness, and

efficiency. The evaluation found that the team was very useful in

exchanging and disseminating information, but that it was less successful

in arranging for technical assistance.

UNAIDS’ best practice collection includes a series of technical updates,

key materials, and case studies that provide strategies and approaches to

prevent infection, provide care to those already infected, and alleviate the

impact of HIV/AIDS on those affected. Topics include improving the safety

of blood products, caring for individuals infected by HIV and tuberculosis,

and increasing access to HIV-related drugs. In 1998, we reported that these

materials were too general and lacked “how-to” guidance. In 1999, the

Secretariat commissioned an independent evaluation18 of the effectiveness,

 18Summary Report of an Evaluation of the UNAIDS Best Practices Collection: Its Strengths

and Weaknesses, Accessibility, Use and Impact, Performance Improvement Pty Ltd., (Nov.

1999).
Page 19 GAO-01-625 Global Health

relevance, and efficiency of the best practice materials. The review

surveyed 164 users who considered the best practice materials to be

authoritative, high quality, user friendly, and comprehensive in coverage.

However, the review concluded that the Secretariat should develop

materials more suited to local circumstances. Some steps have been taken

to increase local specificity in best practice materials. The UNAIDS

Secretariat has worked with some countries, such as Brazil, to develop

best practices that focus on successful approaches and activities taken by

organizations in that country. The review also concluded that the

distribution of the materials should be improved. The review found, for

example, that the Country Programme Advisors—the Secretariat’s

country-based staff—had not systematically distributed the materials and

may not have been sufficiently aware of their responsibilities in this

regard. In January 2001, a senior Secretariat official noted that, while

distribution was still a problem, the Secretariat was trying to address this

issue.

The UNAIDS Secretariat is responsible for developing accurate, up-to-date

information on the worldwide epidemic and for tracking the international

community’s response. According to UNAIDS’ 2000 donor survey, donors

believe that the Secretariat has done well in tracking the pandemic. For

example, the Secretariat and WHO participate in the UNAIDS/WHO

Working Group on Global HIV/AIDS and Sexually Transmitted Infection

Surveillance to compile the best epidemiological information available.

From this data, the Secretariat calculates national HIV infection rates,

which are helpful in raising awareness about the spread of the virus and in

stimulating action. The working group also established the Reference

Group on HIV/AIDS Estimates, Modeling and Projections, which,

according to UNAIDS, has helped set clearer international standards for

assessing AIDS and its impact and is expected to improve the production

of country-specific estimates of HIV prevalence. However, according to

the Secretariat, efforts still need to be increased to support HIV

surveillance activities at the country level. The Secretariat also noted that

WHO has taken steps to increase its efforts in this area.

The UNAIDS Secretariat is also expected to track national and

international responses to the pandemic. Various problems, however, have

hindered its efforts in this area. To track funding, the Secretariat

conducted a study with Harvard University in 1996 and then with the

Netherlands Interdisciplinary Demographic Institute’s Resource Flows

UNAIDS Has Made Some

Progress in Tracking the

Pandemic but Has

Encountered Difficulties in

Tracking Response
Page 20 GAO-01-625 Global Health

Project19 in 1999 to obtain data on HIV/AIDS spending by major bilateral

donors, the United Nations, and developing countries. According to the

Secretariat, getting these entities to report data to the contractor has been

a major challenge, as has been reaching consensus on what counts as an

HIV/AIDS project or activity. In addition, developing countries do not

systematically track HIV/AIDS spending. To improve the monitoring and

tracking of international and national resource flows, the Secretariat has

established a specific unit with devoted staff resources. The Secretariat

also has been developing and implementing the Country Response

Information System since 2000. This database is intended to facilitate the

compilation, analysis, and dissemination of relevant information by

country on HIV epidemics and HIV/AIDS-related programs and activities

by all relevant in-country partners. According to the Secretariat, compiling

this information has been extremely difficult and more complex than

originally envisioned, and it is behind in efforts in this area. The

Secretariat expects to complete a prototype in the second quarter of 2001.

UNAIDS’ governing board directed UNAIDS at its creation to implement

the principles of performance-based programming and to use measurable

objectives in assessing its performance. We reported in 1998 that the

Secretariat was in the process of developing a monitoring and evaluation

plan. UNAIDS' governing board approved a plan in December 1998 that

consisted of multiple elements, including a draft conceptual framework,

theme group surveys, and one-time evaluations of several of the

Secretariat’s specific functions, such as the best practice collection. Since

then, a unified budget and workplan with performance indicators was

added. Key elements of the overall plan—the conceptual framework and

the unified budget and workplan—need to be improved. Furthermore,

despite these evaluative efforts, UNAIDS still cannot measure progress

towards achieving its objectives or overall results, especially at the

country level.

Although the United Nations is not required to comply with the U.S.

Government Performance and Results Act,20 we used the principles laid

 19The Netherlands Interdisciplinary Demographic Institute collaborates with the U.N.

Population Fund to conduct the Resource Flows Project.

20The Government Performance and Results Act of 1993 (P.L.103-62).

UNAIDS’ Monitoring and

Evaluation Efforts Need

Improvement
Page 21 GAO-01-625 Global Health

out in the act to identify the elements of a successful performance-based

system. These include (1) a clearly defined mission, (2) establishment of

long-term strategic and annual goals, (3) measurement of performance

against the goals, and (4) public reporting of results. The act seeks to link

resources and performance so that an organization can show what it has

accomplished compared with the money it has spent and so that it can be

held accountable for the levels of performance achieved.

Using the Results Act as a guide, we identified four major weaknesses in

UNAIDS’ Monitoring and Evaluation Framework. First, the Framework

primarily addresses the Secretariat’s outputs even though the

Framework’s outcomes and impacts also apply to the cosponsors. Second,

because the Framework’s outputs focus on the Secretariat, which acts

primarily at the global level, the Framework does not sufficiently address

UNAIDS’ performance at the country level. Third, the Framework’s

outputs, outcomes, and impacts are not clearly linked, making it difficult

to assess the cause and effect of UNAIDS’ specific activities. Fourth, the

Framework does not establish specific performance baselines, targets, or

other quantitative measures that could help UNAIDS measure overall

results and progress towards achieving its objectives or expected

outcomes.

UNAIDS’ Unified Budget and Workplan 2000-2001, a separate

performance-related instrument, provides additional documentation that

compensates for some of the shortcomings of the monitoring and

evaluation framework. For example, the Workplan provides UNAIDS’

mission statement, goals, and the strategic objectives leading to those

goals. It also provides information on the Secretariat’s and cosponsors’

global and regional activities; includes more specific linkages between

outputs, indicators, and objectives; and better accounts for the respective

roles and responsibilities of the Secretariat and cosponsors. However, the

Workplan also has a number of weaknesses. For example, the Workplan

does not include quantifiable performance targets that would define

success and help UNAIDS to measure its progress. The Workplan also

does not always indicate what is needed to accomplish the stated

objectives. For example, one objective is to “mobilize political and public

support for UNAIDS’ priority themes and initiatives and to provide

leadership and guidance in advocacy, public information, and resource

mobilization efforts.” The only output for this objective—communication

activities—is vague. Furthermore, like the Framework, the Workplan does

not always sufficiently link its components, making it difficult to assess

the cause and effect of UNAIDS’ actions.
Page 22 GAO-01-625 Global Health

Senior Secretariat officials acknowledge that the Unified Budget and

Workplan 2000-2001 has deficiencies. They said that it was the first

document of its kind, compiled quickly, and did not have high-quality

indicators. In addition, because it is organized thematically rather than

functionally, they said it is difficult to track or assess UNAIDS’ progress in

achieving its overall objectives. They also said that developing a

performance-based plan with quality indicators has been especially

challenging because the U.N. system lacks an evaluative culture. However,

they believe the Unified Budget and Workplan 2000-2001 is an important

first step.

UNAIDS Secretariat officials said that evaluation efforts overall have been

hampered by inadequate and inconsistent resources. Changes in personnel

and reliance on consultants over the past several years have resulted in a

lack of continuity and variable levels of effort. It was not until early 1998

that a staff person was hired to lead a performance evaluation unit. The

unit is currently authorized three full-time professional staff and is

supplemented periodically by staff on part-time loan from other agencies.

Because all Secretariat positions are time-limited, there is greater turnover

than normal and difficulty in recruiting and retraining skilled staff.

UNAIDS and U.S. government officials told us that, although UNAIDS has

certain advantages in the fight against HIV/AIDS, a number of key factors,

some of which are external to the organization, have hindered its progress.

UNAIDS was established to be the primary advocate for global action on

HIV/AIDS and has advantages over other organizations, such as bilateral

donor agencies, that combat HIV/AIDS. For example, as a U.N.

organization, UNAIDS may have more credibility than other organizations,

and thus be more effective, because it is seen as a neutral entity that does

not represent any one government. In addition, UNAIDS often has access

to higher-level government officials than do bilateral development

agencies, and it sometimes operates in countries where bilateral agencies

and other organizations do not because of conflict, political tension, or

lack of compelling interest. However, UNAIDS’ broad mission,

organizational structure, initial lack of a political mandate, and a lack of

timely follow-through have hampered its progress.

While UNAIDS has a broad and challenging mission, its progress depends

on actions taken by other entities, such as international donors,

nongovernmental organizations, the private sector, and national

governments. National government leadership on HIV/AIDS is particularly

essential to an effective response to HIV/AIDS, but many national

Key Factors Have

Hindered UNAIDS’

Progress
Page 23 GAO-01-625 Global Health

governments around the world have been slow to respond to the crisis.

For example, until 1999, the President of Zimbabwe denied that HIV/AIDS

was a problem in his country; the government of India was similarly slow

to respond. HIV/AIDS is also an extraordinarily complex disease for which

there is no cure. Combating the pandemic requires a multisectoral

approach that involves addressing the many medical, cultural, behavioral,

economic, social, and political aspects that surround the virus and

contribute to its impact.

As a joint and cosponsored program, UNAIDS’ structure is complicated

and progress depends heavily on the collegiality, cooperation, and

consensus of the Secretariat and seven cosponsors. According to UNAIDS

and U.S. government officials, these qualities were not evident during

UNAIDS’ first several years. They noted that, even though UNAIDS is a

joint program, it was created without the buy-in of the cosponsors.

According to senior Secretariat and cosponsor officials, because UNAIDS

was imposed on the cosponsors, there was a certain amount of hostility

within the program. Furthermore, the cosponsors viewed the Secretariat

as competing for funding and were confused about their role within the

joint program. As a result, until recently, cosponsors were not fully

committed either to incorporating HIV/AIDS into their respective

mandates or to participating in UNAIDS. Since each cosponsor is

accountable only to its own independent executive board, neither the

Secretariat nor UNAIDS’ governing board had controlling organizational

authority over the cosponsors. Thus, little could be done to exert pressure

on the cosponsors to become effective partners within UNAIDS.

UNAIDS’ effectiveness was further hampered, according to U.S.

government officials, because it was created without the necessary

political mandate or funding from the major bilateral donors or the United

Nations. According to a senior Secretariat official, the bilateral donors

heavily influenced the creation of UNAIDS; however, when political

pressure was needed to intensify and fund UNAIDS’ cosponsors’ HIV/AIDS

programs, bilateral donors provided little assistance. In addition,

according to U.S. officials, the United Nations, particularly the SecretaryGeneral, had other priorities on which to focus. The bilateral donors and

the United Nations are beginning to provide needed political and financial

support. For example, in January 2000, the U.N. Security Council held a

session, in part due to U.S. influence, to address the impact of AIDS on

global peace and security—the first session ever held on a health-related

matter.
Page 24 GAO-01-625 Global Health

Finally, according to U.S. officials, while UNAIDS initiates many activities,

it does not always execute them in a timely way, further delaying an

effective response. For example, according to USAID officials, UNAIDS

has initiated various regional strategies to address HIV/AIDS, such as the

International Partnership Against AIDS in Africa and the Eastern

European Regional Strategy, but did not facilitate timely efforts to move

these agreements forward. According to the Secretariat, it does not have

sufficient capacity to always follow through in a timely manner on the

efforts it initiates, such as the International Partnership Against AIDS in

Africa.

UNAIDS was given an enormous challenge when it was created to lead

and expand U.N. and global efforts to combat HIV/AIDS. Intended to be a

model of U.N. reform, UNAIDS was the U.N.’s first joint and cosponsored

program of its type. Because there was no precedent, UNAIDS had to learn

to function effectively, depending heavily on the collegiality and

cooperation of the Secretariat and seven cosponsors. Despite these

challenges, UNAIDS has made progress in many areas, especially in

improving U.N. coordination and advocating for an enhanced global

response to the HIV/AIDS pandemic. However, while UNAIDS’ cosponsors

have recently intensified their commitment and efforts to integrate

HIV/AIDS into their strategies and programs, their slow response has made

it more difficult for UNAIDS to achieve its mission.

UNAIDS has not lived up to expectations with regard to its efforts at the

country level. Overall, UNAIDS’ Secretariat and cosponsors’

representatives in developing countries continue to have difficulty

organizing their efforts and providing assistance to host governments and

others, and UNAIDS does not hold them accountable for results. Some

cosponsors still do not require their senior country-level representatives to

actively participate in theme groups or have not established performance

expectations related to theme group activities. In addition, while the

Secretariat surveys theme group activities annually, oversight is limited

because it does not focus on results. Five years after its creation, the

Secretariat has yet to implement a monitoring and evaluation plan that

would enable UNAIDS to determine the important results of its overall

efforts and measure progress toward achieving its objectives. A quality

performance evaluation plan is critical to assure UNAIDS’ donors and

others in the international community that UNAIDS is using its resources

productively, that it is relevant, and that it is achieving its mission,

especially at the country level. This is particularly important because

Conclusions
Page 25 GAO-01-625 Global Health

UNAIDS’ donors have indicated that future funding increases for UNAIDS

may depend on its effectiveness in showing results at the country level.

To help UNAIDS achieve progress toward its mission and to help

demonstrate this progress, we recommend that

• the Secretary of State direct U.S. representatives on the cosponsors’

executive boards to request the respective cosponsor:

• to accelerate its efforts to integrate HIV/AIDS into the work of its

agency, and

• to hold country-level staff accountable for (1) participation in theme

groups and (2) the results of theme groups’ efforts to help host

countries combat HIV/AIDS.

• The Secretary of State and the Administrator, USAID, request that the

UNAIDS Secretariat and cosponsors improve UNAIDS’ monitoring and

evaluation efforts in order to determine the results of its overall efforts

and measure progress, especially at the country level.

We received written comments on a draft of this report from the

Department of State, USAID, and UNAIDS, which are reprinted in

appendixes IV-VI. At our request, the UNAIDS Secretariat requested and

received comments from UNAIDS cosponsors21 that were included in

UNAIDS' written comments. In addition, USAID and UNAIDS also

provided technical comments to update or clarify key information that we

incorporated, where appropriate.

USAID and the Department of State generally agreed that the program

improvements we recommended were needed. USAID stated that it found

the report to be fair and accurate and that, as a member of the U.S.

delegation to UNAIDS’ governing board, it will focus its efforts on the

recommendations and other issues cited in our report. In addition, USAID

said that it had recently provided extensive written comments to UNAIDS

on the draft U.N. System Strategic Plan 2001-2005 to help ensure that the

plan resulted in increased accountability and improvements at the country

level. While USAID said that it appreciated our acknowledgment of the

 21According to UNAIDS, seven cosponsors were provided a draft for comment; they

received comments from the U.N. Population Fund, U.N. Children's Fund, U.N.

Development Programme, and WHO.

Recommendations for

Executive Action

Agency Comments

and Our Evaluation
Page 26 GAO-01-625 Global Health

impact of external factors on UNAIDS’ progress, it noted that the lack of

bilateral government support following UNAIDS’ creation did not apply to

USAID. In responding to our recommendations, the Department of State

stated that it would instruct its delegations to encourage the cosponsors to

cooperate more fully with UNAIDS, especially at the country level. In

addition, the Department noted that our report will be of immense value to

the UNAIDS governing board-commissioned evaluation, currently in

progress, which is reviewing the entire scope of UNAIDS activities after 5

years of effort.

UNAIDS generally agreed with our findings and recommendations and

noted that the report will provide valuable input to the commission that

UNAIDS’ governing board established to review UNAIDS’ progress.

However, UNAIDS stated that our report did not give the Secretariat and

the cosponsors sufficient credit for the many accomplishments they have

made since we last reported in 1998. Accordingly, UNAIDS’ comments

detailed numerous examples of activities undertaken, including high-level

statements made, "information flows improved," documents written, and

processes improved to demonstrate further the collective

accomplishments of the Secretariat and the cosponsors since 1998. We

disagree that our report did not provide UNAIDS with sufficient credit for

its accomplishments since 1998. We believe that our report provides a fair

assessment of UNAIDS' progress. Our report affirms that UNAIDS has

contributed to increased commitments and funding for AIDS efforts by the

U.N. and national and international entities. Through UNAIDS, the

international community’s response to AIDS has broadened from one that

is focused exclusively on health to one that focuses on multiple sectors.

Further, we note the progress UNAIDS has made in providing countries

with technical support and best practices materials, tracking the epidemic,

and increasing U.N. coordination. Where there are deficiencies in

UNAIDS’ efforts—at the country level and with its monitoring and

evaluation framework—they are deficiencies that UNAIDS, the State

Department, and USAID collectively agree are in critical areas that need

improvement. While we have included, where appropriate, additional

information to address UNAIDS' comments, our overall conclusions

remain unchanged.

As arranged with your office, unless you publicly announce its contents

earlier, we plan no further distribution of this report until 15 days after the

date of this letter. At that time, we will send copies to appropriate

congressional committees; the Honorable Colin Powell, the Secretary of

State; the Honorable Andrew S. Natsios, Administrator of USAID; and the
Page 27 GAO-01-625 Global Health

Executive Director of UNAIDS. We will also make copies available to

interested parties upon request.

If you or your staff have any questions concerning this report, please call

me at (202) 512-8979. An additional GAO contact and staff

acknowledgments are listed in appendix VII.

Sincerely yours,

Joseph A. Christoff, Director

International Affairs and Trade
Appendix I: Status of the International

Partnership Against AIDS in Africa

Page 28 GAO-01-625 Global Health

Because of the catastrophic HIV/AIDS epidemic in Africa and the

inadequate national and international response, the Joint United Nations

Programme on HIV/AIDS (UNAIDS) initiated the International Partnership

Against AIDS in Africa (the Partnership) in 1999. The Partnership is made

up of African governments, the U.N., donors, the private sector,1

 and the

community sector.2

 The objective of the Partnership is to increase

coordination among the five partners and to expand their efforts against

HIV/AIDS in each African country. To achieve this objective, the

Partnership aims to establish and maintain processes through which these

groups can collaborate more effectively at the country level to curtail the

spread of HIV and sharply reduce AIDS’ impact on human suffering and

declines in human, social, and economic development. The vision of the

Partnership is that African nations with the support of the international

community will implement and sustain larger-scale, more effective

multisectoral national responses to HIV/AIDS within the next decade than

they have in the past.

According to the Partnership’s guiding document, The International

Partnership Against AIDS in Africa: A Framework for Action, dated May

2000, each partner has a specific role to play. African governments are

expected to provide national leadership and adequate resources to fight

HIV/AIDS in their respective countries. U.N. organizations are expected to

enhance U.N. coordination and the global response and to provide

program and financial support. Donors are expected to mobilize national

and international efforts and to provide the necessary financial assistance

to support the Partnership’s actions to address HIV/AIDS. The private

sector is expected to provide expertise and resources, and the community

sector is expected to enhance local ownership of the Partnership. In

addition, all partners have a role in advocacy, policy development, and

resource mobilization. The UNAIDS Secretariat facilitated the

development of the Partnership’s framework and is responsible for

 1

The Partnership defines the private sector as including diverse groups such as national

and multinational corporations, pharmaceutical firms, charitable foundations, and trade

unions.

2

The Partnership’s definition of the community sector includes national and international

nongovernmental organizations, community-based organizations, religious organizations,

traditional healers, youth organizations, women’s networks, networks of people with

HIV/AIDS, media houses, and special interest groups.

Appendix I: Status of the International

Partnership Against AIDS in Africa
Appendix I: Status of the International

Partnership Against AIDS in Africa

Page 29 GAO-01-625 Global Health

coordinating the implementation of the Partnership. The Secretariat is not

responsible for providing funding to the Partnership.

According to the UNAIDS Secretariat, the Partnership has achieved many

of its milestones and has made some progress toward achieving its

objectives. For example, one of the Partnership’s milestones was that, by

the end of 2000, at least 12 countries were to have developed national

strategic plans for HIV/AIDS, and according to the Secretariat, a total of 13

countries had achieved this goal. For example, the Partnership helped

develop the National Strategic Plan for HIV/AIDS in Ghana and Burkina

Faso and helped revise the national strategic plans of Ethiopia, Malawi,

Zambia, and Mozambique. According to the Secretariat, these plans have

resulted in the formation of wider and more effective partnerships to

combat HIV/AIDS and have encouraged increased internal and external

mobilization of financial resources. Also, the UNAIDS’ intercountry team

in eastern and southern Africa helped establish technical networks on five

subjects, including traditional medicine and AIDS counseling, and the

intercountry team in Abidjan, Cote d’Ivoire, helped establish networks on

three subjects, as expected, by December 2000. According to the

Secretariat, progress is still being made toward milestones that had not

been met as of January 2001.

However, several respondents to our survey of U.S. Agency for

International Development (USAID) missions expressed reservations

about whether HIV/AIDS-related events occurring in the country could be

directly attributed to the Partnership, since the Partnership is an

enhancement of UNAIDS’ and other partners’ ongoing efforts in Africa.

For example, USAID officials in Malawi stated that the Partnership’s

collaborative principles have been implemented in that country since 1997,

which was prior to the Partnership’s inception. The Secretariat also gives

the Partnership credit for increases in World Bank loans and bilateral

funding that have been announced by several bilateral donor countries,

including the United States, Sweden, Canada, Norway, and Japan. While

these events may have coincided with the implementation of the

Partnership, a true cause and effect relationship is difficult to establish.

Officials from USAID and the cosponsors have said that there is confusion

about the Partnership and concern about its implementation. USAID

agency officials said that the Partnership is poorly implemented and that

there is general confusion within their own and other agencies, especially

about how the Partnership will be implemented in country. For example,

they had recently spoken to one cosponsor’s representative to UNAIDS

who thought that the Partnership had ended. A member of the U.S.
Appendix I: Status of the International

Partnership Against AIDS in Africa

Page 30 GAO-01-625 Global Health

delegation to UNAIDS’ governing board told us that the Partnership

generally lacked coordination among the five partners. Several cosponsor

officials also indicated that there was confusion about the Partnership.

One cosponsor told us that the Partnership did not have much substance

beyond its guiding document and that their country-level offices in subSaharan Africa may be unaware of the Partnership. Agency officials stated

that the UNAIDS Secretariat needs to provide the Partnership with greater

leadership.

In our survey of USAID missions in African countries3 key partners in the

Partnership’s coordination efforts we asked whether the Partnership had

achieved its objective to increase coordination among the five partners

and expand their efforts against HIV/AIDS in Africa. Two of the 10

USAID/Africa missions that responded to this inquiry said that the

Partnership had resulted in better coordination, 3 said it had not, and 5 did

not know. Of those that did not know, the USAID mission in Kenya said

that the Partnership was not well understood and that they had not heard

much about it. We also asked whether the Partnership had resulted in an

expanded response to HIV/AIDS. Of the 10 responding, 4 answered yes, 3

said no, and 3 did not know. The USAID mission in Ghana reported that

the Partnership had contributed to increased media attention on HIV/AIDS

and more programs addressing the epidemic. However, the USAID mission

in Tanzania reported that the Partnership was duplicating existing national

programs and hindering constructive efforts to combat HIV/AIDS in that

country.

One factor that may contribute to the confusion and lack of coordination

among partners is that, while the framework identifies the partners, their

responsibilities, and the deadlines of some objectives and activities, it does

not identify who is responsible or accountable for initiating the

Partnership at the country level or the actions that should be taken if this

leadership is not forthcoming. For example, a respondent to our survey

from the USAID mission in Zimbabwe said that no one person or

organization is leading the Partnership at the country level and thus

nothing is being accomplished. A senior Secretariat official agreed that the

Secretariat has been weak in communicating effectively about the

Partnership. However, according to this official, the Secretariat is in the

 3

The 10 USAID missions that replied to our survey questions on the Partnership are in

Benin, Ethiopia, Ghana, Kenya, Madagascar, Malawi, Mozambique, Uganda, Zambia, and

Zimbabwe. The missions located in Eritrea and Tanzania did not answer our survey

questions but did provide general comments about the Partnership.
Appendix I: Status of the International

Partnership Against AIDS in Africa

Page 31 GAO-01-625 Global Health

process of developing additional guidance on coordination for countrylevel partners, which will be based on lessons learned by partners in

several countries, such as Burkina Faso and Tanzania, that have task

forces to lead coordination efforts. The Secretariat is in the process of

synthesizing these experiences and developing additional guidance for the

Partnership.
Appendix II: Objectives, Scope, and

Methodology

Page 32 GAO-01-625 Global Health

The Chairman of the Senate Subcommittee on African Affairs, Senate

Foreign Relations Committee, requested that we (1) assess the progress of

the Joint United Nations Programme on HIV/AIDS, especially at the

country level, toward increasing the coordination and commitment of the

U.N. and global community; (2) assess UNAIDS’ progress in providing

technical support and information and in developing a monitoring and

evaluation plan to measure results; and (3) identify factors that may have

affected UNAIDS’ progress. In addition, we were asked to provide

information on the status of the International Partnership Against AIDS in

Africa.

To identify whether UNAIDS has made progress toward increasing U.N.

coordination and commitment, especially at the country level, we

interviewed senior officials from the UNAIDS Secretariat in Geneva,

Switzerland, and the HIV/AIDS staff from each of the seven cosponsors.

We also spoke with key officials from the U.S. Agency for International

Development (USAID); the White House Office of National AIDS Policy;

Department of Health and Human Services; the State Department; U.S.

missions to the United Nations in New York City and Geneva; and Family

Health International, a U.S.-based contractor working on HIV/AIDS issues.

We reviewed extensive documentation from the Secretariat and from each

of the seven UNAIDS cosponsors, including strategic plans, annual and

biennial reports, progress reports, the Unified Budget and Workplan 2000-

2001, evaluations of the Secretariat’s and cosponsors’ HIV/AIDS programs

and activities, budget and financial data, UNAIDS governing board

documents, general HIV/AIDS program description documents, press

releases, interagency memorandums of understanding, and memorandums

to staff and major public speeches of the cosponsors’ executive directors.

We also reviewed a UNAIDS-commissioned survey of 12 of its leading

bilateral donors, issued in September 2000, that solicited perspectives on

the extent to which UNAIDS has been successful in its roles and

responsibilities. To obtain additional information on UNAIDS’ efforts at

the country level, we reviewed the Secretariat’s annual surveys of theme

group operations from 1996 to 1999. In addition, we conducted a survey of

36 USAID missions worldwide and received 27 responses1

 that provided

 1

USAID missions completed the survey or provided comments on theme groups covering

Uganda, Zimbabwe, Madagascar, Zambia, Kenya, Benin, Malawi, Ethiopia, Eritrea, Senegal,

Ghana, Mozambique, Bolivia, Guyana, Peru, El Salvador, Jamaica, Nicaragua, Honduras,

Haiti, Guatemala, Ukraine, Russia, Romania, Central Asian Region (Kazakhstan,

Kyrgyzstan, Tajikistan, Turkmenistan, Uzbekistan), Armenia, and Georgia.

Appendix II: Objectives, Scope, and

Methodology
Appendix II: Objectives, Scope, and

Methodology

Page 33 GAO-01-625 Global Health

perspectives on the theme groups’ effectiveness in assisting host country

efforts to combat HIV/AIDS. Of the total 82 USAID missions worldwide,

we selected 36 missions to survey, on the basis that they had been

involved in HIV/AIDS activities for at least 2 years.

To determine UNAIDS’ progress in providing technical support and

information and in developing a monitoring and evaluation plan to

measure results, we interviewed senior officials from the UNAIDS

Secretariat in Geneva, and key officials from USAID, the U.S. mission to

Geneva, the Department of Health and Human Services, and Family Health

International. We reviewed extensive documentation from UNAIDS,

including governing board documents reporting on annual and biennial

progress; monitoring and evaluation documents, including the Unified

Budget and Workplan 2000-2001, the monitoring and evaluation

framework, and commissioned evaluations of the Inter-country Team in

West and Central Africa; the Secretariat’s best practice materials; and the

Secretariat’s strategic planning and development fund process. We also

reviewed a UNAIDS’-commissioned survey of 12 of its leading bilateral

donors, issued September 2000, that solicited perspectives on the extent to

which UNAIDS has been successful in its roles and responsibilities, as well

as a UNAIDS biannual epidemiological report. In addition, in assessing

UNAIDS’ monitoring and evaluation efforts, we used the principles

contained in the Government Performance and Results Act of 1993 to

identify the key elements of a successful performance-based system.

To identify factors that may have affected UNAIDS’ progress, we

interviewed key officials from the UNAIDS Secretariat, cosponsors,

USAID, the Department of Health and Human Services, the State

Department, the U.S. missions to the United Nations in New York and

Geneva, and Family Health International.

To determine the status of the International Partnership Against AIDS in

Africa, we held discussions with UNAIDS Secretariat and cosponsor

officials and also with officials from USAID, the U.S. mission to the United

Nations in Geneva, and the Department of Health and Human Services. We

reviewed key documents, such as the Partnership’s framework for action,

progress reports, weekly bulletins, and meeting reports. In addition, we

reviewed an analysis completed by the Secretariat in January 2001 on the

Partnership’s progress toward its milestones, as outlined in the

framework. As part of our survey of UNAIDS’ efforts at the country level,

we asked USAID mission officials whether the Partnership had achieved

its objectives. From the 22 missions surveyed in Africa, we received 12
Appendix II: Objectives, Scope, and

Methodology

Page 34 GAO-01-625 Global Health

responses,2 10 that answered our survey questions and 2 that provided

other comments.

We conducted our work from August 2000 through May 2001 in

accordance with generally accepted government auditing standards.

 2

The 12 countries were Benin, Ethiopia, Eritrea, Ghana, Kenya, Madagascar, Malawi,

Mozambique, Tanzania, Uganda, Zambia, and Zimbabwe.
Appendix III: Cosponsors’ HIV/AIDS

Programs and Activities

Page 35 GAO-01-625 Global Health

UNAIDS is expected to bring together the efforts and resources of seven

U.N. system organizations to help prevent new HIV infections, care for

those already infected, and mitigate the impact of the pandemic. Each

cosponsor is to contribute to UNAIDS’ work according to its comparative

advantage and expertise. The following briefly describes the seven

cosponsors’ HIV/AIDS programs and selected activities, according to

information they provided.

The mission of the U.N. Children’s Fund (UNICEF) is to advocate for the

protection of children’s rights, to help meet their basic needs, and to

expand their opportunities to reach their full potential. UNICEF supports

services to the poor, rebuilds schools in war-torn societies, and promotes

equal rights for girls and women. Within UNAIDS, UNICEF is the chief

advocate for children and their families. UNICEF’s goal is to address the

underlying causes of the AIDS epidemic; reduce the vulnerability of

children, adolescents, and women to HIV/AIDS; and mitigate the impact of

disease and death due to AIDS. According to UNICEF, it supports

HIV/AIDS programs in 160 countries and focuses its efforts in five areas:

(1) breaking the conspiracy of silence about HIV/AIDS, (2) providing

primary prevention to young people, (3) reducing mother-to-child HIV

transmission, (4) caring for orphans and children living in families affected

by HIV/AIDS, and (5) supporting UNICEF staff members affected by

HIV/AIDS. For example, in the area of primary prevention to young people,

UNICEF is funding scouting groups in Cote d’Ivoire to disseminate

HIV/AIDS prevention messages through games, songs, and popular drama

and to provide counseling to their peers. In 1999, to help reduce mother-tochild transmission, 11 countries took part in a UNICEF-supported pilot

program that offers voluntary and confidential counseling and testing to

women and their partners, administers anti-retroviral medication to

pregnant HIV-positive women, and provides information about infant

feeding options. In Malawi, UNICEF has assisted the government in

developing its national orphan policy and the National Orphan Care

Programme, which emphasizes family-based care and provides support to

extended families for the care of orphans.

The goal of the U.N. Development Programme is to eradicate poverty

through sustainable human development. The Programme serves more

than 170 countries and territories around the world through 132 country

offices and technical networks. The Programme contributes to UNAIDS by

helping developing countries meet the governance challenge posed by

HIV/AIDS and by helping them mitigate the impact of the disease on the

Appendix III: Cosponsors’ HIV/AIDS

Programs and Activities

United Nations Children’s

Fund

United Nations

Development Programme
Appendix III: Cosponsors’ HIV/AIDS

Programs and Activities

Page 36 GAO-01-625 Global Health

poor. The Programme provides advice and development services to

developing country governments and civil society groups in the following

areas: (1) promoting top-level political commitment through advocacy and

policy dialogue; (2) strengthening countries’ capacity to plan, fund,

manage, and implement national responses to the HIV/AIDS epidemic; (3)

providing guidance on integrating HIV/AIDS priorities into the core of

development planning; and (4) providing policy advice to the most

affected countries on maintaining governance structures and essential

services affected by HIV/AIDS. In addition, the Programme promotes a

human rights approach that includes helping national governments

formulate anti-discrimination laws and supports public information and

media campaigns on HIV/AIDS in developing countries such as

Bangladesh, Peru, Laos, and Turkmenistan. In several sub-Saharan African

countries, the Programme is sponsoring policy studies to help

governments deal with HIV/AIDS’ impact on specific sectors, poverty

reduction efforts, and macroeconomic planning. In Botswana, the

Programme supported the publication of a National Human Development

Report that focused on how HIV/AIDS is reducing economic growth and

increasing poverty in that country.

The mission of the U.N. International Drug Control Programme is to work

with nations and people worldwide to tackle the global drug problem and

its consequences. Through its 22 field offices, the Programme contributes

to UNAIDS’s work by helping to prevent the spread of HIV through drug

abuse. The Programme’s prevention activities have focused primarily on

children and adolescents and emphasize the prevention of both drug use

and the risky sexual behaviors associated with drug use. For example, in

Brazil, the Drug Control Programme developed short prevention videos,

which are shown in the streets in regions with the highest crack use, to

target drug abuse among street children. In Thailand, in coordination with

U.N. Population Fund, the Programme is supporting activities that are

aimed at educating Muslim adolescents on reproductive health, drug abuse

prevention, and HIV/AIDS.

The mandate of the U.N. Educational, Scientific, and Cultural Organization

(UNESCO) is to foster international cooperation in intellectual activities

designed to promote human rights, establish a just and lasting peace, and

further the general welfare of mankind. UNESCO has 73 field offices and

units in different parts of the world. In the context of UNAIDS, UNESCO

focuses its efforts on five major areas: (1) education, (2) basic research,

(3) culture, (4) human rights and social and human sciences, and (5)

United Nations

International Drug Control

Programme

United Nations

Educational, Scientific,

and Cultural Organization
Appendix III: Cosponsors’ HIV/AIDS

Programs and Activities

Page 37 GAO-01-625 Global Health

public information and awareness. For example, in Brazil, UNESCO is

currently cooperating with the U.N. International Drug Control

Programme and the Brazilian Health Ministry to provide HIV education in

schools to heighten awareness of HIV and prevent its transmission. In

south Asia, UNESCO published a media handbook on AIDS in eight

different south Asian languages. UNESCO also has been active in

promoting research on AIDS in cooperation with the World Foundation for

AIDS Research and Prevention.

The primary mandate of the U.N. Population Fund is to help ensure

universal access by all couples and individuals to high-quality reproductive

health services by 2015. In developing countries, the Fund works to

improve reproductive health and family planning services on the basis of

individual choice and to formulate population policies in support of

sustainable development. The Population Fund supports HIV/AIDS

activities in 138 countries. The Fund addresses the prevention of HIV

transmission and focuses on (1) supporting information, education, and

communication programs for youth and adolescents both in and out of

schools; (2) providing young people greater access to youth friendly

reproductive health information, counseling, and services; (3) advocating

for relevant youth policies that recognize the rights of young people and

promote their reproductive health; and (4) addressing gender equity

issues. The Population Fund is the largest international supplier of

condoms and is UNAIDS’ focal point for condom programming. The Fund

manages a database on reproductive health commodities and administers

the Global Contraceptive Commodity Programme, which maintains stocks

of condoms to expedite delivery to requesting countries. The Fund also

works to promote the greater involvement of men in HIV prevention. For

example, in parts of Africa, Asia, and Central America, the Fund supports

services, information, and counseling to encourage long-distance truck

drivers to adopt safer sexual practices. In addition, the Fund has been

working with government and national partners to promote programs and

policies that advance reproductive health and well-being. For example, in

the Islamic Republic of Iran, the Fund, in conjunction with the Ministry of

Education, helped distribute 700,000 copies of a poster on HIV/AIDS

transmission and prevention along with 200,000 copies of a pamphlet

designed for teachers to schools nationwide.

WHO’s objective is to attain the highest possible levels of health by all

peoples. WHO performs a range of advisory, technical, and policy-setting

functions, including (1) providing evidence-based guidance in health; (2)

United Nations Population

Fund

World Health Organization
Appendix III: Cosponsors’ HIV/AIDS

Programs and Activities

Page 38 GAO-01-625 Global Health

setting global standards for health; (3) cooperating with governments in

strengthening national health systems; and (4) developing and transferring

appropriate health technology, information, and standards. As a UNAIDS

cosponsor and the leading international health agency, WHO works to

strengthen the health sector’s response to the worldwide HIV/AIDS

epidemic and provide technical assistance to countries to improve their

health policies, planning, and implementation of HIV/AIDS prevention and

care interventions. For example, according to WHO, it has supported and

coordinated research and provided technical support on HIV/AIDS-related

issues such as the prevention and treatment of sexually transmitted

infections, reproductive health, essential drugs, vaccine development,

blood safety, and substance use. WHO has also developed a generic

protocol for planning and implementing pilot projects to prevent motherto-child transmission of HIV in low-income countries in Africa, Asia, and

Latin America. In addition, WHO has projects in several countries with

high HIV prevalence to develop national plans and implement activities for

strengthening care and psychosocial support to people living with

HIV/AIDS. WHO is a key partner in global surveillance of HIV infection and

its behavioral determinants, including developing surveillance guidelines,

updating the global database on HIV/AIDS, and producing fact sheets and

reports on HIV/AIDS.

The mandate of the World Bank, the world’s largest source of

development assistance, is to alleviate poverty and improve the quality of

life. Through its loans, policy advice, and technical assistance, the World

Bank supports a broad range of programs aimed at reducing poverty and

improving living standards in the developing world. As a UNAIDS’

cosponsor, the World Bank provides loans and credits to national

governments to implement HIV/AIDS programs. The World Bank

committed more than $1.3 billion to 109 HIV/AIDS-related projects in 57

countries from 1986 to the end of January 2001. A recent innovation in the

Bank’s support to HIV/AIDS is its multicountry program approach to

lending. In September 2000, the World Bank approved the Multi-Country

HIV/AIDS Program for Africa, providing $500 million in flexible and rapid

funding for projects to fight the epidemic in sub-Saharan Africa.1

 A similar

multicountry program totaling about $100 million in loans and credits for

 1

The figure of $1.3 billion in commitments includes $288 million in specific country

commitments as of the end of January 2001. Adding the $500 million Multi-Country AIDS

Program for Africa would bring the Bank’s total commitment for HIV/AIDS to more than

$1.5 billion.

The World Bank
Appendix III: Cosponsors’ HIV/AIDS

Programs and Activities

Page 39 GAO-01-625 Global Health

the Caribbean is under way. To strengthen the Bank’s capacity to respond

to HIV/AIDS as a major development issue in Africa, the Bank created

ACTAfrica, a dedicated HIV/AIDS unit directly under the Office of the

Regional Vice Presidents. In addition to lending in all regions of the world,

the Bank is also involved in policy dialogue about HIV/AIDS with highlevel officials in the government and civil society. It is also working with

the U.S. Treasury to establish the International AIDS Trust Fund for

HIV/AIDS activities in those countries hardest hit by the epidemic or at

high risk of being so. The United States is providing $20 million to initially

capitalize the fund, and contributions will be sought from other donors.
Appendix IV: Comments From the Department

of State

Page 40 GAO-01-625 Global Health

Appendix IV: Comments From the

Department of State
Appendix IV: Comments From the Department

of State

Page 41 GAO-01-625 Global Health
Appendix IV: Comments From the Department

of State

Page 42 GAO-01-625 Global Health
Appendix V: Comments From the U.S. Agency

for International Development

Page 43 GAO-01-625 Global Health

Appendix V: Comments From the U.S.

Agency for International Development

Note: GAO comments

supplementing those in the

report text appear at the end of

this appendix.

Now on p. 25.
Appendix V: Comments From the U.S. Agency

for International Development

Page 44 GAO-01-625 Global Health

See comment 1.
Appendix V: Comments From the U.S. Agency

for International Development

Page 45 GAO-01-625 Global Health

Now on pp. 22 to 24.
Appendix V: Comments From the U.S. Agency

for International Development

Page 46 GAO-01-625 Global Health
Appendix V: Comments From the U.S. Agency

for International Development

Page 47 GAO-01-625 Global Health

The following is GAO’s comment on USAID’s letter dated May 11, 2001.

In commenting on our first recommendation, USAID suggested that it is

not the U.S. representatives’ role on the cosponsors’ executive boards to

“propose” initiatives to the cosponsors but rather to “request” them to take

action. We modified the recommendation to address this point.

GAO Comment
Appendix VI: Comments From the Joint

United Nations Programme on HIV/AIDS

Page 48 GAO-01-625 Global Health

Appendix VI: Comments From the Joint

United Nations Programme on HIV/AIDS

Note: GAO comments

supplementing those in the

report text appear at the end of

this appendix.
Appendix VI: Comments From the Joint

United Nations Programme on HIV/AIDS

Page 49 GAO-01-625 Global Health
Appendix VI: Comments From the Joint

United Nations Programme on HIV/AIDS

Page 50 GAO-01-625 Global Health

See comment 2.

See comment 1.
Appendix VI: Comments From the Joint

United Nations Programme on HIV/AIDS

Page 51 GAO-01-625 Global Health

See comment 4.

See comment 3.
Appendix VI: Comments From the Joint

United Nations Programme on HIV/AIDS

Page 52 GAO-01-625 Global Health

See comment 5.
Appendix VI: Comments From the Joint

United Nations Programme on HIV/AIDS

Page 53 GAO-01-625 Global Health

See comment 8.

See comment 7.

See comment 6.
Appendix VI: Comments From the Joint

United Nations Programme on HIV/AIDS

Page 54 GAO-01-625 Global Health

See comment 9.
Appendix VI: Comments From the Joint

United Nations Programme on HIV/AIDS

Page 55 GAO-01-625 Global Health

See comment 11.

See comment 10.
Appendix VI: Comments From the Joint

United Nations Programme on HIV/AIDS

Page 56 GAO-01-625 Global Health

See comment 12.
Appendix VI: Comments From the Joint

United Nations Programme on HIV/AIDS

Page 57 GAO-01-625 Global Health

See comment 13.
Appendix VI: Comments From the Joint

United Nations Programme on HIV/AIDS

Page 58 GAO-01-625 Global Health
Appendix VI: Comments From the Joint

United Nations Programme on HIV/AIDS

Page 59 GAO-01-625 Global Health

The following are GAO’s comments on UNAIDS’ letter dated May 14, 2001.

1. UNAIDS commented that they disagreed with our use of a response

from the donor survey to support our finding that their efforts at the

country level were weak. The donor survey stated that half of the donors

responding (the survey was sent to 16 of UNAIDS’ leading bilateral donors,

and 12 responded) believed that UNAIDS was not as successful as

expected in promoting broad-based political and social commitment at the

country level. We did not rely solely on the donor survey; other evidence

corroborates the donor’s concern about UNAIDS’ performance at the

country level. First, the donor survey also found that donors believed that

UNAIDS had not been as successful as they expected in strengthening

governments’ HIV/AIDS activities and ensuring that appropriate and

effective policies and strategies are implemented to address HIV/AIDS.

Second, the Secretariat’s latest annual surveys of theme groups showed

that, between 1997 and 1999, theme groups had made little progress in key

areas, such as joint advocacy action plans and developing a U. N. system

integrated plan on HIV/AIDS. Our December 2000 survey of USAID

missions showed that, after 5 years of experience, theme groups'

performance in strengthening the overall national government response to

HIV/AIDS varied widely. Third, senior UNAIDS officials and members of

the UNAIDS governing board stated in December 2000 that UNAIDS

needed to improve its country-level response. The governing board said

that the performance of UNAIDS’ theme groups required urgent attention,

and UNAIDS' Executive Director said that strengthening UNAIDS’ countrylevel efforts is one of UNAIDS’ top internal challenges. This collective

evidence demonstrates that UNAIDS must strengthen its efforts at the

country level.

2. While UNAIDS agreed with our finding that country-level efforts need

to be strengthened, it also commented that we placed too much emphasis

on theme group efforts at the country level without considering broader

U.N. systemwide efforts. We recognize that there are broader U.N. efforts,

such as the Resident Coordinator System and the Common Country

Assessment/United Nations Development Assistance Framework process.

However, UNAIDS’ documents state that UNAIDS’ theme groups are its

“main mechanism” for coordinating HIV/AIDS activities at the country

level. Our analysis therefore focused on this mechanism.

3. UNAIDS commented that we did not credit the U.N. Development

Programme for actions taken as a result of an HIV/AIDS program

evaluation, prepared in 2000, which found that the agency had not fully

GAO Comments
Appendix VI: Comments From the Joint

United Nations Programme on HIV/AIDS

Page 60 GAO-01-625 Global Health

integrated HIV/AIDS into its strategies, programs, and activities. We

revised the report to include updated information on action taken in

response to the evaluation.

4. UNAIDS was concerned that we did not reflect the cosponsors’

creation of new positions and units focused on HIV/AIDS and cited

numerous examples of these changes. While we may not have cited every

example of actions taken by the cosponsors, we did recognize that some

cosponsors had elevated the position of the HIV/AIDS issue

organizationally and provided an example. We revised the report to

include an additional example of steps taken by the U.N. Children’s Fund.

5. UNAIDS commented that, while they agreed that country-level

coordination and implementation needs strengthening, we had

downplayed how much progress the United Nations has achieved in

coordinating action at the country level. UNAIDS stated that we did not

sufficiently credit them for the Global Strategy Framework, regional

strategy development processes, partner programme reviews, improved

cosponsor responses to HIV/AIDS, and a greater understanding of the

epidemic at the country level. UNAIDS comments also provided additional

examples of activities they believed contributed to an enhanced countrylevel response. We disagree that we downplayed UNAIDS’ efforts. For

example, our report credits UNAIDS for facilitating the development of

U.N. System Strategic Plan and conducting the detailed reviews of the

cosponsors’ HIV/AIDS programs (Partner Programme Reviews), as well as

for the cosponsors’ improved commitment and response to HIV/AIDS. The

report does not discuss the Global Strategy Framework on HIV/AIDS

because it has only recently been finalized and thus it is too soon to gauge

whether this document will increase international commitment, action, or

results. Also, in the absence of an effective monitoring and evaluation plan

that has clear performance indicators, it is difficult to isolate UNAIDS

contributions from those of the many entities working at the country level

to combat HIV/AIDS, including national governments, bilateral donors,

nongovernmental organizations, and foundations.

6. UNAIDS stated that we characterized theme group responsibilities too

broadly and that it was never envisioned that U.N. theme groups would

serve as an operational entity or as the primary mechanism for assisting

developing countries. Our report clearly explains the role of the theme

groups in the background section and elsewhere as, among other things, a

facilitator for coordinating the U.N. response at the country level. This

characterization came from UNAIDS documents that state: “In developing

countries, UNAIDS operates mainly through the country-based staff of its
Appendix VI: Comments From the Joint

United Nations Programme on HIV/AIDS

Page 61 GAO-01-625 Global Health

seven cosponsors. Meeting as the host country’s U.N. Theme Group on

HIV/AIDS, representatives of the cosponsoring organizations share

information, plans and monitor coordinated action....”

7. UNAIDS commented that theme groups are not responsible for

resource mobilization. However, UNAIDS provided us the Resource Guide

for Theme Groups, which devotes one of its five sections to resource

mobilization. This section states that “resource mobilization at the country

level is a key role of the Theme Group.” To avoid any confusion, we

modified the text.

8. UNAIDS noted that our report lacked clarity with regard to the role of

the Country Programme Advisor and the operation of the Programme

Acceleration Funds. To avoid any confusion about the Country

Programme Advisor’s role, we modified the text. The information we

presented in the report on the operation of the Programme Acceleration

Funds was taken directly from UNAIDS documents—primarily the 1999

evaluation of the funding process.

9. UNAIDS provided information on the additional number of integrated

U.N. workplans that have been prepared, to demonstrate the progress

theme groups have made in developing a more unified U.N. response to

HIV/AIDS. However, we were not able to corroborate this information. In

addition, while the information UNAIDS presented shows the number of

workplans completed, it does not indicate the quality and content of the

plans and the extent to which they have been implemented.

10. UNAIDS provided more current information on action taken to

strengthen the performance of theme groups and Country Programme

Advisors--the Secretariat’s country-based staff. We revised the report to

highlight some of these actions.

11. UNAIDS stated that the Unified Budget and Workplan 2000-2001

includes quantifiable performance targets. However, UNAIDS did not

provide specific examples of such targets with its comments. In examining

UNAIDS’ Unified Budget and Workplan in detail during our review, we

noted that it contained outcome indictors. However, the workplan did not

identify specific performance baselines, targets, or other measures that

would enable UNAIDS to determine whether it had succeeded in its efforts

and measure progress toward its objectives.

12. UNAIDS commented that its overall monitoring and evaluation plan

included several one-time evaluations of specific efforts, such as UNAIDS’
Appendix VI: Comments From the Joint

United Nations Programme on HIV/AIDS

Page 62 GAO-01-625 Global Health

development of best practices. We revised the report to clarify that

UNAIDS considers these one-time evaluations part of its overall

monitoring and evaluation plan.

13. UNAIDS raised several concerns about the report’s methodology and

presentation. First, UNAIDS commented that the report focused too much

on the findings contained in our 1998 report and did not adequately credit

UNAIDS for the progress it has made. We disagree. We believe we have

given credit to UNAIDS for progress in a number of areas, several of which

were of specific concern in our 1998 report. For example, the report

highlights increased U.N. and international commitment and funding to

HIV/AIDS efforts, as well as a broadened approach to addressing HIV/AIDS

from one that was exclusively health oriented to one that is now

multisectoral. Further, the report notes the progress made on technical

support and best practices, tracking the epidemic, and increasing U.N.

coordination. However, our report also focused on those areas most

needing improvement—namely, UNAIDS’ country-level efforts and

monitoring and evaluation of UNAIDS’ progress and results. These are

areas that the Department of State, USAID, and UNAIDS agree need

improvement. Where appropriate, we have modified our report and

included some additional information.

Second, UNAIDS commented that the report will be out of date by the time

it is issued. We disagree. The changing political climate surrounding

HIV/AIDS issues does not negate the report’s conclusions and

recommendations. For example, UNAIDS’ comments stated that not only

did they agree that HIV/AIDS-related efforts at the country level need

strengthening but that these efforts will certainly remain the central theme

for “at least the next decade.” Furthermore, the current debate to establish

a $7 billion to $10 billion global trust fund to address the HIV/AIDS crisis

in developing countries makes the issues cited in our report even more

timely and critical. The challenges UNAIDS faced in mobilizing

international support for HIV/AIDS efforts, marshalling donors’ financial

commitments, and establishing a system to evaluate program results are

important lessons learned that should inform the current debate on a new

global AIDS trust fund. UNAIDS’ comments also noted that documentation

used to support the report was largely constructed with data compiled

from the previous year. We used the most current data supplied by

UNAIDS and other information to conduct our analysis, including several

of UNAIDS’ and its governing board’s commissioned evaluations. In

addition, we conducted our own survey of USAID missions to obtain

perspective on UNAIDS’ country-level efforts in December 2000.
Appendix VI: Comments From the Joint

United Nations Programme on HIV/AIDS

Page 63 GAO-01-625 Global Health

Third, UNAIDS noted that the report contained selective quotations from

several of UNAIDS’ evaluations and surveys of specific functions, at the

same time pointing out that UNAIDS’ monitoring and evaluation efforts are

insufficient. We believe our use of available data and information

contained in UNAIDS’ evaluations was appropriate for depicting the steps

taken in and weaknesses of UNAIDS’ efforts. However, while this

information was useful, it does not provide the results of UNAIDS’ overall

efforts or progress made toward its objectives. With bilateral and other

donors responding to UNAIDS’ call for increased resources to combat

HIV/AIDS, a quality monitoring and evaluation effort, which includes a

clearly defined mission, long-term strategic and short-term goals,

measurement of performance against defined goals, and public reporting

of results, is even more important.
Appendix VII: GAO Contact and Staff

Acknowledgments

Page 64 GAO-01-625 Global Health

John Hutton (202) 512-7773

In addition to Mr. Hutton, Leslie Bharadwaja, Sharon Caudle, Lynn

Cothern, Francisco Enriquez, Aleta Hancock, Lynne Holloway, Stanley

Kostyla, and Hector Wong made key contributions to this report.

Appendix VII: GAO Contact and Staff

Acknowledgments

GAO Contact

Acknowledgments

(711538)
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