Global Health: Joint U.N. Programme on HIV/AIDS Needs to Strengthen Country-Level Efforts and Measure Results
Released: 2001-06-08T00:00:00

Letter

Background

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 issues contributing to the spread of the virus. They realized that WHO’s medically based approach was insufficient to effectively combat the virus. In response, the United Nation’s Economic and Social Council 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. UNAIDS is comprised of a Secretariat and seven U.N. cosponsors that act at the global, regional, and country levels. UNAIDS’ Programme Coordinating Board 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 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.

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, 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 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 Coordination and Commitment to HIV/AIDS, but Country-Level Efforts Need Strengthening

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.

UNAIDS Has Worked to Improve U.N. Coordination and the International Community’s Commitment and Approach to HIV/AIDS

According to the UNAIDS governing board, the success of UNAIDS is highly dependent on collaboration within the U.N. system. However, half of UNAIDS’ donors 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’ 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 senior- level 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.

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’s 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 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. 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.

U.N. and Bilateral Donor Funding for HIV/AIDS Has Increased

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.

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 funds 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 increases in contributions to the agency from 1999 to 2000, but these increases were neutralized by the exchange rate.

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. 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.

UNAIDS’ Country-Level Efforts Need Strengthening

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 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.

UNAIDS’ Donors and Senior Officials Believe Country-Level Efforts Are Weak

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.

Theme Groups’ Performance Varies and Accountability for Results is Limited

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. 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 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.

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 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.

UNAIDS’ Country Programme Advisors Have Not Been as Effective as Expected

According to U.S. officials and officials from both the UNAIDS Secretariat and cosponsors, Country Programme Advisors—the Secretariat’s country- based 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.

Theme Groups and Advisors Are Not Actively Submitting Funding Proposals for Country- Level Activities

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 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, 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 Has Made Mixed Progress in Improving Technical Support, Best Practices, and Other Information to Enhance the Response to the Pandemic

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.

UNAIDS Has Made Some Progress Improving Technical Support and Best Practices Materials

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.

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 evaluation of the effectiveness, 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.

UNAIDS Has Made Some Progress in Tracking the Pandemic but Has Encountered Difficulties in Tracking Response

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 Project 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’ Monitoring and Evaluation Efforts Need Improvement

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, we used the principles laid 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.

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.

Key Factors Have Hindered UNAIDS’ Progress

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 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 Secretary- General, 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.

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.

Conclusions

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 UNAIDS’ donors have indicated that future funding increases for UNAIDS may depend on its effectiveness in showing results at the country level.

Recommendations for Executive Action

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.

Agency Comments and Our Evaluation

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 cosponsors 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 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 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.

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

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, and the community sector. 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 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. 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 sub- Saharan 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 countries 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 process of developing additional guidance on coordination for country- level 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

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 responses that provided 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 responses, 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.

Appendix III: Cosponsors’ HIV/AIDS Programs and Activities

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.

United Nations Children’s Fund

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-to- child 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.

United Nations Development Programme

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 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.

United Nations International Drug Control Programme

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.

United Nations Educational, Scientific, and Cultural Organization

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) 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.

United Nations Population Fund

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.

World Health Organization

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) 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 mother- to-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 World Bank

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. A similar multicountry program totaling about $100 million in loans and credits for 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 high- level 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

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

GAO Comment

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.

Appendix VI: Comments From the Joint United Nations Programme on HIV/AIDS

GAO Comments

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’ country- level 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 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 country- level 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 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’ 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.

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

GAO Contact

Acknowledgments

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.