From Three Ones to Actions

This memorandum is prepared for UNAIDS Executive Director, Peter Piot. It’s to have some innovative ideas and to revitalize the HIV/AIDS campaign worldwide. In this memorandum, I will expose the progress and the challenges that we face right now. Then, I will recommend mainly two changes. Firstly, I propose Cross-Sectoral Partnership Meeting to enhance UNAIDS’ coordination objectives. Secondly, I think that UNAIDS should reinvent itself to have a better command on the tasks. In the final part, I will suggest several ways to achieve the recommendations. UNAIDS will need the resources and the support from the US to convene the Cross-Sectoral Partnership Meeting. While UNAIDS reinvents itself to achieve the “Three Ones”, UNAIDS needs to let US assume the hegemony responsibility in many aspects of the combat.

Newest development of the fight against HIV/AIDS
November 21st, UNAIDS and WHO published their annual report on HIV/AIDS, The AIDS Epidemic Update-Special Report on HIV Prevention. In this report, the progress and the challenges are examined country by country, under a regional category. According to the report, the sub-Saharan Africa is still the most hit region in the world. Only Uganda is making some progress. The percentage of HIV/AIDS adult prevalence is still 7.2%.

The MDGs, regardless of their achievability, will not be achievable in Africa if the situation of HIV/AIDS will not improve. According to African Studies Center, 2003, poverty is a key factor leading to behaviors that expose people to the risk of HIV infection. Moreover, poverty exacerbates the impact of HIV/AIDS. Department of Economic and Social Affairs published the report, Population, Development and HIV/AIDS with Particular Emphasis on Poverty, show that AIDS-affected countries present relatively poor socio-economic indicators, which is especially true for the AIDS-affected African countries. In Africa, a little more than half of the population has access to improved sanitation and less than two thirds to an improved water source. The response to HIV/AIDS is more the the response itself due to its correlation with the poverty and development. So, how can the UNAIDS change its format to meet the demand of the MDGs?

The progress of the combat
The good news is that we are making progress on the prevention and the treatment. There are actually many progresses in the field of HIV/AIDS compared to others.

First of all, the more we know about the nature and scope of HIV/AIDS, the more efforts we could make. The society is more and more conscious about the HIV. Scholars also try to see the HIV/AIDS in another way: global public goods. Although the use of the HIV/AIDS antiviral treatment is private goods, the effect of the usage is global public goods. More and more countries are aware of this epidemic, and there are more and more special agencies dealing with this specific disease, such as the unilateral efforts of US President’s Emergency Plan for AIDS Relief.

Second, in September 2003, the “Three Ones” principles are agreed among the countries. One agreed HIV/AIDS Action Framework that provides the basis for coordinating the work of all partners. One National AIDS Coordinating Authority, with a broad based multi-sector mandate. One agreed country level Monitoring and Evaluation System. Three Ones are supposed to coordinate the national response to HIV/AIDS. This is a big breakthrough.

Thirdly, WTO members just agreed on a change in WTO intellectual property rules to facilitate the poor countries to import cheap copies of life-saving drugs. This very important development belongs to the “development package” for poor countries, which will need to be approved in Hong Kong next week. The least developed countries will have until 2013 to implement the intellectual property rules and until 2016 for the patents on pharmaceuticals. This would help the African countries to reach a better coverage on HIV/AIDS patients.

UN’s systemic problems
However, all these progresses don’t translate to the ultimate success. These progresses would be mediocre under the surface if we take a second look. There are still many challenges.

In the Final Outcome Document this fall, the world leaders admit the importance of system-wide coherence in paragraph 168. In paragraph 169, there are four fields that require more system-wise coherence: policy coherence, operational activity coherence, humanitarian assistance coherence and environmental activity coherence. Out of these four, policy and operational activities are considered to be the most serious flaws within the HIV/AIDS community.

The organizational coherence within HIV/AIDS organizations
 More agencies, more efforts≠ more efficiency
There are many actors on the stage. The ten UNAIDS Cosponsors are: The Office of the United Nations High Commissioner for Refugees (UNHCR), United Nations Children's Fund (UNICEF), World Food Programme (WFP), United Nations Development Programme (UNDP), United Nations Population Fund (UNFPA), United Nations Office on Drugs and Crime (UNODC), International Labour Organization (ILO), United Nations Educational, Scientific and Cultural Organization (UNESCO), World Health Organization (WHO), World Bank. Besides the ten UN agencies to deal with epidemic, there are many grassroots groups and NGOs, such as AVERT. There are also respective efforts by individual country, i.e. US President’s Emergency Plan for AIDS Relief. There are also efforts from WTO; however, WTO does not include in the coordination force. Hence, from this observation, we have two organizational problems.

More participating agencies don’t lead to a more efficient way to find a better prevention and treatment. The world recognizes the number of actors is huge and also realizes the importance of coordination. Therefore, UNAIDS was founded in 1996. Due to a recent growing commitment to an effective response to the epidemic, global funding for AIDS has increased 15-fold ever since. The funding is about US $6.1 billion in 2004. However, is this coordination program able to solve the problem of coordination in the combat against the HIV/AIDS? The success is still unclear, but we can see clearly the unsolved problems lying on the road.

Despite the existence of UNAIDS, the coordination within the UN system at country level is not working well. Countries are facing different standard and paper work while dealing with different organizations, which, I believe, is due to the individual organizational behavior of the involving organizations. The organizations tend to differentiate from others to gain more attention because the organizations all want to justify their existence. Moreover, every organization has a different SOP, and this leads to a very different way to handle the problems. Countries thus tend to engage these organizations separately. They don’t have a universal entry point to all the help provided by the UN system. This signifies the misuse of time ad resource.

Another problem which I think as a missing link is that WTO is not one of the cosponsor of UNAIDS. Indeed, the perfect first step to coordinate the UN HIV/AIDS activities would be an attempt to coordinate only the UN agencies. It was in 1996 and now it’s not enough. The fight against the HIV needs WTO because there are many aspects regarding the private sector. WTO is a very important actor because of the role that it can play during the negotiations between the HIV-affected countries and the drug companies.

Case study: Uruguay and drug company negotiations
 The successful negotiations between the drug company and the 11 Latin American countries
Negotiations between 11 Latin American governments and 26 pharmaceutical companies on price reductions for antiretrovirals, the drugs used to fight HIV/AIDS, resulted in a 15 to 55 percent price reduction for the treatment regimens most commonly used in the Region. The cost of a basic treatment regimen (AZT+3TC+NVP), which was US$ 350 per year per patient in 2003 at standard pharmaceutical industry prices, could be as low as US$ 241.

This was an historic negotiation, marking the first time that a group of countries decided to bypass the industry’s high prices through large-scale drug purchases, thus benefiting more than 1.5 million people living with HIV/AIDS in Latin America. The negotiations -- which will benefit Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Mexico, Paraguay, Peru, Uruguay, and Venezuela – were conducted by the countries’ Ministries of Health, with support from the Pan American Health Organization (PAHO). Representatives of six associations of people living with HIV, civil society, and the Clinton Foundation also participated.

 The role of UNAIDS: Be more proactive!
The world knows the urgency of getting everyone the treatment, and the world also knows that this success of drug price negotiations can be duplicated in another region. However, the costs of negotiations are sometimes not affordable for the Sub-Saharan countries. The UN system and WTO should help African countries to do the same. The negotiations would be much easier if UNAIDS can participate and advocate this concept of public goods.

 The legitimacy of UNAIDS and its effectiveness
UNAIDS’ legitimacy is based on its capability to brings together the efforts and resources of ten UN system organizations to help the world prevent new HIV infections, care for those already infected, and mitigate the impact of the epidemic. However, the legitimacy of the UNAIDS is threatened.

UNAIDS is guided by a Programme Coordinating Board with representatives of 22 governments from all geographic regions, the UNAIDS Cosponsors, and five representatives of nongovernmental organizations (NGOs), including associations of people living with HIV/AIDS. Who is the real leader within UNAIDS? When the public and the countries don’t have a clear cut answer, they don’t know which guidance to follow and it can be confusing. Just as a carriage led by several horses running in different directions, UNAIDS’ internal disorder might trigger the international dysfunctions to respond the epidemic in time.

Indeed, Three Ones can make the harmonization better. However, the proposals in Three Ones are still vague. How should the UN agencies translate these affirmations into the real practices? This is a difficult undertaking. In “Three Ones” principle 2, the recommendation is that a national authority is to be established. One of this National AIDS Coordinating Authority’s mandates is to provide domestic oversight. It is also supposed to include the whole civil society. Yet the specific relationship between the government legislature, the international organizations and the NGOs remains undefined.

Case study: Condom use in Thailand
 The campaign in Thailand and the future challenges

The 100% Condom Program started in 1991. This was a public health effort to reduce sex with prostitutes and promote condom use. A five-year educational campaign to increase condom use in Thailand has led to a fivefold decrease in HIV infection among young army draftees in northern Thailand and a tenfold decrease in sexually transmitted diseases (STDs) overall, according to Johns Hopkins research conducted in 1998.
The key of success was the depenalization/legalization of prostitution, the law to require the 100% condom utilization by female sex workers, the nation-wide awareness program via school and workplace training, and the NGO participation to reach the target group. The results: the condom utilization rates by female sex workers rose from 20% in 2000 to 60% by 2004.
However, the challenge is now how to revamp the safe sex programs and adapt to recent development.
 How can we apply this success to the multilateral actions?

This success at the first stage makes Thailand the example for other East Asian countries. Thai government’ program would, if copied, lead to significant decreases in the rates of AIDS and STDs in other Asian countries. How can we duplicate the case?

As we can observe from this case, the legislative plus the NGOs work well to achieve the expected results. UNAIDS is the first United Nations programme to include NGOs in its governing body. Through this example, we should encourage more NGO participation for new ideas and human resources in UN system as well as at country level.

Recommendations
This leads to my recommendation. The UNAIDS needs to provide a linkage between the norm-promoting and more proactive role in field work.

The UNAIDS needs to prove its credibility although it’s not a brand new organization. UNAIDS, when created, meant to harmonize the organizations; UNAIDS is not one agency amongst the others. It should emphasize its role in “valid and effective coordination”.

About policy coherence: Cross-Sectoral Partnership Meeting
I recommend that UNAIDS could reaffirm its legitimacy through hosting an annual meeting, Cross-Sectoral Partnership Meeting , among the IGOs, governments and NGOs. There are two justifications.

First, although the Programme Coordinating Board meets every year and has a thematic meeting every two years, it’s not enough for a larger scale of partnership to take place, and it’s what UNAIDS should have achieved. The participating members are still of small numbers of the global actors. Through the enlarged meeting, the policy of each international organization would reach to a more harmonious level, which will in turn save much time for the countries.

Second, the cross-sectoral partnership could be more easily established through a rally of whole range organizations. UNAIDS, as the one who has the buck, should have a holistic view of the progress and assume the “experience broker” job. For example, Mexico can apply the Thai model to its Mexico-US border. Thai model has been regarded as a pan-Asian model, and Caribbean seems to be Latin American model. However, through studies, we can see the linkage between Thai government campaign and a new way to tackle the disease in northern Mexico. If there is no such an exchange of information, the countries and NGOs would only get this information later. Hence, UNAIDS can build the bridge between the experienced and the in-need via the Cross-Sectoral Partnership Meeting.

About organizational reform: Redefining the leader
Does a new creation of a coordination team help to organize the activities? Will a coordination team above the coordination teams terminate the innate problem of UNAIDS? More agencies are not equal to a faster solution; it is, thus, unreasonable to create another mechanism to complete the coordination family. UN system has already too many mechanisms to do the same thing.

I recommend that UNAIDS could reestablish its reputation through an internal reform of the governing body. The determination of the internal leader of UNAIDS would provide a stronger UNAIDS leadership at international level. UNAIDS would need to have a stronger appearance to guide the others.

The respective functions of the UN Resident Coordinator, the Chair of the UN Theme Group and the UNAIDS Country Coordinator could be defined in a better way. Their respective functions have a clear cut on paper work, but in the real world, they are overlapping and confusing. Priority is to assure these three to form a hierarchy in order to work properly. Secretary-General Kofi Annan could ask to have UNAIDS governing body to be reviewed if it’s too difficult to determine.

Strategies
The first step to achieve a better operational and policy coordination will be to have the US and Japan funding first. The US is the biggest donor in the world. Right now the funding is at 9 billion $ next year, but we will need more money to resuscitate the remaining programs and to start new initiatives to alter the HIV/AIDS new infection rates. Only when we solve the funding problem, can we address more people susceptible to HIV/AIDS. The funding of UN from US and Japan is so important that we have to adjust the mismanagement right now. If UNAIDS can show the donors and the participating partners the willpower to reform, UN as a whole will also have a better organizational image. Hence, UN would have a bigger chance to counter the US-Japan blocking of budget.

US President George W. Bush's Emergency Plan for AIDS Relief is the largest international health initiative any nation has ever undertaken directed at a single disease -- a five-year, $15 billion, multifaceted approach to combat HIV/AIDS in 123 countries around the world. The mission of the Emergency Plan is to work with leaders throughout the world to combat HIV/AIDS, promoting integrated prevention, treatment, and care interventions, with an urgent focus on countries that are among the most afflicted nations of the world. However, there are some debates on the USA-Africa unilateralism. UNAIDS should keep track of US multilateral funding and make sure that the resources are allocated in a more efficient way. Moreover, since this plan is a five-year plan. UNAIDS also needs to make sure that US will continue to provide this public goods to the world. USAIDS would need to persuade US that US, as hegemony, should lead the rest of the world to fight against the disease. US have the technology to develop the drug and also have the power to influence the negotiations if this nation wants to. US do not do this right now although they have this relief plan.

After the funding and the leadership, the form of Cross-Sectoral Partnership Meeting could be like Global Health Council. Unlike the Global Health Council, the Cross-Sectoral Partnership Meeting will only focus on HIV/AIDS.

Conclusion
There is good news in the field, and there are also obstacles which hinder UNAIDS from a better harmonization.
As UNAIDS is convening the meeting on HIV/AIDS treatment options in January, the approaches to providing access are recommended by the group includes country-specific strategies; goals include strict timelines and milestones, clear assignments of responsibilities, elimination of bureaucratic holdups and increased cooperation. It would be a perfect chance to show UNAIDS is well placed to coordinate the war against the outbreak of AIDS.

Bibliography

Réformer les Nations Unis, « Le Monde Diplomatique ». No. 618, 52nd year, September 2005.
Aspirations and obligations, The Economist. September 8th 2005. http://www.economist.com/finance/displayStory.cfm?story_id=4385253
Bolton cuts poverty out of UN World Summit. August 31st, 2005
http://www.netaid.org/press/news/page.jsp?itemID=27265170
Department of economic and social affairs. Population, Development and HIV/AIDS with Particular Emphasis on Poverty. UN publication, June 2005.
Resolution of the General Assembly. 2005 World Summit Outcome. 16 September 2005.
Human Development Report 2005.
Materials from the Global Issues Seminar Series in World Bank, October 2005.
The MDG and the role of the United Nations. 2002.
The World Bank Group Poverty Net

UNAIDS. The “Three Ones ” in Action: where we are and where we go from here. May 2005.
UN Millennium Development Goals
http://www.un.org/millenniumgoals/