Global Health: Joint U.N. Programme on HIV/AIDS Needs to	 
Strengthen Country-Level Efforts and Measure Results (25-MAY-01, 
GAO-01-625).							 
								 
Despite efforts by the international community to reduce the	 
spread of the human immunodeficiency virus, AIDS is now the	 
fourth leading cause of death in the world and the primary cause 
of death in sub-Saharan Africa. The Joint United Nations	 
Programme on HIV/AIDS (UNAIDS), funded in part by the United	 
States, is one important international effort against the	 
disease. UNAIDS was established by the United Nations (U.N.) in  
1996 to provide coordinated U.N. action and to lead and promote  
an expanded global response to the worldwide epidemic. This	 
report (1) assesses UNAIDS' progress, especially at the country  
level, toward increasing the coordination and commitment of the  
U.N. and global community; (2) assesses UNAIDS' progress in	 
providing technical assistance and information and in developing 
a monitoring and evaluation plan to measure results; and (3)	 
identifies factors that may have affected UNAIDS' progress. GAO  
found that UNAIDS has made progress in increasing U.N.		 
coordination and enhancing the global response to the worldwide  
HIV/AIDS epidemic, but its country-level efforts need to be	 
strengthened. UNAIDS has  provided financial and technical	 
support to about 50 HIV/AIDS technical networks worldwide, but	 
has not been as successful in tracking the funding and actions	 
host governments and others have taken to address the AIDS	 
problem. UNAIDS has also been unable to follow its intended model
of U.N. reform, whereby a single Secretariat together with	 
several U.N. agencies would marshal the U.N. and global 	 
community's resources to address the AIDS epidemic.		 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-01-625 					        
    ACCNO:   A00967						        
  TITLE:     Global Health: Joint U.N. Programme on HIV/AIDS Needs to 
             Strengthen Country-Level Efforts and Measure Results             
     DATE:   05/25/2001 
  SUBJECT:   Acquired immunodeficiency syndrome 		 
	     Foreign aid programs				 
	     Health care programs				 
	     International cooperation				 
	     International organizations			 
	     Sexually transmitted diseases			 
	     Abidjan (Ivory Coast)				 
	     Africa						 
	     AIDS						 
	     Botswana						 
	     Canada						 
	     Ethiopia						 
	     Ghana						 
	     South Africa					 
	     Tanzania						 
	     Thailand						 
	     Uganda						 
	     UN Children's Fund 				 
	     UN Development Program				 
	     UN International Drug Control Program		 
	     UN Joint Program on HIV/AIDS			 
	     UN Population Fund 				 

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GAO-01-625
     
Report to the Chairman, Subcommittee on African Affairs, Committee on
Foreign Relations, U. S. Senate

United States General Accounting Office

GAO

May 2001 GLOBAL HEALTH Joint U. N. Programme on HIV/ AIDS Needs to
Strengthen CountryLevel Efforts and Measure Results

GAO- 01- 625

Page i GAO- 01- 625 Global Health Letter 1

Appendix I Status of the International Partnership Against AIDS in Africa 28

Appendix II Objectives, Scope, and Methodology 32

Appendix III Cosponsors? HIV/ AIDS Programs and Activities 35

Appendix IV Comments From the Department of State 40

Appendix V Comments From the U. S. Agency for International Development 43

Appendix VI Comments From the Joint United Nations Programme on HIV/ AIDS 48

Appendix VII GAO Contact and Staff Acknowledgments 64

Table

Table 1: UNAIDS Cosponsors' Estimated Spending for HIV/ AIDS, 1996- 1999 12

Figure

Figure 1: Structure of UNAIDS 6 Contents

Page ii GAO- 01- 625 Global Health Abbreviations

HIV/ AIDS Human Immunodeficiency Virus/ Acquired Immunodeficiency Syndrome
U. N. United Nations UNAIDS Joint United Nations Programme on HIV/ AIDS
UNESCO U. N. Educational, Scientific, and Cultural Organization UNICEF U. N.
Children?s Fund USAID U. S. Agency for International Development WHO World
Health Organization

Page 1 GAO- 01- 625 Global Health

May 25, 2001 The Honorable Bill Frist Chairman, Subcommittee on African
Affairs Committee on Foreign Relations United States Senate

Dear Mr. Chairman: Despite efforts by the international community to reduce
the spread of Human Immunodeficiency Virus/ Acquired Immunodeficiency
Syndrome (HIV/ AIDS), AIDS is now the fourth leading cause of death in the
world and the primary cause of death in sub- Saharan Africa. According to
the Joint United Nations Programme on HIV/ AIDS (UNAIDS), more than 36
million people are living with the virus worldwide, and more than 21 million
have died since 1980. Furthermore, given the scale of the pandemic, HIV/
AIDS has grown beyond a public health problem to become a humanitarian and
developmental crisis. For example, the U. S. National Intelligence Council 1
concluded that the persistence and spread of infectious diseases, such as
HIV/ AIDS, are likely to aggravate and, in some cases, provoke economic
decline, social fragmentation, and political destabilization. In 2000, the
United States classified HIV/ AIDS as a threat to national security, and the
Congress approved approximately $466 million for international HIV/ AIDS
efforts in 2001.

UNAIDS, funded in part by the United States, is one important international
effort against HIV/ AIDS. UNAIDS was established by the U. N. in 1996 to
provide coordinated U. N. action and to lead and promote an expanded global
response to the worldwide epidemic. The organization was charged with
providing technical support and information, including best practices,
epidemiological data, and other information on the national and
international response to HIV/ AIDS. UNAIDS was also expected to evaluate
the progress made toward achieving its mission. UNAIDS is made

1 The Global Infectious Disease Threat and Its Implications for the United
States, No. NIED 99- 17 of the National Intelligence Estimates (Washington,
D. C.: National Intelligence Council, Jan. 2000).

United States General Accounting Office Washington, DC 20548

Page 2 GAO- 01- 625 Global Health

up of a Secretariat and seven U. N. cosponsors 2 with individual
responsibilities that are to work together to achieve UNAIDS? mission. We
reported in 1998 that UNAIDS had made limited progress toward achieving its
mission. 3 We found that U. N. cosponsors had not increased funding to
integrate HIV/ AIDS into their programs as expected and that UNAIDS had not
been effective in coordinating the U. N. response at the country level or in
helping developing countries respond to the worldwide epidemic. In January
1999, UNAIDS launched the International Partnership Against AIDS in Africa
to enhance national and international efforts against the epidemic in
Africa.

This letter responds to your request that we examine UNAIDS? progress in
achieving its mission since we last reported in 1998. In this report, we (1)
assess UNAIDS? progress, especially at the country level, toward increasing
the coordination and commitment of the U. N. and global community; (2)
assess UNAIDS? progress in providing technical support and information and
in developing a monitoring and evaluation plan to measure results; and (3)
identify factors that may have affected UNAIDS? progress. In addition, you
asked us to provide information on the status of the International
Partnership Against AIDS in Africa. (See appendix I for the status of this
Partnership.)

To examine UNAIDS? progress, we interviewed key Secretariat, cosponsor, and
U. S. officials. We reviewed extensive UNAIDS? documentation, including
progress reports, governing board documents, annual surveys of country-
level operations, external evaluations of several of UNAIDS' functions, and
a UNAIDS survey of 12 of its leading bilateral donors published in 2000. We
also conducted a survey of U. S. Agency for International Development
missions, which are key partners in the global response, to obtain
perspectives on UNAIDS' HIV/ AIDS efforts at the country level. Appendix II
provides a more detailed description of our objectives, scope, and methods.

2 The seven cosponsors are the United Nations Children?s Fund; United
Nations Development Programme; United Nations Population Fund; United
Nations International Drug Control Programme; United Nations Educational,
Scientific, and Cultural Organization; World Health Organization; and the
World Bank.

3 HIV/ AIDS: USAID and U. N. Response to the Epidemic in the Developing
World (GAO/ NSIAD- 98- 202, July 1998).

Page 3 GAO- 01- 625 Global Health

Since we last reported in 1998, UNAIDS has made progress in increasing U. N.
coordination and enhancing the global response to the worldwide HIV/ AIDS
epidemic; however, its efforts at the country level need strengthening.
UNAIDS is developing a strategic plan for coordinating the U. N. ?s overall
response to the HIV/ AIDS problem and has helped shift the global
community?s response to HIV/ AIDS from an exclusively healthoriented
perspective to a multisectoral approach that addresses the various
ramifications of high rates of HIV/ AIDS on a country?s development. Most
importantly, U. N. and bilateral donors have increased their funding for
HIV/ AIDS. However, these successes have been partly offset by the inability
of UNAIDS? cosponsors to fully integrate HIV/ AIDS into their programs and
activities and by UNAIDS? weak efforts at the country level. The in- country
representatives of the seven UNAIDS cosponsors have not been sufficiently
effective in coordinating the U. N. ?s

response or assisting host countries in combating the HIV/ AIDS crisis.
UNAIDS? donors have indicated that future funding increases may depend on
UNAIDS? ability to demonstrate that it is achieving results at the country
level.

UNAIDS has provided financial and technical support to about 50 HIV/ AIDS
technical networks worldwide since1998 that link local communities and
regions to HIV/ AIDS- related resources from universities, health
organizations, and private consultants. In addition, UNAIDS has successfully
developed a series of best practices in the form of reports and case studies
on a comprehensive set of issues, including improving the safety of blood
products, caring for individuals infected by HIV and tuberculosis, and
increasing access to HIV- related drugs. Users of the series found the
reports to be authoritative, high quality, and comprehensive. However,
UNAIDS has not been as successful in tracking the funding and actions host
governments and others have taken to address the AIDS problem at the country
level. Further, 5 years after its creation, the Secretariat has yet to
implement a monitoring and evaluation plan that would enable UNAIDS to
determine the important results of its overall efforts and measure progress
toward achieving its objectives, especially at the country level.

Several factors, some of them external to UNAIDS, have impeded UNAIDS?
progress in achieving its multiple goals. UNAIDS was intended to be a model
of U. N. reform whereby a single Secretariat together with several U. N.
agencies would marshal the U. N. and global community?s resources to address
the AIDS pandemic. However, the critical monetary and human resources UNAIDS
Secretariat and cosponsors were expected to marshal are controlled by other
U. N. agencies, as well as bilateral donors, national Results in Brief

Page 4 GAO- 01- 625 Global Health

governments, and the private sector. UNAIDS? influence is thus dependent on
how effectively it can advocate AIDS causes to others. UNAIDS also began
with a weak political mandate from the U. N. and the international
community. This affected UNAIDS? initial efforts to find resources to
address the worldwide HIV/ AIDS problem and to pressure UNAIDS? cosponsors
to integrate AIDS into their development agendas. Finally, UNAIDS has not
always responded to the pandemic in a consistent manner. It has not always
followed through sufficiently on specific efforts, such as developing
regional initiatives, that it undertook to address HIV/ AIDS problems.

This report makes recommendations to help UNAIDS improve the integration of
HIV/ AIDS into the cosponsors? strategies, programs, and activities; to hold
UNAIDS? cosponsor representatives more accountable at the country level; and
to improve UNAIDS? monitoring and evaluation efforts. In written comments on
a draft of this report, the Department of State, U. S. Agency for
International Development, and UNAIDS generally agreed that the program
improvements we recommended were needed and that in some cases, action is
under way. However, UNAIDS commented that the report focused too much on
program shortcomings and that the report did not fully recognize the
positive steps that have been taken by the Secretariat, cosponsors, and
others since our 1998 report. We believe that the report showed progress in
a number of areas since our last report, including increased U. N.,
national, and international commitment and funding to HIV/ AIDS causes,
improved technical support and best practices, and increased U. N.
coordination. Where appropriate, we have modified our report to include
additional information to address UNAIDS? concerns.

The World Health Organization (WHO) established the U. N. ?s first program
to respond to HIV/ AIDS in 1987. Later that same year, the U. N. General
Assembly encouraged WHO to continue its efforts and urged all appropriate U.
N. system organizations to support AIDS control efforts. In the early 1990s,
U. N. officials and bilateral donors increasingly recognized the need for a
multisectoral response to the complex challenges of the HIV/ AIDS pandemic,
including the social, economic, and development Background

Page 5 GAO- 01- 625 Global Health

issues contributing to the spread of the virus. 4 They realized that WHO?s
medically based approach was insufficient to effectively combat the virus.
In response, the United Nation?s Economic and Social Council 5 established
the Joint United Nations Programme on HIV/ AIDS and operations started in
1996. The mission of UNAIDS is to strengthen and support an expanded
response to HIV/ AIDS aimed at preventing the transmission of HIV, providing
care and support, reducing the vulnerability of individuals and communities
to the worldwide epidemic, and alleviating its impact. UNAIDS was not
expected to fund the efforts of the global community.

Intended to be a model of U. N. reform, UNAIDS is the United Nations? first
joint, cosponsored program of its type. 6 UNAIDS is comprised of a
Secretariat and seven U. N. cosponsors that act at the global, regional, and
country levels. UNAIDS? Programme Coordinating Board 7 is the governing body
for all programmatic issues concerning policy, strategy, finance, and
monitoring and evaluation of UNAIDS. Through the Committee of Cosponsoring
Organizations, the cosponsors? executive heads or their representatives meet
twice a year to consider matters concerning UNAIDS and to provide input into
UNAIDS' policies and strategies. The UNAIDS Secretariat, headquartered in
Geneva, Switzerland, and acting primarily at the global level, is in charge
of the overall coordination and management of UNAIDS and leads the
International Partnership Against AIDS in Africa. The seven cosponsors are
independent U. N. agencies that have programs in regions and countries
worldwide. By joining the UNAIDS partnership, they committed to joint
planning and action against HIV/ AIDS. Cosponsors

4 A multisectoral approach involves all government sectors, including
education, defense, and finance. It also involves sectors outside the
government such as the media; the private sector, including business, labor,
and foundations; and nongovernmental organizations such as religious groups.

5 The U. N. Economic and Social Council was established to promote economic
and social progress; human rights; and solutions to international economic,
social, and health problems. The Council reviews work on HIV/ AIDS every 2
years and selects the membership for UNAIDS? governing board.

6 UNAIDS is the first joint, U. N. cosponsored program to organize around
common objectives, to have a fully constituted governing board, and to have
a secretariat that does not have direct authority over its cosponsors.

7 The membership of the Program Coordinating Board includes representatives
from 22 countries; 5 representatives of nongovernmental organizations,
including people living with HIV/ AIDS; and the 7 cosponsors. It is the only
U. N. agency to include representatives of nongovernmental organizations and
people living with HIV/ AIDS on its governing board.

Page 6 GAO- 01- 625 Global Health

are charged with integrating HIV/ AIDS- related strategies, policies,
programs, and activities into the work of their respective agencies. Figure
1 shows the organizational structure of UNAIDS.

Figure 1: Structure of UNAIDS

Source: GAO based on UNAIDS documentation. UN Economic

and Social Council U. N. Economic

and Social Council

UNAIDS Program Coordinating Board UNAIDS Program Coordinating Board
Secretariat

UNICEF UNDP

UNFPA UNESCO UNDCP WHO

World Bank UNAIDS Committee of

Cosponsoring Organizations UNAIDS Committee of

Cosponsoring Organizations

UNAIDS

Page 7 GAO- 01- 625 Global Health

The United Nations creates U. N. ?theme groups? on specific issues to
facilitate its efforts at the country level and to promote a more coherent
U. N. response to national priorities. For example, one type of theme group
focuses on the environment and sustainable development, and another on the
empowerment of women. The U. N. has 132 theme groups on HIV/ AIDS that serve
as UNAIDS? primary mechanism for assisting developing countries. They are
composed primarily of the senior staff of UNAIDS? cosponsors and are located
in- country. The theme groups? principal objectives are to coordinate the U.
N. response at the country level and to support national governments and
others in their efforts to mount an effective and comprehensive response to
HIV/ AIDS. Theme groups are expected to share information, plan, and monitor
coordinated actions with their U. N. partners and, in some cases, jointly
finance major AIDS- related activities in support of host governments and
national partners, such as nongovernmental organizations. In priority
countries, 8 the theme group may be supported by a Country Programme
Advisor, a country- based Secretariat staff member. In addition to
supporting the broader U. N. system, to build national commitment to HIV/
AIDS action, this advisor is expected to provide information and guidance to
a range of host country partners including government departments,
nongovernmental and community- based organizations, and people living with
HIV/ AIDS.

UNAIDS is funded through voluntary contributions from national governments,
cosponsors? cash contributions, and private donations. None of its funds
comes from the U. N. budget or from U. N. member states? assessed
contributions. UNAIDS' biennium budgets (including the Secretariat?s and
cosponsors? activities at the global and regional levels) were $120 million
for both the 1996- 1997 biennium and the 1998- 1999 biennium. The budget for
2000- 2001 is $140 million. Cosponsors also provide funding for their HIV/
AIDS- related activities from their core budgets and solicit supplemental
funding for their country- level activities from bilateral donors and other
sources, such as foundations. The United States is the largest contributor
to UNAIDS, providing $34 million for the 1996- 1997 biennium, $31 million
for the 1998- 1999 biennium, and approximately $32 million for the 2000-
2001 biennium. The State Department is the United States? liaison with
multilateral organizations

8 To more efficiently use its resources, UNAIDS Secretariat focuses on
countries that have the highest HIV prevalence, the fewest financial
resources, and the potential for the greatest impact, among other criteria.

Page 8 GAO- 01- 625 Global Health

such as the United Nations, and the U. S. Agency for International
Development (USAID) manages U. S. funding to UNAIDS and coordinates and
participates in the U. S. delegation to UNAIDS? governing board.

UNAIDS has made progress toward increasing global coordination and
commitment to HIV/ AIDS since we last reported in 1998. UNAIDS is developing
a U. N. system strategic plan that will help coordinate the U. N. ?s

HIV/ AIDS- related programs and activities. In addition, UNAIDS? cosponsors
have increased their commitment and efforts to integrate HIV/ AIDS into the
work of their agencies; however, progress varies from cosponsor to
cosponsor. UNAIDS? advocacy efforts, especially those of the UNAIDS
Secretariat, have helped increase national and international commitment and
approaches to the worldwide epidemic. Funding by U. N. and bilateral donors
has also increased. However, UNAIDS? efforts at the country level are weak.
UNAIDS? theme groups continue to have difficulty organizing a unified U. N.
response and helping host countries combat HIV/ AIDS. Country Programme
Advisors- the Secretariat?s country- based staff- also have not been as
effective as expected in supporting HIV/ AIDS efforts of the theme groups
and host countries.

According to the UNAIDS governing board, the success of UNAIDS is highly
dependent on collaboration within the U. N. system. However, half of UNAIDS?
donors 9 surveyed did not believe that the Secretariat had been as
successful as originally expected in facilitating the coordination of U. N.
actions on HIV/ AIDS. According to USAID officials, the Secretariat?s lack
of clear guidance and coordination produced, in part, confusion within the
U. N. system about the roles of the Secretariat and cosponsors. In response,
the Secretariat is facilitating the development of the U. N. System
Strategic Plan for HIV/ AIDS for 2001- 2005. The plan is designed to provide
a more coherent U. N. response to HIV/ AIDS, documenting the efforts of the
Secretariat, 7 U. N. cosponsors, and 21 other U. N. agencies, such as the
International Labour Organization and the Food and Agriculture Organization.
The Secretariat stated the plan will be presented to UNAIDS?

9 The UNAIDS Financing Study, an independent survey of 12 of UNAIDS? leading
bilateral donors commissioned by UNAIDS? governing board and issued in
September 2000, solicited donors? perspectives on several issues, including
the extent to which UNAIDS has been successful in its roles and
responsibilities. UNAIDS Has Made

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

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

Page 9 GAO- 01- 625 Global Health

governing board by June 2001. In addition, the Secretariat and cosponsors
began conducting detailed reviews of each of the cosponsors? HIV/ AIDS
programs in March 2000. These reviews profile each cosponsor?s mandate,
structure, operations and budget, and HIV/ AIDS- related work. The reviews
are intended to improve UNAIDS? strategic planning and collaboration and to
increase understanding within UNAIDS about each of the cosponsors? roles and
responsibilities.

UNAIDS cosponsors? commitment to HIV/ AIDS has increased since we last
reported. Over the past 2 years, the executive boards of several cosponsors
have issued statements to strengthen agency action on HIV/ AIDS. For
example, in January 2000, WHO?s Executive Board requested that the Director
General strengthen the agency?s involvement in the UNAIDS effort and give
HIV/ AIDS priority in its budget. All UNAIDS cosponsors? executive directors
now speak at major international meetings and events, advocating for
increased attention and activities to combat HIV/ AIDS. Some cosponsors also
have elevated the position of the HIV/ AIDS unit or focal point
organizationally to highlight the visibility and importance of the issue
within the agency. For example, in 1999, to focus on its HIV/ AIDS efforts
in sub- Saharan Africa, the World Bank created a new office that reports to
the agency?s Office of the Regional Vice Presidents. The same year, the U.
N. Children?s Fund established a seniorlevel post and unit at their
headquarters.

On the other hand, the cosponsors? progress toward integrating HIV/ AIDS
into their agency strategies, programs, and activities has varied and
continues to evolve. For example, an external evaluation of the U. N.
Development Programme?s HIV/ AIDS program, prepared in 2000, found that HIV/
AIDS had not been fully integrated into the agency?s work. In response, the
Development Programme made HIV/ AIDS one of its top priorities and launched
a resource mobilization campaign to support country- level activities, among
other efforts. The U. N. Population Fund also evaluated its HIV/ AIDS
programs and concluded in its 1999 report that many of the agency?s efforts
to integrate HIV/ AIDS were superficial. In response, the Population Fund
made HIV/ AIDS a top priority as part of its 2001 agency realignment
process- an action that the agency expects will accelerate efforts to
integrate HIV/ AIDS into its existing programs. The Executive Director of
UNAIDS said that further strengthening cosponsor commitment and integration
of HIV/ AIDS is a top internal challenge for UNAIDS. Appendix III briefly
describes the HIV/ AIDS programs and key activities of each of UNAIDS?
cosponsors.

Page 10 GAO- 01- 625 Global Health

UNAIDS? major donors, U. S. government officials, cosponsor officials, and
others credit UNAIDS, especially the Secretariat, with contributing to the
national and international communities? increased awareness of and
commitment to the fight against HIV/ AIDS. They also credit UNAIDS and the
Secretariat with helping to reframe HIV/ AIDS as an issue involving all
sectors rather than an issue involving only the health sector. Many national
governments around the world were slow to respond to the HIV/ AIDS epidemic,
even those in the most affected areas in sub- Saharan Africa. In response,
UNAIDS? Executive Director visited 21 developing countries in 1999 and 2000,
including 14 African countries. In those countries, the Executive Director
stressed the importance of mobilizing efforts to combat HIV/ AIDS and taking
a multisectoral approach to the countries? presidents and other high- level
national leaders. For example, UNAIDS? Executive Director met with the Prime
Minister of Ethiopia in September 1999 to advocate for a high- level,
expanded, and multisectoral response. In April 2000, the President of
Ethiopia launched the National Council on AIDS, supported by a National
Secretariat in the Office of the Prime Minister and composed of
multisectoral subcommittees. With assistance from the Secretariat and the
World Bank, some countries are incorporating responses to HIV/ AIDS into
their country?s long- term multisectoral development plans.

UNAIDS also has worked with the international community, including the
private sector, to broaden and increase efforts to combat HIV/ AIDS. In
December 2000, the Secretariat, several cosponsors, and the Japanese
government collaborated to develop detailed strategies, goals, and targets
for the Group of Eight?s 10 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

10 The Group of Eight consists of the heads of state of the United States,
Great Britain, Canada, France, Germany, Italy, Japan, and Russia. The Group
meets annually to address the major economic and political issues facing
their nations and the international community.

Page 11 GAO- 01- 625 Global Health

attendee the Bill and Melinda Gates Foundation-- announced a $57 million
grant to expand national HIV/ AIDS programs for youth in Botswana, Ghana,
Uganda, and Tanzania. The Secretariat also has helped cultivate the
involvement of the U. N. Foundation in global efforts against HIV/ AIDS. 11
Since 1998, the U. N. Foundation has allocated at least $25 million for HIV/
AIDS- related activities implemented by UNAIDS? cosponsors in southern
Africa and Ukraine.

Cosponsors reported that estimated spending for HIV/ AIDS programs has
increased significantly in the past 2 years. However, most of the increased
spending came from the World Bank, which provides loans to national
governments for specific HIV/ AIDS- related projects. Bilateral donor
funding increased slightly in 1998 over previous years, but funding has
increased considerably among some donors since then. Despite these efforts,
total funding for HIV/ AIDS efforts is well below what experts estimate is
needed to effectively combat HIV/ AIDS around the world.

Table 1 shows estimated spending for HIV/ AIDS by UNAIDS? cosponsors from
1996 to 1999. Overall, UNAIDS? cosponsors have increased spending for HIV/
AIDS programs and activities from $296.9 million in the 1996- 1997 biennium
to $658.1 million in the 1998- 1999 biennium. Most of this increase (96
percent) came from the World Bank. Four other cosponsors increased spending
for HIV/ AIDS- related activities, although some did so only slightly. The
U. N. Development Programme decreased its spending for HIV/ AIDS.

11 The U. N. Foundation was established in 1997 to oversee the
administration of a gift made by Ted Turner in support of U. N. causes. U.
N. and Bilateral Donor

Funding for HIV/ AIDS Has Increased

Page 12 GAO- 01- 625 Global Health

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

In millions of U. S. dollars

Spending for HIV/ AIDS UNAIDS Cosponsors 1996- 1997 1998- 1999

U. N. Children?s Fund $61.0 $65.0 U. N. Development Programme 95.8 91.9 U.
N. Population Fund 42.5 45.0 U. N. International Drug Control Programme n/ a
a n/ a a U. N. Education, Scientific, and Cultural Organization 4. 1 6.6
World Health Organization 27.6 38.9 World Bank 65.9 410.7

Total $296.9 $658.1

a The U. N. International Drug Control Programme was unable to provide
information on its spending for HIV/ AIDS activities. Although it estimates
that it spent approximately $11 million over the past several years, it
could not isolate HIV/ AIDS spending within its demand reduction program.
Other cosponsors also reported difficulty in tracking HIV/ AIDS spending.

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

Cosponsor officials cited several reasons that affected their ability to
increase HIV/ AIDS spending. First, several cosponsors? budgets have either
declined or remained stable over the past few years. For example, the U. N.
Population Fund?s overall budget declined from $628. 7 million in the 1996-
1997 biennium to $581.7 million in the 1998- 1999 biennium. Second,
earmarked funds 12 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

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

Page 13 GAO- 01- 625 Global Health

increases in contributions to the agency from 1999 to 2000, but these
increases were neutralized by the exchange rate. 13

According to the UNAIDS Secretariat, while bilateral donors maintained their
spending for HIV/ AIDS in 1996 and 1997 at $273 million each year, funding
increased slightly in 1998 to $293 million. 14 As of May 2001, the
Secretariat could not provide us with more current data, but evidence from
specific countries suggests that funding has increased further. For example,
the United States committed approximately $466 million in 2001 compared with
the $293 million spent by all bilateral donors, including the United States,
in 1998. Canada announced in June 2000 that, over the next 3 years, it would
increase its international HIV/ AIDS spending from $20 million to $60
million per year. According to the Secretariat, most major bilateral donors
have increased their HIV/ AIDS funding for Africa since 2000. However, these
increases are much less than the minimum of $3 billion that UNAIDS estimates
may be needed annually for basic HIV/ AIDS prevention, treatment, and care
in the sub- Saharan Africa region alone. The U. N. Secretary- General is
currently advocating for the creation and funding of a global AIDS fund that
would support HIV/ AIDS activities in developing countries. The U. S.
Administration pledged $200 million to the fund in May 2001.

One of UNAIDS? primary functions is to strengthen host nations? capacities
to plan, coordinate, implement, and monitor the overall response to HIV/
AIDS. However, UNAIDS? governing board, donors, and senior officials do not
believe that UNAIDS has been as effective as expected at the country level.
The performance of UNAIDS? theme groups varies widely, and their overall
performance in facilitating the U. N. response at the country level and in
providing effective assistance to host countries? efforts to combat HIV/
AIDS has been weak. In addition, UNAIDS cosponsors and the Secretariat do
not hold theme groups sufficiently

13 For example, in 1999, Denmark gave to the U. N. Population Fund 200
million Danish Krone (U. S. $27. 9 million). Denmark gave the same amount in
2000, but the exchange rates reduced the value of the donation to U. S. $25
million.

14 The Secretariat?s data on bilateral donor spending reflects 1997 prices
and exchange rates and tracks 10 bilateral donors for which data are
available over time. The bilateral donors are Australia, Canada, Denmark,
Germany, Japan, the Netherlands, Norway, Sweden, the United Kingdom, and the
United States. UNAIDS? Country- Level

Efforts Need Strengthening

Page 14 GAO- 01- 625 Global Health

accountable for their efforts. The Secretariat?s Country Programme Advisors
have not been as effective as expected in supporting the theme groups? and
host countries? HIV/ AIDS efforts. The Secretariat has not provided the
advisors with sufficient guidance and training and initially did not hire
individuals with the right mix of skills.

According to UNAIDS? 2000 survey of its donors, UNAIDS has not been as
successful as they expected in strengthening governments? HIV/ AIDS
activities and ensuring that appropriate and effective policies and
strategies are implemented to address HIV/ AIDS. In addition, the survey
said that donors believe UNAIDS has been weak in promoting broad- based
political and social commitment and action to prevent and respond to HIV/
AIDS at the country level. According to the survey, donors? perception of
UNAIDS? lack of sufficient relevance at the country level could be a threat
to future funding. UNAIDS? governing board said that the ultimate test of
UNAIDS? success lies in the degree to which it successfully helps host
countries combat HIV/ AIDS. However, at the latest meeting of UNAIDS?
governing board in December 2000, both the governing board and UNAIDS?
Executive Director noted that UNAIDS needed to improve its country- level
response. The governing board emphasized that a coordinated, consistent U.
N. response was needed and that improving the performance of UNAIDS? theme
groups required urgent attention. UNAIDS? Executive Director concurred with
the board?s assessment, saying that these tasks are a formidable challenge
and that strengthening UNAIDS? country- level efforts is one of UNAIDS? top
internal challenges.

UNAIDS? 132 theme groups on HIV/ AIDS- composed primarily of cosponsors?
senior in- country staff- are UNAIDS? primary mechanism at the country level
to coordinate the U. N. response and support host countries? efforts against
HIV/ AIDS. However, overall theme group performance varies considerably. For
example, in surveying 36 USAID missions worldwide, we asked about the extent
to which the theme groups were strengthening the overall national government
response to HIV/ AIDS. Of the 24 missions responding, 8 said to a very or
great extent, 7 said to a moderate extent, and 9 said to some, little, or no
extent. 15 In addition, UNAIDS? annual surveys of its theme groups from
1996- 1999 indicate that they have made little progress in key areas,
including developing an

15 USAID has a total of 82 missions worldwide. We surveyed 36 missions
representing those that had been involved in HIV/ AIDS activities for at
least 2 years at the time of our survey. UNAIDS? Donors and Senior

Officials Believe Country- Level Efforts Are Weak

Theme Groups? Performance Varies and Accountability for Results is Limited

Page 15 GAO- 01- 625 Global Health

advocacy plan, mobilizing resources, and developing a U. N. system
integrated plan on HIV/ AIDS.

 According to the UNAIDS Secretariat, theme groups are expected to develop
joint advocacy action plans to plan and manage joint advocacy work on HIV/
AIDS and to clarify what the theme group is advocating and by whom and how.
UNAIDS? annual surveys show that, in 1997, 31 percent of theme groups
surveyed had developed a systematic approach to advocacy in the form of a
strategy or plan. In 1999, 37 percent of theme groups had developed an
advocacy plan or strategy. 16

 Since UNAIDS is not a funding agency, mobilizing resources to support
country- level efforts against the epidemic is another key role of the theme
group. According to UNAIDS, in 1997, under one- half of UNAIDS? theme groups
were mobilizing resources for HIV/ AIDS activities, a figure that increased
to about one- half in 1999. Most resource mobilization efforts were ad hoc,
with only one- quarter of theme groups having developed a systematic
approach to resource mobilization as expected.

 According to the UNAIDS Secretariat, a U. N. system integrated plan on
HIV/ AIDS is the basis for coordinated U. N. support to the national
response and is the single most valuable indicator of the U. N. ?s

commitment at the country level. However, according to UNAIDS, as of
February 2000, only 18 out of 86 theme groups surveyed had completed an
integrated plan and one- half had yet to take any steps to begin the process
of completing one.

In 1998, we found that UNAIDS? theme groups were ineffective for a number of
reasons. The UNAIDS Secretariat did not provide timely guidance about
operations or responsibilities. In addition, UNAIDS? cosponsor staff at the
country level were not committed to the UNAIDS mandate, nor were they held
accountable by their respective agencies for their participation in the
theme groups or for the theme groups? results in supporting national HIV/
AIDS efforts.

In our most recent work, we found that some of the cosponsors and the
Secretariat still do not hold theme group members accountable for results.
For example, while the Director- General of WHO directed their country
directors to participate in theme groups, WHO does not assess their
involvement as part of their annual performance review. Neither the World

16 In 1997, the Secretariat surveyed a total of 126 theme groups and
received 64 responses. In 1999, the Secretariat surveyed a total of 129
theme groups and received 86 responses.

Page 16 GAO- 01- 625 Global Health

Bank nor the U. N. International Drug Control Programme requires theme group
involvement or includes it as a required element in annual performance
reviews of senior country- level staff. The UNAIDS Secretariat also does not
hold theme groups accountable for results. While the Secretariat has no
organizational authority over the cosponsors? country- level
representatives, the theme groups are expected to undertake a number of
activities, including developing advocacy and resource mobilization plans.
The Secretariat?s annual surveys of theme groups are one way that UNAIDS
obtains information on theme group operations. However, these surveys
currently focus only on the internal operations and management of the theme
group rather than the implementation of these plans or the extent to which
theme groups are successful in their other efforts to support host
countries? HIV/ AIDS efforts. The Secretariat said that it is improving the
annual surveys to allow for tracking of theme group results. Also, in
recognition of the continuing challenges with theme groups, UNAIDS created
the Interagency Task Team on Theme Group Operations, and the Secretariat
created a new Theme Group Support Unit.

According to U. S. officials and officials from both the UNAIDS Secretariat
and cosponsors, Country Programme Advisors- the Secretariat?s countrybased
staff- have not been effective as expected in supporting HIV/ AIDS efforts
of the theme groups and host countries. For example, guidance provided by
the UNAIDS Secretariat instructs the advisors to advocate to national
governments for expanded efforts on HIV/ AIDS but provides no guidance on
what to do or how to do it. Without adequate guidance or training, an
advisor?s success is dependent on his or her personal talents and skills.
According to the Secretariat, many advisors have not been successful because
they lack crucial diplomatic skills and were not hired at a rank high enough
to successfully interact with and influence U. N. and host country
government officials. In some instances, the Secretariat has increased the
grade level at which these advisors are hired and is in the process of
hiring new advisors with the right skills. UNAIDS also held a meeting on
developing a plan of action to better focus their recruiting efforts and
support the advisors in their work.

While the UNAIDS Secretariat was not intended to fund or implement HIV/ AIDS
activities, it does provide small amounts of funding to support theme group
proposals for projects to stimulate national HIV/ AIDS efforts. These funds
are also expected to help theme groups leverage funds from other sources.
These funds could be used, for example, to support activities to design and
develop national strategic plans or to support the development of major
grants or loans to address HIV/ AIDS. UNAIDS UNAIDS? Country Programme

Advisors Have Not Been as Effective as Expected

Theme Groups and Advisors Are Not Actively Submitting Funding Proposals for
CountryLevel Activities

Page 17 GAO- 01- 625 Global Health

provided $22.9 million in these funds for the 1998- 1999 biennium and
allocated about $23.5 million for the 2000- 2001 biennium. After an
evaluation of the funding process in June 1999, 17 UNAIDS found that 65
percent of projects receiving such funds succeeded in leveraging additional
funds and, in some cases, in involving new sectors and partners. However,
the evaluation also found that theme groups generally were not committed to
submitting proposal requests, were not adequately involved in the proposal
process, and did not always possess the technical expertise needed to
develop a quality proposal. In addition, the evaluation found that the
Country Programme Advisors had not assisted theme groups in preparing
proposals to the extent that the Secretariat had expected. According to
UNAIDS' Secretariat, the proposal process has been streamlined for the
current biennium.

UNAIDS is charged with developing and providing information to enhance the
U. N. and global response to the HIV/ AIDS worldwide epidemic. The UNAIDS
Secretariat has continued to improve its technical support and best practice
materials since we last reported, but the best practice materials have not
been sufficiently distributed. The Secretariat also has made progress in
tracking the pandemic but has encountered difficulties in tracking the
national and international response to the pandemic with regard to funding
and activities. In addition, the Secretariat?s monitoring and evaluation
efforts have various weaknesses, and UNAIDS still cannot report overall
results or measure progress towards its objectives, especially at the
country level. As a result, UNAIDS is constrained in its ability to make
management decisions based on data or to ensure its donors that it is using
program resources productively.

A key function of the UNAIDS Secretariat is to arrange for and provide
selected technical support and to identify, develop, and disseminate best
practices. In our 1998 report, we said that the Secretariat had not
adequately mobilized regional resources to provide technical support. Since
then, the UNAIDS Secretariat has established and supported Technical
Resource Networks to help arrange the technical support needed by U. N.
organizations and others working on HIV/ AIDS activities.

17 The evaluation, Findings From an Analysis of the Strategic Planning and
Development Fund Process, was completed by the Resource Group International
Sarl, Geneva, Switzerland, and issued July 1999. UNAIDS Has Made

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

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

Page 18 GAO- 01- 625 Global Health

These networks consist of groups of individuals, communities, and
institutions that are expected to share information, provide peer support,
and help identify sources of technical information and assistance to those
working on HIV/ AIDS issues. The Secretariat has facilitated the creation of
13 networks since 1998 and has provided financial and technical support-
such as facilitating discussions on technical issues related to HIV/ AIDS-
to 49 networks worldwide. For example, the Secretariat initiated the Forum
of Condom Social Marketing network in 1998 and, with the cosponsors, has
supported groups such as the Asian and European Harm Reduction Networks and
the Religious Alliance Against AIDS in Africa.

To help improve the technical capacity of U. N. cosponsors and others
working on HIV/ AIDS- related activities in a number of geographic regions,
in 1996, the Secretariat and cosponsors began establishing regional
technical teams to serve groups of countries. These intercountry teams-
locate in Abidjan, Cote d?Ivoire (western and central Africa); Pretoria,
South Africa (eastern and southern Africa); and Bangkok, Thailand (Asia and
the Pacific)- are expected to facilitate existing intercountry initiatives
or networks and develop new mechanisms of exchange and collaboration; help
arrange for technical assistance from other organizations, universities, and
private consultants; and mobilize additional resources for subregional HIV/
AIDS efforts. To help determine whether these teams were meeting their
objectives, the Secretariat commissioned an evaluation of the Inter- country
Team for Western and Central Africa, published in January 2001, which
assessed the team?s relevance, effectiveness, and efficiency. The evaluation
found that the team was very useful in exchanging and disseminating
information, but that it was less successful in arranging for technical
assistance.

UNAIDS? best practice collection includes a series of technical updates, key
materials, and case studies that provide strategies and approaches to
prevent infection, provide care to those already infected, and alleviate the
impact of HIV/ AIDS on those affected. Topics include improving the safety
of blood products, caring for individuals infected by HIV and tuberculosis,
and increasing access to HIV- related drugs. In 1998, we reported that these
materials were too general and lacked ?how- to? guidance. In 1999, the
Secretariat commissioned an independent evaluation 18 of the effectiveness,

18 Summary Report of an Evaluation of the UNAIDS Best Practices Collection:
Its Strengths and Weaknesses, Accessibility, Use and Impact, Performance
Improvement Pty Ltd., (Nov. 1999).

Page 19 GAO- 01- 625 Global Health

relevance, and efficiency of the best practice materials. The review
surveyed 164 users who considered the best practice materials to be
authoritative, high quality, user friendly, and comprehensive in coverage.
However, the review concluded that the Secretariat should develop materials
more suited to local circumstances. Some steps have been taken to increase
local specificity in best practice materials. The UNAIDS Secretariat has
worked with some countries, such as Brazil, to develop best practices that
focus on successful approaches and activities taken by organizations in that
country. The review also concluded that the distribution of the materials
should be improved. The review found, for example, that the Country
Programme Advisors- the Secretariat?s country- based staff- had not
systematically distributed the materials and may not have been sufficiently
aware of their responsibilities in this regard. In January 2001, a senior
Secretariat official noted that, while distribution was still a problem, the
Secretariat was trying to address this issue.

The UNAIDS Secretariat is responsible for developing accurate, up- to- date
information on the worldwide epidemic and for tracking the international
community?s response. According to UNAIDS? 2000 donor survey, donors believe
that the Secretariat has done well in tracking the pandemic. For example,
the Secretariat and WHO participate in the UNAIDS/ WHO Working Group on
Global HIV/ AIDS and Sexually Transmitted Infection Surveillance to compile
the best epidemiological information available. From this data, the
Secretariat calculates national HIV infection rates, which are helpful in
raising awareness about the spread of the virus and in stimulating action.
The working group also established the Reference Group on HIV/ AIDS
Estimates, Modeling and Projections, which, according to UNAIDS, has helped
set clearer international standards for assessing AIDS and its impact and is
expected to improve the production of country- specific estimates of HIV
prevalence. However, according to the Secretariat, efforts still need to be
increased to support HIV surveillance activities at the country level. The
Secretariat also noted that WHO has taken steps to increase its efforts in
this area.

The UNAIDS Secretariat is also expected to track national and international
responses to the pandemic. Various problems, however, have hindered its
efforts in this area. To track funding, the Secretariat conducted a study
with Harvard University in 1996 and then with the Netherlands
Interdisciplinary Demographic Institute?s Resource Flows UNAIDS Has Made
Some

Progress in Tracking the Pandemic but Has Encountered Difficulties in
Tracking Response

Page 20 GAO- 01- 625 Global Health

Project 19 in 1999 to obtain data on HIV/ AIDS spending by major bilateral
donors, the United Nations, and developing countries. According to the
Secretariat, getting these entities to report data to the contractor has
been a major challenge, as has been reaching consensus on what counts as an
HIV/ AIDS project or activity. In addition, developing countries do not
systematically track HIV/ AIDS spending. To improve the monitoring and
tracking of international and national resource flows, the Secretariat has
established a specific unit with devoted staff resources. The Secretariat
also has been developing and implementing the Country Response Information
System since 2000. This database is intended to facilitate the compilation,
analysis, and dissemination of relevant information by country on HIV
epidemics and HIV/ AIDS- related programs and activities by all relevant in-
country partners. According to the Secretariat, compiling this information
has been extremely difficult and more complex than originally envisioned,
and it is behind in efforts in this area. The Secretariat expects to
complete a prototype in the second quarter of 2001.

UNAIDS? governing board directed UNAIDS at its creation to implement the
principles of performance- based programming and to use measurable
objectives in assessing its performance. We reported in 1998 that the
Secretariat was in the process of developing a monitoring and evaluation
plan. UNAIDS' governing board approved a plan in December 1998 that
consisted of multiple elements, including a draft conceptual framework,
theme group surveys, and one- time evaluations of several of the
Secretariat?s specific functions, such as the best practice collection.
Since then, a unified budget and workplan with performance indicators was
added. Key elements of the overall plan- the conceptual framework and the
unified budget and workplan- need to be improved. Furthermore, despite these
evaluative efforts, UNAIDS still cannot measure progress towards achieving
its objectives or overall results, especially at the country level.

Although the United Nations is not required to comply with the U. S.
Government Performance and Results Act, 20 we used the principles laid

19 The Netherlands Interdisciplinary Demographic Institute collaborates with
the U. N. Population Fund to conduct the Resource Flows Project. 20 The
Government Performance and Results Act of 1993 (P. L. 103- 62). UNAIDS?
Monitoring and

Evaluation Efforts Need Improvement

Page 21 GAO- 01- 625 Global Health

out in the act to identify the elements of a successful performance- based
system. These include (1) a clearly defined mission, (2) establishment of
long- term strategic and annual goals, (3) measurement of performance
against the goals, and (4) public reporting of results. The act seeks to
link resources and performance so that an organization can show what it has
accomplished compared with the money it has spent and so that it can be held
accountable for the levels of performance achieved.

Using the Results Act as a guide, we identified four major weaknesses in
UNAIDS? Monitoring and Evaluation Framework. First, the Framework primarily
addresses the Secretariat?s outputs even though the Framework?s outcomes and
impacts also apply to the cosponsors. Second, because the Framework?s
outputs focus on the Secretariat, which acts primarily at the global level,
the Framework does not sufficiently address UNAIDS? performance at the
country level. Third, the Framework?s outputs, outcomes, and impacts are not
clearly linked, making it difficult to assess the cause and effect of
UNAIDS? specific activities. Fourth, the Framework does not establish
specific performance baselines, targets, or other quantitative measures that
could help UNAIDS measure overall results and progress towards achieving its
objectives or expected outcomes.

UNAIDS? Unified Budget and Workplan 2000- 2001, a separate performance-
related instrument, provides additional documentation that compensates for
some of the shortcomings of the monitoring and evaluation framework. For
example, the Workplan provides UNAIDS? mission statement, goals, and the
strategic objectives leading to those goals. It also provides information on
the Secretariat?s and cosponsors? global and regional activities; includes
more specific linkages between outputs, indicators, and objectives; and
better accounts for the respective roles and responsibilities of the
Secretariat and cosponsors. However, the Workplan also has a number of
weaknesses. For example, the Workplan does not include quantifiable
performance targets that would define success and help UNAIDS to measure its
progress. The Workplan also does not always indicate what is needed to
accomplish the stated objectives. For example, one objective is to ?mobilize
political and public support for UNAIDS? priority themes and initiatives and
to provide leadership and guidance in advocacy, public information, and
resource mobilization efforts.? The only output for this objective-
communication activities- is vague. Furthermore, like the Framework, the
Workplan does not always sufficiently link its components, making it
difficult to assess the cause and effect of UNAIDS? actions.

Page 22 GAO- 01- 625 Global Health

Senior Secretariat officials acknowledge that the Unified Budget and
Workplan 2000- 2001 has deficiencies. They said that it was the first
document of its kind, compiled quickly, and did not have high- quality
indicators. In addition, because it is organized thematically rather than
functionally, they said it is difficult to track or assess UNAIDS? progress
in achieving its overall objectives. They also said that developing a
performance- based plan with quality indicators has been especially
challenging because the U. N. system lacks an evaluative culture. However,
they believe the Unified Budget and Workplan 2000- 2001 is an important
first step.

UNAIDS Secretariat officials said that evaluation efforts overall have been
hampered by inadequate and inconsistent resources. Changes in personnel and
reliance on consultants over the past several years have resulted in a lack
of continuity and variable levels of effort. It was not until early 1998
that a staff person was hired to lead a performance evaluation unit. The
unit is currently authorized three full- time professional staff and is
supplemented periodically by staff on part- time loan from other agencies.
Because all Secretariat positions are time- limited, there is greater
turnover than normal and difficulty in recruiting and retraining skilled
staff.

UNAIDS and U. S. government officials told us that, although UNAIDS has
certain advantages in the fight against HIV/ AIDS, a number of key factors,
some of which are external to the organization, have hindered its progress.
UNAIDS was established to be the primary advocate for global action on HIV/
AIDS and has advantages over other organizations, such as bilateral donor
agencies, that combat HIV/ AIDS. For example, as a U. N. organization,
UNAIDS may have more credibility than other organizations, and thus be more
effective, because it is seen as a neutral entity that does not represent
any one government. In addition, UNAIDS often has access to higher- level
government officials than do bilateral development agencies, and it
sometimes operates in countries where bilateral agencies and other
organizations do not because of conflict, political tension, or lack of
compelling interest. However, UNAIDS? broad mission, organizational
structure, initial lack of a political mandate, and a lack of timely follow-
through have hampered its progress.

While UNAIDS has a broad and challenging mission, its progress depends on
actions taken by other entities, such as international donors,
nongovernmental organizations, the private sector, and national governments.
National government leadership on HIV/ AIDS is particularly essential to an
effective response to HIV/ AIDS, but many national Key Factors Have

Hindered UNAIDS? Progress

Page 23 GAO- 01- 625 Global Health

governments around the world have been slow to respond to the crisis. For
example, until 1999, the President of Zimbabwe denied that HIV/ AIDS was a
problem in his country; the government of India was similarly slow to
respond. HIV/ AIDS is also an extraordinarily complex disease for which
there is no cure. Combating the pandemic requires a multisectoral approach
that involves addressing the many medical, cultural, behavioral, economic,
social, and political aspects that surround the virus and contribute to its
impact.

As a joint and cosponsored program, UNAIDS? structure is complicated and
progress depends heavily on the collegiality, cooperation, and consensus of
the Secretariat and seven cosponsors. According to UNAIDS and U. S.
government officials, these qualities were not evident during UNAIDS? first
several years. They noted that, even though UNAIDS is a joint program, it
was created without the buy- in of the cosponsors. According to senior
Secretariat and cosponsor officials, because UNAIDS was imposed on the
cosponsors, there was a certain amount of hostility within the program.
Furthermore, the cosponsors viewed the Secretariat as competing for funding
and were confused about their role within the joint program. As a result,
until recently, cosponsors were not fully committed either to incorporating
HIV/ AIDS into their respective mandates or to participating in UNAIDS.
Since each cosponsor is accountable only to its own independent executive
board, neither the Secretariat nor UNAIDS? governing board had controlling
organizational authority over the cosponsors. Thus, little could be done to
exert pressure on the cosponsors to become effective partners within UNAIDS.

UNAIDS? effectiveness was further hampered, according to U. S. government
officials, because it was created without the necessary political mandate or
funding from the major bilateral donors or the United Nations. According to
a senior Secretariat official, the bilateral donors heavily influenced the
creation of UNAIDS; however, when political pressure was needed to intensify
and fund UNAIDS? cosponsors? HIV/ AIDS programs, bilateral donors provided
little assistance. In addition, according to U. S. officials, the United
Nations, particularly the SecretaryGeneral, had other priorities on which to
focus. The bilateral donors and the United Nations are beginning to provide
needed political and financial support. For example, in January 2000, the U.
N. Security Council held a session, in part due to U. S. influence, to
address the impact of AIDS on global peace and security- the first session
ever held on a health- related matter.

Page 24 GAO- 01- 625 Global Health

Finally, according to U. S. officials, while UNAIDS initiates many
activities, it does not always execute them in a timely way, further
delaying an effective response. For example, according to USAID officials,
UNAIDS has initiated various regional strategies to address HIV/ AIDS, such
as the International Partnership Against AIDS in Africa and the Eastern
European Regional Strategy, but did not facilitate timely efforts to move
these agreements forward. According to the Secretariat, it does not have
sufficient capacity to always follow through in a timely manner on the
efforts it initiates, such as the International Partnership Against AIDS in
Africa.

UNAIDS was given an enormous challenge when it was created to lead and
expand U. N. and global efforts to combat HIV/ AIDS. Intended to be a model
of U. N. reform, UNAIDS was the U. N. ?s first joint and cosponsored program
of its type. Because there was no precedent, UNAIDS had to learn to function
effectively, depending heavily on the collegiality and cooperation of the
Secretariat and seven cosponsors. Despite these challenges, UNAIDS has made
progress in many areas, especially in improving U. N. coordination and
advocating for an enhanced global response to the HIV/ AIDS pandemic.
However, while UNAIDS? cosponsors have recently intensified their commitment
and efforts to integrate HIV/ AIDS into their strategies and programs, their
slow response has made it more difficult for UNAIDS to achieve its mission.

UNAIDS has not lived up to expectations with regard to its efforts at the
country level. Overall, UNAIDS? Secretariat and cosponsors? representatives
in developing countries continue to have difficulty organizing their efforts
and providing assistance to host governments and others, and UNAIDS does not
hold them accountable for results. Some cosponsors still do not require
their senior country- level representatives to actively participate in theme
groups or have not established performance expectations related to theme
group activities. In addition, while the Secretariat surveys theme group
activities annually, oversight is limited because it does not focus on
results. Five years after its creation, the Secretariat has yet to implement
a monitoring and evaluation plan that would enable UNAIDS to determine the
important results of its overall efforts and measure progress toward
achieving its objectives. A quality performance evaluation plan is critical
to assure UNAIDS? donors and others in the international community that
UNAIDS is using its resources productively, that it is relevant, and that it
is achieving its mission, especially at the country level. This is
particularly important because Conclusions

Page 25 GAO- 01- 625 Global Health

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

To help UNAIDS achieve progress toward its mission and to help demonstrate
this progress, we recommend that

 the Secretary of State direct U. S. representatives on the cosponsors?
executive boards to request the respective cosponsor:

 to accelerate its efforts to integrate HIV/ AIDS into the work of its
agency, and

 to hold country- level staff accountable for (1) participation in theme
groups and (2) the results of theme groups? efforts to help host countries
combat HIV/ AIDS.

 The Secretary of State and the Administrator, USAID, request that the
UNAIDS Secretariat and cosponsors improve UNAIDS? monitoring and evaluation
efforts in order to determine the results of its overall efforts and measure
progress, especially at the country level.

We received written comments on a draft of this report from the Department
of State, USAID, and UNAIDS, which are reprinted in appendixes IV- VI. At
our request, the UNAIDS Secretariat requested and received comments from
UNAIDS cosponsors 21 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

21 According to UNAIDS, seven cosponsors were provided a draft for comment;
they received comments from the U. N. Population Fund, U. N. Children's
Fund, U. N. Development Programme, and WHO. Recommendations for

Executive Action Agency Comments and Our Evaluation

Page 26 GAO- 01- 625 Global Health

impact of external factors on UNAIDS? progress, it noted that the lack of
bilateral government support following UNAIDS? creation did not apply to
USAID. In responding to our recommendations, the Department of State stated
that it would instruct its delegations to encourage the cosponsors to
cooperate more fully with UNAIDS, especially at the country level. In
addition, the Department noted that our report will be of immense value to
the UNAIDS governing board- commissioned evaluation, currently in progress,
which is reviewing the entire scope of UNAIDS activities after 5 years of
effort.

UNAIDS generally agreed with our findings and recommendations and noted that
the report will provide valuable input to the commission that UNAIDS?
governing board established to review UNAIDS? progress. However, UNAIDS
stated that our report did not give the Secretariat and the cosponsors
sufficient credit for the many accomplishments they have made since we last
reported in 1998. Accordingly, UNAIDS? comments detailed numerous examples
of activities undertaken, including high- level statements made,
"information flows improved," documents written, and processes improved to
demonstrate further the collective accomplishments of the Secretariat and
the cosponsors since 1998. We disagree that our report did not provide
UNAIDS with sufficient credit for its accomplishments since 1998. We believe
that our report provides a fair assessment of UNAIDS' progress. Our report
affirms that UNAIDS has contributed to increased commitments and funding for
AIDS efforts by the U. N. and national and international entities. Through
UNAIDS, the international community?s response to AIDS has broadened from
one that is focused exclusively on health to one that focuses on multiple
sectors. Further, we note the progress UNAIDS has made in providing
countries with technical support and best practices materials, tracking the
epidemic, and increasing U. N. coordination. Where there are deficiencies in
UNAIDS? efforts- at the country level and with its monitoring and evaluation
framework- they are deficiencies that UNAIDS, the State Department, and
USAID collectively agree are in critical areas that need improvement. While
we have included, where appropriate, additional information to address
UNAIDS' comments, our overall conclusions remain unchanged.

As arranged with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 15 days after
the date of this letter. At that time, we will send copies to appropriate
congressional committees; the Honorable Colin Powell, the Secretary of
State; the Honorable Andrew S. Natsios, Administrator of USAID; and the

Page 27 GAO- 01- 625 Global Health

Executive Director of UNAIDS. We will also make copies available to
interested parties upon request.

If you or your staff have any questions concerning this report, please call
me at (202) 512- 8979. An additional GAO contact and staff acknowledgments
are listed in appendix VII.

Sincerely yours, Joseph A. Christoff, Director International Affairs and
Trade

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

Page 28 GAO- 01- 625 Global Health

Because of the catastrophic HIV/ AIDS epidemic in Africa and the inadequate
national and international response, the Joint United Nations Programme on
HIV/ AIDS (UNAIDS) initiated the International Partnership Against AIDS in
Africa (the Partnership) in 1999. The Partnership is made up of African
governments, the U. N., donors, the private sector, 1 and the community
sector. 2 The objective of the Partnership is to increase coordination among
the five partners and to expand their efforts against HIV/ AIDS in each
African country. To achieve this objective, the Partnership aims to
establish and maintain processes through which these groups can collaborate
more effectively at the country level to curtail the spread of HIV and
sharply reduce AIDS? impact on human suffering and declines in human,
social, and economic development. The vision of the Partnership is that
African nations with the support of the international community will
implement and sustain larger- scale, more effective multisectoral national
responses to HIV/ AIDS within the next decade than they have in the past.

According to the Partnership?s guiding document , The International
Partnership Against AIDS in Africa: A Framework for Action, dated May 2000,
each partner has a specific role to play. African governments are expected
to provide national leadership and adequate resources to fight HIV/ AIDS in
their respective countries. U. N. organizations are expected to enhance U.
N. coordination and the global response and to provide program and financial
support. Donors are expected to mobilize national and international efforts
and to provide the necessary financial assistance to support the
Partnership?s actions to address HIV/ AIDS. The private sector is expected
to provide expertise and resources, and the community sector is expected to
enhance local ownership of the Partnership. In addition, all partners have a
role in advocacy, policy development, and resource mobilization. The UNAIDS
Secretariat facilitated the development of the Partnership?s framework and
is responsible for

1 The Partnership defines the private sector as including diverse groups
such as national and multinational corporations, pharmaceutical firms,
charitable foundations, and trade unions.

2 The Partnership?s definition of the community sector includes national and
international nongovernmental organizations, community- based organizations,
religious organizations, traditional healers, youth organizations, women?s
networks, networks of people with HIV/ AIDS, media houses, and special
interest groups. Appendix I: Status of the International

Partnership Against AIDS in Africa

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

Page 29 GAO- 01- 625 Global Health

coordinating the implementation of the Partnership. The Secretariat is not
responsible for providing funding to the Partnership.

According to the UNAIDS Secretariat, the Partnership has achieved many of
its milestones and has made some progress toward achieving its objectives.
For example, one of the Partnership?s milestones was that, by the end of
2000, at least 12 countries were to have developed national strategic plans
for HIV/ AIDS, and according to the Secretariat, a total of 13 countries had
achieved this goal. For example, the Partnership helped develop the National
Strategic Plan for HIV/ AIDS in Ghana and Burkina Faso and helped revise the
national strategic plans of Ethiopia, Malawi, Zambia, and Mozambique.
According to the Secretariat, these plans have resulted in the formation of
wider and more effective partnerships to combat HIV/ AIDS and have
encouraged increased internal and external mobilization of financial
resources. Also, the UNAIDS? intercountry team in eastern and southern
Africa helped establish technical networks on five subjects, including
traditional medicine and AIDS counseling, and the intercountry team in
Abidjan, Cote d?Ivoire, helped establish networks on three subjects, as
expected, by December 2000. According to the Secretariat, progress is still
being made toward milestones that had not been met as of January 2001.

However, several respondents to our survey of U. S. Agency for International
Development (USAID) missions expressed reservations about whether HIV/ AIDS-
related events occurring in the country could be directly attributed to the
Partnership, since the Partnership is an enhancement of UNAIDS? and other
partners? ongoing efforts in Africa. For example, USAID officials in Malawi
stated that the Partnership?s collaborative principles have been implemented
in that country since 1997, which was prior to the Partnership?s inception.
The Secretariat also gives the Partnership credit for increases in World
Bank loans and bilateral funding that have been announced by several
bilateral donor countries, including the United States, Sweden, Canada,
Norway, and Japan. While these events may have coincided with the
implementation of the Partnership, a true cause and effect relationship is
difficult to establish.

Officials from USAID and the cosponsors have said that there is confusion
about the Partnership and concern about its implementation. USAID agency
officials said that the Partnership is poorly implemented and that there is
general confusion within their own and other agencies, especially about how
the Partnership will be implemented in country. For example, they had
recently spoken to one cosponsor?s representative to UNAIDS who thought that
the Partnership had ended. A member of the U. S.

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

Page 30 GAO- 01- 625 Global Health

delegation to UNAIDS? governing board told us that the Partnership generally
lacked coordination among the five partners. Several cosponsor officials
also indicated that there was confusion about the Partnership. One cosponsor
told us that the Partnership did not have much substance beyond its guiding
document and that their country- level offices in subSaharan Africa may be
unaware of the Partnership. Agency officials stated that the UNAIDS
Secretariat needs to provide the Partnership with greater leadership.

In our survey of USAID missions in African countries 3 key partners in the
Partnership?s coordination efforts we asked whether the Partnership had
achieved its objective to increase coordination among the five partners and
expand their efforts against HIV/ AIDS in Africa. Two of the 10 USAID/
Africa missions that responded to this inquiry said that the Partnership had
resulted in better coordination, 3 said it had not, and 5 did not know. Of
those that did not know, the USAID mission in Kenya said that the
Partnership was not well understood and that they had not heard much about
it. We also asked whether the Partnership had resulted in an expanded
response to HIV/ AIDS. Of the 10 responding, 4 answered yes, 3 said no, and
3 did not know. The USAID mission in Ghana reported that the Partnership had
contributed to increased media attention on HIV/ AIDS and more programs
addressing the epidemic. However, the USAID mission in Tanzania reported
that the Partnership was duplicating existing national programs and
hindering constructive efforts to combat HIV/ AIDS in that country.

One factor that may contribute to the confusion and lack of coordination
among partners is that, while the framework identifies the partners, their
responsibilities, and the deadlines of some objectives and activities, it
does not identify who is responsible or accountable for initiating the
Partnership at the country level or the actions that should be taken if this
leadership is not forthcoming. For example, a respondent to our survey from
the USAID mission in Zimbabwe said that no one person or organization is
leading the Partnership at the country level and thus nothing is being
accomplished. A senior Secretariat official agreed that the Secretariat has
been weak in communicating effectively about the Partnership. However,
according to this official, the Secretariat is in the

3 The 10 USAID missions that replied to our survey questions on the
Partnership are in Benin, Ethiopia, Ghana, Kenya, Madagascar, Malawi,
Mozambique, Uganda, Zambia, and Zimbabwe. The missions located in Eritrea
and Tanzania did not answer our survey questions but did provide general
comments about the Partnership.

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

Page 31 GAO- 01- 625 Global Health

process of developing additional guidance on coordination for countrylevel
partners, which will be based on lessons learned by partners in several
countries, such as Burkina Faso and Tanzania, that have task forces to lead
coordination efforts. The Secretariat is in the process of synthesizing
these experiences and developing additional guidance for the Partnership.

Appendix II: Objectives, Scope, and Methodology

Page 32 GAO- 01- 625 Global Health

The Chairman of the Senate Subcommittee on African Affairs, Senate Foreign
Relations Committee, requested that we (1) assess the progress of the Joint
United Nations Programme on HIV/ AIDS, especially at the country level,
toward increasing the coordination and commitment of the U. N. and global
community; (2) assess UNAIDS? progress in providing technical support and
information and in developing a monitoring and evaluation plan to measure
results; and (3) identify factors that may have affected UNAIDS? progress.
In addition, we were asked to provide information on the status of the
International Partnership Against AIDS in Africa.

To identify whether UNAIDS has made progress toward increasing U. N.
coordination and commitment, especially at the country level, we interviewed
senior officials from the UNAIDS Secretariat in Geneva, Switzerland, and the
HIV/ AIDS staff from each of the seven cosponsors. We also spoke with key
officials from the U. S. Agency for International Development (USAID); the
White House Office of National AIDS Policy; Department of Health and Human
Services; the State Department; U. S. missions to the United Nations in New
York City and Geneva; and Family Health International, a U. S.- based
contractor working on HIV/ AIDS issues. We reviewed extensive documentation
from the Secretariat and from each of the seven UNAIDS cosponsors, including
strategic plans, annual and biennial reports, progress reports, the Unified
Budget and Workplan 20002001, 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 1 that provided

1 USAID missions completed the survey or provided comments on theme groups
covering Uganda, Zimbabwe, Madagascar, Zambia, Kenya, Benin, Malawi,
Ethiopia, Eritrea, Senegal, Ghana, Mozambique, Bolivia, Guyana, Peru, El
Salvador, Jamaica, Nicaragua, Honduras, Haiti, Guatemala, Ukraine, Russia,
Romania, Central Asian Region (Kazakhstan, Kyrgyzstan, Tajikistan,
Turkmenistan, Uzbekistan), Armenia, and Georgia. Appendix II: Objectives,
Scope, and

Methodology

Appendix II: Objectives, Scope, and Methodology

Page 33 GAO- 01- 625 Global Health

perspectives on the theme groups? effectiveness in assisting host country
efforts to combat HIV/ AIDS. Of the total 82 USAID missions worldwide, we
selected 36 missions to survey, on the basis that they had been involved in
HIV/ AIDS activities for at least 2 years.

To determine UNAIDS? progress in providing technical support and information
and in developing a monitoring and evaluation plan to measure results, we
interviewed senior officials from the UNAIDS Secretariat in Geneva, and key
officials from USAID, the U. S. mission to Geneva, the Department of Health
and Human Services, and Family Health International. We reviewed extensive
documentation from UNAIDS, including governing board documents reporting on
annual and biennial progress; monitoring and evaluation documents, including
the Unified Budget and Workplan 2000- 2001, the monitoring and evaluation
framework, and commissioned evaluations of the Inter- country Team in West
and Central Africa; the Secretariat?s best practice materials; and the
Secretariat?s strategic planning and development fund process. We also
reviewed a UNAIDS?- commissioned survey of 12 of its leading bilateral
donors, issued September 2000, that solicited perspectives on the extent to
which UNAIDS has been successful in its roles and responsibilities, as well
as a UNAIDS biannual epidemiological report. In addition, in assessing
UNAIDS? monitoring and evaluation efforts, we used the principles contained
in the Government Performance and Results Act of 1993 to identify the key
elements of a successful performance- based system.

To identify factors that may have affected UNAIDS? progress, we interviewed
key officials from the UNAIDS Secretariat, cosponsors, USAID, the Department
of Health and Human Services, the State Department, the U. S. missions to
the United Nations in New York and Geneva, and Family Health International.

To determine the status of the International Partnership Against AIDS in
Africa, we held discussions with UNAIDS Secretariat and cosponsor officials
and also with officials from USAID, the U. S. mission to the United Nations
in Geneva, and the Department of Health and Human Services. We reviewed key
documents, such as the Partnership?s framework for action, progress reports,
weekly bulletins, and meeting reports. In addition, we reviewed an analysis
completed by the Secretariat in January 2001 on the Partnership?s progress
toward its milestones, as outlined in the framework. As part of our survey
of UNAIDS? efforts at the country level, we asked USAID mission officials
whether the Partnership had achieved its objectives. From the 22 missions
surveyed in Africa, we received 12

Appendix II: Objectives, Scope, and Methodology

Page 34 GAO- 01- 625 Global Health

responses, 2 10 that answered our survey questions and 2 that provided other
comments.

We conducted our work from August 2000 through May 2001 in accordance with
generally accepted government auditing standards.

2 The 12 countries were Benin, Ethiopia, Eritrea, Ghana, Kenya, Madagascar,
Malawi, Mozambique, Tanzania, Uganda, Zambia, and Zimbabwe.

Appendix III: Cosponsors? HIV/ AIDS Programs and Activities

Page 35 GAO- 01- 625 Global Health

UNAIDS is expected to bring together the efforts and resources of seven U.
N. system organizations to help prevent new HIV infections, care for those
already infected, and mitigate the impact of the pandemic. Each cosponsor is
to contribute to UNAIDS? work according to its comparative advantage and
expertise. The following briefly describes the seven cosponsors? HIV/ AIDS
programs and selected activities, according to information they provided.

The mission of the U. N. Children?s Fund (UNICEF) is to advocate for the
protection of children?s rights, to help meet their basic needs, and to
expand their opportunities to reach their full potential. UNICEF supports
services to the poor, rebuilds schools in war- torn societies, and promotes
equal rights for girls and women. Within UNAIDS, UNICEF is the chief
advocate for children and their families. UNICEF?s goal is to address the
underlying causes of the AIDS epidemic; reduce the vulnerability of
children, adolescents, and women to HIV/ AIDS; and mitigate the impact of
disease and death due to AIDS. According to UNICEF, it supports HIV/ AIDS
programs in 160 countries and focuses its efforts in five areas: (1)
breaking the conspiracy of silence about HIV/ AIDS, (2) providing primary
prevention to young people, (3) reducing mother- to- child HIV transmission,
(4) caring for orphans and children living in families affected by HIV/
AIDS, and (5) supporting UNICEF staff members affected by HIV/ AIDS. For
example, in the area of primary prevention to young people, UNICEF is
funding scouting groups in Cote d?Ivoire to disseminate HIV/ AIDS prevention
messages through games, songs, and popular drama and to provide counseling
to their peers. In 1999, to help reduce mother- tochild transmission, 11
countries took part in a UNICEF- supported pilot program that offers
voluntary and confidential counseling and testing to women and their
partners, administers anti- retroviral medication to pregnant HIV- positive
women, and provides information about infant feeding options. In Malawi,
UNICEF has assisted the government in developing its national orphan policy
and the National Orphan Care Programme, which emphasizes family- based care
and provides support to extended families for the care of orphans.

The goal of the U. N. Development Programme is to eradicate poverty through
sustainable human development. The Programme serves more than 170 countries
and territories around the world through 132 country offices and technical
networks. The Programme contributes to UNAIDS by helping developing
countries meet the governance challenge posed by HIV/ AIDS and by helping
them mitigate the impact of the disease on the Appendix III: Cosponsors?
HIV/ AIDS

Programs and Activities United Nations Children?s Fund

United Nations Development Programme

Appendix III: Cosponsors? HIV/ AIDS Programs and Activities

Page 36 GAO- 01- 625 Global Health

poor. The Programme provides advice and development services to developing
country governments and civil society groups in the following areas: (1)
promoting top- level political commitment through advocacy and policy
dialogue; (2) strengthening countries? capacity to plan, fund, manage, and
implement national responses to the HIV/ AIDS epidemic; (3) providing
guidance on integrating HIV/ AIDS priorities into the core of development
planning; and (4) providing policy advice to the most affected countries on
maintaining governance structures and essential services affected by HIV/
AIDS. In addition, the Programme promotes a human rights approach that
includes helping national governments formulate anti- discrimination laws
and supports public information and media campaigns on HIV/ AIDS in
developing countries such as Bangladesh, Peru, Laos, and Turkmenistan. In
several sub- Saharan African countries, the Programme is sponsoring policy
studies to help governments deal with HIV/ AIDS? impact on specific sectors,
poverty reduction efforts, and macroeconomic planning. In Botswana, the
Programme supported the publication of a National Human Development Report
that focused on how HIV/ AIDS is reducing economic growth and increasing
poverty in that country.

The mission of the U. N. International Drug Control Programme is to work
with nations and people worldwide to tackle the global drug problem and its
consequences. Through its 22 field offices, the Programme contributes to
UNAIDS?s work by helping to prevent the spread of HIV through drug abuse.
The Programme?s prevention activities have focused primarily on children and
adolescents and emphasize the prevention of both drug use and the risky
sexual behaviors associated with drug use. For example, in Brazil, the Drug
Control Programme developed short prevention videos, which are shown in the
streets in regions with the highest crack use, to target drug abuse among
street children. In Thailand, in coordination with U. N. Population Fund,
the Programme is supporting activities that are aimed at educating Muslim
adolescents on reproductive health, drug abuse prevention, and HIV/ AIDS.

The mandate of the U. N. Educational, Scientific, and Cultural Organization
(UNESCO) is to foster international cooperation in intellectual activities
designed to promote human rights, establish a just and lasting peace, and
further the general welfare of mankind. UNESCO has 73 field offices and
units in different parts of the world. In the context of UNAIDS, UNESCO
focuses its efforts on five major areas: (1) education, (2) basic research,
(3) culture, (4) human rights and social and human sciences, and (5) United
Nations

International Drug Control Programme

United Nations Educational, Scientific, and Cultural Organization

Appendix III: Cosponsors? HIV/ AIDS Programs and Activities

Page 37 GAO- 01- 625 Global Health

public information and awareness. For example, in Brazil, UNESCO is
currently cooperating with the U. N. International Drug Control Programme
and the Brazilian Health Ministry to provide HIV education in schools to
heighten awareness of HIV and prevent its transmission. In south Asia,
UNESCO published a media handbook on AIDS in eight different south Asian
languages. UNESCO also has been active in promoting research on AIDS in
cooperation with the World Foundation for AIDS Research and Prevention.

The primary mandate of the U. N. Population Fund is to help ensure universal
access by all couples and individuals to high- quality reproductive health
services by 2015. In developing countries, the Fund works to improve
reproductive health and family planning services on the basis of individual
choice and to formulate population policies in support of sustainable
development. The Population Fund supports HIV/ AIDS activities in 138
countries. The Fund addresses the prevention of HIV transmission and focuses
on (1) supporting information, education, and communication programs for
youth and adolescents both in and out of schools; (2) providing young people
greater access to youth friendly reproductive health information,
counseling, and services; (3) advocating for relevant youth policies that
recognize the rights of young people and promote their reproductive health;
and (4) addressing gender equity issues. The Population Fund is the largest
international supplier of condoms and is UNAIDS? focal point for condom
programming. The Fund manages a database on reproductive health commodities
and administers the Global Contraceptive Commodity Programme, which
maintains stocks of condoms to expedite delivery to requesting countries.
The Fund also works to promote the greater involvement of men in HIV
prevention. For example, in parts of Africa, Asia, and Central America, the
Fund supports services, information, and counseling to encourage long-
distance truck drivers to adopt safer sexual practices. In addition, the
Fund has been working with government and national partners to promote
programs and policies that advance reproductive health and well- being. For
example, in the Islamic Republic of Iran, the Fund, in conjunction with the
Ministry of Education, helped distribute 700,000 copies of a poster on HIV/
AIDS transmission and prevention along with 200,000 copies of a pamphlet
designed for teachers to schools nationwide.

WHO?s objective is to attain the highest possible levels of health by all
peoples. WHO performs a range of advisory, technical, and policy- setting
functions, including (1) providing evidence- based guidance in health; (2)
United Nations Population

Fund World Health Organization

Appendix III: Cosponsors? HIV/ AIDS Programs and Activities

Page 38 GAO- 01- 625 Global Health

setting global standards for health; (3) cooperating with governments in
strengthening national health systems; and (4) developing and transferring
appropriate health technology, information, and standards. As a UNAIDS
cosponsor and the leading international health agency, WHO works to
strengthen the health sector?s response to the worldwide HIV/ AIDS epidemic
and provide technical assistance to countries to improve their health
policies, planning, and implementation of HIV/ AIDS prevention and care
interventions. For example, according to WHO, it has supported and
coordinated research and provided technical support on HIV/ AIDS- related
issues such as the prevention and treatment of sexually transmitted
infections, reproductive health, essential drugs, vaccine development, blood
safety, and substance use. WHO has also developed a generic protocol for
planning and implementing pilot projects to prevent motherto- child
transmission of HIV in low- income countries in Africa, Asia, and Latin
America. In addition, WHO has projects in several countries with high HIV
prevalence to develop national plans and implement activities for
strengthening care and psychosocial support to people living with HIV/ AIDS.
WHO is a key partner in global surveillance of HIV infection and its
behavioral determinants, including developing surveillance guidelines,
updating the global database on HIV/ AIDS, and producing fact sheets and
reports on HIV/ AIDS.

The mandate of the World Bank, the world?s largest source of development
assistance, is to alleviate poverty and improve the quality of life. Through
its loans, policy advice, and technical assistance, the World Bank supports
a broad range of programs aimed at reducing poverty and improving living
standards in the developing world. As a UNAIDS? cosponsor, the World Bank
provides loans and credits to national governments to implement HIV/ AIDS
programs. The World Bank committed more than $1.3 billion to 109 HIV/ AIDS-
related projects in 57 countries from 1986 to the end of January 2001. A
recent innovation in the Bank?s support to HIV/ AIDS is its multicountry
program approach to lending. In September 2000, the World Bank approved the
Multi- Country HIV/ AIDS Program for Africa, providing $500 million in
flexible and rapid funding for projects to fight the epidemic in sub-
Saharan Africa. 1 A similar multicountry program totaling about $100 million
in loans and credits for

1 The figure of $1. 3 billion in commitments includes $288 million in
specific country commitments as of the end of January 2001. Adding the $500
million Multi- Country AIDS Program for Africa would bring the Bank?s total
commitment for HIV/ AIDS to more than $1.5 billion. The World Bank

Appendix III: Cosponsors? HIV/ AIDS Programs and Activities

Page 39 GAO- 01- 625 Global Health

the Caribbean is under way. To strengthen the Bank?s capacity to respond to
HIV/ AIDS as a major development issue in Africa, the Bank created
ACTAfrica, a dedicated HIV/ AIDS unit directly under the Office of the
Regional Vice Presidents. In addition to lending in all regions of the
world, the Bank is also involved in policy dialogue about HIV/ AIDS with
highlevel officials in the government and civil society. It is also working
with the U. S. Treasury to establish the International AIDS Trust Fund for
HIV/ AIDS activities in those countries hardest hit by the epidemic or at
high risk of being so. The United States is providing $20 million to
initially capitalize the fund, and contributions will be sought from other
donors.

Appendix IV: Comments From the Department of State

Page 40 GAO- 01- 625 Global Health

Appendix IV: Comments From the Department of State

Appendix IV: Comments From the Department of State

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Appendix IV: Comments From the Department of State

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

Page 43 GAO- 01- 625 Global Health

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

Note: GAO comments supplementing those in the report text appear at the end
of this appendix.

Now on p. 25.

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

Page 44 GAO- 01- 625 Global Health

See comment 1.

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

Page 45 GAO- 01- 625 Global Health

Now on pp. 22 to 24.

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

Page 46 GAO- 01- 625 Global Health

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

Page 47 GAO- 01- 625 Global Health

The following is GAO?s comment on USAID?s letter dated May 11, 2001. In
commenting on our first recommendation, USAID suggested that it is not the
U. S. representatives? role on the cosponsors? executive boards to

?propose? initiatives to the cosponsors but rather to ?request? them to take
action. We modified the recommendation to address this point. GAO Comment

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

Page 48 GAO- 01- 625 Global Health

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

Note: GAO comments supplementing those in the report text appear at the end
of this appendix.

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

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

Page 50 GAO- 01- 625 Global Health

See comment 2. See comment 1.

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

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See comment 4. See comment 3.

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

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See comment 5.

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

Page 53 GAO- 01- 625 Global Health

See comment 8. See comment 7.

See comment 6.

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

Page 54 GAO- 01- 625 Global Health

See comment 9.

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

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See comment 11. See comment 10.

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

Page 56 GAO- 01- 625 Global Health

See comment 12.

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

Page 57 GAO- 01- 625 Global Health

See comment 13.

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

Page 58 GAO- 01- 625 Global Health

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

Page 59 GAO- 01- 625 Global Health

The following are GAO?s comments on UNAIDS? letter dated May 14, 2001. 1.
UNAIDS commented that they disagreed with our use of a response from the
donor survey to support our finding that their efforts at the country level
were weak. The donor survey stated that half of the donors responding (the
survey was sent to 16 of UNAIDS? leading bilateral donors, and 12 responded)
believed that UNAIDS was not as successful as expected in promoting broad-
based political and social commitment at the country level. We did not rely
solely on the donor survey; other evidence corroborates the donor?s concern
about UNAIDS? performance at the country level. First, the donor survey also
found that donors believed that UNAIDS had not been as successful as they
expected in strengthening governments? HIV/ AIDS activities and ensuring
that appropriate and effective policies and strategies are implemented to
address HIV/ AIDS. Second, the Secretariat?s latest annual surveys of theme
groups showed that, between 1997 and 1999, theme groups had made little
progress in key areas, such as joint advocacy action plans and developing a
U. N. system integrated plan on HIV/ AIDS. Our December 2000 survey of USAID
missions showed that, after 5 years of experience, theme groups' performance
in strengthening the overall national government response to HIV/ AIDS
varied widely. Third, senior UNAIDS officials and members of the UNAIDS
governing board stated in December 2000 that UNAIDS needed to improve its
country- level response. The governing board said that the performance of
UNAIDS? theme groups required urgent attention, and UNAIDS' Executive
Director said that strengthening UNAIDS? countrylevel efforts is one of
UNAIDS? top internal challenges. This collective evidence demonstrates that
UNAIDS must strengthen its efforts at the country level.

2. While UNAIDS agreed with our finding that country- level efforts need to
be strengthened, it also commented that we placed too much emphasis on theme
group efforts at the country level without considering broader U. N.
systemwide efforts. We recognize that there are broader U. N. efforts, such
as the Resident Coordinator System and the Common Country Assessment/ United
Nations Development Assistance Framework process. However, UNAIDS? documents
state that UNAIDS? theme groups are its

?main mechanism? for coordinating HIV/ AIDS activities at the country level.
Our analysis therefore focused on this mechanism.

3. UNAIDS commented that we did not credit the U. N. Development Programme
for actions taken as a result of an HIV/ AIDS program evaluation, prepared
in 2000, which found that the agency had not fully GAO Comments

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

Page 60 GAO- 01- 625 Global Health

integrated HIV/ AIDS into its strategies, programs, and activities. We
revised the report to include updated information on action taken in
response to the evaluation.

4. UNAIDS was concerned that we did not reflect the cosponsors? creation of
new positions and units focused on HIV/ AIDS and cited numerous examples of
these changes. While we may not have cited every example of actions taken by
the cosponsors, we did recognize that some cosponsors had elevated the
position of the HIV/ AIDS issue organizationally and provided an example. We
revised the report to include an additional example of steps taken by the U.
N. Children?s Fund.

5. UNAIDS commented that, while they agreed that country- level coordination
and implementation needs strengthening, we had downplayed how much progress
the United Nations has achieved in coordinating action at the country level.
UNAIDS stated that we did not sufficiently credit them for the Global
Strategy Framework, regional strategy development processes, partner
programme reviews, improved cosponsor responses to HIV/ AIDS, and a greater
understanding of the epidemic at the country level. UNAIDS comments also
provided additional examples of activities they believed contributed to an
enhanced countrylevel response. We disagree that we downplayed UNAIDS?
efforts. For example, our report credits UNAIDS for facilitating the
development of U. N. System Strategic Plan and conducting the detailed
reviews of the cosponsors? HIV/ AIDS programs (Partner Programme Reviews),
as well as for the cosponsors? improved commitment and response to HIV/
AIDS. The report does not discuss the Global Strategy Framework on HIV/ AIDS
because it has only recently been finalized and thus it is too soon to gauge
whether this document will increase international commitment, action, or
results. Also, in the absence of an effective monitoring and evaluation plan
that has clear performance indicators, it is difficult to isolate UNAIDS
contributions from those of the many entities working at the country level
to combat HIV/ AIDS, including national governments, bilateral donors,
nongovernmental organizations, and foundations.

6. UNAIDS stated that we characterized theme group responsibilities too
broadly and that it was never envisioned that U. N. theme groups would serve
as an operational entity or as the primary mechanism for assisting
developing countries. Our report clearly explains the role of the theme
groups in the background section and elsewhere as, among other things, a
facilitator for coordinating the U. N. response at the country level. This
characterization came from UNAIDS documents that state: ?In developing
countries, UNAIDS operates mainly through the country- based staff of its

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

Page 61 GAO- 01- 625 Global Health

seven cosponsors. Meeting as the host country?s U. N. Theme Group on HIV/
AIDS, representatives of the cosponsoring organizations share information,
plans and monitor coordinated action?.?

7. UNAIDS commented that theme groups are not responsible for resource
mobilization. However, UNAIDS provided us the Resource Guide for Theme
Groups, which devotes one of its five sections to resource mobilization.
This section states that ?resource mobilization at the country level is a
key role of the Theme Group.? To avoid any confusion, we modified the text.

8. UNAIDS noted that our report lacked clarity with regard to the role of
the Country Programme Advisor and the operation of the Programme
Acceleration Funds. To avoid any confusion about the Country Programme
Advisor?s role, we modified the text. The information we presented in the
report on the operation of the Programme Acceleration Funds was taken
directly from UNAIDS documents- primarily the 1999 evaluation of the funding
process.

9. UNAIDS provided information on the additional number of integrated U. N.
workplans that have been prepared, to demonstrate the progress theme groups
have made in developing a more unified U. N. response to HIV/ AIDS. However,
we were not able to corroborate this information. In addition, while the
information UNAIDS presented shows the number of workplans completed, it
does not indicate the quality and content of the plans and the extent to
which they have been implemented.

10. UNAIDS provided more current information on action taken to strengthen
the performance of theme groups and Country Programme Advisors-- the
Secretariat?s country- based staff. We revised the report to highlight some
of these actions.

11. UNAIDS stated that the Unified Budget and Workplan 2000- 2001 includes
quantifiable performance targets. However, UNAIDS did not provide specific
examples of such targets with its comments. In examining UNAIDS? Unified
Budget and Workplan in detail during our review, we noted that it contained
outcome indictors. However, the workplan did not identify specific
performance baselines, targets, or other measures that would enable UNAIDS
to determine whether it had succeeded in its efforts and measure progress
toward its objectives.

12. UNAIDS commented that its overall monitoring and evaluation plan
included several one- time evaluations of specific efforts, such as UNAIDS?

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

Page 62 GAO- 01- 625 Global Health

development of best practices. We revised the report to clarify that UNAIDS
considers these one- time evaluations part of its overall monitoring and
evaluation plan.

13. UNAIDS raised several concerns about the report?s methodology and
presentation. First, UNAIDS commented that the report focused too much on
the findings contained in our 1998 report and did not adequately credit
UNAIDS for the progress it has made. We disagree. We believe we have given
credit to UNAIDS for progress in a number of areas, several of which were of
specific concern in our 1998 report. For example, the report highlights
increased U. N. and international commitment and funding to HIV/ AIDS
efforts, as well as a broadened approach to addressing HIV/ AIDS from one
that was exclusively health oriented to one that is now multisectoral.
Further, the report notes the progress made on technical support and best
practices, tracking the epidemic, and increasing U. N. coordination.
However, our report also focused on those areas most needing improvement-
namely, UNAIDS? country- level efforts and monitoring and evaluation of
UNAIDS? progress and results. These are areas that the Department of State,
USAID, and UNAIDS agree need improvement. Where appropriate, we have
modified our report and included some additional information.

Second, UNAIDS commented that the report will be out of date by the time it
is issued. We disagree. The changing political climate surrounding HIV/ AIDS
issues does not negate the report?s conclusions and recommendations. For
example, UNAIDS? comments stated that not only did they agree that HIV/
AIDS- related efforts at the country level need strengthening but that these
efforts will certainly remain the central theme for ?at least the next
decade.? Furthermore, the current debate to establish a $7 billion to $10
billion global trust fund to address the HIV/ AIDS crisis in developing
countries makes the issues cited in our report even more timely and
critical. The challenges UNAIDS faced in mobilizing international support
for HIV/ AIDS efforts, marshalling donors? financial commitments, and
establishing a system to evaluate program results are important lessons
learned that should inform the current debate on a new global AIDS trust
fund. UNAIDS? comments also noted that documentation used to support the
report was largely constructed with data compiled from the previous year. We
used the most current data supplied by UNAIDS and other information to
conduct our analysis, including several of UNAIDS? and its governing board?s
commissioned evaluations. In addition, we conducted our own survey of USAID
missions to obtain perspective on UNAIDS? country- level efforts in December
2000.

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

Page 63 GAO- 01- 625 Global Health

Third, UNAIDS noted that the report contained selective quotations from
several of UNAIDS? evaluations and surveys of specific functions, at the
same time pointing out that UNAIDS? monitoring and evaluation efforts are
insufficient. We believe our use of available data and information contained
in UNAIDS? evaluations was appropriate for depicting the steps taken in and
weaknesses of UNAIDS? efforts. However, while this information was useful,
it does not provide the results of UNAIDS? overall efforts or progress made
toward its objectives. With bilateral and other donors responding to UNAIDS?
call for increased resources to combat HIV/ AIDS, a quality monitoring and
evaluation effort, which includes a clearly defined mission, long- term
strategic and short- term goals, measurement of performance against defined
goals, and public reporting of results, is even more important.

Appendix VII: GAO Contact and Staff Acknowledgments

Page 64 GAO- 01- 625 Global Health

John Hutton (202) 512- 7773 In addition to Mr. Hutton, Leslie Bharadwaja,
Sharon Caudle, Lynn Cothern, Francisco Enriquez, Aleta Hancock, Lynne
Holloway, Stanley Kostyla, and Hector Wong made key contributions to this
report. Appendix VII: GAO Contact and Staff

Acknowledgments GAO Contact Acknowledgments

(711538)

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