The Role of UNGASS Declaration of Commitment in the Fight Against HIV/AIDS in Africa: Can We Sustain the Momentum? -ICAD, Canada ***************************************** The Role of UNGASS Declaration of Commitment in the Fight Against HIV/AIDS in Africa: Can We Sustain the Momentum? [Moderator's note- The following is a paper presented by Dr. Roland Msiska at the National Press Club in Ottawa, Canada. Dr. Roland Msiska is the Project Director for UNOPS executed UNDP Regional Project on HIV and Development in sub-Saharan Africa-Pretoria, South Africa. Dr. Msiska was speaking at the Annual General Meeting of the Interagency Coalition on AIDS and Development (ICAD)-September 27, 2002.] Introduction The United Nations General Assembly Special Session on HIV/AIDS (UNGASS) held in June 2001 is a political milestone in the 20 years since the global response to HIV/AIDS first emerged. Governments from 189 countries committed themselves to a comprehensive program of action to fight HIV/AIDS by adopting the declaration of commitment on HIV/AIDS, which has time-bound targets. This declaration will serve to galvanize global, regional and national actors to respond in coordinated and comprehensive way to what is considered a serious obstacle to the realization of the global development goals adopted at the millennium summit of the United Nations. In the past, resolutions of this kind have not borne the desired fruit; this has largely been the result of insignificant resources to take action in areas that require financing, especially in sub-Saharan Africa, where the majority of those with HIV and AIDS live. This time around, the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM) has been created to facilitate the implementation of UNGASS. The GFATM is already operational and, by April 25, 58 out of more than 300 proposals were approved for funding. This Fund provides a catalyst to ensure that this resolution produces desired changes in the world in general and, more significantly, in sub-Saharan Africa. In order to contextualize for Africa the events preceding UNGASS: the African Development Forum (ADF 2000) was organized by the Economic Commission for Africa and focused on leadership in responding to AIDS in Africa. This event brought together political and religious leaders, and youth, to debate on how to move the continent forward in responding to the devastationof AIDS. This was followed by the Abuja Declaration on AIDS, Tuberculosis and other related infectious diseases, where Heads of State from Africa committed themselves to provide the required political leadership and increase expenditure towards health to the level of 15% of national budgets. From the events of the last two years, one can confidently conclude that a measure of momentum has been generated by UNGASS and the creation of the GFATM for an effective well coordinated response to HIV, especially in Africa. But one has to be cautious: we live in a world of competing global, regional and national agendas, and AIDS could easily slip away from the world development radar. It is not a secret that commitment towards responding to AIDS varies from country to country both in poor and wealthy nations my particular concern is basically how do we ensure that the momentum that has been generated by UNGASS and GFATM is sustained, but, even more importantly, how can we ensure that these commitments are translated into program actions that will make a difference to the spread of HIV, and, at the same time provide the needed compassionate care for those already living with HIV and AIDS. This paper attempts to contribute to potential ways of ensuring that this momentum is increased and sustained for at least 20 years. In order to achieve this, I am suggesting that we respond to the following questions: (a). What is the current situation of HIV/AIDS and what are the implications for achieving the global millennium goals? (b). What are the key areas of focus for sustaining the momentum of UNGASS implementation at global, regional and national levels? (c). How can we ensure that the GFATM facilitates the implementation of UNGASS at global, regional and national levels? (d). How can we ensure that wealthy nations facilitate countries in the sub-Saharan Africa to meet UNGASS commitments? What is the overview of the HIV/AIDS situation in the world? At the end of 2001, UNAIDS estimates that a total of 40 million adults and children were living with HIV/AIDS in the world. Although sub-Saharan Africa has less than 10% of the world’s population, 70% of people living with HIV/AIDS are in sub-Saharan Africa. In 2001 alone it has been estimated that 3 million people died from AIDS globally, and about 2.3 million were from sub-Saharan Africa where AIDS is now the number one cause of death. The disease presents an unbearable burden on all those affliectedyet the problem with AIDS related deaths is that they are not as politically visible as deaths from floods, cholera, famine, or conflict. These deaths are easily ignored by those in positions of authority. The challenge is how to ensure that AIDS deaths become as politically visible as other conditions in the region. The consequences of increased AIDS related mortality and illnesses in the 15 to 49 age group include increases in orphaned children and child-headed households as well as erosion of key sectors of the economy. In high HIV prevalence countries, food security is threatened as adult labor drops. Health workers and teachers are dying faster than they can be replaced by existing training institutions. AIDS is causing a development crisis in sub-Saharan Africa. Its tentacles are reaching into Asia, Latin America, Caribbean and Eastern Europe. Although the full implications of AIDS related impacts on development are yet to be fully understood, we already know how, in high HIV prevalence countries, life expectancy is dropping, and mortality among children under five is on the increase. Although there have been controversies regarding the ultimate impact of AIDS on GDP, studies have clearly shown that, at the micro level, AIDS is going to have devastating impacts. And these impacts are going to make it difficult for countries with high HIV prevalence to reach the millennium goals, as the recent UNDP report reveals. The impact of AIDS in sub-Saharan Africa is real: AIDS is causing household poverty to increase. And yet, in this ocean of AIDS related devastation, we see hope as countries as diverse Senegal, Uganda and Zambia are either maintaining or reducing HIV prevalence associated with behavior change. But what is even more remarkable is the emergence of robust community based organizations and networks in the regions which have effected change at all levels of society. Here one is also encouraged by the position taken by the President of Botswana, who not only chairs the National AIDS Council, but has also made a point of ensuring that Government agencies are working together to respond to the devastating challenge of HIV and AIDS. This is in contrast to what is happening in some of its neighbouring countries. What are key areas of focus to sustain the momentum generated by UNGASS and GFATM? To expand, deepen and sustain the momentum that has been generated thus far, we need to focus on the following: Firstly, we must ensure a common understanding of what is expected of all the major stakeholders that are involved in the implementation of UNGASS. Some of the terminology used in the declarations are loadedthey require unbundling for those at the operational level to translate into actual programmes. I have in mind statements such as “political commitment”, “multi-sector response to HIV/AIDS” and many other such statements. In short, we need something like an idiot’s guide for translating UNGASS into action. It may also be important to provide in a rationale of why certain percentages where chosenis it model based or research based or purely consensus? Secondly, we must try to understand what were the political processes that led to the formulation of UNGASS in June 2001? This would be in form of who were the key actors? What were the messages and how were they delivered? How can one maintain these political processes so as to ensure that AIDS remains on the global, regional and national agenda? Here I find that we will need the help of our colleagues from political sciences to help us understand what is increasingly becoming a global movement to respond to AIDS and how it can be sustained for a long period. Thirdly, was there something in the economic environment that would have been responsible for this change of heart at global, regional and national levels? Are there economic parameters that one could monitor to see which direction the general global, regional and national opinion is going to move? If we understand these processes then we will be in position to develop strategic approaches using the economic environment as an entry point. How can we ensure that those who manage the global economy in the private or public sector understand that responding to AIDS makes economic sense? Here I am speaking beyond the elaborate socio-economic impact studies, which I have had the privilege of participating in, only to discover that the research is not responding to the questions that policy makers in the private and public sector are interested in. Fourthly, what social forces would have been at play in ensuring that AIDS is brought to the center of the global, regional and national agendas? Here I am thinking what was the contribution of various community based organizations in the formulation of UNGASS? Were these just loose coalitions that developed for this particular purpose and therefore cannot be used to expand or sustain the momentum generated? Fifthly, what role did the media play at global, regional and national levels that would have resulted in the formulation of UNGASS? Is it possible to engage the media in ways that ensures that AIDS is maintained as development agenda item, globally, regionally and nationally? Sixthly, what role did technological change play in accelerating the debate on AIDS globally, regionally and nationally? Here I am thinking of the impact of Anti-retroviral therapy on the response to HIV/AIDSespecially the high profile debates on access, costs, pricing, patents and the recent round of world trade negotiations. Anti-retroviral therapy has brought a new lease of life to the dialogue on HIV/AIDS, and it has brought to the surface the glaring differences in access: for example, out the estimated 6,000,000 who should have access to these drugs in the developing world, only 230,000 do have accessand half of these are from one country: Brazil. In my view, analyzing political, economic, social and technological factors and trends should be carried out at each level of the system so as to identify those areas which we should be focusing on to ensure that commitments made by various stakeholders in UNGASS are carried through. An annual meeting of non governmental organizations and other interested parties to review the trends with a view of taking corrective measures is a good example of such an approach. As part of our ongoing strategy for maintaining AIDS at the center of the development agenda in sub-Saharan Africa, we have developed key questions that policy makers from Government and non governmental organizations can use to help them understand the bi-directional relationship between AIDS and development efforts. For example: if a country is discussing a governance project, we encourage the policy makers to ask the following questions as part of the conceptualization of the project: (a). What is the impact of AIDS related deaths and illnesses on governance? And, therefore, what policies, strategies and actions should be put in place to minimize these impacts? (b). What activities in implementing the governance project would inhibit transmission of HIV in the community? And, therefore, what policies, strategies and actions should we put in place to encourage such actions? (c). What activities in implementing the governance project would facilitate transmission of HIV in the community? And, therefore, what policies, strategies and actions should be put in place to modify such actions? Using system and strategic planning methods, and tools from the private sector, we have been encouraging policy makers from government and non governmental organizations to change policies, strategies, and organizational arrangements so as to facilitate the bringing of AIDS to the center of their development efforts. This way we will ensure that we have development approaches in sub-Saharan Africa that will also result in the reduction of HIV transmission in the region. Now: if we ask ourselves whether UNGASS and GFATM made a difference in responding to AIDS in Africa, the answer is yes and no. Yes, when you consider what the situation was 10 years ago, and no, when you look at the size of the emergency versus current responses; nearly all governments in the region have declared AIDS as an emergency, and a majority of them have gone a step further and made the necessary organizational and financial arrangements to ensure a reversal of the HIV epidemic. For example, nearly all countries in the region have a national strategic plan that is multi-sector in nature. These plans are developed in a very participatory manner and include major stakeholders and can take up to 18 months from initiation of the process to the final product. A recent review of national strategic plans by UNAIDS shows that activities are not well costed, making it difficult to define the financial gap. One also finds that the concept of a multi-sector response means different things to different peoplein some cases it means expanding work place programs to other sectors, and very few attempts to foster a response include sector response based on comparative advantage. UNAIDS, in collaboration with the Regional Project, organized a workshop to look at how to improve the situation. The costing of these plans have become important given their need for external funding including World Bank loans and grants and the recent GFATM. Over 80% of countries in the Region now have in place structures meant to coordinate, monitor and evaluate the implementation of a multi-sector response to HIV/AIDS. The locating of these national coordinating agencies varies from country to country, with some still under the Ministry of Health, others in the Prime Minister’s office or the Vice-President’s office. In the last 10 years, many of these countries would organize resource mobilization events at the country level, with very limited success. For example countries like Tanzania and Zambia have sometimes only managed to raise 20% of the required amount to implement the national strategic plan. This is where GFATM properly applied could easily make a significant difference to the response on the continent. For this to be possible, it will be necessary to ask some very hard questions: will the strategies articulated in these plans, if implemented, result in a change in the AIDS situation? My preliminary analysis of current national strategic plans reveals no major differences between what is in the UNGASS declaration and what is reflected in the current national responses in sub-Saharan Africa. This could easily be explained by the fact that a majority of those who participated in the formulation of UNGASS had also been participants in the formulation of national strategic plans. This brings me to an important subject that I feel we must address on an annual basis: review whether the assumptions made in UNGASS, given our current understanding of the epidemic and the changing technology, are still valid. This is where I find the concept of building the ship while we sail being criticalthe need for constant revalidation of assumptions made in UNGASS is important, if we are to keep abreast with our increasing understanding of the epidemic. How can we ensure that GFATM facilitate the implementation of UNGASS? In order to ensure that GFATM facilitates the implementation of UNGASS, a number of steps have to be taken; Firstly, ensure that the current technical criteria for approval of country proposals take into account the elements and targets set in UNGASS. GFATM has already produced technical criteria for approving of proposals; we need to see how proposals which meet GFATM criterion when implemented would result in achieving UNGASS goals and targets. Secondly, develop a common framework for monitoring and evaluating proposal funded through GFATM and UNGASS. UNAIDS has already developed guidelines to monitor and evaluate country implementation of UNGASS targets. In order to avoid duplication of efforts at the country level, UNAIDS, GFATM and countries must agree on a common framework for monitoring and evaluating national responses to HIV/AIDS. Thirdly, the GFATM must open two windows for country proposals: one is what I would call the competitive windowthis is the one that will use the current approach. The second is the non-competitive window that has all those proposals that do not go through in the competitive windowa rapid assessment is carried out to identify whether the failure of a proposal is a reflection of poor capacity in the said country. And if the conclusion is made, with the concurrence of the country in question, that is the case, GFATM must then proceed to identify a global, regional or national institution that would implement a minimum required set of actions that would result in the reversing of the HIV/AIDS situation in that given country. Fourthly, in a majority of countries, issues constraining a multi-sector response to AIDS include such basic issues as logistics and supply. For example it is not uncommon to find in the most of remotest past of Africa Coca Colbut not condoms. One can see an opportunity at global level for GFATM to negotiate with Coca Cola to assist in the distribution of condoms as an in kind contribution. If Coca Cola were to provide 10% space in their delivery vehicles for condom distribution, the government could respond to HIV/AIDS in remote areas. This could also apply to strategic planningthe private sector, in general, has better expertise than the public sector. Fifthly, GFATM should not in any way replace local resource mobilization; a formula must be developed that treats resources from GFATM as complimentary to internal resource mobilization by governments and the private sector. For example: what would stop the GFATM board from insisting that services or products procured through the fund should be exempt from taxes as a local government contribution. One would also encourage Governments to use tax rebates as a system to stimulate private sector participation in the response to HIV/AIDS. As to how the GFATM will mobilize it own resources, I have, during preparation of this presentation, seen some remarkable recommendations. Sixthly, GFATM must now also be engaged in managing the expectations that have been generated through these processes. It is important that we are all very clear on the timelines required to achieve what is suggested in the UNGASS commitments. In my short years of working in this field I have seen how an excellent proposal has been thrown to the winds due to failure to manage the expectations of those involved. How can we ensure that wealthy nation facilitate the countries in the region to achieve the UNGASS commitments? Wealthy nations can facilitate countries in the region to achieve UNGASS targets by the following: Firstly, continued advocacy; the political leadership from wealthy nations must acquaint themselves with UNGASS declarations so that they are able to encourage their counterparts in the region. For example in the recent presentation of NEPAD in the United Nations General Assembly, if one of the politicians from the wealthy nations had indicated that their support to NEPAD is tied to Africa’s commitment to achieving the UNGASS targets, this would have brought AIDS to the center of African development agenda. Secondly, standardize project development, implementation and evaluation procedures at the country level for HIV in line with UNGASS targets. In developing donor supported programs on HIV/AIDS at country level, policy makers should, as much as is possible, take into consideration the general context of those areas from UNGASS that are relevant, so that the review process will also result in reviewing the country’s implementation of UNGASS targets and goals. Thirdly, one of the commitments made in UNGASS is the mobilization of between 7 to 10 billion US dollars. Each of the wealthy nations should contribute their allotted share, based on a formula that should be agreed upon within the framework of current UN resolutions. Fourthly, wealthy nations can facilitate the implementation of principles articulated in UNGASS through their country level programming by a careful use of project approval criteria and process. For example, a number of countries in the region may still find it difficult to work with civil society on HIV/AIDS related issues. The wealthy nations could include in their criteria for approving AIDS programs clarification that spells out civil society’s participation in terms of what proportion of resources should be used by civil society. Fifthly, wealthy nations supporting development projects at the country level should ensure that AIDS is taken into account at each stage of the projects. For example in high HIV prevalence countries, every project that is supported by the wealthy nations must determine how it is going to achieve its targets given the increase in AIDS related death and illness. Conclusion The UNGASS and the GFATM have generated the required momentum for coordinated global, regional and national response to HIV/AIDS. In a world of competing agendas, this momentum must be expanded and sustained by a clear understanding of the political, economic, social and technological processes that brought AIDS to centre of the global agenda, with the view to ensuring that these processes are maintained at each level of the system. Continued advocacy by bilateral and multi-lateral agencies in ensuring that the criteria for selecting proposals for the GFATM reflect some of the key elements of UNGASS will go a long way in ensuring that momentum is sustained and expanded. The standardization of the monitoring and evaluation framework for UNGASS and GFATM would further foster implementation at the country level. Wealthy nations would be expected not only to advocate but also contribute to the global fund, and standardize their development project procedures to ensure that they take AIDS into account. Reference: 1. UN Resolution A/RES/S-26/2 2. UNAIDS (2001) Keeping the PromiseSummary of the Declaration of Commitment on HIV/AIDS--- United Nations General Assembly Special Session on HIV/AIDS 25-27 June 2001 New York 3. Lancet Vol 359 pages 1581-1582 May 2002 Global Fund Makes Historic First Round of Payments. 4. (OAU 2001) Abuja Declaration on HIV/AIDS, Tuberculosis and other related infectious diseases 5. UNAIDS (2002) World Report on AIDS 6. World Health Report 2001 7. UNDP (2002) HIV/AIDS and Poverty Reduction Strategies 8. UNDP (2002) Case-Study 1 Assessment of UNDP Assistance to a multi-sector National Response to HIV/AIDS in Tanzania. 9. UNAIDS (2002), Monitoring the Declaration of Commitment on HIV/AIDS---Guidelines on Construction of Core Indicators. 10. Bernard Rivers (2001) The Global AIDS and Health Fund-Suggestions on How to Maximize Private Sector Funds Raised. 11. George Honadle (1999 Kumarian Press) How Context matters, Linking Environmental Policy to People and Place. *---* A posting from AF-AIDS (af-aids@healthdev.net) To submit a posting, send to af-aids@healthdev.net For anonymous postings, add the word "anon" to the subject line To join, send a blank message to join-af-aids@healthdev.net To leave send a blank email to leave-af-aids@healthdev.net You are currently subscribed to af-aids as: kate@fahamu.org Archives before 19 September 2001: http://www.hivnet.ch:8000/africa/af-aids Archives after 19 September 2001: http://archives.healthdev.net/af-aids *********** The forum is moderated by the Health & Development Networks Moderation Team (HDN, www.hdnet.org) on behalf of the AF-AIDS Policy and Steering Committee (HST, HDN & SAfAIDS) with support from Fondation du Present (FdP) and technical support from Health Systems Trust (HST). The views expressed in this forum do not necessarily reflect those of HDN, HST, SAfAIDS or FdP. 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