Examination of Witnesses (Questions 367
- 379)
MONDAY 17 MARCH 2008
Mr Elhadj Amadou Sy
Q367 Chairman:
Good afternoon, Mr Sy. Can I first of all thank you very much
for coming to talk to us. Can I also tell you that the event this
afternoon is being recorded and you will have an opportunity to
see the transcript of the evidence and make any corrections you
think are necessary. We would also like you to feel free to write
to the Clerk with any more information after the hearing this
afternoon if you think there is anything we have left out or not
covered that we should have done. If you are happy with that,
I will proceed.
Mr Sy: Yes, thank you.
Q368 Chairman:
I would like to start by asking about UNAIDS. My understanding
is that this was formed in part because there was fragmentation
in the approach to AIDS, and what we would like to know is whether
you think this is the right route to go down in terms of dealing
with this specific disease, because it is really very targeted
in this way. Is this the best structure? Perhaps in answering
that you can touch on the governmental structure of UNAIDS and
how effectively that works.
Mr Sy: First of all, thank you for giving us
the opportunity to talk with this Committee on behalf of UNAIDS
and its Executive Director. We are doing so on behalf of all the
Co-sponsoring agencies, but also I may take this opportunity to
stress the specific view from the Secretariat of the Joint and
Cosponsored Programme. With regard to your question, we believe
that AIDS is a multi-dimensional problem which calls for a multi-sectoral
response. We know very well about the health dimension and the
health components of HIV, but there are so many other societal
and development-related issues that need to be addressed at the
same time. What sometimes appears to be like a fragmentation of
the response, is what we call a multi-sectoral response to the
epidemic. We call on different UN agencies ranging from WHO for
the health part to UNDP for the development aspects, down to sector-specific
responses such as the one being implemented by UNESCO. ~We recognise
that we need different entry points to the problem in order to
make an impact. We have to promote a broad base: a multi-sectoral
response. As far as UNAIDS is concerned we believe that it was
a very innovative idea to have a programme such as UNAIDS and
we still believe so after ten years. With the results which I
hope we can talk about later on in the discussion, it remains
the best structure and the best approach both for a coordinated
response and to minimise transaction costs at country level for
partners.
Q369 Chairman:
We have not used this approach to other specific diseases, have
we? Do you think it is one that should be used for other specific
diseases? Or do you think that AIDS is of a special type?
Mr Sy: We do believe that HIV/AIDS has revealed
many socio-economic dysfunctionalities, more than any other disease
before. If you look at the different aspects of the response,
the amount and the volume of activities that happen outside of
the health sector will show how different it is from other diseases.
For example, the issue relating to stigma and discrimination—of
course, we may find that with some diseases, but the magnitude
of it as far as AIDS is concerned is quite unique. There are aspects
relating to human rights and gender and gender-based violence
are critical; because of the very nature of the epidemic, it is
a gender issue par excellence that we would not find in many other
diseases. What we have also found is that the way it impacts on
the health system is quite unique. If we are in a country, for
example, where 33 per cent of the adult population is HIV-positive
and between 50 and 70 per cent of all the patients in infectious
disease wards have some kind of HIV-related conditions and illnesses,
then addressing that particular disease from the health point
of view as well as from a societal and economic point of view
would be alleviating the impact not only on the health sector
but would also have a major impact in terms of even how societies
will be kept together; how some of the enterprises will continue
to function given the fact that it is the people in the prime
of their lives who are becoming HIV-positive; how families can
be kept together, given the fact that it is those who are the
most productive in society and who should be taking care of the
education of children most affected by AIDS. If we look at this
further in the way governments' organise themselves and implement
their sectoral approach as well as the development policies, we
see the uniqueness of this epidemic that really makes it so different
from any other disease we have seen so far, even though we can
find many similarities with some of the major infectious diseases
such as tuberculosis and malaria, in Africa in particular.
Q370 Lord Geddes:
Good afternoon, Mr Sy. In the UNAIDS evidence in Issue 6, Paragraph
4, it says that the structure of UNAIDS "has often been cited
... as an example of UN reform in action". As I understand
it, UNAIDS is not only a vertical programme focusing on the fight
against AIDS but also a horizontal programme bringing in a number
of other interests, not least development, education, sexual health,
et cetera. What puzzles me—and I think puzzles a number
of the members of this Committee—is how does all that activity
mesh with that of the World Health Organisation, which is the
main intergovernmental health body? What is WHO's attitude to
you? Does it work well? Are there pluses? Are there minuses?
Mr Sy: We recognise that HIV/AIDS is a health
problem and, because of that, WHO has a very important role to
play. Our relationship with WHO is strong and healthy for many
reasons. Number one, UNAIDS is administered and managed by WHO
both because in the nature of the work as well as our geographic
proximity here in Geneva. Number two, whatever WHO is doing in
relation to HIV/AIDS does not only concern the WHO response to
AIDS but it also constitutes the whole UNAIDS response to AIDS
as far as the health sector is concerned. When we brought partners
together, we agreed on a Division of Labour where each of the
Cosponsoring agencies will take a lead role based on their comparative
advantage. The biomedical aspect of AIDS issues related to the
health system, training and retaining of healthcare workers, these
are all WHO-led activities. They lead in these areas not only
for their own sake but for the whole UN systems. When we talk
about UNAIDS' work on HIV/AIDS and health, what we do is to describe
WHO work on that. It is a very healthy relationship that will
allow a number of things: better coordination, avoiding the duplication
of efforts, and recognising also the lead agencies; and this applies
also in the way we structure our programmes as well as the way
we use our own resources. We are the only UN programme with what
we call a Unified Budget and Workplan where, at the beginning
of a biennium we work together with the ten Cosponsoring agencies
and agree on what needs to be done to make a difference in the
response to AIDS. Based on that agreement we give tasks and leadership
to each of the agencies as well as resources to do. So the resources
are mobilised and a big chunk of what we get from the partners
goes to WHO for its HIV/AIDS work within the health sector. If
we look at it more broadly, as I said a little bit earlier on,
alleviating the impact of AIDS on the health sector is already
a contribution to better health but at the same time providing
an opportunity for others to look at the broad-based response
that each of Cosponsors will lead either from a particular sector
or from a societal or development point of view or from a human
rights point of view that will allow an enabling environment for
a response. We feel there is a false dichotomy between a horizontal
or a vertical programme. We are horizontal in the fact that we
do contribute to strengthening health systems but also we are
very specific in addressing issues that are very important to
the response which, as I said before, will range from gender to
human rights to socio-economic impact and alleviation of the AIDS
epidemic, taking care of orphans and vulnerable children et cetera.
Q371 Lord Geddes:
Is there any danger of duplication between what UNAIDS does and
what the WHO does?
Mr Sy: What UNAIDS does in the health sector
is done by WHO. If I had to describe UNAIDS work in health and
AIDS, then I would call on WHO to do that because they are the
lead agency in that area and they are the guardians of that particular
area of responsibility. They also get resources from UNAIDS and
account for it both in terms of money as well as in terms of results.
In addition to that we have what we call the Committee of Cosponsoring
Agencies, which brings together the Heads of all ten Cosponsoring
agencies of UNAIDS to design the programme, monitor its implementation
and evaluate the impact. It is an additional platform where complementary
activities and better coordination will be discussed to avoid
duplication.
Q372 Lord Avebury:
In your evidence and in your two replies so far you have described
how the ten co-sponsoring agencies each undertake work within
their own fields and that you exercise this coordinating role,
as you have described it. Who decides the overall budget which
applies to all ten co-sponsoring agencies? Or are they each determining
the amount of money which they spend on this work on their own
initiative and separate from all the others?
Mr Sy: They have to decide how much money the
ten Cosponsoring agencies get?
Q373 Lord Avebury:
You exercise a coordinating role, you say.
Mr Sy: Yes.
Q374 Lord Avebury:
Does that coordinating role extend to advising on the budget for
the whole of the AIDS effort devoted by the ten co-sponsoring
agencies? Or are each of them responsible for their own budgets
and they do not present you with the sum?
Mr Sy: In order to be a Cosponsor of UNAIDS
each of the agencies has to have a certain number of requirements
in place. Number one, they should each have a dedicated team working
on HIV/AIDS; they should each have a dedicated budget from their
own resources and work plan on HIV/AIDS. This is the first basis
to come together around the table to discuss what needs to be
done, what each of the UN agencies are investing from their own
resources. Then we evaluate, based on the programme that we want
to deliver together with what the gaps are. In the last biennium
what we realised was that issues such as strengthening health
systems, looking at the biomedical aspects of HIV/AIDS, investing
more in monitoring the epidemic in the way that it is going, investing
together with our partners at country level on what we call "know
your epidemic" and then act on it were priorities, and we
allocated a big chunk of the resources. The number one Cosponsor
which received most of the resources was WHO and it represented
a significant percentage of the overall investment that we made;
and if we compare this with all the other Cosponsors, they are
getting more than double of each of the other Cosponsors that
you could compare with. We look at the next priority, such as
under the heading "creating an enabling environment for the
AIDS response," and the issues that relate to that are human
rights, to gender as well as governance of the AIDS response.
Then we discuss with UNDP, look at the whole contribution and
then make an additional contribution to fill the gap. Then there
were the three areas in order of priority: UNDP looking at the
socio-economic impact and then the mainstreaming of HIV/AIDS into
development programmes; the next one was UNICEF for prevention
of mother-to-child transmission and orphans and vulnerable children;
UNFPA came next, and then the smaller investments were made with
organisations like the World Food Programme, UNESCO and UNHCR.
Given the specifics of their activities and with regard also to
the amount of resources that they were investing in the AIDS programme,
to get the final agreement of all of that, we put in place a peer
review mechanism where each of the Cosponsoring agencies will
be presenting to the group what their priorities are, what is
the amount of resources they put in themselves and what the gaps
are. Then we compare that within the overall strategic plan for
the UN system and agree the partition of the resources that we
are getting from our Unified Budget and Workplan.
Chairman: That sounds a very complex
organisation you have there and quite difficult for you.
Q375 Lord Hannay of Chiswick:
I would like to ask you a little bit further about the comment
in your evidence that this is an example of UN reform in action.
I still find it a little hard to see what the extremely complex
arrangements you have just described are. They look slightly more
like making the best of a very complicated situation but not something
that should be replicated anywhere else. If it was UN reform in
action, then one would expect it to be done in a lot of other
places, but I think that would probably be—from your own
initial answer—not the right thing to do. I wonder if you
could just say a little bit more about that. Do you not think
that some of the donors find this situation extremely complicated
to deal with and not very easy to handle?
Mr Sy: I think we have taken the complexity
on ourselves so that countries do not have to deal with it. The
whole effort that we are putting in designing the Joint and Cosponsored
Programme relies upon a Unified Budget and Workplan, this will
result at a country level in simplification and the establishment
of one single entry point for a Joint UN team on AIDS for partners
at country level. That is the reason why we are saying that UNAIDS
is UN reform in action, because instead of having to deal at country
level with ten Cosponsoring agencies and the Secretariat, what
we have is a Joint UN team on AIDS that is working alongside a
number of principles. The number one principle is the principle
of harmonisation and simplification for AID effectiveness that
is derived from the Paris Declaration. The other one is the principle
of delivering as one at a country level. It is a very simple translation
at a country level, through a Joint team with one UNAIDS Country
Coordinator that is interfacing with all of the partners and calling
on the different Cosponsors based on an agreed Unified Budget
and Workplan with a division of labour to deliver the programme
which is a Joint Co-sponsored programme. Before UN reform was
put in motion it was the only programme in the United Nations
that could really demonstrate that they were delivering as one
at a country level. When the UN country pilots were put in place—I
think we have about eight countries where it is being implemented—the
preliminary results have shown that it is possible to deliver
as one. The example of UNAIDS in countries turned out to be one
very specific way of doing it and the feedback that we are receiving
also from the partners at a country level is that it has reduced
tremendously the transaction costs because instead of dealing
with ten they are dealing with one. They know also that there
is already a plan, which is not a UN plan for countries but a
UN plan to support a country response that we discussed and agreed
on with partners. More importantly, since the creation of the
Global Fund, it has also proven itself to be extremely effective
because it provides a platform to negotiate a strategic plan for
the country that the Global Fund can use also to channel its finances
so that it complements all the other efforts.
Chairman: That is a very important area,
but we do need to move on. If you get any more thoughts about
this I think we would quite like to hear them. It is a very different
sort of organisation for one disease. I appreciate you have marked
it up as a very different type of disease requiring a different
structure, but it does raise this interesting question—if
it is a reform of the UN structures, why does it not apply to
some of the others? If you have any more thoughts on that, we
would like to hear them in due course
Q376 Lord Desai:
I would like to ask, first a question about the co-sponsors that
you have been describing. You say in your evidence at Issue 7,
Paragraphs 10-13 that "there is an urgent need for more systematic
and more consistent approaches and for greater cohesion with health-sector
responses". Could you elaborate on this because, in a sense,
obviously what you have got is good but you feel it should be
better somehow?
Mr Sy: We have realised that there are a number
of activities, both in terms of prevention as well as treatment,
and treatment is the most obvious part that should be better integrated
with the health system. For prevention, let me just mention one
which is the most obvious, that is the prevention of mother-to-child
transmission that can be better integrated into maternal and child
health programmes which already exist. Because of the huge stigma
that used to be related to HIV/AIDS and the very little access
to testing for women, it was quite a good approach at the beginning,
to develop access to voluntary testing and counselling for mothers.
Once you get a critical mass now it is really imperative that
we get into better integration and we are working together with
partners to achieve that. Treatment is thus the most obvious part.
Antiretroviral drug have made a lot of difference in the response
to AIDS but they have also revealed a lot of weaknesses in the
health system in terms of poor diagnosis, in terms of laboratory
equipment and testing, in terms of capacity for the health personnel.
What HIV also did indirectly, beyond revealing those weaknesses,
was to contribute to strengthening our laboratory systems, strengthening
our diagnosis and providing big opportunities for training and
capacity building for healthcare workers at a different levels.
The treatment component will be more and more integrated in both
central as well as peripheral health structures, so that integration
and coordination is really necessary and we are working together
with WHO to further strengthen it while maintaining the other
aspects of the work that cannot be dealt with within the healthcare
setting.
Q377 Lord Desai:
You mentioned the Global Fund a while ago and there is also the
Gates Foundation in your Memorandum of Understanding with the
Global Fund. Is there a need for some further root-and-branch
rationalisation of all the various efforts which are being devoted
to stop the spread of HIV/AIDS? Do you feel that there are problems
with rationalising—things that stand in the way of rationalising—and
how would you bring about the coordination of the Global Fund,
the Gates Foundation and UNAIDS?
Mr Sy: I am very pleased to report to this Committee
that the relationship with the Global Fund is a very good and
very beneficial one for partners at country level. I would like
just to highlight a number of key elements to illustrate that.
We have seen that countries which have benefited from the support
of UNAIDS in the design of their proposals of the Global Fund,
their success rate for getting a grant increased substantially
from 40 per cent—which used to be the success rate of proposals
submitted to the Global Fund—and those who benefited from
the support of the UN reached a rate up to 70 to 75 per cent which
was a good indicator that the collaboration works well if we work
where we should and partner together at a country level. When
the Global Fund gives grants to countries they apply what they
call a performance-based funding which is mainly based on two
main issues, one is monitoring and evaluation and the other is
quantifiable results within a timeframe. UNAIDS has deployed 65
Monitoring and Evaluation Officers at country level and the majority
of their work centres around supporting countries, implementing
their Global Fund grant. Thirdly, all ten Co-sponsors, based on
their comparative advantage, have provided countries with technical
support for great advances of their grant implementation. Those
range from training by WHO, to procurement in management systems
by the World Bank and UNICEF, to setting up the country coordinating
mechanism through governance, through UNDP and the UNAIDS Secretariat
and supporting the overall management of the grant and the accounting
for it. What we tried to do in the Memorandum of Understanding
was to capture the principles of the collaboration and to look
also at the different areas of collaboration, which is the strategic,
direction and advice we are providing to the Global Fund the technical
support to make current grants successful and then monitoring
and evaluation. Those areas have been agreed upon and the Global
Fund has fully endorsed it. The Memorandum of Understanding will
be finally approved by our board in April and the Global Fund
Board in October and will provide a good basis to further strengthen
our partnership for the benefit of countries.
Q378 Lord Howarth of Newport:
Turning to the governance of UNAIDS, you said just now that coordination
was the number one requirement in this field. UNAIDS has a Programme
Coordinating Board which, I understand, contains representatives
of 22 governments across the world, UNAIDS co-sponsors who also
have their own committee and I think five NGOs. This would appear
at first glance to be a fairly top heavy Programme Coordinating
Board and difficult to manage. Do they manage you? Or do you coordinate
them? Is this board an arena in which the coordination that is
so badly needed is actually achieved? Or is it an arena in which
the different organisations appear, pay lip service to coordination
but then go away and continue to do the same things as they were
doing before? Or is it, worse, an arena in which they bicker and
defend their own interests?
Mr Sy: The configuration of the Programme Coordinating
Board of UNAIDS is a very innovative set up in the sense that
it provides an opportunity for both so-called recipient countries
as well as donor countries to come together and discuss sometimes
very difficult issues and provide the Secretariat and Cosponsors
guidance. It is extremely useful because beyond the fact of the
governance aspect, it is a policy forum that allows our different
partners to discuss extremely complex and extremely difficult
issues where different perspectives are needed. This kind of agreement
at that level will allow us to get very clear guidance from a
broad base of partners and then actually take on the implementation
of programmes at regional and at country level. It is a very innovative,
very effective board. We have seen the recent development in the
international health architecture, they get inspiration pretty
much from the Programme Coordinating Board. The Global Fund has
almost copied the Programme Coordinating Board of UNAIDS because
they think it is a very good thing for a public/private partnership,
moving programmes forward. Given the fact that we have different
partners on the board that will balance the view and the perspective
and we are not under pressure of one single constituency or one
single group, be it a group of recipients or a group of donors.
So it provides a kind of balanced view that allows us to implement
programmes in the most effective way. The only challenge we face
is that quite often we find the same countries and the same actors
in different boards of the UN system, including even in the board
of the Global Fund Providing inconsistent messages. Greater consistency
in the message and in the position would be quite useful. In some
instances, unfortunately, we may find ourselves with members of
the board providing guidance in a certain direction at the Programme
Coordinating Board of UNAIDS and take a different view at the
Board of UNDP and the Board of the Global Fund, because sometimes
they are different people either coming from health and the others
coming from the Ministry of Foreign Affairs, and the coordination
is not always very well established. That is the only constraint
that we face and, whenever we interact with Board members, we
call on them and plead for that consistency and to constantly
support us. Apart from that, we think the way the board is structured
and the different views it provides will give us quite a well-balanced
platform to operate on.
Q379 Lord Howarth of Newport:
As you describe it, it sounds an attractive and valuable model,
but there are difficulties in achieving strategic follow-through
throughout the system. Can I ask you to comment on what was said
in a recent report by the United Kingdom's Department for International
Development? They said, "UNAIDS's ability to create change
is dependent on the willingness and capacity of its co-sponsors,
leaving them little room for manoeuvre". Then they went on
to say that "current governance mechanisms do not enable
UNAIDS to effectively demand accountability from their co-sponsors".
What are your reactions to that?
Mr Sy: As I said earlier on, in order to be
a Cosponsor of UNAIDS each of the agencies will have to present
their own plan, including its own resources that are coming from
its own budget before they access the Unified Budget and Workplan
that it gets through UNAIDS. What I can say is that every cent
that a Cosponsor gets from the Unified Budget and Workplan is
accounted for and there is a very strong accountability mechanism.
Every year there is a target for an objective that is agreed upon
within the Unified Budget and Workplan and is very closely monitored,
and only when that target is reached and the first dispersement
has been accounted for, then UNAIDS make a second dispersement
to the Cosponsor. Where I think the accountability is suffering
a little bit is in the investment of the Cosponsors which the
UNAIDS Secretariat does not have control over; and if we call,
as is in the report, for a stronger accountability mechanism in
that the good model that we have within the Unified Budget and
Workplan should also reach into the use of the other resources
that Cosponsors are investing themselves. There we are in a discussion
with the agencies to make sure that it falls within the same framework
and the discussion is also going on in our board to strengthen
this accountability so that we do not have two measures and then
two lines within the Joint Programme, but the one that seems to
work best should be the model that will be including also resources
invested by the Cosponsors.
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