COORDINATION − FIT FOR PURPOSE: STRIVING FOR MORE EFFECTIVE AIDS COORDINATION AT COUNTRY LEVEL

AIDS Architecture - Emerging Issues for Discussion

Cindy Carlson

AIDS governance and coordination is a key element of the AU Roadmap

1 More diversified, balanced and sustainable financing

models

Develop financial sustainability plans

with clear targets

Ensure development partners meet

commitments and align with Africa’s

priorities

Maximise opportunities to diversify

funding sources and increase

domestic resource allocation

Invest in leading medicines

manufacturers – focusing on AIDS,

TB and malaria

Lay foundations for a single African

regulatory agency

Acquire essential skills through

technology transfers and south-south

cooperation

Incorporate TRIPS flexibilities and

avoid "TRIPS-plus" measures in trade

agreements

Use strategic investment

approaches for scale-up of basic

programmes

Support communities to claim their

rights and participate in

governance of the responses

Ensure investments contribute to

health system strengthening

Mobilise leadership at all levels to

implement the Roadmap

3 Leadership, governance

and oversight for sustainability

2

Access to medicines –

local production and

regulatory harmonisation

Priority actions

2

The beginnings of a new national AIDS architecture

• Time for a rethink on AIDS governance and coordination

• Some countries are already making changes

• These efforts need to besupported and shared

• The purpose of thismeeting is to consider the role of regional bodies in supporting national efforts.

AIDS Architecture – what do we mean?

‘AIDS Architecture’ refers to the structures and mechanisms developed to coordinate and manage the national HIV response.

• In most developing countries governance, coordination and management has been through some form of ‘national AIDS coordinating authority’ –NACA, and its secretariat,

• The AIDS strategy is operationalised through multiple implementingi partners

• Countries receiving Global Fund financing also have country coordinating mechanisms (CCMs)

What have been the primary coordination and management functions?

• Responsibility for developing and coordinating national policy and the NSP

• Monitoring and evaluation of the HIV response

• Mainstreaming and Partnership relations

• Resource mobilisation

• Grant management

How have main functions been situated to date?Council/Commission Secretariat Implementers

EssentialFunctions

1.Deliberateon,andadvocatefor,nationalAIDSpolicyandstrategytoforwardtolegislatureandexecutive

forapproval

1.Providetechnicalinputinto,andformulationof,AIDSpolicyandstrategy.

1.ImplementAIDSinterventionsalignedwithnationalpolicyandstrategy

2.Reporttoexecutiveandlegislature

onnationalstrategyprogresstowardsachievingresults

2.Aggregateprogrammedatainto

monitoringreportsfortheNACAandotherstakeholders

2.Providemonitoringdata

toSecretariatfornationalreporting

3.Establishhighlevelplatformforholdinggovernment,privatesectorandcivilsocietytoaccountfor

contributingtoandreportingonAIDSresults.

3.Facilitateannualorsemi-annualmulti-stakeholdermeetingsonnationalresponseprogress

3.Activelyparticipateinnationalmulti-stakeholdermeetings

4.Advocateforandmobiliseincreaseddomesticresources(public

andprivate)forAIDSresponse

4.Monitorandprovidefinancialinformationonaggregateresource

needforthenationalresponse

4.Providefinancialreportsonexpenditureandneed.

5.Advocatefortheremovaloflegislativebarriersthatprevent

providingservicesandinterventionsforkeyvulnerablegroups.

5.InformAIDSCouncilofbarriersandchallengesthatexist

5.Reportonobstaclesandchallengesto

implementation(social,financial,political,etc)

SupplementaryFunctions

a.Donorgrantmanagement

b.Donorrelationsandcoordination

c.Coordinateannualworkplans

forentiretyofnationalresponse

Examples of different coordinationCountry Description of Coordination

Brazil National AIDS/STD Control Programme within MOH supported by a multi-partner Commission

India National AIDS Control Organization headed by Director General within Ministry of Health, supported by State AIDS Control Societies, led by Indian Administrative Service Officers.

Moldova Independent multi-stakeholder National HIV/AIDS, STI and TB Coordination Council under the Ministry of Health with Secretariat based in the National Centre for Health Management, Ministry of Health

Rwanda Institute within the Ministry of Health reporting to a non-Ministry Board of Directors that in turn reports to the Minister of Health

South Africa Independent council under the Office of the President; with autonomous Secretariat housed within the Department of Health, and national strategy covering HIV and TB ;

What has worked well with AIDS coordination?• Raised the profile of HIV and AIDS in most countries;

• Promoted inclusive multi-stakeholder and multi-sectorial approaches including for planning and implementing strategies;

• Promoted one M&E framework and one coordinating authority;

• Supported the mobilization of financial resources

• Promoted rights based approaches to AIDS

• Created some momentum for government and donors to harmonize with one AIDS strategy 8

What have been the key challenges?

NACAs:

• problems with public accountability mechanisms and getting high level representation

Secretariats

• Too often dependent on donor funds and operating more as ‘PMU’ than national coordination body

• Weak coordination of implementation, monitoring and poor accountability for national AIDS response results across all partners

• Effectiveness more to do with inter-personal relationships rather than high level placement (weak political support)

• Challenges with maintaining smooth working relationships across government, especially between NAC Secretariats and MOHs

• Slow and costly decision making processes9

What lessons have we learned?• Structures are not a substitute for political

commitment• Location of NAC is not as critical as function of NAC

• Creation of new structures with weak or no legal mandate limits institutional effectiveness, leading to• Duplication and unhealthy competition with other

government structures.• Lack of sustainability

• Stand alone NACs have been very expensive (e.g. up to 20% of HIV programme costs in some Asian countries) and have been highly dependent on external support

• One size does not fit all!!

Why are we talking about needing change now (1)?

Changes in AIDS science and epidemiology:

• Growing evidence indicates that the majority of effective investment is bio-medical in nature, including treatment as prevention, PMTCT and circumcision, implying need to;

• Strengthen national health sector response and underpinning health systems

• Increase integration of HIV and AIDS services with other health services

• Other, non-medical, prevention interventions, e.g. BCC, should be contributing to, and learning from, experiences of both infectious and chronic disease prevention

• Progress in national responses means AIDS is no longer an emergency -> now needs long term, sustainable interventions and related governance

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Why are we talking about needing change now (2)?

• Changes in funding ->Declining funding for development assistance generally and HIV sepcifically

• But still need to achieve results (getting to zero), using funding more effectively and efficiently

• Bring AIDS ‘out of isolation’ and build synergies between HIV and other national development priorities.

• Attention to who, what and how for:

• Leadership and accountability for achieving results

• Sustainable structures for medium and long term with legal mandates

• Greater integration of programme interventions and management for greater effectiveness and efficiency of HIV investments.

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HIV responses – alternatives post 2015

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Type of strategy

Stand alone HIV strategy

HIV fully integrated

into health or development

strategies

Strengthening of HIV approaches in sector

strategies with accountability integrated into

national health or development coordination

Multi-sectoralaspects

determined in NSP and

coordinated via NAC

Multi-sectoral aspects defined as part of

‘health is everybody’s business and

managed through MOUs with a

government body charged with coordination

HIV a chapter in national

development plan with sectoral

action plans

AIDS Architecture–Main principles

1. Government should be central to governance of the HIV response within the context of shared responsibility and global solidarity

2. Coordination that includes HIV and AIDS needs to remain inclusive of multiple stakeholders (across government sectors, civil society, people living with HIV and AIDS and the private sector).

3. Coordination that includes HIV and AIDS structures should adapt and embed innovations from HIV programming in other areas of health and development sectors (and vice versa).

4. Any new configuration of coordination that includes HIV and AIDS should not conform to a prescribed model.

5. The core role of any coordination that includes HIV and AIDS should be to continue to lead and coordinate the planning and monitoring of the HIV/AIDS response.

6. A further important role is also to ensure alignment of partner resources to national priorities, accountability for achieving results and investments represent better value for money.

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How can we move things forward?

• Critical analysis of the national AIDS responses and their strategies

• Analysis of who needs to be involved to directly implement the strategies and who needs to be involved to enable its implementation.

• Critical analysis of the current coordination arrangements

• Analysis of what resources are available from domestic and from external sources

• Prioritisation of the whole sphere of AIDS response action 15

Anything is possible!