2004 Report on the global AIDS epidemic
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National responses to AIDS: more action needed |
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Low- and middle-income countries face four fundamental issues as they build their AIDS responses. These include the need for:
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Since the turn of the millennium, AIDS leadership and resources have markedly increased. But the challenge is great; for two decades the epidemic has been tightening its grip on development. Lack of resources in low- and middle-income countries has hindered their ability to develop effective national responses to the AIDS epidemic. To this day, the epidemic is growing at a faster rate than funds can be raised to respond to it. In many countries with generalized epidemics, the challenge has shifted from finding additional resources to ensuring that new resources are efficiently absorbed into a growing and sustainable national AIDS response. A major roadblock is the lack of national capacity to scale up AIDS initiatives to critical coverage levels. In the hardest-hit countries, AIDS-related migration, illness and death are draining precious governmental capacities. This, in turn, contributes to the epidemic’s spread, causes other development efforts to fail, and creates a vicious circle.
In every country, HIV prevention and AIDS treatment and care are complex problems that exceed the capability of any one sector. An effective response requires combining strong national leadership and ownership, ensuring good governance, resource mobilization, multisectoral planning and coordination, reinforcing capacity to absorb resources and implement programmes, closely monitoring and evaluating the AIDS response, and significantly involving communities, civil society and the private sector.
Bilateral and multilateral donors face their own challenges. An effective sustainable AIDS response cannot be achieved merely by giving countries multimillion-dollar grants, or by providing foreign specialists. National AIDS commissions frequently complain of ‘donor-driven’ agendas that favour narrow, short-term results, and ignore broader, long-term national planning and needs. They also say human resources are further stretched by individual donor-reporting requirements that create burdensome paperwork. As more external stakeholders offer assistance, it is increasingly important to create donor harmonization and coherence around national structures, strategic plans, and monitoring and evaluation systems.
Over the years, one of the greatest obstacles to developing effective national AIDS responses is a lack of political will to tackle, or even talk about, the AIDS epidemic. Political commitment has recently increased in the hardest-hit countries. Still, in many countries where HIV is quickly spreading, such as those in Asia and Eastern Europe, a lack of leadership raises fears these countries will not adequately address the epidemic until it is too late.
Progress update on the global response to the AIDS epidemic, 2004National responses: improving, but still short of what is needed
Source: Progress report on the global response to the HIV/AIDS epidemic, UNAIDS, 2003; Coverage of selected services for HIV/AIDS prevention and care in low- and middle-income countries in 2003, Policy Project, 2004; The level of effort in the national response to HIV/AIDS: The AIDS program effort index (API), 2003, Round, UNAIDS/USAID/WHO and the Policy Project. |
In sub-Saharan Africa, the epidemic’s scale is convincing more leaders to take personal responsibility for implementing the national AIDS response. For example, Kenya’s President Mwai Kibaki is chairing a new Cabinet Action Committee on AIDS and enlisting leaders from Kenya’s major religions to deal with stigma and discrimination. The government has also abolished school fees, which immediately helped tens of thousands of Kenyan children orphaned by AIDS.
Botswana’s President Festus Mogae was instrumental in the decision to provide free antiretroviral medicines and develop a national prevention of mother-to-child-transmission programme. Malawi’s president, Bakili Muluzi, appointed a Minister for AIDS Health to improve coordination of the national response. In Lesotho, in March 2004, Prime Minister Pakalitha Mosisili and more than 80 senior civil servants were publicly tested for HIV to help break the stigma that discourages voluntary counselling and testing.
Elsewhere, in 2003, the world’s two most populous countries made leadership breakthroughs. On World AIDS Day, Chinese Premier Wen Jiabao made an unprecedented hospital visit during which he met AIDS patients and promised the government would protect their rights, provide free schooling for their children, and offer free treatment for poor patients. In July, India’s first National Convention of the Parliamentary Forum on AIDS stressed the need to overcome stigma. Prime Minister Atal Bihari Vajpayee said it was more urgent than ever to deal with India’s epidemic, and he called for ‘openness and a complete absence of prejudice towards affected persons’ (Kaiser Daily AIDS Report, 2003).
The Association of South-East Asian Nations devised a Work Programme on HIV/AIDS for 2003–2005. Governments and donors are supporting and implementing the Programme’s key initiatives, including intercountry activities on mobile populations and stigma and discrimination. In September 2003, ministers and senior officials from 62 countries and territories of the United Nations Economic and Social Commission for Asia and the Pacific adopted a resolution to tackle AIDS as a development challenge.
In the Caribbean, one example of activism is Denzil Douglas, Prime Minister of Saint Kitts and Nevis and leader of the Pan Caribbean Partnership against HIV/AIDS. He is particularly active in international negotiations, promoting reductions in the cost of health-care services, and increased access to antiretroviral therapy.
In the Commonwealth of Independent States (CIS), two Heads of Government summits (in Moscow and Moldova in 2002) endorsed a Programme of Urgent Response of the CIS Member States to the AIDS Epidemic, which created national coordinators for multisectoral responses. In February 2004, high-level government representatives from 53 countries attended the European Union’s ‘Breaking the Barriers’ Conference in Dublin, and pledged to achieve concrete targets to reduce HIV and AIDS within Europe and Central Asia.
Traditional leaders can also make an impact. In Fiji, the Great Council of Chiefs (a constitutional body of 50 hereditary leaders) co-hosted the ‘Accelerating Action against AIDS in the Pacific’ Conference. The President of Fiji and the Chiefs committed themselves to the country’s AIDS response and called on community, business and religious leaders to follow suit.
Ultimately, leadership must translate into concrete action. UNAIDS monitors the progress of the global AIDS response in various ways, and its AIDS Programme Effort Index is one tool for measuring country-level commitment. The Index was developed by the United States Agency for International Development, the UNAIDS Secretariat, the World Health Organization (WHO), and the United States-based Policy Project. It tracks a country’s effort in 10 different programme categories but does not measure actual output, such as coverage of a specific service.
The results between 2000 (40 countries) and 2003 (54 countries) show there is a general pattern of improvement (USAID et al., 2003). Significant gains in national commitment were recorded in the categories of treatment and care, political support, policy and planning, and programme resources. Improvements in providing resources, and treatment and care, were particularly notable since these were the lowest-rated components in 2000 (see Figure 45). The creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria and rising bilateral donor funding levels explain much of the resource component’s increase. The increase in care-related efforts probably reflects international donors’ new emphasis on treatment access.
In 2003, additional data were collected from 103 countries to track national commitment and action, and policy development and implementation (UNAIDS, 2003b). The data show an increase in the number of countries with comprehensive, multisectoral national AIDS strategies, and government-led national AIDS coordinating bodies. However, the existence of national AIDS bodies and plans does not necessarily translate into efficient and concerted action. One striking finding was that resources were often not invested in programme areas with the greatest impact. For example, in several Latin American countries, programmes for injecting drug users and men who have sex with men were scarce even though these populations suffered from high HIV infection rates (see ‘Finance’ chapter).
Better governance for more effective responsesDemocratic and efficient development activities depend on good governance, full constituent participation, the rule of law, transparency, community responsiveness, consensus-building, equity, effectiveness and accountability. These are complex and interrelated issues, but they have concrete applications. For example, countries with high levels of constituent participation generally have more dynamic national AIDS responses. South Africa’s recent treatment and care policy changes were spurred on by steady pressure from the country’s HIV-positive community, prominent legal and health professionals, and many national and international NGOs. An open, participatory governance system allowed for civil society to provoke positive change. Similarly, the rule of law is based on legislation and regulations, and on citizens being fully aware of their rights and how to protect them within existing legal frameworks and policies (UNDP, 2002). Applying rule of law and good governance concepts to AIDS activities inspires democratic planning and implementation. In 2002, the UN Secretary-General established a Commission on HIV/AIDS and Governance in Africa to combine applied research, policy dialogue and advocacy. The Commission is based at the Economic Commission for Africa in Addis Ababa, Ethiopia. It matches current knowledge gained from AIDS responses with knowledge gaps, and works to make good governance relevant to Africa’s policy-makers and implementers. In a similar vein, UNDP’s South-East Asia HIV and Development Programme has strongly promoted good governance in AIDS responses in countries such as China, the Lao People’s Democratic Republic and Viet Nam (UNDP, 2002). In Eastern Europe, UNDP promotes creating open and inclusive environments. This includes comprehensive, multisectoral policies, and innovative partnerships that build trust and reduce stigma to turn back the epidemic. |
In some countries, policy and strategic planning moved ahead, but legislation did not keep up because regressive or contradictory laws remained on the books. In the context of injecting drug use, some countries with restrictive laws have nonetheless carried out pilot projects involving needle and syringe exchanges, methadone maintenance therapy, and condom promotion at entertainment establishments. In the Russian Federation, a recent criminal-code amendment allowed for harm-reduction projects to operate legally. Unfortunately, some legal barriers remain—most notably, the ban on substitution therapy (UNAIDS/Ministry of Health, 2003).
Legal obstacles exist in other areas. The 2004 report of the United Nations Development Programme (UNDP), Reversing the epidemic: Facts and policy options—HIV/AIDS in Eastern Europe and the Commonwealth of Independent States, notes many government agencies in the region cannot transfer funds to the accounts of nongovernmental organizations (NGOs), or subcontract programme activities to them. Furthermore, many NGOs have their own problems, including inadequate skills and capacity, high staff turnover, and a mistrust of authorities that is not always justified. To resolve these issues, the Report calls for improved staff training, dialogue between state and non-state participants, and legal frameworks for NGO activities.
Political leadership on AIDS comes from all sectors of society. For example, in various parts of the world, several religious communities have made important contributions. In West Africa, Muslim authorities enlisted the moral weight of local imams. In Mali, backed by Population Service International and USAID, the Malian League of Imams and Islamic Scholars created four lessons for the imams’ Friday prayers, including prevention guidance and messages of compassion for people living with HIV (Development Gateway, 2003).
Meanwhile, an Argentinian Lutheran pastor, Lisandro Orlov, is urging Latin American churches to adopt more inclusive approaches to sexuality and HIV. In Nepal, at the 2003 South Asia Inter-Faith Consultation on Children, Young People and AIDS, various faith-based communities made a commitment to join the front-line AIDS response, and pledged to provide care, protection and support to those infected with and affected by HIV.
The South African Anglican Church has been a consistent advocate on AIDS issues. At major events, Anglican Archbishop Njongonkulu Ndungane has challenged the South African Government’s policies on antiretroviral drugs and AIDS in prisons. Meanwhile, the NGO Positive Muslims responds to stigma and discrimination within the larger South African community.
Religious groups have also emerged as leaders in care. In Durban, South Africa, Swami Saradananda, of the Ramakrishna Centre, has counselled and cared for people living with HIV or AIDS for many years, regardless of their religious background. These activities have spread to other Hindu clinics, and the Hindu Council of Africa now works on AIDS-related issues. Another example is the Samaritan Ministry home-care programme in Nassau, Bahamas. The programme is an interfaith activity that trains community volunteers to reach out to people living with HIV, along with their families and loved ones. It is now in its 14th year, and has trained more than 300 volunteers.
Community groups and civil society organizations that emerge in the AIDS response reflect the diversity of those affected by the epidemic. All have a key role to play. Civil society organizations often have innovative approaches to the epidemic, and can channel funds to communities, augment state service delivery, and monitor national government policies. People living with HIV particularly need to be involved in all aspects of the response, from planning and decision-making, to implementation and review (see ‘People living with AIDS’ focus).
For instance, the International Federation of Red Cross and Red Crescent Societies has formed a partnership with the Global Network of People Living with HIV/AIDS. Their joint activities focus on eradicating stigma through forming links between national and local Red Cross and Red Crescent Societies and HIV-positive organizations. The arrangement also ensures that people living with HIV play a major role in antiretroviral treatment programmes, particularly in helping people gain access to care and in assisting patients with treatment adherence.
Civil society organizations are most valuable and effective if they work with, rather than in parallel to, governments. Both sides need to be open to partnerships, and it is up to governments to provide a positive environment. Factors that enable these groups to contribute include legal recognition, tax incentives, streamlined contracting regulations, and agreed ground rules to involve them in decision-making and information sharing. In addition, both sides need to adopt measures to ensure accountability and transparency.
At the community level, governments’ administrative procedures must be flexible enough to include local NGOs. In India, an evaluation of targeted interventions showed some state agencies found it almost impossible to work with community-based organizations because of rigid agency costing and accountability guidelines. For example, grant applications must include copies of the organization’s official registration certificates, annual reports, and audited financial reports for the previous three years. Few community groups can provide this information (Lenton et al., 2003).
Some governments have successfully enhanced communities’ capacity to use their own resources and talents in AIDS activities. For example, Malawi’s national strategy on children orphaned by AIDS encouraged community-based groups to care for orphaned children. The country now has 97 community-based orphan-care groups, and some offer educational support to enrolled children (UNAIDS, 2003b).
National AIDS authorities are increasingly turning to formal partnership forums to stimulate nongovernmental participation, broaden national ownership of the response and increase transparency. This approach was first developed in Africa, under the International Partnership against AIDS in Africa. The concept is now more widespread, but its best examples are still in sub-Saharan Africa. For example, the Uganda AIDS Partnership is a national coordinating mechanism of nine ‘constituencies’ working on AIDS that represent all stakeholders at all levels. They share information and jointly plan and coordinate activities.
In neighbouring Kenya, an annual Joint AIDS Programme Review by all stakeholders supports the country’s multisectoral response. The review was first conducted in May 2002 by the National AIDS Control Council, civil society groups, donors and other stakeholders. Among other advantages, the review provides the government with a way of linking its strategic plan and other important policy-making processes.
Both the World Bank Multi-Country HIV/AIDS Programme and the Global Fund to Fight AIDS, Tuberculosis and Malaria aim to involve civil society in direct ways. The Programme works through its financing channels to NGOs, while the Global Fund explicitly requires NGOs to participate in its Country Coordinating Mechanisms that prepare proposals for AIDS-related projects. For instance, in Morocco national NGOs have direct responsibility for managing 30% of the monies provided by the Fund. They participate in many Ministry of Health activities, and work with civil society organizations in providing local services.
Working with civil society is a constant process of learning and adapting for everyone involved. A recent International AIDS Alliance paper assessed NGO participation in the Global Fund’s first round of granting funds. The paper revealed that government commitment to working with NGOs appeared to be somewhat hollow. Many appeared to cooperate with NGOs only to secure funding, and afterwards lost interest in collaborating. The study also found most NGOs invited to participate in Country Coordinating Mechanisms were based in capital cities. Rurally based organizations and those working with marginalized populations were under-represented. Furthermore, several countries said their national AIDS committees lacked the capacity to handle Global Fund disbursement to NGOs.
At the same time, many NGOs did not have enough resources or technical and managerial skills. Some NGOs were more focused on competing with each other rather than forging a cohesive voice within the NGO community. All of these factors had a negative impact on NGOs’ abilities to participate in the Global Fund process. The Alliance paper recommended that NGOs receive technical and financial support to improve their networking and participating capacity. It also called on governmental partners to adopt more positive attitudes about working with NGOs (International AIDS Alliance, 2002).
Businesses can contribute to the AIDS response at different levels, depending on their size, industry and location. Their three main contributions are in the form of workplace programmes, leadership and advocacy for AIDS work, and partnerships with the community and government for a strengthened response to the epidemic. To engage the private sector at different levels, UNAIDS provides technical guidance, brokers partnerships, and develops mechanisms and tools. Its strategy is to build on what works. Involving membership associations is a key focus. These include business organizations, such as the Global Business Coalition on HIV/AIDS and the World Economic Forum; civic organizations and such as the Rotary Club; business associations and coalitions; chambers of commerce; and trade unions.
The Global Business Coalition on HIV/AIDS: a corporate leader
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In countries hard-hit by HIV, workplace AIDS programmes are increasing; however, employers and trade unions could still play a much larger role in the global AIDS response. To date, most workplace projects focus on prevention, and have yielded valuable experience. For example, in Indonesia, the International Labour Organization (ILO) and Aksi Stop AIDS (a Family Health International project) have set up an AIDS-in-the-world-of-work campaign targeting workers, employers and government. By the end of 2004, the campaign aims to bring HIV-prevention activities to more than 900 000 workers.
Some multinational corporations are implementing workplace programmes with a global reach. One is Standard Chartered Bank, which has some 30 000 employees in more than 50 countries. It is the largest international bank in China and India, and employs over 5000 people in 13 African countries. Its current peer-education programme, ‘Living with HIV’, is delivered by volunteer ‘champions’, and focuses on HIV-positive employees. It helps them discuss what they can do to live positively, and how they can gain access to practical and emotional support.
In high-prevalence countries, workplace efforts are integrating prevention and treatment strategies. In South Africa, mining and other companies have been leaders in providing medicines to workers. Initiatives are springing up in other parts of Africa, as well. In Cameroon, the National AIDS Commission and the country’s employers’ association help companies obtain essential medicines, condoms, low-cost antiretrovirals and other supplies for their employees. This partnership received a four-year credit from the World Bank Multi-Country HIV/AIDS Programme, and companies also committed their own funds to it (UNAIDS, 2003).
Some businesses go further than their own workplace and become wider AIDS advocates. A business can influence its sourcing partners and distributors, companies in other sectors, consumer groups, communities and governments. The Thailand Business Coalition on HIV/AIDS, American International Assurance (Thailand), and the Population Council have directly encouraged 125 Thai businesses to implement HIV-prevention programmes by providing life insurance premium bonuses of 5–10% to companies with workplace prevention activities.
The Global Reporting Initiative is linking the world of work to wider questions of governance. It has chosen South Africa for the first phase of its efforts to develop international standards for AIDS reporting by businesses and other organizations. Project partners include the Johannesburg Securities Exchange, the South African Institute of Chartered Accountants, the Actuarial Society of South Africa, some of the country’s major companies, and representatives from other interested parties such as labour, government and the Treatment Action Campaign (Cape Argus, 2003; GRI, 2003).
In recent years, public-private partnerships have emerged as a way of redressing the AIDS-related resource imbalance between low- and middle-income and industrialized countries. The Accelerating Access Initiative, the Global Alliance for Vaccines and Immunization, the International AIDS Vaccine Initiative, the International HIV Treatment Access Coalition, and the Stop TB Partnership are examples of such international partnerships.
At national and regional levels, the most visible public-private AIDS partnerships involved major pharmaceutical companies. In Botswana, the Ministry of Health, the Bill and Melinda Gates Foundation, and the Merck Company Foundation formed an antiretroviral treatment programme known as Masa, a Setswana word meaning ‘new dawn’. By early 2004, more than 14 000 patients were receiving antiretrovirals throughtheprogramme(see‘Treatment’ chapter).
Survey on the business impact of AIDSIn 2004, the World Economic Forum released results of a global survey on business leaders’ perceptions and responses on the impact of AIDS on their businesses. The Forum/UNAIDS/Harvard University survey was called ‘Business and AIDS: Who, me?’ Key findings revealed that:
Only 28% of executives believe their response to the epidemic is lacking in any way. However, 56% of those who expect the epidemic to have a serious impact on their business are dissatisfied with their companies’ responses. The report concluded that:
Full report: www.weforum.org/site/homepublic.nsf/Content/Global+Health+Initiative%5CGHI+Global+Business+Survey |
In Romania, a public-private partnership involving the government and six major pharmaceutical companies (Abbott Laboratories, BoehringerIngelheim,Bristol-Myers Squibb, GlaxoSmithKline, Hoffman-La Roche, and Merck and Co.) has worked on the country’s national plan for access to AIDS treatment and care. Under the plan, the Romanian Government supports AIDS-patient treatment and care costs from national budgets. The companies have agreed to reduce certain drug prices by between 25% and 87%, or to donate drugs and equipment to measure viral load and CD4 counts.
Businesses are also forming AIDS response partnerships with civil society organizations. For instance, in Namibia, Namdeb Diamond Corporation provides support to the Lironga Eparu (‘learn to survive’) organization of people living with HIV.
Adhering to the principle of multisectorality through involving public, private and civil society sectors maximizes resources—financial and otherwise—for the response to AIDS in countries. It allows countries to move away from depending on external support for AIDS activities, and towards national autonomy. The 2001 UN Declaration of Commitment on HIV/AIDS urges diverse stakeholders to be actively involved in national responses. By 2003, countries were expected to establish and strengthen national-response mechanisms by involving the private sector, civil society partners, people living with HIV, and key vulnerable populations.
UNAIDS monitoring shows more than 90% of reporting countries have created national multisectoral bodies to facilitate AIDS coordination between the government, the private sector and civil society. The growth of national AIDS commissions, government-led partnership forums and working groups, expanded UN Theme Groups on HIV/AIDS and the Global Fund’s Country Coordinating Mechanisms attests to the unprecedented efforts to involve diverse participants in the national response.
Nonetheless, in many countries, poorly defined roles between ministries of health and national AIDS councils have caused confusion and conflict, which has slowed national strategy implementation. Government ministries often have little incentive to follow the guidance of national coordinating mechanisms. Many perceive cooperation as a threat because they may lose influence and budgetary control. This has sometimes led to outright jurisdictional battles between national AIDS councils and health ministries. Furthermore, in far too many countries, civil society representatives still do not participate in high-level decision-making.
For instance, the Bangladesh National AIDS Committee was set up as a multisectoral body. But it is led by the Ministry of Health and Family Welfare, and has no clear policy or management framework. Other ministries saw the Committee as an extension of the Health Ministry, and did not agree to be part of the coordination process. Without any real influence, the Committee did not function effectively; it last met in 2002.
In Sri Lanka, a similar situation is unfolding. The National AIDS Commission is run by the Ministry of Health and focuses on health-related implementation issues. Participation by other ministries is low and sporadic. The Bangladesh and Sri Lanka experiences show that national leaders at the highest level need to support AIDS councils politically and legally. Equally, when bilateral and multilateral donors support and communicate with AIDS coordinating bodies, they reinforce the bodies’ position as leaders of multisectoral responses.
Firm donor support also increases AIDS authorities’ capacities to create a national monitoring and evaluation system, and to produce strategic information. The Global Fund and the World Bank have promoted this concept in their AIDS work, but bilateral support is more uneven. A 2004 UNAIDS Secretariat survey found 71% of African national AIDS authorities had formal relationships with bilateral initiatives. But in Asia, these links were established in only 56% of surveyed countries; in Eastern Europe, in only 43% (see Figure 46).
The support of bilateral donors is critical to the functioning of true national coordinating bodies. This is a particularly important principle since ministries of health will play a central role in the global scale up of antiretroviral treatment. Health ministries cannot handle this massive task alone. To rapidly expand antiretroviral access, national AIDS councils need to play a strong coordinating role, and to involve local governments and civil society.
Institutions ideally address AIDS-related issues through ‘mainstreaming’, ensuring that every relevant activity they carry out has an AIDS component. Mainstreaming addresses sectoral links to the AIDS response, as well as the root causes of the epidemic’s spread. For example, education ministries need to provide AIDS education in schools. They also need to ensure young girls have equal access to a broader education to empower them in society, and thus decrease their vulnerability to HIV infection.
Mainstreaming is a key strategy in converting global commitments into national development agendas. The Millennium Development Goals and the 2001 UN Declaration of Commitment on HIV/AIDS have set the global agenda. To boost mainstreaming implementation, in 2001, the International Monetary Fund and the World Bank declared it was a priority to mainstream AIDS into major development frameworks. However, in early 2004, in 44% of the African countries surveyed by the UNAIDS Secretariat, there was no involvement of national AIDS commissions in the preparation of the Poverty Reduction Strategy Papers, which are prerequisites for World Bank and International Monetary Fund debt relief.
Even in countries that reported a link, it is often tenuous at best. Additional analysis carried out by UNAIDS clearly indicates a need to ensure AIDS is factored into Poverty Reduction Strategy Papers. In late 2003, a UNAIDS survey in 63 countries found all respondents reported key sectors had started mainstreaming, but only 13% had actually made progress in implementing sectoral plans (see Figure 47).
Another chronic problem is inadequate funding for multisectoral work. The highest levels of government need to protect AIDS budgets, and ministries of finance need to ensure monies are budgeted and allocated to priority ministries. Burkina Faso, Cameroon, Guinea, Malawi, Mozambique, Uganda and Zambia have AIDS components in their Poverty Reduction Strategy Papers. But AIDS initiatives are often addressed in a cursory manner. In the UNAIDS survey, only 15 countries had Poverty Reduction Strategy Papers that included HIV and AIDS indicators.
In Zambia, mainstreaming AIDS into all government sectors is a priority. For example, the government recently began training Ministry of Agriculture and Cooperatives staff to encourage them to incorporate AIDS concerns into their work. The UN’s Food and Agriculture Organization is also involved, helping to change the perception that AIDS is entirely the Ministry of Health’s responsibility. The training emphasizes the epidemic’s role in eroding food security, and focuses on how agricultural officials can mitigate that impact with labour-saving technologies and practices. In addition, the training shows staff members how to preserve knowledge, enhance gender equality, improve nutrition for agricultural workers living with HIV, and promote economic and food safety nets (FAO and Government of Zambia, 2003).
In Ghana, an innovative mainstreaming arrangement places different sectoral AIDS funds in the hands of the Ghana AIDS Commission. Each ministry is required to devote 5% of its AIDS budget to mainstreaming. The Ghana AIDS Commission releases the remaining 95% of the budget only after sector managers have agreed to this. This arrangement ensures there is ‘buy-in’ from the ministries to the main streaming process (Elseyand Kutengule, 2003).
But multisectorality is not a one-size-fits-all formula. The epidemic’s highly varied nature rules out resolving it through detailed global guidelines. In high-prevalence countries, the epidemic touches all of society. National AIDS commissions and other coordinating bodies need to act like ‘councils of war’, and directly involve the head of state. Countries with lower prevalence also require strong multisectoral prevention and care responses, and they need to use the comparative advantages of individual ministries in addressing the epidemic.
In several low-prevalence countries of Asia and Eastern Europe, health ministers still consider AIDS their ‘turf’. But they do not have the will or strength to catalyse, leverage or lead the necessary comprehensive response. In these regions, there are many examples of interministerial AIDS commissions, but they usually only have an advisory role.
Decentralization is one of the chief strategies used to improve good governance and development programme implementation. In this process, central governments devolve powers and responsibilities to lower administrative institutions. Decentralization aims to make decision-making more democratic, equitable and locally responsive. As a result, the process inspires ‘national ownership’, along with civil society and private sector involvement in policy-planning.
However,AIDS-response decentralization has often faltered (Lubbenetal.,2002). Governments are used to working within strict hierarchical structures, and the benefits of involving communities are not always clear. At the same time, communities often do not have the necessary representative structures or administrative capacity to participate effectively. A great deal of training and facilitation may be necessary on both sides if they are to work effectively with each other (Mpanju-Shumbusho, 2003).
Despite the problems, AIDS-related decentralization is a reality in several countries. Papua New Guinea, Uganda and the United Republic of Tanzania have successfully decentralized their national responses to community and household levels. Similarly, in Morocco, multisectoral regional and provincial AIDS committees were established to develop local strategic plans, coordinate activities and monitor implementation. In Burkina Faso, Ethiopia, Kenya and Uganda, the World Bank Multi-Country HIV/AIDS Programme has helped prevention and care programmes to reach communities and households. In Ghana, the Programme is funding the country’s District Response Initiative, which is decentralizing the AIDS response in 27 districts.
The UNDP also emphasizes decentralizing AIDS efforts. In Cambodia, its Community Enhancement Programme works with the Ministry of Rural Affairs to encourage communes (local districts) to prepare development plans rather than have the government allocate a set amount of funding to each commune for uniform activities. This Programme includes building local capacity to collect and analyse AIDS data used to support planning and monitoring. In a recent planning cycle, most Commune Councillors identified AIDS as a local priority, and said they were willing to create detailed care and prevention plans.
Various country experiences show that strong financial and political investment is needed to create effective district and local coordination bodies. At the local level, capacity gaps pose challenges, much as they do at the national level. There is now an urgent need to develop innovative ways of addressing capacity issues at all levels of health systems, particularly at lower staff levels. This situation is becoming even more urgent as access to antiretroviral therapy expands.
Harmonization and coherence
The relationships between donors and recipient countries, and between the donors themselves, can have a powerful impact on how the national response is implemented. Some donors pursue their own agendas without reference to national priorities, or to other donors’ actions. However, this is changing, particularly when countries and donors engage in constructive dialogue. In February 2003, a watershed understanding was reached when senior officials of about 50 countries and more than 20 multilateral and bilateral development institutions issued the Rome Declaration on Harmonization, which recognized that donor aid imposes high transaction costs on recipients.
Donors can alleviate this problem by coordinating their strategies and reporting requirements, and helping partner countries to lead their own development processes. Harmonization is facilitated by creating national AIDS action frameworks that align all partners. Sector-wide approaches often have shown promise in developing the health, education and agriculture sectors. These approaches coordinate investments around a jointly developed national strategic plan with an agreed financial administrative framework and reporting system.
In Malawi, AIDS-funding mechanisms have recently improved a great deal—most notably, in June 2003, when the government and four international donors (Canada, Norway, the United Kingdom and the World Bank) created a ‘pooled’ funding arrangement of US$ 72 million for 2003–2008. It operates alongside the traditional ‘earmarked’ donor-funding system. Within it, the National AIDS Commission can allocate funds to its national priority areas.
If there is a need to reallocate funds to accommodate unforeseen changes in plans, donor transactional costs are reduced because all participants are working from a common workplan, financing mechanism and technical-reporting format. For the first time, Malawi’s arrangement has allowed the World Bank to pool AIDS funds. It is hoped the National AIDS Commission’s dual system of pooled and earmarked funding will provide sufficient checks and balances, which will help create a more effective national AIDS-funding mechanism.
In Myanmar, the Joint Programme for HIV/AIDS proves that funding from multiple donors can be secured, harmonized and disbursed even under difficult political circumstances. The country’s ruling party and political opposition consider AIDS a social emergency and have called for donor funding. Because of its unique position, the UN system led the way in creating the 2003–2005 Joint Programme, and the related Fund for HIV/AIDS in Myanmar. Together, the programmes are channelling US$ 24 million (mostly from Norway, Sweden and the United Kingdom) into AIDS projects that are part of an integrated workplan designed and implemented by government bodies, civil society and UN agencies.
More funds are flowing into the global AIDS response, and using them effectively is increasingly important (see ‘Finance’ chapter). This is an integral part of improving governance—particularly transparency (seeing how and why decisions are made) and accountability (making decision-makers answerable for their decisions and their consequences).
In many countries, multisectoral AIDS-funding arrangements have met with serious problems. They have been plagued by poor planning and a lack of clearly defined roles and working arrangements between national AIDS coordinating bodies, the ministries responsible for implementing most HIV programming (typically Health and Education), and the Ministry of Finance, which holds the purse strings. The result is that many action plans are not fully funded and, thus, never fully implemented.
Another problem is rigid or outmoded allocation practices, which contribute to the ‘money-shaping programmes’ phenomenon. For example, in some former Soviet countries, government accounting practices have not fully evolved since the Soviet era. In several Central Asian countries, only government health resources can be spent in government hospitals and clinics. Therefore, NGO outreach programmes cannot procure or distribute individual HIV-prevention tools such as clean syringes, needles, condoms, disinfectants and test kits.
For instance, in Kazakhstan, much of the central and local governments’ AIDS funds are still swallowed by mass testing programmes. This is despite the fact that the 2001–2005 National AIDS Response Programme calls for balancing HIV prevention, testing and treatment activities. This discrepancy occurs because there is no budgetary classification for prevention; changing this requires a specific government decree. Therefore, government-funded prevention activities cannot be implemented. A related issue is the tendency of many AIDS service organizations to focus on testing—the only activity that receives government funding. Recent additional extrabudgetary funds, including a two-year, US$ 6.5 million Global Fund grant that includes prevention activities, have helped, but the overall imbalance persists.
If financing is to be effective, it needs to be continuous. In Paraguay, the National AIDS Programme currently provides antiretroviral therapy to 300 people. However, for several months each year, funding shortfalls stop treatment (UNAIDS, 2003b). In the Indian state of Andhra Pradesh, a recent evaluation showed that NGOs there face serious funding delays (Lenton et al., 2003).
In April 2004, at a meeting in Washington DC, co-chaired by UNAIDS, the United Kingdom and the United States, a historic agreement was reached by donors and low- and middle-income countries to work more effectively together in scaling up national AIDS responses. They adopted three core principles for concerted country-level action—the ‘Three Ones’.
The concepts of national ownership, multisectorality, mainstreaming, harmonization and coherence have been combined into these principles, which aim to increase the pace of the AIDS response and promote using resources more effectively by clarifying relevant roles and relationships. The blueprint begins with one agreed AIDS action framework, which is a nationally devised strategic plan for coordination across partnerships and funding mechanisms.
The national AIDS coordinating body needs to have legal status, a strong, broad-based multisectoral mandate, and a democratic oversight mechanism to function effectively. It is responsible for managing partners’ actions within the framework. The coordination body also requires overarching national policy leadership in order to facilitate the partnership arrangements that allow for implementing and reviewing the action framework. Many countries state that national AIDS councils and national strategic plans exist, but only a few meet the specific criteria described above.
Even rarer is the existence of one agreed monitoring and evaluation system that provides a single mechanism to account for various funding arrangements, monitors AIDS programme effectiveness, and provides the strategic information needed to adjust the action framework (UNAIDS, 2003).
The AIDS epidemic works in a vicious circle, striking hardest in those countries with the weakest capacity to respond to it. In many countries, AIDS is currently depleting technical and administrative capacity faster than it can be replenished. This is creating an unparalleled crisis in human resources, and is reversing many of the development gains made in previous decades. In parts of Uganda and Malawi, the World Bank reports that nearly one-third of all teachers are HIV-positive. In the Central African Republic, AIDS was responsible for 85% of the 340 deaths among teachers between 1996 and 1998.
Even before HIV emerged, public service systems in low- and middle-income countries were struggling to meet their citizens’ needs. In the health-care sector, problems included poor delivery infrastructure; inadequate human resources;poorlydefinedservices,functions, skills and protocols; and inadequate management and administration. In much of sub-Saharan Africa, AIDS has turned these weaknesses into crises. In Malawi, a recent impact study found a total of 1462 health-sector employees died between 1990 and 2000. In a 2004 review of 50 low- and middle-income countries, 95% of UNAIDS Secretariat offices in African countries said a lack of health personnel was severely hindering the AIDS response (see Figure 48).
In Asia, 67% of representatives reported health resourcedifficulties,versus47%inLatin American and the Caribbean (see Figure 48). These countries face a significant increase in demand for health services. They also face a greater disease burden with the resurgence of other related health issues such as tuberculosis, malnutrition, diarrhoea and pneumonia. Indeed, some countries in sub-Saharan Africa report HIV patients occupy 60–70% of hospital beds. This makes it very difficult for patients with other conditions to receive the treatment and care they need.
Capacity-building requires funding and political commitment, but it also calls for a broader vision that combines short-term emergency measures with long-term, sustained strengthening of the fundamental institutions of modern statehood. The most immediate requirement is to preserve existing capacity by keeping people alive and healthy. In the worst-affected African countries, no other measure will so quickly and directly arrest the decline in national capacity as providing treatment and care (Piot, 2003). At the same time, efforts will need to focus on using existing capacity to its fullest as HIV-treatment initiatives get up to speed. A wide range of untapped community resources (particularly people living with HIV) will need to compensate for formal skills gaps.
Furthermore, additional efforts are required to minimize the ‘brain drain’—the migration of trained civil servants to higher-income countries. This phenomenon is most obvious in the health sectors of Southern Africa, where doctors and nurses are emigrating to Australia, Europe, the Gulf countries, Japan and the United States. These countries offer these workers an attractive alternative to the poor conditions and low pay that characterize their own health-care systems.
South Africa is particularly hard-hit by an exodus of doctors and nurses leaving for higher-paid jobs overseas (Thomson, 2003; IOM, 2003). The South African Medical Association estimates as many as 5000 doctors have left the country in recent years. The Democratic Nursing Organization of South Africa says 300 trained nurses leave each month. Zambia is another hard-hit country; it has only 400 practising doctors. Once, it had 1600 (Lauring, 2002).
Some countries, such as the United Kingdom, have established codes of conduct to prevent ‘poaching’. Improving working conditions and wages in affected countries can also keep health professionals from moving abroad. An International Organization for Migration programme, called ‘Migration for Development in Africa’, helps African countries to encourage their qualified expatriates to return, and to retain professionals who might otherwise be tempted to leave. The programme operates in Benin, Cape Verde, Ghana, Kenya, Rwanda and Uganda (IOM, 2003).
Inadequate training of new health professionals is another major issue. In some cases, the pre-service training system in hard-hit countries has completely broken down. For example, in Malawi, the state-run nursing school closed in 2003 due to a lack of funds, and the medical school faced a similar budget crisis. UNDP’s Southern Africa Capacity Initiative is exploring ways to build sustainable capacity across sectors. The Initiative has a training component that supports local institutions in training professionals in key sectors. Information technology is also helping health systems to do more with fewer trained staff. UNDP also advocates non-traditional approaches to stemming the loss of workers in all sectors. Examples include franchising out public-service delivery to civil society organizations or international NGOs to achieve greater quality and higher motivation. Similarly, the private sector can be contracted to provide public services.
South-South cooperation: Brazil leads the wayCooperation between low- and middle-income countries (‘South-South’ cooperation) can provide key support to national responses, particularly in capacity-building. Brazil excels at this type of cooperation, particularly among the Portuguese-speaking countries of Africa and among Central and South American nations. In 2001, the Brazilian Cooperation Agency established a partnership with the United Nations to transfer Brazilian experience in reproductive health and in preventing and treating HIV and sexually transmitted infections to other low- and middle-income countries (SELA, 2003). One example is a three-year project with Mozambique to improve the quality of AIDS and reproductive health information for young people, particularly through youth associations and institutions that work with them. The project is supported by the United Nations Educational Scientific and Cultural Organization (UNESCO), the United Nations Population Fund (UNFPA), the United Nations Children’s Fund (UNICEF), and the United States Agency for International Development (USAID), and has a number of NGO and bilateral partners. Brazil is also working with Bolivia, Colombia, the Dominican Republic, El Salvador and Paraguay, and has helped them receive antiretroviral drugs worth about US$ 1 million to support pilot projects to treat people living with HIV. In June 2003, Russian officials and experts visited Brazil to learn about its experience in providing treatment and about government and civil society cooperation for school-based youth HIV-prevention programmes. |
In Botswana, a variety of strategies underpin the Masa antiretroviral treatment programme. The country does not have enough qualified professionals to cope with expanding services. Foreign professionals are hired to provide much-needed treatment and care, and to build local capacity through a training programme carried out in partnership with the Botswana-Harvard AIDS Institute Partnership. Botswana’s Ministry of Health also has a training programme called Kitso (‘knowledge’ in Setswana). By mid-2003, over 700 people at all levels (approximately 10% of the public health-sector workforce) had received AIDS-specific training. Private practitioners and health personnel at hospitals run by large mining companies have also been trained. In addition, a ‘preceptorship’ programme brings HIV experts from top international institutions to mentor national staff (UNAIDS, 2003).
Strategic informationInvestment by countries and the global community in creating and using strategic information is critical to turning the epidemic around. Policy-makers and programme planners, communities and countries need the evidence base to make informed decisions about the best courses of action.
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WHO works with the German Agency for Technical Cooperation to help African and European institutions become ‘knowledge hubs’ in AIDS treatment and HIV prevention for regional skills transfer and training. In Uganda, a knowledge hub has been established with the Joint Clinical Research Centre and other leading training providers. So far, it has provided hands-on training to hundreds of Ugandan health workers, and has recently started providing capacity-building opportunities for other countries in the region. Similar knowledge hubs have been established in Eastern Europe and West Africa.
Strategic information is any information that can usefully guide policy and programming decisions. All decision-makers facing the tough choices and dilemmas presented by AIDS need evidence-informed policy guidance. For example, decisions about introducing appropriate harm-reduction strategies or mixes of combination prevention for sexual transmission need to be informed by clear evidence about what works.
For example, while needle exchange has been shown to reduce HIV transmission and bring injecting drug users into contact with health and social services, it is too soon to gauge the effectiveness of supervised injection centres, which hold the promise of reducing HIV transmission among the injecting drug users most at risk of exposure to HIV. In other cases, decisions about how to balance promoting abstinence, delaying sexual debut, reducing the number of sexual partners and encouraging condom use need to be informed by scientific evidence about the effectiveness of each strategy in different contexts, and young people’s and adults’ perspectives on what might work best.
If policies and programmes are to reflect the epidemic’s realities, countries need the capacity to track the epidemic and analyse trends, understand behavioural patterns, measure social and economic impact, monitor programme indicators, evaluate progress and conduct operations research to refine programmes. Both the short-term and long-term effectiveness of national responses depend on knowing which data are needed, and how to collect, compile, analyse and translate them into strategic information to move policy agendas forward and ensure the most effective programming. In many parts of the world, this ‘data-informing-decisions’ capacity needs strengthening.
During 2003, UNAIDS worked with partners such as WHO, the US Centers for Disease ControlandPrevention,FamilyHealth International, the East-West Center and the Futures Group International to build and enhance capacity at country level for modelling and estimation of the epidemic. Over 300 representatives from national AIDS programmes and the research institutions of 130 countries have been trained in skills for capturing, validating and interpreting HIV-related data and in use of updated modelling methodologies to improve HIV and AIDS estimates.
Classicsurveillancecollectsinformation suchasHIVprevalence,AIDScasesand mortality.Second-generationsurveillance adds risk behaviour information. Both help countries to assess the course of their epidemics and decide on strategic responses. Examples of behavioural data collection activities include India’s massive 2001–2002 national behavioural survey and the UNAIDS Second-Generation Surveillance Project, funded by the European Community and carried out in partnership with WHO and eight countries in Africa, Asia, the Caribbean and Latin America.
Including NGOs in surveillance activities helps provide access to hard-to-reach populations. In Vietnam and Mexico, NGOs facilitated access to injecting drug users for behavioural research. In the Dominican Republic, the sex workers’ association MODEMU, and the gay men’s organization Amigos Siempre Amigos (‘friends always’) provided peer interviewers (WHO/UNAIDS, 2003).
Recently, Indonesia conducted behavioural surveillance covering nearly half its provinces and all key populations at higher risk—men who buy sex, sex workers (women, men and transgender), injecting drug users, men who have sex with men and youth at higher risk. Robust provincial estimates were developed on the number of people at risk of infection and already infected with HIV. This permitted policy-makers, community groups, NGOs and local AIDS Control Commissions to adapt existing programming to actual conditions. For example, harm reduction programmes now focus on sexual and injecting risk, since it was found that many male injectors—up to 70% in one major city—have unprotected sex with sex workers. Furthermore, condom promotion programmes have a renewed emphasis on reaching potential clients of sex workers.
Operations research collects and analyses information as programmes are implemented and scaled up. This research uses a systematic approach to ‘learning by doing’ and captures information in a way that helps programme managers and designers to make the best use of it.
Key questions for treatment scale up include: how best to avoid drug stock-outs; the most useful components of community treatment literacy programmes; how to maintain adherence; the tasks care providers can undertake and the training needed; how best to keep costs down; which laboratory monitoring is essential; and how to measure the clinical effects of treatment and return to normal function. For instance, Senegal monitored antiretroviral adherence in relation to the costs born directly by patients. The more patients paid on a sliding scale by income, the less adherent they were. These findings influenced Senegal’s decision to introduce a universal access, free-of-charge antiretroviral programme.
Operations research in prevention can focus on many different aspects of programming, such as comparing results of various methods of offering HIV testing and assessing the effects on stigma of prevention programming. Prevention-treatment integration can influence the effectiveness of prevention and treatment. For example, antiretroviral treatment programmes in Khayelitsha, South Africa; Masaka, Uganda; and Cange, Haiti have helped support prevention activities by documenting increased interest and willingness of community members to come forward for HIV testing (see ‘Prevention’ chapter).
UNAIDS’ major priorities include reporting on the impact of the global response and building country capacity to carry out credible monitoring and evaluation. To drive this agenda forward, UNAIDS provides innovative links between monitoring, evaluation research and financial tracking.
Monitoring and evaluation are essential to determining whether programmes are reaching target populations and accomplishing their objectives. This information is needed to garner additional resources by showing proof of money well spent. It also helps with refining interventions for maximum impact, tracking increasing access to services and supporting the information needs of new partners, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria. Yet, lack of technical capacity and resources is hindering action in this crucial area.
In September 2003, UNAIDS published its first Progress report on the global response to the HIV/AIDS epidemic. It reported that 75% of 103 reporting countries feel inadequate capacity is a serious obstacle to their ability to report reliably on national indicators such as HIV workplace policies, coverage of antiretroviral treatment and access to services for preventing mother-to-child transmission. Only 43% of reporting countries had a national monitoring and evaluation plan, and only 24% had a national budget dedicated to these activities (UNAIDS, 2003b).
When the 2001 UN Declaration of Commitment onHIV/AIDSwasdrafted,UNAIDSwas charged with assessing progress on achieving its defined goals and targets. In close collaboration with its partners in the UNAIDS Monitoring and Evaluation Reference Group, a set of core indicators was finalized for countries to use in measuring progress. For the first time, standardized data could be compared across countries in many critical areas: AIDS awareness levels, availability of prevention and treatment services, reduction of risk behaviour, levels of financial investments and impact on new infections.
Progress has been made in political commitment and improved policy environments, but has been lacking in human rights and human capacity. Prevention and treatment service coverage also remains extremely low. The second progress report will be released in 2005 and will measure progress made on an expanded list of service delivery targets, including the WHO and UNAIDS ‘3 by 5’ Initiative.
The Country Response Information System (CRIS)—supporting management of national AIDS informationUNAIDS has spearheaded efforts to supply countries with a user-friendly database management tool designed to strengthen the management of strategic information and its analysis at the country level. This database tool houses indicators, project and resource tracking, and country-level research. It is housed in National AIDS Commissions (or their equivalents). From October 2002 to April 2004, an ambitious training programme, involving 18 workshops and over 100 countries, introduced CRIS as a tool within country monitoring and evaluation frameworks. Its modular approach permits national and subnational indicators and programme information to be stored. The first indicator module is in English, French, Spanish, Russian and Chinese, and was released in June 2003. In late 2003 and early 2004, the resource tracking module was tested in Indonesia, Kenya and Uganda. The research inventory module, financially supported by the US National Institutes of Health, was tested in Bangladesh and Uganda. These modules are slated for release in mid-2004 to complete the integrated database tool. By the end of 2003, 25 countries were already using CRIS to store and analyse data. Information from country reports will be reflected in the 2005 UN Declaration of Commitment progress report. In partnership with other UN agencies and strategic partners, UNAIDS has led efforts to facilitate data transfer between existing and new tools. A common transmission format for indicators—an XML transfer tool—will ensure easy data transfer between CRIS, UNICEF’s DevInfo and WHO’s HealthMapper. |
Spurred on by UNAIDS, over the past three years various stakeholders have come to a consensus on global indicators for various comprehensive response interventions. But this is just a beginning. It is now time to focus on country capacity to measure these indicators, and to use this information to improve programmes so they work effectively.
To build capacity, a comprehensive approach is needed, which includes training, technical assistance, access to improved guidelines and tools, and helping countries to recruit national expert staff for monitoring and evaluation activities. UNAIDS, and other partners such as the United States government, have conducted regional training sessions. These sessions use a standardized curriculum to teach monitoring expertise, computer database use and ways to present complex data to different audiences.
The Global AIDS Monitoring and Evaluation Team, housed at the World Bank, concentrates on helping countries to find and hire local monitoring and evaluation staff and to develop functioning monitoring and evaluation offices. To mentor and assist these efforts, UNAIDS and the US Centers for Disease Control are sending a group of experts to key countries. They will build on existing efforts and address key monitoring and evaluation information gaps.
A good example of expanding country capacity is Zimbabwe’s District Response Information System, which is based at District AIDS Action Committee Offices, and is being piloted in 10 districts. It is linked to community subdistrict offices and implementing agencies (NGOs, mission hospitals and other sector ministries), as well as to the National AIDS Commission headquarters and provincial offices. At the field level, front-line workers and Village AIDS Action Committees collect village-level data which are validated at monthly meetings of all village front-line workers. The National AIDS Commission worked with UNAIDS, the US Centers for Disease Control and the University of Zimbabwe to define a set of standardized national indicators. The System will feed indicator data into the national Country Response Information System (see box on page 173).
An effective global response will only be achieved if countries own and drive their national responses within their own borders. International financial and technical assistance from UN agencies, donors, bilateral funders, foundations and others is important. But it only works effectively if it is embedded within national responses. The cornerstones of nationally led responses to AIDS are best summed up by the concept of the ‘Three Ones’.
The key to success is national leadership that involves and empowers all levels of civil society, particularly women. Time after time, national success stories are clear examples of such inclusiveness. In addition, responses only become truly effective if all activities are harmonized among all key participants. Too often, the opposite occurs, and responses at international and domestic levels are fragmented, ad hoc, or even haphazard.
Finally, bottlenecks exist within both international and domestic systems, causing delays in the transfer of funding and other resources to the key stakeholders who can best use them. Often, bureaucratic factors keep funding blocked at the national level. In other cases, attempts to involve community-level participants are mere window-dressing, because these participants may not readily have the opportunities or skills to participate in the response. Often, they are not empowered to be effectively involved in decision-making that affects them. Ultimately, this means that the energy and commitment of people on the front lines of the response are not harnessed.
Future challenges include:
