Over the past two decades, National AIDS Commissions (NACs) have been set up as the main organisation expected to lead, govern and coordinate national multi-sectoral AIDS responses. Many countries have adopted a similar organisational ‘model’ to carry out this mandate: a high level multi-stakeholder governing body (the Commission or Council) and an operational body (the Secretariat), usually positioned under the Office of the President or Prime Minister.
Evidence from successful early country responses (e.g. Uganda, Senegal) where high level multi-stakeholder bodies, accountable to the President, were established to engage different sectors (including civil society) in the fight against HIV/AIDS, have shaped the development and roll out of the NAC ‘model’. The establishment of NACs, often as stand-alone organisations, with their own resources and infrastructure, separate to ministries of health, have been widely promoted by global AIDS agencies and coordination policies and are now part of the AIDS ‘architecture’ in many countries.
The importance and contribution of NACs has been widely reviewed. They are recognised for pioneering multi-stakeholder participation that can serve as a public health approach for other health and social issues[i]. Civil society involvement in governance arrangements, from Council membership to reporting mechanisms, has improved the acceptability, effectiveness and reach of national AIDS programmes. NACs have facilitated the development and funding of complex multi-sector and multi-stakeholder AIDS plans, including participatory monitoring processes of the plan’s implementation.
Notwithstanding these successes, there is a large body of evidence that NACs have struggled to fulfil their mandate[ii] (see selected links below). Some of the problems stem from their institutional and governance arrangements.
- Roles and responsibilities of National AIDS Commissions: Debates and Issues (HLSP Technical brief) ;
- Coordinating HIV control efforts: what to do with the national AIDS commissions (The Lancet);
- Five Myths about the HIV Epidemic in Asia (Plos);
- Committing to results: Improving the effectiveness of HIV/AIDS assistance : an OED evaluation of the World Bank’s assistance for HIV/AIDS control (WB)
- The global fight against AIDS: how adequate are the national commissions? (Journal of international development)
The performance of the multi-stakeholder Councils has not been conducive to incisive action for results. Council members are political appointments, selected for their representation of traditional or religious sectors, and other constituencies, rather than their ability to ensure good corporate governance or to drive a goal-oriented organisation. The process of appointment of members has frequently been criticized for being opaque, subject to patronage, lacking in meritocracy. They often lack training, support, mentoring and rarely have their own performance frameworks. Council membership is often large (although this is changing) which has compromised the quality of the debate and reduced the role of the Council to a stakeholder forum, where information is exchanged. Councils are often wagged by the executive tail, easily influenced by the head of the Secretariat, rather than holding the management of the Secretariat to account.
NACs lack the authority to ‘compel’ coordination of multiple sectors and stakeholders despite their location under the highest office, and in most cases, their establishment through an Act of Parliament, While many stakeholders agree that a key function of a NAC is coordination, few stakeholders are prepared to accept their authority to enforce it – either in other ministries or in civil society.
NACS have tended to be characterised by weak governance. Ambiguous, un-transparent and often inconsistent institution and programme accountability adds to the challenge. Hierarchical structures can easily confuse lines of accountability; it is often not clear, for example, if and how the public can hold the NAC to account, or whether Secretariats are accountable to their Councils or to the parent ministry (such as Office of the President). Although lead stakeholders are often identified as responsible for delivering certain interventions in the national AIDS plan, few plans discuss accountability mechanisms. How Secretariats are expected to hold sectors to account for their part in the plan, or for reporting programme data, and what happens when they stakeholders fail to perform or deliver against the plan are chronic issues for NACs, affecting their legitimacy and performance.
The Global Fund and the role played by its multi-stakeholder country coordination mechanisms (CCM) is increasingly important, particularly where the Global Fund provides the majority of funding for a country’s AIDS programme. There is considerable risk that stakeholders perceive greater legitimacy in the CCM In many cases, this is already happening, where the CCM brings the major stakeholders together through ‘Country Dialogue’ processes, makes ‘de-facto’ policy through its funding decisions, and where the same people are represented on the CCM and the NAC, leading to conflicts of interest.
Setting priorities but not funding priorities: Stakeholders tend to agree that the role of NAC is to identify and set priorities, yet few agree that the NAC should have a role in allocating and channelling funding against these priorities. As many NACs have expanded their mandate to include the role of Principal Recipient of Global Fund grants, relationships with the stakeholders they are expected to coordinate have often become strained. Opaque systems of resource allocation, perceived re-centralisation of control of the AIDS response, and unresolved power issues between NACs and ministries of health contribute to tensions. Yet, as with authority, even when priorities are set, NACs cannot ensure funds are allocated and spent consistently with these priorities. Much of the dissatisfaction with donors arises from this issue – the inconsistency between donor priorities and official NAC-set priorities.
Fit-for-purpose structure and operations: For a number of reasons, many NACS have, in effect, mimicked health sector National AIDS Programmes in their internal structures; with departments for ‘prevention’, ‘continuum of care’, M&E, etc. And tended to staff them with recruits from the Ministry of Health. The failure to see that ‘coordination’ is a specific functional operation, requiring its own structure and processes, has tended to make many NACs simply shadow health sector National AIDS Programmes – or vice versa: to the detriment of both.
What can be done?
NACs were set up with grand intentions but much of this vision is now being challenged. Developments in global health thinking for post-2015 (Universal Access and the SDGs), changing epidemiological patterns (rise of NCDs and clearer understanding of the dynamics of the HIV epidemic in different parts of the world), dramatically strengthened health sector responses, and funding constraints for HIV, all raise questions about the continued role, cost, and effectiveness of NACS.
NACs often represent substantial political, organizational and financial investment in countries and cannot be easily transformed or simply wished away. But for NACs to remain relevant they need to be clearer in their contribution, scope, efficiency and effectiveness, and corporate accountability. The wider constituency representation of the Council, once appropriate for emergency responses, should now be replaced with a strong governance and leadership role. They need clearer governance and accountability, and a more rigorous results-oriented culture.
Independent institutional and functional reviews of NACs are the principle way in which issues of governance, accountability, performance, service-orientation, cost and efficiency improvements can be identified and discussed.
As a first step, critically review the real added-value of external multi-sectoral coordination (is the NAC actually necessary and in what form? Or can the functions be managed more efficiently elsewhere?). Second, ensure the governance, accountability, legitimacy and capability of the coordinator is accurately and precisely defined (is the NAC actually accountable? Or does accountability actually lie elsewhere? Is the legitimacy of the NAC recognized by all? Or do stakeholders see legitimacy in other places?). Third, consider carefully whether the topic to be dealt with (e.g. AIDS or Non Communicable Diseases etc) justifies the investment in external ‘coordination’ (are there more cost-effective partnerships that will enable coordination goals to be met?)
These reviews will not provide immediate resolution of the fundamental issue: what architecture works best for the country for HIV/AIDS. But they can provide an evidence base upon which more rational decision- and policy-making can take place.
Peter Godwin, Independent Consultant
Clare Dickinson, HIV/AIDS Specialist, HLSP Institute, London
[i] Carlson C, Getahun M 2013 Adapting and Strengthening National AIDS Response Coordination in Africa. UNDP unpublished
[ii] Godwin P, Dickinson C 2012 HIV in Asia: Transforming the Agenda for 2012 and Beyond: Report of a Multi-Donor Joint Strategic Assessment of HIV in Ten Asian Countries, AusAID Health Resource Facility