[Ip-health] Health Policy Watch: Selection Of New UNAIDS Executive Director Raises Larger Questions About Agency’s Purpose & Direction

Thiru Balasubramaniam thiru at keionline.org
Wed Jun 26 20:35:56 PDT 2019


Selection Of New UNAIDS Executive Director Raises Larger Questions About
Agency’s Purpose & Direction

26/06/2019 by Elaine Ruth Fletcher

A sensitive, closed-door selection of the new Executive Director for UNAIDS
has kicked up a noisy social media debate among a number of leading global
health figures, who questioned whether a separate bureaucracy for one
disease, founded at the height of the AIDS epidemic, remains justified
today – when bigger global health threats now loom.

Noncommunicable diseases now represent the lion’s share of the disease
burden even in developing countries, critics say, but the current global
health architecture allocates few resources towards those yawning needs.

Rather than remaining in disease silos, they say, global health
institutions should be driving countries towards more comprehensive systems
of universal health coverage – which is a key strategic focus of the global
health community.

The informal, but very public social media debate over the agency’s future
took shape as the UNAIDS Programme Coordinating Board (PCB) met this week;
the PCB was expected to issue its recommendation on a new Executive
Director from a short-list of 5 candidates by Friday.

Although UNAIDS said that it would not formally reveal the names of the
candidates to protect their confidentiality, sources told Health Policy
Watch that the short-list included only one woman, Winnie Byanyima, Oxfam
Executive Director, as well as four men: Sani Aliyu, Director General of
the Nigerian National Agency for the Control of AIDS (NACA); Salim Abdool
Karim, Director of the Centre for the AIDS Program of Research (CAPRISA),
South Africa; Chris Beyrer, Professor at Johns Hopkins Bloomberg School of
Public Health; and Bernard Haufiku, former Minister of Health and Social
Services of Namibia.

The PCB will make its recommendation to the Agency’s Committee of
Cosponsoring Organisations – which includes 10 UN agencies, the World Bank,
and the UNAIDS secretariat. Following that, the cosponsoring organisations
would provide their consensus recommendation to the UN Secretary General,
who would make the final appointment.

Gender balance of the candidates’ shortlist looms as another background
issue in light of the sexual harassment scandals that have recently
shadowed the agency and its former Executive Director, Michel Sidibé.

In May, Sidibé left UNAIDS to become Health Minister of Mali, following a
tumultuous year in which protestors picketed the agency’s Geneva
headquarters and an independent review found that the Executive Director
had created a “patriarchal culture” tolerating harassment and abuse of

Protest over UNAIDS sexual harassment scandal outside the Programme
Coordinating Board (PCB) meeting in June, 2018.

Debate Over Agency’s Purpose and Direction

But the debate that erupted yesterday in social media went beyond the
legacy of the sexual harassment scandal, or the pros or cons of candidate
selection processes, to consider the larger role UNAIDS should or could
play in the evolving global health landscape.

It was kicked off by Robert Yates, head of the UHC Policy Forum of the
Centre on Global Health Security at the UK-based independent think tank,
Chatham House, in a Twitter post, stating that the most important qualities
of the new UNAIDS Executive Director should be: “Courage and ability to
wind up the organisation and integrate it into WHO.”

Yates went on to say that “the 10s (or 100s?) of millions of dollars
required to finance a UN bureaucracy could be utilised more efficiently and
equitably fighting HIV within other agencies.”

Yates’ comments were quickly echoed by a former senior WHO official,
Anthony Costello, who chimed in, asking: “Why do we need a UNAIDs separate
from WHO which is 100 yards across the road? And 600 yards from the Global
Fund? Why not merge all three… with an operational global fund for health
answerable to the World Health Assembly.”

Other critics noted that while 60 percent or more of HIV positive people in
Africa are receiving treatment, access to treatment for non-communicable
diseases, such as diabetes and hypertension, is less than 5 percent on the

In an interview with Health Policy Watch, Yates said that the generally
positive responses that he had received to his comments indicated that he
was not alone in questioning the future direction of the institution, or
its existence.

He noted that UNAIDS was founded at the height of the AIDS epidemic and in
the era of the UN Millennium Development Goals (MDGs). In terms of health,
the MDGS were largely focused on combatting three big diseases,
tuberculosis (TB), HIV/AIDS and malaria, as well as improving maternal and
child health.

“Huge successes were recorded in those areas,” he observed, and
particularly for HIV/AIDS, he noted, where antiretroviral treatment became
widely available, and preventive strategies were greatly improved, leading
to a sharp worldwide decline in HIV/AIDS transmission and incidence.

Meanwhile, the proportionate burden of noncommunicable diseases such as
stroke, heart attack, diabetes and lung disease soared, he said, and became
the major cause of premature deaths in many low and middle income countries
– along with affluent ones. And yet access to vital treatments for those
conditions remained largely unavailable to the poor in many parts of the

“Given the situation we face in 2019 with the tremendous progress that has
been made around treating HIV, is it really appropriate to have a whole UN
agency devoted to one disease, particularly when all of the focus right now
is universal health coverage, which is a bolder ambition of everyone
accessing the health services they need without undue financial hardship?”
asked Yates.

UNAIDS headquarters next to WHO headquarters, Geneva.

“We need to be getting maximum health benefits out of the resources that we
have,” he added. “If you are able to reduce the bureaucracy that individual
agencies will have, in terms of country representatives and headquarters
costs and overheads, which are big costs, then, might that not be better
spent on direct delivery through WHO with its UHC goal? It is time to
question overall resource allocations and maybe the architecture and
institutions that there are in global health,” he said.

“There is a big, big danger in health that we get very fragmented, that we
are in disease silos. That reduces resources [and] increases competition,”
he said, noting that “there is a lot to be said for rationalising what we
do, rationalising the number of institutions on a global level, when UHC is
a great thing to rally behind.”

“I am not running down the work or belittling the problem, but just looking
rationally at the use of resources,” he stressed. “It would take a
courageous leader to say our institution has done wonderful things, but it
might be better now to wind up and put all of these resources in other
agencies. That would be difficult to do, but it is what a lot of us in
international development should be doing – not only in health but in other

UNAIDS: ‘Unique’ Among UN Agencies

UNAIDS was established by the United Nations Economic and Social Council
(ECOSOC) in 1996, amid growing global concern over the expansion of the
HIV/AIDS epidemic and its deadly toll – in 1995 nearly 17.9 million people
were living with HIV globally, and nearly 3.6 million had died from AIDS
since the beginning of the epidemic, according to UNAIDS: The First 10

As the only co-sponsored joint programme of the United Nations system,
UNAIDS coordinates the efforts of its 11 cosponsoring UN organisations –
WHO and the World Bank – around ending the HIV/AIDS epidemic.

With offices in 70 countries, and 70 percent of its staff based in the
field, the UNAIDS secretariat had a budget in 2018 of US$ 140 million,
while the budget for the entire joint programme in 2018 was US$ 242 million.

At the time of its founding in the mid-90’s, as the HIV/AIDS epidemic
gained traction, “only a special United Nations system programme… [was
deemed] capable of orchestrating a global response to a fast-growing
epidemic of a feared and stigmatized disease whose roots and ramifications
extend into virtually all aspects of society,” the cosponsoring
organisations of the new agency said in their 1995 report to ECOSOC.

The cosponsors also underlined that a special UN programme was needed not
only because of the “urgency and magnitude” of the HIV/AIDS epidemic, but
“because of its complex socioeconomic and cultural roots, because of the
denial and complacency still surrounding HIV and the hidden or taboo
behaviours through which it spreads, [and] because of the discrimination
and human rights violations faced by the people affected.”

UNAIDS is governed through its Programme Coordinating Board (PCB), which
includes 22 member states, 5 NGO representatives and the 11 UNAIDS
cosponsors. Although criticised at times for meeting behind closed doors,
UNAIDS is in fact the only United Nations organisation with civil society
represented in its governing body.

Despite the long shadow cast by the recent sexual harassment scandals, it
could also be said that UNAIDS also became a victim of its own success.

“A world without AIDS was almost unimaginable when the General Assembly
held its first special session on the epidemic 18 years ago,” United
Nations Secretary-General António Guterres said in his April 2019 report on
the last decade of progress in ending the AIDS epidemic.

“Since then,” he said, “the global determination to defeat one of history’s
greatest health crises has produced remarkable progress.” While in 2017 the
total number of people living with HIV stood at 36.9 million globally, the
report noted that over the past 10 years, the number of people living with
HIV on treatment increased by 5.5 times, reaching 21.7 million.

Representing both the success of recent efforts and the challenges that lie
ahead, Guterres reported that at the end of 2017, approximately 75 percent
of people living with HIV knew their status, 79 percent of those accessed
treatment, and 81 percent of those on treatment had suppressed viral loads.

According to UNAIDS’ website, the organisation is unique among UN agencies
as it “places people living with HIV and people affected by the virus at
the decision-making table and at the centre of designing, delivering and
monitoring the AIDS response.”

“UNAIDS,” it says, “has helped to position, shape and scale up the response
to HIV like no other organization, encouraging dialogue and bringing in
communities that have been left out of decision-making.”

“Without UNAIDS,” the website says, “the human rights of people living with
HIV would have been held back and the voice of civil society would be heard
far less often.”

In response to a Health Policy Watch request for comment, UNAIDS
spokesperson Michael Hollingdale said:  “UNAIDS is a joint programme that
brings together 11 UN organizations. An effective AIDS response has to be
multisectoral and UNAIDS plays a vital role in ensuring that all people
affected by AIDS have access to life-saving services and their rights are
protected. To achieve the SDG target of ending the AIDS epidemic, we need
to strengthen UNAIDS. There is much work remaining to be done and as a
joint programme we are confident that by bringing all our strengths and
assets together we can deliver results for the people we serve.”

Regarding the closed-door nature of the candidate selection process,
Hollingdale said that the Programme Coordinating Board had decided to
follow a process similar to the one used in 2008 to select the previous
executive director [Sidibé], and protecting “confidentiality of the
candidates to the maximum extent possible” was regarded as important.

“Board members have the possibility to express views on the different
candidates,” Hollingdale said. “Subsequently, the Committee of Cosponsoring
Organizations, under the leadership of UNFPA’s Executive Director, Dr
Natalia Kanem, will be providing its consensus recommendation to the UN
Secretary-General, who will appoint the Executive Director. There are still
several steps left in the process, which reinforces the need to protect the
confidentiality of the candidates.” He also noted that timelines and
materials on the candidate selection process are published on the agency’s

David Branigan contributed to this story.

Thiru Balasubramaniam
Geneva Representative
Knowledge Ecology International
41 22 791 6727
thiru at keionline.org

Thiru Balasubramaniam
Geneva Representative
Knowledge Ecology International
41 22 791 6727
thiru at keionline.org

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