Evaluation of WHO's Contribution to "3 by 5": Main Report

"...Important progress was made during the two-year period of "3 by 5" leading up to December 2005, as the number of people on antiretroviral therapy (ART) in low- and middle-income countries nearly doubled in 2005 alone (to about 20% of those needing treatment)....However, this was less than half of what "3 by 5" set out to achieve and there are still huge disparities in who has access to treatment across regions and within countries. It is also evident that HIV prevention efforts are not containing the pandemic, since some 4.9 million more people became infected with HIV during 2005...."

This 138-page report examines the administrative, technical and managerial guidance that the World Health Organization (WHO) provided during the "3 by 5" initiative, which was launched in December 2003 with the intention of mobilising the international community to address the global inequity in access to antiretroviral therapy (ART) by treating 3 million people living with HIV/AIDS in low- and middle-income countries by the end of 2005. Based on an independent evaluation conducted by 6 international consultants between August 2005 and January 2006, the report provides an appraisal of WHO's role in advocating and supporting the "3 by 5" target - with a focus on the extent to which WHO mobilised, sustained and contributed to this major global partnership by improving harmonisation between United Nations agencies and working with other stakeholders. By reflecting on some of the insights gained into the continuing challenges that WHO, national governments and the development community face in their efforts to deliver affordable essential HIV/AIDS drugs, the report identifies future collaboration opportunities between WHO and partners and gives recommendations for the way forward.

In brief, selected findings include:

• Scaling up access to antiretroviral therapy (ART) and HIV prevention - Many countries have made significant progress over a relatively short period to increase the total numbers of people who are receiving ART in low- and middle-income settings - from 400,000 in 2003 to about 1.3 million at the end of 2005. However, there are still striking differences between regions and countries, and HIV prevention efforts have been shortchanged. Nonetheless, "3 by 5" has substantially contributed to promoting the right to health for people living with HIV/AIDS (PLHA), and has highlighted the special needs of vulnerable populations such as sex workers, intravenous drug users (IDUs) and men having sex with men (MSM). Gender and equity considerations - and the treatment needs of children - still need further attention.
• WHO contributions to the health sector response to HIV and AIDS - "There is consensus among stakeholders, development partners, other United Nations institutions and national governments that WHO is the multilateral agency mandated to lead the global health sector response to HIV. But there are also perceptions that the Organization has yet to fulfil its role to meet this level of expectation..."
  
  • WHO contributions through leadership, advocacy and partnerships - "....When '3 by 5' was launched, WHO made a strong commitment to working with a broad range of partners, yet the mechanisms for achieving this have tended to be loosely defined....[T]he Organization could have engaged in partnership opportunities more effectively and it will be increasingly expected to work within a broader global partnership for Universal Access."
  • WHO contributions in providing direct country support - "...By introducing dedicated technical officers (WHO '3 by 5' officers) in 41 of the 49 focus countries, WHO has started to create a strategic network that has the potential to make an increasingly important contribution to learning what is happening 'on the ground'; disseminate good practices; monitor national responses; and facilitate technical assistance....In general, [though,] WHO has found it challenging to develop and influence new types of partnerships within countries, outside of its traditional relationship with the MOH [Ministry of Health]..."
  • WHO contributions through developing and operationalising standardised tools and guidelines - "...WHO has...demonstrated a promising strategy based on Integrated Management of Adolescent and Adult Illness (IMAI)....Programmatic integration with related primary care approaches for child health (IMCI) and maternal care (IMPAC) would make sense, but there is no institutional strategy for this and the effectiveness and feasibility of sustaining these integrated approaches still need to be demonstrated....WHO has produced an extensive range of high-quality technical guidance and tools for scaling up national health sector responses, mostly in collaboration with other technical partners. Resources that were allocated to WHO for this normative work...have been insufficient..."
  • WHO contributions to securing reliable supplies of effective medicines and diagnostics - "There are current concerns about whether secure supplies of adequate quantities of quality antiretroviral drugs (ARVs) and diagnostics can meet the growing global demand (based on existing supplies of the active pharmaceutical ingredients that are used to manufacture these drugs), both for current first-line treatments and for second-line drugs and paediatric formulations....The WHO-managed Prequalification Project has been successful in establishing an innovative mechanism that encourages voluntary improvement in the manufacture and supply of quality drugs (especially generic ARVs). There is now a need to prioritize second-line drugs..."
  • WHO contributions through "learning by doing" - "...WHO is ideally situated (and expected) to lead knowledge management through its country networks and international technical partnerships. It should serve as an effective 'knowledge network' for the global response to HIV. The internal systems for routinely monitoring programme activities are not yet firmly established within WHO. Knowledge management functions are divided across departments and lack integration....WHO has not done much to build the evidence base for guiding decisions about what service delivery approaches are most suitable and how to optimize the provision of chronic HIV care and support..."
• Performance of the HIV programme area within WHO - "...The '3 by 5' Initiative has been described as an ambitious, but weakly conceived programme with insufficient structure against which results could be measured or performance monitored for the enormous amount of effort that has gone into it."
• Influences of the broader development context and the particular challenges facing Africa - "...Many of the worst-affected African countries are still far from containing their growing AIDS crisis and the absolute number of people who need treatment and do not have access to this is still growing....Even though WHO significantly increased its investments in Africa through '3 by 5', the Organization has not yet strengthened its focus and capacity adequately to provide the level of support necessary to meet the scale of these challenges in Africa."

For each of the above sections, strategies/recommendations are advanced for WHO and/or its development partners. To cite just a few examples:

• One suggestion for further scaling up access to ART and HIV prevention is promoting cooperation between the various global health initiatives to improve their combined efficiency and effectiveness in delivering health systems strengthening interventions. South-to-South cooperation is a particular focus; WHO could do more to facilitate collaboration and draw on the experience and expertise among developing countries, southern institutions and regional networks to deliver technical assistance.
• Along these lines, to foster more effective decision making about scaling up "3 by 5", WHO could "create and support purpose-oriented learning networks that are based in communities of practice. These should espouse the principles of knowledge-sharing and providing practical humanitarian assistance, allowing broad and inclusive participation by leaders, technical experts, politicians, communities, businesses and nongovernmental organizations (NGOs) in jointly defining the problems; proposing innovative solutions and engaging in collaborative actions."
• Increased efforts to address "the crisis in human resources for health" through such approaches as regional training initiatives and public-private ventures are also suggested.
• One particular set of recommendations focuses on strategies that multilateral institutions and international donors could use to influence the broader development context. For instance, securing a solid funding basis for WHO is crucial for ensuring that the organisation can provide effective technical leadership in scaling up HIV and health-sector
  responses. Efforts on the part of large organisations and financing structure to harmonise their approaches and support for the benefit of stronger and more effective country responses are needed; political support for those national efforts - which are enhanced through broader and more effective involvement and participation by PLHA, civil society organisations and the private sector - can support this process further.