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The Global Programme on AIDS (GPA) at the WHO should be radically
overhauled, says a report to be published later this year. An independent
review of the programme will recommend that other agencies, such as the
UN Development Programme (UNDP) and the World Bank, must take greater responsibility
for AIDS.

The report will recommend that in the long term the WHO should withdraw
much of its direct support to AIDS programmes in member states so that it
can concentrate on advising their health ministries and coordinating other
bodies.

A summary of the report, which has been seen as a strong criticism of
the GPA, has been circulated to interested parties in advance of the full
report. The programme’s director, Michael Merson, says he is waiting for
the full version before making a formal reply. Observers say the GPA is
‘paranoid’ about the criticisms, but Merson says he wants to be open about
them and will welcome the final report. ‘Many of the issues identified we
were aware of already,’ Merson told New Å®ÉúСÊÓƵ.

The review was commissioned in 1989 by the GPA’s management committee,
whose members include the WHO’s donor countries, other agencies, and delegates
from the WHO’s regional offices. This was during the leadership of the GPA’s
first director, Jonathan Mann.

Mann resigned in 1990 over differences with the WHO’s director-general,
but had already begun making changes to the programme. The report acknowledges
further changes made by Merson but bases its conclusions on the history
of the GPA since 1985.

The independent review group consisted of 10 social scientists, economists
and public health researchers. It was chaired by Bernadette Freers, formerly
of the Ugandan health ministry.

‘The current worldwide effort to prevent the spread of HIV and cope
with the consequences of AIDS does not match the magnitude of the problem’,
in spite of the WHO’s and others’ efforts, the report says. Although AIDS
will remain primarily a health problem, it also affects the economy and
other spheres of life, and it is unrealistic to expect the WHO to cope alone,
it says.

It praises the GPA for its far-sightedness in the early days of the
AIDS pandemic, its ‘critical role’ in fighting discrimination against people
with HIV, and its rapid response. But it is also sharply critical.

The GPA helped countries to set up their AIDS programmes with a series
of short-term and medium-term plans. Although these plans were once a useful
framework for rapid action, says the report, they were ‘not sensitive’ to
the differing conditions in particular countries.

‘Perpetuation of standardised planning in the late 1980s, after understanding
of the major routes of transmission had progressed, delayed the development
of (plans) targeted on critical priority areas in individual countries,’
says the report. The GPA counters that it has already changed its policy
to make plans that meet the needs of individual countries.

The review attacks the GPA’s mechanism for passing on donors’ money.
In an attempt to speed up and target funding, the programme set up a ‘trust
fund’ in 1987, to pool funds and allocate them directly. But this was inefficient,
says the report. Again, funding arrangements have now changed, says the
GPA.

Unlike many WHO operations, the GPA has provided direct support to countries,
for example through technical advisers and the supply of equipment such
as test kits. But bureaucratic delays in Geneva frequently delayed deliveries
and the advisers often lacked experience, says the report.

Among the other criticisms, the report highlights the GPA’s failure
to consider the question of how to care for AIDS patients. It says the programme’s
listed priorities lack focus and criticises a lack of long-term vision.
The GPA lists as its second priority ‘planning for the social and economic
consequences of AIDS’. This is ‘more properly the responsibility of another
agency such as the UNDP or the World Bank’.

The GPA has failed to collaborate fully with others, says the report.
The WHO ‘has been cautious about encouraging greater involvement from other
organisations, and has at times attempted to control or mediate the global
response’, it says.

Merson denies that GPA has been territorial about AIDS. He says he has
been demanding more support from the other agencies and stresses that the
WHO and UNDP have collaborated since 1988.