Accountability is an important social justice issue in the global response to HIV because effective systems of accountability are powerful tools to improve the quality, accessibility and equitable delivery of HIV-related services. Effective accountability will increasingly require measurement of programme outcomes (in addition to financial and other inputs) and giving voice to the needs of those most profoundly affected by the epidemic.
In many ways the first three decades of the HIV pandemic have been characterized by a lack of accountability among key actors who have often failed to live up to their own commitments or meet the needs of those they serve. Many governments have not acted in a fully responsive manner to protect their populations from HIV infection or death from HIV disease. Many countries, rich and poor, still fail to devote adequate resources to address their national epidemics, choose not to implement evidence-based programming, or ignore the needs of marginalized groups affected by HIV. Donors and international agencies, while making crucial contributions to the global HIV response, have often not fulfilled their promises to provide needed resources or appropriate technical supports.
Accountability is often called for but rarely defined in the current global dialogue on HIV. The notion of accountability is that progress towards goals, commitments or responsibilities are assessed, and those responsible for action in these areas are held to account in some public fashion. The ultimate goal of accountability is not passing judgement, however. Through a process of accountability, it is hoped responses will be improved, either because outside critiques help those responsible learn to refine their work, or because accountability mechanisms bring with them a perceived price to pay for underperformance.
Without accountability, no one is responsible for getting the job done, there are no criteria to assess the work of institutions, and public commitments are little more than hollow promises. With a sense of accountability comes the assertion that results can and should be measured and that institutions are answerable to a community outside their own doors.
Promoting accountability requires identifying who is to be held accountable for what. In the field of HIV and health generally there are numerous possible answers to these questions, so accountability must continue to mean many different things. In fact, the diversity of perspectives and independence of credible voices are essential elements in holding governments and other institutions accountable.
Who is accountable?
Accountability efforts can focus on a wide variety of actors, including national governments, United Nations organizations, bilateral programmes and many others. It seems likely that national governments will remain a central focus of accountability efforts, because governments bear responsibility for serving their populations, need to be engaged in order to secure sustainable service systems and (unlike external actors) can take full ownership of their national responses.
The issue of in-country ownership is a crucial element of success in building sustainable, accountable health systems, and is an important theme of Global Fund financing, design of the International Health Partnership and several other recent global health efforts. If national governments and planning bodies are, however, to be the locus of ownership in the response to HIV, it will be critical that multiple stakeholders are able to participate in national planning and implementation and have the resources, freedom and access to information necessary to hold national entities to account.
It is also true that national governments of heavily impacted countries cannot be the only focus of accountability efforts. In a world where the resources available to many countries are dwarfed by severe national health challenges, the role of global institutions and bilateral and private donors will remain essential, and these organizations also need to be accountable.
Accountable for what?
The question of what governments and other institutions are accountable for depends on who is doing the accounting. Institutions might be held to account for specific commitments they have made (such as a governments' overseas development funding level, or targets for the number of people receiving HIV treatment) or for responsibilities that are asserted by others (such as pharmaceuticals making lifesaving products they have produced available to the poor).
Although assessing resource commitments and other inputs to health services will remain essential, accountability mechanisms should also look for opportunities to focus on measuring tangible outcomes, such as treatment utilization, or reduced mortality and HIV incidence. To use the example of another disease, the target of ‘polio elimination’ is more powerful than ‘expanding the delivery of polio immunization’. A focus on outcomes draws attention to the end goal of health delivery and challenges actors to use their combined resources (financial, human and other) to maximum impact in accomplishing benefits for society. An outcomes orientation can drive attention to adequate financing, the use of evidence-based responses and good management and planning.
With a social and public health phenomenon as multifaceted as the HIV epidemic, it may be considered unrealistic to hold particular institutions responsible for specific outcomes. A United Nations agency cannot control what the government of a member state does. Even those governments that do act decisively may not be able to control their epidemic, at least for a time. Often the relationship between delivering services (such as prevention interventions) and population-level outcomes is uncertain. In many cases the inputs are easier to quantify (funding levels, units of service delivery) than are particular results (number of infections or deaths averted).
The challenges of an outcomes focus need to be carefully considered in developing accountability mechanisms and in judging the work of institutions, but should not dissuade advocates and others from an increasing concentration on measuring the ‘bottom line’ in responding to HIV and other health needs.
Evolving mechanisms of accountability
The past few years have seen a proliferation of target setting initiatives and efforts to hold institutions accountable for achieving particular goals. In 2001, the United Nations held a Special Session on AIDS that produced a Declaration of Commitment (DoC) outlining specific programme and outcome targets in countries heavily impacted by HIV. The following year the World Health Organization launched its ‘3 by 5’ campaign with the aim of reaching three million people in low and middle income countries with HIV treatment by the end of 2005. In 2006 the G8 nations pledged to come ‘as close as possible’ to ‘universal access’ to HIV services by 2010. These campaigns are consistent with a general movement in HIV and health services towards greater accountability and outcomes tracking. Examples include ‘results-based’ financing through the Global Fund, ‘compacts’ through International Health Partnership to promote institutional accountability, and a significant investment by the Joint United Nations Programme on HIV/AIDS (UNAIDS) in monitoring and evaluation in heavily affected countries. There are also efforts to harmonize monitoring and evaluation, for example the UNAIDS Monitoring and Evaluation Reference Group, which seeks to establish common indicators and evaluation tools to be used by UNAIDS, the Global Fund, the US President's Emergency Plan for AIDS Relief (PEPFAR) and other bilateral programmes.
The ‘3 by 5’ campaign marked a change in perspective about the usefulness of target setting and accountability measures. The campaign ended in 2005 having fallen significantly short of its goal. Yet ‘3 by 5’ was catalytic in the HIV treatment effort, sending a clear message to governments and donors that treatment delivery was possible, even in the poorest settings, and that measurable results were expected from international agency and national efforts. National AIDS authorities devised plans to meet their ‘3 by 5’ targets. Advocates used the campaign as a rallying cry. Even in its failure, ‘3 by 5’ changed the landscape of the AIDS movement.
With HIV treatment now firmly on the international agenda, advocates are challenged to design accountability processes that can leverage continued progress on the national and global levels. Today it is increasingly important to consider what aspects of policy and programming should be evaluated in order meaningfully to assess the work of institutions and drive change.
In some cases, the obvious evaluation measures may give an incomplete picture of the response that is needed. For example, in HIV treatment, tracking the number of people who have ever initiated treatment is different to determining the percentage of people that remain on treatment, the change in mortality rates, or the share of people who benefit from adherence services. The PEPFAR programme releases annual estimates of the number of people it has helped access antiretroviral drugs. Many advocates now emphasize the need to scrutinize multiple aspects of PEPFAR's response, in addition to the numbers of people receiving treatment, such as the quality of health services or adherence to treatment regimens.
Current HIV-related accountability efforts
An impressive variety of accountability projects have emerged over the past few years. Most of these efforts are focused on reporting the level of government commitment on HIV services, the appropriateness of government policy, and the accessibility of HIV-related services in particular countries and among specific population groups. Each of these projects brings a unique voice to assessing the response to HIV and recommending changes.
The most prominent and widely recognized global accountability project in the field of HIV is the United Nations General Assembly Special Session (UNGASS) DoC, first developed in 2001 and signed by 189 United Nations member states. The DoC sets out a variety of specific goals for national-level policy change and expanded service delivery. The document also calls for monitoring of progress towards these goals.
Since 2001, UNAIDS has distributed a series of ‘core indicators’ to help countries measure and report movement towards UNGASS commitments. In 2006, 115 of 189 nations submitted Country Progress Reports to UNAIDS based on these indicators. Reporting rates have improved markedly for 2008. By March of that year 147 of 192 countries had submitted their reports. In addition, in 2005, 2006 and 2008 numerous civil society groups produced their own ‘shadow reports’ assessing progress toward DoC commitments in countries.
As the United Nations (UN) convened in June 2006 for another Special Session to review progress on the UNGASS Declaration, the UN Secretary General observed that ‘While certain countries have reached key targets and milestones for 2005 as set out in the Declaration, many countries have failed to fulfill their pledges.’ . Many civil society groups voiced grave concern with governments' failure to achieve UNGASS targets, and many were disappointed with what they perceived as scaled back commitments in the new Declaration issued at the 2006 Session.
For its mid-2008 UNGASS Review, UNAIDS produced a revised set of core indicators to assist countries in preparing their reports. The 25 national indicators cover areas such as national spending, policy, service delivery levels, knowledge and risk behavior of key population groups, and outcomes measures such as HIV infection rates among young people.
Tracking follow-through on UNGASS commitments will probably become an increasingly important accountability activity, particularly as UNAIDS is working closely with governments to improve their own monitoring and this process will yield a rich set of data. Still, the limitations of UNGASS-related monitoring should be acknowledged. Official reports from UN member governments will only tell the government's side of the story. And the UNAIDS core indicator questions cannot be expected to capture all the important aspects of what is needed to sustain the effective and equitable delivery of a range of HIV services.
Below is a brief summary of some accountability efforts by non-governmental organizations (NGO). The first group of projects is tied explicitly to tracking progress on the DoC, whereas the second group uses other measures to assess national and global efforts.
Projects centered on implementation of the UNGASS Declaration
UNAIDS encouraged national governments to engage civil society in the 2005 country reviews of progress toward the DoC. CARE International commissioned surveys of civil society experiences in national UNGASS reviews in Cambodia, Kenya, Malawi, Thailand, the United Kingdom and Vietnam. Research was based on a standardized questionnaire with questions for government and civil society informants. The CARE report was published in April 2006 .
International Council of AIDS Service Organizations
The International Council of AIDS Service Organizations (ICASO) funded a series of ‘shadow reports’ by civil society advocates to accompany official government reports to the UNGASS 2005 review. The final report ‘Community monitoring and evaluation: implementation of the UNGASS Declaration of Commitment on HIV/AIDS’  draws from research in 14 countries: Cameroon, Canada, El Salvador, Honduras, Indonesia, Ireland, Jamaica, Morocco, Nepal, Nigeria, Peru, Romania, Serbia and Montenegro and South Africa. The document reviews common themes and cross-cutting issues and provides highlights from individual country reports. Research was based on a standard questionnaire that was adapted in each country.
The civil society organization GESTOS, in partnership with other NGOs, produced a series of UNGASS Forums to review the implementation of the DoC in Brazil. ‘Monitoring the fulfillment of targets and commitments foreseen in the United Nations Declaration on HIV and AIDS adopted by Brazil’  is based on interviews and other research, including discussions at the Forums. It provides a detailed assessment of progress and challenges on several areas of the DoC, including prevention and treatment services, human rights, and services for children.
PANOS Global AIDS Programme
PANOS commissioned studies of the implementation of the DoC in Bangladesh, Ethiopia, Haiti, Latvia, Malawi, Pakistan and Sri Lanka. The goal was to contribute to the official UNGASS review process from a civil society perspective. PANOS has issued a series of country-specific issue briefs critiquing policy issues, financing, programming and public mobilization, and making recommendations for improvements .
Public Health Watch: Open Society Institute
The Open Society Institute Public Health Watch programme contracted with civil society researcher/writers in Nicaragua, Senegal, Ukraine, the United States, Vietnam and Zambia to evaluate national efforts to comply with the DoC. The project has issued several reports on HIV policy in these countries. The reports are based on a standardized survey template tied to the DoC. The template covers such issues as HIV programme financing, prevention and treatment policy, human rights, and monitoring efforts. The Public Health Watch programme also supports a variety of other civil society accountability efforts globally beyond those tied to the DoC. For example, the project has issued a series of reports on TB/HIV policy .
Ongoing monitoring efforts
AIDS Accountability International
This new project is developing a ‘scientifically based independent assessment tool’ to measure the progress of governments towards UNGASS and other goals. AIDS Accountability seeks to use objective measures, like those employed in the Human Development Index and the Corruption Index, to monitor government actions on HIV and hold officials accountable .
Centre for Economic Governance and AIDS in Africa
The Centre for Economic Governance and AIDS in Africa (CEGAA) seeks to improve economic governance, fiscal policy and financial management and accountability around HIV services through budget monitoring that is ‘owned and driven’ by organizations in affected countries. CEGAA provides budget monitoring training, ongoing guidance and other supports to promote local monitoring and related advocacy. It also offers assistance with budget development and the costing of national AIDS plans. CEGAA has published training materials and a report on HIV financing .
Human Rights Watch
The organization's reports document human rights violations that help drive the global HIV epidemic. Recent reports cover topics such as the failure to protect children and youth in Romania, government failures and human rights abuses related to the HIV response in Zimbabwe, and human rights violations that are impeding the response to HIV in the Ukraine .
International Treatment Preparedness Coalition Missing the Target reports
The International Treatment Preparedness Coalition (ITPC) is a global group of AIDS activists that has produced a series of ‘Missing the Target’ reports analysing barriers to HIV service delivery and making recommendations to governments and multilateral and bilateral agencies. Seventeen country teams contributed to the November 2007 report. The qualitative research is based on a standardized template developed by the full research team, which is then adapted by in-country civil society monitors. The reports also include critiques of the work of global agencies based on findings by in-country teams and other research .
Physicians for Human Rights
Physicians for Human Rights has issued a series of reports that address barriers to testing, human trafficking, the human resources for health crisis, discrimination in healthcare and other topics. Recent reports have addressed issues such as the unequal legal status of Thai women and how this leads to discrimination and lack of healthcare access, the need for protection from HIV-related discrimination in Botswana, and an ‘action plan’ to prevent the brain drain of health professionals in lower income countries .
The World AIDS Campaign
The World AIDS Campaign publishes the Universal Access Campaigner's Update, a quarterly newsletter on civil society efforts to ‘hold leaders accountable to keeping their promises on universal access to prevention, treatment care and support’ .
Assessing today's accountability projects
Diversity and independence are important strengths of today's HIV accountability efforts. The projects described above come from multiple different agencies and in many cases are closely informed by the perspectives of healthcare consumers and advocates based in heavily affected countries. It is important to maintain this diversity of approach. When accountability becomes defined by a few stakeholders, or a few evaluation measures, or when accountability projects seek the imprimatur of one or more established ‘authorities’, then there is a real danger that accountability as a whole will fail to represent diverse interests or make tough demands of established institutions.
A review of the projects above suggests several ways in which the HIV accountability enterprise can be more effective over the coming years. First, some accountability projects have not achieved the level of visibility and impact necessary to motivate real change. Research reports and other products that assess the work of various actors are valuable accountability tools, but there is the potential for reports to sit on shelves and not influence the policy debate. Some accountability projects have not made recommendations that are specific and actionable, or named particular organizations or individuals that should take specific actions; linked their publications to ongoing advocacy aimed at making sure recommendations are implemented; designed and presented publications in a way that garners maximum media attention locally, nationally and internationally; and distributed their reports widely among government, donor, global agency and grass roots organization representatives.
Second, many accountability initiatives are not sufficiently linked to the consequences of failure. Monitoring progress on goals can help drive change, but governments and other institutions may need to perceive the real costs of failure for accountability reports to have meaning. Lara Stemple of University of California at Los Angeles Law School has observed that ‘Accountability must… entail consequences…. The clarity that measurable goals provide is undermined by the lack of real consequences for states that do not meet these goals.’ .
The perceived consequences of failure that could win the attention of policy makers include negative media coverage, flagging interest of donors and dissatisfaction among voters. With that in mind, HIV accountability projects can maximize their impact by building stronger links to donors, media, civil society, political institutions and advocates, and by establishing direct communications with government leaders. These projects should also look for opportunities to garner maximum attention, such as international conferences, UNGASS meetings, and other events that attract media interest.
Finally, accountability projects need to make sure they are asking the right questions. As the response to HIV evolves the most effective accountability measures will change. For example, in the ‘3 by 5’ era, setting a numerical target proved powerful in treatment advocacy. At present, investigating particular aspects of service delivery – for example, the strengths and weakness of drug procurement and supply chain management systems – is also critically important. The growing donor interest in promoting health systems strengthening over ‘vertical’ disease programmes argues for accountability measures that assess health services broadly, while simultaneously tracking HIV services. As noted above, accountability projects should also consider emphasizing the measurement of outcomes (such as incidence rates, care utilization, or disparities across groups) as well as inputs (such as funding levels or the engagement of civil society).
Recommendations: new directions for accountability
Several recommendations for promoting new directions in HIV accountability follow from the discussion above.
Recommendation 1: connect accountability and advocacy
Accountability projects will have more impact if they are tied to direct contact with policy makers and linked to sustained advocacy. To the degree accountability work fosters dialogue between health consumers and policy makers, it has the potential to open meaningful dialogue about policy and implementation. For example, researchers can communicate with policy makers in their Ministry of Health or the national AIDS authority as part of researching a report, and they can set up meetings with government officials after the report's release. In this ‘age of implementation’ in global HIV, accountability projects should strive to provide specific, actionable recommendations identifying which particular institutions need to act. General observations about inequities in service delivery or lack of access among particular populations may often have less relevance than targeted recommendations that are specific as to who should do what and when. As a greater quantity and diversity of HIV-related services are provided in different settings, accountability projects can also make important contributions by identifying best practices and offering solutions in addition to identifying where responses have fallen short.
Recommendation 2: reconsider measures
Everyone engaged in accountability activities should think carefully about the measures used in their assessments. Commonly used measures of treatment and prevention services may provide a wholly incomplete picture of the quality and sustainability of efforts. Assessing the appropriateness of national prevention responses is a particular shortfall in current efforts. UNAIDS' ‘core indicators’ ask questions about usage rates for condoms and sterile injection equipment, knowledge about HIV among young people, and the delivery of ‘prevention programmes’ to ‘at-risk’ populations. Missing from this assessment are questions that might give a fuller indication of the appropriateness of the national prevention programme, such as: whether resources and programming are appropriately targeted to suit the particulars of the national epidemic; whether evidence-based programming is used; whether community norms and structural drivers in vulnerability are addressed in some fashion; and whether needed interventions have been brought to a scale sufficient to have population-level impact.
Recommendation 3: hold multiple actors accountable
As noted above, many accountability efforts rightly concentrate their critiques on national governments. Future efforts should do more to identify the capacities and responsibilities of other actors in addition to governments. For example, United Nations organizations need to be involved in distributing resources, providing technical support, setting standards and promoting effective policy. The contributions of these agencies should be evaluated more closely. PEPFAR is the largest single sponsor of HIV services, and its funding and programming would benefit from greater transparency and objective evaluation. The work of major global health funders, public and private, should also be the subject of accountability work. Civil society organizations and NGO might also be more self-reflexive, identifying where they and their partners can have greater impact.
Recommendation 4: support in-country capacity
Accountability will mean little if it does not serve the interests of health consumers in countries heavily affected by the epidemic. The more that researchers, civil society, and advocates in countries can be provided with the tools to mount their own accountability efforts, the more directly this work will be responsive to local needs and build local capacity for ongoing engagement. Monitors working at the country level may benefit from training and support with research, budget analysis, writing, interaction with the media, and advocacy with government and other agencies, as well as instruction on public health concepts and the roles of different institutions.
Recommendation 5: make the International AIDS Conferences into a platform for accountability
In a Lancet article  published soon after the 2006 International AIDS Conference, Richard Horton argued that these bi-annual events present an important opportunity to inject increased accountability into global HIV efforts. The conferences can become a ‘global accountability mechanism to monitor country progress, to hold all parties responsible for the part they play in defeating HIV, and to set specific, measurable objectives for the succeeding two years’, Horton wrote.
The article in the Lancet proposed that those involved in planning the international conferences identify ‘priority’ countries and hold sessions focused on each. Multiple stakeholders would do ‘mapping, evaluating, and planning’ for that country's response.
International AIDS Conferences have strengths and limitations as venues to promote accountability and planning. On the positive side, these conferences bring together an impressive diversity of people with areas of expertise that span the field of HIV. Conference delegates come from every continent in the world and the events receive considerable international media attention.
There are also important constraints to consider in realizing Horton's vision, including: (i) whether public officials will recognize the meetings as legitimate planning sessions; and (ii) whether the intended purpose of promoting accountability will create an environment of conflict instead of open discussion and strategic planning. Some of the countries most in need of improved HIV policy and programming are likely to have government leaders who do not want to plan their domestic policy in front of a large audience of the media, activists and others, especially those from countries other than their own.
The Conference is generally regarded as a place to share information, publicize research findings and advocate on particular issues. The ability to do extensive, in-depth planning in this environment is less well established. It can be anticipated that many key players will not acknowledge the legitimacy of the International Conferences as venues to assess their work, make commitments, or plan future efforts.
Horton's worthy recommendation could meet with most success if: (i) The concept is designed as a pilot. Two or three countries might be identified as focus countries, with the goal of testing various formats for accountability, planning and goal setting discussions and launching a larger effort at the subsequent Conference. (ii) A combination of fora are used. Discussions at the Conference might be preceded by smaller pre-conference meetings among key stakeholders to discuss issues in particular countries. These smaller meetings might allow for candid discussion, detailed review of data and facilitated planning exercises. Findings and recommendations from the pre-conference meeting group would then be discussed at one or two conference sessions open to all delegates. Accountability activities (such as critiquing the work of governments) might be separated from planning sessions to allow for a more productive planning environment. For example, one session might provide time for advocates and researchers to present their findings about successes and shortfalls. A separate meeting, to follow, would be dedicated to collaborative planning and problem solving. (iii) Trusted conveners and skilled facilitators are involved. Each series of meetings focusing on a particular country might have two conveners; for example, one from government or a UN agency, another from civil society or an in-country academic institution. A primary role of conveners would be to emphasize the need for the open exchange of ideas and collaborative efforts to tackle challenges in a practical manner. (iv) All voices are heard. Government, UN agency, consumer and civil society perspectives should all be aired as part of these discussions. There should be ample opportunity for the variety of groups doing accountability projects to share their findings and recommendations on particular countries and institutions.
In conclusion, a more robust accountability effort will require increased financial and technical support. Donors in the public and private sectors can play a valuable role in advancing HIV accountability by: funding accountability projects that have demonstrated impact; supporting capacity building of health consumers and civil society organizations engaged in accountability projects; and sponsoring meetings among advocates, health researchers, and health consumers to discuss the most powerful measures for assessing the work of government and other institutions.
Accountability efforts will also benefit from ongoing consideration of how to be most effective in the changing HIV response. These efforts can be increasingly tied to advocacy to influence government and other actors directly, and should support an expanded role for advocates and health consumers in heavily affected countries. Those who would hold governments, global institutions and other institutions accountable for a more equitable and effective response to HIV should continually review which measures of success promise to have the most tangible relevance for improving prevention and treatment outcomes.
Conflicts of interest: None.
Chris Collins is an editor and co-author of the ITPC Missing the Target series of reports and he authored two Open Society Institute reports on HIV policy in the United States. These reports are noted in this paper.