www.thelancet.com Vol 381 June 22, 2013 2147
On May 30, 2013, the UN Secretary-General’s High-
Level Panel of Eminent Persons on the Post-2015
Development Agenda published its eagerly anticipated
report.1 The unequivocal conclusion of the report is
that the “unfi nished business” of the Millennium
Development Goals (MDGs) cannot be swept aside,
and that the goals set 13 years ago are ripe for renewal
and remodelling.1 In a similar process of critical self-
refl ection, the global AIDS community is identifying
features of the AIDS response that we wish to protect,
enhance, and extend as we move into a diff erent era of
global health and development.
The AIDS response is among the most successful
public health initiatives of the past 50 years. People
living with HIV, aff ected communities, scientists, and
policy makers joined in common cause, driven by the
urgency and scale of the pandemic. Governance—the
ways we organise ourselves within countries and at the
international level to tackle such challenges—is the glue
that has held the response together; and it ushered in
New global, regional, and national institutions were
created to ensure HIV prevention and treatment.
Pioneering mechanisms of inclusion and accountability
enabled aff ected communities to participate meaning-
fully in governance processes. Citizen activism spurred
unprecedented political leadership, new global com-
pacts, debates in the Security Council and UN General
Assembly, and a series of instrumental UN political
declarations. In a spirit of global responsibility, western
governments and the private sector played vital parts in
scaling up HIV treatment worldwide.
AIDS governance: best practices for a post-2015 world
Communities might judge the Newhints intervention to
be unsatisfactory. The solution seems to be embedded
in the Newhints protocol: to work in close collaboration
with health management boards and professional
organisations, and ensure that key national neonatal
policy makers are involved right from the beginning.10
We also suggest that communities have early input and
that developmental partners are invited. There might be
the fear that the intervention would take people out of
facilities. On the contrary, Newhints has been shown to
encourage women with children to come into facilities;
hence, those who need the intervention can be readily
identifi ed and empowered to participate in the study. In
cash-strapped communities (usually with the weakest
health systems and highest neonatal mortality rates),
lack of cash might be an immediate disincentive to
implementation of the Newhints intervention because
of the burden of incremental cost from increased facility
use due to the intervention. These are costs that have to
be counted before setting out.
The Newhints intervention can be used to stan dardise
care and help mothers adopt healthier life styles, necessary
for a lasting improvement in health. The intervention
might enable a much needed improve ment in the quality
of newborn care in health facilities. Translation of research
into reality is timely in sub-Saharan Africa, especially in
rural and remote areas. The chance of success is very high.
*Taiwo O Lawoyin, Olusheyi O Lawoyin
Frontline Research and Training in Reproductive and Family Health,
PO Box 133, Columbia, MD 21045, USA (TOL); and Goizueta
Business School, Emory University, Atlanta, GA, USA (OOL)
We declare that we have no confl icts of interest.
1 Darmstadt GL, Lawn JE, Costello A. Advancing the health of the world’s
newborns. Bull World Health Organ 2003; 81: 224–25.
WHO, UNICEF. Home visits for the newborn child: a strategy to improve
survival. Geneva: World Health Organization, 2009.
Kirkwood BR, Manu A, ten Asbroek AHA, et al. Eff ect of the Newhints
home-visits intervention on neonatal mortality rate and care practices in
Ghana: a cluster randomised controlled trial. Lancet 2013; published online
April 9. http://dx.doi.org/10.1016/S0140-6736(13)60095-1.
Rose-Wood A, Doumbia S, Traore B, Castro MC. Trends in malaria morbidity
among health care-seeking children under age fi ve in Mopti and Sévaré,
Mali between 1998 and 2006. Malar J 2010; 9: 319.
Amouzou A, Habi O, Bensaïd K, the Niger Countdown Case Study Working
Group. Reduction in child mortality in Niger: a Countdown to 2015 country
case study. Lancet 2012; 380: 1169–78.
Carroll G, Villar J, Piaggio G, et al, for the WHO Antenatal Care Trial Research
Group. WHO systematic review of randomised controlled trials of routine
antenatal care. Lancet 2001; 357: 1565–70.
Eisele TP, Larsen DA, Anglewicz PA, et al. Malaria prevention in pregnancy,
birthweight, and neonatal mortality: a meta analysis of 32 national
cross-sectional datasets in Africa. Lancet Infect Dis 2012; 12: 942–49.
Tura G, Fantahun M, Worku A. The eff ect of health-facility delivery on
neonatal mortality. Systematic review and meta-analysis.
BMC Pregnancy Childbirth 2013; 13: 18.
Lawoyin TO, Onadeko MO, Asekun-Olarinmoye EO. Neonatal mortality and
perinatal risk factors in rural south western Nigeria: a community-based
prospective study. West Afr J Med 2010; 29: 19–23.
10 Kirkwood BR, Manu A, Tawiah-Agyemang C, et al. NEWHINTS cluster
randomized trial to evaluate the impact on neonatal mortality in rural
Ghana of routine home visits to provide a package of essential newborn
care interventions in the third trimester of pregnancy and the fi rst week of
life: trial protocol. Trials 2010; 11: 58.
www.thelancet.com Vol 381 June 22, 2013
But we must recognise that the old ways of doing
business are obsolete. The fi nancial crisis has created
funding constraints. Multilateralism is under pressure.
Critical development issues contend for attention. A
more ambitious global health agenda is increasingly
focused on health rather than disease.2 In forging a
transformative governance architecture that will serve
people best in 2020 and 2030, the principles that are
fundamental to the success of the AIDS response must
remain at the heart of the new agenda.
First is the centrality of justice, human rights, and
gender equality—hallmarks of the AIDS movement and
the catalyst for real progress in countries. Yet much
more remains to be done. Discrimination, stigma, and
criminalisation of people living with, and at increased
risk of, HIV remain the main barriers to services in many
societies. We must continue to promote human rights
as both an entitlement and engine of development.
Second, people and communities most aff ected
by AIDS should have a central place in governance
arrangements. The participation of people living
with HIV was crucial to the legitimacy of AIDS
initiatives, and directly improved the acceptability and
eff ectiveness of programmes. The same is true of civil
society organisations that are hardwired into AIDS
governance arrangements—from board membership
to reporting mechanisms.3
Integration is a third principle. The recognition
that AIDS requires multisectoral action was key to
the creation of national AIDS councils and UNAIDS
as a joint programme of several UN entities. But
we need to exploit further synergies across health
and development. The post-2015 agenda should be
designed to build better linkages throughout the new
development architecture—and the place of AIDS within
it—in a more holistic way.
Finally, the AIDS response is underpinned by the
principle that action should be data-driven, evidence-
informed, and results-oriented. Gathering good data
is challenging, but it is essential to measure progress,
target resources, and discover and document what
works in real time; it is also the keystone of transparency
and accountability. The Global AIDS Response
Progress Reporting system represents an unparalleled
governance achievement: in 2012, 96% of all countries
reported on their epidemics and responses, and often
on challenging issues.4 We can and must continue to
make our actions ever more evidence-informed. Data is
a governance input and output: it drives what we do and
shows what we have achieved.
In confronting dysfunctional systems, the AIDS
movement might have only created “good enough”
governance, but it drove a revolution in governance
nonetheless.5 As discussions on the future of sustainable
development continue6 in the wake of the report
by the High-Level Panel of Eminent Persons on the
Post-2015 Development Agenda,1 we must protect AIDS
governance innovations, and the principles behind them,
because they deliver results. It is encouraging to see that
the report by the High-Level Panel of Eminent Persons
on the Post-2015 Development Agenda identifi ed many
of these principles: the importance of inclusiveness;
the interconnected nature of development challenges;
the need for global partnerships; and the importance
of eff ective, open, and accountable institutions.1 These
principles must remain prominent as the discussion now
shifts from “what” to “how”.
Whilst the AIDS community has a crucial part to
play in forging the post-2015 agenda,7,8 we also need
to listen, learn, and identify areas for improvement.
Although AIDS has been a catalyst for many innovations
in governance, much of the AIDS governance
architecture was created on a reactive, ad-hoc basis.
Current arrangements are unwieldy and inefficient, do
not deliver enough accountability, do not give sufficient
prominence to the voices of the global South, and are
not progressive or ambitious enough in their agendas.
These arrangements need a shake-up. We must not,
Comment Download full-text
www.thelancet.com Vol 381 June 22, 2013 2149
however, fall into the traps that lead to a new round of
institution creation. We must aim instead for radical
simplification. The global health architecture needs
no more than three agencies: one to handle financing;
one to set norms and standards; and one for advocacy
and accountability. An effective apex mechanism could
bring different actors together, including the private
sector. That is all the complexity needed.
However, we should not impose particular models
on countries—their needs will vary according to local
epidemics and broader governance arrangements.
Governance should evolve to become truly multisectoral
and inclusive, avoid duplication, and wield the necessary
political clout to deliver health-in-all-policies. Further,
governments and other institutions must move from
a model of mutual accountability to one of people-
centred accountability, with greater independence
and real sanctions to discourage non-performance.9
Governance is by and for the people—and they are best
placed to hold us to account. This would represent a true
democratisation of global health.
The post-2015 development agenda should empower
those aff ected to become active agents of change. This
demands that people should be supported to know their
rights, are given the political space to mobilise around
them, and are enabled to articulate them as concrete
demands. Human rights literacy is “demand creation”.
These eff orts must include young people, enabling them
to mine the data revolution and use social media and
other forms of activism to demand justice.
We must also continue to look critically at ourselves
while daring to pursue an alternative future. The
UNAIDS and Lancet Commission: From AIDS to
Sustainable Health,10 cochaired by Joyce Banda,
Nkosazana Dlamini Zuma, and Peter Piot, will have
a critical role as we move forward and build on the
proposals of the High-Level Panel of Eminent Persons
on the Post-2015 Development Agenda. But ultimately,
enhanced governance needs to come from within—
from the trust generated within systems and society,
between people and leaders.11
The AIDS movement is at a risky juncture. Any
disinvestment in the response endangers the health
MDGs and jeopardises returns on past investments.
Greater country ownership and integration between
health and development issues, although desirable,
could challenge some of the central principles of the
AIDS response. But these challenges bring opportunities
to reignite and fi ght for the global sense of purpose
we had at the start of the MDG period. We have
an unprecedented opportunity to sow the seeds
of a broad-based movement for change rooted in
principles of solidarity and global justice. Transforming
global governance for health will require continued
investment—but it will be an investment in results.
Michel Sidibé, *Kent Buse
Joint United Nations Programme on HIV/AIDS (UNAIDS),
1211 Geneva 27, Switzerland
MS is Executive Director of UNAIDS. KB is Chief, Political Aff airs and Strategy,
UNAIDS. We declare that we have no confl icts of interest. We thank the
participants of the Thanda Dialogue on AIDS Governance, May 29–30, 2013,
where these ideas were presented and discussed, particularly Per Strand of Star
for Life and Simon Rushton of Sheffi eld University, UK.
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Agenda. A new global partnership: eradicate poverty and transform
economies through sustainable development. The Report of the High-Level
Panel of Eminent Persons on the Post-2015 Development Agenda. New
York: United Nations Publications, 2013. http://www.post2015hlp.org/
the-report (accessed June 4, 2013).
Task Team for the Global Thematic Consultation on Health in the Post-2015
Development Agenda. Health in the post-2015 agenda: report of the global
thematic consultation on health. April, 2013. http://www.worldwewant2015.
org/fi le/337378/download/366802 (accessed June 4, 2013).
Peersman G, Ferguson L, Torres MA, Smith S, Gruskin S. Increasing civil
society participation in the national HIV response: the role of UNGASS
reporting. J Acquir Immune Defi c Syndr 2009; 52 (suppl 1): S97–103.
UNAIDS. UNAIDS global report on the global AIDS epidemic 2012. Geneva:
Joint United Nations Programme on HIV/AIDS, 2012. http://aidsdatahub.
the-global-aids-epidemic-2012-unaids-2012 (accessed June 4, 2013).
Sidibé M, Tanaka S, Buse K. People, passion and politics: looking back
and moving forward in the governance of the AIDS response.
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and global health in the post-2015 debate. May 26, 2013. http://www.unaids.
20130526_PR_UNAIDS_LancetCommission.pdf (accessed June 4, 2013).
11 Tyler TR. Trust and democratic governance. In Braithwaite VA, Levi M, eds.
Trust and governance. New York: Russell Sage, 2003: 269–75.