The Global Fund that we want: civil society speaks on the need for stronger community-based interventions
More than 120 people gathered on 23-24 June in Bangkok for the Asia-Pacific partnership forum: the second of its kind convened by the Global Fund to solicit voices from civil society and a range of stakeholders to feed into strategy development for the 2017-2021 period.
The expressed wishes and needs of the implementers representing 20 countries in both the Asia Pacific and Middle East and North African regions were made clear from the keynote statements delivered by Maura Eliarpe and Zakaria Bahtout, two prominent HIV activists in Papua New Guinea and Morocco respectively.
We need to “come together as equals, not as beneficiaries,” to foster an environment that “does not leave anyone behind,” they said – signature concerns among communities facing the likelihood of transitioning away from Global Fund support and losing the only resource envelope currently available to support programs for key populations and marginalized groups.
But while the concerns and specific needs of key populations are addressed better through the Global Fund ecology than any other existing bilateral or national mechanism, it is not all perfect, emphasized Eliarpe, highlighting feelings of “disrespect” and tokenism that colored the participation and engagement of disease-affected groups in the conversations at national level, even as part of country dialogue.
This feeling, including a sense of being ill-prepared and without the same degree of technical acumen as other participants, meant that even the interventions and activities that have been conceived to target key groups such as people living with HIV, men who have sex with men, sex workers and others, do not fully consider their needs.
One of the most obvious examples is in the consideration of funding to treat opportunistic infections. There is no point in investing in scaling ARV treatment if people are going to be unable to access drugs for Hepatitis C, noted Eliarpe, who has also called for nutrition support – such as multivitamins – for people whose ARV treatment is paid for with Global Fund resources.
Ensuring a gender balance in programs that were aligned to a human-rights approach will be critical to achieving success and the best possible impact of Global Fund-supported programs, participants said during plenary sessions. Steve Krause, the Asia Pacific regional director for UNAIDS, called the Fund’s draft strategy ambitious and urged stakeholders to “stay hungry” in order for sustainable impact to be achieved, both operationally and in terms of the legislative environment.
Ninety percent of countries in the region criminalize sex work and 50% make it a crime to be gay, he noted, demonstrating the need to develop a broader advocacy model to engage at policy levels that complements targeted interventions.
The two-day event also afforded participants the opportunity to explore ways to influence the Fund’s own structures beyond the development of this next strategy, including governance by a Board whose composition and voting block structure would appear to be at odds with the Fund’s purported ambition for universality and community inclusiveness.
Other innovations, such as the inclusion of a strategic objective focused on health and community systems, were well-received, though with caveats that ownership by communities themselves was essential. It is not enough for an objective to be declared at the global level, noted Edgar Vernon Cruz from the Pilipinas Shell Foundation; proper tools must be made available in countries to adapt the objective to the national context and to have it embraced by communities themselves.
Other thematic areas were the subject of small-group discussions on day two; below is a brief summary of some of the main areas of interest:
Tailored approaches to challenging operating environments, sustainability and transition
Group discussions demonstrated the need for more work to define what constitutes a challenging operating environment, as well as greater flexibility from the Fund and a tailored approach to each individual country’s particular challenges. Acute crises need a different range of responses than protracted ones do, and the needs in a conflict scenario are different than those in the aftermath of a natural disaster, participants noted. Also important is an approach that responds to how crisis can affect neighboring countries, particularly when large populations are displaced across borders.
Countries in transition would also benefit from a differentiated approach that acknowledges the need to maintain a national platform for state and non-state actors to engage and interact. One of the greatest strengths of the Global Fund approach is that it brings a disparate group of actors to the decision-making table; post-transition the risk is that not only would that group fracture but the table itself would disappear.
Disease-specific priorities and a new allocations methodology
Basing allocation of Global Fund resources only on disease burden and economic classification – with some nebulous and unexplained qualitative factors thrown in – is not only unsound but potentially dangerous, participants said.
The next allocations methodology must be more differentiated, factoring in unmet need, concentrated epidemics and key populations – even in countries where the overall disease burden is declining. Co-morbidities and co-infections are an emerging challenge in Asia Pacific, such as the interaction between Type II Diabetes and TB in Fiji, or the threat that the Hepatitis C virus poses to achieving universal access to HIV prevention, treatment, care and support in Indonesia.
Key priorities outlined by the forum were:
- Better balance between treatment and prevention activities for key populations
- Supporting countries with concentrated epidemics through incentives to “go the last mile and leave no one behind”
- Wider engagement at country-level dialogue beyond traditional health sector partners to match health priorities with state budget allocations
- More of a regional approach to disease elimination that considers other criteria beyond disease burden and individual income
Human rights and gender
Human rights are an emerging priority for the Global Fund at the global level that has yet to be fully articulated in countries. More elaboration is needed about the level of support the Fund is prepared to provide to countries with human rights challenges – particularly those preparing to transition away from Fund support. In those countries where key populations are criminalized, it is critical that the Fund establishes what sort of role it is prepared to play to provide ongoing support to advocacy on behalf of human rights, key populations and women that may have limited sources of alternative funding.
The risk that those advocacy efforts are suspended for want of financial support is great, many stakeholders emphasized. One recommendation centered on the provision of a package of technical support and financial assistance being made available to those countries to improve knowledge and understanding of the removal of legal barriers, to try and improve access to justice as well as education of so-called gatekeepers: the health workers and law enforcement officers who are at times barriers rather than facilitators to access to services.
Discussions of gender were primarily shaped by the need by the Global Fund to move towards real gender programming, inclusive of transgender people, men and boys, while also paying more than just lip service to the particular needs of women and girls. Indicators should be developed to measure equitable gender outcomes, improving gender dimensions in malaria and TB programming and to encourage better attention to gender-based violence in concept notes, especially in crisis settings.
Engaging with, and on behalf of, young people was also promoted as a human rights issue.
Resilient and sustainable systems for health – health and community systems strengthening
Robust and lively discussions around health and community systems strengthening, clearly called for a conceptual shift in thinking: a move away from siloed disease-specific programming towards a holistic systems for health approach. Overwhelmingly, delegates agreed that community and health systems are inextricably linked and that any new strategy from the Global Fund would be incomplete without a policy, process and funding environment conducive to inclusive systems for health models.
Continued investment in data and information systems remains a priority so as to capture much-needed and glaringly incomplete sub-national unmet need and KAPs data. Here, too, the benefit of differentiation and inclusion was emphasized, as different actors in different systems play different roles – and have decidedly different levels of both capability and capacity. When provincial and municipal level health systems rely on paper-based reports that are often hand-carried in plastic bags to central health facilities, the system has to reflect and respond to those limitations, rather than ignore or gloss over them.
In adopting the series of recommendations to be shared at its conclusion, forum participants also highlighted the need for the Global Fund to remain cognizant and contextually relevant outside of sub-Saharan Africa, despite that region being the largest recipient of Fund support and commanding most of its attention.
Participants questioned whether the Fund will be able to accommodate these regional nuances in its strategy and in the development of the allocation methodology for the next allocation period. Others expressed concerns that the Forum itself was an exercise in self-congratulation and was likely to have only negligible impact on the deliberations surrounding the development of the strategy, the broad lines of which have already begun to take shape.