The Global Fund should consider other approaches
In his recent New York Times op-ed, Paul Farmer called for increased funding for the Global Fund. He is right. But to really put muscle into the fight against HIV/AIDS, the Global Fund needs to change its top-down approach and find new ways to get funding to grassroots groups. As Farmer points out, the Global Fund has succeeded in getting antiretroviral medicines to millions of people, thus saving many lives. It did this by leveraging multilateral funding to strengthen health ministries and medical services for people living with HIV/AIDS, and insisting that civil society be part of the process of grant management. Yet civil society continues to be marginalised in many countries where the idea of a "non-governmental organisation" is still new and still threatening to an authoritarian government. Developing a comprehensive national health care response to HIV/AIDS requires infrastructure. Thus, a good portion of the Fund's grants rightly focus on building medical systems, working closely with government agencies in the process. In the Global Fund model, multi-stakeholder country coordinating mechanisms (CCMs) submit joint proposals and select a principal recipient (PR) that manages the grant and awards sub-grants to others. It's a sensible, top-down response to a national epidemic, which begins with the buy-in of senior leaders who can mobilise national systems. But HIV/AIDS challenges that logic. HIV targets populations that are socially and economically marginalised - and, often, criminalised. While the flows of funds largely follow the channels of power, the trajectories of HIV transmission follow the channels of marginalisation. This is where CCMs run into trouble. In practice, despite the "multi-stakeholder" vision, CCMs are often arms of the state. According to a 2008 report on CCMs by the International Treatment Preparedness Coalition (ITPC), civil society and PLWHA representatives are outnumbered by government officials and their allies, and are often not taken seriously in the decision-making process. Civil society representatives may also be simultaneously trying to run their own under-resourced NGOs and responding to the needs of vocal and critical communities, so their focus is divided. They have to wade through reams of Global Fund reports and paperwork in technocratic English, in which the representative may or may not be fluent. And there is no system for making sure that civil society representatives actually consult with, or report back to, the communities they represent. In some cases, CCMs have become little more than rubber-stamps for government proposals. But the problems go beyond the makeup of the CCM, especially in authoritarian or conservative societies. In those countries, power hews closely to government centres and to those with good government relationships. But drug users, sex workers and others on the margins of society don't have those relationships. When my organisation, Asia Catalyst, travels around Asia to train grassroots HIV/AIDS NGOs, we are often struck by the fact that their geographical marginalisation mirrors their political marginalisation. One of the first HIV/AIDS NGOs I visited in Hong Kong was a case in point. Here, in one of the wealthiest and most socially progressive cities in Asia, the HIV/AIDS NGO was hidden in the back of an old airport terminal, behind a retail automobile showroom, under a sign labelled, "Activity Center." Even in this remote location, staff said, a sign that more explicitly described them would attract outrage from their neighbours. We've held workshops for sex workers in a car wash, trainings for drug users in a back-alley storefront, and seminars for gay men in an unmarked residential apartment building. We've held workshops in the upstairs rooms of churches on a weekday afternoon, when the front gate was locked and the church apparently closed. Community members skulk into these facilities while looking over their shoulders to check if they've been seen. Their economic background, educational background, and even the way they talk and dress - combined with their connection to one of the most stigmatised epidemics in human history - all mark directors of grassroots NGOs as outside of the halls of power. They are unlikely to have the connections needed to get access to funds that flow down from the top of a hierarchy. Or, as a director of a drug user NGO put it to me once, "At every level of the system, someone takes a cut of our grant. By the time it gets to us, we might get a third of what we were promised." One study done in 2008 found that only 19% of Global Fund grants go to NGOs. CCMs are an illogical way to get funding to groups working on the margins of society. The challenge posed by HIV/AIDS demands that we think of innovative ways to fund programmes developed by and led by those communities. This could mean direct funding for national networks that work with specific communities such as sex workers, drug users, persons living with HIV/AIDS and men who have sex with men (though even this wouldn't address the need for programming among communities so politically marginalised that even organising networks could be challenging - e.g., indigenous groups, migrants and refugees). Another approach might be to give grants to smaller coalitions of diverse stakeholders (NGOs, government, academics, private businesses) to work on specific projects. This would promote multi-sectoral cooperation that is targeted and pragmatic, bringing together people with shared priorities. One way or another, the Global Fund and other international donors need to think from the margins, not just the centre, to find new ways to get funds into the hands of people on the front lines of the epidemic.
Sara L.M. Davis, Ph.D. (mdavis@asiacatalyst.org) is executive director of Asia Catalyst, which provides capacity-building services to grassroots groups working on health rights in East and Southeast Asia. For more information, visit www.asiacatalyst.org.