The Global Fund’s 45^th Board meeting, held on 11 and 12 May, discussed a number of updates and reports from various departments. However, the annual update of the Secretariat’s efforts to advance community, rights and gender (CRG)-responsive programming through its investments relating to the five operational objectives under Strategic Objective 3 (SO3) of the 2017–2022 Strategy was not delivered during the actual Board meeting itself. Instead, it was discussed during the pre-Board meeting that took place on 10 May and one hour was allowed for discussion.

This article is based on the paper circulated prior to the Board meeting, constituency views and the discussion of the paper, in the scant time allowed; but even in this short space of time it was clear that Global Fund stakeholders had concerns about the lack of progress in CRG.

Purpose of the CRG update

The Strategy Questions addressed in the Update focused on:

• What have been the Secretariat’s primary streams of work for advancing SO3 under the current strategy?
• What progress has been made against each of SO3’s five operational objectives?
• What challenges have been faced in advancing SO3 to date?
• What actions are being taken in NFM3 and beyond to improve the Global Fund’s performance against the five operational objectives of SO3?

Input sought from the Board

The Board was asked to provide inputs on the following areas:

1. Based on progress to date, in what specific areas does the Board feel more emphasis is required under each of the five operational objectives?
2. The global health landscape has shifted significantly in a number of ways since the current strategy was adopted, including but not limited to the COVID-19 pandemic. How should the Secretariat adjust its approach to advancing SO3 to account for new challenges (and opportunities) that have arisen over the past four years to ensure maximum progress is made by end of 2022?
3. What approach should the Global Fund take to further encourage human rights and gender-responsive investments while continuing to uphold the principle of country ownership?

Conclusions of the Strategy Committee

The Strategy Committee (SC) is one of the Global Fund Board’s Committees comprising a balanced number of nominated representatives from the various Board Constituencies, who are then required to provide feedback to their Constituencies’ members. The SC is mandated to discuss in-depth proposed decision points and Strategy implementation, including CRG, and provide their conclusions to the Board for decision points, for information or to seek Board feedback. All items (with a few exceptions) on the Board agenda must first go through the Committees.

1. The scope and scale of the Global Fund’s investments in adolescent girls and young women (AGYW) have expanded considerably under the current Strategy with marked progress in the adoption of national AGYW strategies and HIV incidence reduction targets in the 13 priority countries, coinciding with a steady aggregate reduction in HIV incidence (KPI 8). However, advancing high-impact sexual and reproductive health (SRH) investments ― including optimizing the integration of SRH and HIV prevention services ― remains both a challenge and clear opportunity in need of heightened focus in NFM3 and beyond.
2. The collection of quantitative and qualitative data to identify, monitor and understand the drivers of health inequities has improved and been an area of strong collaboration with technical partners. Nonetheless, the collection and reporting of disaggregated data at the Secretariat and country levels must continue to be strengthened; an increased focus is needed on using such data to design programs and target investments to reduce inequities.
3. Significant increases are seen in the scale and scope of human rights investments, particularly in Breaking Down Barriers (BDB) countries. Matching funds have been vital for driving human rights investments; an increased proportion is coming from within allocations, however, signaling growing country ownership. BDB mid-term assessments point to marked progress in all countries evaluated to date. The Secretariat is working to mainstream the numerous lessons learned from BDB across its portfolio; however, challenges include how to incentivize investments in countries ineligible for matching funds.
4. Secretariat investments in supporting community and civil society engagement have achieved remarkable growth by expanding engagement support across the grant cycle and solidly into malaria and tuberculosis (TB) and expanding geographic reach. In NFM3, the Secretariat is focusing on creating stronger linkages and synergies between the CRG Strategic Initiative (SI) and its other SIs to increase impact and efficiency.
5. Community systems and responses are a critical enabler for advancing human rights-based and gender-responsive programming that meets the needs of key and vulnerable populations (KVPs). Historically, the scale of civil society strengthening (CSS) investments has been relatively modest; signed NFM3 grants to date are showing a marked increase, however, particularly in community-led monitoring.

Summary of Strategy Committee discussion

Strategy Committee (SC) members expressed broad agreement that, despite encouraging increases, the overall level of investment in CRG activities remains too low and more must be done to accelerate progress.

The success of catalytic investments and evidence of their role in driving increased commitments from governments was welcomed. The BDB Initiative, in particular, was praised and members expressed interest in discussing how lessons learned can be scaled up in the future. With respect to the CRG SI, the SC wanted to hear more about experiences with the provision of long-term versus short-term technical assistance.

The SC emphasized the need for the Global Fund to take a more comprehensive approach to equity, inclusive of dimensions beyond age and gender. Concern was raised over the Fund’s current conceptualization of equity and the notion that advancing equity requires a trade-off between efficiency and effectiveness. The SC challenged this, emphasizing that the focusing on reducing inequities drives impact and should be regarded as core business.

A desire to see more information on TB and malaria related-work was expressed, especially in the light of the significant impact of COVID-19 on the human rights-related aspects of the global TB response.

The SC voiced concern about the Secretariat’s internal processes potentially incentivizing expediency, absorption, and lower risk, and disincentivizing more complex, longer-term investments, such as those in human rights.

How the Global Fund should approach political discussions with countries on matters of human rights and gender was cited as a topic requiring more thorough discussion. Likewise, the need for the Global Fund to advance an approach to human rights and gender that fosters collaboration between national governments and communities, and civil society, while building greater country ownership of investments in these areas, was underscored.

A key challenge cited by the SC was how to best incentivize increased investments in the areas under SO3, raising questions about levels of prescriptiveness; internal processes and incentive structures; and the role of catalytic investments.

Constituency feedback

Most constituencies commended the CRG department for its achievements under extremely difficult circumstances, especially as human rights abuses and gender disparities have been heightened by COVID-19. However, despite these, representatives again pleaded for an in-depth analysis of what was needed to make the achievement of SO3 a reality.

Several constituents noted that they had repeatedly reiterated their support for developing a new Strategy that addresses the weaknesses of the Global Fund's delivery of the current strategy. These weaknesses have consistently been in the delivery of programming to address human rights barriers, ensure gender equality and build strong community systems across all levels of the Global Fund; and the new Strategy needs to provide strong direction to address these concerns. Numerous Technical Evaluation Reference Group and Technical Review Panel reports have highlighted the failure to include, in grants, programming to build and strengthen community systems and tackle human rights barriers for KVPs.

Several constituency members noted that leadership and championing CRG issues were confined mainly to one department instead of CRG issues being embedded in the whole institution. They noted: ‘When our delegation refers to CRG issues, we are not talking about a department but the work on CRG that should be undertaken and prioritized by the Global Fund as a whole. We request that all future CRG updates focus more on CRG related efforts across the Global Fund’. A number of recommendations were made to this effect:

1. That the Global Fund addresses the low investments in community-led advocacy and research and other community responses which remain weak. This portrays a clear lack of commitment across the Secretariat to meaningfully support communities and treat them as equals.
2. Most SO3 funding is concentrated in specific regions and countries that are focused on and assessed for impact on AGYW, as is the case of the work around BDB. There is a need to increase the covered countries and regions using results obtained from previous implementation.
3. Many countries lack the data that are needed to help estimate population size, particularly of key populations. Where data do exist, they are frequently not disaggregated; but such data are needed on a regular and consistent basis to inform grant-making. Their provision would ensure reaching larger KVPs with fewer resources and capabilities with targeted programming.
4. The Global Fund must embed human rights and gender considerations throughout the system from Global Fund Secretariat, Board, Principal- and Sub-Recipients to Country Coordinating Mechanisms, and ensure the appropriate levels of funding and human resources to guarantee the real changes needed to see a move from written or verbal commitments to reality.

Most constituents agreed that, especially in this time of crisis, it has become even more important to address the important issue of human rights and gender equality. Restrictive policies in many countries have had devastating effects on the communities served by the Global Fund partnership. Accordingly, constituents want the partnership to continue to make progress towards SO3 and for capacities in this regard to be scaled up at all levels including in the CRG Department and across the Secretariat. Constituents wanted to know what progress had been made in relation to the CRG Accelerate Initiative and how its effects were monitored. They also reiterated their feelings that the Global Fund should use its leverage to engage in political dialogue with partner countries to reduce human rights barriers for key and marginalized populations.

The Global Fund still has a long way to go in its efforts to enhance CRG

Despite only an hour for presentation of the paper and subsequent discussion, participants at the pre-Board meeting made their feelings clear in no uncertain terms. Debate included the following observations:

• There was a consensus that the overall level of investment in CRG and SO3 remains low.
• There is a need for the Global Fund to adopt a more comprehensive view of equity beyond the current definition.
• A better balance has to be struck between investments to meet targets on the one hand and achieving CRG objectives at the community level on the other: the latter takes longer to achieve.
• The Global Fund needs to look at the ways in which it could use its diplomatic position to challenge punitive laws.

And, overwhelmingly:

• The approach to CRG must be strengthened as a priority.

Several speakers from various departments within the Global Fund, ranging from portfolio managers, disease specialists, the recently created health financing unit and grant management to CRG itself, made brief presentations. The new phrase to emerge from this was that CRG is considered to be ‘mission-critical’ and an integral core part of all investments and not just an add-on.

Sounds familiar? Yes, we have been here before. So, what exactly has to be done to really make that vital difference in how the countries not only view CRG – perhaps, worst-case scenario, as something foisted on them, among so many other competing exigencies? - but to operationalize CRG in a way that still fosters country ownership?

The panel discussion ended with each speaker being asked to nominate one thing that would make CRG stronger in the next Strategy. Their responses were:

• Invest in a variety of in-country learning to catalyze countries to learn from each other through peer learning and sharing success stories.
• Be more creative, bolder, and vastly scale-up community responses through various mechanisms such as providing incentives, multi-country grants, and policy levers, to make CRG more community-led-organization-friendly.
• Continue to learn, to move beyond the platitudes.
• Encourage domestic funding for CRG interventions. Matching Funds have helped but there needs to be more innovation.
• Anticipate and prepare, to keep the pressure on.
• Finally, the discussion ended on a rather radical suggestion for a solution: using a ‘sticks and carrots’ approach: get these right, both at the headquarters and country levels, by rewarding staff who take CRG seriously and career-limiting those who do not.

The Executive Director, in his opening speech to the 45^th Board meeting, had emphasized the significant improvement in Community Rights and Gender (CRG)-related interventions and provided several examples of this positive evolution: in the grants signed at the end of 2020, the budget for CSS investments in the resilient and sustainable systems for health (RSSH) grants had increased by about 145% while human rights investments in HIV grants had increased by 66%. The increase in investments for grants including robust programs for adolescent girls and young women (AGYW) is also remarkable (25%), and builds on the success of “Her Voice” and its Francophone equivalent Voix Essentielles, launched in March 2021 with the support of Chanel. At the Secretariat level, the human resources dedicated to AYGW have doubled in support of this engagement.

This is encouraging news. However, nevertheless, skepticism remains that efforts to strengthen CRG interventions within investments are still going to fall short of what is really needed to make that elusive difference.