The exchanges back and forth between Ethiopia’s country coordinating mechanism (CCM) and the Technical Review Panel (TRP) during the review of Ethiopia’s recent TB/HIV funding request illustrate just how hard it can be to make headway in providing services for men who have sex with men (MSM) and transgendered persons in a country where sexual activity between persons of the same sex is criminalized, and where stigma and discrimination toward MSM and transgendered persons are pervasive.
Initial TRP review
When it reviewed the funding request, the TRP noted that it did not make any reference to MSM and transgendered people. The TRP said that it appreciated that there may be some profound cultural and political obstacles to even acknowledging the existence of persons who engage in sexual practices that are not accepted in society in Ethiopia –– and that this might also extend to people who inject drugs (PWID). However, it said, in the context of the epidemiological situation in Ethiopia, the lack of access to services for these populations is a major flaw and amounts to discrimination and the denial of basic human rights of these populations.
The TRP pointed out that this issue was raised by the TRP and the GAC when they reviewed previous concept notes; that recommendations were made; and that this has not resulted in the inclusion of interventions for these populations in the current funding request.
The TRP requested that Ethiopia reconsider its position towards MSM, transgendered people and PWID, and develop approaches to collect data on HIV risks and vulnerabilities, needs assessments, and stigma and discrimination related to these populations. The TRP further requested that the CCM provide a clear plan of action to ensure that services are provided to these populations through government or alternate systems. The TRP also requested that the CCM ensure a mechanism be put into place that enables MSM, transgendered persons and PWID to provide meaningful input to the plan of action, while protecting their privacy and safety. The TRP said that technical partners and other organizations should be able to assist in this process.
Response from the CCM
Aidspan understands from sources that when the CCM responded to the TRP’s clarifications, it did not mention MSM or transgendered persons. Apparently, the CCM said that it is addressing the TRP’s concerns within the context of the legal framework and the culture of the country. We understand that the CCM said that the Federal Ministry of Health (FMOH) is responsible for the delivery of health services to all citizens of Ethiopia without discrimination; and that the constitution states that every Ethiopian has the right of equal access to publicly funded social services.
In its response, the CCM said that one of the agendas of Ethiopia’s Health Sector Transformation Plan (HSTP) is to ensure quality and equitable health services “which [are] safe, reliable, patient-centered, efficient and provided to all in need in an equitable and timely manner,” and which “[do] not differ by any personal characteristics including age, gender [and] socioeconomic status.” (Source: Health Sector Transformation Plan, Federal Democratic Republic of Ethiopia.)
The CCM further noted that the HSTP calls for a health workforce that is “caring, respectful and compassionate,” and health facilities that are free of stigma and discrimination. The CCM said the health sector is fulfilling its duties, although it acknowledged that discrimination could occur. The CCM mentioned female sex workers, saying that fear of stigma and concerns about confidentiality are among the barriers to testing cited by this population.
The CCM said that the response to HIV in Ethiopia is targeting female sex workers, truck drivers, inmates, daily laborers and other vulnerable population groups, but it did not name MSM or PWID.
We further understand that in its reply, the CCM said that it would conduct an assessment of the attitude of health professionals toward at-risk populations; and that it would strengthen user-friendly HIV services in the context of its HIV Catch-Up Initiative.
TRP comments on the CCM clarifications
Sources told Aidspan that the TRP replied that it was “not fully satisfied” with the clarifications. The TRP said that it would be reasonable to assume that MSM and transgendered persons are covered by the provisions of the constitution and the HSTP, but that even though may be entitled by law to access services, the TRP said, they are likely to confront barriers to the use of these services for several reasons, including the persistence of stigma and discrimination, particularly on the part of health care providers; and the fact that MSM and transgendered persons may exclude themselves from accessing services for fear of being reported to authorities.
We understand that the TRP also said that MSM and transgendered persons have specific needs that regular health services may not be prepared to provide. For example, the TRP said, they need to know how to use condoms properly and where to procure them; how to prevent HIV and STI transmission; why and how to test periodically for HIV; and how to access peer counseling and support. Information of this kind is rarely provided in health facilities serving the general public, the TRP said.
We understand that the TRP suggested that Ethiopia consider creating male health clinics staffed by specially trained personnel where MSM and transgendered persons could remain anonymous. Global Fund financing has been used in several countries to support this type of facility, the TRP noted.
Sources told Aidspan that the TRP called on the Secretariat, with support from technical partners, to negotiate with the Ethiopian CCM a “work-around” that will guarantee access to services for MSM and transgendered persons while protecting their privacy.
Final word from Aidspan
These challenges are not unique to Ethiopia, and the Global Fund always walks a delicate line between country ownership and its own strategic objectives. Many of the cultural sensitivity challenges to implementing programing for certain key populations require longer-term solutions, however frustrating that may be for the persons needing the services now and for the people advocating on their behalf. In Ethiopia, these longer-term solutions will hopefully be explored by the CCM, the principal recipients of the grants and the fund portfolio manager during the life of these grants.
See separate article in this issue on the approval of Ethiopia’s TB/HIV funding request.
Do you have any reaction to this article (or any article in GFO)? To send a note to the editor, just click here. We value your feedback.