16 May 2017
Non-traditional vulnerable populations overlooked

When people think about key populations in the context of the Global Fund, they tend to think about the ones that are mentioned most often – such as sex workers, transgender people, people who inject drugs, and men who have sex with men. When it reviewed the funding requests from Window 1 of the current funding cycle, the Technical Review Panel (TRP) said that other vulnerable populations were overlooked or, if they were mentioned at all, there was a limited understanding of their needs. The TRP said that these other vulnerable populations included: people with a disability; miners; indigenous populations; and mobile populations (i.e. migrants, internally displaced persons and refugees).

This was just one of many findings contained in a debriefing document prepared by the TRP which describes the outcomes of its review of the funding requests as well as lessons learned from these requests. Aidspan obtained a copy of the debriefing document from the Secretariat. The TRP is planning to produce a report for public release but not until after it has also reviewed the requests from Window 2, for which the deadline for applications is 23 May 2017. 

This is the last of three articles that Aidspan has prepared on the contents of the TRP’s debriefing document. In this article, we report on the lessons learned in two priority areas: human rights and gender, and resilient and sustainable systems for health (RSSH).

[In the first article, also in this issue, we provide information on (a) the outcomes of the TRP’s review (including requests for matching funds); and on (b) the general lessons learned from the review. And in the second article, also in this issue, we report on the technical lessons learned from the Window 1 funding requests for malaria, TB and HIV.]

Please note: (1) The TRP debriefing document was in the form of a slide deck, which means there were lots of bullet points and very few complete sentences. In this summary, we have done our best to correctly interpret the meaning of the TRP’s many findings and recommendations. (2) For space reasons, we have had to be selective in terms of which findings and recommendations we include in this article.


Using data to prioritize people, places and programs

Findings: Compared to previous proposals, the Window 1 funding requests contained more information on sex-disaggregated data and data on key populations as well as the use of this data to help design interventions. Nevertheless, there was a lack of: (a) population size estimates for key and vulnerable populations; (b) data on geographically delineated populations; (c) quantitative indicators for human rights and gender; and (d) sex-disaggregated data in critical areas, and also across the HIV treatment cascade. | Sex- and age-disaggregated data is largely missing in target setting and in reporting. | In general, RMNCAH data is missing outside of prevention of mother-to-child transmission of HIV and antenatal care. (RMNCAH = reproductive, maternal, newborn, child and adolescent health.)

There was an “absence of discussion” of gender in initiatives related to human resources for health (HRH) and health systems strengthening (HSS)… This is a missed opportunity for improving women’s access to health services.

Recommendations: Applicants should conduct population size estimates; should include RMNCAH data in funding requests; and should strengthen targets and progress reporting using sex- and age-disaggregation. | Partners should provide technical assistance and support to strengthen collection and reporting of sex- and age-disaggregation in funding requests. Partners should support countries to strengthen outcome measures for reporting HRG, and should consider aligning with some of the PEPFAR indicators.

Gender, women and girls

Findings: TB and malaria funding requests contained increased discussion of gender. | There are gaps in gender analysis across all three diseases, and gaps in understanding gender v. sex. | In HIV proposals, there was little discussion of women and girls, particularly in concentrated and low generalized epidemics. | There are weak linkages with RMNCAH in all three disease programs. | Women’s organizations were generally not included in descriptions of country coordinating mechanism and consultative processes. | There was an “absence of discussion” of gender in initiatives related to human resources for health (HRH) and health systems strengthening (HSS). The TRP said this is a missed opportunity for improving women’s access to health services. The TRP cited the example of one country where 80% of the maternal and child health workforce is male.

Recommendations: Applicants should include women’s organizations in governance structures. | Partners should provide technical assistance on the integration of RMNCAH in disease programs and the integration of gender in HRH/HSS.

Women’s and girls’ empowerment

Findings: The TRP said that it observed increased attention to gender-based violence (GBV) in HIV funding requests, but that there was limited or no discussion of GBV in TB and malaria requests. | The scale of the response to GBV and to violence against women and children was very limited. | There was limited discussion of harmful practices – such as FGMC (female genital mutilation/cutting), child marriage and widow cleansing – and their impact, where relevant, including for countries that have conducted a gender assessment that identified these issues. Some funding requests did include discussion of harmful practices, but no discussion of interventions. | There were limited interventions to address critical drivers of gender-equality measures that impact improved long-term outcomes – i.e. social norm change; working with men and boys; economic empowerment; and cash transfers for school retentions.

Recommendations: Applicants should strengthen programming for GBV, integrated with disease programs. Applicants should consider including interventions that focus on social norm change and economic empowerment, especially for matching funds. | Partners should strengthen technical assistance in gender programming and GBV. Partners should consider stronger GBV indicators such as post-rape care and empowerment (aligned with PEPFAR indicators).

Stigma, discrimination and community systems strengthening (CSS)

Findings: The funding requests recognized the lack of adequate community involvement as one of the reasons for poor case detection and treatment outcomes in TB. | CSS interventions tend to be conflated with service provision. | Communities are rarely engaged as equal and valued partners

Applicants should prepare a separate assessment for transgendered persons, and should propose transgender-specific interventions where appropriate.

in the response, particularly for TB and malaria. | Funding requests tend to conflate stigma and discrimination with human rights. In many cases, the sole proposed human rights intervention is behavior change communication and training to reduce stigma. | There was a lack of data on stigma and discrimination.

Recommendations: Applicants should expand community engagement in the response. Applicants should use the UNAIDS Stigma Index for HIV and build on this data to develop appropriate responses. | Partners should support countries, especially for TB and malaria, to incorporate community systems in the response. Partners should build country capacity to use the UNAIDS Stigma Index to identify gaps and inform interventions.

Under-identified key and vulnerable populations

Findings: For all three diseases, there is a lack of data and comprehensive evidence-based interventions for people (including women) in closed settings – including jails and pre-trial detention. | Interventions for transgender women are absent from most funding requests, though some countries provided good-practice examples. | There was very limited discussion of age-appropriate interventions for children in general and orphans and vulnerable children in particular, for all three diseases. | Other vulnerable populations that were overlooked, or for which there was a limited understanding of their needs, included: people with a disability; miners; indigenous populations; and mobile populations (migrants, internally displaced persons, refugees).

Recommendations: Applicants should prepare a separate assessment for transgendered persons, and should propose transgender-specific interventions where appropriate. For overlooked vulnerable populations, applicants should develop an evidence base, and systematically describe and assess needs. Applicants should include interventions for ministries of justice and police within proposals for people who inject drugs and people in closed settings. | Partners should support countries to develop interventions for transgendered persons. Partners should extend technical support to countries to identify vulnerable populations and develop specific interventions. Partners should support countries to develop and implement comprehensive evidence-based interventions for people in closed settings.  

Finance and sustainability

Findings: Some funding requests discussed mechanisms for sustainable financial and programmatic support for community-based organizations (CBOs) working with key and vulnerable populations, including social contracting. | Where there were evidence-based interventions supported by CBOs, they tended to be under-resourced. | Cuts in country allocations tended to correlate with cuts in interventions for key and vulnerable populations. | It was difficult to determine from the funding requests what the budgets were for human rights and gender initiatives. | Sustainability planning for countries nearing transition did not systematically include plans for funding CBOs/NGOs following transition.


Procurement and supply chain management

Findings: The funding requests reveal continued weakness in supply chain management. While the “center” of the supply chain may be improved, problems persist at the periphery. | Equipment maintenance and repair functions are rarely mentioned in funding requests. | GeneXpert and other medical equipment have been introduced without attention to the demands they place on system support (maintenance, transport of specimens, capacity development, etc.) | Large countries procuring domestically has had an impact on global supply prices. | Evaluations of value for money and quality assurance are needed in context of decentralization and moves towards local procurement.

Recommendations: Applicants should do a careful readiness assessment before introducing new equipment or decentralizing laboratories. The Global Fund should examine its shrinking market share and the declining leverage of its Pooled Procurement Mechanism. Applicants and the Secretariat should consider the use of non-public sector contracting to handle supply chain and equipment maintenance functions.

Human Resources for Health (HRH)

The funding requests reveal continued weakness in supply chain management. While the “center” of the supply chain may be improved, problems persist at the periphery.

Findings: Regarding public sector employment, the numbers, management, retention and integration of supportive supervision are all inadequate. | In almost all cases, the occupational health and safety of community health workers (CHWs) was not considered. | Using project funding to compensate CHWs is not sustainable. | The use of task shifting (moving down the chain) is increasing; this may require legal justification. | Few countries are assuming responsibility for salary costs. | The multiple responsibilities of CHWs continue to increase with service integration; there is a risk that CHWs may become ineffective as a result of overloading. | A lack of human resources remains a key bottleneck to accessing services and to sustainability in most settings.

Recommendations: Support provided by the Global Fund should be within the Fund’s HRH strategy. | The Secretariat should consider documenting innovative initiatives, such as PPMs (public-private mixes) in urban services for TB.

Decentralization and governance

Findings: Decentralization is growing in all regions. Decentralization may threaten program quality and impact if its implications are not addressed. | There are challenges with fund flow and supervision in many decentralized systems. The funding requests made no reference to democratic oversight of decentralized structures. | There was a lack of attention in the funding requests to improving quality and standards in cases where the private sector is delivering key services. | CCMs don’t usually have RSSH expertise. | The influence of key populations is often weak even when they are represented on CCMs.

Recommendations: Weak CCMs should be strengthened, particularly in countries where there are no PRs from the non-government sector. CCMs should be better linked to governance bodies, including central ministries such as Finance and Planning. The composition of CCMs should take into account “special considerations” such as refugees and migrants. | Countries should seek technical advice from the World Health Organization (and possibly UNDP) on the implications of decentralization with relation to fund flow, potential integration of services, devolution of data responsibility, procurement, accountability, etc. Alternatively, applicants and/or the Secretariat could make the case for continuing verticalization (such as for malaria programs whose goal is pre-elimination).  

Community system strengthening

Findings: Many countries use CHWs. | There was virtually no reference in the funding requests to using CSS to enable the communities to perform as partners in putting in place resilient health systems. | Few countries have social contracting mechanisms to enable governments to support key civil society organizations (CSOs) when the Global Fund exits.

Recommendations: Applicants should support CSOs to ensure that the communities play a role in oversight and support for CHWs, and for local health initiatives. Applicants should develop social contracting mechanisms.

The TRP’s debriefing document on Window 1 funding requests is on file with the author. The TRP is scheduled to review Window 2 funding requests from 19-28 June 2017.

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