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The much-vaunted concept of country ownership is found wanting
GFO issue 437

The much-vaunted concept of country ownership is found wanting



Article Type:
Editor's Note

Article Number: 1

Isn’t it time for honesty and a rethinking of the approach ?

We start this issue by looking at whether or not the Global Fund and other external partners have really cracked the concept of country ownership’ when it comes to national disease plans and, in at least one country, even the space given to civil society. Last week the United Nations convened four High-Level Meetings to discuss the Sustainable Development Goals, tuberculosis, universal health coverage and pandemic preparedness and response, we discuss the importance of these meetings and announce the winners of the Stop TB Partnership awards. We report on the worsening situation regarding the funding for PEPFAR as well as the increasing infringement of the rights of LGBTQI people in Eastern Europe and Central Asia. Finally, we bring you three articles from our French-language sister publication, on paediatric HIV, domestic health financing in Africa and why Cameroonians don’t like their mosquito nets.


Dear subscribers,


A bumper issue of 10 articles this week! We delayed our publication of this issue by one week to bring you news on the events of last week, when the UN General Assembly convened four High-Level Meetings (HLMs) on health during its 78th session (UNGA 78) in New York. These presented an “historic opportunity for world leaders to place health back on the high-level political agenda as they recommit to ending tuberculosis (TB), delivering universal health coverage (UHC) and strengthening pandemic prevention, preparedness, and response”. UNGA 78 culminated on Friday, the end of a unique week which saw four consecutive summits to discuss global health issues and challenges. These were the Sustainable Development Goals (SDG) Summit to commemorate the mid-term of the 17 SDGs adopted by the international community in 2015; the Summit on Pandemic Prevention, Preparedness and Response regarding lessons learned from the impact of the COVID 19 pandemic; the High-Level Meeting on UHC; and the Summit on Tuberculosis.


The press release for the meetings goes on to say that “At this mid-point towards the SDGs, the world is off track to achieve the health targets by 2030. Millions of people cannot access life-saving and health-enhancing interventions. Out-of-pocket spending on health catastrophically affects over one billion people, pushing hundreds of millions of people into extreme poverty. The situation has worsened due to the COVID-19 pandemic”.


Indeed, these are the first HLMs to be held since the COVID-19 pandemic and, together with its global effects making themselves felt, we have also had to deal with the repercussions of multiple humanitarian and climate crises, an economic recession and the Russian invasion of Ukraine. As the UN says, “Upholding the human right to health and building equitable health systems are essential to achieve UHC, to build sustainable prevention, preparedness and response to pandemics as well as other health emergencies, and to ending epidemics such as TB”.


Some unhappiness with the HLM outcomes


The universal aim of these meetings was to establish the right direction to address these acute health challenges by 2030. Declarations had been painstakingly put together during several months of long and sometimes tedious processes which international civil society hoped would “be as concrete as possible: previous decisions should be reaffirmed, new strategic approaches should be defined, concrete implementation steps should be named, responsibilities should be determined and their financing should be guaranteed.”


Many civil society stakeholders feel that the results of the summits were far from meeting expectations. Action Against AIDS Germany issued a press release which said: “Weak declarations were adopted that represent nothing more than a minimum consensus of the involved community of states. Declarations that hurt no one and do not do justice to the multiple problems. Until the beginning of the meetings, it was anything but certain that the declarations would be adopted at all: on the eve of the summit meetings, Russia, in solidarity with a few states within its sphere of influence, had threatened to boycott the adoption of the declarations. Their voices had been ignored in the negotiations, the letter claimed.”


“Unfortunately, the opposite is true,” said Sylvia Urban, spokesperson for Action against AIDS, “too many concessions were made to the forces that propagate conservative values. Of course there are differences in ideas about family, women’s rights, the perception of sexual identities and the status and importance of civil society involvement. But to stop naming vulnerable groups is going too far!


“In the final declaration on UHC, there is no mention of the target groups that are particularly relevant for HIV prevention, such as men who have sex with men, other LGBTIQ+ communities, drug users and sex workers. Obviously, those states have prevailed here that deny the representatives of these groups their rights and needs or deny their existence. This is not the way to successfully implement ‘Health Care for All’! The price of consensus building is borne by the groups that are excluded from care.”


German civil society also complained that, unlike previous years when the Federal Government delegation included the broad participation of civil society, this year it broke with the tradition of assembling an official delegation including civil society representatives, despite being asked to do so several times. Communities and civil society were thus deprived of the opportunity to voice their demands during the meetings. This indicates that in Germany the possibilities for civil society engagement are decreasing and this is not a good sign for the importance that the Federal Government currently attaches to civil society.


You may remember that in our last GFO 436 we discussed the forthcoming HLM on TB and the problems inherent in trying to reach consensus from a wide range of stakeholders without ‘watering down’ the PD (What do we want and expect from the High-Level Meeting on TB?). We saw some of the problems faced by stakeholders in getting the right content, intent and language into this critical document; so, it has been interesting to note that it is not only the TB meeting and PD that seems to have caused controversy. There had already been signs of discontent in the form of a letter dated 17 September to the UNGA President from representatives from the delegations of Belarus, Bolivia, Cuba, the Democratic People’s Republic of Korea, Eritrea, the Islamic Republic of Iran, Nicaragua, the Russian Federation, the Syrian Arab Republic, Venezuela, and Zimbabwe “in relation to the unfortunate situation created around the draft political declarations of the SDG Summit, the High-level meeting on pandemic prevention, preparedness and response, the High-level meeting on universal health coverage, and the High-level meeting on the fight against tuberculosis”.


The letter goes on to state that “it is regrettable that it has not been possible to find a political solution to the current stalemate, created, not only due to the lack of will of some developed countries to engage in true and meaningful negotiations to have balanced and acceptable outcomes for all, but also due to the lack of transparency and poor handling of your predecessor’s team of all these processes”.


These delegates feel that the legitimate concerns of a large number of developing countries have been ignored and, as such, they have a duty to express their “strong concerns on the unacceptable way in which this situation unfolded, running in clear contradiction with the spirit of multilateralism and the overall goal of ‘leaving no one behind’”.


Our two articles on the TB Summit, therefore, New global pledge to end TB and TB community and stakeholders meet for Stop TB awards at UNGA 78 High-Level Meetings bring you a flavour of the TB Summit and the Stop TB Partnership awards ceremony. However, we first kick off this week’s issue with two articles which raise the sometimes contentious issue of country ownership.


The holy grail of national ownership


Against this backdrop of UNGA 78, the self-determinism of countries to learn from these global events as well as from the national context within which HIV, TB and malaria services are delivered, takes on an added importance. But do we really believe that countries have full and proper ownership of their national disease plans and funding applications? Or is everything so prescribed for them by international funders that countries go through the motions of jumping through the hoops in order to be able to access external aid? Our first article discusses the crux of ‘national ownership’ and if this is merely lip service to something that is desirable in principle but unattainable in reality. Whose national strategy? focuses on country ownership of national disease plans or NSPs.


We follow this with an example from Zambia, Heavy-handedness will not deliver the best results, where civil society has very publicly taken the Global Fund Country Team to task through an open letter to Peter Sands, Global Fund Executive Director, complaining of its controlling behaviour during grant-making negotiations. How far is too far, we ask, when a country’s right to decide its own programs seems to be at odds with what the funder of these programs wants to see? And especially when a donor’s ideas of country ownership are pushed by funders as the ideal that countries must aspire to.


The backwards trajectory of enabling environments


Our article PEPFAR threatened with closure describes the in-fighting between America’s two main political parties as PEPFAR struggles to ensure its future in the face of increasing conservatism. We look at PEPFAR’s incredible achievements since its inception and what might happen to HIV rates if PEPFAR were to withdraw.


We have reported previously on the punitive and increasingly hostile environment for key populations in certain African countries but unfortunately this pervasive trend is apparent in other regions as well. Our next article examines the worsening situation in Eastern Europe and Central Asia, specifically, the infringement of the right to health of certain groups (LGBTI