The country dialogue process and the preparation of funding requests is either underway or complete in most Global Fund recipient countries. This article looks at whether gender is being considered in country discussions and how these discussions translate into differentiated needs and approaches in funding requests.

Two-thirds of new HIV infections affect girls and women worldwide. Harmful practices against women increase their exposure to the epidemic. It is impossible to control the AIDS epidemic if the rate of new infections remains high. In Ethiopia, Malawi, the United Republic of Tanzania, Zambia, and Zimbabwe, there are five to six infected girls for every infected boy aged 15 to 19. The role of young people, especially girls, is critical to overcoming the pandemic (source: UNAIDS 2019).

With regard to malaria, pregnant women are particularly vulnerable. In 2018, 11 million pregnant women living in 38 African countries were infected with malaria. This is equivalent to almost a third of all African pregnancies (source: United Nations Population Fund (UNFPA), 2019). However, in the same year, only 31% of pregnant women living in at-risk areas received the three doses of preventive malaria treatment recommended by the World Health Organization (WHO). Malaria in pregnant women can lead to the birth of premature babies, who are also more susceptible to childhood diseases. The WHO has estimated that 872 000 children on the continent were born underweight.

Leading causes of death for women worldwide                  

Leading causes of death among adolescent girls worldwide

Source: WHO, The global strategy for women’s, children’s and adolescents’ health (2016–2030)

In view of these alarming figures, it is easy to understand the Global Fund’s determination to make gender awareness a priority, as reflected in the 2017–2022 strategy, one of the pillars of which promotes gender and human rights. But what is really happening?

The guidance tools

The Global Fund Secretariat houses the Community, Rights and Gender department, which has developed tools to guide stakeholders in the response to the HIV, tuberculosis, and malaria epidemics. The department issued a briefing note in October 2019 entitled “Gender Equity” that provides practical guidance for countries in using a gender equity approach to maximize the impact of programs. The note includes a checklist developed by the United Nations Development Programme (UNDP), to highlight important issues to be raised at each stage of the country dialogue. The checklist is designed to ensure that the activities proposed in the modules systematically address gender inequalities and contribute to strengthening women’s access to health care. Unfortunately, this 20-page document is not widely disseminated, nor used as a “compass” by the CCMs and actors involved in the process of writing funding requests. None of the interviewed consultants had ever seen it, nor had the members of the country coordinating mechanisms (CCMs) whom we talked to. The document is available on the UNDP website and mentioned in the GF’s gender briefing. When used, it is as a retrospective tool to check that the steps have been taken, whereas gender needs to be anticipated at all levels: strategic planning and training of CCM members and their partners in grant implementation. Without this integration, this checklist only confirms the lack of gender mainstreaming.

Gender representation not reflected in funding requests 

In its report of June 9 on lessons learned from requests submitted in the first window of March 2020, the TRP again pointed out that the majority of funding requests are gender-blind. Contextual data is scarce or non-existent in the funding requests, despite a significant effort by donors (in particular UNAIDS, Stop TB, Roll back Malaria and the Global Fund) to collect and make available accurate quantitative and qualitative data on gender equality, and on the economic, social, and political situation of women. Gender diagnostics are now available in many countries, but unfortunately, they are not provided to the writers of the concept notes as key resource documents. In the absence of knowledge and awareness of gender inequalities, the topic is neither discussed during the country dialogue nor translated into concrete actions in the funding requests.

Mainstreaming gender requires a rethinking of society 

Gender issues, referring to the social role given to girls and women, their access to economic resources and health care, and their opportunities, are not commonly addressed in the health sector. This is because these are deep and multidimensional subjects that further complicate the response to epidemics. Discussions on gender do take place, in ministries for the promotion of women, in women’s workshops and conferences, in programs aiming to empower girls and women funded by donors such as The United Nations Entity for Gender Equality and the Empowerment of Women, the German Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) and French Agence Française de Développement (AFD) (and other Foreign Ministry agencies), the UNFPA, and in women’s organizations. But these are other ecosystems, with actors who rarely participate in CCM discussions and country dialogues.

The Global Fund points out that the criteria for composition of the CCM require a balanced representation of both men and women, but this representation can be proven to be symbolic.

Global Fund documents emphasize the interconnection between gender roles and epidemics and call on those involved in the response to consider activities that reduce women’s exposure to epidemics, particularly HIV and malaria. However, it is not a question of studying the place of women in society to verify how the response must take into account all barriers and specificities. Rather, it is a question of bringing gender into a pre-established framework for responding to epidemics.

Failure to take gender into account leads to poor grant performance: too many children are born to HIV-positive mothers and are not tested or treated. This is partly related to the fact that prevention of mother-to-child transmission (PMTCT) activities are not producing the desired results in many countries. Too many pregnant women do not have access to testing and health services.

To make real progress, more attention must be given to the reasons why pregnant women do not seek health care but choose to give birth at home, and what needs to be done to change this; what can convince pregnant women to leave their homes, young children, and their activities (such as field work or selling at the market) to attend health care facilities? How are pregnant women welcomed and treated there? What are the social, economic, and cultural levers that contribute to increasing the number of pregnant women’s consultations, depending on their social background, education, and marital status? These topics can be addressed through integrating the management of epidemics with maternal health, or when developing a comprehensive health care system approach.

Adolescent girls are disproportionately infected with HIV. Therefore, traditional campaigns that rely on “educational talks” and mass communication are clearly not very effective.

Key issues that cannot be overlooked include literacy and encouraging girls to stay in school; meeting their needs to avoid transactional sex; condom procurement (and access to the female condom) and negotiating its use. Also, access to methods of contraception, marital traditions (dowry payments, child marriages, and virginity requirements), tolerance of sexual violence, and lack of prevention and care measures should be considered. These are some of the complex issues that cannot easily be summarized in training activities on HIV transmission.

Bringing about a change in behavior among adolescents and young adults requires the involvement of more actors than just adolescent girls and young people themselves. The cross-cutting and multidimensional nature of gender issues is clear from these examples.

Because of its partnership approach, the Global Fund is well placed to contribute to the dialogue.

Incomplete budgets and the need to train Global Fund staff on gender issues

This lack of gender mainstreaming is also visible in gender-blind budgets. For example, a campaign for the use of the female condom and its dissemination, particularly in the networks that will facilitate its acquisition by girls and women, should be budgeted for. However, these campaigns generally only include the costs of acquiring and transporting condoms to the implementers’ offices.

A proactive strategy to encourage pregnant women to visit health facilities for HIV testing and malaria prevention will accelerate the PMTCT or prevention of HIV transmission among adolescent girls. Such a strategy entails costs, beyond the direct costs of testing and treatment, such as transporting pregnant women, especially when they live in remote areas far from health facilities.

To achieve gender-responsive budgeting, stakeholders must understand the social and cultural barriers and the different services that are required or do not cater for girls and women. Stakeholders should also identify the structures needed to implement these services, potential gaps, and new services that should be introduced and costed.

Most of the actors involved in grant making and management should be trained on gender mainstreaming. CCM members and members of the HIV, TB and malaria programs should be trained to ensure that they take gender into account and integrate it into national strategies and operational plans. Also, the Global Fund country teams, implementing partners, and consultants involved in developing funding requests should be trained too. The training should be extended to traditional healers and midwives. They are not regularly consulted, but are important as they have influence and are respected by women.

A different approach to gender issues is needed   

The Global Fund’s proposal forms could be revised in form and substance: they should include a gender analysis when the strategic plans are being developed and then presented at the beginning of the funding request.

Human rights and gender issues should be presented separately in the funding requests. This is because they require complementary but different types of analyses. Importantly, the budget format should include issues related to the costs of ensuring that girls and women have access to services. Principal recipients (PRs) and sub-recipients (SRs) should be trained, as they play a critical role in implementing programs, and should be sensitized to gender mainstreaming.

Finally, decompartmentalization is necessary at all levels in order to enable collaboration between the appropriate actors: UN Women, a key actor in the promotion of gender, is not associated with the actions of the Global Fund and could become an important partner, in the same way as UNICEF or UNFPA. Partnerships with civil society organizations specializing in gender and health should not only be created in the countries but also included in the partnership approach of the CRG Department. Within countries, the Ministries of Health and Women’s Ministries need to coordinate with HIV, malaria, tuberculosis and sexual and reproductive health programs urgently for mutual learning, as well as pooling and optimization of funding, in order to provide young girls and women with adapted services.

In its gender equality strategy, the Global Fund acknowledged its responsibility to promote equality and gender-balanced programs, and highlighted that “the strength of the Global Fund is its ability to be a catalyst, supporting countries’ efforts to take the gender dimensions of the three epidemics into account in their proposals and subsequent program implementation, while recognizing the need for a broad network of partners to support countries to do this.” All of this needs to happen, and now is the right time.