Global Health Policy

 

Does the Global Fund Reach the Most Marginalized and At-Risk Populations? (Postcard from Vienna)

July 22, 2010


Under the banner “Rights Here, Right Now,” the International AIDS Conference currently taking place in Vienna is committed to translating funding for human rights-based programming for HIV to address the stigma and discrimination that often impede an effective response. On Wednesday, Global Fund executive director Michel Kazatchkine and others participated in a session titled “The Global Fund: Proving Impact, Promoting Rights.”  The majority of their discussion focused on how the Global Fund can better address the most vulnerable and marginalized populations—those living with and most at-risk of acquiring HIV/AIDS—rather than the successes of the Global Fund.

While the session was very interesting—perhaps, the most interesting of my four straight days here—the most dynamic takeaway was what was not said when a group of about ten Middle East and North Africa (MENA) representatives marched silently to the front of the room waving signs, wearing t-shirts, and taping stickers over their mouths with the slogan “I want to be eligible.” Their argument: The Global Fund’s current funding architecture doesn’t enable money to flow to the most at-risk populations in their countries.

To be clear, the Global Fund DOES provide funding to countries in the Middle East and North Africa.  However, most of these countries fall within the lower-to-middle income range, which means that funding allocations are conditionally based upon their ability to address the “cost sharing” principles of the Fund (read: funding is shared between the Global Fund, domestic resources, and contributions from other donors).  A representative from the MENA group did not refute the importance of contributions from middle-income national governments to the HIV/AIDS response.  Rather, his concern is that in a region with a marginalized epidemic among populations that are so hidden and so stigmatized by these same governments, funds must go straight to the civil society organizations invested in these populations in order to be effective.

Findings from a recent World Bank report, which offers the first comprehensive look at the evidence on the spread of HIV in a region where knowledge of the epidemic has been very limited and subject to controversy, confirms this view.  The report asserts that strengthening civil society contributions to HIV efforts is essential to the MENA region, where HIV transmission is concentrated in hidden and stigmatized populations. “A structural weakness of the HIV response in MENA is the meager contribution of nongovernmental organizations, community organizations and people living with HIV groups in the formulation, planning, and implementation of the response,” the report states.  In theory, the Global Fund’s Country Coordinating Mechanism (CCM) model is one way for these countries to gather and invest in civil society.

However, while CCMs are a good mechanism for bringing all sectors of the HIV/AIDS response together for planning and implementation, in many countries, national governments dominate the CCMs even though they are supposed to represent all sectors of the community.  In some lower-middle income countries, government-dominated CCMs PLUS a significant portion of the funding for the HIV/AIDS response coming from and handed to these national governments—which routinely stigmatizes the most at-risk populations, a la many MENA countries—leads to not only limited representation on the CCM, but also to limited programming targeted toward these marginalized populations.

In fairness, I need to give the Global Fund some credit for recognizing that this is an issue.  Here in Vienna and at the replenishment prep meeting in March, Global Fund representatives acknowledged that the Fund’s work in middle-income countries has a “catalytic value…particularly in galvanizing domestic support and targeting particularly vulnerable communities.” However, as the Global Fund gears up for their replenishment—to be held October 4-5 of this year—they need to think hard about how the MENA region and others are represented within the current structure.  Beyond examining their overall impact on the disease as a justification for more funding, the Global Fund and its board should reassess how to strengthen the funding architecture—like the CCMs and cost sharing—that often present barriers to funding the most at-risk populations.

Possibly Related Posts

  AddThis Social Bookmark Button


4 Responses to “Does the Global Fund Reach the Most Marginalized and At-Risk Populations? (Postcard from Vienna)”

  1. Nandini Oomman :
    July 23rd, 2010 at 10:24 am

    Christina-great post. The Global Fund does indeed have to begin to make sure that funding is targeted to those who need it the most. Like you point out many CCM’s are indeed more political, defeating the goal of being a representative country entity and ensuring that funding is targeted to recipients based on need. I would add that there is another issue that prevents funding to flow to the most at risk groups, even when a non-government organization is a PR. When I was in Zambia, a non-government PR told me how difficult it was to include community based groups (who do some of the most valuable work with marginalized groups)as sub-recipients. The reason: very difficult for them to participate in the PBF model of the Global Fund because they don’t have the capacity to develop targets and then measure them in order to report performance and receive the next tranche of funding. This is a very serious issue and one that will be essential to increase universal access to treatment, prevention and care. The Global Fund will have to convince its donors that it can figure out ways to target its funding in a more equitable way for greater impact and in accordance with a human rights agenda. I’m interested to see how they will address this moving forward.

  2. Jennifer Lentfer :
    July 25th, 2010 at 7:10 pm

    In response to Ms. Oomman’s comment:

    The myth of “no capacity” perpetuated about small and local organizations in the HIV/AIDS discourse is pejorative and disparaging, and does not do justice to these vast and vital efforts.

    I wonder of those 20,000 experts at the International AIDS Conference, how many have actual “on-the-ground” expertise? How many participants have cared for their dying neighbor and counseled a child who has lost a parent? Let me say, not enough.

    When will the policy wonks, public health “experts” and donors finally come to appreciate community-based organizations’ strengths, such as their resourcefulness, flexibility and community responsiveness that is resulting in real care for affected families?

    It’s time to abandon the “expertise infusion” and rather than the community-based groups needing to change, it’s the NGOs and donors that need to require power asymmetries to be part of their staff’s consciousness in a more comprehensive and meaningful way. It’s the donors and NGOs who need to restructure and revise their accountability requirements to focus on the minimum structure and financial controls necessary, in order to lower the “glass ceiling” for CBOs to participate in and benefit from the Global Fund.

    A mapping exercise sponsored by UNICEF identified over 1,800 community-based organizations focused on orphans and vulnerable children in Malawi alone (Network of Organizations working with Vulnerable and Orphaned Children in Malawi, 2005). Most were linked to local churches, schools, or clinics or were independent groups that assist children by extending support and services into areas that are not reached by government or international agencies.

    Thus, we have to ask—what is the cost to all of us when so many of the best minds and perspectives from the community-level are left out of navigating the paradox of universal access? This is where we clearly need all the help we can get.

    Humility is needed to acknowledge the vision, structure, and impact that CBOs do have. Clearly these under-recognized and under-resourced folks have knowledge and expertise could be invaluable to the multi-billion dollar(!) fight against HIV and AIDS.

    Read more at: http://www.how-matters.org/201.....l-experts/

  3. Acuvue :
    July 25th, 2010 at 9:36 pm

    Thanks for the insight and experience Christina.

    Another reason why countries in North Africa and Mid East don’t optimize funding is the rife corruption and bribery that goes on there so whilst on paper it appears a certain country received funding, it often goes to many corrupt “middleman” who are more interested in lining their pockets than helping the AIDS cause.

    Keep up the magnificient work.

  4. Erin Hohlfelder :
    July 28th, 2010 at 3:23 pm

    I think it’s worth noting that beginning in Round 10, the GF will adopt a new grant prioritization scheme, which aims to prioritize money for the world’s poorest while also providing a separate (albeit small) pool of funds for most at-risk populations in middle-income countries. See in particular pages 19-25 of the Board’s April decisions http://bit.ly/atVA0X

Post a Comment

We value frank and constructive exchanges and encourage you to use your real name in your comments.

  • Global Health Policy is a group blog discussing the issues facing the donor community on everything from HIV/AIDS financing to pharmaceutical R&D to broader health systems concerns. Comments are strongly encouraged, and suggestions for new posts can be sent to us here.

    The Race Against Drug Resistance
    A short film tells the story of Khalifa, a nurse in Ghana who contracted typhoid. She takes one drug and then another—each more expensive than the last—but still she isn’t well. The film uses expert interviews and animation to explain why drug resistance threatens us all—and what we can do about it.

    Learn more about our Combating Drug Resistance initiative.

  • Translator

  • Monthly Archives

  • Categories

  • Most Recent Comments

  • Blogs & Other Useful Resources