Voices of the People III: Asia Pacific & MENA II
The Global Fund has convened the sixth in a series of Partnership Forums that is taking place virtually between 2 February 2021, its launch, and 15 March when the Forums will be formally closed. Within this, three regional Partnership Forums were held with representatives from across the globe to actively contribute their regional expertise to help develop the aims and areas of future focus for the next Global Fund Strategy from 2023 onwards. The last in the series of Partnership Forums brought together participants from Asia, the Pacific (A&P) and six countries (Jordan, Iraq, Lebanon, Palestine, Syria and Yemen) in the Middle East and North Africa (MENA II) for plenary meetings and breakout sessions over three days.
The Global Fund asked participants to review input, evidence and guidance received on Strategy development and to identify the most pressing challenges and opportunities in the fight against AIDS, tuberculosis (TB) and malaria; building resilient and sustainable systems for health (RSSH); promoting and protecting human rights and gender; and mobilizing resources. Participants also reflected on how these aims have been or may be affected by COVID-19 and broader changes in the health and development landscape.
The key messages coming out of the A&P & MENA II Forum showed many commonalities, particularly focusing on the need for the Global Fund to put communities at the centre of the next Strategy. However, there were also divergences on the priorities and recommendations for achieving the Goals of the next Strategy, particularly on the Global Fund’s role in responding to COVID-19 and future pandemics.
Note that the Partnership Forums resource centre contains plenty of useful information through background notes and other documents that formed the background basis for the discussions.
What have the Asia and the Pacific and MENA regions achieved so far with Global Fund resources?
Figure 1 shows the results to date of Global Fund supported programs in these regions.
Figure 1. Achievements to date in A&P & MENA 2*
Progress towards the 2030 Sustainable Development Goals (SDGs)
The most important of these goals for Global Fund partnership is SDG 3 (ensure healthy lives and promote well-being for all at all ages) which has two relevant targets: (1) Target 3.3: by 2030, end the epidemics of AIDS, TB, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases; and (2) Target 3.8: achieve universal health coverage (UHC), including financial risk protection, access to quality essential health care services, and access to safe, effective, quality and affordable essential medicines and vaccines for all.
Participants scored the Global Fund high in terms of how successful it has been in supporting countries to maximize impact against HIV, TB, and malaria, and the 2019 results report showed considerable success in saving lives. This has enabled the Global Fund to play a key role in progress towards the SDGs, especially SDG3.
However, significant shortfalls remain and, according to participants, this includes reducing the number of new infections, building strong health systems, and promoting and protecting human rights and gender equality. In addition, COVID-19 threatens to reverse the extraordinary gains made by the Global Fund Partnership: health and community systems are overwhelmed, with treatment and prevention programs disrupted and resources diverted to deal with the pandemic.
HIV: progress and challenges
While overall there was a 12% reduction in new HIV infections and a 29% reduction in deaths from 2010- 2019 in A&P, many countries continue to be off track with new infections on the rise. Key and vulnerable populations (KVPs) and their partners remain disproportionally affected, representing 98% of new infections in the region in 2019. In MENA, HIV infection is growing; a 22% increase since 2010, with KVPs and partners accounting for 97% of new infections. Both regions continue to report low prevention, testing and treatment coverage, and structural barriers to services due to punitive laws, violence, stigma and discrimination.
TB: progress and challenges
In 2019 South East Asia (SEA) had the largest global share of people with TB (44%). Western Pacific had the third largest (18%). Both regions have the two lowest TB treatment success rates (52% and 58% in 2019). However, the Eastern Mediterranean region of the World Health Organization (WHO), to which MENA II countries belong, has seen a 3.5% TB incidence reduction, with a 11% death reduction from 2010 –2019 and high treatment success rate at 91%. For both regions, gaps persist in TB screening and TPT coverage. Four countries in the A&P region account for 42% of the global gap between incidence and notification, and 75% of people with HIV with associated TB are not reported in the MENA region.
Malaria: progress and challenges
Progress towards Global Technical Strategy (GTS) targets is mixed in the A&P region. SEA has the highest reduction in incidence (73%) and deaths (74%) compared to other regions between 2000-2019 and all countries are on track to achieve the GTS 2020 targets, except Indonesia with a 37% mortality reduction. However, the Western Pacific region has seen a 5% increase in incidence and only a 10% reduction in deaths since 2010. There is concern that increasing drug and insecticide resistance in A&P will impact on the region’s progress in reducing incidence, and on the future of the region’s malaria response.
Between 2010 and 2019, malaria incidence increased by 15% in the MENA region and death rates by 16%. This is due to the region’s continuing humanitarian emergencies, population displacement and health system fragility which has impacted malaria progress, alongside climate factors with frequent floods, especially in Somalia, Sudan and Yemen.
RSSH and COVID 19: progress and challenges
COVID-19 has presented significant challenges to health systems in A&P, with health service coverage not on track to meet the 2030 targets. In MENA, it is putting a strain on countries with fragile health systems. In both regions, COVID-19 is having a catastrophic impact on the most vulnerable communities and threatens progress against HIV, TB, and malaria. In MENA, this is exacerbated by systems fragility, population displacement and the flow of refugees.
Key priorities and recommendations
A key message from the A&P and MENA II Partnership Forum was the call for the Global fund to keep its focus on the three diseases, as there is still unfinished business in the fight to end them. Participants also wanted to make it clear that they rejected the language of ‘trade-offs’ used by the Global Fund. It is not about a choice between funding prevention versus treatment, or health systems over community systems. It is about investing efficiently to identify, reduce and end inequalities that create barriers to services for people living with and affected by the three diseases and to achieve impact through integration and systems strengthening.
Participants also stressed that the biggest barriers to HIV, TB and malaria for their regions was the lack of political leadership and failure to prioritize health; stigma and discrimination and other human rights related barriers to health services; and that current programs are insufficiently tailored to meet KVPs’ needs.
In terms of how best the Global Fund can strengthen its impact, the overarching recommendation was to have a greater focus on equity, community systems strengthening, community-led services and on KVPs. In addition, participants mentioned the importance of investing in country-specific and differentiated approaches, and bringing innovations to scale by strengthening partnerships with the private sector, academia and communities for evidence-generation, operational research, technical support and for rapid scale up and use of new tools.
In response to the question on what the Global Fund can do better to achieve its mission, the key words used were: Flexibility, Advocacy, Integration, Human Rights, Key Populations, Civil Society Strengthening, Community Leadership, Value for Money, Collaboration and Listening.
The breakout discussions concentrated on defining the focus and direction of the next Strategy, pathways to achieving the goals and partnership priorities. Some of the recurring priorities and recommendations from the thematic breakout group discussions are described below.
Put communities front and center of the next Global Fund Strategy
A key soundbite that was repeated during the discussions was that the Global Fund is the ‘People’s Fund’ and one of the unique advantages of its model is community engagement and leadership. The next Global Fund Strategy needs to do more to champion and increase investment in community, rights, and gender (CRG) interventions, amplify community capacity and leadership in the HIV, TB, and malaria response, and ensure meaningful community engagement in all governance and grant making processes.
Recommendations from participants on the ‘How’ included re-commitment to dual track financing, ensuring communities and community-led interventions are at the core of its investment priorities, and increased partnership support for institutional strengthening of country and regional community and civil society networks. The Global Fund also needs to recognize communities and key populations as leaders and experts, and not only beneficiaries.
Participants also called on the Global Fund partnership to ensure that investment and support for civil society and communities is championed and operationalized at all levels; from the Global Fund Secretariat, especially country teams, to Country Coordinating Mechanisms (CCMs) and by technical partners and governments. This investment and support for communities should not be a one-off investment or managed by governments but should be overseen by civil society and communities to build structures and processes that will continue after transition; including government and national systems and mechanisms to support investment for community engagement in the response.
Equity, human rights, gender, and key and vulnerable populations
In A&P and MENA regions, human rights barriers, including punitive laws and policies, stigma and discrimination, and gender-based violence, are disproportionately impacting women and key populations.
Participants from the breakout groups all agreed that the next Strategy should maintain and prioritize human rights and gender equality as a key objective that is integral to stepping up the progress on HIV, TB, and malaria. This includes scaling up investment in regional and multi-country programs, evidence-based gender and human rights interventions that are innovative, adaptable, and responsive to the needs of KVPs, and for the Global Fund to leverage its political and social capital in countries to safeguard and support civil society to challenge access and legal barriers that criminalize people and behaviors. The Global Fund must also ensure meaningful community engagement in the design, implementation, monitoring and evaluation of programs and invest in advocacy to address equity, human rights, and access issues.
Community systems strengthening must be a cornerstone of resilient and sustainable systems for health
Global Fund investments in CRG and CSS contribute to improvements in country health systems, play a crucial role in reaching the most vulnerable and contribute towards progress on SDG 3. Participants felt that the next Strategy needs to have more clarity on the objectives of the Global Fund’s investment in RSSH, with clear targets and qualitative indicators to track impact, and ensure that there is a clear directive that investments in community systems are an integral part of building resilient and sustainable health systems, and achieving UHC.
Participants from the breakout groups on integration and systems for health also stated that ‘Leaving no one behind requires better data.’ Quality data are crucial for decision-making, program adaptation and responding to KVPs’ needs. The Global Fund needs to be innovative and invest in strengthening national data and reporting systems, and recognize the value of and invest in community-led monitoring, evaluation, reporting and research. The focus should also be on qualitative data to develop people-centered responses and scaling up the use of digital tools and platforms.
Recommendations on resource mobilization included the development of investment cases and sustainability plans based on qualitative data; and support for innovative domestic and external approaches and partnerships. This includes diversifying collaboration with other investment initiatives, development banks and partners, technical agencies and the private sector, and for the Global Fund to advocate for partnerships with communities and civil society in discussions and decision-making processes.
Participants in both regions called on the Global Fund to ensure that any plans for transitioning interventions to domestic funding for health should continue to support community-led and rights-based approaches that respond to the needs of marginalized and criminalized populations. Transition for key populations or human rights programs can only take place when governments learn how to manage and fund these programs and integrate them into their public health response to ensure no one is left behind.
Participants also identified the need for the availability, affordability and accessibility of lifesaving medicines and diagnostics, and equitable and affordable access to tests, treatments and vaccines. This includes investing in treatment advocacy, and reviewing and revising national patent laws, legislations, and frameworks.
Global health solidarity and not global health security
Communities and civil society raised their concerns about the use of the term Global health Security, which at times has been framed within the perspective of protecting countries in the global north from infectious disease. Participants agreed that, while the Global Fund has a responsibility to support emerging global health issues, this needs to be done through ending the three diseases and better integrated systems for health. The Global Fund also has a role to play in championing the need for multisectoral partnerships, strengthening community systems and addressing COVID-19 and future pandemic responses through the lens of equity, human rights and gender equality.
This article only provides a snapshot of the varied, in-depth, and detailed discussions that took place at the A&P and MENA II Partnership Forum. Participants coming into this meeting were clear on the priorities and recommendations for the next Strategy, which have been captured by the Global Fund and will be part of the discussions in the next stage of the post-2022 Strategy development process.
There are also a number of position papers and statements developed by civil society and communities in the A&P and MENA regions. These include a statement from participants in the Global Fund’s community and civil society 2021 Pre- Partnership Forum collective (including statements from participants from both regions); the Frontline AID Asia position paper; the MENA CRG Regional Platform report on identified priorities for the Global Fund Strategy; and The Global Fund We Still Want statement.
In closing, please do show your support to the Asia Pacific civil and communities’ statement on the post 2022 Strategy ‘GLOBAL FUND THAT WE STILL WANT STATEMENT!