Voices of the People V: Civil society and community reflections on the Global Fund Partnership Forums to inform Global Fund Strategy development
The Global Fund to Fight HIV/AIDS, TB and Malaria is a critical mechanism that civil society and communities continue to support because of the great impact that the organization has had on the lives of millions of people. Global Fund supported health programs have saved 38 million lives, supported 20.1 million people on antiretroviral therapy for HIV, treated 5.7 million people with TB and distributed 160 million mosquito nets.
These are great accomplishments – but communities and civil society would like to see a number of remaining improvements. The recent Partnership Forums, whose goal is to gather input from many actors within the Global Fund partnership for the Strategy development process, heard from many civil society and community representatives who want to use the already significant impact of the Fund’s work as a starting point to push the work of the Global Fund further; to be more effective and reach more people. To put it more clearly, as Maurine Murenga, Board Member for the Communities Delegation, asked during the African/MENA (Middle East and North Africa) Partnership Forum – “Where do we want to be by 2030? What is the smart way to adjust the agenda and shape the programs we want?”
Advocates and community members have found, overall, that the process for the strategy has been inclusive, albeit with some ‘bumps’ and room for improvement. Perhaps the biggest challenge of all was the virtual nature of the Partnership Forums, which did not allow for much interaction between participants. Stakeholders especially missed the side conversations that lead to the richer discussion and connections between people that come out of in-person meetings. The biggest stumbling block for advocates and communities was the lack of a list of participants, which really did limit outreach and interaction.
While people have expressed this sentiment in various ways throughout the lead-up to the Partnership Forums and during them, if input had to be boiled down to one point only, it is likely to be the following:
While there is much diversity in community and civil society from and within regions and countries, one of the overarching messages we heard during the Partnership Forums was on Global Health Security and an expanded mandate for the Global Fund. Overall, the Global Fund Advocates Network (GFAN) has heard most civil society and community voices say that the Global Fund should maintain a focus on the three diseases but that the new Strategy is an opportunity to further define the Global Fund’s role in and approach to community systems strengthening (CSS) and resilient and sustainable systems for health (RSSH). It is also critical that the new Strategy identify its value-add within the COVID-19 response to date and how the systems and approach of the Global Fund will position it to respond to future challenges and pandemics. Community-driven interventions and stakeholders should be the basis for health sustainability and resilience. Hence, the Global Fund should keep its current focus but use its funds and power within the Global Health architecture to leverage and influence broader health system strengthening goals by driving inclusion and ensuring equitable access for communities to decision-making bodies.
While there were some challenges with the format, the Partnership Forums’ discussions did enable a broad set of views and specific recommendations to come forward. The first recommendation is that the Global Fund should use its not inconsiderable power and influence to encourage multisectoral approaches that strengthen the participation of key and vulnerable populations (KVPs) across decision-making forums both inside the Global Fund architecture (notably the Country Coordinating Mechanisms (CCMs)) but also external regional and national forums. It should also utilize the existing commitments made by partners’ countries in various forums (such as the African Union, G20, etc.) to encourage more inclusion of and investment in KVPs to increase diversity and equity in Global Fund grants. This multisectoral approach was also raised to ensure stronger country-led coordination, alignment, pooling and harmonization of all donor investments.
The Global Fund is seen as a key partner in international and regional forums to support efforts to eliminate user-fees, ensure more transparency and accountability of public funds, and to better understand the implications of various instruments such as loan buy downs, and debt swaps.
Access to services and treatment must not be prevented by human rights barriers; so, the Global Fund needs to change its approach in such a way that it embeds rights-centred approaches within all its processes leading to grant making. One suggestion heard at the Africa Partnership Forum was the need for country assessments. These should identify the key challenges and issues related to human rights, diversity, and equity in each country so that CCMs and Global Fund Secretariat staff can factor in corrective actions at all stages from prioritization to concept notes to grant management.
CCMs must evolve and be strengthened so that there is real representation from KVPs, adolescent girls and young women, and other community and civil society groups. These representatives should be engaged at all stages of a grant from prioritization, conceptualizing, drafting, identifying performance benchmarks, implementing, monitoring and evaluating. Fostering regional learning between CCMs and countries was raised a number of times during discussions.
Community and civil society groups need opportunities to obtain funding from within and outside country allocations. Participants recommended that a certain percentage of funding should be reserved for and dedicated to community-led initiatives. Many proposed and supported the idea that, to address human rights and equity issues and not simply fund commodities and testing, the Global Fund should set aside a percentage of funding to tackle these key issues. They noted that the Joint United Nations Programme on HIV and AIDS (UNAIDS) had proposed a benchmark of 30% for this purpose.
Participants felt that a new approach is required for developing and investing in RSSH with a new mapping, understanding and analysis of blockages, gaps and the conditions/terms of RSSH grants in each country. In addition, within RSSH, CSS receives a very low percentage of overall funding and participants suggested that the Global Fund should increase the CSS share of RSSH funds to ensure more integrated care and better supported community systems.
Participants pointed to the need to embed community-led data, monitoring and findings across all health system processes. They felt that the Global Fund should use its political leverage with countries to ensure that they develop plans and ensure the integration of community led data capture and monitoring.
Participants also drew attention to areas that they consider require urgent scaling-up in the next Strategy. A priority is to deal with adolescents, young women and women’s rights; and to address this, participants called for more youth participation and leadership across all areas of work. They also want to see an enhanced focus on and funding of disease prevention efforts, particularly those affecting KVPs; importantly, they emphasized that those efforts should be led by the KVPs themselves. Participants also want to see that, in the next Global Fund Strategy, ’pilot’ projects or initiatives that have shown to be effective are brought to scale (a specific example being Breaking Down Barriers). They also want the next Strategy to improve the flexibility, agility and responsiveness of the Global Fund in Challenging Operating Environments. Finally, they also recommend that the Global Fund’s partnership model should specifically address and include the partnerships needed for sustainability, such as for countries transitioning from Global Fund support.
Several advocates strongly made the case for the need to examine and potentially revise the disease split prior to the next allocation cycle and that this must be done in a way that examines the Global Fund’s added value to each area of focus (the three diseases and RSSH) to determine its focus and funding levels for each area.
Resource mobilization needs to be more strategic than ever and situated within a strong narrative of the impact of the Global Fund generally, as well as specifically related to the challenges in case detection and access to treatment and support raised by COVID-19. Additionally, it is important for resource mobilization to be accompanied by clear, strong, increased and accountable domestic resources with distinct monitoring and reporting of co-financing. The Global Fund needs to provide strong support to advocates and activists in implementing countries to encourage and challenge countries to develop the requisite tools (national health accounts, community health insurance, etc.) and take advantage of existing tools (such as Debt2Health) to maximize the resources available for addressing the three diseases.
Many participants recognized the Global Fund’s catalytic role in terms of the introduction of new tools and many spoke of the need to encourage research and the introduction of new tools through both national planning and also the inclusion of civil society organizations, as well to ‘create demand’ for innovation.
The Seventh Replenishment – as well as the full conversion of the Sixth Replenishment and co-financing and other domestic resources – will determine the ability of the Global Fund to implement its next Strategy. Throughout the discussions, it was clear that the next Replenishment will be challenging, both to maintain and increase donor support but also to be clear about the challenges implementing countries face because of the amount of upheaval to existing programs and services, and the economic challenges brought by COVID-19. The next Replenishment will need to have a clear resource mobilization goal that can enact the ambitious goals of the next Strategy and will need to outline implementing countries’ requirements if they are to get back on track towards 2030 in a post-COVID-19 reality.
In conclusion, participants stated that civil society and communities will continue to advocate their priorities following the Partnership Forum. They will work together to ensure Global Fund board members take into account their concerns for the direction of the Global Fund Strategy and, ultimately, to fund what they hope will be its ambitious goal to have a community-led, inclusive and equitable approach to meeting the 2030 goals.
GFAN is grateful to the many participants in the four telephone consultations organized since late January and all the participants in the pre-meetings and Partnership Forums who shared notes and advice with colleagues to ensure better participation. Over the months leading up to the Partnership Forums, GFAN focused on virtual consultations and the key priorities list as a way to bring civil societies’ and communities’ input together; and will focus on advocacy to Board representatives in the coming months through direct communications and social media.
*Katy Kydd Wright is the Interim Executive Director of GFAN.