Nadia’s Presentation:The Global Fund: The Next 5 Years14:30 – 16:00 THSY05Symposia Session/ Session Room 1Since its creation in 2002, the Global Fund has become the main financier ofprogrammes to fight AIDS. Taking into account the recent organizationalreforms, this session will discuss the strategic direction and future hopes ofthe Global Fund from the perspective of the recently appointed GeneralManager, implementing countries, members of civil society, and the donorcommunity.***************************************************************************Introduction:Good afternoon everyone. My name is Nadia Rafif. For the past 10 years, I havebeen acommunity-based HIV advocate and program implementer in the MENAregion.I wear several hats in the global HIV response: I am the Executive Director of an AIDS Service Organization based in Marrakech, Morrocco – L’association de Lutte Contre le SIDA. I am also one of two African representatives to the NGO Delegation of the UNAIDS Programme Coordinating Board. And finally, I am the regional coordinator of CSAT, the Civil Society Action Team, whose role is to strengthen civil society engagement in every component of the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund).It’s a privilege to speak with you all today.As the only civil society speaker forthis important session, I want to bring a community perspective to ourdiscussion on the strategic direction and future hopes of the Global Fund.I have thought a lot about this, and I have solicited input from other civil societyleaders as well. I have narrowed my thoughts into several key areas of concern: 1. The restructuring of the Global Fund 2. How restructuring has negatively impacted HIV programs 3. The dismantling of the Global Fund’s Structures to Engage with Civil Society 4. Transparency and Accountability 5. The New focus on High Impact Countries 6. The demand driven model in perilBut first, let me start by affirming, very clearly, WHY CIVIL SOCIETY ENGAGEMENT ISCRITICAL TO ACHIEVING MAXIMUM IMPACT AT THE GLOBAL FUND. Let us be clear –THE GLOBAL FUND IS ALSO OUR FUND. A concerted effort must be made to
support linkages and synergies between civil society, the Global Fund, andprogram implementers. CIVIL SOCIETY IS NOT INCLUDED PROPERLY IN THECURRENT CRITICAL DECISIONS TAKEN BY THE SECRETARIAT and we allfear that the transformation in place will put us far away with the goldenmodel of demand driven that was the initial philosophy of the fund.The Global Fund, which has made direct investments in 150 countries, hasachieved landmark impacts to date in global health – especially with regard totreatment access. The Global Fund provides about two-thirds of totalinternational funding for tuberculosis (TB) and malaria services, and one-fifthfor HIV services.But we cannot, and should not, measure IMPACT solely by treatment coverage.The Global Fund also plays a crucial role in strengthening and linking healthsystems and community systems in order to ensure that programs can besustainable, mutually supportive, and effectively scaled up. The Global Fund hasbeen a powerful force in advancing human rights and placing people infectedwith and affected by HIV and AIDS.Having spent the last ten years working on HIV in Morocco, and the last 4 yearsin 19 countries in the Middle East/North Africa region, I can personally attest tothe radically positive changes imparted by the Global Fund. I saw treatmentwaiting lists for AIDS patients disappear, when previously, individuals in need oftreatment had to wait until someone in the program died in order to be enrolledin the program. I have seen extremely marginalized and excluded groups –including men who have have sex with men, sex workers, and injecting drugusers -- regain their dignity and full access to the same quality healthcareservices as any other citizen. I have seen NGO actors negotiate on equal termswith government representatives about the HIV funding priorities in theircountries and how best to manage international aid.As the ultimate beneficiaries of investments in health and an effective responseto epidemics, communities are also able to provide unique feedback about thequality and effectiveness of programs funded by the Global Fund. In the EasternEurope/Central Asia region, civil society and key affected populations are themost vocal proponents of evidence-based practices and measures to protecthuman rights. In Ukraine and Kirgizstan for example, civil society organizationsled their respective initiatives which legalized WHO recommended opioidsubstitution therapy which is now available broadly in both countries throughprograms supported by the Global Fund. Advocacy by civil society groups forcontinued investment in effective services and for defense of human rights is notonly good for public health, it is an effective risk managementmeasure.Civil Society is also uniquely positioned to reach out to and develop trustingrelationships with other community members to mobilize communities forbehavior change and provide services like needle and syringe programs, peersupport or other community outreach services. Moreover, as principalrecipients, civil society organizations in the EECA region have been among the
most successful implementers of programs supported by the Global Fund andother donors. As the ultimate beneficiaries of investments in health and aneffective response to epidemics, communities are also able to provide uniquefeedback about the quality and effectiveness of programs funded by the GlobalFund.As civil society, therefore, we have the daunting, life saving task of ensuring thatthe world does not backtrack on gains so far made. If the global community is toprevent this potentially enormous setback threatening the health and lives ofmillions of people – and realize the numerous commitments made by UnitedNations member states through the Millennium Development Goals and at the2011 High Level Meeting-- swift and decisive action has to be taken – and it mustbe taken with us involved. The Global Fund is also our Fund, andit is the bestmechanism the world has for realizing the possibility of a world without AIDS.With that in mind, I would now like to convey the key concerns held by civilsociety regarding the Future of the Global Fund:1/ The restructuring of the Global Fund: confusion & worriesGabriel, you tell all of us not to worry ….But we are all confused and we are all worried… not only civil society, butgovernments, CCMs, beneficiaries of the Fund and the communities we all serveall around the word.Since the last Global Fund Board Meeting (which took place in Accra, Ghana, inNovember 2011), many changes have been set in motion: First, the announcement that the Round 11 Funding Cycle was cancelled Second, a change in the strategic direction of the Fund, namely the the Global Fund Board’s adoption of a new strategy for the period 2012-2016. And finally, the restructuring process currently taking place, which is still in progress and expected to be completed by the end of the yearEverybody is confused: we hear about the 55% rule or the 10% Rule; prioritycountries; high impact interventions; abolishment of the civil societydepartment; departure of more than 50% of the staff from the Genevasecretariat;a drastic reduction of CCM units, and so on …When we ask questions, we are told to wait, but time is running out. I would liketo highlight several specific issue areas of concern:2. First: the negative impact of restructuring on HIV programsThe many changes happening at the Global Fundcome at a time when the worldis, now more than ever, so close to the end of AIDS. It also comes at a time whena decade of investment in malaria and tuberculosis through the Global Fund hasresulted in so many saved lives and improved quality of life across the threediseases.
If the Global Fund scales back now, the negative impact on individuals andcommunities will be devastating; and in fact, these negative effects are alreadybeing observed in many countries. I want to give a few specific examples: - First, program interruption. Since the crisis started, many grants have stopped. The situation in some countries is becoming unacceptable. The Global Fund was our ally in resource-limited countries. Now, in many countries, its the source of problems, with grants disbursed very late, leading to human resources without salaries (which we have seen, for example, in Mali, Burundi, Nepal). - The Transitional Funding Mechanism is also problematic. The principle behind the TFM was supposed to be the continuation of funding for essential services, but in reality, it has simply meant no more enrollment of new patients in some countries. When we hear that only “essential services” can be funded; and at the same time, find out that new patients aren’t being enrolled, it sounds like: “Treating new patients is not an “essential task” of the Global Fund !!!!” This is unacceptable. - Drug Stock-Outs are also occurring. In Mauritania for example, the combination of a complex bureaucracy coupled with confusion made by the recent Global Fund changes led to a late disbursement of Global Fund monies. Although Mauritania learnt at the last minute that they will be eligible for TFM and they prepared an application, the late disbursement of funds means that there will soon be a stock out of ARVs, and no new eligible patients are receiving treatment at the moment. - National Strategic Plans are going unfunded. In the new Republic of South Sudan, 80% of the national AIDS plan remains unfunded. South Sudan was counting on Round 11 to cover antiretroviral treatment costs and to fund a nascent HIV prevention strategy facing extra stress from returnees from neighbouring countries with high HIV prevalence. - Finally, there is increased vulnerability among Key Populations. The cancellation of Round 11 leaves Bolivia with no means of scaling up HIV prevention services for key populations affected by HIV, including at-risk groups not currently being reached such as prisoners and indigenous people. Therefore, an increase in HIV transmission amongst vulnerable populations is expected.3. Our second key concern is the dismantling of the Global Fund Structuresto Engage with Civil Society:We are also worried that some of the recent changes to the structure of theGlobal Fund will weaken civil society communication and cooperation with theSecretariat – and that this will hinder the Global Fund’s effectiveness, riskmanagement and sustainability of programs supported by the Fund.Previously, civil society involvement was facilitated through the Civil SocietyPartnerships Team. This work has been vital, but we fear that it has beensignificantly weakened within the new structure. In the reform of the secretariat,the Civil Society Partnerships Team was disbanded. We understandthatresponsibility for interaction with civil society is now supposed to be
integrated throughout the different departments and portfolios, some of whichmay or may not have the skills, capacity or commitment to have an overreachingaim of maximizing synergy with civil society for improved country level healthoutcomes.Furthermore, we also understand that within the new structure, the fullyfunctional CCM Team will be diminished to a far smaller CCM Hub, andfrom now on, the main responsibilities of building partnerships with allcountry stakeholders -- including facilitating an active and inclusive CCM --will be with Fund Portfolio Managers. Joint efforts of the CCM Team and theCivil Society Partnerships Team were instrumental in bringing civil societystakeholders into national decision-making and effective grant oversight. Theabolishment of both Teams is very concerning.Gabriel, you tell us"dont worry, the CCM function will be mainstreamedinto grant management." But this reassurance to too vague to bemeaningful.We need you to understand that CCMs matter, and not just for ethical reasons:they are important for very pragmatic reasons too.If the Global Fund’s programs are dictated from Geneva, the program’s prioritieswill be wrong, and there will be no country ownership and bad implementation.If you dont ensure the CCM works properly, what you get is huge unmanagedconflicts of interest inside the CCM. It is precisely those conflicts that lead toCCMs funding the wrong things, and to corruption.That is why the Global Fund must dedicate the staff necessary to liaising withCCMs to ensure that all members fully understand and respect the letter and thespirit of the CCM guidelines. Our CCMs will listen to the Global Fund, the biggestfunder of their response to AIDS, TB and malaria. And please remember: theroot cause of both corruption and low program performance is poorlyfunctioning CCMs.Meaningful engagement of civil society and key affected populations is essentialto the success of the Global Fund. This engagement must happen in the planning,implementation, and evaluation of national level programs.We fear that without a clear focus onthis responsibility, paired with adequatehuman resources to make it happen, meaningful engagement of civil society andcommunities will not get the support it needs to serve its proper role. We willbecome simple a tick box on a very long check list, and the essential functions wehave provided to the Global Fund since its inception will begin to fall apart.Someone needs to be responsible and accountable for the entire civil societystrategy within the Global Fund secretariat and the over Global fund generally.We do not see this in the current structure yet.Transparency and Accountability
We have seen cases of corruption among Global Fund programs in Mauritania,Mali, Zambia, Djibouti. Unfortunately, this has been perceived by some donors asa golden opportunity to justify their withdrawal of support to the Global Fundwithout losing face, or seeming to renig on their moral obligations to health.In reality, the misappropriated funds are miniscule (0.3%) when compared tothe overall amount involved. The Global Fund has been a victim of itstransparency, which should have been upheld as an example of accountability inthe history of international development. The Fund itself set up the means ofmonitoring and financial control that helped reveal fraudulent activities. Andevery time the abuse was proven, the programs were frozen and the recipientStates urged to give back the misappropriated funds.It is extremely difficult for HIV implementers in the field to explain to aCongolese patient that she can not get the treatment she needs, because of thecurrent economic environment. We cannot let this be an excuse to underfundprograms that provide life-saving HIV prevention, care and treatment programs.Why should she be punished because, in some countries on some programs, atiny portion of the money spent on the fight against AIDS has not been usedcorrectly? We urge all donor nations to re-commit to the Global Fund.Coming from a MENA region I am particulary concerned about the GlobalFund’s new emphasis on high-impact countries.You are talking about IMPACT, but what about the estimation of patientsthat will receive treatment until 2015, thanx to the Global fund support? Isthere a difference between a person in Morocco, in Argentina and inZimbawe ? How will we able to measure that this changes are working andmeet the needs of people on the field? We need a financial model that isflexible and inclusive. We certainly want to save as many lives as possible – butwhat is going to happen to middle-income countries, with low generalprevalence, but with concentrated epidemics among key populations like menwho have sex with men, sex workers, transgender people, and injecting drugusers? We have heard so much at this International AIDS Conference abouttargeting funding and interventions at key populations. But in this newstructure, regions where concentrated epidemics are exploding – especiallyEastern Europe, Central Asia and the MENA Region – will go unfunded. Again,despite the rhetoric, the key populations will be left out. This is will also impactthe effectiveness of the TB response within those population groups, particularlyMDR TB.Many countries are transitioning from low to middle income, butpoverty in middle income countries remains high, contributingsignificantly to negative health outcomes. Poverty inmiddle income countries is exacerbated by rising income inequality.At the World Economic Forum in Davos in 2011, income inequalitywithin countries was recognized as one of the most serious challengesfacing global development. In fact, 60% of the the world’s poor live in 5middle income countries: Pakistan, India, Nigeria, China and Indonesia.
Of thetop ten countries by contribution to global poverty, only four are lowincome.We urge the Global Fund to recognize that a short-term vision is a weakapproach, and instead, to prioritize long-term investment in a systemensuring good health of the poorest and most excluded.5. The demand driven model in peril I want to come to my final point: Ensuring that the principles that anchor the Global Fund are left intact. Here I am talking again about our fear that many governments are proposing a new Global Fund funding model that abandons the demand driven principle of the Global Fund, and embraces hard caps or allocations on what countries or regions could receive. We believe this would be a disastrous mistake. At the moment science is telling us that we can fight to realize the end of AIDS, if we have enough funding, the right policies, and the right interventions--capping or limiting country or restricting demand completely contradicts our shared goal of a demand driven fund. Its like we want to do the think right then doing the right think. It won’t encourage at tall country ownership, innovation and creativity, and flexibility. We say no to this approach. As the people waiting in line for services, as the people the Global Fund has been established to support, we say no. Therefore, we are asking key leaders such as yourself to COMMIT yourself--we are calling on you to stand with us. Gabriel, Eric, Rachel, Mireille--you sit at the Board, you have a critical role. So I am asking my colleagues to COME FORWARD "As the world prepares to embark on a course to end AIDS and as the Global Fund reviews its grantmaking model, that I will defend the demand-driven Global Fund, and oppose any measure that undermine scale up, resource mobilization oruniversal access. In particular, I will oppose proposals to create ceilings or envelopes that cap countries ambition when applying to Global Fund." Thank you."