Community, Rights, Gender
and the New Funding Model
Global Fund Briefing
For
Technical Assistance Providers
March 2014
The New Funding Model
• Bigger impact: focus on countries with the highest disease burden
and lowest ability to pay, while keeping the portfolio...
New vs. old funding model
• Investment selection
• Active portfolio management by
Secretariat
• Predictability
• Involved ...
New funding model cycle and timing
2nd
Grant
Approvals
Committee
Meeting
Concept Note
2-3 months
Grant Making
1 ½ - 3 mont...
National strategic plans:
The basis for Global Fund funding
2
National strategic plan* Robust NSP*
NSP
Assessment
Concept
...
Structure of the concept note
7
CCM Eligibility Requirements 1 & 2
Section 1: Country context and response
Overall funding...
The modular approach is a framework that runs
through a grant's life cycle
• The modular approach is a framework used to
s...
Preparing for the new funding
model
Submission dates 2014-2016
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec...
Timings: work backwards
Minimum Standards for Principal Recipients
PR demonstrates
effective management
structures and planning
PR has the
capacit...
Community Systems
Strengthening
UNAIDS for community systems strengthening
“AIDS forever changed the focus, role and participation of affected
communities...
Support for community systems strengthening in
the Global Fund
“Clearly, government-based planning, health information sys...
Support for community systems strengthening
in the Global Fund Strategy
16
Emphasizes the need to support national system...
Types of community/civil society action
Service
provision
Promoting
accountability
Types of community/civil society action
Community
mobilization
Service
provision
Promoting
accountability
Communities and service provision
Service
provision
Facility-based services
Auxiliary health services
Health promotion and...
Principles for supporting service provision
 Responding to gaps in provision of services
 Identifying where community/ci...
Communities and accountability
Promoting
accountability
Governance and management of health
services
Monitoring of health ...
Principles for supporting accountability
 Community engagement is most effective on directly relevant
issues
 Access to ...
Challenges for community-led responses
 Community groups are often informal and unregistered
 Lack of understanding of c...
Community systems
“Community systems are the
structures, mechanisms, processes, and actors through which
communities act o...
Modules: grant structure
ModulesComponent
Malaria
TB
HIV
Vector Control
Case
management
Specific
prevention
interventions
...
Community systems strengthening
“Community systems strengthening promotes the
development of informed, capable and coordin...
Interventions in the disease components
Intervention 1: Community-based monitoring for accountability
Intervention 2: Advo...
Community systems strengthening under
health systems strengthening
 Community systems strengthening does not appear as a ...
Community-based monitoring for accountability
Community-based organizations establish and implement
mechanisms for ongoing...
Advocacy for social accountability
Communities and affected populations conduct
consensus, dialogue and advocacy at local ...
Social mobilization, building community
linkages, collaboration and coordination
Community action, establishment of commun...
Institutional capacity building, planning and
leadership development in the community sector
Capacity building of communit...
Modules under tuberculosis
TB Care and Prevention
MDR-TB TB/HIV
Community Systems Strengthening
Removing Legal Barriers to...
Modules under HIV
Treatment, Care and Support
PMTCT TB/HIV
Community Systems Strengthening
Removing Legal Barriers to Acce...
Human Rights
Human rights are personal
Talk to the person
sitting next to you
Share one example of a rights
abuse that happened to a fr...
Human rights in the Global Fund strategy
Gender Equality Strategy, 2008
Sexual Orientation and Gender Identities (SOGI)
St...
When does one person’s bad luck rise to the level of a
human rights violation?
Local
court
Appeals
court
Supreme
court
1. ...
Universal Declaration of Human Rights, December 10, 1948
1. International Covenant on Civil and Political Rights
 Right t...
• Life;
• Liberty and freedom of movement;
• Equality before the law;
• Presumption of innocence until proven guilty;
• Be...
• Work;
• Equal Pay for equal work;
• Form and join trade unions;
• Social security;
• Special protection to the family, m...
• What is the “highest attainable standard of health”?
• General Comment No. 14
• Availability – quantity
• Accessibility ...
States have to do three things to uphold your rights
Laws and
policies
Due process
Remedy
• Sign and ratify international ...
All human rights are created equal
Universal for
all political
systems and
cultures
Interdependent – Your
level of enjoyme...
The UN Office of the High Commissioner for Human Rights (OHCHR) monitors the
treaties
Universal Periodic Review
Human Righ...
Global Fund applicants must identify structural barriers
to accessing health services
Stigma and Discrimination
Fear of ar...
What the Global Fund will support to address human rights:
Human Rights for HIV, TB, Malaria and HSS Grants Information No...
Sample programs: Using a rights-based approach
for health service design & delivery
• TB and migrants program in Yunnan, C...
Example: Removing Legal Barriers package of interventions
Addressing hospital discrimination on the basis of HIV or TB sta...
Example: Removing legal barriers package
Addressing barriers to prevention services for sex workers
50
Global Fund module ...
Resources
• Global Fund Information Notes: HIV and Human Rights, TB and Human Rights - http://www.theglobalfund.org/en/acc...
Gender
What are we talking about?
53
Source: Sam Killermann, http://itspronouncedmetrosexual.com/2012/01/the-genderbread-person/
...
54
What’s gender got to do with it?
 Why gender?
- Gender norms – feminine, masculine, no in-between.
- Gender inequaliti...
So… gender analysis is useful to make programs
more effective
• Why is gender equality critical to malaria control?
• Whic...
Why gender? “Structural interventions” to act outside
the health sector to influence health outcomes
56
57
A gender-responsive approach
 How?
- One size does not fit all
- The questions should always be asked!
Gender-sensitiv...
Illustrative Examples: Gender-responsive,
-sensitive, -transformative approaches
Gender blind Gender-sensitive Gender-resp...
What works for women?
59
www.whatworksforwomen.org
60
The Global Fund Gender Equality Strategy (2008)
 Overall aim of the GES
- Fund proposals that scale-up services that r...
Illustrative “limited GES influence”
61
Women’s limited participation in the Global Fund decision-making at country level:...
62
FYI: Secretariat “renewed commitment” in 2011
Responding to the Pangaea evaluation, the Secretariat made a renewed comm...
PMTCT for children and women
PMTCT is about more than preventing vertical transmission in pregnant
women.
• Prong 1: Prima...
Interaction between the Gender Equality Strategy and
the new funding model
Board
approvalGuidance package
Prioritizing gen...
65
New Gender Equality Strategy Action Plan
Initial consultation with the partners (technical partners, global civil
socie...
Next Steps and Opportunities
Strong partners’ interests on accelerating gender integration
into new funding model process ...
Quick exercise: What can we advise the Country Team?
(Grant Approvals Committee presentation by country x)
• Feminization ...
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Crg presentation to technical assistance providers

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  • The principles of the new funding model were established by the Board of the Global Fund as part of the Global Fund’s strategy for 2012-2016. It is based on feedback from countries and partners about how the Global Fund could better help them.We all share a vision of a world free of the burden of HIV/AIDS, tuberculosis and malaria, and in a world of limited resources, we need our investments to go further in order to achieve this.Therefore, the new funding model was established to make a bigger impact, with more reliable results, to reward ambitious vision, to work on more flexible timings and with a more streamlined approach.The bigger impact principle is delivered by establishing which countries have the highest disease burden and lowest ability to pay, and focusing more resources on this group.By introducing the idea of an ‘allocation’ for each country, and by supporting each country as they develop their intervention plan, the Global Fund will be able to ensure a more reliable result, with predictable financing levels and a higher success rate of applications.Rewarding ambitious vision is achieved by developing a picture, based on National Strategic Plans or investment cases, of what each country would ideally like to do, over and above their funding allocation. By eliciting the full expression of demand and having a pool of ‘incentive’ funding available, the Global Fund is able to allocate additional funds to the most compelling investment cases.Another big change is to move away from the rounds based competition with a set application date, and allow countries to apply at a time that meets their own national schedules, within the 2014-2016 time frame.Finally, by including much of the implementation plans up front in the initial proposal, and with greater support from Global Fund Country Teams in the early stages, we are able to make it simpler for countries to navigate the new process. By reducing complexity we are able to cut a lengthy process that used to take 2 years down to an average of 10 months.
  • So how is the new model different from the previous model?In the previous model, which was in place for the first 10 years of the Global Fund’s existence, the Secretariat deliberately had a passive role in influencing investments. It would evaluate every proposal that was submitted in each round, and allocate funds to the strongest proposals, regardless of whether these proposals came from the countries most in need. In the new model the Secretariat will play a much more active role in portfolio management, by allocating and protecting funds for all eligible countries, with consideration for overall disease burden and ability to pay, amongst other factors.In the past the Global Fund operated on a rounds based system, with one application window which may or may not have matched the country’s strategic planning timeframe. In the new model the timelines will be largely defined by each country, and they are able to plan their application timing alongside their national priorities and schedule.Up until now the Global Fund has deliberately been ‘hands off’ prior to Board approval, which meant there was often a significant amount of rework in the grant making stage when the Country Teams would finally engage with the CCMs on agreeing implementation plans. Now the Country Team will be actively engaged in the country dialogue and the concept note development process, giving guidance and support on the implementation plans upfront and making sure known risks are addressed in the Concept Note.A great challenge for countries applying in the previous system was the low success rate of applications, leading to an overall poor level of predictability when applying for Global Fund funding. Within the new model countries and the Global Fund work together to optimize plans that will deliver the greatest impact, and success rates will get to 100% over time.Finally, the cumbersome and time-consuming process to get to grant signing was fraught with problems, and in the new model the grants will be disbursement-ready, resulting in a much lighter and shorter process overall.
  • Let’s begin by looking at the cycle of the new funding model and the overall timings. It starts with your National Strategic Plan, which underpins the funding request. It is very important that this is as robust as possible, and considers interventions that take into account sub-national epidemiological data and data for key affected populations.The Secretariat the communicates the funding allocation. After receiving the allocation amount the CCM can start developing the funding proposal, which is called the ‘concept note’. In the concept note the CCM will be expected to present a funding request that is based on a costed plan with prioritized interventions flowing from the national strategic plan, with up front risk and capacity assessments. The concept note must be developed using an inclusive ‘country dialogue’ process, with the input of a broad range of stakeholders, including key affected populations and people living with the disease.The Global Fund Country Team will be engaged with the CCM over the duration of country dialogue, and will present the concept note to the Technical Review Panel, an independent body that assesses the quality of the proposal and recommends what interventions to fund. Once the concept note has been approved by the TRP it is presented at the Grant Approval Committee, which sets the level of approved funding for grant-making.One of the big changes in the new funding model is that grant-making occurs prior to Board approval. Grant making will be a short window, where the implementation plans that have been agreed at the TRP are finalized with the principal recipient. Once the grant is disbursement-ready it is presented to the Board for approval. The grant life has now been extended to 3 years.Some key points to highlight:You can come to the Global Fund when it best suits you, with allocated funds being held in reserve for you until you apply. Funds from the 2014-2016 allocation can be used beyond 2016, for a 3 year period after the grant is signed.Concept notes for different diseases or HSS can be submitted at different times, (although for countries with a high TB/HIV co-infection rates a joint TB/HIV proposal should be submitted.)
  • As mentioned, National Strategic Plans or investment cases are the basis for Global Fund support.NSPs should be: Costed, prioritized, and developed through inclusive, multi-stakeholder efforts involving key affected populations and people living with or affected by the diseasealigned with international normative guidance, national health sector strategies, and developed in coordination across the three diseasesWe strongly encourage you to assess your NSP using a credible, independent, multi-stakeholder process based on agreed frameworks, such as the Joint Assessment of National Strategies (JANS) tool.This will ensure that your NSP is aligned to international normative guidance, and it is robust enough to identify and prioritize the programmatic gaps to be included in your funding application.Grant funds may be reprogrammed to support NSP development, especially data strengthening at subnational level and for sub populations.
  • This is the heart of the funding request – the concept noteFinal version of concept note and guidance on how to complete it will be available end Dec
  • The Global Fund has now confirmed the timing of concept note submission dates for each TRP review windows for 2014-2016. Each country will be asked to sign up for one TRP review for each concept note (which could all come in the same TRP window if desired). This information will help partners and the Global Fund coordinate support for your country.
  • Importance of planning ahead… consider when you will need grant money and then work backwards to identify the right concept note submission window. Here is an example to help you anticipate the length of each stage – this is a best case example.The best way to speed up the time required is to work ahead on strengthening national strategies, involving key groups in country dialogue, and ensuring CCM and implementer capacity is sufficiently strong. It is up to the country, in consultation with its FPM, to estimate how long it will take to access funds, based on its country context, and then plan accordingly.
  • As part of the new funding model, the Global Fund will also assess grant implementers against a set of 12 minimum standards. Theseform the basis of implementer assessments carried out by the Global Fund.You will see that the CCM will be asked to make a preliminary assessment of the nominated PR(s) against the minimum standards in Section 5 of the concept note.PRs must comply with the minimum standards for grant-signing, which are re-checked during grant implementation.More detail on the PR Minimum Standards can be found in the Annex 2 of the Concept Note instructions or Appendix 4 of the Transition Manual (which contains the Minimum Standards Checklist).
  • Mention that guidance calls for decrim of sex work, MSM, TG
  • First I wanted to clarify what we are talking about. Gender is often thought to be « about women », and a lot of this presentation will be about women and girls.Gender identity & expression: how you identify and how you express it. Psychologists believe that gender identity, knowing whether one is a girl or a boy, is set before a child turns 3. The expression part is less relevant to our work here, but on a daily basis it may be the most important – how we express our feelings about our own gender.Biological sex is the mix of chromosomes, organs & hormones that define one’s sex. We tend to assume it’s binary, but again it’s a continuum, with all kinds of variations in individuals.Sexual orientation is about attraction to others.It’s important to note that these things are all independent of one another. How one looks, dresses and identifies cannot be assumed to indicate who they are attracted to, or more directly related to our work, what kinds of sexual practices they engage in.The GF has 2 strategies concerning gender: the Gender Equality Strategy, about which I will talk, but also the SOGI – Sexual orientation and Gender identity strategy. The GES is about what we might call the heterosexual majority, whose gender identity, presentation and biological sex are concordant.
  • We separate the GES and the SOGI, but they both deal with problems linked to gender norms and gender inequalities. There is much talk of gender, and 2 things often happen. First, people assume that gender is about women (which as I have just shown is not the case). Second, they are a bit annoyed at having to integrate “women’s things” in their work when it feels irrelevant.1. What is gender about?When it first started being used, the term gender was chosen precisely to avoid talking about men and women. Gender is about how societies and communities define the masculine and the feminine. These are called gender norms. ex. women should only have hair on the top of their head, men should be interested in watching other men play with a ball.Some people are opposed to this gender binary and find it oppressive; it is true that when people do not fit neatly in a category, they may face severe consequences. But for most people and for our work, gender norms in themselves are not so much a problem.The problems start when there is a hierarchy between the masculine and the feminine. Generally, the masculine is more valued than the feminine, and “male” attributes/occupations/behaviours are more valued than feminine ones. This often gives men more power than women, through various institutions, legal dispositions and economic and cultural practices.Also, given this hierarchy, gender norms are often severely enforced: it is thought that men should not give up their superiority by adopting “female” traits, and women should not try to go beyond their allotted subordinate place by adopting “masculine” traits. Men and women who do challenge their society’s gender norms often face violent reactions.Note: the irony of masculinity, which is about strength, being so fragile and constantly under threat. Maintaining masculinity is constant work, especially for men who cannot access professional or economic domination.Another set of problems comes when people face discrimination on the basis of their gender, which Meg talked about yesterday. This is better-known in cases of employment, but also happens in other instances including health services, education, etc. It is important to note that sexism often compounds other discriminations. This is where it is important to pay attention to women who are part of key populations, because as a rule of thumb, women have it worst.2. So what does that have to do with us?The Global Fund must take gender into account in its work for two reasons. First, human rights, which we covered yesterday. Women’s rights are human rights, and gender inequalities and discrimination often constitute an important barrier to access.Secondly, the integration of gender is about achieving impact. Gender norms are pervasive, and they affect the way men and women live, the way they get sick, the way they react to illness and seek treatment, and the causes of their deaths. If we want to prevent infections and save lives, we have to be aware of the ways in which gender influences the lives of the people we are trying to help.We are not UN Women, but gender inequality is a pervasive form of inequality that contributes to poor health, so it needs to be integrated in our work where it is relevant (and it often is).
  • So how does this work?First, it is important to note that one size does not fit all, and there is no recipe for gender integration in 3 easy steps. It all depends on the epidemic and on the national context. Hege will present a tool develop by UNAIDS to assess which responses are most appropriate.Before we get to the specifics, I want to clarify what we mean by “gender-responsive”, which you will stumble upon if you read the materials that we produce. There are two broad ways of reacting when a gender-related problem has been detected. - gender-sensitive: you are trying to achieve a certain goal, and you make sure that you adapt to prevailing gender norms in order to reach that goal – which may have nothing to do with gender at all.ex. Cambodia men working in forest, design mosquito nets for their hammocks- gender-transformative: when gender norms are inherently linked to a health problem, they are considered harmful and it is not possible to address a health problem without changing them. Obviously, much harder, can backfire.ex. Intimate partner violence is linked to HIV. Can you adapt to this? Tell men to wear condoms when they rape their wife? No. You have to try to change the norms that make it okay for a man to be physically and sexually violent to his partner.Any approach that is either gender-sensitive or gender-transformative is deemed gender-responsive: it simply means that you have asked the question about the role of gender in your epidemic, and have taken it into account in your response.
  • To help younavigatethese questions and findprogramminganswers to specificproblems, thereis a brand new toolthatyoucanfind online. You asked for evidence, hereis the evidence.(Describe the websitebriefly)
  • You may think this is all well and good, but how much of this gender equality really falls under the GF’s mandate?The answers lie in a policy that we have had for over 5 years now, the GES. The GES lists a series of goals and focus areas.What? GoalsReducing gender-related risksReducing the burden of diseaseMitigating the impactAddress structural inequalitiesHow? 4 strategic objectivesPolicies, procedures and structuresPartnershipsCommunications & advocacyLeadership
  • A number of evaluations have foundthatitwassound, but thatitfacedserious challenges in itsimplementation.Example: Women’srepresentation on CCMs.As you know, nextyear the proportion of women on CCMswillbecome a requirement. But whatisbehindthat proportion of femalemembers? Is itreallyhelpingwomen’srepresentation?66% of CCM members in 2012 were men.Of the 33% of womenmembers, more thanhalfrepresentedgovernment and bilateral and multilateraldonorsThis left about a third of women, so 11% of total CCM members, representing civil society and people living with the diseases – so in a position wherefemale CCM members are potentiallyrepresentative of a constituencythatholdthemaccountable.
  • After another evaluation found that the implementation was not going so great, the Global Fund responded with a statement, in 2011, about its renewed commitment. It also defined some priority areas of action for programming for women and girls.* PMTCT is 4 pronged!And now we have a golden opportunity to put these policies and commitments into action through… (next slide: the NFM).
  • Illustrative “add-value” of gender responsive programming and/or participation in the CD process. Emphasize importance of having “stronger case” with clearly identified gaps and action plans to mitigate those gaps. (and pre-CD buy-in on gender mainstreaming into HIV programs through gender assessment of national HIV programs, if possible)
  • Crg presentation to technical assistance providers

    1. 1. Community, Rights, Gender and the New Funding Model Global Fund Briefing For Technical Assistance Providers March 2014
    2. 2. The New Funding Model
    3. 3. • Bigger impact: focus on countries with the highest disease burden and lowest ability to pay, while keeping the portfolio global • Predictable funding: process and financing levels become more predictable, with higher success rate of applications • Ambitious vision: ability to elicit full expressions of demand and reward ambition • Flexible timing: in line with country schedules, context, and priorities • More streamlined: for both implementers and the Global Fund Principles of the new funding model Principles of the new funding model
    4. 4. New vs. old funding model • Investment selection • Active portfolio management by Secretariat • Predictability • Involved in country dialogue and concept note development • Process • Disbursement-ready grants • Timelines • Secretariat engagement • Defined by country • Timing, success rates, indicative funding range Rounds-based funding New funding model
    5. 5. New funding model cycle and timing 2nd Grant Approvals Committee Meeting Concept Note 2-3 months Grant Making 1 ½ - 3 months Board Approval Technical Review Panel 1st Grant Approvals Committee Meeting Ongoing Country Dialogue National Strategic Plan/ Investment Case Grant Implementation 3 years Countries can apply anytime in 2014-2016 – identify now when funds are needed for each disease Grant funds will run to the next replenishment at least
    6. 6. National strategic plans: The basis for Global Fund funding 2 National strategic plan* Robust NSP* NSP Assessment Concept Note with prioritized programmatic gaps Before assessment Epi analysis & program review Grant funds may be reprogrammed to support national strategic plan development, especially data strengthening.* or investment case
    7. 7. Structure of the concept note 7 CCM Eligibility Requirements 1 & 2 Section 1: Country context and response Overall funding landscape, additionality of resources requested & financial sustainability Summary information about the request Section 4: implementation arrangements and risk assessment The funding request, including a programmatic gap analysis & the modular template Section 2: Section 3: Essentialinfo &processContent
    8. 8. The modular approach is a framework that runs through a grant's life cycle • The modular approach is a framework used to structure the information that defines a grant • It runs throughout a grant's lifecycle, providing consistency at each stage – During the concept note stage, a funding request is defined by selecting a set of interventions per module to align with national strategy – During the grant making stage, each approved intervention is further defined by identifying and describing the required sets of activities – During grant implementation, progress of each intervention is monitored as laid out in the prior stages Program level Module Intervention Activity
    9. 9. Preparing for the new funding model
    10. 10. Submission dates 2014-2016 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 201420152016 TRP TRP TRP TRP TRP TRP TRP TRP TRP # Submission deadline on 15th of the month Technical Review Panel review meeting (approx.) TR P Submission deadline for EoI (regionals only) EoI EoI
    11. 11. Timings: work backwards
    12. 12. Minimum Standards for Principal Recipients PR demonstrates effective management structures and planning PR has the capacity & systems for effective management & oversight of SRs Data-collection capacity and tools are in place to monitor program performance Functional routine reporting system with reasonable coverage to report program performance CCM actively oversees the implementation of the grant, & intervenes where appropriate 1 2 No conflict-of-interest for the selection of the PR(s) & SRs Program implementation plan provided in the funding request is sound 3 4 Internal control system of PR is effective to prevent & detect misuse or fraud The financial management system of the PR is effective & accurate 5 6 Central & regional warehousing have capacity, & aligned with good storage practices Distribution systems & transportation arrangements are efficient to ensure secure and continued supply 7 8 9 10 11 12 * Please refer to Appendix 4 of the Transition Manual for full text and descriptions of the Global Fund’s Minimum Standards for Implementers Implementers have capacity to comply with quality requirements & monitor product quality throughout the in-country supply chain 5 The Global Fund will now expect grant implementers to meet 12 minimum standards
    13. 13. Community Systems Strengthening
    14. 14. UNAIDS for community systems strengthening “AIDS forever changed the focus, role and participation of affected communities as essential partners in global health responses... It means rethinking our approaches to delivery... Community-based and task-shifting approaches... We must no longer think of a community health worker as a nice person who helps out. We need to try to make them an integral part of the structures of health” Michel Sidibe, December 2012
    15. 15. Support for community systems strengthening in the Global Fund “Clearly, government-based planning, health information systems and public health clinics are critical components for delivering health services to people. But the health system does not stop there. The health system extends deep into communities… Because vulnerable populations are often the hardest to reach we need to leverage and strengthen the systems that are best positioned to effectively deliver services to them. In many cases that means partnering closely with and strengthening civil society…” Report of the Executive Director, 29th Board Meeting, 18-19 June 2013
    16. 16. Support for community systems strengthening in the Global Fund Strategy 16 Emphasizes the need to support national systems, defined as “all country systems, including both government and non-government systems” Strategic Action 1.1 (Ensure appropriate targeting of most-at-risk populations) includes “make explicit provision in the funding model for greater emphasis on community systems strengthening.” Strategic Objective 4 (Promote and Protect Human Rights) “The “Gender Equality Strategy” and “Sexual Orientation and Gender Identity Strategy”, along with support for community systems strengthening, are further contributions made by the Global Fund to advancing human rights in the context of the three diseases.
    17. 17. Types of community/civil society action Service provision Promoting accountability
    18. 18. Types of community/civil society action Community mobilization Service provision Promoting accountability
    19. 19. Communities and service provision Service provision Facility-based services Auxiliary health services Health promotion and empowerment Addressing social and environmental determinants
    20. 20. Principles for supporting service provision  Responding to gaps in provision of services  Identifying where community/civil society organizations are best placed to fill gaps  The role of community/civil society organization provision in reaching excluded groups and increasing impact  National policies and frameworks which might facilitate or block effective community/civil society action  Effectiveness of links and referrals to other providers
    21. 21. Communities and accountability Promoting accountability Governance and management of health services Monitoring of health services Advocacy to demand services and accountability Involvement in research
    22. 22. Principles for supporting accountability  Community engagement is most effective on directly relevant issues  Access to relevant information  Understanding of mechanisms by which change happens in the context (local and national levels)  Improving service delivery through accountability efforts is effective so long as resources are also invested in developing the primary care system
    23. 23. Challenges for community-led responses  Community groups are often informal and unregistered  Lack of understanding of community role by formal sectors  Quality standards and norms  Representation and involvement of the most marginalized and excluded groups  Agreeing on most appropriate implementation roles for different sectors  Quantification, allocation, measurement ...Hence community systems strengthening...
    24. 24. Community systems “Community systems are the structures, mechanisms, processes, and actors through which communities act on the challenges and needs they face. They are made up of different types of entities: community members, formal and informal community organizations and networks, and other civil society organizations.” Community Systems Strengthening Information Note, February 2014
    25. 25. Modules: grant structure ModulesComponent Malaria TB HIV Vector Control Case management Specific prevention interventions Interventions LLIN - Mass Campaign LLIN - Routine distribution IRS Activities Procurement of LLINs Workshops Mass media event ... Training Modules, interventions and activities will replace current heterogeneous service delivery areas • Some current service delivery areas refer to interventions, some are at activity level • Service delivery areas are not harmonized across the various documents, preventing the linking of targets to budget M&E Other vector control measures Behavior change communication Cost Inputs Product cost Transport Storage ... Quality Assurance HCSS
    26. 26. Community systems strengthening “Community systems strengthening promotes the development of informed, capable and coordinated communities, community-based organizations, groups, networks and structures. It enables them to contribute to the effectiveness and long-term sustainability of health and other interventions at the community level, including the development of an enabling and responsive environment.” Community Systems Strengthening Information Note, February 2014
    27. 27. Interventions in the disease components Intervention 1: Community-based monitoring for accountability Intervention 2: Advocacy for social accountability Intervention 3: Social mobilization, building community linkages, collaboration and coordination Intervention 4: Institutional capacity building, planning and leadership development in the community sector
    28. 28. Community systems strengthening under health systems strengthening  Community systems strengthening does not appear as a separate module under health systems strengthening  However, many health systems strengthening modules and interventions can be used to strengthen community systems, for instance:  Activities that are aimed at improving equitable distribution and retention of skilled health workforce especially in hard-to-reach areas and to serve marginalized populations  Capacity building and training of… non-government and other relevant personnel to improve policy-making, policy-execution and monitoring functions  Activities which contribute to improving provision of financial resources to public, private and non-government /community institutions for effective delivery of services
    29. 29. Community-based monitoring for accountability Community-based organizations establish and implement mechanisms for ongoing monitoring of health policies and performance and quality of all services, activities, interventions and other factors that are relevant to the disease, including prevention, care and support services, financing of programs, and of issues and challenges in the environment, (such as discrimination and gender-based inequalities), that constitute barriers to an effective response to the disease and to an enabling environment.
    30. 30. Advocacy for social accountability Communities and affected populations conduct consensus, dialogue and advocacy at local and national levels aimed at holding to account responses to the disease, including health services, disease-specific programs as well as broader issues such as discrimination, gender inequality and sustainable financing, and aimed at social transformation.
    31. 31. Social mobilization, building community linkages, collaboration and coordination Community action, establishment of community organizations and creation of networking and effective linkages with other actors and broader movements such as human rights and women’s movements. Strong informal and formal relationships between communities, community actors and other stakeholders enable them to work in complementary and mutually reinforcing ways, maximizing the use of resources and avoiding unnecessary duplication and competition.
    32. 32. Institutional capacity building, planning and leadership development in the community sector Capacity building of community sector groups, organizations and networks in a range of areas necessary for them to fulfil their roles in service provision, social mobilization, monitoring and advocacy. Includes support in planning, institutional and organizational development, systems development, human resources, leadership, and community sector organizing. Provision of stable, predictable financial resources for communities and appropriate management of financial resources by community groups, organizations and networks. Provision of technical, material and financial support to the community sector as required to enable them to fulfil roles in service provision, social mobilization, monitoring and advocacy.
    33. 33. Modules under tuberculosis TB Care and Prevention MDR-TB TB/HIV Community Systems Strengthening Removing Legal Barriers to Access Health Information System and M&E Program Management 33
    34. 34. Modules under HIV Treatment, Care and Support PMTCT TB/HIV Community Systems Strengthening Removing Legal Barriers to Access Health Information System and M&E Program Management Prevention programs for Key Populations- MSM, TG, Sex Workers, PWID Prevention programs for general population Prevention programs for other vulnerable populations Prevention programs for Adolescents and youth- in and out of school 34
    35. 35. Human Rights
    36. 36. Human rights are personal Talk to the person sitting next to you Share one example of a rights abuse that happened to a friend or family member Did anyone try to help? Were they able to help? What were some obstacles or challenges?
    37. 37. Human rights in the Global Fund strategy Gender Equality Strategy, 2008 Sexual Orientation and Gender Identities (SOGI) Strategy, 2009 Global Fund Strategy 2012-2016 Strategic Objective 4: Protect and promote human rights 4.1 Integrate human rights throughout the grant cycle 4.2 Increase investment in programs that address human rights- related barriers to access 4.3 Ensure the Global Fund does not fund programs that violate human rights
    38. 38. When does one person’s bad luck rise to the level of a human rights violation? Local court Appeals court Supreme court 1. When all domestic remedies are exhausted Human rights violation Police abuse Police abuse Police abuse Police abuse 2. When abuses become widespread and systematic The responsibility for respecting, protecting and fulfilling human rights ultimately lies with the state. States need to protect and promote human rights -- systematically. Human rights violation
    39. 39. Universal Declaration of Human Rights, December 10, 1948 1. International Covenant on Civil and Political Rights  Right to freedom of expression and opinion  Right to freedom of religion  Right to freedom of association  Rights as a person before the law  … and more 2. International Covenant on Economic, Social and Cultural Rights  Right to highest attainable standard of health  Right to just and favorable conditions of work  Right to food  … and more 3. International Covenant on the Elimination of All Forms of Racial Discrimination 4. Convention on the Elimination of All Forms of Discrimination Against Women 5. Convention Against Torture 6. Convention on the Rights of the Child 7. International Convention on the Protection of Rights of Migrant Workers 8. International Convention on the Protection of All Persons from Enforced Disappearance 9. Convention on the Rights of Persons with Disabilities Human rights are enshrined in international law These three laws make up the International Bill of Human Rights New! Ninecorehumanrightstreaties You can read all these at www.ohchr.org
    40. 40. • Life; • Liberty and freedom of movement; • Equality before the law; • Presumption of innocence until proven guilty; • Be recognized as a person before the law; • Privacy and protection of that privacy by law; • Legal recourse when rights are violated; • Freedom of thought, conscience and religion; • Freedom of opinion and expression; • Freedom of assembly and association. • What if any implications are there for Global Fund country dialogue, grant- making, implementation, evaluation? Civil and political rightsNon-discrimination,dueprocess
    41. 41. • Work; • Equal Pay for equal work; • Form and join trade unions; • Social security; • Special protection to the family, mothers and children; • An adequate standard of living, including food, clothing • and housing; • Education; • Highest attainable standard of health. • What if any implications are there for Global Fund country dialogue, grant- making, implementation, evaluation? Economic, social and cultural rights
    42. 42. • What is the “highest attainable standard of health”? • General Comment No. 14 • Availability – quantity • Accessibility – non-discrimination, physical accessibility, economic accessibility, information accessibility • Acceptability – respectful of ethics and culturally appropriate • Quality – scientifically and medically appropriate • Progressive realization – states take continual and deliberate steps to make progress • Underlying determinants of health - housing, water, sanitation… Right to highest attainable standard of healthNon-discrimination
    43. 43. States have to do three things to uphold your rights Laws and policies Due process Remedy • Sign and ratify international human rights treaties • Reform the country’s laws and policies to comply • Inform citizens about their legal rights • Ensure the laws are implemented fairly • Independence of the courts • Good governance • If there is a rights violation, individuals should be able to file complaints or lawsuits and obtain justice Cross-cutting principles: Transparency Accountability Equality Non- discrimination
    44. 44. All human rights are created equal Universal for all political systems and cultures Interdependent – Your level of enjoyment of one right depends on level of enjoyment of other rights Inalienable – Cannot be separated from a person or group without due process Indivisible – One right cannot be prioritized at expense of another right Interrelated – Improvements in one right depend on other rights
    45. 45. The UN Office of the High Commissioner for Human Rights (OHCHR) monitors the treaties Universal Periodic Review Human Rights Council 9 Treaty Bodies 9 Core Human Rights Treaties Every four years, each state submits a report on compliance with UDHR and other instruments the state is party to. Civil society submits their reports Human Rights Council reviews everything, as ks state questions Based on review, Council makes recommendations to state State answers Council’s questions Similar review process to Human Rights Council Special procedures (of the Human Rights Council) - Committees and individual experts who monitor specific countries, or specific human rights. …the process is repeated four years later Individuals can also file complaints with the OHCHR Like the Council, treat y bodies review state compliance with treaties. They also issue guidance to interpret the human rights treaties. Anand Grover Special Rapporteur on Right to Health
    46. 46. Global Fund applicants must identify structural barriers to accessing health services Stigma and Discrimination Fear of arrest Forced sterilization Gender inequality Migrants lack ID cards Lack of legal aid Police abuse No right to register an NGO Prison overcrowding Denial that key pops exist Availability of facilities Financial barriers Harmful gender norms Gender-based violence Consult with key pops and human rights experts Barriers to health services Many or all barriers may exist in one country Need to ask: Who are key populations to reach with services? Identify 1-3 priorities to address with costed community systems strengthening or human rights interventions
    47. 47. What the Global Fund will support to address human rights: Human Rights for HIV, TB, Malaria and HSS Grants Information Note Interventions Use a rights-based approach to health services • Consult with key populations for HIV, TB and malaria • Put the person at the center, tailor services to their needs, integrate services with local community platforms Package to remove legal barriers to access • Legal environment assessment • Law and policy reform • Legal literacy • Legal aid services • Rights training for officials, health workers, and police • Community-level monitoring • Policy advocacy and social accountability Examples • In South Africa, prisoner support groups monitor and advocate on treatment access • Myanmar networks of PLHIV and key populations monitor local cases of medical discrimination against PLHIV and TB patients, and work with a national law reform working group to change the laws • In Kenya, KELIN provides legal aid to women living with HIV who lose their inheritance rights • In Indonesia, LBH Masyarakat trains people who inject drugs as community paralegals for peers • In Peru, an Ombudsman monitors the government response to TB Care and exposes problems
    48. 48. Sample programs: Using a rights-based approach for health service design & delivery • TB and migrants program in Yunnan, China - 20 percent of the population is “floating” in Yunnan – difficult to reach and retain into care; - 8 out of 10 MDR-TB patients are migrants; - Living in crowed and basic shelter - Low-paid jobs in construction sites, restaurants - Variety of different dialects, low literacy • Difficulty in accessing care and treatment - Working long hours on construction sites; - Cost of treatment; - Lack of information; - No health insurance; - No health center nearby; - Fear of losing job. • Improving access and adherence: - Patients home visit for community-based DOT; - Reducing costs to patients by training TB physicians to cost effective treatment (no use of 2nd line drugs for drug sensitive TB, no liver and kidney drugs, no use of computerized tomography (CT) scan if not necessary…); - Collaboration with private pharmacies and clinics for referral of patients suspected of having TB; • Protecting: - Engaging with construction trade unions to allow more flexible working hours; - Engaging with landlords unions to protect migrants from losing their home if diagnosed with TB; • Increasing awareness: - Working with construction companies to allow outreach workers on site; - Reaching out to children in the four schools of the community; - Education activities at markets within the community and free symptoms screening on site;
    49. 49. Example: Removing Legal Barriers package of interventions Addressing hospital discrimination on the basis of HIV or TB status 49 Global Fund module Global Fund intervention Sample activity Removing legal barriers Community-based monitoring PLHIV and TB community-based organizations are trained to document cases of discrimination by health providers Policy advocacy and social accountability Each month, the community-based organizations meet with local health officials to share cases and discuss follow-up. Legal literacy and legal aid Lawyers work with key pops networks to train community members in their right to non-discrimination Rights training for health workers Hospital works with key pops networks and lawyers to train health workers on using universal precautions, non- discrimination Law and policy reform A working group of health officials, legal experts, members of Parliament, and PLHIV/TB patients draft new laws and policies to address discrimination. This includes tough new non-discrimination policies for the Ministry of Health. Community systems strengthening Institutional capacity-building Core funding to the national networks to support an office, financial systems, management training Social mobilization National networks work together on advocacy to support the law reform process The problem: In some countries, NGOs report that health workers routinely refuse to treat people with HIV or TB. Global Fund health services are not reaching people most at need. One solution: Combine community systems strengthening and removing legal barriers interventions to bring together health service providers, legal experts and communities to address this barrier.
    50. 50. Example: Removing legal barriers package Addressing barriers to prevention services for sex workers 50 Global Fund module Global Fund intervention Sample activity Removing legal barriers Community-based monitoring The national sex worker network are trained to monitor and document cases where police use condoms as evidence. Legal literacy and legal aid Sex worker HIV prevention outreach workers are trained to be “community paralegals” and advise peer sex workers about their rights. When sex workers are detained, they can call on peers to come to the police station and provide support. Rights training for police Technical partners hold trainings for judges and police and bring in representatives of the sex workers’ network to share their experiences and co-facilitate the training. Law and policy reform Civil society groups work with the national bar association to draft proposed changes to the criminal code that will remove condoms from the list of acceptable evidence of sex work. Community systems strengthening Institutional capacity-building Core funding to the national networks to support an office, financial systems, management training Social mobilization National networks work together on advocacy to support the law reform process The problem: In many countries, police use condoms as evidence of sex work, and use the threat of arrest to extort bribes and sexual services from sex workers. Sex workers who know about the risk of HIV do not carry or use condoms as a result. One solution: Combine community systems strengthening and removing legal barriers interventions to change the criminal code, educate police, and empower sex workers.
    51. 51. Resources • Global Fund Information Notes: HIV and Human Rights, TB and Human Rights - http://www.theglobalfund.org/en/accesstofunding/notes/ • Gender Equality Strategy , Sexual Orientation and Gender Identities Strategy - http://www.theglobalfund.org/en/library/publications/other/ • Mark Dybul, “Better Health, Better Human Rights” – Huffington Post, June 2013 - http://www.theglobalfund.org/en/blog/32491/ Reports on human rights at the Global Fund: • UNDP, Analysis of Key Human Rights Programmes in Global Fund Supported HIV Programmes (2011). - http://www.undp.org/content/undp/en/home/librarypage/hiv-aids/analysis-of-key-human-rights-programmes-in-global-fund-supported-hiv-programmes.html • Joanne Csete, Open Society Foundations. Human Rights and the Global Fund to Fight AIDS, TB and Malaria (2011). - http://www.opensocietyfoundations.org/reports/human-rights-and-global-fund-fight-aids-tuberculosis-and-malaria • Daniel Wolfe and Robert Carr, Open Society Foundations. “Strengthening Global Fund Protections Against Human Rights Abuses.” Annex 4 in Human Rights and the Global Fund to Fight AIDS, TB and Malaria Meeting Report (2011). - http://www.opensocietyfoundations.org/sites/default/files/global-fund- human-rights-20110901.pdf Human rights laws and standards: • Universal Declaration of Human Rights (UDHR) - http://www.un.org/en/documents/udhr/ • International Guidelines on HIV/AIDs and Human Rights - http://www.ohchr.org/Documents/Issues/HIV/ConsolidatedGuidelinesHIV.pdf • Patients’ Charter for Tuberculosis Care - http://www.who.int/tb/people_and_communities/patients_charter/en/ • Core international human rights treaties - http://www.ohchr.org/EN/ProfessionalInterest/Pages/CoreInstruments.aspx • UNAIDS Reference Group on HIV and Human Rights. HIV and Tuberculosis: Ensuring Universal Access and Protection of Human Rights (2010). - http://data.unaids.org/pub/ExternalDocument/2010/20100324_unaidsrghrtsissuepapertbhrts_en.pdf Information on human rights in countries • OHCHR Human Rights in the World website lists treaty body recommendations, special rapporteur reports and more by country. - http://www.ohchr.org/EN/Countries/Pages/HumanRightsintheWorld.aspx • Human Rights Watch annual report has chapters with annual updates on each country. - http://www.hrw.org/ • Freedom House annual report ranks countries as “free”, “partly free” and “not free” each year. - http://www.freedomhouse.org/report/freedom-world/freedom- world-2013 • The U.S. State Department publishes quite comprehensive annual reports on human rights in each country (and China responds each year with their own human rights report on the U.S.). - http://www.state.gov/j/drl/rls/hrrpt/humanrightsreport/index.htm For more training… • Asia Catalyst, Korekata AIDS Law Center, and Thai AIDS Treatment Access Group. Know It: The Rights Framework (2012). A human rights manual for community-based organizations, with lesson plans. - http://www.asiacatalyst.org/nonprofit_survival_skills/ Contact: Meg Davis, Senior Adviser, Human Rights at the Global Fund Email: sara.davis@theglobalfund.org
    52. 52. Gender
    53. 53. What are we talking about? 53 Source: Sam Killermann, http://itspronouncedmetrosexual.com/2012/01/the-genderbread-person/ GES
    54. 54. 54 What’s gender got to do with it?  Why gender? - Gender norms – feminine, masculine, no in-between. - Gender inequalities – hierarchy between masculine and feminine. - Gender discrimination – people being denied services/employment/opportunities because of being of a particular gender. So what? - Human rights: women & girls have rights that are more frequently denied - Health impacts of inequalities and discriminations The lower an individual’s socioeconomic position, the higher their risk of poor health (WHO).
    55. 55. So… gender analysis is useful to make programs more effective • Why is gender equality critical to malaria control? • Which gender norms make girls vulnerable to HIV? • Why men are not accessing TB treatment, or accessing it too late? • Is gender-based violence (excluding rape cases) actually making women more vulnerable?  Lots of hints/answers are available when we take good look at disease responses from gender lens. 55
    56. 56. Why gender? “Structural interventions” to act outside the health sector to influence health outcomes 56
    57. 57. 57 A gender-responsive approach  How? - One size does not fit all - The questions should always be asked! Gender-sensitive: Adapting to gender norms to achieve a goal Gender-transformative: Attempting to change gender norms that are inherently harmful Gender- responsive
    58. 58. Illustrative Examples: Gender-responsive, -sensitive, -transformative approaches Gender blind Gender-sensitive Gender-responsive Gender-transformative Distributing condoms at health centers Distributing male and female condoms at health centers Community-based distribution of male and female condoms with training on negotiation skills for women Peer-led behavior change communication and social mobilization of women’s decision-making on condom uses ART for eligible adults ART for eligible men and women, available at other health services frequented by each group (e.g., ANC for women) ART for eligible men and women, available at hours and locations that are accessible for all (e.g. mobile ART services, workplace program, night clinics) ART for eligible men and women, complemented by home-based care training for men, socio-economic support for keeping girls at school, etc. 58
    59. 59. What works for women? 59 www.whatworksforwomen.org
    60. 60. 60 The Global Fund Gender Equality Strategy (2008)  Overall aim of the GES - Fund proposals that scale-up services that reduce gender-related risks and vulnerabilities - Decrease the burden of diseases for those most-at-risk - Mitigate the impact of the diseases - Address structural inequalities and discrimination  4 strategic objectives of the GES: 1. Ensure that the Global Fund’s policies, procedures and structures effectively support programs that address gender inequalities 2. Establish and strengthen partnerships for effectively support development and implementation of programs addressing gender inequalities and reduce women’s and girls’ vulnerabilities 3. Robust communications and advocacy strategy to promote the GES 4. Provide leadership to support and advance the GES
    61. 61. Illustrative “limited GES influence” 61 Women’s limited participation in the Global Fund decision-making at country level: Country Coordinating Mechanism participation (data as of end 2012) 65% 12% 6% 8% 3% 6%0% All male CCM members female: ML/BL female: GOV female: NGO female: PLWD other female members transgender
    62. 62. 62 FYI: Secretariat “renewed commitment” in 2011 Responding to the Pangaea evaluation, the Secretariat made a renewed commitment (2011) to: • Recognizes implementation of the Gender Equality Strategy needs to be prioritized at all levels of the Secretariat and through the Global Fund Strategy 2012-2016 and in the new funding model • Promises for stronger engagement with internal and external stakeholders for women and girls and key affected populations • Identified Secretariat’s strategic focus on women and girls in the areas of: 1. PMTCT and MNCH 2. Prevention of gender-based violence and harmful gender norms 3. Female population of most-at-risk populations – especially female sex workers and drug users. • Commits supporting capacity building (including Board and Technical Review Panel members), guidance and technical support, engaging Country Coordinating Mechanisms in order to ensure integration of gender concerns into grants at the country level • Supports evidence-based programming, including the promotion of the collection and reporting by age and sex-disaggregated data.
    63. 63. PMTCT for children and women PMTCT is about more than preventing vertical transmission in pregnant women. • Prong 1: Primary prevention of HIV infection among women of childbearing age • Prong 2: Preventing unintended pregnancies among women living with HIV • Prong 3: Preventing vertical HIV transmission • Prong 4: Treatment, care and support to mothers living with HIV and their children and families 63
    64. 64. Interaction between the Gender Equality Strategy and the new funding model Board approvalGuidance package Prioritizing gender and women’s issues in the NSP – by 2. partnership effort 1. Secretariat guidance to strengthen gender integration Concept Note (prioritized full demand) Country Dialogue Grant-making TRP review Potential TRP review Secretariat Info / Analysis SIFs and tools Indicative funding range Minimum Standards National Strategic Plan Women’s 1. CCM engagement, consoli dated voices be heard 1.Sex-disaggregation of data for M&E and proposals Give feedback on tools (i.e., unpacking SIF “critical enablers” modules) 1.TRP capacities on gender, guided by gender- related guidance etc. GAC approval Recommendation to GAC 2. Women’s advocacy and community monitoring for retention of gender programs 4. Board, TRP & MEC leadership to keep gender high in agenda Women and girls’ active and meaningful participation through CCM and other engagement opportunities – to be supported by partners and the Secretariat 2nd GAC approval
    65. 65. 65 New Gender Equality Strategy Action Plan Initial consultation with the partners (technical partners, global civil society organization networks, key gender/RMNCH advocates) recommends: • New Action Plan should be developed to achieve “increased funding” outcomes, with more grants addressing gender inequalities • In line with the Global Fund Strategy 2012-2016 SO 4.3 Increase investment in programs that address rights-related barriers to access (including those relating to gender inequality) • Not being prescriptive – in order to avoid tokenistic tick-box approach, to be fully bought-in by all country stakeholders • Working with partners to further mainstream gender in the national strategic plans • Final draft under internal validation – to be completed by end January 2014
    66. 66. Next Steps and Opportunities Strong partners’ interests on accelerating gender integration into new funding model process and grants – DFID/Global Fund pilot initiatives on women and girls – French 5% technical assistance funding for integrating gender into Global Fund grants/processes – Gender workshop at the 32nd Board Meeting in Jakarta: to increase governance-level interests 66
    67. 67. Quick exercise: What can we advise the Country Team? (Grant Approvals Committee presentation by country x) • Feminization of the epidemic: 59% of estimated 61,000 adults aged 15+ living with HIV are women • HIV prevalence is considerably higher among key populations: • 26.1% among MSM; 7.5% among CSW; 8.3% among prisoners (2012 IBBS) • Very low PMTCT coverage – Pregnant women receiving ARV: 19% (2013) – VCT among pregnant women: 21% (2010) • While DHS 2011-2012 found: – % of pregnant women receiving antenatal care: 93% – % of pregnant women giving births at health facilities: 92% 67

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