Since entering the New Funding Model (NFM) as an early applicant in 2013, Zimbabwe has been a unique case for Global Fund investments. The country submitted a single HIV concept note in April 2013 (before integrated HIV/TB concept notes were encouraged), was granted $311.2 million, and began implementation in January 2014. Then, the country was granted an additional $126.1 million in HIV funding in 2015, based on tweaks to the Fund’s allocation methodology. In another unusual move, Zimbabwe was invited to submit an extra HIV concept note in May 2015, this time for incentive funding only. Subsequently, another $25.3 million was awarded. Zimbabwe has one of the world’s highest HIV prevalence rates at 14.7% and is home to 1.4 million people living with HIV.
After a one-year costed grant extension, Zimbabwe’s current HIV grant is set to run until the end of 2017. It is now aligned with the regular grant cycle (instead of being a year early), and aligned with the country’s TB grant (making an integrated funding request possible). Now, the country is gearing up to prepare its HIV/TB funding request for the 2017-2019 grant cycle, likely to be submitted in the 23 May 2017 window. Building on the momentum from the NFM, civil society and communities are proactively engaging, analysing program gaps and setting priorities for the next three years. Aidspan spoke to several of these stakeholders to get a sense of the emerging themes for the country’s upcoming funding request.
“Zimbabwean civil society from all perspectives – key populations, criminalized populations, networks of people living with HIV and their allies – are all acutely cognizant that the new grant cycle presents a crucial opportunity for them to push forward a comprehensive agenda for higher quality service delivery,” says Asia Russell, the Executive Director of Health GAP. Russel has been working with partners in Zimbabwe to prepare for the next Global Fund grant cycle. Zimbabwe’s previous experience with concept note development underscores the need for an actively engaged civil society. In a report which reflects on Zimbabwe’s NFM experience as an early applicant, a key lesson learned is that specific community needs often risk being sidelined. The report recommends a minimum funding set-aside for community responses, so this is not overshadowed by health systems strengthening and other biomedical priorities.
One of the top priorities that civil society is pushing for in the next Global Fund request is universal access to immediate HIV treatment for all people living with HIV, regardless of CD4 count. Commonly referred to as “test-and-treat”, the World Health Organization began recommending this approach back in September 2015. More than a year later, Zimbabwe has yet to adopt these guidelines as national policy. Many other countries in the region have already done so: Malawi (as of April 2016), Lesotho (as of June 2016), Botswana (as of June 2016), Kenya (as of July 2016), Rwanda (as of July 2016) South Africa (as of September 2016), among others.
Stakeholders told Aidspan that the Zimbabwe government is apprehensive about the cost implications of offering HIV treatment to all. As a compromise, seven (out of 59) districts have rolled out test-and-treat on a pilot basis, supported by the United States President’s Emergency Plan for AIDS Relief (PEPFAR) and the Zimbabwe Ministry of Health and Child Care. However, activists charge that this is not good enough. “Why on earth is a person living with HIV in one geographic area more deserving of the latest science?” asks Russell. Treatment access is human rights issue in the country, with some provinces achieving much higher coverage levels than others (Figure). For instance, 74% of people living with HIV in Matabeleland North have access to antiretroviral therapy (ART), compared to just 44% in Manicaland. Part of the reason for this are sub-optimal HIV testing strategies, which often miss those who are most at risk. The next Global Fund funding request is an opportunity to close these gaps and move closer towards treating all.
Rwanda is commended for being on good track towards ending AIDS epidemic. HIV prevalence in general population (15 – 49 years old) has been kept at 3% since the last decade. However HIV is estimated at 6% in the City of Kigali. Stakeholders agree that a particular focus is needed in the areas with higher HIV prevalence. Strategic planning requires using evidence this will help control AIDS epidemic. The prevalence is also reported to be higher in certain groups of populations.
The Permanent Secretary in the Ministry of health Dr Jean Pierre Nyemazi commended development partners and civil society organizations for their contribution and support provided to the country in the fight against AIDS epidemic and health sector in general.
The Ministry of Health values the involvement of all stakeholders in this journey of AIDS response. Civil society organizations have been playing the forefront role we will continue engaging them in all process of planning and implementation of activities. Evidence informed planning is essential if we are to control AIDS epidemic.
43 stakeholders from four African countries were interviewed
A new research report has found that civil society and community groups face a range of critical information barriers with respect to the Global Fund’s regional grants in Africa. The report acknowledged that while several studies have detailed civil society participation and community engagement in national-level Global Fund processes at the national level, few have sought to understand the extent to which these groups are able to engage at the regional level. The title of the report – “You just find things happening in a cloud over your head” – captures the overall disconnect that civil society involved in implementation on the ground express about regional grants. A GFO article with the same title shared preliminary results from this research project back in April.
The report was published by the Eastern Africa National Networks of AIDS Service Organizations (EANNASO) in its capacity as host for the Regional Platform for Communication and Coordination for Anglophone Africa (part of the Global Fund’s Community, Rights and Gender Special Initiative).
Results in the report were drawn from 43 key informant interviews conducted with stakeholders in four African countries: Botswana, Mozambique, Nigeria, and Uganda. EANNASO chose to conduct interviews in these countries because they were involved in a high number of regional grants; these four countries are included in nine out of the eleven regional grants in Anglophone Africa. Both Botswana and Uganda are each included in five regional grants.
The PRs gathered in Nairobi to share experiences
Civil society principal recipients (PRs) from across Africa recently gathered in Nairobi, Kenya to consolidate their collective knowledge and experiences and establish a formal community of practice. From 29-31August, 65 participants from 20 African countries demonstrated their commitment to strengthening the implementation of Global Fund grants through increased collaboration and peer learning. This is the first time such a diverse group of civil society PRs – from Liberia to Somalia to Comoros – were together in the same space, brought together by a common goal.
The meeting was jointly hosted by the Technical Support Facility for East and Southern Africa (TSF ESA); the Regional Platform for Communication and Coordination for Anglophone Africa (hosted by EANNASO); and the UNAIDS Regional Support Team for East and Southern Africa.
Since Round 8, the Global Fund has urged countries to implement grants using a system of “dual-track financing,” where there are PRs from both the government and civil society. The importance of civil society for the Global Fund continues to be emphasized and institutionalized. “You are the ones who made the Global Fund,” John Ochero told participants during his opening address at the meeting. Ochero is the fund portfolio manager for Kenya, based at the Global Fund Secretariat. Following Ochero, Dr. Henry Tabifor, from the UNAIDS country office in Kenya, said that “Civil society is the engine of the Global Fund. They make the money work.”
“There are clear signs of progress, but challenges must be addressed”
The Global Fund is poised at a critical and exciting juncture in the evolution of its work on gender quality and key populations. But if a range of fundamental challenges go unaddressed, further progress will be severely limited. This was the conclusion of a report released last week by the Community, Rights, and Gender (CRG) Department at the Global Fund.
The 58-page report, Gender Equality and Key Populations: Results, Gaps and Lessons from the Implementation of Strategies and Action Plans, is technically a progress assessment of the Gender Equality Action Plan 2014-2016 and the Key Populations Action Plan 2014-2017, but is functionally an overview of the steps the Global Fund itself has taken since 2014 in the areas of gender equality and key populations. The report, which was developed by long-time advocate Sarah Middleton-Lee, focuses on, “the role of the Global Fund Secretariat in developing, implementing, monitoring, and promoting the Action Plans.” Thus, its focus is narrowly upon the actions of the Secretariat, and not on the wider experience of Global Fund-supported programs.
The report goes through the gender equality and key populations action plans objective-by-objective and provides examples of progress, wherever they were found, between 2014 and 2016. The findings are then synthesized into a series of “strategic messages,” which form the heart of the document. The strategic messages seem to be the author’s attempt to present findings in a useful and actionable way, particularly for the Global Fund Secretariat, which is the primary audience of the report. Below we summarize each of the strategic messages.
CGR issues received a big boost in the Fund’s new Strategy 2017-2022
The Global Fund has been successful at raising awareness about the importance of community, rights, and gender (CRG) and promoting the inclusion of CRG issues in country dialogues and concept notes. However, challenges remain in translating these achievements into impact in programs on the ground.
This is a central theme of the Community, Rights and Gender Report (2016) presented to the Board at its recent meeting in Abidjan. This is the second annual CRG report to the Board (click here to view the first report).
Community responses, human rights, and gender equality have been heavily prioritized by the Global Fund Secretariat throughout the rollout of its new funding model (NFM). The growing capacity of the Fund’s Community, Rights, and Gender department has enabled its CRG advisors to provide direct support to 83 of the 113 countries receiving funding and to 20 of the 32 regional applications.
The CRG special initiative demonstrates further commitment to these issues. The initiative is a $15 million set-aside for technical assistance, capacity building of key populations and the establishment of six regional platforms – all aiming to ensure that community, rights, and gender are central to how The Global Fund does business.
The Global Fund’s new Strategy for the period 2017-2022 enshrines this focus going forward. After a widely consultative process – perhaps the Fund’s most extensive ever – the new Strategy significantly strengthens The Global Fund’s dedication to supporting community responses, human rights, gender equality, and programming for women and girls as well as key and vulnerable populations. The CRG report praises the new Strategy, pointing to several sub-objectives that prioritize these issues.
However, a recently commissioned review of the Fund’s Gender Equality Strategy and Sexual Orientation and Gender Identities Strategy (not yet released) has found that while the Secretariat has led or mobilized significant progress in terms of policies, processes, portfolio analyses, and coordination on CRG issues, there remain concerns about the extent to which these efforts have translated into more and better investments in gender equality and key populations at country level. Indeed, the 2016 CRG report flags several persistent challenges around measuring impact and tracking investments on the ground.
The issue of impact
According to the CRG report, while there is evidence of greater inclusiveness in country dialogue, and some evidence of improved concept note content as a result, work is needed to show how this translates to more effective programs at country level. It is especially necessary to demonstrate how having communities engaged on these issues results in greater impact against the three diseases. A report released last year by EANNASO (the Eastern African National Network of AIDS Service Organizations), host of the regional platform for Anglophone Africa, which is part of the CRG special initiative, aimed to do this (see GFO article). EANNASO’s research linking country dialogue participation to effectiveness of Global Fund investments will be presented as an oral abstract session at the International AIDS Conference in South Africa in July.
The CRG report notes that new key performance indicators have been proposed to accompany the 2017-2022 Strategy which promise to improve documentation of impact for community responses. Specifically, the proposed new KPI framework aims to strengthen the previous indicator on human rights by changing the focus from reported human rights violations to measuring progress in reducing human rights barriers to services. The new KPIs would also document increasing programming for key populations and measure the extent to which programming for key populations and human rights are increasingly absorbed by domestic funders, particularly as countries approach transition from Global Fund support.
The issue of investment
Possibly linked to historic challenges in showing CRG-related impact, there is evidence of insufficient funding for community responses in several areas. The CRG report highlights that less than 20% of country concept notes submitted in Windows 1 to 7 of the NFM requested funding to support community monitoring. Similar gaps in funding requests for community responses have been previously identified. For example, out of 119 concept notes submitted to the Global Fund in Windows 1 to 5, 72% identified human rights barriers to access but only 10% actually requested funding for the corresponding removing legal barriers module (see GFO article). In the same vein, the Technical Review Panel has expressed concern that funding requests for the community systems strengthening module are not well-aligned with identified needs. In its report on concept notes submitted in Windows 3 and 4, the TRP said that many submissions which provided analysis of CSS did not accompany this with appropriate budgets for these interventions. Many of these concept notes placed CSS activities in the above allocation requests, meaning they are an “extra ask” and are less likely to be awarded funding.