Transcript Governance, Advocacy and Service Delivery The Global Fund

Increasing Country & Community Involvement in
Global Health Policy Processes?
The Case of the Global Fund to Fight HIV/AIDS,
Tuberculosis and Malaria
Carlos Bruen
Ruairí Brugha
Department of Epidemiology & Public Health
International Conference
2012
Presentation outline
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Aims & Methods
Context
Findings
Discussion
Project Aims & Methods
Global Perspectives: Evolution & Impact of Global Health
Initiatives (GHIs)
• Identify, track and evaluate evolution of GHIs:
– Focus at the global level and global-country interface
– Focus on issues of partnership, governance, influence of individuals,
organizations and networks etc
• Results:
– Address rationales and evolving roles of GHIs
– Document stakeholder perspectives on selected GHIs, e.g. i) role of
individuals and organizations in shaping GHIs; ii) GHI impact on health
systems of southern African countries
• Methods include:
– Documentary Reviews
– Stakeholder mapping & in-depth telephone interviews of purposively
selected people across 8 constituencies (n=36) (2009-10)
Context: NGO Engagement in Global AIDS
Treatment, Prevention & Related Interventions
• 1980-90s: Gradual shift from Northern domestic to
transnational AIDS civil society networks
• 1996: UNAIDS launched, guided by a Programme
Coordinating Board (PCB) that includes NGOs
• 2000: International AIDS Conference, Durban
• 2001: Organisation of African Unity summit on HIV/AIDS,
Tuberculosis and Other Infectious Diseases, Abuja; UNGASS
• 2001: Launch of Transitional Working Group (TWG) that
established the Global Fund to Fight HIV/AIDS, TB & Malaria
• 2002: Global Fund launched & NGO inclusion guaranteed
NGOs & the Emergence of the Global Fund
• Early discussions on global HIV financing initially shaped by donor
priorities and contested positions
– Infrastructure V Product investment?
– Horizontal or vertical approach?
• NGOs engaged in advocacy & lobbying of governments
– Divided by similarly contested positions as donors
• Northern AIDS treatment NGOs directly involved in negotiations
through the Global Fund Transitional Working Group
– “Political Entrepreneurs” with incentives and capacity to invest in
creation of a new institution
– Personal connections and positive reputation among influential actors
– Consultation initially limited to network connections between small
number of Northern NGOs and dominant NGOs in countries
Early Gains
• NGOs move from the fringes to the core
• Institutional access created greater potential for NGOs to influence
agenda-setting, decision-making and organisational operations.
• NGOs came to be considered a source of credible information for
other Board members and Secretariat staff, winning over ‘doubters’ at
senior levels
• NGOs developed delegation systems to enhance
representativeness, provide support and manage their
relations
• 2004: NGOs representing affected communities Delegation get voting
rights
• Through the Global Fund and in countries, facilitated
significant scale-up of treatment and impact on three
diseases
Early Challenges
• Perception of undemocratic and anti-participatory
processes at global level, exacerbated by:
– Who had access to new technology or to the global
centers of influence
– Dominance of large NGO networking associations
– Slow release of information
– Resource constraints and expanding workload at global
and country levels
• Divisions and rivalries between NGOs/Civil Society
groups, e.g.
– Northern and Southern NGOs or between AIDS
Treatment NGOs and Primary Health Care NGOs
Global Fund, NGOs and Evolving Relations
• Influence at Board and Secretariat level, e.g.
– Expansion of original Global Fund Framework document e.g.
Community Systems Strengthening, gender & sexualities policies
– Board decisions rejecting Secretariat-arranged drug donations
• Increased funding & competition between NGOs
– In some countries, a barrier to cooperation at country level,
with implications for global level activities
– Financing prioritized service delivery/implementation activities
at expense of advocacy, research and other activities
• NGOs concerned about donor co-option:
– Diverting activities for sake of attracting finances?
– Poachers turned gamekeepers?
– Constraining advocacy and watchdog activities?
Lasting Challenges
• Global activities perceived as disconnected from country and community
realities
– Distracting from community and country priorities & needs
– Weak mechanisms for information sharing or community engagement and
participation at national and global levels
• Shifting landscape:
– Dependency on larger Northern NGOs lessening & not as exclusively driven by AIDS
treatment NGOs
– Increasing cooperation at global level, creating conditions for coordination of resources
across GHIs & reduction of ‘warring factions’, e.g. International Civil Society Support (ICSS)
• NGO Accountability: To whom, for what, and how?
– “What is important is to be aware that they are not observers standing on the
sidelines with a watchdog function, figuring out what’s right to do. They also are
similarly interested in finance from the Global Fund. That is often overlooked I
think, and the Civil Society role as advocates and watchdog and drivers of
fairness needs…to be looked at very carefully
• C28, Senior Donor/GHI Representative
Discussion Points
• 2001-2011 was a period of structured experimentation in
global health governance and policy leading to many positive
outcomes
• However, need to continue the movement beyond
consultations with civil society ‘leaders’ to develop structured
mechanisms for participation from community level upwards
to enhance community-based responses
• Important to recognise that NGOs are increasingly part of the
power structures
Acknowledgments
• Special thanks to all participants who were willing
to take part in consultations, interviews, and
follow up queries.
• Project colleagues
– Impact of GHIs in Africa Project
– Global HIV/AIDS Initiative Network
(www.ghinet.org)
• Funding Organisation
– Funded by EU Framework 6 INCO-GHIs