On the 9th – 10th of May 2018, the Global Fund’s Board will consider revisions to the Fund’s Eligibility Policy based upon recommendations from its Strategy Committee. While some of these recommendations are positive, others raise serious concerns. By this Statement we – the organizations representing civil society and including communities of people living with and affected by the three diseases and other key populations from different countries and regions – would like to share with Global Fund Board members our position on several critical issues that should be considered by the Board during its deliberations on the Eligibility Policy.
Ensure Access to Transition Funding for Countries Moving to High Income Status
Evidence demonstrates that in upper-middle income countries (UMICs) where the Global Fund has transitioned out abruptly, governments do not automatically step up and fund life-saving services for criminalized and marginalized populations who have elevated vulnerability to the three diseases and face barriers to accessing services. Experience shows that instead, people who inject drugs, men who have sex with men, transgender persons, sex workers, migrants, homeless and other key populations are being left behind, with limited to no access to health services and support.
GNI per capita – which is used by the Global Fund as one of the key eligibility criteria – is a poor measure of a country’s wealth, since it masks countries’ internal income inequality and sheds no light on how much of the income goes to health and responses to the three diseases in particular or social inequalities and injustice. It is important to have multiple–criteria framework for eligibility and take into account fiscal space and heath expenditures that are devoted to the three diseases.
Thus, restricting access of countries to transition funding because of a World Bank decision to change their income status without taking into account their readiness to sustain the response to three diseases is considered by us as an irrational and unfair punishment of people affected by the diseases, who already suffer as a result of their own government’s lack of political will.
The most recent example of the application of this irrational provision of the Eligibility Policy is in the Russian Federation, where the last HIV grant (the only one ever granted under the “NGO-rule”, developed and coordinated by communities themselves and which proved itself as effective) was finished in December 2017 without any transition funding being available. This closure could have serious implications for the lives of communities most affected.
Do not restrict access to funding for HIV, TB and malaria responses of UMIC G-20 countries with high disease burden
We consider the requirement that UMIC G-20 countries must have an ‘extreme’ disease burden in order to be eligible for the Global Fund’s funding is purely political, absent of any rational approach to eligibility. Thus, this requirement should be completely eliminated. It particularly would make sense considering the intention to simplify/remove the five disease burden categories and replace them with a single threshold for UMICs. All upper-middle income countries with at least ‘high’ disease burden that are members of the Group of 20 (including those not being on the OECD-DAC List of ODA recipients) should become eligible to receive an allocation for any disease component.
Do not restrict access to funding for HIV for countries not on the OECD DAC List of ODA
The OECD DAC ODA requirement for UMICs to be eligible for HIV funding has existed since 2007. For the 2017-2019 allocation period, there were two countries whose HIV components are not eligible because of this requirement – Romania and Bulgaria. These countries both have high HIV disease burden. Like in a number of other countries in transition, the main challenges in Romania and Bulgaria are to sustain HIV prevention programs among key populations.¹² Romania, which ended the Global Fund HIV grant in 2011 with low epidemic and recorded concentrated epidemic after a closure of many services and since then systematically has lacked political will on behalf of its government to fund the HIV prevention among key populations. Bulgaria ended its HIV grant in 2017 and it is yet to be seen whether its new national HIV program will lead to sustaining the response, in particularly whether the government will deliver full-scale funding in line with the national program and establish a working mechanism to fund community and civil society groups to provide services the key populations. It is not the first time we advocate for the elimination of this provision in the Eligibility Policy and, in our opinion, by continuously preserving this requirement the Global Fund itself creates a political barrier that precludes the provision of evidence-informed interventions for key populations in these countries.
In a scenario where there is elimination of the “G-20 Rule” and “OECD DAC ODA Requirement”, a non-CCM option for directly financing non-governmental and civil society organizations should be ensured for countries which demonstrate human rights and gender barriers to accessing services among key populations.
In a scenario where the “G-20 Rule” and “OECD DAC ODA Requirement” are considered to be preserved in the new version of the Eligibility Policy – the so called “NGO Rule” should be expanded to cover to all ineligible upper-middle-income countries that have been excluded for political reasons under the OECD DAC rule and the G-20 requirement but meet the disease burden criteria. This would make Romania, Bulgaria and Russia eligible under the OECD DAC Rule and potentially China, Brazil, Argentina and Mexico eligible as G-20 countries. Also, the language of the “NGO Rule” on “political barriers” should be revised as this terminology has no clear definition, is inconsistent with international law and could be interpreted against the interests of key affected populations in countries. We suggest it to be replaced with “human rights and gender barriers” as a terminology being consistent with UN human rights standards.
The eligibility requirement of meeting eligibility criteria for two consecutive years should be modified if not removed. It is inhumane and ineffective from economic standpoint to wait for the second year for UMICs if new epidemiological data shows increased burden and they have been classified as UMIC for the last two years. Epidemics do not disappear over one year. Moreover, the epidemiological data arrives with a delay of one or more years after the burden increases due to data analysis and verification.
For the Eligibility Policy to be effective, it should be synchronized with other key policies, like the Sustainability, Transition and Co-Financing Policy and Allocation Methodology. There should be flexibility to find solutions for these––so far few––countries that become re-eligible in the middle of the Global Fund’s three-year allocation period; some re-eligible countries might find themselves in situations of zero allocation in spite of re-eligibility in the phase of epidemiological emergency and challenges to fund services among key and vulnerable groups. As the sustainability is an ongoing process that does not end with the Global Fund’s support transition and the Global Fund has committed strongly to the issue, the Global Fund should work with bilateral donors and private foundations to establish the ‘safety net‘ or sustainability bridging funding to address the transition and sustainability challenges faced in the countries that have phased out or are phasing out from the Global Fund, without waiting for the countries to become re-eligible due to emerging epidemics among vulnerable groups, as it was the case of Montenegro, Serbia and some other countries. That support could be given small time-bound grants to civil society and technical assistance to address the most challenging elements, like contracting and financing services for vulnerable groups that are delivered by community and civil society groups.
To conclude, we hope that when Global Fund Board members are making decisions on the afore-mentioned issues, they will take our position into account as it is in line with Global Fund’s mission, founding principles in the Framework Document, and strategy to end the three diseases. We share that commitment to ensuring the Global Fund can achieve high impact in responding to AIDS, TB and malaria in our regions and we strongly believe that our proposal helps us all advance that shared goal.
Eurasian Harm Reduction Association
Harm Reduction International
International HIV/AIDS Alliance
International Network of People who Use Drugs (INPUD)
MSMGF (the Global Forum on MSM & HIV)
LHL International Tuberculosis Foundation
Eastern Africa National Networks of AIDS Service Organisations (EANNASO)
European AIDS Treatment Group (EATG)
Alliance for Public Health (Ukraine)
Canadian HIV/AIDS Legal Network
Eurasian Coalition on Male Health
International HIV Partnerships
East Europe & Central Asia Union of PLWHIV (ECUO)
Romanian Harm Reduction Network
International Centre for Science in Drug Policy
MDR-TB Patients Support (Romania)
The Federation of PLHIV Organizations (Romania)
Ukrainian Network of People who Use Drugs
ARAS – the Romanian Association Against AIDS
Youth for Youth (Romania)
Romanian Angel Appeal Foundation
Andrey Rylkov Foundation for Health and Social Justice (Russia)
Association PROI (Bosnia and Herzegovina)
NGO Phoenix PLUS (Russia)
NGO AFI (Act For Involvement), Republic of Moldova
Addiction Research Center – Alternative Georgia
Eurasian Key Populations Health Network
Salud por Derecho (Spain)
Mecanismo social de apoyo y control en VIH de Colombia – MSACV
Public association “Supporting people living with HIV” Kuat” (Kazakhstan)
NGO “Center for humane policy” (Bulgaria)
Intercambios Civil Association (Argentina)
Forum Droghe (Italy)
Latinoamérica Reforma (Chile)
Transform Drug Policy Foundation
Network Medicus Mundi Switzerland
Association “Prevent” (Serbia)
Tendo’s World (Arts & Health)
Amitiel Welfare Society (Pakistan)
NGO Women for Health (Georgia)
Association de lutte contre le sida (Morocco)