Increasing Country & Community Involvement in Global Health Policy Processes?

The Case of the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria

Carlos BruenRuairí Brugha Department of Epidemiology & Public Health

International Conference 2012

Presentation outline

• 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