To:

The Global Fund Secretariat and the Global Fund's Strategy Investment and Impact Committee (SIIC) Eurasian Harm Reduction Network (EHRN) on behalf of: International Network of People who Use Drugs (INPUD) International Drug Policy Consortium (IDPC) International Council of AIDS Service Organizations (ICASO) KNCV Tuberculosis Foundation The Global Forum on MSM & HIV (MSMGF) Recommendations for the development of the New Funding Model (NFM) of the Global Fund October 10, 2012

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Note: This set of recommendations summarizes the views on the NFM, expressed by civil society and community representatives who participated in the 2nd EECA Regional AIDS Forum a post-conference hub of the XIX International AIDS Conference (IAC), which took place in Kyiv on September 28, 2012, and the feedback, collected by the Civil Society Action Team (CSAT) for Eastern Europe and Central Asia within the consultative process on the NFM, from a range of experts in EECA, including current implementers of the Global Fund grants. ___________________________________________________________________________________ Summary of key recommendations: Within the NFM the Global Fund should expand the use of MARPs channel, regional and non- CCM modalities of funding as they are essential for most of the globe where epidemics are concentrated among MARPs due to the marginalization of key populations as a result of severe stigma and discrimination in government policies and lack of political will to invest in the evidence-based programs that target MARPs. The formula to define the allocation to country bands must be nuanced and, in addition to disease burden and ability to pay, take into account: 1. The epidemic growth and dynamics, particularly among MARPs; 2. Coverage of MARPs by high impact interventions; 3. A governments willingness rather than just ability to pay for these services.

To ensure that the Global Fund meets the needs of the MARPs effectively and globally, the NFM needs to have both a) a MARPs reserve band, and b) a MARPs reserve built into every country band.

While we understand that allocation by diseases based on historical levels is meant to be a temporary one-year or less measure, we would like to voice our strong concern about this process and believe that a better measure of burden/need must be developed as soon as possible. In addition, it is critical that these global diseases allocations not impede on country ability to develop ambitious proposals. Procedures for regional and non-CCM proposals must be simplified and streamlined to eliminate multiple hurdles and barriers to such vital streams of funding that are mostly implemented by Civil Society Organizations (CSOs) and Community Based Organizations (CBOs) and target the most-at-risk populations underserved within national programs. Prior to relying on NSPs in the Global Fund proposal development and resource allocation decisions, the Global Fund and technical partners must evaluate the NSPs to see how they score on respect for human rights and the levels of adequate national investments in MARPs, particularly in concentrated epidemics. As part of the iterative process and risk prevention strategy, the Global Fund needs to negotiate prioritization and selection of human-rights based programs in legal environments that limit access to services and/or are detrimental to the quality and effectiveness of MARPs programs. Strong and empowered civil society should be acknowledged by the Global Fund as an in- country stakeholder best positioned and most invested in sustaining the long lasting impact of MARPs programs funded by the Global Fund. The Global Fund must invest in civil society capacity building and strengthening affected communities. Community ownership of responses to the epidemics can only be guaranteed within the country-owned proposals to the Global Fund if the proposed program is in full alignment with international guidance on human rights. Otherwise, the Global Fund must resort to multi- country/regional and/or non-CCM proposals and invest in critical enablers to reach MARPs with prevention and treatment and to build the capacity of CSOs and CBOs to advocate for national policies, practices and budget allocations that are inclusive of and respect the human rights of key affected communities. In order to ensure the continuity and sustainability of MARPs programming after the Global Fund funding is gradually phased out, transition plans should be part of the grant negotiations within the iterative process in MICs. When preparing and submitting the Concept Note within the NFM the countries should have the opportunity to express the full demand and include all activities they consider critical for an effective response to their epidemics. Countries should not be limited by a certain funding ceiling at this initial stage of the iterative process and should have an opportunity to negotiate

programmatic and funding priorities within the indicative funding range and which would go into a competitive incentives stream. While CCMs may have representation of key affected populations (KAPs), these groups, as primary beneficiaries, must be fully engaged in the development, implementation, monitoring and evaluation of Global Fund programming (particularly in quality assurance). Representatives of KAPs must be included into and supported to participate meaningfully in the iterative process as well as in the process of the grant renewals and reprogramming.

Detailed recommendations for the New Funding Model (NFM) of the Global Fund and the Rational: The Global Fund should guarantee that most at risk populations (MARPs) for HIV/AIDS and TB, particularly people who inject (PWID), men who have sex with men (MSM), sex workers, and their respective communities, and prisoners, including those in middle-income countries (MICs), can benefit from Global Fund investments and programming within the New Funding Model (NFM) in order for the Global Fund to have a sustainable impact globally. The Global Funds MARPs channel, multi-country/regional and non-CCM grants are essential for most of the globe where HIV epidemics are concentrated among MARPs Europe (Eastern Europe in particular), Asia, Middle East and North Africa, Central America and the Caribbean and South America. Such modes of funding are vital where national governments have not fully embraced the human rights based response to the epidemics nor have the political will to invest in the evidence-based programs that effectively reach MARPs. Often despite the countries ability to pay, there is a limited or absent willingness to pay on the part of governments. Investments in high impact interventions targeting MARPs and related critical enablers and community systems strengthening (e.g. advocacy, capacity building etc.) are vital to curbing concentrated epidemics sustainably, as well as to preventing the concentrated epidemics from spilling into the general populations through bridge populations such as sexual partners of PWID. Within the NFM the Global Fund must recognize the cost effectiveness of prevention of a generalized epidemic by assisting a country to nip the epidemic in the bud in an evidence-based, human rights respecting effective way. Country Bands According to the recent Global Fund Board decision GF/B27/DP7, the principles for determining the composition of and funding allocation to each Country Band are expected, at a minimum, to be based on disease burden and ability to pay (e.g. income level). However, in our view the formula to define the allocation to country bands must be more nuanced. In addition to disease burden and ability to pay, take into account:

Not just disease burden but also the pace of epidemic growth and dynamics, particularly among MARPs; - Level of coverage of MARPs by high impact interventions; - A governments willingness rather than just ability to pay for these services. To ensure that the Global Fund meets the needs of the MARPs, the NFM needs to have both a) a MARPs reserve band, and b) a MARPs reserve built into every country band. The NFM must preserve eligibility and access of countries where i) the Global Fund currently provides the majority of resources for MARPs; ii) too few or no other reasonable alternative sources of funding are identifiable for MARPs and CSOs/CBOs rely on the Global Fund support to sustain and scale up services for vulnerable populations; iii) governments are unable or unwilling to support MARPs programs. Within the NFM the MARPs channel, introduced in Round 10, should be strengthened to generate more focused investment in marginalized and highly affected populations. For new and renewed grants, the Global Fund needs to i) ensure that the MARPs channel remains dedicated to the most-at-risk populations (rather than being too broadly defined as would have been the case for Round 11 before its cancellation); ii) increase funds available for the MARPs channel; iii) adjust maximum amounts for individual grants to reflect different country size and needs; iv) strengthen guidance on investment in critical enablers that are crucial to effective programming.

MARPS programming and sustainability In order to ensure the continuity and sustainability of MARPs programming after the Global Fund funding is gradually phased out, transition plans should be part of the grant negotiations within the iterative process in MICs. The counterpart financing, as a strategy to ensure countrys co-investments, works best for interventions that are politically acceptable in applicant countries, whereas programs targeting MARPs still require considerable advocacy by civil society and by affected communities. In countries where the governments are unwilling to support MARPs programs, the Civil Society Organizations (CSOs) and Community Based Organizations (CBOs) predominantly rely on the Global Fund and other donors to sustain and scale up MARPs programs and few other reasonable resources are identifiable in the short term. The Global Fund therefore needs to invest in the civil society capacity building and strengthening affected communities. Strong and empowered civil society should be acknowledged by the Global Fund as an in-country stakeholder best positioned and most invested in sustaining the long lasting impact of MARPs programs funded by the Global Fund. In the contexts where this applies, The Global Fund, for reasons of clear effectiveness and efficiency, should address the drivers of the epidemic. Enabling (for a time-limited initial stage) a lasting catalytic role of civil society is the evident strategy for ensuring that authorities in the short and long run will reach MARPS with an evidence-based, human rights respecting and thus effective intervention strategy.

MARPS programming and risks framework The NFM will introduce a system where each country and project will have a specific risk assessment based on past performance and local risk factors. The risk profiling of programming focusing on MARPs needs to take into account the complexity of working in these communities. Adjustments may be needed to ensure the risk framework is appropriate for MARPs. Limited national resources and/or absent political will often result in the National Strategic Plans (NSPs) being developed and implemented in disregard of the health and human rights needs of MARPs, whose behaviors are likely to be criminalized and the evidence of effectiveness of essential prevention and treatment interventions that target MARPs is ignored. Therefore, prior to relying on NSPs in the Global Fund resource allocations decisions, the Global Fund and technical partners must evaluate the NSPs to see how they score on respect for human rights and the levels of adequate national investments in MARPs, and they should assess the quality of the epidemiological data on which the NSPs are based, particularly in concentrated epidemics. Affected communities, including MARPs groups, should be included in this appraisal process. As part of the iterative process and risk prevention strategy, the Global Fund needs to negotiate selection of human-rights based programs in legal environments that limit access to services and/or are detrimental to the quality and effectiveness of MARPs programs, and encourage human rights advocacy and programming supplementing it with legal aide to the MARPs. Achieving this will require the Global Fund be more open to funding proposals outside of CCM channels, where it is clear that CCMs are acting as a barrier to effective programming. Proposal development process When preparing and submitting the Concept note the countries should have the opportunity to express the full demand and include all activities they consider critical for effective response to an epidemic. Countries should not be limited by a certain funding ceiling at this initial stage of the iterative process and should have an opportunity to negotiate programmatic and funding priorities within the indicative funding range and which would go into a competitive incentives stream. Nothing about us without us: Engagement in access to funding process The Global Fund has a commitment to multi stakeholder engagement in all its processes. While CCMs may have representation of key affected populations (KAPs), these groups may need additional support to ensure that, as beneficiaries, they can be fully engaged in the development, implementation, monitoring and evaluation of programming (particularly quality assurance). In particular, they should be included into and supported to participate meaningfully in the iterative process for funding applications under the NFM, as well as in the process of the grant renewals and reprogramming. Community ownership of responses to the epidemics can only be guaranteed within the country-owned proposal to the Global Fund if the proposed program is in full alignment with international guidance on human 5

rights. Otherwise, the Global Fund must resort to multi-country/regional and/or non-CCM proposals and invest in critical enablers to reach MARPs with prevention and treatment and build the capacity of CSOs and CBOs to advocate for national policies, practices and budget allocations that are inclusive of and respect the human rights of key affected communities. In order to ensure such an involvement, the Global Fund Secretariat should include into its Guidelines and Requirements for CCMs an additional requirement to include CCM members representing non- government sector into the CCM relevant working groups or committees responsible for the development of the grant proposals and to engage representatives of MARPs communities in the capacity of experts to participate in the work of such structures (the same concerns the CCM Oversight Committee). Country Fund Portfolio Managers (FPMs) and Local Fund Agents (LFAs) should ensure compliance. In order to do this, FPMs should be fully aware of the in-country situations with regard to the involvement of communities representatives in the relevant CCM processes, structures and establish closer contacts with CSOs and CBOs implementing Global Fund grants as sub and sub-sub-recipients, and those acting as independent watchdogs and advocates. CCMs should continue to implement the practice of collecting inputs/feedbacks from CSOs/CBOs and all other interested parties on the scope (priorities, interventions, allocations) of the country proposals to the Global Fund within the NFM in advance to the development of the proposal concept note. To achieve this CSOs/CBOs must be better informed about opportunities to provide their feedback and to take part in all the consultative processes related to grant development, implementation, monitoring and evaluation. Simple, transparent, clear and user-friendly channels of bilateral feedback and communication between CCMs and civil society/communities should be developed and introduced in countries. Also the Global Fund Secretariat and TRP must have the capacity to undertake country level dialogues on CSS, human rights, the Sexual Orientations and Gender Identities (SOGI) policy, gender issues, etc. and develop plans to address their respective gaps and weaknesses in expertise/knowledge/awareness etc. Significant investment in building this capacity is required. The Dual-Track Financing model should take priority, where appropriate, as civil society and the private sector can, and should, play a similar role as government structures in the implementation and oversight of grants at the country level. In many countries, the only way of achieving effective MARPs programming is to work through non-governmental implementers. The Global Fund Secretariat should enact the recommendations of the 2011 evaluation of the SOGI Strategy and work with partners to develop a specific action plan for people who inject drugs, ensuring that the Secretariat continues to support and protect the large portfolio of investments in harm reduction within the NFM.

Multi-country and regional proposals

Within the NFM the Global Fund resources must be accessible through the multi-country funding channel in the form of proposals from a Regional Coordinating Mechanisms or Regional Organizations, as a means to providing a less politicized and safer platform than at a country level on which to advocate for the needs of key affected populations (KAPs) severely underserved through national programs.

Regional projects and activities provide valuable opportunities for sharing experiences, developing networks of civil society and community based organizations, building the capacity of civil society and strengthening the community systems in countries that have common cultural, linguistic and historic values. Regional projects establish platforms for exchange of best practices and engage a broader range of stakeholders in activities that face barriers at country level. Regional proposals give a boost to advocacy for reform of national policies with account to international mechanisms and regional practices, which is crucial for most regions with prevalence of LICs or MICs. The principle of funds allocation for regional proposals should be clearly determined within NFM. When developing such principles SIIC should take into account that: - Multi-county proposals targeted at MARPs should have different and broader funding options from MARPs single-country proposals because these activities have different goals and operate at a much different scale, dealing with regional policy and advocacy, community mobilization as well as service development on the regional level including coordination and migration issues. - The determined funding amount for each multi-country/regional proposal should be within the same funding range for which at least 51% of countries included into the proposal are eligible for within their bands if they submit their own request for funding for that same component through a single-country application. Non-CCM proposals The Global Fund should maintain possibility for NGOs to submit non-CCM proposals. The non-CCM window remains an opportunity for groups marginalized as a result of stigma and discrimination in government policies. The Secretariat could better define key and vulnerable populations and determine eligibility of non-CCM proposals on the basis of the target population. Having an opportunity to submit non-CCM proposals is important for CSOs and CBOs in situations when: - governments fail to cooperate with NGOs or criminalize vulnerable groups such as MSMs, PWIDs or sex workers;

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CCMs refuse to include into the Global Fund proposals the activities, which are effective and of high impact and are in direct response to the country epidemic context, and proposed by community groups and NGOs; Government programs and policies for working with MARPs are associated with non-respect for human rights a country is currently in conflict, facing natural disaster or/and complex humanitarian emergency and there is no legitimate government in the country.

OECDs DAC list eligibility filter

According to the Global Fund Policy on Eligibility Criteria, Counterpart Financing Requirements, and Prioritization of Proposals for Funding from the Global Fund UMICs not listed on the list of recipients of Official Development Assistance (ODA) of the Organization for Economic Co-operation and Development (OECD) recipients are ineligible to apply for funding for HIV and AIDS proposals except if the application is submitted by a non-governmental organization (NGO) within the country in which activities would be implemented and for which the government of such country shall not receive any funding. Being not listed in the OECD DAC list should not be a barrier for any country to apply for the Global Fund HIV grants. There is no such requirement for TB or Malaria grants and it is not clear at all why it should exist for HIV grants. NGO rule If the OECDs DAC filter remains within the NFM, the NGO rule should be retained too. NGOs should have an opportunity to submit CCM/non-CCM proposals targeted at MARPS if their countries are not listed on the OECDs DAC list of official development assistance recipients and therefore are not eligible to apply for Global Fund funding for HIV, and if these countries do not support MARPs programs within their national health budgets at an appropriate level. This will allow such countries as Russia, Lithuania, Bulgaria and starting from 2012 Latvia to effectively address the HIV concentrated epidemics among MARPs in these countries. The principle that NGO rule overrides the G-20 rule, which states that G-20 upper MICs with less than an extreme disease burden, are not eligible to apply should also remain.