PUNISHING

SUCCESS
Impact of the new Global Fund Business Model and Eligibility Criteria on the MENA Region

Only two percent of the total estimated number of people living with HIV reside in the Middle East and North Africa region. This can be a relief for us. Yet, recent estimates show that it is one of the two regions with the fastest growing epidemics. Insufficient commitment, stigma, discrimination, and inappropriate laws continue to obstruct work with people livin with HIV and people on the margins. The relatively small number is our window of opportunity. We need to act quickly before demand exceeds supply. We must redouble our efforts to ensure countries meet their goals towards Universal Access to HIV prevention, treatment, care and support. Stronger political and societal determination will bring the change needed in the Middle East and North Africa region. () Michel Sidib -UNAIDS Executive Director -Under Secretary-General of the United Nations UNAIDS Mena Report on AIDS, 2011

November 2012

How to reconcile the Global Fund success in the Region with one hand and yet punish MENA countries for that success with the other? This advocacy brief was commissioned by the CSAT MENA Hub1 to highlight concerns that the New Funding Model of the Global Fund raises for the Middle East and North Africa (MENA) Region. on a rapid analysis in two countries - Morocco and Tunisia - including documentation review, face to face interview with more 30 major stakeholders in the 2 countries an d at regional level (UNAIDS MENA regional support team - UNAIDS country office - CCM chair - National Aids programs - PR & SR NGOs - KAPS - PLWA), and on-line survey distributed to more than 50 civil society actors in Morocco and Tunisia2, this paper, gives a brief overview of the MENA Region, looks at the positive benefits of Global Fund support to the Region and discusses the inherent weaknesses in the Banding process and makes recommendations for nuancing these processes to ensure the MENA Region is not punished for its success. From these interviews we are able to ascertain the significant impact the Global Fund investment has had on the disease response in the region and the improvement in peoples lives. The time pressure this work has been realized in October, following the Twenty-Seventh Board Meeting (13 sept. 2012 - 14 sept. 2012) - and resource limitations made it impossible to cover more than two countries for this work. We strongly believe that this short analysis should be built upon and a larger study commissioned to cover the whole Region. We faced different problems regarding TB. It was simply the lack of available information and critical mass of people with which to engage that created problems. We acknowledge this but it should not detract from the strength of the information in this Paper. Opinions expressed in this publication are those of the author(s) and expert(s) and do not necessarily reflect the views of CSAT Global, its management, staff, partners or donors.

Summary recommendations
In an ever-changing world of shifting economic paradigms, greater understanding of effective disease response and management, and the maturation of the organisation, the Global Fund has to evolve. The NFM is a significant stage in that evolution. This we do not challenge but the structure, formulae and implementation plans and processes raise many issues and concerns for the MENA Region. The NFM in its current iteration by the SIIC that will be presented to the Global Fund Board for a decision at its November Board Meeting holds little encouragement for MENA countries unless important modifications are made. As can be understood by this document there is really only one conclusion we can come to regarding the NFM as presented in the SIIC Decision Points. The current iteration of the NFM is not acceptable for MENA, because the risk that all the progress made will be undermined and set back or reversed is too palpable.
1

http://www.csactionteam.org/

Improving the performance of Global Fund grants : CSAT will help civil society organizations with project proposals and implementation through brokering technical support and coordinating advocacy nationally, regionally and globally.
2

http://csatmena.org/surveys/spip.php?article1

We need guarantees and appropriate Board decisions on our main recommendations listed below, before any support can be given. v Clearly the process for deciding Country Bands is inadequate and the criteria MUST be modified and nuanced to provide more accurate country profiles v Willingness to pay MUST be included despite the misgivings of the Secretariat whose claims regarding the degree of difficulty in assessing this seem weak. Using a probability matrix, whilst not a perfect solution, would address the issue during the interim period until an acceptable permanent solution is devised v The process of developing the criteria for the Targeted Band MUST include Civil Society and representatives of key affected populations from the MENA Region, in particular on the issue of qualitative criteria. The amount of funding allocated to the Targeted Band MUST be a minimum 10% v The definition of Good Performance needs to be re-visited in the context of the requirements of the NFM so that evidence of the catalysing effect the Global Fund has had on many important areas in the Region is not lost or ignored v The Secretariat MUST be instructed to ensure appropriate representation from Civil Society and KAPs during the Iterative Dialogue processes, essential for building on progress in the MENA Region v The NFM must be made more explicit how the SOGI, GES and Human Rights strategies will be incorporated in the NFM v Sufficient funding must be made available to preserve ambition and incentive v The NGO rule must be strengthened to cover all three diseases and the facility for non-CCM and Regional proposals must be made explicit. These areas need to be addressed, as they would have a significant impact on the effectiveness and equity of the NFM. The responsibility now lies with the Global Fund Board and we urge Delegations to make the right decision in November and insist that the changes articulated in our recommendations are acted upon.

PUNISHING SUCCESS: Impact of the new Global Fund Business Model and Eligibility Criteria on the MENA Region.

Recommendations Willingness to pay probability criteria Nuance the criteria for deciding Country Bands Broaden scope of Targeted Band to go beyond essential services Ensure Critical Enablers and CSS funding is preserved for U-LMIC and UMIC Re-define Performance in the context of the NFM Ensure the Incentive envelope is properly resourced The CCM MUST remain as the central platform for proposal development and grant oversight and its essential role in facilitating CS and MARPs critical, formal involvement in the Iterative Dialogue process. Operationalising of the SOGI, GES & Human Rights Strategies must be made explicit The NGO rule to be expanded to include TB & Malaria or the OECD DACs filter eliminated

Rationale & Background

Once these have been agreed I will insert at the appropriate place in the text as well.

Historically the debate regarding Country Eligibility for Global Fund has been around since 2007.The Portfolio Committee of the Global Fund, during the 15th Board Meeting (April 2007)3 was requested to comment and to recommend changes to the eligibility criteria (based on the summarised criteria listed below) that are designed to restrict access to funding for HIV and TB responses in Upper Middle Income Countries. The criteria are: 1. Prevalence in the adult population is at or above 1%, or prevalence in at least one vulnerable population is at or above 5%; 2. Presence of appropriate levels of counterpart financing or domestic investments; 3. Countries must be on the OECD list for Official Development Assistance. The bottom line is that the combination of these criteria would exclude a significant number of MENA countries from Global Fund assistance, and that these criteria systematically discriminate against vulnerable populations (people who use drugs, sex workers, men who have sex with men, prisoners, minorities) who in low prevalence settings are at significantly increased risk of infection with and the transmission of HIV and or Tuberculosis. Deliberations and discussions continued until in November 2011, when the Global Fund Board decided that 55% of its funding commitments in any given year should be allocated to low-income countries4. The Board had previously agreed a range of measures to guide resource allocation to middle-income countries including capping funding to upper middle-income countries at 10%, counterpart financing 5 and a Most at Risk Populations (MARPs) channel. 6
3 4

GF/B15/DP35 Modification of Grant Renewals and Transition to New Funding GF/B25/DP16 5 Decision Point GF/B23/DP23

In order to implement the 55% funding allocation decision, the Board Chair announced in February 2012 that he had decided to cap phase two renewals at 75% of TRP-approved totals for all upper lower-middle income countries and upper middle income countries7. This process, alongside other factors, has eventually evolved into the development of a New Funding Model for the Global Fund. The New Funding Model (NFM) should be consistent with the Global Fund Strategy, to allow the Global Fund to invest strategically and ensure an appropriate focus is placed on countries with the highest disease burden and least ability to pay, while retaining the global reach of the Global Fund. The new model will aim to foster predictability of process and financing, align with country-level schedules and priorities, create efficiencies and simplify the grant making and approval process, and allow for a full expression of quality demand. The new model should enhance participation by all stakeholders, including civil society, and will support continued funding for key affected populations8. As a part of operationalizing the new funding model The Global Fund proposes the establishment of Country Bands. The New Funding Model (NFM) will group eligible countries using a bands system. The system is based on the principle of whether a country can afford to pay to address the diseases and whether the burden of disease is high. Countries will be eligible for types and size of funding that is in some way related to the band that they are determined by the Global fund Secretariat to be in. But can GNI and disease burden truly be trusted to provide enough accurate data for strategic decision making affecting hundreds of thousands of lives in the MENA region? The criteria that establishes Bands is still to be determined. But the criteria needs to go beyond the ability to pay and burden of disease and consider other factor such as the willingness to pay; footprint of the Global Fund in the country; building on success (such as low HIV prevalence) and other investments. If not then MENA countries will be severely prejudiced against under the NFM. A wealth of research shows that the best way to protect a society within concentrated epidemic to more generalized epidemics is to aggressively invest into large-scale prevention campaigns among vulnerable populations before prevalence among them reaches 5%. Has the fluid complexities and interdependence and interaction within communities been ignored as the aim of simplicity and high impact results takes precedence over building on progress and contributing to long-term sustainability? One of the possible dangers of the NFM, should it be adopted, is that MENA countries with low prevalence among vulnerable populations would not be eligible, for example, for funding for prevention efforts, but would become eligible only when the absence of prevention has led to prevalence levels of 5%.
6

GF/B21/DP18 B25/ER/05 GF/B27/DP7 Annex 1

Domestic spending for HIV prevention in upper-middle income countries is low The proposed banding and eligibility criterion disregards fundamental realities about the nature of countries ability to pay and ignores successes that have been achieved: while investments do take place, they are normally not adequately directed towards the health sector and within the health sector, HIV and TB are generally low on the agenda, because other, more prevalent diseases require more attention. Ministers of Health struggle for their budgets and pressure groups that could argue for attention to HIV and TB are weak. At the same time, those with the biggest needs for HIV prevention (key affected populations such as people who inject drug, sex workers, men who have sex with men, prisoners, and minorities) have the weakest representation and lobby. Low Level Strategic Oversight and Decision Making The proposed banding and Income Based Eligibility Criteria, the 55% rule and the capping at 75% Phase Two renewals appear to be inconsistent with the Global Funds own Strategy Framework 2012-2016 Investing for Impact, and the UNAIDS led new Investment Framework for HIV9. The Global Fund Strategy Framework highlights the Investment Framework and lists prevention services for KAPS as a key indicator. However, if we look very briefly at the Aims of the Investment Framework, in the context of the NFM, it is apparent that, in its current iteration, the NFM requires more lot work and thinking through of important issues. The aims of the Investment Framework are: Maximise the benefits of the HIV response. It is hardly strategic for the Global Fund to punish MENA countries for their success in keeping HIV prevalence relatively low by restricting access to the very funding that has enabled them to achieve this. Support more rational resource allocation based on country epidemiology and context. The Global Fund Banding and Eligibility Criteria based on a countries income and disease burden, which ignores context and successes, is contradictory with its own mantra of Investing for Impact. Encourage countries to prioritise and implement the most effective programmatic activities. The Global Fund decisions will act as a disincentive in countries where the legal and cultural environment already makes working with certain vulnerable populations problematic. Increase efficiency in HIV prevention, treatment, care and support programming. If the health sector receives limited priority in Upper-Middle Income Countries and if within their health sectors HIV and TB has low priority, then the net effect will be that entire populations will be left without attention, care and support. These groups are exactly those that due to discrimination and stigmatization are excluded from access to health care in a great many countries.

UNAIDS Issues Brief 2011 A New Investment Framework for HIV Schwartlander et al.

Brief Regional Overview MENA is one of the top two regions in the world where new HIV infections and AIDS related deaths, continue to rise
The MENA Region10 is geographically, culturally, politically and economically diverse. It has the smallest population of all the Global Fund regions, being home to around 350 million people. Although the overall HIV prevalence in the MENA region is still low, the rise in new infections in 2011 has put MENA among the top two regions in the world with the fastest growing HIV epidemics, with Eastern and Central Asia region. The epidemic in this region is primarily concentrated among people who use drugs, men who have sex with men and sex workers. Recent Modes of transmission studies in Iran, Tunisia and Morocco11 and repeated rounds of bio-behavioural surveys in countries such as Egypt, Morocco and Tunisia have supported this assumption.12 In 2010, there were 84,000 [57,000-130,000] new HIV infections and 39,000 [28,000-53,000] AIDS- related deaths in the Middle East and North Africa region. The annual estimated new HIV infections and AIDS-related mortality has almost doubled in the past decade. The estimated number of adults and children living with HIV in the region increased from 330,000 [200,000-480,000] in 2001 to 580,000 [430,000- 810,000] in 2010. In 2009, 500,000 cases of TB were reported and in 2008 4,300 cases of MDR TB were also confirmed. While countries have increased provision of antiretroviral therapy (ART) by 25% in 2010, the total regional coverage remains low, with only 8% of eligible people living with HIV accessing treatment in 2010. Achieving regional targets for ART access mainly relies on countries to scale up their national treatment strategy, together with serious commitment to expand HIV testing and counsellig. UNAIDS projections for the next five years show that a rapid increase in treatment coverage to 80% could save the lives of more than 32,000 individuals, averting 62% of expected deaths due to AIDS by 2015. Even if the antiretroviral therapy provision increases from its current level to 50% of those eligible for treatment, 25 000 deaths can be averted in 201513. HIV remains a highly stigmatized health condition in the region and, in many settings, stigma and discrimination and punitive laws are preventing affected communities from accessing the HIV services they need. In their 2010 UNGASS country progress reports for UNAIDS, only 4 of the 24 MENA states reported having protections for one or more vulnerable or marginalized population; on the contrary, 11 countries reported having laws, regulations or policies that present obstacles to effective HIV prevention, treatment, care and support to vulnerable or marginalized groups. The criminalisation of drug use and sex work further complicates the delivery of HIV interventions in some countries. Male-male sexual relationships remain illegal in at least 13 of the countries and territories, four of which regard such relationships as capital crimes. In addition, eight countries from the region have retained laws that make drug offences (such as possession or supply) punishable by
10

Mena region: Afghanistan, Algeria, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Occupied Palestinian Territories, Qatar, Saudi Arabia, Somalia, North Sudan*, South Sudan*, Syria, Tunisia, United Arab Emirates and Yemen 11 National Sentinel Surveillance Report, Morocco. 2010 - Integrated bio-behavioural survey among men who have sex with men, Morocco, 20102011 show a prevalence of 5,6% for MSM (southern part) & 17,9% for PUD (northern of Morocco) / Tunisia: 13% for MSM (2011, report to be published) 12 Abu-Raddad L, Akala FA, Semini I, Riedner G, Wilson D, Tawil O, et al. Characterizing the HIV/AIDS epidemic in the Middle East and North Africa: Time for Strategic Action. Middle East and North Africa HIV/AIDS Epidemiology 13 UNAIDS MENA Report on AIDS 2011 Morocco coverage: 30% / Tunisia coverage: 10%

death14. Tuberculosis is the leading HIV-associated opportunistic infection in low and midde income countries, and is a leading cause of death among people living with HIV globally. Although antiretroviral therapy is shown to reduce incidence of tuberculosis, the percentage of co-infected patients that are receiving treatment is low in most countries of the region. Few countries in the region have a framework for TB/HIV collaborative activities. Again, the challenge for most countries to improve the coverage of tuberculosis and HIV co-treatment is directly related to the marginalized populations most in need of the services. Large scale population movements also present a challenge to the effective delivery of health services. Due to its location at the intersection of Africa, Asia and Europe, and the conflicts happening, the region is criss-crossed by major trade and migratory routes, leading to extensive migration and high population mobility, including refugees. 15 Key challenges to scale up AIDS programmes among key populations at higher risk of HIV still remain. The low coverage is a contributing factor to the limited HIV knowledge and high levels of risk behavior within these populations. There are also other populations in the region at heightened risk to HIV that do not have adequate access to effective prevention programs, including prisoners, and mobile and migrant populations such as truck drivers, seafarers, uniformed services, migrant workers, and refugees and displaced persons. The settings in which these populations live give rise to behaviours strongly associated with increased HIV risk, and pose barriers to access to services. In addition, the MENA region has a rapidly growing population of young people between the ages of 15 and 30. In many countries in the region, more than 20% of the population falls into this age bracket. In 2008, the MENA region had the highest percentage of young people who were looking for a job as well as the lowest percentage of young people who were participating in the labour force, compared to the rest of the world. The social dynamics facing young people in the region does creates some increased levels of risky behaviours and greater likehood of HIV transmission16. A complex set of cultural, economic and social factors make women across MENA especially vulnerable to HIV. Female unemployment rates are at least double those of men across the region, economic insecurity increases womens vulnerability to HIV, condom use is rare, both within and outside of marriage and a significant proportion of women experience gender based violence, both at home and in public places. Stigma and discrimination is even fiercer against women living with HIV than against men because of societal expectations of female behaviour and a popular association between infection and illicit practices, such as sex outside of marriage and drug use. Women across MENA are hemmed in by restrictionspolitical, economic, social and culturalthat limit their scope and indirectly increase their vulnerability to HIV on many fronts. It is unclear how the political upheavals that began this decade will change that. 17
14 15 16

How Laws and Policies Affect the HIV Response - UNAIDS PCB NGO Delegation Report -2011 Making a Difference: Middle East and North Africa. Global Fund Regional Results Report 2011

Facts of life : YOUTH SEXUALITY AND REPRODUCTIVE HEALTH IN THE MIDDLE EAST AND NORTH AFRICA BY Farzaneh Roudi-Fahimi AND Shereen el Feki. Population Reference Bureau 2011 - www.prb.org/Reports/2011/facts- of-life.aspx. 17 Standing Up Speaking Out. UNAIDS: Women and HIV in MENA 2012

If you ask people in MENA to put a face to HIV, it is, invariably, a mans. And no wonder with a few notable exceptions, men account for more than three-quarters of known infections in most countries in the region. But these are the officially reported cases: behind them lie hundreds of thousands of undetected or unregistered infections. Among these are the regions most vulnerable peoplethose who, because of personal circumstances or sociocultural constraints, do not come forth for testing or treatment, conditions which leave them open to infection in the first place. This hidden epidemic has distinctly female features: according to UNAIDS estimates, women account for more than 4 0% of adults thought to be living with HIV in the region.
Standing Up Speaking Out. UNAIDS: Women and HIV in MENA 2012

However there has been significant policy development and scale up of programmes indicating an increased political will in the region to address the AIDS epidemic. The majority of countries in the region have put in place national strategies to address AIDS and some have initiated programmes for key populations at higher risk, including sex workers, people who use drugs and men who have sex with men. Civil society organizations are now playing a more prominent role in the HIV response compared to just a few years ago18. One of the key challenges facing CSOs that want to scale-up programs is the need for the tools and training required to work effectively with key populations at higher risk, and the support from international donors. In the MENA region, these associations do not have the staff and financial means to sustain their work. They also often face significant and persistent stigma and discrimination within their local communities, which means their outreach work can come with considerable personal risk and makes the path towards realization of positive health, dignity and prevention for all people living with HIV in the region even longer19. Given the gaps in HIV data, and HIV testing, particularly related to key populations at higher risk, it is likely that the scope of the HIV epidemic and its impact in the region continues to be underestimated. The perception of low prevalence in the Middle East and North Africa Region obscures the urgency of meeting the challenge of preventing and mitigating the impact of the epidemic, especially among key populations at risk, and hampers the achievement of universal access by diverting traditional donors attention and support20. Global Fund in the Mena Region There is a large divergence in wealth across the region; with Bahrain and Oman considered High Income countries while an estimated 51 million people across the region are living on less than US $2 per day. Finally, funding for HIV prevention is an issue across the region, regardless of a countrys economic status. Based on data supplied by the countries as part of their global reporting, it is clear that the amount of funding allocated for prevention is not sufficient, particularly among
18 19

UNAIDS MENA Report on AIDS 2011 Abu-Raddad L, Akala FA, Semini I, Riedner G, Wilson D, Tawil O, et al. Characterizing the HIV/AIDS epidemic in the Middle East and North Africa: Time for Strategic Action. Middle East and North Africa HIV/AIDS Epidemiology 20 Investing in Universal Access HIV Prevention, treatment, care and support in MENA. UNAIDS June 2010

countries that can afford to increase their domestic spending on HIV prevention21. The percentage of the total budget funded from domestic public resources ranges from 1% (Afghanistan), to Morocco (60%), up to 100% (Kuwait), although the majority of countries rely on international funding. For many countries, including those with the financial capacity to support an expanded response to HIV, the problem appears to be one of resource allocation, both in terms of governments willingness to provide funding and to allow public health experts to use those funds where they would be most effective. Without the necessary political leadership and political will, it is likely that critical programmes in these countries will not receive sufficient funding to make a significant impact on the spread of HIV. The Global Fund to Fight AIDS, Tuberculosis and Malaria is the largest source of external funding in the region, which represents up to 70% of the overall support22. There are 50 grants currently in progress across the region: 21 HIV, 18 TB and 11 Malaria grants23. KEY RESULTS IN MIDDLE EAST AND NORTH AFRICA - 201124

__________________________________________________________________________________ The total amount of approved funding for the region is: US$ 1,665, 128,503 across the three diseases. The amount of funding dispersed (this represents actual payments made by the Global Fund to recipients) is: US$ 1,066, 905, 437.
21

Abu-Raddad L, Akala FA, Semini I, Riedner G, Wilson D, Tawil O, et al. Characterizing the HIV/AIDS epidemic in the Middle East and North Africa: Time for Strategic Action. Middle East and North Africa HIV/AIDS Epidemiology 22 UNAIDS MENA Report on AIDS 2011 23 MENA Key Results The Global Fund. September 2012
24

GFATM Making a Difference - MENA Regional Results Report 2011

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Breakdown of disbursed funds by disease and year since 2003.

For the MENA region, a total of $578 million has been approved for HIV that is 6% of the Global Fund portofolio. Of this total, 55% of the funds have been dispersed. HIV proposal success rates have increased from 28% on average to 44% in Round 10, with four of nine eligible proposals being approved (two of the three MARPs proposals were approved). Round 10 approved funding for the MENA region totals $117.3 million. All 42 grants are performing well, with no grants rated unacceptable. As a result of GF funding, between 2002 and 2010 - 204,000 lives have been saved, and by 2010 - 73,000 people will be receiving anti-retroviral treatment. The Middle East and North Africa Region has the smallest share of the Global Fund HIV portfolio, receiving 5 percent of the cumulative approved funding between 2002 and 2009. This share reflects both the size of the region and the relatively low disease burden there, but it also indicates the ongoing local challenges of demand mobilization and capacity building. Despite challenges, great results have been achieved with this amount of money. At the 6th Regional Meeting for MENA, 2009 in Jordan Dr Daniel Low-Beer in his presentation on Global Fund Financing and its Impact stated: Over the last year there has been a marked increase of between 39-52% in people reached by services of ARV and DOTS treatment (for TB) as well as insecticide treated bed nets. By the end of 2008, Global Fund supported interventions in the region have kept 2,000,000 people on ARV treatment for HIV/AIDS, 4,600,000 people treated under DOTS for TB and 70,000,000 insecticide-treated nets distributed to prevent malaria. He concluded with: The Global Fund provides a model to save lives and for achieving the MDGs. HIV prevention has to be strengthened by scale, focus on groups at risk and involvement of communities need to be built into the processes.25

The Global Fund crucial Investment in the MENA Region: a window opportunity
As illustrated there has been significant investment in the region from the Global Fund but it is important to understand what the consequences of this investment has been. MOROCCO AND TUNISIA SNAPSHOT - 2011 Morocco Tunisia

25 The Global Fund Meeting Report 6th Regional Meeting for MENA 21-23 April 2009 Amman Jordan

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Population Human development index GDP per capita Number of PLWA Income level Number of people living with HIV receiving ART Prevalence key affected population

32,4 millions Medium 2,739 $ 29 000 Lower middle income 4047 5,2% PS (South) 5,6% MSM (south) 22,5% IDU (North)

10,4 millions Medium 3,876 $ 2400 Upper middle income 483 0,61%PS 13% MSM 2,4% IDU 10% Round 6=16,1millions$ NC

Treatment coverage Global Fund Grant Amount pledged Share of HIV expenditures from domestic sources

30% Round 1/Round 6/Round 10= 55,932 millions$ 51,3%

Stimulation of a comprehensive disease response, involving a variety of actors Morocco Since the appearance of the first AIDS cases in Morocco (1989), the National AIDS Control Programme was set up, followed just a few years later by the first associations to fight AIDS. The Morocco CCM, was created in 2002, to oversee proposal development and oversight of Global Fund Round 1 grant application. The first comprehensive long term National strategic plan is the result of a strategic planning process initiated in April 2000, which has mobilized all departments and NGO actors, and was the basis for the first Morocco GF Proposal. Prior to the Global Fund investment, there was limited attention paid to HIV and TB and National investment in HIV treatment, care and prevention was a very low priority.26 The first Global Fund HIV grant to Morocco, in Round 1 (2002), focused mainly on reducing vulnerability to HIV and mobilizing public awareness and support, particularly among women and young people, in order to maintain the low prevalence in the country (estimated to be below 0.1 percent). An additional HIV grant from the Global Fund in Round 6 (2006) aimed to strengthen and expand interventions for vulnerable population groups. These two grants, with support from partners such as the Joint United Nations Programme on HIV/AIDS (UNAIDS), have helped to plug gaps in the national response to HIV and will soon be complemented by an approved Round 10 grant). The HIV proposal to Round 10 is aligned with the objectives of the national strategy to control AIDS and will enable Morocco, to ensure universal access to a package of services for the prevention of HIV for populations most at risk and treatment for people living with HIV. Furthermore, the coverage of the needs of bridge and vulnerable populations through information and services in the prevention of HIV and reproductive health, will have been significantly extended27.
26 27

Unaids Coutry Office, Morocco Round 10, Morocco proposal

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Tunisia In Tunisia, the political commitment to the fight against HIV/AIDS has been evident since 1987, when the PNLS/MST, part of the CNLS (1992), was created, with its Secretariat (Directorship of basic health care services - DSSB) and its technical committees28. Tunisia developed has first developed a short- term action plan realized by MOE and its partners. But the first comprehensive national strategic plan came in 2006, with the preparation of Global Fund Round 6. Tunisia has a low HIV prevalence of 0.1 percent among the adult population, but is higher among KAPs. According to 2011 sero-behavioural surveys, prevalence is around 13% in MSM29. The strategic plan 2011-2015 includes plans to strengthen programmes and intervention coordination among KAPs, notably by integrating the strategy for the reduction of risks associated with injectable drug use, which is currently being finalised. The GF program supported by grant 6 aimed to reduce sexually transmitted infection and HIV transmission among groups with high risk behavior; strengthen the prevention of sexually transmitted infections and HIV and AIDS preventive measures among vulnerable groups; improve the quality of life for people living with HIV and their families through better access to adequate and complete care; and implement a national monitoring and evaluation system related to sexually transmitted infections and HIV and AIDS. The program targeted people living with HIV and their families; young people in school and out of school; most at-risk populations, such as men who have sex with men, prisoners, commercial sex workers and their clients and injecting drug users; pregnant women; and frequently mobile groups30. The advent of the Global Fund in both countries has significantly increased the attention paid to the diseases and to HIV in particular. The Global Fund multi-sectoral approach has been a catalyst for achieving important collaboration, and has facilitated high-level political engagement, the involvement of Religious Leaders, as well as representation from previously unrecognised or accepted vulnerable populations. Collaboration and coordination among the different organisations and agencies has increased facilitating a more comprehensive disease response, there has been a general improvement in transparency and accountability and countries and organisations have become more aware and involved in the international response to the three diseases31 . Due to Global Fund requirements and the availability of additional financing, countries have been able to develop and to fund comprehensive National Strategic Plans to combat the diseases, with ambition to have a real and sustained impact32. Global Fund made the difference, gathering people around vision and ideas that could be operationalized. National budgets have increased, although the ambitions within many National Strategic Plans remain dependent upon continued Global Fund Financing33, which still represents more than 80% for activities targeting KAPs. Access to treatment Morocco
28 29

Director of CCM Tunisia UNGASS country report, Tunisia. 2011 30 Round 6, Tunisian proposal 31 Association of PLWA, le Jour, Morocco 32 National Aids Program, Morocco 33 National Aids Program, Morocco

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Before Global Fund, in Morocco there was a waiting list for access to ARV treatment, based on strict eligibility criteria: when one person died another person could take that place on the ARV treatment programme34. The first generic versions of ARVs were introduced in the country in 2003. Today, most ARVs used are generic. Efforts to reduce costs are made on an on-going basis by the Ministry of Health, together with NGO, which has benefited from favourable international opportunities for price reductions, due in part to the additional purchasing power derived from Global Fund grants, have initiated negotiations with the pharmaceutical industry and steadily, generic competition has lowered the cost of treatment significantly year after year. In December 30, 2011, the number of people living with HIV receiving antiretroviral therapy in Morocco was 4047, whereas it was only 2647 in 2009. A significant increase in treatment coverage has been recorded since 2006. The number of people receiving ART doubled between 2006 and 2009. A recently completed estimate, based on new WHO recommendations gives a coverage rate of 28% for Before Global Fund support, treatment in 2010 using as a criterion for the initiation of treatment with 35 people did not want to be CD4 counts less than 350/mm3. Tunisia Tunisia has had free access to ART since 2000, thanks to the Access initiative. Before this, there were waiting lists and strict eligibility criteria. Civil Society advocacy with the government enabled this to happen. Since then, and with the scaling up made possible with the Global Fund financial support, the prices have been reduced by 70% and national guidelines have been developed36.

tested, as they were afraid not to receive treatment. Global Fund changed our life. Finally, there were hope PLWA in Morocco.

Global Fund helped Tunisia to take measures expand of the list of available antiretroviral drugs, the development of national guidelines on antiretroviral therapy, biological monitoring of PLHIV, the creation of support groups for people living with HIV, the establishment of a national psychosocial support for PLHIV with access to income-generating activities and involvement of PLHIV in the national response through the training of health mediators that helps some PLWA for treatment adherence37. 1st line ARTs treatments are purchased with MOE budget and those of the second line with the support of the Global Fund. At the end of 2011, the number of patients under ART was 483. A recently completed estimate based on new WHO recommendations gives a coverage rate of 10% for treatment in 2011, using as a criterion for the initiation of treatment with CD4 counts less than 350/mm3.38 This low percentage is due, among others reasons, to the fact that the majority of people living with HIV do not know their HIV status39.

34 35

Association of PLWA, Le Jour, Morocco Missing the Target North AFrica report, to be published, end of 2012 36 Director of CCM Tunisia 37 National Aids program, Tunisia 38 Missing the Target North AFrica report, to be published, end of 2012 39 Ungass report 2010-2011, Tunisia

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Treatment availability and access to HIV and AIDS treatment has been massively scaled up. But it is not simply treatment availability that has improved. Procurement and Supply Management systems have been developed, put in place (where none existed) and professionalised40. Health and community systems were strengthened, as well as Co-ordination of services and responses stopped, with most relevant departments and agencies, local, national and international operating in silos41. Due to Global Fund requirements, countries have been able to use the leverage of the purchasing power, derived from Global Fund financing, to negotiate cheaper drug prices, enabling scale up to happen more rapidly. MSM programmes The most visible and significant impact of Global Fund support in the region has been within KAPS. Any work with KAPS was through self-funded INGOs or bilateral donors42, either in Tunisia or in Morocco. 43, with the consequence of frequent interruption of the program, which operates only in one or two cities. Men who have sex with other men (MSM) were not recognised as an identity group and although there was some availability to condoms, access to lube was none existent. Only one NGO in Morocco was working with MSM and they operated on limited, self-raised funding44. For Sex Workers (SWs) the picture was depressingly similar and only in Morocco through funding from Mdecins Sans Frontires was any services for SWs available in one city.45 Prevention programmes were limited to sensitisation and fostering dialogue about HIV and AIDS and some condom distribution, all aimed at the general population46 Key affected populations (KAPS) were fundamentally invisible to Governments and to the general populations and their health and social issues and rights were not a consideration. The aspiration to be represented in meetings and discussions that were making decisions directly impacting on their lives was non-existent47. With Global Fund support, prevention programmes have been initiated, where none existed before and existing programmes scaled up to include not just the general population but also through the education system and with a focus on vulnerable populations. It has played a major role in encouraging SRHRs organisations to prioritise HIV and AIDS within their strategic planning48. Programs targeted KAPS are increasing and importantly MSM are
40 41 42 43 44 45

Lube was completely non- existent in the country. Now lube is available for MSM. Not only we can buy it, but we were at the origin of the creation of a specific code for import at the Custom administration ATL Director, Tunisia

PR Global Fund Grant, Morocco Development association, AMSED, Morocco International HIV AIDS Alliance in Tunisia, UNAIDS for Morocco UNAIDS Country Officer - Morocco

MSM program national coordinator, ALCS, Morocco Female sex worker national coordinator, ALCS, Morocco 46 Family planning association, AMPF, Morocco 47 MSM focus groupe, Morocco 48 Association of development, AMSED, Morocco

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increasingly recognised as an identity group and this is making a huge difference in both accessing essential services and also in self- respect, although legally, for many, the environment remains precarious49. In Tunisia, the MoH, with the support of UNAIDS and NGOs have carried out researches on Sex workers, and MSM populations, thanks to the Global Fund support, something unthinkable previously. This enabled the generation of critical data to use for advocacy and for understanding the HIV prevalence among MSM, which reached 13% in the last 2011 IBBS survey50. This work facilitates understanding of what needs to be done and is vital for scaling up programmes51. MSM issues are now routinely included in National Strategic Plans. Programmes for SWs have also seen an impressive scale up through Global Fund financing. In Tunisia, ATL NGO programmes now provide services to 2,300 FSWs in two cities, both funded 100% through Global Fund grants52. In Morocco, ALCS provide services in 25 cities working with SWs, including on legal issues, violence prevention, abandoned children and working with the Police53. None of which would exist, on such a scale, without Global Fund financing. For people living with HIV and AIDS (PLWAs) there has been a significant improvement. HIV+ people now have renewed hope, which has positively impacted on their quality of life and the number of people receiving ARV treatment has increased incrementally across the Region. The availability of treatment has been the catalyst for increased testing which in turn has improved surveillance and enabled more accurate planning of services and national budgeting. In Morocco, national testing days are funded through the Global Fund grants, and more than 44 Testing and counselling centers in Morocco, and 19 in Tunisia, realized respectively in 2011, 55 451 test and 8 000 test 54. Global Fund financing has enabled more consistent and professional support networks, an essential component of living effectively with HIV and AIDS. Associations of PLWAs have been created, thanks to the encouragements of Global Fund to countries.55 PLWAs have representation on CCMs increasing visibility and helping to combat stigma and discrimination as well as being able to contribute to decisions affecting their lives56. There are now 4 organisations of PLWAs in Morocco where there was none prior to Global Fund financing. In Tunisia, the revolution made possible the registration in 2011 of the first PLWA association57.

49 50

MSM focus groupe, Tunisia Ungass report, Tunisia 2010-2011 51 Director of Aids NGO, ATL, Tunisia 52 Director of Aids NGO, ATL, Tunisia 53 National Coordinator NGO Sex Work Programmes, ALCS, Morocco
54 55

MTT North Africa, to be published, 2012 Association le Jour, Morocco/ Association Rahma, Tunisia 56 Association of PLWA, le Jour, Morocco 57 Support group of PLWA, Tunisia

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For people who use drugs the Global Fund has been a catalyst for the advent of Harm Reduction and substitution therapy programmes and these have been integrated into National Plans. In Morocco there is a specific Harm Reduction Strategy within the National Strategic Plan itself and in Tunisia, the work is in Countries could never progress as the HRS is under approval58. Substitution therapy was succeed if left alone, as introduced 2 years ago (2010) in Morocco, and is the only programme they have never really been outside of Iran and Lebanon in the Region to offer this. In Tunisia the only harm Reduction and needle exchange programmes are those funded through Global Fund grants59. Before, some NGOs began working on drug centres, but the Harm Reduction strategy came with Global Fund60. A Critical platform, the Country Coordinating Mechanism
very supportive for civil society. Investing in such countries is very cost effective. If we dont do it now, we will have to manage a crisis later. CCM

It is not simply Global Fund financing that has been and continues to be important to the Region. The Global Fund structures and As a person who uses drugs, requirements have catalysed multi-sectoral and collaborative the Global Fund helped us to have dignity as human working; the CCMs are important and influential platforms that beings.this is a lot IDU enable coordination, transparency, representation from specific Tunisia. identity groups, provide accountability, benefits that go beyond Global Fund related work. Ministers became a actor like another one, and civil society were able to become chair of CCM, which changed the balance of power.61The involvement of communities in processes has led to increased reach into rural and semi-isolated villages building trust and contributing to increasing the capacity of these communities to develop their own local responses. It has enabled integration into the global response, raising awareness of what is happening at international level as well as at national levels. It has strengthened health and community systems and helped countries develop norms and standards in diagnostics, treatment, surveillance, training and monitoring and evaluation. It has allowed for the expansion of programmes across the countries rather than limited to small projects based in a few cities. The emergence of the Global Fund has provided both the means and the incentive to make significant and important changes to this rather bleak environment in the Region. Although the situation is far from perfect the changes facilitated by the availability of Global Fund financing have been important and for many individuals, life changing. Relationships between key population groups and Government Ministrys (E.G. MoH) have improved and government attitudes in general have become less problematic, although clearly this is an on- going process given the many MENA countries in transition. There has been significant breaking down of barriers to working with marginalised and vulnerable groups, including MSM, IDUs and SWs and Religious leaders, so important in the Region, have begun to engage and there has been an opening of dialogue on difficult and sensitive issues.
58 59

Unaids country office, Tunisia IDU focus groupe, Tunis 60 Chair of the CCM, Tunisia 61 Chairs of the CCM, Tunisia & Morocco

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The visibility and representation of PLWAs in important meetings and forum and the creation of organisations of people living with HIV and AIDS has enabled people living with HIV and AIDS to express their needs and make a positive contribution to decisions affecting their future. Prevention activities have been scaled up and their focus and targeting greatly improved and this has led to changes in perception about HIV and AIDS and other issues on many levels. Hope and aspiration has returned to people who had none before, increasing their self-respect and ability to manage crisis. It has taken 10 years of Global Fund support to achieve all of this and now is the time to build on what has been achieved to ensure that the gains that have been made are sustained. The new Global Fund Business Model (NFM) and the proposed banding and eligibility criteria jeopardises the successes that have been achieved in a Region where it is notoriously difficult to address many of the issues discussed for a variety of political, and cultural reasons. As the Global Fund looks at changing the way it does its business there is the real danger that the people that will be punished are the most vulnerable, whose status is the most fragile and who have the weakest lobby.

Key Elements of the NFM and their potential consequences for the MENA Region
There remain legitimate questions about the NFM despite the Boards approval in principle62. The NFM appears inconsistent with the principles of the Global Funds Framework Document and Founding Principals. It does not seem to be aligned with the Strategic Investment Framework and indeed the narrow focus proposed most in need, least ability to pay is too simplistic to be able to answer strategically to the needs of the region. This paper will not focus on a decision already taken but on the operationalizing and implementation detail to try and mitigate the potentially damaging impact the NFM will have on the MENA Region and the most vulnerable populations in particular. Establishment of Country Bands The SIIC paper63 outlines four different approaches to divide into country bands none of which, in their current iteration, adequately recognise the successes achieved in the MENA Region and require significant re-modelling. The Economic Indicator based only on GNI per capita, along the lines of the World Banks income classification, is and always has been an unrealistic indicator. Income alone gives a distorted and unrealistic picture of the true wealth distribution in a country and of the reality for the majority of a countrys population. The Disease Burden Indicator would ignore success in maintaining low disease prevalence and would, if used, represent a significant waste of previous Global Fund investment which had been instrumental in keeping prevalence at a low level64.
62 63

GF/B27/DP7 th SIIC Paper 5 Strategy Investment and Impact Committee Version: 22/10/2012 64 Chair Chair, Tunisia

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The Hybrid Economic/Disease burden Indicator is a combination of two flawed approaches. It encapsulates the weaknesses of the first two indicators and provides little benefit or accurate projections. The Economic Indicator and Transition makes too many assumptions regarding the graduation from Global Fund support and the continuation of effective disease responses. If the choice would be the hybrid proposal (Alternative 3) of the SIIC discussion paper, even though there would be discretion to move countries across bands, there would still be outstanding concerns as follows: applying this methodology to the current portfolio of investments would result in potentially 60 countries in the Targeted Pool for funding 19 from Latin America & the Caribbean (LAC), 15 from Eastern Europe & Central Asia (EECA), 12 from East Asia & the Pacific (EAP), 3 from South Asia, 8 from North Africa & the Middle East, and 3 from Sub-Saharan Africa. Looking across the other three bands, there would only be six LAC and EECA countries. This raises legitimate concerns of the threat of countries being pushed out of the Global Fund Portfolio, and diminishes the commitment of the Global Fund in remaining responsive to global needs. The concerns for the MENA Region are: Without a more nuanced formula for deciding which band a country is allocated to, many in the MENA Region will, in reality, be punished for their success in keeping disease prevalence relatively low and this will have serious consequences both for the countrys and for the most vulnerable populations in particular. The current approach, focused as it is on economic indicators, disease burden or a hybrid of both, does not provide an accurate picture in a country and undermines the ability to make a strategic funding decision. For example indicators such as literacy levels, the number of people living in a single household, accessibility to clean water or on grid electricity in rural areas, the number of people on minimal salaries, the size of the informal economy, the number of child workers, child mortality, the number of young people and unemployed young people, the % of people having health insurance, the legal environment for KAPS, are all important indicators to gain a true understanding of countries in the Region65. These indicators should be considered because they have a significant bearing on a countrys ability to prioritise health and the three diseases in particular and are hidden indicators that affect a countrys ability to pay. The Global Fund Secretariat does not recommend Willingness to Pay as a quantifiable variable and yet willingness to pay is far more important than ability to pay. Ability to pay judged on a Countrys GNI provides a distorted picture of the reality and does not probe deep enough in making this type of assessment. For example a country like Morocco does not hold a lot of foreign currency reserves and this makes the purchasing of medication difficult and increases the likelihood of stock-outs66. In Tunisia the regime before the recent political changes in that country falsified their GNI, presenting to the world a more positive and wealthier picture than was actually the reality67.In addition to this

65 66

CCM Chair, Tunisia & ALCS NGO in Morocco NAP program, Morocco 67 Chair ATL NGO, Tunis

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there are no other major donors investing in or supporting the Region and this is unlikely to change in the foreseeable future68. Willingness to Pay is difficult to assess but whatever formula the Secretariat could develop it will most likely be a process based on probability. For example analysing a countrys history of investing in the three diseases (or a single disease) from the national budget, reviewing the national health strategy to define where the disease response comes in terms of priority, analysing the history of support and gaps for NGOs and KAPs and other vulnerable groups, it should be possible to create a probability matrix from which a probability based decision could be extrapolated. This would be no less imprecise than using disease burden and ability to pay and would in fact strengthen those two in terms of a more accurate picture. Of course this is just an example of how Willingness to Pay might be calculated. Willingness to pay MUST be included despite the degree of difficulty. Using a probability matrix, whilst not a perfect solution, would address the issue during the interim period until an acceptable permanent solution is devised. The Global Fund has been an important and influential lever to encourage increased domestic investment in the three diseases but if the Global Fund investment is discontinued or severely curtailed, as would be the case for countries in the lowest priority banding where would be the incentive for continued scale up of domestic investment against so many other competing priorities. U-LMICs and U-MICs are the most likely to be placed in the lowest banding and would qualify only for the Targeted Band. Such mathematical profiling of a country would see an erosion of many of the gains made over the past decade, some of which are obvious but others less so. This is the case because such narrow focused assessment of a country does not take into account other important and relevant issues particularly for the MENA Region. It is Global Fund financing that has made Civil Society and key populations involvement in processes a reality and has, to some degree equalised the power dynamic in a country in relation to the disease response69. This has led to better and more effective programming. If this dynamic changes because the number of NGOs/CBOs reduces through a lack of funding (from the Global Fund) and the ones that are left are dependent upon Government funding effective advocacy and involvement will also be drastically reduced70, which in turn undermines effective programming especially in areas of great sensitivity in the Region and the model can, potentially operate against the Global Fund principle of PLWAs involvement. In Tunisia, its estimates that 80% of NGO will close If Global Fund does not support the country any more71. Regional/multi-country and non-CCM applications must be made possible within each Country Band, particularly in case of unwillingness of governments to pay for programs targeting key affected populations underserved within National Strategic Plans in both low and middle income countries.
68 69

Unaids regional country office Director of ATL NGO, Tunis 70 Director of development association, AMSED, Morocco 71 CCM Chair, Tunisia

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NGO rule should be preserved and expanded to include TB and Malaria as there is little reason for excluding the other two diseases and both, TB especially, along with HIV are critical for MENA; or the OECDs DAC list filter should be eliminated Many countries in the region are experiencing transition, with a significant number moving from more secular to Islamic parties within Governance systems. It does raise concerns regarding the future of services to vulnerable and identity specific populations whose activities do not sit comfortably in this environment. Without Global Fund financing, which in addition to targeted financing of specific identity groups, supports a focus on the wider environment including legal services and human rights (a key pillar of the Global Fund strategy), there is a threat that the situation will revert to pre-Global Fund times72, which is surely not what the NFM is trying to achieve. Therefore we strongly urge the SIIC and the Global Fund Board to take a more nuanced and accurate approach to criteria for deciding on which band a country is allocated to. The process for deciding Country Bands is inadequate and the criteria MUST be modified and nuanced to provide more accurate country profiles. Most at risk Populations Targeted Band In principle we support the concept of a targeted band for Key affected populations but question whether this would work effectively in the MENA Region unless its scope is increased? At the moment it is intended that between 5% and 10% of Global Fund resources that are available for grants will be apportioned to the Targeted Band providing there is sufficient funding available and depending on the success of the Replenishment process. The Targeted Band is what many countries in MENA will be left with should the banding criteria not take a more nuanced approach. This would have disastrous consequences for KAPs 73 because of the restrictions and limitations that are inherent in the current model. It remains unclear what will be funded through a Targeted Band and this is where the potential problem lies. For the Targeted Band to be effective the scope needs to be broad because it makes little sense to offer funding for key affected populations unless funding is also offered to address other issues that are more related to the political and social environment within which KAPs live. In MENA such groups do not exist as separate communities: many young men can have sex with other men because of separation between girls and boys. Many poor women (and men) can sell sex occasionally because they need money without being really part of a KAPS identified community.

72 73

MSM focus group, Morocco The Global fund definition of MARPs is: Sub populations within a defined and recognised epidemiological context: 1) 2) 3) That have significantly higher levels of risk, mortality and/or morbidity Whose access to or uptake of relevant services is significantly lower than the rest of the population Who are culturally and/or politically disenfranchised and therefore face barriers to gaining access to services. Annex 1 SIIC Papers: evolving the Funding Model (Part three)

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Understanding this is particularly important in the MENA Region, although it is applicable to every region. The Targeted Band MUST be broadened in scope and resourcing to a minimum of 10% and ensure Critical Enablers and CSS Funding are preserved and available for U-LMIC and UMIC. In addition, of concern is the fact that critical enablers will not be funded. This would mean areas such as stigma reduction, gender equality, community mobilisation and wider areas such as health and community systems, social protection and gender-based violence will be unlikely to receive financial support. Throughout 2012 AIDS Strategy Advocacy and Policy (ASAP) has been working with the Global Fund secretariat and UN Women to review nine HIV programs funded by the Global Fund in Rounds 8 & 9 to establish the extent to which gender responsive programs have been supported. In September 2012, a country case study was undertaken in Zambia. Overall, the review has found limited implementation of activities scaling up responses to HIV to address the needs of women and girls in a way that would transform local responses to HIV and better the lives of women, their families and communities. This despite the clear direction set by the Global Funds Gender Equality Strategy (GES) and supported by clear guidance notes issued to countries by the secretariat.74 . Similarly with the Global Fund SOGI Strategy and Human Rights. The decision point, going to the Board now states that absolute dollar terms will be used to apportion resources to indicative and incentive funding, and the Finance and Operational Performance Committee will recommend to the Board what this dollar amount would be at the 29th Board Meeting. This indirectly results in the creation of envelopes, as the likely result of allocating an absolute dollar amount (as opposed to an earlier recommendation of using a range of percentages) would be a disproportionately high allocation to indicative funding. This could result in applications not prioritizing interventions based on Community Systems Strengthening (CSS), the Sexual Orientation and Gender Identity (SOGI) Strategy, and the Gender Equality Strategy. In addition, interventions providing life-saving commodities and services (for instance, harm reduction) would potentially not be prioritized by some countries75. 38. There is too little clarity as to how the SOGI, GES and Human Rights strategies will be operationalized within the NFM and this needs to be addressed before a final Board decision is made. How the SOGI, GES and Human Rights Strategies are to be operationalized with the NFM MUST be made explicit within the SIIC Decision Point. However, it appears likely that many of these issues will only be on the table for discussion and negotiation during the Iterative Dialogue process which we look at later in this paper. However it would seem that Health and Community System Strengthening (HCSS) support could be available as either a cross-cutting issue in the General Pool or within the disease specific pools, but how this would apply to U-LMIC and UMICs who do not qualify for the General Pool is unclear. For the MENA Region the issue of funding for stigma reduction, anti-discrimination programmes and gender based violence and equality work is of primary importance because although considerable
74

Direct quote: Annex 2 to the Analysis of the Implementation of the Global Fund Gender Equality Strategy in Round 8 and th 9 HIV Programs R. Gorna Director ASAP (AIDS Strategy, Advocacy and Policy Ltd) 10 October 2012
75

ICASO Issues Briefing Number 3 November 2012

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progress has been made the gains achieved are fragile and may easily be undermined as many countries transition into new forms of governance. With no additional donors in the region it is unlikely this work will be funded from national budgets76. Also it seems the criteria for funding from the Targeted Band if imposed the way it would appear at present, is inconsistent with the Strategic Objective 4. Promote and protect human rights of the Global Fund Strategy Framework 2012-2016 and 1.3 Maximise the impact of Global Fund investments on strengthening health systems of Strategic Objective 1. Invest more strategically77. The worry is that whilst HSS may be funded from the general pool, community systems will not and they are the very systems that not only underpin the health system but are also the ones that provide the majority support to KAPs. The building of health and community systems takes time and without investment in community systems for MENA, how will it be possible to build a critical mass of civil society and identity specific organisations to enhance and develop a sustainable disease response in preparation for transition out of Global Fund financed support? We would call for the Targeted Band criteria to be nuanced to reflect the specific needs within each region. The process of developing the criteria for the Targeted Band MUST include Civil Society and representatives of vulnerable populations from the MENA Region, in particular on the issue of qualitative criteria. The amount of funding allocated to the Targeted Band MUST be a minimum 10%. Performance and Ambition and Incentive Funding There is a need to clarify exactly what is meant by good performance? The issue of how performance is assessed comes into focus because The Incentive Stream access and the Iterative Dialogue process will include priority given to well performing programmes (GF/B27/DP7 4.ii Annex 1). The question is what criteria will be used to make this assessment? Will it be the type of information that is currently used to assess if a grant is performing well and which we have no problem with, as far as they go. Or, with the advent of the NFM do we need to consider a broader definition of what constitutes good performance in the context of the political, legal and social environment as well as the more statistical evidence, to ensure the changed funding model does not prejudice countries who, in view of their status in these areas, have also performed well? As has been described earlier in this paper, many countries in the MENA Region have made remarkable progress, with Global Fund intervention, in ways which are not considered when assessing for performance. It is critically important both for the Global Fund, in making strategic funding decisions and the MENA Region that this progress is included as a part of a performance assessment. Consider re-defining the parameters for good performance to better reflect the benefits accrued from a Global Fund Grant, that go beyond the existing assessment criteria. Ambition and Incentive Funding
76 77

NAP, Tunisia Global Fund Strategy Framework Investing for Impact 2012 - 2016

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A further concern regarding the NFM is the potential to moderate ambition. Although it is understood that not every country can have everything it asks for and that some rationalisation needs to happen, the NFM and its inherent capping of funding access for certain U-LMICs and UMICs will have a detrimental effect on the progress of the disease response. The net effect of the banding and the capping that comes with it will be to anaesthetise rather than stimulate ambitions to achieve universal access, zero discrimination or the elimination of TB. Incentive Funding is designed to incentivise countries with well performing programmes (see above for discussion on re-defining performance) to submit robust, ambitious request based on a national strategic plan or through articulation of a solid business plan or investment case. The principles for awarding Incentive Funding and managing unfunded quality demand include: ambition, strategic focus, alignment, sustainability, simplicity, proportionality and co-investment or willingness to pay (The last one, of course, has yet to be agreed). The suggestion is that the funding in this stream will be substantial, although this is more aspirational than definite. The amount of funding allocated to the Incentive Stream will be determined by available funds after allocation to the indicative/general pool. Additional resources raised through the replenishment process could then be apportioned to incentive funding, but it is not made explicit that it will be the case. However, this is critical if we want countries to be ambitious in deciding what they need to build on what has already been achieved. Unless this is substantial, as has been discussed, ambition will shrink to fit the size of the pool. The funding allocation for Incentive Funding MUST be substantial to ensure that countries maintain their enthusiasm to develop ambitious disease responses and proposals. And it is not simply about the amount of funding available it is less tangible but no less important. If countries are told they are only eligible for a very limited amount of financial support, their ambition will shrink to fit the size of that support. Areas that are sensitive and complex to address in the MENA Region will no longer be considered and the previous gains that have been made will be lost. The ambition and innovation, as seen with the Moroccan Round 10 proposal with a clear focus on KAPs, enabling environment, and CSS, will be nullified78. The imagination, the aspiration and enthusiasm that have emerged from a decade of consistent progress in so many difficult areas will retreat back into the shell of conservatism. Iterative Dialogue Process During the Transition Phase (to the NFM) the Secretariat will invite a small group of countries to submit Concept Notes and compete for incentive funding in the transition to the new funding model, based on a number of factors, including the following : i. Existence of an independently validated, current National Disease or Health Strategy or equivalent, to be used as the basis for a Concept Note; ii. Capacity (including Country Coordinating Mechanism (CCM), Principal Recipient(s) and partners) to quickly develop a Concept Note based on existing plans and engage with the Secretariat in the iterative process;
78

Director of ALCS NGO, Morocco

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iii. Engagement and recommendation by the relevant Country Teams within the Global Fund Secretariat; and iv. History of, or clear potential for, significant and rapid impact; preference for incentive stream funding would go to countries that have a potential to significantly affect the global trajectory of the diseases or affect the achievement of the Millennium Development Goals79. The concept of the NFM does appear to be moving inexorably towards a more Government focused hierarchy rather than strengthening the broad representation approach (including NGOs, Civil Society and representatives from KAPS) as articulated in the Global Fund Framework Document. How will the Global Fund ensure that People Living with HIV and AIDS and other vulnerable population and identity groups will be engaged effectively in the Iterative Dialogue (on the concept note) with the Secretariat and the CCM? It should be made explicit, by the Board decision, that a concept note will not be discussed unless representation of KAPs is guaranteed and documented as such. The Secretariat MUST be instructed to ensure appropriate representation from Civil Society and KAPs during the Iterative Dialogue processes, essential for building on progress in the MENA Region. It must be made more explicit how the SOGI, GES and Human Rights strategies will be incorporated in the NFM? Without the effective involvement of KAPs in the Iterative Process there will inevitably be a dilution of the KAPs response in many countries. This will be the reality unless clear and enforceable guidelines and directives are made regarding the Iterative Dialogue Process, to ensure there is a true representation of a countrys needs.

Conclusion & recommendations

In an ever-changing world of shifting economic paradigms, greater understanding of effective disease response and management, and the maturation of the organisation, the Global Fund has to evolve. The NFM is a significant stage in that evolution. This we do not challenge but the structure, formulae and implementation plans and processes raise many issues and concerns for the MENA Region. The NFM in its current iteration by the SIIC that will be presented to the Global Fund Board for a decision at its November Board Meeting, holds little encouragement for MENA countries unless
79

Evolving The Funding Model Draft DP SIIC 22/10/2012

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important modifications are made. As can be understood by this document there is really only one conclusion we can come to regarding the NFM as presented in the SIIC Decision Points. The current iteration of the NFM is not acceptable for MENA, because the risk that all the progress made will be undermined and set back or reversed is too palpable. We need guarantees and appropriate Board decisions on our main recommendations listed below, before any support can be given. Clearly the process for deciding Country Bands is inadequate and the criteria MUST be modified and nuanced to provide more accurate country profiles. Willingness to pay MUST be included despite the misgivings of the Secretariat whose claims regarding the degree of difficulty in assessing this seem weak. Using a probability matrix, whilst not a perfect solution, would address the issue during the interim period until an acceptable permanent solution is devised. The process of developing the criteria for the Targeted Band MUST include Civil Society and representatives of vulnerable populations from the MENA Region, in particular on the issue of qualitative criteria. The amount of funding allocated to the Targeted Band MUST be a minimum 10%. The definition of Good Performance needs to be re-visited in the context of the requirements of the NFM so that evidence of the catalysing effect the Global Fund has had on many important areas in the Region is not lost or ignored. The Secretariat MUST be instructed to ensure appropriate representation from Civil Society and KAPs during the Iterative Dialogue processes, essential for building on progress in the MENA Region. The NFM must be made more explicit how the SOGI, GES and Human Rights strategies will be incorporated in the NFM Sufficient funding must be made available to preserve ambition and incentive. The NGO rule must be strengthened to cover all three diseases and the facility for non-CCM and Regional proposals must be made explicit. These areas need to be addressed, as they would have a significant impact on the effectiveness and equity of the NFM. The responsibility now lies with the Global Fund Board and we urge Delegations to make the right decision in November and insist that the changes articulated in our recommendations are acted upon.

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REFERENCES UNAIDS, UNAIDS NGO PCB Delegation, UNGASS Reports & World Bank UNAIDS MENA Report 04/12/2011 Information Brief UNAIDS MENA Report on AIDS 2011 UNAIDS urges action against HIV in Mena - Helmy Dec. 2011 UNAIDS MENA report 2011 UNAIDS MENA report 2011 UNAIDS MENA report 2011 How Laws and Policies Affect the HIV Response UNAIDS PCB NGO Delegation, December 2011 The impact of reduction in funding for HIV on Civil society UNAIDS PCB NGO Delegation, June 2012 MENA records highest number of HIV infections ever in 2010 - UNAIDS Dec. 2011 UNGASS Report Egypt 2012 UNGASS Report Morocco 2012 UNGASS Report Tunisia 2012 MENA Time for Strategic Action World Bank 2010 Morocco Morocco Global Fund Grants, Proposals & report - 16 Documents Strategic HIV/AIDS plan Morocco 2002 - 2004 Strategic HIV/AIDS Plan Morocco 2012 2016 Morocco NASA analysis (2007-2009) Egypt Egypt Global Fund Grants, Proposals & report - 14 Documents Combating HIV/AIDS related Stigma in Egypt - A. Morrow & N. Samir Tunisia Tunisia Global Fund Grants and Proposals - 12 Documents Arab World (General) Facts of Life Population Reference Bureau 2011 Secretive Arab World faces HIV epidemic - Yasbeck Dec. 2011 Facts of life : YOUTH SEXUALITY AND REPRODUCTIVE HEALTH IN THE MIDDLE EAST AND NORTH AFRICA. BY Farzaneh Roudi-Fahimi AND Shereen el Feki. Population Reference Bureau 2011 - www.prb.org/Reports/2011/facts Global Fund specific GFATM Making a Difference MENA Regional Results Report 2011 GFTAM Making a difference - MENA regional GF Meeting, Casablanca October 2011 GFTAM Making a difference MENA regional GF Meeting, Amman May 2009 GFAN 24. Annotated Global Fund Board Decision Points - GFAN Sept. 2012 25. GFAN CGD Blog - Future of the Global Fund. O. Ryan amFAR

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26. GFAN Issue Briefing Number 2 Oct. 2012 INGOs & Networks International HIV/AIDS Alliance Policy Brief May 2012 Letter to GF General Manager Sept 2012 INPUD, NSWP, MSMGF, GATE, CETH Guiding questions for analysis of Global Fund Rd 11 Cancellation - MSF ICASO CSAT Info Alert : Changes at the Global Fund Oct. 2012 ITPC Issues briefing Number 1. Global Fund and NFM 23/10/2012 ITPC Missing the Target North Africa - 2012 Bridging the Gap - Action TBEC Sept. 2012 Global Fund Observer Issue 146 2012 Eastern Europe and Central Asia Quitting while not ahead: eurasian Harm Reduction Network May 2012 The crisis in Harm Reduction in EECA - draft EHRN EE-CAR Impact of Eligibility Criteria - discussion paper 26/09/2007 Upper Middle Income Countries - discussion paper 16/08/2007 3Global Fund Support to Civil Society in the Soviet - Harmer et al 2012

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