By Sara L.M. Davis
In his recent New York Times op-ed, Paul Farmer calls for increased funding for the Global Fund to Fight AIDS, Tuberculosis and Malaria. He's right, but to really put muscle into the fight against HIV/AIDS, the Global Fund also needs to change its top-down approach to funding, given the reality that HIV/AIDS specifically targets the most marginalized people in any society.
As Farmer rightly points out, the Global Fund has dramatically increased funding to get antiretroviral medicines to millions of people--an important victory that has saved many lives. It did this by leveraging multilateral funding to strengthen health ministries and medical services for people living with HIV/AIDS, and insisted that civil society be part of the process of applying for and managing grants. Yet civil society continues to be marginalized in many countries where the idea of a "nongovernmental organization" is still new and threatening to an authoritarian government.
Developing a comprehensive national healthcare response to HIV/AIDS requires infrastructure. Thus a good portion of the GF's grants have focused on building medical systems, and rightly so. In the Global Fund model, countries create "country coordinating mechanisms", or CCMs, "multi-stakeholder" groups that bring together representatives from industry, government, academe, and civil society, as well as people living with the diseases. These CCMs submit proposals that reflect their collective plan for HIV/AIDS prevention and treatment. They are responsible for selecting a primary recipient, who handles the national grant and awards sub-grants to others. It's a sensible, top-down hierarchical approach to managing a national epidemic.
But HIV/AIDS challenges that logic. HIV has tended to affect people who are most vulnerable to sexual and blood-borne transmission: sex workers, drug users, sexual minorities--populations who are also socially and economically marginalized--often, criminalized. While the flows of funds largely follow the channels of power, the trajectories of HIV transmission follow the channels of marginalization. This is where CCMs run into trouble.
In practice, despite the "it's a small world after all, we're all in it together, multi-stakeholder" vision, CCMs tend to be dominated by government representatives. As an ITPC report found, NGO and PLWHA representatives are often outnumbered by government officials and their allies, and are often just not taken seriously in the decision-making process. In addition, NGO and PLWHA representatives may also be simultaneously trying to run their own under-resourced NGOs and respond to the needs of a vocal and critical community, so their focus is divided. They also have to navigate through reams of reports, policies and other paperwork for the Global Fund, usually in English, in which the NGO or PLWHA representative may or may not be fluent. And there is no system for making sure that civil society representatives actually consult with, or report back to, the people they are supposed to represent. In some cases, CCMs have become little more than rubber-stamps for government proposals.
But the problems go beyond the makeup of the CCM--especially in authoritarian or very hierarchical societies. In these countries, power hews closely to government centers and to those with good government relationships. But drug users, sex workers, and others on the margins of society don't have those relationships.
In fact, when we travel to cities and towns in Asia to work with grassroots HIV/AIDS NGOs, it is often striking how their geographical marginalization mirrors their political marginalization.
I still remember one of the first HIV/AIDS NGOs I visited in Hong Kong in 2002. Here, in one of the wealthiest and most socially progressive cities in Asia, the NGO office was hidden in the back of an old airport terminal, behind a retail automobile showroom and a bowling alley, under a sign labeled, "Activity Center" (活动中心)。 Even in this remote location, the NGO staff said, a sign that more explicitly described their HIV/AIDS work would attract outrage, fear and retaliation from their neighbors.
The nonprofits we work with are frequently hidden in this way. We've held workshops for sex workers in a car wash, trainings for drug users in a back-alley storefront, and seminars for gay men in an unmarked residential apartment building. We've held workshops in the upstairs rooms of churches on a weekday afternoon, when the front gate was locked and the church apparently closed. The communities our local partners serve skulk into these facilities, with tense casualness, while looking over their shoulders to check if they've been seen.
Their economic background, educational background, and social background--combined with their connection to one of the most stigmatized epidemics in human history--all mark directors of grassroots NGOs as outside of the halls of power. For all these reasons, they are less likely to be able to leverage the connections needed to get access to funds that flow down from the top of a hierarchy. Or as one NGO staff person put it to me once, "At every level of the system, someone takes a cut of our grant. By the time it gets to us, we're lucky to get a third of what we were promised." One study found that only 19 percent of Global Fund grants go to NGOs.
CCMs are an illogical way to fund groups that are led by and that serve people on the margins of society. The challenge posed by HIV/AIDS demands that we think of new ways to get funding to programs developed by and led by those communities. This could mean direct funding for national networks that work with specific communities such as sex workers, drug users, PLWHA, and MSM (though even this wouldn't address the need for HIV/AIDS programming among communities so politically marginalized or restricted that they can't even organize NGOs or networks--for instance, certain indigenous groups, ethnic groups, migrants and refugees).
Another approach might be to grant to coalitions of diverse stakeholders (NGOs, government, academics, private businesses) that work on specific problems. This would promote multi-sectoral cooperation that is targeted and pragmatic, bringing together people with shared priorities to work on programs.
The solution the Global Fund has come up with, in China, is to terminate its support. This month, the Global Fund announced that due to shortfalls, it will phase out funding for Chinese HIV/AIDS projects by 2014. The Global Fund's argument is that China is a middle-income country, which should be able to fund the AIDS response directly.
This may be true--but it doesn't make it any more likely that China's grassroots NGOs will get that funding. The Global Fund, and other international donors, should develop new mechanisms to get the funds to groups on the margins, not the center.