Everyone knew that the crisis at the Global Fund to Fight AIDS, TB and Malaria would have a serious impact across southern Africa, which is still the epicentre of the HIV and AIDS pandemic. But no one knew exactly how serious it would be - or what would be most affected.
But now new research from Malawi, Swaziland and Zimbabwe has highlighted just how devastating the cancellation of Round 11 funding has been on the HIV and TB response in the region.
Funded by the Open Society Initiative for Southern Africa (OSISA) and the Open Society Foundations (OSF), the report - entitled The First to Go: How communities are being affected by the Global Fund Crisis - details how the funding crisis has severely undermined efforts to tackle HIV and AIDS in southern Africa by weakening civil society organisations, diverting funds away from critical support programmes and preventing countries from targeting some of the most-at-risk groups.
"Forced to choose between providing essential medical services or funding the initiatives that support them, these countries have shifted budgets away from civil society organisations, human rights programming, community mobilisation and politically-sensitive programmes," said the report's author, Laura Lopez Gonzalez. "UNAIDS believes that these activities are crucial to the overall success of any national HIV response but they are the First to Go."
Round 11 funding would have supported community-based NGOs to provide treatment literacy and adherence support; lead community education, mobilisation and prevention efforts; and address barriers to treatment, care and support. It would also have allowed countries to fill critical gaps in HIV and TB treatment, diagnostics, and other commodities; scale-up prevention interventions such as the prevention of mother-to-child HIV transmission services and medical male circumcision; and strengthen health systems.
Civil society organisations (CSOs) in all three countries were already facing a funding crisis when Round 11 was cancelled. This new research reveals that the organisations most vulnerable to current cuts in resources are community-based organisations working at the local or district levels - and particularly organisations for People Living with HIV (PLWH).
"Years after UNAIDS and the Global Fund drove the involvement of PLWH, their organisations are among those most at risk of closure," said Lopez Gonzalez. "With little hope of sourcing alternate funds, civil society networks are in danger of collapse."
Indeed, 100 percent of the CSOs interviewed for the study reported that their networks have been adversely affected by shrinking budgets in recent years. With the closure of CSOs, their networks and governments lose the advantages and structures they have grown to rely on, especially in countries facing huge challenges in domestically financing HIV and TB responses.
Round 11 would have been a watershed moment in southern Africa. Under its HIV application, Swaziland planned to include interventions for sex workers, men-who-have-sex-with-men (MSM) and a small community of injecting drug users in its Global Fund proposal for the first time. Malawi's application would have been the second to include MSM and sex workers but possibly the first to be funded.
"Considering that same-sex relationships, sex work and drug use are criminal offences in Malawi and Swaziland, targeting these most-at-risk groups would have been a major step forward," said Chivuli Ukwimi, Marginalised Populations Coordinator for the Open Society Initiative for Southern Africa (OSISA).
Given the serious impact of the cancellation of Round 11, the report calls on the Board of the Global Fund to issue a new call for applications as soon as possible and to emphasise the importance of investing in 'critical enablers' to increase the effectiveness of core programme activities.
The report also urges the Board to reaffirm the importance of CSOs in health responses and to call on the Secretariat to develop a strategy that outlines how CSOs will be supported through the implementation of the new Global Fund strategic plan (2012-2016).
At a time when US Secretary of State, Hillary Clinton, has announced earmarked US support for reaching vulnerable populations, such as sex workers, the Fund's technical partners must take an active role in safeguarding the involvement of CSOs that are best placed to reach these most-at-risk groups.
"Technical partners, like UNAIDS and the Stop TB Partnership, should provide concise technical guidance to countries applying for Global Fund money to safeguard support for critical enablers, including community-based service design and delivery," said Shannon Kowalski, programme officer at the Open Society Foundations Public Health Programme. "Strengthening community systems to support decentralising healthcare, moving healthcare out of clinics and into communities, is crucial to making sure services reach those in need."
"The Global Fund is one of only a handful of donors that support this kind of community systems strengthening," she added.
Finally, the report calls on all donor countries, including new and emerging donors, to meet their commitments to funding sustainable HIV, TB and malaria programmes through increased - and long-term - pledges to the Global Fund at its next replenishment conference in 2013.