Despite a forward looking Gender Equality Strategy (GES), few Global Fund programmes seem to be reaching women and girls in ways that will genuinely transform their lives and turn the HIV epidemic around.
There is substantial analysis showing what needs to be done to make HIV programmes gender transformative - i.e. programmes that will not only meet the immediate HIV needs of women and girls, but also address underlying conditions that enhance HIV vulnerability and risk for men and boys, as well as women and girls, because of gender stereotypes and dynamics prevalent in many societies. (Levels of gender awareness are described by the USAID Interagency Gender Working Group as gender exploitative, gender sensitive, and gender transformative.)
Despite this substantial analysis, the right programmes are still not being implemented with Global Fund resources - or if they are, it is nearly impossible to track.
Throughout 2012, AIDS Strategy Advocacy and Policy (ASAP) has been working with the Global Fund Secretariat and UN Women to review nine HIV programmes funded through Rounds 8 and 9 to establish the extent to which gender responsive programmes have been supported since the introduction of the GES. ASAP's review found limited implementation of programmes that would transform local responses to HIV and better the lives of women, their families and communities. The review highlighted that - despite guidance in many documents from UNAIDS, UN Women and others - countries have a weak understanding of the most strategic gender-transformative programmes, and that structural barriers within Global Fund processes have limited strategic investments and have not created incentives for gender programming.
So, why is the clear direction of the GES not translating into action? Responsibility for this insufficient response falls across many actors in the global and local response. At a national level, the locus of responsibility for all aspects of the response, including gender, lies with national AIDS commissions, the government and the many partners the government does - or does not - bring together. That includes responsibility for not forging adequate links with women's organisations, especially networks of women living with HIV. The UN too - and the myriad technical agencies present in many countries - also bear responsibility. It is concerning that although a number of countries we reviewed had national gender strategies, as well as national AIDS strategies, these were not well reflected in programming. Several countries have good and forward looking gender programmes - e.g. within women's ministries - but these rarely become visible within AIDS planning processes.
What can the Global Fund do?
So what of donors, and in particular the Global Fund? As a non-technical partner, how can the Fund be held accountable for inadequate progress with gender transformative programmes? Our review has found that there are many aspects of Global Fund processes that could be enhanced so that programmes really meet priority needs for women and girls. At this important moment of transition for the Fund, several actions should be taken to ensure that funds go to the right places and support strategic programming that will turn the epidemic around by addressing the inequalities and drivers of HIV, as well as their more direct impacts on girls and women.
First, the Global Fund Board needs to ensure that the strategies they agreed on -Gender Equality, and Sexual Orientation and Gender Identity (SOGI) - continue to be core and do not get lost in the pressure to develop new, and often "gender blind," approaches and processes to support grant management. But - as our review finds - simply having the GES is not enough. Strategies are only as good as their implementation.
A big part of the problem is that data is not available to tell whether the GES is being implemented. Sex- (and age-) disaggregated data needs to become the norm for Global Fund reporting so that we can track whether spending and programme implementation have the right impacts. For example, is antiretroviral therapy scale-up reaching women and men equally (or at least proportionate to the epidemic profile)? Are there gender differences in survival rates? This is a simple step, and not an unusual one for donors. (DFID, for example, requires that sex-disaggregated indicators be included in logframes wherever possible.)
The Global Fund has placed huge store on effective M&E systems; tweaking them to be gender sensitive would not be hard, and would have a huge impact. This includes simple steps like requiring gender programmes to be tracked in performance frameworks. It's the old story: "What gets counted gets done." Not only will sex-disaggregated data assist in monitoring, it will also remind principal recipients and others that gender transformative programming matters, and should be the norm - tailored, of course, to local epidemic realities.
The Global Fund's new funding model provides real opportunities for improvement. As the model is further developed, in addition to requiring sex-disaggregated data, other "check points" should be put in place. For a start, the applicant's concept note should always include a gender analysis of the country's needs. And the SIF (Strategic Investment Framework) guidance provided by the Global Fund needs to include clear direction on gender responsive programming (as opposed to just relying on the current UNAIDS SIF which is "gender blind").
Just having a gender analysis in the concept note would not be sufficient. The membership of the Technical Review Panel needs to include people with the gender skills to judge whether the analysis and proposals are sound, and to provide feedback to countries where strengthening is needed.
Our review - and the precursor review commissioned by the Global Fund Secretariat that looked at the quality of gender analysis in proposals (but not implementation) -found that following adoption of the GES, most countries integrated gender analyses in their proposals. The analyses were rarely perfect; but the real problem was at the point of transition from proposal to implementation.
Equally important, if not more important, is the quality of grant management and advice as proposals move into the implementation phase. ASAP found no evidence of fund portfolio managers (FPMs) intervening to support countries to deliver the gender aspects of proposals. Nor was there any evidence that FPMs saw it as their role to track the implementation of gender transformative responses. As the Global Fund evolves its model to take on a more active grant management role, FPMs must take some responsibility for ensuring that countries deliver on their proposals, and implement Global Fund Board-agreed policies and strategies, including the GES and the SOGI Strategy. This boils down to sharper grant management and making sure that FPMs have the right skills and incentives to be most effective as grant managers.
Ultimately, as with all things concerning the Global Fund, it is how the partnership works best - through the country coordinating mechanisms (CCMs), and through the broader partnership between technical partners, civil society and government. We found examples of countries with strong and effective women's rights organisations, and vibrant networks of women living with HIV - yet these groups seemed to be distant from the central decision-making processes. And we never found gender parity or strong representation of gender experts on the CCMs we looked at.
Hard questions must be asked about the Global Fund's internal procedures, and how these incentivise stronger performance by partners. What are the triggers to ensure that Board-agreed strategies and guidance notes are fully implemented? How can the people and processes responsible for grant management be most effective so that countries are guided to deliver programmes that are most strategic and will have maximal impact?
A simple first step is for the Global Fund Secretariat to require sex-disaggregated data in all reporting. This will ensure that the reports generated to meet the needs of this (very special) donor tell the story as to whether or not the funds are transforming societies so that women and girls are best able to resist the impacts of HIV. The Global Fund is well placed to take this simple action now, and to take further action to ensure that all the good words and intents in existing strategies and policies really translate into action where it matters.
Robin Gorna (email) is the Director of ASAP, a small consultancy of associates working globally to deliver a better response to AIDS, women's health and global health more broadly. Robin has worked in HIV since 1986; she has been involved with the Global Fund since 2003 when she headed up the Global AIDS Policy Team of the (UK) Department for International Development and was a member of the UK-Australia delegation to the Global Fund Board. The ASAP website contains further details of the project described in this article, which benefited from the work of associates Hanke Bokma de Boer-Nubé and Sophie Dilimitis.