analysisBy David Garmaise
Concept notes should address structural barriers
The Global Fund should examine its position on policies and practices shown to have negative impacts on human rights, including "100% condom use" programs, the detention of TB patients, the use of drug registries, limitation of services for active drug users, forced sterilization, and use of condoms as evidence in court cases.
These were among the recommendations contained in a report on a workshop in Geneva on 23-24 May 2014 on managing the risks of human rights violations in Global Fund-supported programs. Co-hosted by the Global Fund and the Geneva Academy of International Humanitarian and Human Rights Law, the workshop brought together some 60 participants, including leading experts in health and human rights, technical partners, representatives of networks of key populations and people living with HIV, donors, grant recipients, civil society organizations, scholars and Global Fund board members and staff.
Workshop participants urged the Global Fund to end funding for health programs in drug detention centers. (On 1 July, after a long campaign by human rights advocates, the Global Fund stopped funding and services in drug detention centers in Viet Nam. See GFO article.)
Participants also recommended that the Global Fund not support any programs that include compulsory "rehabilitation" of sex workers or lesbian, gay, bisexual and transsexual persons; and that the Fund ensure that it does not support or promote mandatory HIV testing.
There is a need to distinguish between individual complaints of human rights violations, for which the Global Fund cannot itself provide redress, and policy-level complaints that relate to more systematic practices in Global Fund-supported programming, according to the report. The Fund has a clear responsibility to seek some form of "systemic redress" or improvements in the quality of services in the latter case, they said.
Participants observed that the Global Fund's will achieve impact only if it is able to address structural barriers. A key challenge is to ensure that programs to address those barriers are included in concept notes.
Sufficient time should be allowed to ensure that country dialogues are truly participatory, participants said; therefore, countries should not rush into developing concept notes and civil society should be supported to participate effectively in the country dialogues. Participants cited the example of a recent country dialogue in Cambodia for the TB concept note submitted in June, where civil society participation was facilitated by the Global Fund's country team. Participants noted that country dialogues were often rushed during the transition phase of the new funding model (NFM) and that, as a result, community input into the identification of priority interventions was inconsistent.
Countries lack adequate data on key populations and human rights, including evidence of rights-based interventions (e.g. police training). As a result, participants said, it is difficult for the Technical Review Panel to assess whether proposals adequately address these issues, and it is easy for countries that lack political will to leave important interventions out of the concept notes.
Participants predicted that most applicants will not use the optional human rights module in their concept notes, and that governments will continue to neglect community-based programming. Some workshop participants urged the Global Fund to impose conditions in grant agreements related to human rights programming. However, others argued against setting human rights conditions because it could backfire and result in retaliation against domestic advocates and discontinuation of services.
The Global Fund was urged to reconsider its approach to withdrawing funding from upper-middle-income countries, where many community-based and key population-led organizations struggle to survive, and where governments often do not prioritize human rights and the provision of services to key populations.
A greater effort should be made by technical partners at the country level to bring civil society, the health sector and governments together on human rights issues, participants said. They noted that the Global Fund and UNAIDS sometimes work in silos, and that much of the good work on human rights is dependent on individual personalities.
A worrying amount of tokenism continues to exist with respect to the involvement of key populations on country coordinating mechanisms (CCM); equally, representatives of these populations frequently struggle because they are not adequately equipped and supported.
Participants noted that fund portfolio managers have relatively little capacity to monitor and respond to rights violations, and need to connect effectively with partners at the county level. However, they added, partners with human rights expertise are themselves under-resourced. A recent report from UNAIDS revealed that 59% of civil society organizations implementing human rights programming have reported decreases in funding.
At a session on harm reduction, one panelist said that although the Global Fund has been the biggest donor to harm reduction, overall funding for harm reduction remains inadequate. For example, global coverage of opioid substitution therapy (OST)is only 8%; antiretroviral therapy coverage for drug users is only 4%; and people who inject drugs receive an average of only 1-2 needles each per month.
With respect to services for people in prisons, participants observed that Global Fund programming is sometimes constrained by national policies that prohibit harm reduction interventions and condoms in prisons. Participants recommended that the Global Fund develop policies with respect to what it expects in terms of prison-based programming, and that the Fund describe the types of programs it will and will not support.
Some participants suggested that the Global Fund become more engaged in advocacy around issues such as prison health, international drug policy, and laws that criminalize key populations. The workshop recommended that the Global Fund decide whether it will systematically and consistently speak out publicly on human rights violations, or take a more "quiet diplomacy" approach.
Global Fund staff attending the workshop cautioned that many of the recommendations have budgetary implications at a time when resources are tight. The staff said that it will be necessary to determine what is feasible and to "not further burden already over-burdened staff with additional tasks and bureaucratic processes".
The recommendations on drug detention centers and other forms of compulsory treatment, and on health and human rights advocacy, were referred to the Strategy, Investment and Impact Committee (SIIC) for further discussion. On compulsory treatment, the SIIC asked the Secretariat to prepare a policy options paper for the committee to review in October. On advocacy, the SIIC asked the Secretariat to consult with technical partners to identify opportunities for joint advocacy.
Other recommendations have been shared with Secretariat staff and the Human Rights Reference Group.