A new survey report compares African key populations' engagement in the decision-making processes of large funding partners. The report is jointly published by African Men for Sexual Health and Rights (AMSHeR), the African Sex Worker Alliance (ASWA), Gender DynamiX, and TransBantu Association Zambia, and was launched at the 21st International AIDS Conference in Durban, South Africa. Its findings build on the results of AMSHeR's November 2015 survey, which identified significant participation gaps for African key populations in the Global Fund's new funding model (see GFO article).
The report is a rapid review of an online survey (99 respondents from 25 African countries), site visits in Nairobi, Kenya and Lilongwe, Malawi, focus group discussions, and key informant interviews in six countries. The majority of survey participants identified themselves as representing men who have sex with men (n=64), lesbian, gay and bisexual people (n=59), and transgender people (n=53), though most respondents said they represent multiple key populations.
The results reveal that engagement levels are significantly higher for Global Fund concept notes than they are for PEPFAR country operational plans (COPs) (Figure 1). Overall, 33% of survey respondents had ever been consulted for a Global Fund concept note compared to just 19% who had participated in a PEPFAR COP. Survey respondents were also more likely to provide input into drafts and budgets for Global Fund concept notes than they were for PEPFAR COPs.
Though participation is reported as higher for the Global Fund than it is for PEPFAR, the Global Fund "engagement cascade" is steeper. This means that key populations who are consulted for Global Fund concept notes are more likely to "drop out" of the process as it progresses towards draft and budget input. Of those ever consulted, only one fifth had provided input into Global Fund concept note budgets compared to nearly one third for PEPFAR COP budgets. This could indicate that while Global Fund processes appear more widely consultative, engagement in PEPFAR processes may be more meaningful, since a greater proportion of those consulted provide input into documents and budgets.
Figure 1: Number of key populations who participated in various stages of consultation
Notably, for both the Global Fund and PEPFAR, respondents were less and less involved as the process evolved. This reinforces the commonly-held view that key populations engagement is often quite superficial.
Information gaps help to explain the low levels of key populations' engagement for both the Global Fund and PEPFAR, as well as the difference between the two. Only 7% of respondents felt that they understood the Global Fund's tools and processes well, compared to 4% who said the same for PEPFAR. Both of these figures are exceedingly low. Respondents reported a steep learning curve in engaging with the Global Fund and PEPFAR, including a deluge of acronyms, and new tools and processes to learn. Compounding these difficulties was the fact that this engagement often occurred in the participant's non-native language. There were also major gaps in budget knowledge identified.
Access to information includes knowing how and where to ask for help. Aidspan has previously reported that representatives of key populations are less likely than other civil society members to know they can request technical assistance (TA) from the Global Fund's Community, Rights and Gender (CRG) department. This knowledge barrier directly translates into limited access to support. AMSHeR's survey revealed that just 3% (n=3) of respondents reported that they received Global Fund CRG technical assistance (Figure 2). An overwhelming proportion (47%) did not even know that GRG TA was available. This is a slight improvement over the results of another survey conducted by the Eastern Africa National Network of AIDS Service Organizations (EANNASO) six months earlier, which found that 71% of key populations were unaware of the CRG technical assistance program. This could indicate that key populations knowledge of CRG TA is improving over time.
Figure 2: Key populations' knowledge and access to Global Fund technical assistance
The survey report identifies the availability and quality of data on key populations in Africa as another possible explanation for the limited engagement of these communities in PEPFAR and the Global Fund. According to respondents, the number of people who make up key population communities is grossly underestimated, which has significant implications on how loudly their voices are heard in negotiating spaces. One respondent from Kenya raises questions about how the country's size estimate of 10,000 men who have sex with men was reached. "We had disputes over how the data was collected. We questioned where they got their information," says Peter Njane, Executive Director of Ishtar-MSM.
In support of Njane's view, a systematic review presented at the 21st International AIDS Conference confirmed that key populations themselves are seldom meaningfully involved in their own size estimation studies. Out of the 71 key population size estimations reviewed, just 12 had evidence of key population engagement during study design.
Despite persistent barriers faced by key populations when engaging in both Global Fund and PEPFAR processes, respondents insist that progress must not be discounted. "We are getting there, compared to two years back," one participant affirms. Most expressed cautious optimism, saying they would continue to engage, while asserting that much remains to be done to deliver on the promises made by the Global Fund, PEPFAR, and other global financing institutions with respect to engagement.
"I was formerly part of the team at the Global Fund who developed the new funding model," said Meg Davis, lead author of the survey report. "The research confirmed both my best hopes and worst fears," she continued. "We found that key populations have seized the opening to engage in country after country, but that many were out-gamed and shut out when the time came to actually dole out the funds. If national HIV programs don't do better at directly funding key populations-led work, there will be no 'end of AIDS'- end of story."