Reflections on replenishment: Montreal, Malawi, and doing better
I had the privilege of attending my first Global Fund Replenishment meeting last month in Montreal, Canada, as a GFO correspondent. My reports on the formal meeting and side events appeared in GFO 296. The event was split over two days: an afternoon of speeches and a pledging session, in which countries, one-by-one, announced their contributions from the stage, followed by a morning of more speeches and panel discussions. The overall feel was of celebration and optimism. Canadian Prime Minister Justin Trudeau, playing host this year, praised the Global Fund and its track record of saving lives and averting new infections, and backed up his talk with a US$720 million pledge to kick things off. The various other heads of state, health ministers, and private sector leaders all commended the Fund and the work that it supports—and, of course, themselves for contributing. The meeting closed with a heartwarming visual: Trudeau on stage, with a rainbow of people behind him—ostensibly representing all the types of people who are helped by the Fund—proclaiming, “We have reached our goal! Together, we have raised almost US$13 billion, and in doing so we have saved eight million lives.”
Global Fund Replenishment meeting closing, Montreal.
Theatrics aside, this is fantastic. Over the next three years, the Global Fund is on track to prevent the deaths of as many people as live in all of New York City, because thirty-five some odd countries came together to do the right thing. It is a truly remarkable achievement in a world we so often think about as being defined by conflict and suffering. There are some bright spots after all. The Global Fund, the countries that contributed, and all of the tax paying citizens of those countries who motivate their governments to contribute, should be commended.
But honestly, they could do better. Health GAP’s Matthew Kavanagh pointed this out clearly in his article Fuzzy Math at the Global Fund Replenishment? “…The Global Fund replenishment goal of $13 billion was adopted despite the fact that … leaves a 20% gap in what’s needed to adequately address AIDS, tuberculosis, and malaria over 2017-2019,” based on the Global Fund’s own assessment of the total cost of effectively addressing the three diseases over this period. And Canadian philanthropist and advocate Stephen Lewis minced no words on the eve of the meeting: “The Global Fund should be asking for much more money.”
Donor governments should be doing everything they can to end the epidemics of HIV, TB, and malaria. These epidemics, and the poverty that drives them, are part of the legacy of colonialism and the continued pillaging of African and other “developing” countries’ wealth and resources by rich nations. The donor countries are doing something, but not enough. And no one country could be doing more than it is now than China.
China can do better
Frankly, China should be ashamed of its contribution. In a room where countries with significantly smaller economies were pledging hundreds of millions of dollars, the Chinese government representative came, as he put it, “with empty hands.” A few days after the meeting, however, China did announce an US$18 million pledge. For a country like China, to call that paltry is an understatement. According to the website Trading Economics, China’s economy accounts for almost 18% of all economic activity on the planet. In 2015 China’s GDP exceeded US$10 trillion. That US$18 million contribution represents just 0.0001% of China’s GDP. For comparison, Italy, which has a GDP of about US$2 trillion, pledged about US$175 million, or 0.008% of its GDP. So Italy contributes an amount, relative to its economy, 80 times larger than China does. But this isn’t about numbers, it’s about doing the right thing.
One cynical argument to be made—and one that I would ordinarily entertain—is that the European powers contribute to the Global Fund, among other aid programs, out of a sense of guilt over, or in rectification of, colonialism. It’s a form of atonement for Europe’s past sins, past sins that China simply didn’t commit.
Past sins, maybe not. But the level of current Chinese economic activity in Africa is significant and visible. It too is deriving massive wealth from Africa, at Africa’s expense. Where China’s hands were empty in Montreal, they are certainly full in Africa.
About a week after the Replenishment meeting in Montreal, I visited Malawi (another great privilege). According to the World Bank, Malawi is the fourth poorest country on Earth, with a per capita GDP of around US$380 per year. That’s about the cost of 1.5 nights at the Chinese hotel in Lilongwe. That’s right, in Lilongwe there is a big hotel which specifically targets a Chinese clientele. And from what I could tell, it’s one of only two or three large business hotels in the whole city. Also, there is a Chinese pagoda overlooking Malawi Square, near the Parliament Building. What this all suggested to me was that there are significant Chinese economic interests in Malawi. So significant that they might account for half of all business visitors to the capital.
Pagoda on Malawi Square, Lilongwe.
Presumably there are some benefits for Malawi and Malawians that come with the Chinese investment. But it’s not an endeavor of altruism. It’s business. So was colonialism. And the Chinese government should not be allowed point to its business endeavors as how it is contributing to the wellbeing of Malawi’s people. China needs to do better, in Malawi and everywhere. It should take every opportunity to give back to those countries, and those people, whom it is extracting vast wealth from. The Global Fund is as important and impactful of an opportunity that they will find. Moving the Chinese contribution towards numbers more like Italy’s would be a great way to begin embracing that opportunity wholeheartedly.
The Fund is also not doing the best it can in Malawi
The Global Fund, too, is present in Malawi in a big way. The Global Fund has disbursed nearly US$900 million in Malawi since 2003. According to a 2014 analysis by the University of California, San Francisco, Malawi is the tenth largest recipient of Global Fund disbursements overall. And with an HIV prevalence rate of about 10%, and nearly 10% of annual deaths being due to malaria, if the retargeting of Global Fund grants to “high burden, low income” countries means anything, the Fund’s investment in Malawi should only increase in coming years. The Malawian response to the three diseases is profoundly dependent on the Fund and other donors, and as such, donors can set much of the tone of the responses.
The Fund talks often about country ownership of the responses. In fact, “Country Ownership” is one of the Fund’s four guiding principles. The Fund thinks of its model as reaching, “beyond the mindset of paternalistic aid,” and having “countries take the lead in determining where and how best to fight diseases.” That approach is right and good. But coming out of Montreal, where there was great talk of community partnership and the importance of countries managing their own responses, it was striking, to say the least, to find that local civil society organizations in Malawi are largely being left out of the response, in favor international players.
There are two Principal Recipients for the main Malawi HIV/TB grant: the Ministry of Health, and a civil society PR, Action Aid, which is based in Johannesburg. Of the nine civil society sub-recipients on the Action Aid grant, exactly three of them are domestic. The local civil society representatives I spoke with expressed frustration and feelings of powerlessness in the face of international NGOs which have deemed them to have “insufficient capacity” to manage grants, and thereby ineligible as sub-recipients. Although the responsibility for selection and supervision of PRs is the job of CCMs, these decisions are reached through a collaborative process involving the Global Fund country team and grants management division, which held considerable sway in the process that led to the selection of the current civil society PR.
It’s hard to reconcile the marginalization of Malawian civil society with the mantra of country ownership. There may very well be legitimate concerns about the capacity of local organizations. But that concern should inform solutions, not sidelining. From what I heard, there has not been any effort on the part of the PR, or any other actors to build the capacity of local organizations so that, sometime soon, they can meet the standards required to be SRs or PRs. It should be everyone’s priority to empower local communities and organizations to take on the leadership and management of their response. And international PRs should be accountable for carrying that effort forward. Because the current arrangement doesn’t look like “country ownership;” It looks like foreign ownership, which is what colonialism looks like.
Which brings me back to Montreal. The process that unfolded there is essential to the Fund: it is how the money is raised to then be sent to the countries who need it. The Replenishment meeting was mostly about dollars. But it was also about replenishing the commitment of donors to the cause of ending HIV, TB, and malaria. That commitment was replenished by praising their generosity, describing the impact of their contributions, and affirming them as members of, as Chris Collins, president of Friends of the Global Fight, put it, “a club that these countries want to be a part of.”
But I wonder if all the praise and affirmation wasn’t a bit off the mark. As donors, they, quite literally, just sign the checks. It is the people in recipient countries who are living the realities of these epidemics and doing everything they can to end them who should be receiving the applause. They should be celebrated, not told that they have “insufficient capacity.”
So just as we replenish the Fund and the resolve of its donors, I hope we can find more and bigger ways to replenish the spirits and resolve of those who bear the biggest burden in all of this: the women, men, transgender people, children, advocates, outreach workers, and healthcare providers without whom none of the great achievements of the Global Fund would be possible. They make the most valuable contributions of anyone. The money is simply the gas in their tank. And with the miles they’re putting on, they can always use more of that. China, would you like to start the pump?