A focus on human rights and gender equality is front and centre in The Global Fund’s new strategy for 2017-2022. Approved at the 35th Board meeting in Abidjan at the end of April, the new strategy has four strategic objectives, each with several operational objectives (see GFO article for an overview of the new Strategy).
This article takes a closer look at the third strategic objective – to promote and protect human rights and gender equality – and its five operational objectives, which are as follows:
- Scale-up programs to support women and girls, including programs to advance sexual and reproductive health and rights.
- Invest to reduce health inequities including gender- and age-related disparities.
- Introduce and scale up programs that remove human rights barriers to accessing HIV, TB, and malaria services.
- Integrate human rights considerations throughout the grant cycle and in policies and policy-making processes.
- Support meaningful engagement of key and vulnerable populations and networks in Global Fund-related processes.
The need for an intensified rights and gender approach to end the three diseases is clear. In 2016, there are still 75 countries that criminalize same-sex sexual relations and 72 countries with laws specifically criminalizing HIV non-disclosure, exposure, or transmission. Women who sell sex are 14 times more likely to have HIV than other women. Transgender women are 50 times more likely than the general population to have HIV. In some high burden countries, adolescent girls are eight times more likely to become infected with HIV than their male peers. Men who have sex with men (MSM) are both more likely to have HIV than the general population, and less likely to access treatment and prevention services.
TB is the leading cause of death among the world's prisoners, with conditions such as poor ventilation and overcrowding fuelling TB transmission and reactivation. Further, in correctional facilities adequate care may also be denied. Malaria remains a leading cause of morbidity and mortality among refugees and internally displaced people, with inhumane living conditions and poor nutrition exacerbating susceptibility, particularly for pregnant women and young children.
Levels of funding
The Global Fund needs a strong focus on human rights and gender equality in the Strategy to motivate the necessary levels of funding for rights-based and gender-transformative approaches. Out of all concept notes submitted in 2014 (a total value of $7.9 billion), just $17.5 million was requested to address human rights barriers to access. In a recent UNAIDS survey of HIV and human rights organizations, just 25% of respondents reported accessing Global Fund money for their human rights work. None of those respondents was from Africa.
The human rights funding deficit is perhaps even starker for malaria and TB programs. In an analysis of 42 malaria concept notes and 23 TB concept notes submitted in Windows 1-5, although 50% of malaria concept notes and 65% of TB concept notes identified human rights barriers to access, not a single one of these notes requested funds for removing legal barriers (see GFO article). The operational objectives to introduce and scale-up programs that remove human rights barriers to access, and to integrate human rights considerations throughout the grant cycle, aim to rectify this shortfall. In the coming months, the Global Fund will identify 15-20 focus countries for in-depth studies on scaling up human rights programing that will be implemented over the life of the new Strategy. In these countries, baseline studies will examine specific human rights barriers to access to explore the cost and potential impact of bringing human rights interventions to scale.
Currently, approximately 60% of Global Fund investments benefit women and girls. For the next allocation period (2017-2019), sub-Saharan African countries with the highest HIV infection rates in women and girls will receive about 30% more resources based on the revised allocation methodology (see GFO article). But, gaps persist in governance at country level, which the new strategy seeks to address with its operational objective to boost meaningful engagement of key and vulnerable populations.
There is still not gender parity on CCMs, which creates power imbalances for important decisions about funding and programming. In 2015, 40% of CCM members (globally) were female and only 37 CCMs were chaired by women. CCM induction trainings on gender and human rights will begin this year, in line with the new Strategy.
To further reduce health inequities driven by gender and age disparities, the Fund’s strategy commits to working with partners to improve data collection, ensuring that sex- and age-disaggregated data appropriately informs national health strategies. Technical support through partnerships with other UN agencies will also be made available at country level.
Reaching key populations
Importantly, the human rights and gender equality strategic objective underpins a critical operational objective elsewhere in the Strategy, which is to scale up evidence-based interventions with a focus on the highest burden countries with the lowest economic capacity and on key and vulnerable populations disproportionately affected by the three diseases. Many high-burden countries with limited ability to pay are also places with restrictive legal and policy environments, making it even harder to reach key and vulnerable populations. This is no coincidence. Laws and policies that violate human rights and limit gender equality fuel the spread of the three diseases and hamper treatment efforts. (A recent report entitled “Open for Business” makes the link between economic prosperity and non-discriminatory environments for sexually diverse populations.)
The Fund’s Investment Case for the 2017-2019 replenishments illustrates why The Global Fund’s human rights and gender equality strategic objective is so critical for reaching key populations. The investment case shows that an optimized allocation approach would include expanding test-and-treat and pre-exposure prophylaxis (PrEP) for key populations in several countries with significant human rights barriers to access.
The investment case says, for instance, that early antiretroviral therapy for MSM needs to be added as an intervention country-wide in Sierra Leone, Mali, Botswana, Swaziland, Democratic Republic of Congo (DRC), Cameroon, and Zimbabwe, as well as in all but one district in Nigeria. Similarly, it says that PrEP for sex workers should be introduced across Congo, Sierra Leone, Rwanda, Zambia, Kenya, Zimbabwe, Mozambique, and South Africa.
In most of these countries, homosexuality or sex work is criminalized. This makes the roll-out of these high-impact interventions for key populations extremely challenging unless there are tandem investments in enabling environments which protect human rights and promote gender equality.
UNAIDS suggests that countries devote 8% of resources to programs to reduce human rights–related barriers to accessing services, and to programs that support advocacy and political mobilization by 2020 (see GFO article).
To support scale-up of interventions among key and vulnerable populations, The Global Fund’s operational objective to support meaningful engagement of these groups in Global Fund-related processes will carry forward some of the work begun through the Community Rights and Gender (CRG) Special Initiative. The CRG is investing approximately $5 million in eight global key populations networks through a partnership with the Robert Carr Network Fund. The aim is to strengthen engagement of key population network members at country level to participate meaningfully in Global Fund processes.
Further, the operational objective to scale-up programs to support women and girls, including programs to advance sexual and reproductive health and rights, will build upon the Fund’s current partnership with UNICEF. Begun in April 2014, the partnership supports countries to include strong reproductive, maternal, newborn, child, and adolescent health components in concept note submissions. This results in strengthening the integration of sexual and reproductive health interventions for equitable access to services that are anchored in human rights and gender responsive programs.