Carlos Bruen Ruairí Brugha Department of Epidemiology & Public Health

1. Increasing Country & Community Involvement in Global Health Policy Processes? The Case of the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria Carlos Bruen Ruairí Brugha Department of Epidemiology & Public Health International Conference 2012

2. Presentation outline • Aims & Methods • Context • Findings • Discussion

3. Project Aims & Methods Global Perspectives: Evolution & Impact of Global Health Initiatives (GHIs) • Identify, track and evaluate evolution of GHIs: • Focus at the global level and global-country interface • Focus on issues of partnership, governance, influence of individuals, organizations and networks etc • Results: • Address rationales and evolving roles of GHIs • Document stakeholder perspectives on selected GHIs, e.g. i) role of individuals and organizations in shaping GHIs; ii) GHI impact on health systems of southern African countries • Methods include: • Documentary Reviews • Stakeholder mapping & in-depth telephone interviews of purposively selected people across 8 constituencies (n=36) (2009-10)

4. Context: NGO Engagement in Global AIDS Treatment, Prevention & Related Interventions • 1980-90s: Gradual shift from Northern domestic to transnational AIDS civil society networks • 1996: UNAIDS launched, guided by a Programme Coordinating Board (PCB) that includes NGOs • 2000: International AIDS Conference, Durban • 2001: Organisation of African Unity summit on HIV/AIDS, Tuberculosis and Other Infectious Diseases, Abuja; UNGASS • 2001: Launch of Transitional Working Group (TWG) that established the Global Fund to Fight HIV/AIDS, TB & Malaria • 2002: Global Fund launched & NGO inclusion guaranteed

5. NGOs & the Emergence of the Global Fund • Early discussions on global HIV financing initially shaped by donor priorities and contested positions • Infrastructure V Product investment? • Horizontal or vertical approach? • NGOs engaged in advocacy & lobbying of governments • Divided by similarly contested positions as donors • Northern AIDS treatment NGOs directly involved in negotiations through the Global Fund Transitional Working Group • “Political Entrepreneurs” with incentives and capacity to invest in creation of a new institution • Personal connections and positive reputation among influential actors • Consultation initially limited to network connections between small number of Northern NGOs and dominant NGOs in countries

6. Early Gains • NGOs move from the fringes to the core • Institutional access created greater potential for NGOs to influence agenda-setting, decision-making and organisational operations. • NGOs came to be considered a source of credible information for other Board members and Secretariat staff, winning over ‘doubters’ at senior levels • NGOs developed delegation systems to enhance representativeness, provide support and manage their relations • 2004: NGOs representing affected communities Delegation get voting rights • Through the Global Fund and in countries, facilitated significant scale-up of treatment and impact on three diseases

7. Early Challenges • Perception of undemocratic and anti-participatory processes at global level, exacerbated by: • Who had access to new technology or to the global centers of influence • Dominance of large NGO networking associations • Slow release of information • Resource constraints and expanding workload at global and country levels • Divisions and rivalries between NGOs/Civil Society groups, e.g. • Northern and Southern NGOs or between AIDS Treatment NGOs and Primary Health Care NGOs

8. Global Fund, NGOs and Evolving Relations • Influence at Board and Secretariat level, e.g. • Expansion of original Global Fund Framework document e.g. Community Systems Strengthening, gender & sexualities policies • Board decisions rejecting Secretariat-arranged drug donations • Increased funding & competition between NGOs • In some countries, a barrier to cooperation at country level, with implications for global level activities • Financing prioritized service delivery/implementation activities at expense of advocacy, research and other activities • NGOs concerned about donor co-option: • Diverting activities for sake of attracting finances? • Poachers turned gamekeepers? • Constraining advocacy and watchdog activities?

9. Lasting Challenges • Global activities perceived as disconnected from country and community realities • Distracting from community and country priorities & needs • Weak mechanisms for information sharing or community engagement and participation at national and global levels • Shifting landscape: • Dependency on larger Northern NGOs lessening & not as exclusively driven by AIDS treatment NGOs • Increasing cooperation at global level, creating conditions for coordination of resources across GHIs & reduction of ‘warring factions’, e.g. International Civil Society Support (ICSS) • NGO Accountability: To whom, for what, and how? • “What is important is to be aware that they are not observers standing on the sidelines with a watchdog function, figuring out what’s right to do. They also are similarly interested in finance from the Global Fund. That is often overlooked I think, and the Civil Society role as advocates and watchdog and drivers of fairness needs…to be looked at very carefully • C28, Senior Donor/GHI Representative

10. Discussion Points • 2001-2011 was a period of structured experimentation in global health governance and policy leading to many positive outcomes • However, need to continue the movement beyond consultations with civil society ‘leaders’ to develop structured mechanisms for participation from community level upwards to enhance community-based responses • Important to recognise that NGOs are increasingly part of the power structures

11. Acknowledgments • Special thanks to all participants who were willing to take part in consultations, interviews, and follow up queries. • Project colleagues • Impact of GHIs in Africa Project • Global HIV/AIDS Initiative Network (www.ghinet.org) • Funding Organisation • Funded by EU Framework 6 INCO-GHIs