1. Nadia’s Presentation:
The Global Fund: The Next 5 Years
14:30 – 16:00 THSY05
Symposia Session/ Session Room 1
Since its creation in 2002, the Global Fund has become the main financier of
programmes to fight AIDS. Taking into account the recent organizational
reforms, this session will discuss the strategic direction and future hopes of
the Global Fund from the perspective of the recently appointed General
Manager, implementing countries, members of civil society, and the donor
community.
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Introduction:
Good afternoon everyone. My name is Nadia Rafif. For the past 10 years, I have
been acommunity-based HIV advocate and program implementer in the MENA
region.
I wear several hats in the global HIV response:
I am the Executive Director of an AIDS Service Organization based in
Marrakech, Morrocco – L’association de Lutte Contre le SIDA.
I am also one of two African representatives to the NGO Delegation of the
UNAIDS Programme Coordinating Board.
And finally, I am the regional coordinator of CSAT, the Civil Society Action
Team, whose role is to strengthen civil society engagement in every
component of the Global Fund to Fight AIDS, Tuberculosis and Malaria
(the Global Fund).
It’s a privilege to speak with you all today.As the only civil society speaker for
this important session, I want to bring a community perspective to our
discussion on the strategic direction and future hopes of the Global Fund.
I have thought a lot about this, and I have solicited input from other civil society
leaders as well. I have narrowed my thoughts into several key areas of concern:
1. The restructuring of the Global Fund
2. How restructuring has negatively impacted HIV programs
3. The dismantling of the Global Fund’s Structures to Engage with Civil
Society
4. Transparency and Accountability
5. The New focus on High Impact Countries
6. The demand driven model in peril
But first, let me start by affirming, very clearly, WHY CIVIL SOCIETY ENGAGEMENT IS
CRITICAL TO ACHIEVING MAXIMUM IMPACT AT THE GLOBAL FUND. Let us be clear –
THE GLOBAL FUND IS ALSO OUR FUND. A concerted effort must be made to

2. support linkages and synergies between civil society, the Global Fund, and
program implementers. CIVIL SOCIETY IS NOT INCLUDED PROPERLY IN THE
CURRENT CRITICAL DECISIONS TAKEN BY THE SECRETARIAT and we all
fear that the transformation in place will put us far away with the golden
model of demand driven that was the initial philosophy of the fund.
The Global Fund, which has made direct investments in 150 countries, has
achieved landmark impacts to date in global health – especially with regard to
treatment access. The Global Fund provides about two-thirds of total
international funding for tuberculosis (TB) and malaria services, and one-fifth
for HIV services.
But we cannot, and should not, measure IMPACT solely by treatment coverage.
The Global Fund also plays a crucial role in strengthening and linking health
systems and community systems in order to ensure that programs can be
sustainable, mutually supportive, and effectively scaled up. The Global Fund has
been a powerful force in advancing human rights and placing people infected
with and affected by HIV and AIDS.
Having spent the last ten years working on HIV in Morocco, and the last 4 years
in 19 countries in the Middle East/North Africa region, I can personally attest to
the radically positive changes imparted by the Global Fund. I saw treatment
waiting lists for AIDS patients disappear, when previously, individuals in need of
treatment had to wait until someone in the program died in order to be enrolled
in the program. I have seen extremely marginalized and excluded groups –
including men who have have sex with men, sex workers, and injecting drug
users -- regain their dignity and full access to the same quality healthcare
services as any other citizen. I have seen NGO actors negotiate on equal terms
with government representatives about the HIV funding priorities in their
countries and how best to manage international aid.
As the ultimate beneficiaries of investments in health and an effective response
to epidemics, communities are also able to provide unique feedback about the
quality and effectiveness of programs funded by the Global Fund. In the Eastern
Europe/Central Asia region, civil society and key affected populations are the
most vocal proponents of evidence-based practices and measures to protect
human rights. In Ukraine and Kirgizstan for example, civil society organizations
led their respective initiatives which legalized WHO recommended opioid
substitution therapy which is now available broadly in both countries through
programs supported by the Global Fund. Advocacy by civil society groups for
continued investment in effective services and for defense of human rights is not
only good for public health, it is an effective risk managementmeasure.
Civil Society is also uniquely positioned to reach out to and develop trusting
relationships with other community members to mobilize communities for
behavior change and provide services like needle and syringe programs, peer
support or other community outreach services. Moreover, as principal
recipients, civil society organizations in the EECA region have been among the

3. most successful implementers of programs supported by the Global Fund and
other donors. As the ultimate beneficiaries of investments in health and an
effective response to epidemics, communities are also able to provide unique
feedback about the quality and effectiveness of programs funded by the Global
Fund.
As civil society, therefore, we have the daunting, life saving task of ensuring that
the world does not backtrack on gains so far made. If the global community is to
prevent this potentially enormous setback threatening the health and lives of
millions of people – and realize the numerous commitments made by United
Nations member states through the Millennium Development Goals and at the
2011 High Level Meeting-- swift and decisive action has to be taken – and it must
be taken with us involved. The Global Fund is also our Fund, andit is the best
mechanism the world has for realizing the possibility of a world without AIDS.
With that in mind, I would now like to convey the key concerns held by civil
society regarding the Future of the Global Fund:
1/ The restructuring of the Global Fund: confusion & worries
Gabriel, you tell all of us not to worry ….
But we are all confused and we are all worried… not only civil society, but
governments, CCMs, beneficiaries of the Fund and the communities we all serve
all around the word.
Since the last Global Fund Board Meeting (which took place in Accra, Ghana, in
November 2011), many changes have been set in motion:
First, the announcement that the Round 11 Funding Cycle was cancelled
Second, a change in the strategic direction of the Fund, namely the the
Global Fund Board’s adoption of a new strategy for the period 2012-2016.
And finally, the restructuring process currently taking place, which is still
in progress and expected to be completed by the end of the year
Everybody is confused: we hear about the 55% rule or the 10% Rule; priority
countries; high impact interventions; abolishment of the civil society
department; departure of more than 50% of the staff from the Geneva
secretariat;a drastic reduction of CCM units, and so on …
When we ask questions, we are told to wait, but time is running out. I would like
to highlight several specific issue areas of concern:
2. First: the negative impact of restructuring on HIV programs
The many changes happening at the Global Fundcome at a time when the world
is, now more than ever, so close to the end of AIDS. It also comes at a time when
a decade of investment in malaria and tuberculosis through the Global Fund has
resulted in so many saved lives and improved quality of life across the three
diseases.

4. If the Global Fund scales back now, the negative impact on individuals and
communities will be devastating; and in fact, these negative effects are already
being observed in many countries. I want to give a few specific examples:
- First, program interruption. Since the crisis started, many grants have
stopped. The situation in some countries is becoming unacceptable. The
Global Fund was our ally in resource-limited countries. Now, in many
countries, it's the source of problems, with grants disbursed very late,
leading to human resources without salaries (which we have seen, for
example, in Mali, Burundi, Nepal).
- The Transitional Funding Mechanism is also problematic. The
principle behind the TFM was supposed to be the continuation of funding
for essential services, but in reality, it has simply meant no more
enrollment of new patients in some countries. When we hear that only
“essential services” can be funded; and at the same time, find out that new
patients aren’t being enrolled, it sounds like: “Treating new patients is not
an “essential task” of the Global Fund !!!!” This is unacceptable.
- Drug Stock-Outs are also occurring. In Mauritania for example, the
combination of a complex bureaucracy coupled with confusion made by
the recent Global Fund changes led to a late disbursement of Global Fund
monies. Although Mauritania learnt at the last minute that they will be
eligible for TFM and they prepared an application, the late disbursement
of funds means that there will soon be a stock out of ARVs, and no new
eligible patients are receiving treatment at the moment.
- National Strategic Plans are going unfunded. In the new Republic of
South Sudan, 80% of the national AIDS plan remains unfunded. South
Sudan was counting on Round 11 to cover antiretroviral treatment costs
and to fund a nascent HIV prevention strategy facing extra stress from
returnees from neighbouring countries with high HIV prevalence.
- Finally, there is increased vulnerability among Key Populations. The
cancellation of Round 11 leaves Bolivia with no means of scaling up HIV
prevention services for key populations affected by HIV, including at-risk
groups not currently being reached such as prisoners and indigenous
people. Therefore, an increase in HIV transmission amongst vulnerable
populations is expected.
3. Our second key concern is the dismantling of the Global Fund Structures
to Engage with Civil Society:
We are also worried that some of the recent changes to the structure of the
Global Fund will weaken civil society communication and cooperation with the
Secretariat – and that this will hinder the Global Fund’s effectiveness, risk
management and sustainability of programs supported by the Fund.
Previously, civil society involvement was facilitated through the Civil Society
Partnerships Team. This work has been vital, but we fear that it has been
significantly weakened within the new structure. In the reform of the secretariat,
the Civil Society Partnerships Team was disbanded. We understand
thatresponsibility for interaction with civil society is now supposed to be

5. integrated throughout the different departments and portfolios, some of which
may or may not have the skills, capacity or commitment to have an overreaching
aim of maximizing synergy with civil society for improved country level health
outcomes.
Furthermore, we also understand that within the new structure, the fully
functional CCM Team will be diminished to a far smaller CCM Hub, and
from now on, the main responsibilities of building partnerships with all
country stakeholders -- including facilitating an active and inclusive CCM --
will be with Fund Portfolio Managers. Joint efforts of the CCM Team and the
Civil Society Partnerships Team were instrumental in bringing civil society
stakeholders into national decision-making and effective grant oversight. The
abolishment of both Teams is very concerning.
Gabriel, you tell us"don't worry, the CCM function will be mainstreamed
into grant management." But this reassurance to too vague to be
meaningful.
We need you to understand that CCMs matter, and not just for ethical reasons:
they are important for very pragmatic reasons too.
If the Global Fund’s programs are dictated from Geneva, the program’s priorities
will be wrong, and there will be no country ownership and bad implementation.
If you don't ensure the CCM works properly, what you get is huge unmanaged
conflicts of interest inside the CCM. It is precisely those conflicts that lead to
CCMs funding the wrong things, and to corruption.
That is why the Global Fund must dedicate the staff necessary to liaising with
CCMs to ensure that all members fully understand and respect the letter and the
spirit of the CCM guidelines. Our CCMs will listen to the Global Fund, the biggest
funder of their response to AIDS, TB and malaria. And please remember: the
root cause of both corruption and low program performance is poorly
functioning CCMs.
Meaningful engagement of civil society and key affected populations is essential
to the success of the Global Fund. This engagement must happen in the planning,
implementation, and evaluation of national level programs.
We fear that without a clear focus onthis responsibility, paired with adequate
human resources to make it happen, meaningful engagement of civil society and
communities will not get the support it needs to serve its proper role. We will
become simple a tick box on a very long check list, and the essential functions we
have provided to the Global Fund since its inception will begin to fall apart.
Someone needs to be responsible and accountable for the entire civil society
strategy within the Global Fund secretariat and the over Global fund generally.
We do not see this in the current structure yet.
Transparency and Accountability

6. We have seen cases of corruption among Global Fund programs in Mauritania,
Mali, Zambia, Djibouti. Unfortunately, this has been perceived by some donors as
a golden opportunity to justify their withdrawal of support to the Global Fund
without losing face, or seeming to renig on their moral obligations to health.
In reality, the misappropriated funds are miniscule (0.3%) when compared to
the overall amount involved. The Global Fund has been a victim of its
transparency, which should have been upheld as an example of accountability in
the history of international development. The Fund itself set up the means of
monitoring and financial control that helped reveal fraudulent activities. And
every time the abuse was proven, the programs were frozen and the recipient
States urged to give back the misappropriated funds.
It is extremely difficult for HIV implementers in the field to explain to a
Congolese patient that she can not get the treatment she needs, because of the
current economic environment. We cannot let this be an excuse to underfund
programs that provide life-saving HIV prevention, care and treatment programs.
Why should she be punished because, in some countries on some programs, a
tiny portion of the money spent on the fight against AIDS has not been used
correctly? We urge all donor nations to re-commit to the Global Fund.
Coming from a MENA region I am particulary concerned about the Global
Fund’s new emphasis on high-impact countries.
You are talking about IMPACT, but what about the estimation of patients
that will receive treatment until 2015, thanx to the Global fund support? Is
there a difference between a person in Morocco, in Argentina and in
Zimbawe ? How will we able to measure that this changes are working and
meet the needs of people on the field? We need a financial model that is
flexible and inclusive. We certainly want to save as many lives as possible – but
what is going to happen to middle-income countries, with low general
prevalence, but with concentrated epidemics among key populations like men
who have sex with men, sex workers, transgender people, and injecting drug
users? We have heard so much at this International AIDS Conference about
targeting funding and interventions at key populations. But in this new
structure, regions where concentrated epidemics are exploding – especially
Eastern Europe, Central Asia and the MENA Region – will go unfunded. Again,
despite the rhetoric, the key populations will be left out. This is will also impact
the effectiveness of the TB response within those population groups, particularly
MDR TB.
Many countries are transitioning from low to middle income, but
poverty in middle income countries remains high, contributing
significantly to negative health outcomes. Poverty in
middle income countries is exacerbated by rising income inequality.
At the World Economic Forum in Davos in 2011, income inequality
within countries was recognized as one of the most serious challenges
facing global development. In fact, 60% of the the world’s poor live in 5
middle income countries: Pakistan, India, Nigeria, China and Indonesia.

7. Of the
top ten countries by contribution to global poverty, only four are low
income.
We urge the Global Fund to recognize that a short-term vision is a weak
approach, and instead, to prioritize long-term investment in a system
ensuring good health of the poorest and most excluded.
5. The demand driven model in peril
I want to come to my final point: Ensuring that the principles that
anchor the Global Fund are left intact.
Here I am talking again about our fear that many governments are
proposing a new Global Fund funding model that abandons the
demand
driven principle of the Global Fund, and embraces hard caps or
allocations on what countries or regions could receive. We believe
this would be a disastrous mistake.
At the moment science is telling us that we can fight to realize the
end of AIDS, if we have enough funding, the right policies, and the
right interventions--capping or limiting country or restricting demand
completely contradicts our shared goal of a demand driven fund. Its
like we want to do the think right then doing the right think. It won’t
encourage at tall country ownership, innovation and creativity, and
flexibility.
We say no to this approach. As the people waiting in line for
services, as the people the Global Fund has been established to
support, we say no.
Therefore, we are asking key leaders such as yourself to COMMIT
yourself--we are calling on you to stand with us. Gabriel, Eric,
Rachel, Mireille--you sit at the Board, you have a critical role. So I
am asking my colleagues to COME FORWARD
"As the world prepares to embark on a course to end AIDS and as
the Global Fund reviews its grantmaking model, that I will defend the
demand-driven Global Fund, and oppose any measure that
undermine scale up, resource mobilization oruniversal access. In
particular, I will oppose proposals to create ceilings or envelopes that
cap countries' ambition when applying to Global Fund."
Thank you."