On May 9-10, the board of the Global Fund to Fight AIDS, TB and Malaria will meet in Skopje, Macedonia to approve a new policy on which countries are eligible for funding.

I’ve been immersed in this labyrinthine policy as a consultant for the three civil society delegations on the board of the Fund: Developing Country NGO Delegation, Developed Country NGO Delegation and Communities Delegation. They came together to press for an overhaul of the policy. For a variety of reasons, that didn’t happen.

But there has been some progress; there are some big questions for civil society to weigh in on before May, and some critical areas to monitor if the current version is approved.  Here’s an overview: heads up, it’s a long blog.

Why an eligibility policy? Funds are limited, lives are literally at stake, and difficult choices must be made about where to invest. What are the principles that should be used when you’re facing three global crises – the epidemics of HIV, TB and malaria? This is not just a question of health economics – it is also an ethical challenge.

It’s a problem that dates to the beginning of the Fund, when grants were in the millions, not hundreds of millions. To solve it, the World Bank offered to draft an approach. Sixteen years later, with over $10 billion to allocate, the criteria the World Bank identified over a decade ago still define Global Fund eligibility: national income and disease burden.

Disease burden is calculated based on data reported by WHO and UNAIDS. In the new draft policy, countries will be split into just “high burden” and “not high burden”, much clearer than the multiple categories used in the 2016 policy (low, moderate, high, severe, extreme). That’s progress.

The national income classification, however, is based on one problematic World Bank indicator: Gross National Income per capita (GNIpc, calculated using the Atlas Method to manage currency fluctuations. Note that GNIpc is not the same as GDP). Under the Global Fund’s new policy, countries with low GNIpc would be eligible. Countries with high GNIpc will continue to be ineligible. And then there’s the vast diversity of middle-income countries, the focus of all the debate.

Of course, GNIpc is a single number that tells you nothing about who in any country has the income, who doesn’t, and how much of it goes to health. I’m writing this blog from Mexico, an upper-middle-income country (or UMIC, in Fund parlance) where a lot of income is in the hands of elites and drug cartels. Try getting those wealthy elites to fund the health needs of key populations – or for that matter, those in many other UMICs. GNIpc is an arbitrary number that fails to capture a country’s internal inequality. However, it’s the main criterion used by the Fund to determine national income, in part because no other indicator (GINI coefficients, the Human Development Index, etc.) has enough reliable country data.

In the new draft policy, all low-income and lower-middle-income countries are eligible, regardless of disease burden. Upper-middle-income countries (the UMICs again) are eligible, if they have high disease burden. For HIV, that means either a generalized epidemic, or HIV prevalence over 5% in at least one key population (men who have sex with men, transgender people, sex workers, prisoners, or people who inject drugs). If you look at the data UNAIDS has online, you can see that nearly a third of UMICs report no data on any key population, often because governments deny key populations exist and don’t do research on their health needs. My civil society clients on the board pushed for, and got, a commitment that as part of the new eligibility policy, when a country has no government-reported HIV prevalence data for any key population, the Fund will consult with UNAIDS and use other data which they provide to determine whether the country is eligible. This is a small change that could make a big difference in eligibility for some countries. Monitoring this will be crucial.

Another nice win, buried in the footnotes, would be a little more flexibility on transition funding for countries that are ‘transitioning’ out of eligibility. Right now, those countries get one allocation (normally, three years) of transition funding to tide them over. The new draft policy states that the Global Fund Secretariat can request a second allocation of funding on a case-by-case basis, and may consult UNAIDS on HIV incidence data – which would show if HIV is on the rise during the transition process, and the country needs more time.

The rest of the debate in the policy focused on political exclusions and the NGO Rule, so a few words about this complicated jigsaw puzzle.

First, there are two groups of UMICs that are ineligible in the policy purely because of the foreign policy agendas of countries that donate to the Fund, and that are a powerful voice on the Board. The first group excluded is three UMICs that are not on the OECD Development Assistance Committee (DAC) list of Overseas Development Assistance (ODA) recipients. This is a list that many donor countries use to guide their foreign assistance. Under this rule, three countries are ineligible for HIV allocations: Russia, Romania and Bulgaria.

My civil society clients have been trying to eliminate this rule altogether, arguing that it has nothing to do with the need to fight the three diseases wherever they are. Other constituencies tried to expand the exclusion to TB and malaria as well as HIV. The result is a draw: the rule stays in place for HIV only, just like in the old policy.

The second political exclusion applies to UMICs that are also Group of 20 or G-20 members, which in the past were not eligible for HIV funding unless they had “severe” disease burden. India, South Africa and Indonesia are G-20 members that had severe disease burden, so despite being G-20 members, they were eligible. Argentina, Brazil, China, and Mexico were excluded because their disease burden was not “severe” enough. Now that the eligibility policy disease burden has been simplified to “high” or “not high”, no more “severe”, this G-20 rule had to be revised too.

Civil society pushed for the G-20 exclusion to be eliminated, while others wanted to keep it in place. The compromise was that it’s eliminated, but with a “grandfather clause” stating that previously ineligible countries (Argentina, Brazil, China, and Mexico) are still ineligible. (Russia is a G-20 member, but they fall under the section below.)

This brings us to an important piece of the policy: the NGO Rule. Do some deep breathing here, because if you thought the above stuff was complicated, you may need a yoga break before tackling the next bit.

In the old policy, the NGO rule stated that UMICs with high disease burden that are excluded under the OECD DAC provision (reminder: that’s Bulgaria, Romania and Russia) could get funding solely for civil society – if the country also has “political barriers”.

What are “political barriers”? Great question. This is not a category established under international law – it’s purely a Global Fund invention. What it has meant in the past was that Russia, which legally restricts harm reduction, was deemed eligible for the NGO Rule.

With their NGO Rule grant, Russian activists implemented a successful three-year program that mobilized key populations to deliver peer-led harm reduction, HIV and TB services, litigate for their rights, and successfully advocate for funding from government agencies. This work ground to a halt after December 2017, when Russia was deemed ineligible by the Fund due to a brief spike in its GNIpc. (As the economy has since been troubled, I think Russia should be eligible in 2018, but let’s see: the World Bank has yet to publish Russia’s latest GNIpc.) The civil society delegations pushed for Russia to be eligible for the NGO Rule in the new policy, and got a useful clause added to the policy.

What about Romania and Bulgaria? These two countries also don’t fund much harm reduction, but the Secretariat never deemed them eligible for the NGO Rule. This was due to a headache-inducing interpretation of “political barriers” to mean that to be eligible, a country had to have laws on the books that restrict evidence-based interventions for key populations. If the country didn’t have such laws, but just lacked political will to save the lives of key populations, that didn’t count as a “political barrier”. Romania and Bulgaria were deemed ineligible.

To be clear, there’s no grounding in international law for this distinction between “political barriers” and “political will”: it is an arbitrary distinction. UN human rights treaty bodies and special rapporteurs on the right to health have all clearly called the failure by countries to invest in harm reduction a grave violation of the right to health. There has been no suggestion that “lack of political will” is a less serious violation than having restrictive laws on the books. Obviously, if you’re a drug user in Romania with no harm reduction service access, it probably doesn’t matter to you why that is. Either way, your right to health is not being fulfilled.

My clients also pushed for a revision of the “political barriers” language, to make it clearer, but so far that has only resulted in even more confusingly elaborate new proposed language which I think may just mean the same thing as the old language. This is an important area for HIV and human rights experts to weigh in on, before the May meeting.

Finally, my civil society clients pushed to expand the NGO Rule to cover the excluded G-20 members (Argentina, Brazil, China and Mexico). That didn’t happen, but there is a commitment to discuss some other form of funding for communities in ineligible UMICs. This discussion will happen when the Board starts to look at its allocation method this summer.

The challenge I foresee is that one potential outcome of this “discussion” is that the funding stream comes out of catalytic funding, or is left to multi-country proposals. Catalytic funding is an amount of money taken off the top of the Fund’s resources before it allocates the rest among eligible countries, and set aside to tackle programs and objectives that aren’t covered within country allocations. This amounted to $800 million last time, but may wind up being less next time, if the overall funding for the next Global Fund replenishment is less.

Locating this stream within catalytic funding might pit key populations in Argentina, Brazil, China and Mexico against other powerful players – UN agencies, civil society in other countries, technical assistance providers, small island economies and multi-country grant recipients, etc. – all vying over a share of a diminishing pot of funds. Using multi-country proposals is also risky, I think, because the size of the countries is great, and could consume the relatively small amounts allocated for multi-country grants. Communities in those countries should ask tough questions about any future proposal to lump them in with the growing contenders for catalytic funds.

In conclusion… if you’re still here…bravo. The Global Fund opened its doors in 2001 with the mandate to create a ‘war chest’ to fight the three diseases globally. Over time, income classification become the main determinant of eligibility, with disease burden only applied to some middle-income countries to prioritize among them. Because the GNIpc metric and the arbitrary categories of income classification are not meaningful descriptions of the more complex and fluid reality of the three diseases, exceptions and exclusions have been piled on in headache-inducing complexity.

But the Fund is also unique among donors for its commitment to transparency and civil society participation in governance. What this all boils down to, for civil society is:

Share your views with the Board before May on everything about the policy, especially:

• Whether there should be funding for civil society to address HIV in ineligible UMICs such as Argentina, Brazil, China and Mexico
• How that funding should be managed and administered
• How “political barriers” should be defined in the NGO Rule

If the policy goes through, be ready to monitor:

• Which UMICs have no government-reported data on any key population group – and whether UNAIDS has access to other credible HIV prevalence data that could be shared with the Fund Secretariat, in order to determine whether that country should be eligible. It’s important for key populations in those countries to press their UNAIDS country or regional offices to advocate on their behalf with Geneva headquarters
• Countries going through “transition” – where the Fund should ask for a second allocation if the process isn’t going well, or where HIV incidence data shows a spike

And bear in mind for the future:

• We have to keep pushing for a better system of assessing country economic capacity to address health, beyond GNIpc, because this is crazy. The Fund’s own Equitable Access Initiative recommended analyzing fiscal capacity through qualitative assessments of the national funds available for health, which ought to be feasible for the small number of UMICs.
• A radical thought: perhaps donors who are financing efforts to end an epidemic should not withdraw their funds from a country at all until that epidemic is under control.

To provide input, please contact Mike Podmore, new Board member of Developed Country NGO Delegation on the Global Fund Board; Rico Gustav, Board member of Communities Delegation; or Allan Maleche, Board member of Developing Country NGO Delegation.

I hope this is helpful – will try to answer questions in the comments.