Community Consultation on Gender Equality and the Global Fund to Fight AIDS, Tuberculosis and Malaria

Transcription

1 Community Consultation on Gender Equality and the Global Fund to Fight AIDS, Tuberculosis and Malaria June 2015

2 Table of Contents Introduction 1 Key Takeaways 3 Text Box: What is the most important action the Global Fund could take to ensure stronger attention to women and girls? 4 Limitations 5 The Global Fund s Leadership and Commitments to Women and Girls 6 Participation of Women and Women s Organizations in Global Fund Processes 8 Increasing the Global Fund s Investments in Women and Girls: From Country Dialogues to Grant Implementation 14 Text Box: Gender Indicators and Data 17 Funding the Right Things for Women and Girls 18 The Global Fund s Strategy: Strategic Objectives and Actions 23 Text Box: The Global Fund and Post Conclusions 26 ANNEX I: DEMOGRAPHIC PROFILE OF SURVEY RESPONDENTS 27 ANNEX II: IN-PERSON CONSULTATION AGENDA 30 ANNEX III: IN-PERSON CONSULTATION PARTICIPANT LIST 32

3 Introduction The Global Fund to Fight AIDS, Tuberculosis and Malaria has a deep commitment to gender equality and women and girls. With the Gender Equality Strategy, the Global Fund has attempted to increase its strategic investments in interventions that improve the health of women and girls. However, the Global Fund and its partners recognize that implementation of the strategy has been mixed and much more needs to be done to effectively meet the prevention, diagnosis, treatment, care and support needs of women and girls who are living with or affected by the three diseases. To this end, the Global Fund contracted the International Women s Health Coalition to organize a community consultation to seek feedback on how the Global Fund can better met the needs of women and girls through its strategic investments, policies, and processes. The results of the consultation are intended to inform the process of developing the Global Fund s strategic plan for the period The community consultation had two parts: an in-person consultation and an onlineconsultation. The online consultation was conducted in English, French, Spanish and Russian with a total of 317 respondents. The intention of the online consultation was to assess the extent to which women living with and affected by the three diseases, women in key populations, and women s organizations were able to engage with Global Fund processes at the country level; the extent to which the outcomes of country dialogues, concept notes and the work of the CCMs addressed gender equality and women s and girls health needs; and solicit feedback on areas where the Fund should be investing its resources. The in-person consultation was held on March 15, 2015 in New York, with 24 participants. The objectives of the in-person consultation were: To identify what works, what doesn t, and what more needs to be done to implement the existing gender equality strategy; To develop strategic recommendations on gender equality, women and girls; and To identify how the Global Fund can invest more effectively in the prevention, treatment, care and support needs of women and girls. While it touched on a number of the same areas as the online consultation, it focused on the development of critical recommendations for the Fund s strategy. Participants in the consultation had direct experience working with the Global Fund as advocates, board and committee members, technical partners or technical support providers, CCM members, and implementers of Global Fund programs and thus brought diverse perspectives to bear on the discussions. This report provides the results of the in-person and English, French, Spanish and Russian online consultations. The report is divided into chapters that examine: Key Takeaways Limitations; The Global Fund s Leadership and Commitment to Gender Equality and Women and Girls Women s Participation in Global Fund processes 1

4 Increasing the Global Fund s Investments in Women and Girls: From Country Dialogues to Grant Implementation Funding the Right Things for Women and Girls; and The Global Fund s Strategy: Strategic Objectives and Actions Each of these chapters provide key findings from the online and in-person consultations, as well as recommendations for the Fund s future work in each of these areas. In addition, there are three annexes that provide demographic information about the online survey participants; the agenda for the in-person consultation; and the participant list for the inperson consultation. 2

5 Key Takeaways While respondents felt that the Global Fund generally does try to meet the different health needs of women and girls, the institution is not doing well at addressing broader, systemic issues of gender inequality and gender-related barriers to access to care, which drive vulnerability to the three diseases. Respondents had a much better perception about the Global Fund s support for humanrights based programs than for programs focused on gender equality and the health needs of women and girls. This could be related to inclusion of human rights in the Global Fund s current strategy, along with a high-level corporate indicator, which not only communicates this area as an institutional priority but also drives institutional action. This underscores the need for a strategic objective and relevant, high-level corporate indicator to drive the institutions commitment to address gender equality in the next strategy. In addition, participants recommended ensuring that gender equality concerns are integrated throughout the strategic framework. Communication and leadership from the Global Fund Secretariat was identified as both a weakness and an opportunity to increase the both quality of participation of women in Global Fund processes and the types of gender-transformative interventions that should be prioritized. Although women are participating in country dialogues, concept note development and CCMs, there is the perception that their participation does not have a meaningful impact on the outcomes of these processes, particularly as it relates to a focus on women and girls. Communication and lack of awareness about these processes were noted as the biggest barriers to participation across the board. Respondents felt that for influencing the concept notes and participation in CCMs, it was national-level policies and procedures on women s participation that were most critical. There were mixed results on the engagement of women and girls, particularly from key populations, in country level processes and decision making bodies, which could be reflective of the very different capacities of CCMs. This points to the need for differentiated responses from the Secretariat, and using tools such as the CCM improvement plans, to identify where there are problems and proactively responding to build the CCMs capacity to engage communities and translate their recommendations to effective, funded gendertransformative interventions. The lack of responses from women and gender advocates who work to respond to malaria and TB, and who participated in country dialogue and concept note processes to inform GF response to these diseases, is notably low (13% and 35% respectively). This reflects the broader reality that gender advocates need to be more active in these spaces, and do better to work with mainstream health communities to identify the gender-related barriers to services and most appropriate responses. 3

6 In terms of programming, there are some clear areas where the Global Fund could and must invest more and more strategically. These include Integrating HIV, TB and malaria services, particularly with sexual and reproductive health services, so that women and girls were able to receive comprehensive care that addressed their needs holistically; addressing the needs of adolescent girls; addressing gender norms and gender-related barriers to access to health care services; and supporting community systems strengthening and the role of communitybased organizations. The Global Fund s new funding model provides a great opportunity to increase the quality and scale of investments in gender equality and women and girls at the country level and the Global Fund Secretariat should take advantage of it to achieve this goal. What is the most important action the Global Fund could take to ensure stronger attention to women and girls? Respondents in the online consultation were asked to select one action, out of a possible 9, the Global Fund could take to ensure stronger attention to women s and girls needs through the programs it funds, or provide their own suggestions. Thirty-one percent of respondents (56/182) indicated that the most important action the Global Fund could take would be to require that the process to develop national strategic plans and investment cases include a gender analysis and the involvement of women s organizations, women living with HIV or affected by TB and/or malaria, and women in key populations. This was followed by requiring specific budget allocations for programs targeted at meeting the specific needs of women and girls and addressing gender-related barriers to prevention, diagnosis, treatment, care and support (23%, 42/182). Significant support was also received for providing financial support to women s organizations that are working to implement community-level programs (15%, 27/182) and requiring the participation of women living with HIV or affected by TB and/or malaria, and women key populations in the CCM (12%, 22/182). 4

7 Limitations The in-person consultation was held to coincide with the Commission on the Status of Women in the hope that there would be considerable numbers of women living with or affected by the diseases and from implementing countries that could participate. In the end, the majority of participants were technical partners, board members, and advocates from the Global North. In the future, we would recommend holding in-person consultations as standalone activities and inviting specific participants to attend in order to ensure more diverse and representative participation. The online survey sample size is relatively small. Although the majority of participants in the online survey had some involvement with the Global Fund, mostly at the country level, a significant number indicated that they had no engagement with the Fund. These survey participants were less likely to complete the survey, particularly the questions regarding engagement with the Global Fund and country-level processes, and in our analysis, did not skew the overall results. While the online survey was prepared in four languages English, French, Russian, and Spanish, there were significant gaps in participation from countries and regions where other languages are used. In particular, there was weak participation of participants from the Middle East and North Africa, where Arabic is a primary language. A significant effort was made to ensure the participation of women living with HIV and women in key populations. However, there was a notable gap in respondents who said they worked with these populations, as opposed to those who identified as being a part of these groups. For example, 26% (71) of survey respondents indicated they worked with transgender and gender non-conforming people, however only 5.4% (17) of respondents identified as transgender or gender non-conforming; 24% (67) indicated they worked with people who inject drugs, whereas only 7.7% (24) identified as a person who uses drugs; and 41% (113) indicated they worked with sex workers, while only 8.7% (27) respondents identified as sex workers. In addition, there was no participation of women living with TB and affected by malaria and limited participation of organizations that work primarily to address TB (15, 5%) and malaria (4, 1%). However, 32% (88) and 13% (37) indicated that a women living with or affected by TB and malaria respectively were populations that were a focus of their work. It is not clear whether this is reflective of their limited participation in Global Fund processes overall, or a result of limited outreach on the part of the researchers. In the majority of cases, participants were asked to select from fixed responses and did not have the ability to add or expand upon their answers. As a result, the results lack depth that could be obtained from further follow up with participants to better understand their responses. Despite these limitations, the results of both consultations provide useful insight into what the Global Fund is doing well, where it could improve, and where it could have the greatest impact on improving the lives of women and girls. 5

8 The Global Fund s Leadership and Commitments to Women and Girls The Global Fund adopted a gender equality strategy in 2008 that outlines commitments to ensure that the Fund s funding model and processes are inclusive of and respond to the needs of women and girls; establish partnerships to prioritize investments in women and girls at the country level; and improve communication and leadership of the Global Fund on these issues. While participants in both the online and in-person consultations generally felt that the Global Fund is committed to address the needs of women and girls, there was the perception that this commitment had not translated into concrete action at the country level or significant increases in investments in programs for women and girls, beyond services for the prevention of motherto-child transmission. Online Consultation In the online survey a number of questions were asked about respondents perceptions of the Global Fund s support for women and girls. The majority of respondents (60%) agreed or strongly agreed that the Global Fund cares about women and girls. However, fewer agreed or strongly agreed that the Global Fund was investing in the right programs to address the needs of women and girls (40.6%) or that the Global Fund provided sufficient guidance to countries about the importance of programming for women, girls and gender equality (41.4%). Similarly, only 45% (45.08%) of participants agreed or strongly agreed that the Global Fund actively advocates for the importance of addressing structural barriers to gender equality. On the other hand, 55.3% (135/244) of respondents agreed or strongly agreed that the Global Fund supports programs that reduce barriers to prevention, treatment, care and support for women and girls and 46.7% agreed or strongly agreed that Global Fund programs meet the different needs and vulnerabilities of women and girls, as compared to men and boys, as well as men who have sex with men, transgender people, bisexual people and lesbian women. Perceptions of the Global Fund improve when it comes to their support for human-rights based programs: 67.6% of respondents agreed or strongly agreed that the Global Fund ensures that the programs it finances respect human rights in service delivery, including non-discrimination and respect for informed consent and confidentiality. In-person Consultation While the board approved the Global Fund s gender equality strategy in 2008, participants reflected that they did not consistently see the leadership of the Fund actively addressing the needs of women and girls in their communications and advocacy work. They further noted that responsibility for implementing the strategy has never been institutionalized and the Secretariat is not held accountable for delivering results. Instead, the Global Fund s Community, Rights and Gender team seem primarily responsible for ensuring its implementation. The lack of institutional leadership and diffusion of responsibility for implementing the strategy throughout the organization has resulted in overall weak implementation and impact. 6

9 The Global Fund s current strategic plan does not have a specific focus on gender equality and women and girls, nor does it establish targets or key performance indicators for its work in this area. As a result, the Board does not routinely monitor the Fund s performance. Participants noted that, in contrast, the clear commitment to human rights in the strategic plan has resulted in concrete action to promote and protect human rights throughout Global Fund programs. Further, a specific indicator on prevention of mother-to-child transmission (PMTCT) resulted in a significant scale-up in Global Fund support for PMTCT programs. Participations did note that at a recent Board retreat, the Board did identify gender equality and addressing the prevention, treatment, care and support needs of women and girls as a critical priority for the next strategic plan. Participants also noted that the leadership of the organization has demonstrated recent increased political will to improve its work in this area. Key recommendations: Ensure that gender equality is adequately addressed in the strategic plan with appropriate targets, strategic actions, and key performance indicators. Develop staff-level performance indicators on gender equality, particularly for country teams, to ensure widespread responsibility for delivering results for women and girls. Increase the visibility of gender equality and women and girls in Global Fund s communication, advocacy materials and presentations and speeches by senior staff and board members. 7

10 Participation of Women and Women s Organizations in Global Fund Processes A key part of the Global Fund s Gender Equality Strategy is enhancing women s meaningful participation on CCMs and in other country-level Global Fund Processes. The strategy recommends, for example, a goal of achieving gender parity in the participation and leadership of CCMs. However, until recently the CCM Guidelines contained only a recommendation that women constitute 30% of CCM membership. In January, the recommendation was changed to a 30% requirement. Since the development of the Gender Equality strategy, the Global Fund s funding model has changed significantly. In addition to CCMs, there are also opportunities for women, young women and women s organizations to engage in country dialogues and the development of concept notes. Guidelines that have been developed by the Fund on both have stressed the importance of ensuring women s participation in these processes. The topic of participation in Global Fund processes was discussed during the in-person consultation and was the focus of a series of questions in the online consultation. In both, most noted improvements, but that significant work needed to be done to further enhance participation, particularly of women and girls living with and affected by the diseases, women in key populations, women s health and rights organizations, and grassroots women s organizations. For example, a plurality of respondents in the online consultation agreed or strongly agreed that the Global Fund does support the active engagement of women and girls, including those in key populations (45%); women s organizations (36%); and youth organizations (30.7%). However significant proportions disagreed or strongly disagreed with these statements (24%, 33.6%, 25% respectively), suggesting that the Global Fund needs to improve its efforts to support the engagement of women and girls and their respective organizations. Participants in both consultations noted a few key things that were necessary to strengthen women s participation, including country-level policies that had specific guidelines for participation of women and girls as well as longer-term capacity building and technical support efforts to ensure that when they did participate, their participation was meaningful and influenced outcomes. 1) Participation in Country Dialogues Online Consultation Of the respondents that answered questions about their participation in country dialogues, 41.4% (101/244) indicated that they had. The majority participated in a country dialogue on HIV programs (88.5%, 85/96), while 32.3% (31/96) had participated in a TB dialogue, 12.5% (12/96) in a malaria dialogue and 17.7% (17/96) in a health systems strengthening dialogue. Some participants reported that they participated in specific dialogues on community systems strengthening, maternal and child health, HIV-TB co-infection, key and special populations or programming for MDGs. 8

11 Respondents reported challenges in ensuring active and diverse participation in the country dialogues. While half (51%) of the respondents agreed or strongly agreed that women living with HIV or affected by TB or malaria were effectively engaged in the country dialogues they participated in; 28% (27) disagreed or strongly disagreed with that statement. A smaller percentage (30.2%, 29/96) agreed that adolescent girls living with or affected by the diseases were effectively engaged, and a greater number 46.88% (45/96) disagreed or strongly disagreed. Fewer than half (46.88%, 45/96) agreed or strongly agreed that the country dialogues were designed and implemented to reflect a broad range of perspectives, including those of people who are living with and affected by HIV and key populations, with specific attention to women. However, of those who did participate, a plurality (44.79%, 43/96) felt that their participation did have an impact on the outcomes of the country dialogues. [An] invitation was sent to the organisation to participate in discussion around gender and HIV. Discussion in effect interpreted gender to mean only MSM and transgender and female sex worker issues. The issue[s] of the situation of women and adolescent girls were brought up, however the excuse was that there is a lack of specific data on the impact on adolescent girls and that the Global Fund is only funding programmes on MSM, sex workers and transgender persons. Online Survey Respondent Of those that did participate, many identified enabling factors that encouraged their involvement, including policies that encouraged participation of women and girls (36%), adequate information (44%), guidance and participation requirements from the Global Fund itself (32%), technical support (30%) and for a small number, funding support (16%). For those that did not participate, a number of barriers were identified, the most common being a lack of knowledge about the process (51%, 71/138). The lack of transparency or openness of the dialogues (18%), lack of a process for specifically engaging women s groups (19%), and lack of funding were identified as other significant barriers (14%) by respondents. A small number of respondents reported that country dialogues really only engaged elite or large organizations, and excluded grassroots women s organizations, small organizations, or those that are willing to challenge the status quo. If you are vocal in raising issues, you will not be invited. In-person consultation Online Survey Respondent Few participants in the in-person consultation had directly engaged in country dialogues. However, it was observed that although Global Fund guidelines do encourage women s participation, the extent to which women and women s organizations do engage is not currently tracked by the Global Fund in a systematic way. 9

12 2) Participation in Concept Note Development Online consultation Only about a quarter (29%) of respondents (67/231) participated in the writing or review of a concept note for the Global Fund. Of those who did, most participated in the development of concept notes for HIV (86%, 55/64) and TB (38%, 24/64). A small number participated in the development of concept notes for health systems strengthening (9%, 6/64) and malaria (8%, 5/64). In Peru we finished drafting a concept note for TB. We have found that aspects such as gender equity or a specific gender approach were not taken into consideration, and neither were the ways in which gender differences affect morbidity and mortality and access to services. Online Survey Respondent Similar to participation in country dialogues, respondents reported a number of enabling factors that supported their participation in the development of concept notes. The most significant of these included policies or procedures that encouraged women s participation (36.5%, 23/63); adequate information provided in advance about the process (34.9%, 22/64); the Global Fund s guidance and requirements (31.7%, 20/64); and technical support (28.6%, 18/63). The major barriers to participation in concept notes included a lack of knowledge about the process (52%, 84/161); a lack of transparency and openness of the process (23%, 37/161); no process for ensuring the involvement of women s groups (19%, 31/161); lack of funding (12%, 20/161). However a small number reported that this was an exclusive process open to a relatively small number of elite actors at the country level and inaccessible to many, particularly smaller, grassroots NGOs. In-person consultation Participants observed that although more Global Fund Concept Notes included solid gender analyses, similar to the online survey respondent from Peru, the gender analysis in concept notes is not always translated into appropriate programs. They encouraged the Technical Review Panel of the Global Fund to continue closely analyzing the ways gender is addressed in the concept notes and make concrete recommendations in this area. They also recommended that feedback mechanisms be established at the country level to share draft concept notes with county dialogue participants and ensure that concept notes reflect priorities identified at country dialogues, especially by women living with or affected by the three diseases, women in key populations and women from community-based and implementing organizations. 3) Participation in Country Coordinating Mechanisms Just over a third of survey respondents had participated in a Global Fund country coordinating mechanism (CCM) (36.6%, 82/224). Of those who have participated in CCM, respondents had very mixed views about the level of women s participation, including those in key populations, and the extent to which the CCM actively engages or reaches out to organizations representing 10

13 women, girls and women in key populations for participation in country dialogues and other processes. The CCM is in the process of implementing its Improvement Plan (a consequence of last year's evaluation), and it is expected to implement policy changes that will further encourage participation with a gender approach. The communities that are usually represented have reached a "tacit agreement" that representation must be shared between men and women. Online Survey Respondent While a plurality agreed or strongly agreed that women living with HIV, TB or affected by malaria (46%, 36/78) and women representing key populations (38.46%, 30/78) effectively participate and are represented in country coordinating mechanism, significant numbers disagreed or strongly disagreed (29%, 23/78 and 34.6%, 27/78 respectively). Further, more respondents disagreed or strongly disagreed (41%, 32/78) that their CCMs actively engage or reach out to organizations representing women, girls and women in key populations to participate in country dialogues and other processes than those who agreed or strongly agreed (29.49%, 23/78). We demanded our own participation and used information from international networks. Online Survey Respondent Many respondents (39.7%, 31/78) also felt that their CCMs do not routinely monitor how the three diseases specifically impact women and girls, including transgender people and other women and girls in key populations. However, close to a third agreed or strongly agreed that this type of monitoring takes place (29.49%, 23/78). When it came to information sharing beyond the CCM, most respondents agreed or strongly agreed that their CCM has a mechanism to meaningfully communicate with affected communities about Global Fund processes (37%, 29/78). Further, most also agreed or strongly agreed that their CCM shares information about the outcomes of country dialogues (40%) 26/65; concept notes (51.28%, 40/78); and implementation of grants (42.3%, 33/78). However, about 20% of respondents also noted that in their CCMs there are limited processes to share information about country dialogue outcomes, concept notes and grant implementation. The organisation participated in the election process from the Civil society group. The entities selected to represent civil society do not share information with the wider civil society organisations. Numerous requests have been made by my organisation for information but this has not been forthcoming. Online Survey Respondent Respondents identified four key enabling factors that contributed to participation on CCMs: policies and procedures were established to ensure the engagement of women (27.8%, 20/72); adequate information was provided by CCM secretariat and technical partners about opportunities to participate (30.6%, 22/72); the existence of a fair and transparent election process (25%, 18/78); and the Global Fund s guidance and requirements for CCMs (30.6%, 22/78). 11

14 At the National Assembly of People with HIV we have always embraced the principle of equal participation of men and women. It is our organization that ensures equal participation, NOT the CCM. In the case of TB, there are no women representatives, and the trans community and female sex workers have not been engaged either. Respondents who have not participated in CCMs identified a number of barriers to their participation. The most significant included a lack of knowledge about how to engage (45%, 63/140); a CCM election process that was not transparent or open (21%, 30/140); the lack of funding to support participation (15%, 21/140); and the lack of specific seats for women s groups on the CCM (16%, 22/140). The process was not open and transparent to young people living with HIV and AIDS. They always leave youth behind even if we demand our seats, they [do] not allow us. In-person consultation Recent analyses of CCM membership demonstrates that there is increasing participation of women on CCMs across all countries, however many of these women are representatives of governments, donors or technical partners. Securing the participation of women living with or affected by the three diseases, women in key populations and women from community-based and implementing organizations continues to remain a challenge. Some observed that even though an increasing proportion of CCM representatives are women, this does not necessarily mean that they are champions of strategies to address gender equality and women s specific health needs within the CCM. Further, many pointed to power dynamics within CCMs due to gender, political influence and position that may make it difficult for women, especially those from grassroots or community-based organizations or key populations, to advocate for strong attention to gender equality and women s health needs, or object when these considerations are left out of concept notes or proposals. It was observed that CCM assessments could be used as an opportunity to identify weaknesses in women s participation in CCMs, as well as their capacity to comprehensively address gender equality and women s health issues. A number of participants emphasized that long-term capacity building and technical support for both the CCMs and individual women within CCMs would be important to ensure strengthened participation and impact. Key recommendations to improve women s participation in Global Fund processes: Put the responsibility for ensuring women s participation in country dialogues, concept note development and CCMs on those who are responsible for organizing them, and not on women themselves. Increase efforts to ensure that organizations working with women living with and affected by the diseases, women in key populations and on women s health are aware of opportunities to participate in country processes. 12

15 Track and report on the extent to which women and women s organizations are involved in Country Dialogue processes and develop differentiated strategies to increase participation in countries and regions where it is lacking. Invest in advocacy and capacity building of women living with or affected by the three diseases, women in key populations and women from community-based and implementing organizations in order to strengthen their meaningful participation in country dialogues and CCMs. Use CCM assessments and improvements plans as tools to address gaps in the participation of women living with or affected by the three diseases, women in key populations and women from community-based and implementing organizations. Support women s organizations to monitor CCMs and hold them accountable for women s participation, as well as their work to oversee implementation of Global Fundsupported programs for women and girls. Review guidelines to hold CCMs accountable for ensuring the effective implementation of gender-responsive and transformative programs. 13

16 Increasing the Global Fund s Investments in Women and Girls: From Country Dialogues to Grant Implementation There are a multitude of factors that influence whether or not in any given country the Global Fund s investments adequately address gender equality and the specific health needs of women and girls. For example, because the Fund is deeply committed to country-driven approaches, much of its funding is aligned closely with national-level health strategies; if women s health needs are not adequately addressed through these strategies, it is much more difficult to ensure that they are included in concept notes and ultimately budgets and performance frameworks. Nonetheless, experience in other areas has shown that the Global Fund can have a significant impact on what is and is not included in grant agreements. For example, when the Global Fund recognized that its investments in PMTCT programs were not at scale, they worked with technical partners and a set of 21 priority countries in Africa to significantly increase its funding in that area. In Zimbabwe, for example, coverage of PMTCT increased from just 9% to 78% of eligible women between 2009 and The new funding model, with its iterative process and enhanced engagement of Global Fund staff in the process of developing performance frameworks, can also create opportunities for ensuring that programs that promote gender equality and address women s health needs are adequately prioritized, measured, and budgeted for. The results of both the online and in-person consultation demonstrate that ensuring that the Global Fund is truly funding the right things to address the differential impacts of HIV, TB and malaria on women and girls and men and boys is an area where more, targeted work needs to be done. This chapter looks at various stages in the funding process, from the outcomes of country dialogues and the development of concept notes, to implementation. It also provides key recommendations on what the Global Fund needs to invest in, in order to truly make a difference in the health and lives of women and girls. 1) Gender Equality and Women s Health Needs in Country Dialogues and Concept Notes Online Consultation Participants expressed that more needs to be done to improve the extent to which the country dialogues and concept notes specifically focus on gender equality and the health needs of women and girls. Almost 40 percent (39.6%, 38/96) of respondents who participated in country dialogues agreed or strongly agreed that the dialogues were informed by sex- and age-disaggregated data. Forty-four percent (43.75%) (42/96) agreed or strongly agreed that the dialogues included a specific focus on the prevention, treatment, care and support needs of women and girls. Fewer respondents (37.5% 36/88), however, felt that the gender dimensions of the diseases were reflected in the records of the dialogues. 14

17 Most respondents agreed or strongly agreed that concept notes included a gender assessment or analysis (53.13%, 34/64); took into account gender-specific barriers to access to prevention, treatment, care and support (51.56%, 33/64); and addressed the specific needs of women and girls in key populations (50%, 32/64). However, less than half of the respondents agreed or strongly agreed that the concept notes prioritized issues that were identified by women s organizations or women in key populations (45.31%, 29/64), addressed the specific health needs of women and girls (37.5%, 24/64), or addressed the linkages between gender-based violence and HIV (39.6%, 25/64). At the same time, about a third of respondents disagreed or strongly disagreed that concept notes prioritized or addressed the health needs of women and girls, and a quarter disagreed that the specific needs of women and girls in key populations were addressed. Fewer felt the concept notes addressed the needs of women-led organizations (26.56%, 17/64), while most disagreed or strongly disagreed (48.4%, 31/64). In-person consultation Participants noted that all concept notes that are submitted to the Global Fund for consideration for funding must include a gender analysis. However, the quality of that analysis and the extent to which it gets translated into programs that meet the needs of women and girls varies considerably. Concept notes must be based on the country s disease strategy or health strategy. If those strategies do not contain their own gender analysis and gender-responsive programs, addressing the specific needs of women and girls in concept notes can become more challenging. Participants observed that the Global Fund s new funding model allows for greater engagement of the Secretariat in the design of concept notes, which are ultimately reviewed and approved by the Global Fund s independent Technical Review Panel (TRP). The TRP has been giving greater attention to the gender dimensions of concept notes. Country teams are also closely involved in the design of performance frameworks and budgets and could play a greater role in ensuring that gender analyses are translated into programs with specific budgets. 2) Gender Equality and Women s Health Needs in Grant Implementation Online consultation Only ten (3.6%) of the respondents to the survey had experience as principal recipients of Global Fund grants, and half of these were in Latin America. Nonetheless, given that relatively few organizations globally have experience as principal recipients, their responses are instructive. Three out of the eight who responded to additional questions about their experience as a principle recipient felt that adequate budgets had been allocated to address the gender dimensions of the three diseases; activities had been integrated into the grant agreement that specifically addressed the needs of women and girls; and opportunities had been created for organizations representing women affected by the diseases and/or women in key populations or women s organizations to become sub- or sub-sub-recipients. Two indicated that gender-specific indicators had been integrated into their monitoring and evaluation plans. 15

18 However, three of the eight indicated that they had inadequate budgets for programs to address the gender dimensions of the diseases, and five of the eight did not agree that gender-specific activities and indicators had been integrated into the grants. Almost a third of respondents (32.1%, 69/215) indicated that they had experiences as subrecipients or sub-sub-recipients of Global Fund grants. Of these, 64.6% (42/65) agreed or strongly agreed that opportunities were created to ensure that organizations representing women living with HIV or affected by TB or Malaria or women in key populations, and women's health and rights organizations could be sub-recipients or sub-sub-recipients. Majorities also agreed or strongly agreed that they received adequate technical support (57%, 36/63) and monitoring and evaluation support (62.3%, 38/61) in order to implement the grant. Further, most (78%, 50/64) agreed that they were linked to other organizations implementing similar activities. Slightly more than half of the organizations (35/62) that are sub- or sub-sub-recipients reported that they were involved in designing the budgets and program activities and only 39% (31/64) agreed or strongly agreed that those programs were effectively meeting the needs of women and girls in their communities. Less than one-fifth (15.6%, 10/64) agreed that the funding they received was adequate to effectively implement program activities. Key recommendations: Work with technical partners to provide coordinated and strategic support during the development of concept notes and performance frameworks, including through the provision of tools for gender analysis, programming, prioritization, and costing. Ensure feedback mechanisms are established at the country level to share draft concept notes with participants in country dialogues or/and women living with or affected by the three diseases, women in key populations and women from community-based and implementing organizations to ensure that concept notes reflect priorities identified at country dialogues and by communities themselves. Increase the capacity of the Global Fund Secretariat to provide support to countries and ask appropriate questions with regard to the epidemics impact on women and girls and programs to address them. Encourage the Technical Review Panel to continue to closely analyze the ways in which the gender dimensions of the three diseases are addressed in concept notes and make concrete recommendations in this area. Require that the gender analyses in concept notes are translated into appropriate programs to address the specific prevention, treatment, care and support needs of women and girls, with assigned budgets. Include a specific module in the application form focusing on gender equality and specific HIV, TB and malaria programmes for women and girls. Increase the transparency in the process of negotiating performance frameworks, with feedback loops to CCMs and country dialogue participants. 16

19 Provide guidance, funding and technical support to women s organizations to ensure that they can effectively participate in the drafting of concept notes and in the implementation of grants. Ensure ongoing internal and external monitoring and evaluation of the way that gender is addressed in concept notes, performance frameworks and budgets, including monitoring efforts by women s groups at the country level, and act upon recommendations accordingly Give specific attention to middle income countries where the Global Fund is transitioning out to ensure that investments are being made in the long-term capacity of women s organizations and organizations of women in key populations to be able to sustain programs for women and girls in their communities. Gender Indicators and Data A significant challenge is the continuing lack of gender and age-disaggregated data and genderspecific indicators that are included in performance frameworks and collected by countries. While there have been some recent improvements, the core indicators that are used by the Global Fund, and which are developed largely by technical partners, are still insufficient. Key Recommendations: Require gender-disaggregated data for all relevant indicators. Work with technical partners to incorporate, or develop where needed, gender-specific indicators for the Global Fund s core list of indicators. Conduct internal and support external analyses of the impact of the Global Fund s work on women and girls. 17

20 Funding the Right Things for Women and Girls The consultations were clear that the Fund not only needed to improve the scale of funding for programs for women and girls, but it also needed to ensure that it was funding the interventions that were most likely to be effective in improving their health. In the online consultations respondents were asked to provide feedback on the most effective programs to address women s and girls HIV, TB and malaria prevention, treatment and care and support needs, as well indicators for the success of these programs. During the in-person consultation, participants were asked to consider major gaps in Global Fund programming for women and girls, and for each of these areas consider strategic investments and indicators. Here, the focus was primarily on HIV interventions. Through both, there were some key areas that were identified as warranting specific attention. These included: Integrating HIV, TB and malaria services, particularly with sexual and reproductive health services, so that women and girls were able to receive comprehensive care that addressed their needs holistically; Addressing the needs of adolescent girls; Addressing gender norms and gender-related barriers to access to health care services; and Supporting community systems strengthening and the role of community-based organizations. HIV 1) Online Consultation For HIV, respondents were asked to rank the top six of a possible eighteen program interventions. They identified: Primary HIV prevention programs for women and girls (54 ranked 1, 26 ranked 2) Comprehensive sexuality education (skills-based education that addresses human rights, gender norms, power dynamics in relationships, and non-violence as well as evidence-based education on sexuality, reproduction, prevention and treatment of sexually transmitted infections, including HIV, and unwanted pregnancies, among other things) (39 ranked 1, 10 ranked 2) Prevention of unwanted pregnancies for women living with HIV (including through access to a choice of contraceptive methods) (19 ranked 1, 29 ranked 2) HIV treatment for women who are pregnant or breastfeeding (13 ranked 1, 20 ranked 2) Antenatal and post-natal care for women living with HIV (7 ranked 1, 21 ranked 2) Lifelong HIV treatment for women (15 ranked 1, 15 ranked 2) 18

21 When asked to select the greatest indicator of successful programs for women and girls in the HIV response in their countries, the three highest ranking indicators were: Reduced incidence of HIV infections among women in key populations (30% 52/173) Adolescent girls have knowledge about key ways to prevent HIV infection and feel empowered to act upon them (24%, 41/173) Reduced incidence of HIV infections among adolescent girls (21%, 36/173). Malaria For malaria, respondents were similarly asked to rank to top six of a possible ten program interventions. They identified: Integration of malaria diagnosis, prevention messaging and treatment services into sexual and reproductive health services or other primary health care services (64 ranked 1, 36 ranked 2) Community-based distribution and advocacy to increase use of insecticidetreated nets (25 ranked 1, 35 ranked 2) Programs to address gender-related barriers to malaria prevention, diagnosis and treatment (18 ranked 1, 8 ranked 2) Social mobilization to encourage pregnant women to visit antenatal care multiple times during the pregnancy (13 ranked 1, 14 ranked 2) Provision of insecticide-treated nets for pregnant women attending antenatal care (4 ranked 1, 21 ranked 2); and Programs that specifically meet the needs of rural women (7 ranked 1, 11 ranked 2). When asked to select the greatest indicator of successful programs for women and girls in the malaria response in their countries, the two highest ranking indicators were: Reduced child mortality due to malaria (41%, 60/148); and Reduced incidence of malaria among pregnant women (29%, 43/148) Tuberculosis For tuberculosis, respondents were asked to rank the top six of a possible eleven program interventions. They selected the following: Integration of TB screening, isoniazid preventive therapy, and TB treatment into reproductive health services including family planning, antenatal and postnatal care, PMTCT and other HIV services (86 ranked 1, 25 ranked 2); Adherence support and counseling for women receiving treatment for TB (22 ranked 1, 61 ranked 2); Training to strengthen the capacity of healthcare providers, HIV testing counselors, and community health workers to provide women with TB prevention, screening, treatment and treatment literacy in their routine work with women (23 ranked 1, 25 ranked 2); 19

22 Other programs to address barriers to access to TB diagnosis and treatment for women (8 ranked 1, 5 ranked 2); Childcare support for women receiving treatment for TB (4 ranked 1, 18 ranked 2); and Community-based active case finding with sputum collection targeting women who do not have access to TB diagnosis (7 ranked 1, 9 ranked 2) When asked to select the greatest indicator of successful programs for women and girls in the TB response in their countries, the three highest ranking indicators were: Reduced incidence of TB and MDR-TB among women (47%, 78/166) Increased TB and MDR-TB treatment success rate of women (20%, 33/166) Increased case detection rate for women (17%, 28/1166) 2) In-Person Consultation Participants in the in-person consultation were asked, as a starting point, to identify critical gaps in Global Fund programs. They identified the following five areas: a. Women in Key Populations b. Adolescent girls c. Integration of services and SRHR d. Communities and community system strengthening e. Changing gender norms and gender-related barriers at all levels They then broke into working groups to discuss key interventions for those groups and consider indicators for success. a. Women in Key Populations Key Interventions: Programmes to prevent and respond to violence and human rights abuses against women in key populations. Comprehensive services to holistically meet the health needs of women that integrate specific responses for women in key populations and of various identities. General women s health services should be accessible, acceptable, and meet the needs of women in key populations, similarly specialized services for key populations should provide for all health needs, not just those linked to their key population identity. Community-led and inclusive research and data collection and analysis with a gendered approach and sex disaggregation in order to establish key populations and their HIV, TB and malaria needs in specific country contexts. Measures of success: Increase in the numbers of women in key populations accessing health services Increase in the numbers of women in key populations accessing prevention services and services focused on overall well-being. Improvements in quality of services determined by user experience through surveys and focus groups, utilization rates, and audits of facilities Decrease in HIV incidence among women in key populations 20