Reaching vulnerable populations: lessons from the Global Fund to Fight AIDS, Tuberculosis and Malaria.

Abstract

Since its inception in 2002--in partnership with civil society, donors, governments, people affected by the target diseases and the private sector --the Global Fund to Fight AIDS, Tuberculosis and Malaria has supported and championed country ownership of programmes that, together, have saved over 20 million lives. (1) While substantial progress has been made, attempts to achieve target 3.3 of the sustainable development goals--i.e. to end epidemics of acquired immunodeficiency syndrome (AIDS), malaria, neglected tropical diseases and tuberculosis by 2030--are being hampered because services are failing to reach vulnerable and excluded populations. This failure reflects the many deep-seated gender-related, human-rights-related, cultural, financial, political and social barriers that such populations face. Approaches that address the differences between diseases and between affected communities--while strengthening health systems--need to be developed, especially as countries become less reliant on donor funds. The Global Fund has a responsibility to use its resources to achieve the greatest possible impact while ensuring the rights of those it serves are respected and promoted. This paper discusses how, in order to achieve these goals, the Global Fund has changed its approaches since 2002 and developed a new strategy for 2017-2022. Defining vulnerability Decades of efforts to fight AIDS, malaria and tuberculosis have shown that a business-as-usual approach leaves many of the most vulnerable people behind. The Global Fund has always emphasized the need to reach key and vulnerable populations but initially provided little guidance on how to define and identify them. Country-level efforts supported by the Global Fund between 2002 and 2012 were often directed towards general population groups and, perhaps, failed to focus adequately on those who were most vulnerable. (2) From 2013, the Global Fund began to develop context-based definitions that enabled countries to identify key and vulnerable populations for each targeted disease and for each epidemiological context (Box 1). Box 1. Definitions of key and vulnerable populations In 2016, the Global Fund to Fight AIDS, Tuberculosis and Malaria3 defined key and vulnerable populations as follows: Key populations: Epidemiologlcally, the group faces increased risk, vulnerability and/or burden to at least one of the three diseases--due to biological, socioeconomic and structural factors. Access to relevant services is significantly lower for the group than for the rest of the population. Dedicated efforts and strategic investments are required to expand coverage, equity and accessibility. The group faces frequent human rights violations, systematic disenfranchisement, social and economic marginalization and/or criminalization, increasing vulnerability and risk and reducing access to services. Vulnerable populations: People whose situations or contexts make them especially vulnerable, or who experience inequality, prejudice, marginalization and limits on their social, economic, cultural and other rights. Encouraging investments Since 2013, the Global Fund has also updated its policies and procedures to enhance the effectiveness and scale of programmes targeted at vulnerable groups. The Global Fund considers community voices to be a critical component of grant design. While the Global Fund has always required countries to establish country coordinating mechanisms that included community representation, the associated guidelines were revised in 2013 to ensure that women and key populations had a voice. Since then, any country funding requests have had to be based on a broad nationwide dialogue that included all vulnerable groups. The participation of key and vulnerable populations was bolstered by the Global Fund's special initiative on community, human rights and gender. This provided communications outreach to community and civil society groups, dedicated technical support and long-term capacity building--with a particular focus on key and vulnerable populations. …