Like bean counting, but for human rights

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A new report by Open Society Foundations on the Global Fund to fight AIDS, Tuberculosis and Malaria states that “Human rights principles in the Global Fund’s work merit the kind of oversight that the [Global Fund] secretariat brings to such questions as corruption and mismanagement”.  The Fund, like most other aid donors, have very strict checks and balances and safeguards to detect and deal with financial irregularities.  They take corruption seriously and so they should, since corruption means that money isn’t spent on what it should be, it compounds bad governance, and it seriously undermines the credibility of donor aid programmes.  Indeed, the Global Fund itself has recently had funding withheld by a number of donor countries based on reports of financial mismanagement uncovered by the Fund’s own Inspector General. 

Important as fighting corruption is, I sometimes can’t help thinking the safeguards are pushed too far.  I remember a colleague calling me a few years ago to ask me if I really thought it made sense to go and buy project bananas* from a supermarket at ten times what they cost in the market, for the sole reason that the supermarket could provide a receipt with official VAT registration details.  Around the same time a small sex worker association doing peer outreach had their funding suspended because on one of the 30 or so reporting sheets – designed to serve as proof that activities really happened – there was an inconsistency in the way the national ID card number of one of the participants had been written up.  It’s bad enough taking down personal information from stigmatised and criminalised people – all the project was doing was giving them condoms and a talk on sexual health – but then interrupting services for reasons like that is really taking things too far.  So you’ll understand why I’m a little bit sceptical about the value of some of the financial procedures we put in place in aid projects. 

What to make of the recommendation in this new report to pay the same sort of attention to human rights?  On the face of it, it is appealing: protecting human rights is surely far more important than protecting financial integrity.  I wish people worried more about how effective programmes are and whether programmes are damaging to communities.  But there’s a bit of a conceptual problem.  Aid programmes are supposed to advance human rights anyway.  The Global Fund was set up to help fulfil the right to health of hundreds of millions of people by helping them avoid getting ill and by helping them get access to good quality treatment.  Isn’t that enough?  Well, no, because advancing human rights is one thing, but protecting them is quite another.  Once you get involved in national responses to problems as big as AIDS, TB and malaria you invariably also come up against these protection issues: arbitrary detention of people with TB; sterilisation of people living with HIV; the abject poverty of the people most affected by malaria.  And when it comes to HIV there are all sorts of other issues such as the criminalisation of homosexuality, drug use and sex work, which aggravate vulnerability to HIV and which make providing services nearly impossible.  It isn’t really possible to have an effective response to HIV in these contexts.

The report focusses on the ways in which the Global Fund might support the promotion of human rights of particularly marginalised and stigmatised groups – for instance by only agreeing to fund “human rights based” programmes or turning down requests to fund programmes which violate human rights; by funding legal support, law reform advocacy campaigns; and by using its good offices and considerable influence to advocate with authorities at the national level.  Last year we saw an example of this when the Executive Director of the Fund raised the issue of criminalisation of homosexuality with the President of Malawi.

Like tracking financial management and corruption, monitoring human rights is easier said than done.  One approach, discussed in the report and already adopted to an extent by the Global Fund, is to make the application process more sensitive to identifying the relevant issues: for instance by better labelling of human rights related activities for which funding is requested, and by asking applicants to outline how human rights problems which get in the way of programmes will be addressed.  I think it is fine to do this but I also think it is a blunt instrument.  I’ve reviewed dozens of Global Fund proposals, and I’ve written a few too.  Even though the application form is very long and detailed, the level of information that it is possible to convey just isn’t deep enough to identify what we would need to know.  The “Human rights” section of the application form is one of hundreds of questions, and doesn’t tend to be top of the list of things countries discuss when putting together their application – and yet they still get funded.  There is also a “scale” issue – even if a proposal includes good human rights programming, it is not easy to know whether what has been included is really necessary or sufficient to resolve the problems.

Some of the money that gets given on the basis of these proposals ends up going through several subcontracts and intermediaries, so that there are hundred or thousands of small organisations using the money on the ground: describing what each of these is going to do (and the ways in which they will promote human rights or refrain from violating them) isn’t realistic.  Moreover, what a funding proposal says is one thing, and the way the project is implemented is quite another. Refusing outright to fund proposals that contain some problematic components is itself fraught with difficulties since there may be other components that are absolutely fine and which, by themselves, can be considered to “advance” human rights.  An example might be a proposal including, on the one hand, antiretroviral treatment for tens of thousands of people living with HIV – treatment they wouldn’t get otherwise – and on the other hand, repressive and coercive strategies for HIV prevention with sex workers.  In situations like this surely the best outcome would be for the Global Fund to make clear its “red lines” and to try to convince applicants to rectify the problematic sections in order to be able to continue getting funding.  Refusing funding, or interrupting funding for a whole programme has to be less attractive than simply trying to fix the bits that are unacceptable.

Another challenge is that, at country level at least, there isn’t always consensus on what human rights means.  The Global Fund itself has progressive policies on issues such as sexual orientation and gender identity, but officials in ministries of health and other AIDS actors – including civil society organisations – can be more inclined to think that homosexuality and sex work are in and of themselves human rights violations, that need to be stopped. Moreover even if they are on the right side of the argument, the ability of ministries of health and other AIDS actors to influence decisions and policies of other ministries is limited.

The Fund requires countries to put in place governance structures (country coordinating mechanisms) that are aimed at ensuring different sectors and marginalised groups are represented.  A key aim of this is to ensure country applications to the Fund are accountable to different groups and respectful of human rights; there have certainly been some “success stories”, but for the moment many of those representing marginalised populations are not that well equipped to effectively advocate in a formal meeting attended by government ministers and donors.  As a process for assuring human rights protection, it is still rather hit and miss.

The Open Society Foundations report makes the point that, in the same way that financial controls are not considered to be a challenge to national sovereignty, human rights monitoring needn’t be.  This underestimates the political sensitivities and controversies around what human rights are.  Nonetheless, the Global Fund is entitled to introduce whatever controls it likes, providing its donors let it and providing countries will continue to take its money.  This is just as well since, in my opinion, in order to really effectively embrace what is being proposed and to monitor human rights “compliance” it isn’t enough to check that the funding proposals look OK and to demand transparent processes for developing them.  There also needs to be some form of in-depth, intensive, on-the-ground monitoring, and a mechanism for credibly identifying and responding to human-rights related challenges as they arise.  It’s no small ask.

 

* What the hell is a project banana, you ask?  They were being used as makeshift condom demonstrators.

 

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Going out for a pint. And an STI test?

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Update 12pm 1 April 2011.

I’m sure most readers will have figured out that this was nothing more than a bit of April Fools fun.  But there is a slightly serious side to it, which is that we wanted to promote the fact that most STI testing these days is done through urine samples… so the scare stories about being poked and prodded down at the clinic shouldn’t put people off getting themselves checked out.  And whatever your results are, be safe.

More good information on common STIs and where to go for a check up on the NHS Choices website, here.  Do also check Sexedukation’s blog for a far more detailed “reveal” and several other links.

—-Original post—-

Given that a lot of the HIV prevention-related work I’ve done has involved working with stigmatised people and communities in general, it’s probably fair to say I’m particularly prone to questioning bio-medical strategies that are promoted as magic bullets for sexual health promotion.  So I had a bit of a knee-jerk reaction when I heard that some pubs are piloting a scheme where toilet water is replaced with urine testing reagents, so that drinkers can basically get on-the-spot warnings that they may be infected by some STIs.  The water turns a different colour once you pee in it, and you check that against a colour chart in the loo and, hopefully, if you need to, get yourself checked out and treated.  I heard about it from a friend in Bath who had seen it in action, and Sexedukation has researched and written a blog post explaining what is going on.

My first reaction was to wonder about consent – it looks like you don’t have any choice but to have the test if you need to and relieve yourself.  Surely this can be got around since it isn’t necessary to have this test in every stall/urinal, and they could be clearly labelled.  But what about confidentiality – surely the result is available for the next person who comes in to see?  And I’m guessing some people might rightly find the fact that the test is more accurate for women than men problematic (something to do with urine that travels a longer distance getting too aerated to give a good result) – this might further promote men’s sexual irresponsibility. 

However, I think these issues can be got round… and if so, why not go for it?  Getting toward a stage where people are systematically checked up might help destigmatise the whole area of sexual health, and it could be a good way of putting pressure on people who don’t go to the loo: just what have they got to hide?

Also, pub loos also tend to have condom vending machines so it’s a timely reminder to use condoms.  And I certainly don’t buy the “anti-sex” argument that this scheme will just promote hook-ups, encourage people who get the all clear to go without condoms, or even lead to celebratory infection-free quickies in the toilets.  I’ve also heard that there are the tired old concerns that because kids might use the loos this is yet another example of children being forced to grow up to soon.  But I think that, if anything, by promoting awareness it will discourage unsafe sex; and careful communication of the fact that not all STIs are detected by the tests should be enough to stop people using negative results as an excuse for going bare-back.

Because I work in low-income countries I’ve also been wondering about the relevance of this scheme in other contexts.  In desert environments, peeing and defecating in water historically tends to be a no-no as it contaminates a precious resource – and this norm still prevails in those cultures even when there is running water.  And in many other contexts where I have worked, public loos are often poorly lit pit or squat latrines so it would be impossible for people to see what colour the water had changed.  Moreover, with poor infrastructure and health systems I would worry that the reagents might not get replaced enough.  Also a key part of the scheme is good information, but in places with high levels of illiteracy or even just places where people aren’t used to getting information via the written word, I’m just not sure it would work.  So while I am interested to see the results of the UK pilot, none of this is much use to me in my own work.