Remembering Abel


It’s hard to imagine what sort of pressure a dynamic, articulate activist for an unpopular cause must come under, but Abel Shinana, who died in a road accident earlier this year, knew all about it. Abel was a gay sex worker in Namibia, who very soon after starting to speak out, became one of the country co-ordinators for the Namibian office of the African Sex Worker Alliance.


By the time I met him, Abel was being asked to travel to regional and international meetings on HIV and sex work, to talk about the experiences of sex workers in his country.  When he wasn’t being expected to interpret and comment lucidly on the possible sampling errors that bias global modelling on the role sex workers play in HIV epidemiology, or the human rights implications of the WHO’s guidelines on HIV programming with sex workers, he was being asked to run research and training projects with sex workers back in Namibia. In September 2011 (just before he flew off to another international consultation) we trained 17 Namibian sex workers to carry out some qualitative research with sex workers in five towns – a piece of work that got people to recognise, both locally and nationally, that working with sex workers on HIV requires a lot more than distributing free condoms. Abel was a pleasure to work with, but although he did an excellent job, he became somewhat withdrawn over the course of the five day training session.  My frustration with him was misplaced: he’d spent most of the week dealing with homophobic abuse and jealousy that he’d been asked to help run the show.   

Why was he asked? Because he was talented, passionate, and because we believed it was important to try as hard as possible to encourage leadership of sex workers themselves.  Over the next few months, we talked from time to time about his role in Namibia, about how he might focus, either on activism, or programming, in order to give him a bit more space.

Abel’s untimely death – as well as the recent deaths of two of the 17 sex worker researchers we trained – has been a big reminder of the fragility of leadership; and of the weaknesses of the haphazard ways in which external do-gooders, albeit with the best of intentions, tend to gravitate towards, and heap expectations on, the rare talents they find.  I’m not sure what the answer is, but World AIDS Day is for remembering. Raise a glass.


PEPFAR’s Blueprint


The US government has published its Blueprint for Creating an AIDS-free Generation: despite funding stalling, this World AIDS Day is characterised by the optimism of all the big agencies, the narrative is that the end is in sight.

I’ll get round to reading the whole thing some day, but for now I’ve turned straight to page 26, which is all about what PEPFAR is going to do with Populations at Greatest Risk of HIV. Here are a few notes.

The first thing to note is that “Populations at Greatest Risk” are subdivided into several categories: people with tuberculosis; Key Populations; people living with HIV; women and girls; orphans and vulnerable children; and young people.  Some might say the definition of “greatest risk” is rather broad, particularly given that strategies aimed at supporting women will also, of necessity, target men. While the blueprint does put welcome dollars against some specific initiatives, it does not go as far as stating how it will allocate PEPFAR’s substantial funds to these different groups.

However, the use of the term “key populations” to describe men who have sex with men, sex workers, transgender people, and people who inject drugs, will be seen by many as progress, given that up until recently the preferred term was the more stigmatising “most at risk populations”.

Advocates for key populations are likely to pay particular attention to the language on sex workers, given PEPFAR’s history of very restrictive and highly conditional support to programmes with this group.  First thing to note: PEPFAR is now firmly using the term “sex worker” rather than “prostitute”: another welcome shift in language.  There is no word on whether PEPFAR intends to develop guidance for programming with sex workers (guidance on programming with men who have sex with men and people who inject drugs is already available).  There is good language on the importance of properly involving key populations in developing and delivering programmes; however, PEPFAR still requires subgrantees to adopt a policy explicitly opposing sex work as work, a regulation which effectively rules out the involvement of sex worker led organisations.

Among the key actions PEPFAR plans to take, there are points that led me to raise my eyebrows:

7. Support civil society and faith-based work best able to address the epidemic in key populations through mechanisms such as country small grants.

Without wishing to deny the undoubtable contribution faith-based organisations have made to the response to AIDS, particularly in the area of care and support, I know of few if any examples of effective programming by faith-based organisations with key populations.  And every faith-based project with sex workers I have ever seen has involved ineffective, misguided and sometimes damaging “rehabililtation” programmes.

9. Prioritize engagement in health diplomacy to promote the health and human rights of women, girls, and LGBT populations, and advance gender equality.

The omission of sex workers, and people who use drugs, from this section on human rights, is glaring.  The blueprint does acknowledge the existence of laws and stigma against key populations, but while it emphasises that these laws and stigma affect peoples’ access to services, it stops short of recognising that these laws and stigma are at the very heart of what makes key populations vulnerable to HIV, and all manner of human rights abuses, in the first place.  It’s also worth thinking carefully about PEPFAR’s stated support for science-based approaches and human rights, given that the section on “principles” cites Cambodia’s 100% condom use programme for sex workers as an exemplary strategy. The approach raises significant concerns, in particular in relation to informed consent for HIV testing and STI treatment, and the role that law enforcement officers are given in implementing the policy.

Summary: despite some encouraging improvements (not least the very existence of the Blueprint in the first place), we may still have a long way to go before key populations in general and sex workers in particular receive the support they need from the global response to AIDS.


What role do communities and civil society organisations play in improving health?


It is fairly well acknowledged that it takes more than the delivery of health services to improve health.  Communities, and community based organisations, play important roles in complementing formal health services, and in influencing the broader social determinants of health.  But despite this acknowledgement, most health planning and funding still focuses on formal health services.  Comic Relief asked me to do a literature review to analyse the different ways in which community and civil society action contribute to better health, and to identify recommendations that would help planners and funders provide more effective support to these movements.  Here it is.

The Global Fund – reinventing “country ownership”


The appointment of a new Executive Director of the Global Fund to fight AIDS, TB and Malaria on November 15th was expected; and few will be surprised that Mark Dybul, former head of PEPFAR, got the job.  His name has been in the frame ever since the previous Executive Director left.

Perhaps more unexpected was the announcement that the Board of the Global Fund has terminated the employment of the Inspector General. Many activists and advocates have not really forgiven the IG for the heavy criticisms faced by the Global Fund about cases of fraudulent expenditure, uncovered by his office (and published in full on the GF website, as per policy).  The Global Fund has made it clear that the Office of the Inspector General will remain, and has initiated the process to find a new Inspector General.

As the Global Fund begins a new phase – new leadership, second decade, new funding model, stronger grant management – it will be interesting to see how it pursues the task of monitoring and auditing grants.  Certainly, the restructuring of the Fund over the last few months, which has shifted the bulk of staffing into grant management and supervision roles, indicates the intention of paying more attention to what gets funded and how.  While this is welcome, however, I hope that actors in recipient countries will also take greater control and ownership.  Because if you take a look at any one of the many reports published by the OIG, you’ll notice something a little bit disturbing.  Take the Ethiopia report.  Here is one of the 86 recommendations:

Recommendation 1 (Significant priority)

To improve the quality of malaria and tuberculosis diagnosis, the FMOH should ensure:

(a) Microscopes are maintained in proper functioning order.

(b) Running water is available in the health facilities.

(c) Refresher training is provided to laboratory technicians based on a needs assessment.

(d) Internal and external quality assurance of the health facility laboratories is conducted as planned and is duly documented.

And here’s another:

Recommendation 75 (High priority)

The PFSA should ensure:

(a) Appropriate racking and other storage media are provided to the facilities in order to facilitate proper storage of health products. In particular, direct storage on the floor as observed in some facilities may lead to products being damaged by moisture hence pallets should be used. Correct handling equipment reduces the risk of injury to workers and damage to stock. Stock organization on shelves and pallets enhances accessibility which facilitates use of first in first out (FIFO) and first expiry first out (FEFO) issuing systems.

(b) Temperature monitoring in storage areas is introduced in order to maintain optimum storage conditions.

So, make sure that broken microscopes get fixed, make sure there is running water, and have proper storage in health facilities.  I don’t think the OIG was wrong to include these observations in his report. In fact, if I was conducting an audit and saw these problems, I’d write them up too.  Had local supervisors or activists already documented these problems in Ethiopia?  If so, how long would it have taken to fix them?  Did those responsible even have the resources to fix them? I have no idea, but I am pretty sure that if the success of Global Fund grants depends on a crack team of highly paid international auditors ferretting out problems like this – when the Fund supports services in tens of thousands of health facilities and community organisations – that there is something wrong with the model.  

The Global Fund does, of course, provide some support to country-level monitoring and accountability – through the Country Coordinating Mechanisms.  But when you compare the oversight tools used by the CCMs to the sorts of data digested by Global Fund portfolio managers and the OIG, there is no comparison – Fund officials have far more information, and far more resources to digest it, than the CCMs.  Moreover, the data that CCMs are encouraged to monitor is somewhat abstract.  By and large, people that sit on CCMs representing marginalised and underprivileged populations are not trained to interpret spreadsheets and performance ratings.

I’d like to see much more support going to community level monitoring of health services.  It does happen, but not nearly enough.  And there is evidence that it has a positive impact on how services are provided, and on health outcomes.  A fantastic example of where it does happen is in Cameroon, where the organisation Positive Generation supports people with HIV and TB to monitor things like stock outs, provider behaviour, and overpricing of services in 40 treatment facilities in the country.

People who get shoddy services should be able to find out why (i.e., because the microscopes are broken, or the water isn’t running, or the drugs have gone bad); as should people who are refused services or who are subject to human rights violations.  And should be able to raise hell and demand changes.  They need the support of civil society organisations, human rights organisations, UN agencies, and the Global Fund to do this.  I’m hoping that as well as being more diligent in its international grant management, the new Global Fund can find ways of generating greater ownership of the problems in the countries it is funding: not just ownership by governments, but ownership by the people who the Fund was set up to help.