Backing Civil Society in the March to End Epidemics

In the last 15 years, the U.S. has spurred huge progress combating the epidemics of our time. Among the health programs and partnerships the U.S. supports, the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) has saved an estimated 22 million lives, and unlocked hundreds of billions of dollars in growth and savings. But backsliding on this remarkable record, a veritable U.S.-spearheaded Marshall Plan for public health, when it is halfway finished remains a possibility. Shortsighted proposed funding cuts present more than one obstacle.

Equally dangerous is stepping back from empowering civil society as a central driver to curb these diseases – particularly at a time when illiberal leaders worldwide impair freedoms of expression, assembly, association and conscience.

Designed and launched in 2002 as a public-private partnership to be more inclusive than solely member state-based multilateral institutions, the Global Fund defines civil society as: “Those stakeholders who are neither government bodies nor private sector enterprises: groups such as nongovernmental organizations, advocacy groups, faith-based organizations, networks of people living with the diseases, and so on.”  For the Global Fund’s work, civil society is “at the heart of everything.” Likewise, the 2017 guidelines for the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the largest initiative led by a nation to combat HIV/AIDS – or any health problem – labels civil society a “leading force” while UNAIDS’ strategic blueprint identifies civil society engagement as a “global public good.”

Sustained support for the vital role civil society occupies in combating these diseases, and in recognizing bottlenecks which inhibit that role at the community level, are needed to keep making these definitions a reality. The clock is ticking as the sustainable development goals (or SDGs) commit all countries to end the AIDS, tuberculosis (TB), and malaria epidemics by 2030, while a demographic youth bulge and drug resistance threaten reversals in the progress made over the last 15 years.

Civil society has a proven record as an enabler – indeed, a force multiplier – in the march to ending epidemics. For example, civil society acts as vanguard for accountability and promoting public-sector investments in sustainable responses to these diseases. Dual-track financing, where a government and civil society actors jointly execute projects, exhibits promise. Under this approach, the UN Development Program successfully transitioned away from its principal recipient role in El Salvador to the Ecuadorian Ministry of Health and Plan El Salvador, a non-governmental organization, in 2012 and 2013. In other cases, community-based services provide a lifeline for care when more “mainstream facilities” are unavailable.

In the past, Global Fund support has had the auxiliary impact of strengthening working relationships among civil society and the public sector, according to one assessment of Georgia, Kyrgyzstan and Ukraine. A Council on Foreign Relations analysis by Dr. Yanzhong Huang found that Global Fund support broke ground for civil society voices in decision-making even in very challenging settings.

Civil society is also a bona fide engineering corps for building bridges to key populations, or groups that are critical to turning the tide of these epidemics and are often marginalized by the societies in which they live.

In Kyrgyzstan, for example, civil society helped promote greater representation of key populations in the country’s Global Fund grant application process in 2015. In the same year in Benin, the Global Fund’s Community, Rights and Gender Special Initiative strengthened consultations among representatives and advocates for people living with HIV, as well as gender-based violence groups, youth organizations, health professionals and lawyers, to encourage government actors to both address legal barriers to care and adopt rights-based practices.

A report of Eastern Africa National Networks of AIDS Service Organizations has demonstrated a statistically significant relationship between the report’s “Voice” and “Accountability” governance indicators on the one hand and the integration of civil society perspectives in Global Fund grant applications on the other. Yet, civil society faces growing strain worldwide. Prominent human rights groups and the UN have sounded the alarm on the disintegration of sufficient space for civil society to act, often with states actively circumscribing their participation, including heightened risks for rights defenders. Political instability, internal conflict, and violence also threaten medium to long-term efforts to buoy civil society in planning and implementation.

Moreover, actors at the community level have said international grants intended to integrate advocacy efforts into community-wide systems can be too piecemeal to succeed in the long-term. A 2016 study from the International Council of AIDS Service Organizations (ICASO) and the AIDS & Rights Alliance for Southern Africa (ARASA) found that 40 percent of civil society organizations and community groups have seen funding decline since 2013.

As nations transition from international support, the endeavor to end epidemics must regard civil society capacity as much as it expects governments to take responsibility. True country ownership in this transition cannot be meaningful without robust civil society capacity. It is like trying to clap with only one hand. The Action Global Health Partnership estimates that at least 24 countries could risk access to essential services, especially among vulnerable populations, as they undergo major transitions from external to national financing for health programming over the next five years. During and after transition periods, there is a need for stronger application of innovation – such as e-learning and other aspects of the data revolution – to channel technical expertise among, to and from civil society.

As a world leader in fighting epidemics, the U.S. should consider the following questions urgently:

• What takeaways can be learned from civil society’s enabling role in combating these epidemics to date?
• How can civil society be best-equipped to occupy a more sustained role in public discourse, strategy formulation and implementation?
• What are best practices related to better U.S. and international support for community-level advocacy, as well as accountability and transparency at the public level?
• How can programmatic investments and U.S. diplomacy better support civil society while minimizing the chance of reactionary countermeasures from illiberal governments?
• In what ways can flexibility be included in foreign assistance to spur innovation and a surge in domestic capacity building?

Empowered civil society is crucial to understanding the experience of people using health and other services, and to implementing policies that ensure peoples’ well-being. Successful transition to countries taking responsibility for their own disease response and ending epidemics for good requires thought and investment from the U.S. about civil society now more than ever.