Recognizing the evolving global context and the need for Canada to adapt its response and approach to international assistance, Global Affairs Canada held a review with Canadians and partners from May to July 2016. The consultation sought evidence-based recommendations to shape Canada’s new international assistance policy, funding and delivery framework. For more information please visit Canada’s webpage on the process. In July 2016, ICAD made a submission to the international assistance review on behalf of its membership:
We are at a critical juncture in a time when it comes to curbing the HIV epidemic and addressing related development challenges. The Sustainable Development Goals (SDGs) have been ushered in, providing ambitious targets for the global community to address a range of development challenges. UNAIDS has put forward a global Fast-Track target of reducing HIV infections to less than half a million per year by 2020. Impressive gains have been made in improving treatment access for people living with HIV. Global talks now speak to universal access and universal health coverage, yet 18 million people are still awaiting access to antiretroviral treatment (ART), and still for every 2 people put on treatment, 5 become infected (The Gap Report) . While tremendous gains have been made in addressing HIV at home and around the world, much remains to be done.
ICAD’s Submission to the International Assistance Review (IAR)
POLICY ISSUE: HEALTH AND RIGHTS OF WOMEN AND CHILDREN
- Building on our commitment to a feminist approach and support for the gender equality goal of the 2030 Agenda, where should Canada focus its international assistance efforts in this area? Can Canada take advantage of specific opportunities to demonstrate new or continued leadership on women’s empowerment and gender equality?
- How can Canada’s efforts support well-being and empowerment better benefit children and youth, including in the education sector?
- What strategic role can Canada play in advancing health-related SDGs to improve the health of women and girls, including adolescents, in particular their sexual and reproductive health and rights?
1) Front-load increased Canadian investment in HIV as a cross-cutting issue integral to meeting, advancing and exceeding the ambitious targets outlined in the 17 Sustainable Development Goals.
HIV is profoundly a human rights issue and one which is critical to successful and sustainable development and poverty reduction. The two worlds of HIV and development are inextricably linked. HIV is a fundamental development issue as it is both a cause and a consequence of poverty. We see from countries around the world, that HIV can have a devastating impact on human and institutional capacity, on economies, the labour force, health, education and social systems, and food security affecting societies from the national level down to the level of the household. This is amplified when basic and fundamental rights and freedoms are denied to groups based on their sexual orientation, their gender identity, and/or their gender expression, personal behaviours and practices.
The SDGs include an outcome-focused health goal (Goal 3) with nine targets including: achieving Universal Health Coverage, ending AIDS and TB epidemics, and securing universal access to SRH care services by 2030. The renewed UNAIDS strategy (October 2015) identifies a range of important synergies with other goals that can support interventions on HIV, TB and broader health and create opportunities for development partners to join up investment. Front-loading increased Canadian investment in HIV as a cross-cutting development issue will be key to successfully attaining the 2030 global goals for sustainable development. Relevant goals include:
Similar to the connections between HIV and development, we see clear linkages between sexuality and poverty. In many areas of the world, LGBT people are generally amongst the most vulnerable, with restricted employment opportunities, exclusion from the economy and meaningful participation in society, and are subject to intimidation, violence and persecution. Discrimination on the basis of sexual orientation can also impede one’s ability to ask for and get choice and control over services – including general health care and other HIV specific services – where access may, by association, disclose personal information such as health status and/or sexual orientation. Sexual and reproductive health and rights is an integral component of a comprehensive HIV response that addresses gender-based inequalities and violence, poverty, harmful cultural practices, and policies and laws which criminalize same-sex practices.
Canada must increase and front-load its investment in HIV as a cross-cutting issue, which is integral to meeting and exceeding the ambitious targets outlined in the 17 Sustainable Development Goals. This means investing in HIV and related epidemics such as TB, beyond its contribution to the Global Fund to Fight AIDS, TB and Malaria and other multilateral institutions.
Moreover, a Canadian global health strategy in relation to HIV would identify how Canadian investment would contribute to the broader set of priorities identified by key multilateral strategies released in 2015 (e.g., the renewed UNAIDS strategy 2016-2021, the revised strategy of the Global Fund to Fight AIDS, TB and Malaria 2016-2021, the WHO HIV strategy 2016-2021). Each of these multilateral strategies stress the importance of front-loading investment to support countries to reach the bold ambitions to end the HIV and TB epidemics and to secure a truly sustainable response to AIDS and TB. The next five years are critical in determining whether we will, or won’t, meet global health targets by 2030.
2) Canadian investment in global strategies that advance inclusive research for female initiated HIV prevention technologies including microbicides and a preventative HIV vaccine.
Over the years, women have increasingly carried the burden of HIV and AIDS. According to reports from the WHO, UNAIDS and UNFPA, HIV/AIDS is now the leading cause of mortality among women of reproductive age globally. When this statistic is unpacked, we see that HIV doesn’t just impact a woman, it impacts her entire family. In fact, according to studies conducted by UNICEF, in many places around the world, within two years of a mother’s death, her children are 10 times more likely to die themselves. What’s more, women are a driving force for economics. This is equally true for countries like Canada as it is for countries in sub-Saharan Africa. Women and girls traditionally bear unequal responsibility for the work of caregiving for those who are sick or orphaned due to HIV and AIDS. What happens to their families when they are too sick to work? Poverty, violence and inequality continue to put women and young girls at heightened risk of HIV infection. Women require new ways to protect themselves, including microbicides, a class of products designed to reduce the transmission of HIV and/or sexually transmitted infections that women can control even if they cannot ensure their male partners use a condom.
We know that it is in Canada’s best interest–both domestically and internationally – to continue to invest in disease prevention efforts, which will save lives and money in the long term and increase productivity by reducing the incidence of HIV. Canada has previously provided important funding support to coordinated global research efforts via the International Partnership for Microbicides (IPM) and the International AIDS Vaccine Initiative (IAVI). It is critical to the search for multi-purpose prevention technologies (MPTs) and HIV vaccine research that global initiatives be adequately and consistently resourced, and that wealthy nations, such as Canada, share in this global responsibility. Canada is well positioned to take on a catalytic role convening leading researchers, civil society partners and other stakeholders in Canada, the US and in developing and middle income countries to forge global research partnerships, to share approaches and research findings, and to build local capacity to support the development and roll- out of an effective, affordable and accessible preventative HIV vaccine and multi- purpose prevention tools including microbicides. Canada’s leadership in this area will amass tremendous contribution to women’s empowerment, gender equality and will harness the strength and innovative potential of global partnerships.
3) Uniting the discourse: Making explicit the connection between women and girls, key affected populations, HIV, and sexual and reproductive health and rights.
Integral to achieving gender equality and women’s empowerment is the importance and centrality of intersectionality. The reality is, that people in all their diversity, rarely, if ever experience their identity in one linear, singular way. For instance, understanding the health concerns of key affected populations and women and girls must reach beyond the lens of gender to also consider the full range of dynamic social and cultural categories such as class, sexual orientation, race, age, etc. and how these impact on the range of health concerns, needs and priorities of girls, women and transgender women. Intersectionality also contextualizes the multiple forms and layers of stigma and discrimination that remain a leading driver of the HIV epidemic and inhibit access to critical services, including rights-based sexual and reproductive health services. Canadian leadership and investment is called for to advance a rights-based, person- centred approach to health-service delivery – one which meets the sexual and reproductive health needs of all people in all their diversity.
Similarly, ensuring that women and girls most affected by HIV are well-informed and empowered to make positive choices about their sexuality, their health and well-being through greater rights-based health literacy across the life-course, including comprehensive sexuality education, means that in fact – we are protecting children born free from HIV from acquiring HIV later in their life.
Invest in programming that accelerates global efforts to ensure that inclusive societies and enabling environments flourish and fully enable personal and individual identities and expression as being key to sexual rights — free from violence. This includes changing restrictive policies and other structural barriers that prohibit people, especially young people from accessing comprehensive SRHR and HIV information and services. Such efforts will similarly strengthen and complement those which support, protect and promote governance, pluralism, diversity and human rights as well as partnership and innovation.
There is now wide recognition that community and civil society responses must play an increasing role in the years ahead to address the epidemic, including the provision of integrated SRHR service delivery. In particular, it is critical that community responses are led by and involve those most affected by the epidemic and those most inadequately served by health systems. Community mobilization and community system strengthening are essential pillars for strategic investment in healthy societies. As a social enabler, it must be adequately resourced and funded.
POLICE ISSUE: GOVERNANCE, PLURALISM, DIVERSITY AND HUMAN RIGHTS
- How can Canada best help implement Goal 16 of the 2030 Agenda – to promote peaceful and inclusive societies, provide access to justice for all, and build effective, accountable and inclusive institutions at all levels?
- How can Canada promote including, advance respect for diversity and uphold human rights?
- In what areas of governance can Canada’s international assistance have the most impact?
1) The need for Canadian leadership in setting the bar for responsible and sustainable transition planning for Middle Income Countries to protect hard won gains in curbing HIV and related epidemics ensuring that the impact of previous investments is not jeopardized or abandoned.
The 2016 Political Declaration on HIV and AIDS ratified in June 2016 at the United Nations High Level Meeting on HIV and AIDS, includes strong commitment to the UNAIDS 90-90-90 strategy as well as issues of access to treatment and financing, among others. These advances must be accompanied by a strong commitment to human rights, good governance, inclusive and pluralistic societies as demonstrated through the greater and more meaningfully engagement of key affected populations (including but not limited to: people living with HIV, Indigenous peoples, migrants, non-status and refugee people, lesbian, gay, bisexual, two-spirited and transgender people, people who use drugs, sex workers, people in prisons and other closed settings, young people and adolescents; women, grandmothers and older people) as leaders and game-changers to the HIV response.
As noted in above sections, health and HIV are fundamentally human right issues and are central to meeting the 2030 global goals in all countries, including Middle Income Countries (MICs). Unfortunate trends are witnessing many donor governments withdrawing their financial support to MICs, often without appropriate plans for responsible and sustainable transition, and ignore the many reasons why MICs are not in a position to quickly take on the responsibility for their health systems and to meet the needs of their populations through continued service delivery. Key affected populations and human rights programs, which are often funded by external donors, are now needing to discontinue their service provision as donors withdraw from MICs. In order to prevent increases in new cases of HIV and to sustain progress made on HIV, there is an urgent need for sustainable transition plans and principles to help avoid gaps in the HIV response and ensure HIV service delivery for the poorest and most marginalized wherever they are. Technical agencies and donors, together with recipient countries, must develop guidelines on the content and process for ensuring sustainable transitions that can be implemented throughout the life of a grant. Predictable funding, long-term plans, and ensuring formal systems support human rights and community system strengthening, are essential for responsible transitions.
Canada has valuable expertise in this area and an important role to play in this regard. Without appropriate, responsible and coordinated planning of social, economic, and political commitment, inequalities will continue to widen and undermine efforts to advance diversity and human rights, as well as those directed towards building effective, accountable and inclusive institutions.
POLICY ISSUE: RESPONDING TO HUMANITARIAN CRISES AND THE NEEDS OF DISPLACED POPULATIONS
- How can Canada support needs-driven, effective and timely responses to humanitarian crises with predictable yet flexible support?
- How can Canada better support the protection of vulnerable populations in crises and strengthen respect for humanitarian principles?
- How can we facilitate more comprehensive and coordinated responses to better meet the needs of populations affected by crises and optimize the impact of humanitarian, development and peace and security initiatives?
In our increasingly complex world, fragile and emergency contexts are diverse and reach beyond the traditional definitions of humanitarian crises. In fact, we recognize a humanitarian emergency as also being an event or series of events and conditions, within and/or crossing nation states, that represent a critical threat to the health, safety, security or wellbeing of a community or other large group of people. These contexts are driven by socio-economic status, isolation and social exclusion, and fueled by other social and structural drivers (such as lack of access to housing, employment, health services and community resources). All of which, exacerbate conditions that place individuals at greater risk and vulnerability to global public health threats such as HIV infection and tuberculosis (including multi-drug resistant and extreme drug resistant forms of TB,) and create barriers to attaining optimal and timely health and wellbeing.
While many fragile, conflict and emergency settings are supported through international humanitarian agencies, there has been limited success to date in initiating locally-led responses to HIV and other health related challenges, and in building long-term capacity. Local communities, organizations and networks, including networks of people living with HIV (PLHIV), make significant contributions to HIV and emergency responses, and this role needs to be better communicated and acknowledged.
Communities and community health workforces bring local expertise, on-the-ground agility and established networks, which are responsive to the changing circumstances that fragility brings. Communities and community health workers, including volunteers, represent a sustainable and critical resource by working with the formal health system, mobilizing communities, implementing innovative community-based service delivery models, assuring sustainability of health responses through community systems strengthening, outreaching vulnerable community members and linking them to care.
We highlight five key areas where we call upon Canada for its strong voice and leadership in international development:
- Capacity, preparedness and coordination must be strengthened. Although the UN set up clusters around specific themes, some countries are concerned about dis-organization within the HIV cluster. Communities and national civil society organizations need to be better linked to national and local disaster preparedness training and systems so they are better equipped to respond to the needs of communities in crisis.
- Strengthen strategic information on HIV burden in emergency contexts.
- Build in and support greater flexibility in funding for emergency situations, including cross border and regional proposals; and, ensure that new funding for public health responses supports longer-term community system strengthening with an emphasis on human resources for health.
- Call for and fund – innovative testing, treatment and retention strategies, making use of community based peer-led approaches, and integration in services. Focus on inequity in access to HIV and health services to avoid further exclusion and marginalization. The ambitious goal to end the AIDS epidemic by 2030 can only be met if all populations affected by the epidemic are included.
- And finally, that a broader definition of emergency contexts be considered and integrated into Canadian policy documents and programming at headquarters and in country offices in the follow-up to the International Assistance Review. Within that definition, we need to emphasize the need for a differentiated response to different conditions that cause fragility.
POLICY ISSUE: DELIVERING RESULTS
- What concrete steps could Canada take to make its international assistance delivery approaches and mechanisms more efficient, effective and innovative? How can we promote greater coherence between of development, trade and diplomacy efforts?
- How can Canada foster development innovation?
- Which organizations, communities, coalitions or partnerships should Canada work with? How best can we work with them to deliver our international assistance objectives?
- How can we engage a wider range of partners to leverage the resources and expertise necessary to achieve the sustainable development goals?
1) Investing in community systems and civil society strengthening as critical to building resilient and sustainable systems for health.
In 2015, UNAIDS and the Lancet Commission issued a sobering series of recommendations for the global HIV response to effectively evolve in the new era of sustainable development. Robust investment in civil society and community systems was among the leading recommendations and recognized as a “global public health good”.
However, despite evidence indicating the added value and cost-effectiveness of key population networks, civil society coalitions and community systems, we continue to witness an accelerated downward trend in financing for community responses, including networks and coalitions. It is increasingly difficult to identify and secure funding for coalition-based work, yet it is repeatedly clear that we can’t reach our collective 2030 global goals if we work in isolation from one another – particularly in a highly integrated global development architecture as evidenced by the SDGs. We will only reinforce the silos that we continue to work across and try to break down.
Even for those institutions that are interested and willing to fund advocacy work (of which there aren’t many) – they are often only interested to fund advocacy that is directly related to service provision. Funders are often less interested in funding convening and uniting voices for common advocacy goals or for regional or global advocacy work for which impact that is more long term is more difficult to link to direct impact on people’s lives.
UNAIDS modelling exercises suggest that investments in community mobilization should increase threefold to 3%, and social enablers (this includes, advocacy, political mobilizations, law and policy reform, human rights, public communication and stigma reduction) should reach 8% of total expenditure in low and middle-income countries by 2020.
In 2015, Funders Concerned About AIDS analyzed the funding trends of 228 philanthropic funders and HIV funding for advocacy using 2014 data. Analysis shows that Philanthropic funders currently provide the majority of funding for HIV advocacy globally. Even though this is the case, the actual amount of funding is extremely limited. Total philanthropic resources for all HIV programming in LMICs account for just 2% ($620 million) of total resources for HIV. Of that 2%, only 11% ($87 million) was directed for advocacy. And that tiny amount is not going up. It is actually going down. This has recently been confirmed by the recently released report issued by the Kaiser Family Foundation and UNAIDS (July 2016).
Human rights advocacy for legal and policy change is an essential pillar of community responses and is widely considered a social enabler. In another UNAIDS survey focusing more specifically on funding for HIV and human rights, even more drastic funding decreases were reported. Of the 123 organizations that responded, 59% reported that their funding for HIV and human rights work had decreased in the previous two years. It’s important to clarify, survey results found that organizations delivering legal services related to HIV were much less affected by funding cuts than organizations focusing on things like human rights advocacy, legislative reform or strategic litigation (ICASO, 2016).
The success of the Sustainable Development Goals and the UNAIDS Fast Track Strategy to end AIDS as a global public health threat by 2030 largely depends on a robust community and civil society response in partnership with formal (public) health systems.
We call on Canada to demonstrate leadership in this area by creating and offering longer-term and multi-country funding opportunities for community and civil society groups and to increase their investment in innovative and game-changing funding mechanisms, such as the Robert Carr Networks Fund, which supports international networks that address the needs and human rights of inadequately served populations.
2) Ensure strong Canadian government and civil society representation in global policy and governance spaces while promoting robust cross-departmental communications and collaboration within Canada’s government where ministerial mandates share issues of global engagement and action.
With the growing global rise of conservative governments and health-related policies, Canada will play an increasingly important role demonstrating and advancing evidence- informed policies, programming and practices that are grounded in human rights and resonate guiding principles of good governance, peaceful, inclusive and just societies. It will be of increasing importance that these positions be advanced through strong Canadian presence (representatives from government and civil society) in the hallways and formal global policy spaces of the UNAIDS Programme Coordinating Board (the governance board of UNAIDS), board meetings of the Global Fund to Fight AIDS, TB and Malaria, and other UN related high level meetings, policy dialogues and governance spaces. Already in 2016, Canada has demonstrated strong global leadership in its renewed commitment to the Global Fund to Fight AIDS, TB and Malaria, and to programs such as, TB Reach. Presence at such governance and policy spaces will help to protect and advance Canada’s leadership, guidance and secure its influence in shaping the new development architecture of the SDGs.
Similarly, close coordination between PHAC and GAC and community and civil society partners will work to further maximize the expediency, efficiency and effectiveness of Canada’s global response to HIV, SRHR, gender equality and women’s empowerment.