How Local Civil Society Can Advance Investments in Health and Pandemic Response: Learning Among Advocates

By Maurine Murenga, Caroline Cummings and Mark P. Lagon

In the wake of the COVID-19 pandemic, societies, governments and multilateral global health organizations are endeavoring to cope with both the consequences of COVID and its rippling repercussions on “the big three” endemic infectious diseases, HIV/AIDS, tuberculosis and malaria. Civil society and affected populations throughout the global South have a vital role – and not just in this protracted crisis situation – to weigh in with local and national authorities about what health investments should be prioritized.

Maurine Murenga, an HIV and TB advocate based in Kenya

Civil society voices need to effectively advocate for sufficient domestic resource mobilization (DRM) to fund resilient health systems which leave no one behind, provide universal health coverage and eliminate the big three epidemics. Although donor funding is vital to address health emergencies, local governments must step up with broad-based DRM for long-term health care. Some external funders propel DRM, including the Global Fund to Fight AIDS, Tuberculosis and Malaria. Nevertheless, the first and best voice for DRM is a country’s own civil society. COVID-19 has devastated national economies and GDP growth projections, inhibiting civil society advocates and organizations in low to middle income countries from eliciting the increased DRM needed from their political leaders. Still, effective domestic advocates are the most potent force to boost political will.

First, opaque budgets prevent civil society advocates from accessing information on how much money is allocated for health funding and where gaps in funding exist. Without knowledge of how money is spent on particular interventions, compared with the amounts obligated by a government, it is difficult to deduce which health programs have sufficient funds and what areas are most in need of additional resources. There are discrepancies between what is budgeted and what is funded. For example, authority figures might divert money to other projects. When so many health initiatives are desperate for support, knowing exactly where public health funding is going (or not going) in one’s country is critical information.

Additionally, budget cycles vary among countries. Navigating budget timing and processes often requires unique skills and expertise. It would be advantageous for health advocates to connect with budget and financial specialists from their country to gain insight on (1) when during the fiscal year it would be optimal to advocate for health funding and (2) what distinct areas of health spending are most in need of advocacy. The latter is why amfAR, The Foundation for AIDS Research, collaborated with the Coalition to Build Momentum, Power, Strategy, and Solidarity (COMPASS) to provide advocacy resources for budget monitoring in countries with which the U.S. works to combat HIV in sub-Saharan Africa and elsewhere, such as Haiti and Vietnam. Access to detailed information about funding levels as well as program performance of the President’s Emergency Plan For AIDS Relief (PEPFAR) make it more possible for local civil society advocates’ to monitor health services and pinpoint health areas that are in need of additional government support.

Two particular challenges to successful advocacy for resources are formulating advocacy “asks” with enumerated costs and concrete answers for how “asks” would be paid for. Working relationships between advocates and specialists on budgeting and on financing for health need to be durable to maintain and strengthen DRM efforts over time.

Likewise, it is essential for civil society advocates to identify key decision-makers shaping and adopting budgets—sometimes more subtle than what appears on the surface. Civil society advocates need to gain buy-in from these key decision-makers so that these leaders will exert their power to influence government budgets on behalf of their society and disease-affected populations.

Increased accountability and monitoring of budgets are crucial in order to (1) be aware of how much funding is allocated to health at present and (2) ensure that money designated for health is spent on its intended purpose. Monitoring is necessary to counter corruption from shortchanging how much money is indeed allocated towards health. To this end, it would be beneficial to facilitate connections between government watchdog organizations and health advocates to probe whether all funding is spent as intended—to avoid diversion or neglect of vulnerable, criminalized, marginalized and often stigmatized groups. Partnerships between health advocates and more general governance and human rights organizations need to be ongoing as well.

Lastly, we need to share best practices for advocacy between civil society groups. Lack of communication between local organizations leads to failures to utilize already-tested tactics, hence missing opportunities to increase DRM advocacy’s effectiveness. Mutual learning between (1) various civil society advocates in low to middle income countries and (2) local and donor countries’ advocates could bolster DRM advocacy by building on each other’s knowledge and practices. This, in turn, could help to spur governments of the South to back increased, more consistent resources for health. For example, civil society organizations (CSOs) could leverage each other’s expertise and past experiences to learn how to craft an argument or create a visual representation of problems and solutions rooted in empirical data that resonates with decision-makers. Therefore, CSOs ought to create and expand platforms to share their best tactics and proven approaches to increase the likelihood of gaining domestic health funding.

Fortunately, there are examples of progress, despite tough odds. Effective campaigning among national and global advocates has delivered results. In response to recurring national antiretroviral treatment (ART) stockouts in Uganda[ML1] , a coalition working in trans-national solidarity including Health GAP, the Coalition for Health Promotion and Social Development, Sexual Minorities Uganda[ML2]  and International Community of Women living with HIV Eastern Africa secured a major increase in domestic funding for ART from the government of Uganda. It also secured a new commitment by the Ministry of Finance to ring fence from any diversion all funding for ART.         

In Uganda, concerted advocacy blossomed in 2011, when the Center for Health, Human Rights and Development sued the government over rampant preventable maternal morbidity and mortality. Prominent HIV organizations working in Uganda and globally leveraged this strategic litigation in order to secure meaningful shifts in Uganda’s appropriations for maternal and child health[ML3] . By 2012, the Coalition to Stop Maternal Mortality used its campaigning savvy to secure passage of an unprecedented emergency supplementary budget to fight maternal death. National advocates also knew that this was an important strategy for augmenting funding to support the HIV response, because there were primary and secondary overlaps of maternal mortality with HIV. Functional health systems with adequately paid and sufficient health workers were needed for people with HIV and pregnant people. In response, civil society sought recognition from the Ugandan government that escalation of maternal health initiatives was necessary to combat HIV. CSO advocates rejected the premise of a zero-sum game, as investments in maternal health benefitted HIV initiatives. The campaign targeted parliamentarians and cabinet members. The president committed substantial resources to hire numerous additional health workers deployed at local levels–from whom women often receive care and services. This was the first time the Ugandan government made a commitment to women’s health.

Inspired by this case, now more than ever, funding for public health must be secured to heal from the COVID-19 pandemic and its aftermath. Optimizing advocacy for DRM could be a critical tool for gaining increased and stable funding to curb longstanding disease threats and to reinforce health systems, personnel and coverage in the global South. It serves the ethical goal of meeting basic human needs of the vulnerable, and could ultimately strengthen health security, maintain the vitality of significant economic partners, and promote stability throughout the global South. 

Maurine Murenga is Founder and Executive Director[ML4]  of the Lean on Me Foundation in Kenya, and a member of Friends’ board.  Caroline Cummings is a senior at The University of Texas at Austin concentrating in biology and Plan II Honors. Mark P. Lagon is Chief Policy Officer at Friends.