The response to HIV, tuberculosis (TB) and malaria is more important than ever in countries increasingly affected by conflict, disasters and economic crises. The worst refugee crisis in recent times is affecting all parts of the world, particularly the Middle East – and, the Global Fund points out, as people move, so do diseases. Through its multi-country grant in the Middle East, the Global Fund is balancing investment risks in fragile governance settings with the compelling needs of populations with increased vulnerability and providing a differentiated and flexible approach to grant investment and management. The grant has a single Principal Recipient (PR), the International Organization for Migration (IOM), a regional grant management platform based in Jordan, disease-based allocation (versus country-based) and is leveraging partnerships across the UN family with government counterparts. A programme to address the needs of countries in conflict The Global Fund has classified countries addressed by the Middle East Response (MER) Initiative grant as challenging operating environments (COEs) – countries or regions that experience disease outbreaks, poor access to health services, manmade or natural disasters, armed conflicts, and/or weak governance. The countries are Iraq, Jordan, Lebanon, Syria and Yemen, to be joined by Palestine in the forthcoming phase of the grant. The COE Policy classifies COEs based on countries with the highest External Risk Index level in the Global Fund portfolio and allows for ad hoc classification to enable rapid responses to emergency situations. The region has experienced more than a decade of shockingly high numbers of population displacements which continue to grow. For example, Jordan has a long history of taking in refugees and, after Turkey, hosts the second largest number of refugees per capita in the world, at 87 refugees per every 1,000 citizens according to the United Nations High Commissioner for Refugees (UNHCR). The country’s 2015 census reported 9.5 million people — a significant increase from 5.1 million in 2004. Roughly 40% of those, including 662,010 registered Syrian refugees as of July 2019, rely on the Jordanian Ministry of Health for health services. The six countries are coping with the effects of conflict, humanitarian and economic crises, as well as large numbers of internally displaced persons (IDPs) and refugees. As a result, these countries face constantly shifting needs, limited capacity and severe constraints to providing essential services. In Iraq, Syria, and Yemen, countries with fragile health systems, most of the health facilities have been destroyed by conflict, and infrastructure, equipment, people, and resources are scarce. The health infrastructure in countries hosting displaced populations, such as Palestine, Jordan and Lebanon, is overstretched. In the latter two countries, stronger health systems have been suddenly overwhelmed with a deluge of refugees – adding a third to their populations and draining systems and economies. This situation has been exacerbated by COVID-19, meaning that scarce resources are stretched even further than before, with staff, money, and medicines diverted from other programs in order to be able to address the pandemic and its fallout. A multi-country grant for countries at varying economic levels of development but with overarching commonalities To better respond to the regional challenges, in 2017 the Global Fund launched an initiative to offer more flexibility to support the region in its efforts to address the three diseases. The MER grant was designed to provide essential HIV, TB and malaria services to key and vulnerable populations (KVPs), including people on the move such as IDPs, migrants, refugees, and other key affected and hard-to-reach populations in Iraq, Syria and Yemen, as well as to Syrian refugees in Jordan and Lebanon. However, for HIV some countries are also addressing men who have sex with men (Lebanon) and drug users (Palestine). The multi-country modality enables the Global Fund to support countries that would not usually be eligible owing to their economic status classification, such as Jordan, as well as countries that are much worse off, such as Yemen, under one umbrella. Six countries will be covered under MER-3.

Figure 1: Middle East Response Initiative Countries Phase 1 was launched in 2017/2018, followed by Phase 2 for 2019 to 2021. The Funding Request for the third phase, 2022-2024, was submitted in April 2021.

  Table 2 highlights MER’s main achievements in the past year, despite service disruptions as a result of COVID-19.     These results and others were achieved in an environment that the Fund Portfolio Manager for the grant, Emmanuel Olatunji, describes as “political and pandemic ‘double’ restrictions”. In other words, the pandemic is a huge burden that is making itself felt in a region that is already encumbered by socio-political contexts that make service delivery particularly challenging. Olatunji adds: “The MER grant depicts the innovation, flexibility, and adaptability of the Global Fund support mechanism. The recorded success of MER is a ‘celebration’ of a strong and robust partnership with frontline colleagues, technical partnership and other humanitarian sectors in making sure essential services reach those in need and hard-to-reach locations within the MER countries, for example in Iraq, Syria, and Yemen, while continuing to support access to health services in an overstretched health system in Jordan and Lebanon as a result of the increasing influx of migrants, refugees, and displaced families due to constant political unrest”. Partnership and coordination: Increasing collaboration with national and regional partners What makes the MER grant so noteworthy is the collaboration and coordination between the international partners: Global Fund, IOM, the United Nations Joint Programme for AIDS (UNAIDS), and the World Health Organization (WHO). The tension that sometimes exists between international agencies lobbying for the limelight and competing for scarce resources is seemingly absent in the region. Instead, all agencies pull together in an overwhelmingly difficult situation to work with national disease program counterparts in delivering critical services to some of the world’s most vulnerable key populations. None of this is more apparent than through the creation of the MER Technical Support Group (TSG). It was established with WHO/Eastern Mediterranean Regional Office (EMRO) and UNAIDS as co-chairs and IOM as the Secretariat, and members include the national HIV, TB, and malaria programs. The TSG’s overall aim is to coordinate technical, advocacy, partnership and policy support for MER’s effective implementation. TSG provides advice on the prioritization of essential interventions to maximize MER’s impact among targeted populations and coordinates activities with the humanitarian response in these settings to maximize value for money of the Global Fund’s investments. Olatunji says that “the success of the recent regional and multi-country-led Funding Request (MER-3) development process is attributed to the effective collaboration and partnership with the regional and technical partners. The next implementation cycle should see the MER grant as an example of an inclusive partnership engagement in a COE context, achieving impact in the three Global Fund focus diseases as well as responding to the challenges of COVID-19 in the six countries”. The partnership is invaluable for service delivery in these COE countries, and this was evident when the Government of Yemen suspended the HIV program in April 2018 for allegedly promoting sex and besmirching the ‘norms and values of Arabic and Yemeni culture. Although it has since been reinstated, this is largely thanks to the efforts of the TSG and other international partners who pulled together to ensure that the suspension was less than six months and normal services resumed. As Olatunji says, “We must also recognize the critical role played by our colleagues in the national programs, community workers and volunteers – all mutually contributing to making the partnership and the money work”. It is an apt lesson in the ‘fragility’ of the HIV response in this region. HIV service delivery is challenging enough for many countries when it comes to targeting ostracized KPs with tailored services. However, in the conservative Middle East context – and with the usual stigmatized and discriminated KP groups expanded to include other vulnerable populations such as IDPs, refugees, and migrants – the HIV response is fighting a very real battle for survival. Part II of our article on HIV in the Middle East will be published in GFO issue #398 in June.