Global Fund Assign. 5

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Global Fund Assignment #5 – Actors and Agencies Name: Joshua Auvaa Email: jauvaa@uw.edu Country: Peru Disease Focus: HIV/AIDS Reminder: document all citations using the APA citation style! APA Style Guide Instructions: Answer the following 6 questions. Peru operates under a presidential republic, though their political history has been punctuated by numerous military coups and changes of constitution (Moore & Davies, 2018). Additionally, the World Health Organization states that an estimated 28% of Peru’s population is still living in rural areas, leaving them to face the brunt of social, political, and economic inequities while being neglected and disadvantaged in terms of access to quality health and education services. The country’s leadership does not demonstrate a credible commitment to health services, and they must prepare urgently if it is going to “…successfully face the challenges posed by the country’s epidemiological transition…” (WHO, n.d.). Through a newer decentralization process, the health sector will need to overcome the development of extensive infrastructure, equipment, and supplies to face the ever-changing epidemiological health profile. The shortcomings in government accountability and standards are reported to be the weakest in the poor inner departments of the country, thus Department of Global Health Page 1 Question 1: Describe the political climate in your chosen country. Is the country a democracy? Does your country’s leadership demonstrate a credible commitment to health services? If yes, how? If no, why not? (150-200 words)

development of an effective consultation process that considers all stakeholders’ perspectives and expectations will contribute to the necessary change to a transparent and effective culture (World Health Organization, n.d.) Peru has a decentralized health care system administered by 5 entities, which consequently results in a system with multiple providers of services, often performing functions with a high degree of overlap and little coordination (World Health Organization, 2012). This leads to health workers working several jobs in multiple subsectors on a regular occurrence, contributing to the overall inequitable distribution of health workers (WHO, n.d.). Under Peru’s presidential republic, “elected leaders and representatives are the key agents in creating and implementing policy” ((Freedom House, 2020). However, special interest groups and businesses influence officials through bribes and other illicit payments. This undermines the influence of typical voters in a nation where government corruption is already a critical problem. Peru has been praised over the last two decades for introducing a series of reforms aimed at achieving Universal Health Coverage (Gianella et al., 2020). Nevertheless, reforms have failed to overcome the historical fragmentation of the system, where access to health services is determined by income, gender, and geographical location (Gianella et al., 2020). In 2020, Jorge Muñoz, the mayor of Lima, signed the Paris Declaration to end the AIDS epidemic in cities, joining the Fast-Track cities initiative (UN AIDS, 2020). This initiative is committed to ending Department of Global Health Page 2 Question 2: Describe the constraints on your country’s ability to provide health services. For instance, is your country under structural adjustment? To what extent does the country dictate its own policies? (150-200 words) Question 3: Describe the current national capacity (state of systems and services) that exists in response to your chosen disease (e.g., level of human resources available, health and other relevant infrastructure, types of interventions provided). (200-300 words)

the AIDS epidemic as a public health threat by 2030, and its approach hopes to educate, raise awareness, launch non-discrimination campaigns, and implement a work plan to train health personnel and promote access to information and sex education (UN AIDS, 2020). A notable improvement in the fight against HIV/AIDS surrounds transwomen in Peru. As a group, transwomen have the highest prevalence of HIV in the country, while also having little access to HIV prevention, testing, and care services (Salazar et al., 2016). In 2014, The Ministry of Health expressed its commitment to improve programming for transwomen and prioritized the development of a “Targeted Strategy Plan of STIs/HIV/AIDS Prevention and Comprehensive Care for Transwomen” (Salazar et al., 2016). This comprises of a five-year plan that includes new national guidelines for HIV prevention, care and support, and country-level investments in infrastructure and equipment. Further, the Ministry of Health builds onto new biomedical strategies with the intent to incorporate several strategies which address structural factors contributing to the vulnerability of transwomen (Salazar et al., 2016). UNAIDS has proven to be a primary actor in Peruvian HIV/AIDS services, as seen in their contributions towards transgender women. UNAIDS has acted in partnership with the Peruvian Ministry of Health, organizing a national consultation on combination HIV prevention, opening the dialogue between stakeholders and community leaders on the future of HIV prevention in Peru (UNAIDS, 2016). Some implemented practices include special trainings of health personnel at STI treatment centers, the provision of prevention services, HIV testing and linkage to health services for antiretroviral therapy and awareness-raising of local law enforcement personnel on the respect of human rights and prevention of gender-based violence for the transgender community (UNAIDS, 2016). Department of Global Health Page 3 Question 4: Name the main national and international agencies involved in national responses to your chosen disease/condition in-country and their main programs. What is the specific government entity within the country that coordinates the response to your chosen disease? Are the goals of that entity known/clear? (150-250 words)

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The Global Fund has also made notable contributions towards fighting the prevalence of HIV/AIDS. Peru has received around $70 million for HIV/AIDS from the Global Fund, which helped the emergence of important breakthroughs in the HIV/AIDS response, primarily concerning treatment access, focus on vulnerable populations and development of a coordination body (Amaya et al., 2014). This work does appear to supplement national health systems effectively. With the UNAIDS plan surrounding transgender women being translated into practice, Mao, a transgender women activist and peer educator of the ministry of Health, said, “The focused plan is bringing services closer to the community. Some transgender women who could not go to the sexually transmitted infection treatment centers are now asking for condoms and testing, for information and for comprehensive health services. We are proud of being part of this initiative” (UNAIDS, 2016). Future phases of the transgender health plan are set to include an increase in the number of decentralized prevention and treatment service sites, incorporating into and aligning with the national HIV program (UNAIDS, 2016). In terms of the Global Fund, the financial support in tandem with recent economic growth has enabled greater government funding. However, doubts remain concerning the transition from Global Fund support to increasing national HIV/AIDS funding (Amaya et al., 2014). This uncertainty comes from reliance on the Global Fund financing prevention activities via non-governmental organizations, on top of the lack of government direction and weak regional governance. An effective transition to government-led financing will require strengthening government and regional capacity and fostering accountability mechanisms (UNAIDS, 2016). Department of Global Health Page 4 Question 5: Does this work supplement national health systems effectively? How does the work of these other entities impact health systems nationally? Does the work of other organizations possibly interfere with the work of the government? (200-300) Question 6: Does the government appear, from past and current actions, genuinely committed to addressing your chosen disease? What limitations does the government show, and what are areas for improvement? (150-250 words)

Given the assistance Peru has received from UNAIDS, the Global Fund, and other organizations alike, the government does appear to have a respectable amount of commitment invested in fighting HIV/AIDS. The biggest challenge standing in front of improvement is the transition from reliance on the Global Fund to government led- financing. Until 2010, a large portion of HIV/AIDS programs were financed through external assistance, with the Global Fund being the largest contributor in the lot (Amaya et al., 2014). With the shift in Peru’s economic standing, they became an upper-middle-income country, allowing them to only apply for smaller grants focused on key populations due to the Global Fund’s eligibility criteria. The main area for improvement in this case would then be budgeting on the national scale. Investments in HIV/AIDS and tuberculosis activities did happen to see 0.2 percent increase from 2011 to 2012 (Amaya et al., 2014). This is one example of incremental change that will benefit the mitigation of HIV/AIDS, as long as policies are enforced and given reasonable means to operate. Department of Global Health Page 5

References Amaya, A. B., Caceres, C. F., Spicer, N., & Balabanova, D. (2014). After the Global Fund: Who can sustain the HIV/AIDS response in Peru and how? Global Public Health , 9 (1-2), 176–197. https://doi.org/10.1080/17441692.2013.878957 Freedom House. (2020). Peru: Freedom in the World 2021 Country Report . Freedom House. https://freedomhouse.org/country/peru/freedom-world/2021 Gianella, C., Iguiñiz-Romero, R., Romero, M. J., & Gideon, J. (2020). Good Health Indicators are Not Enough. Health and Human Rights , 22 (2), 317–319. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7762920/ Moore, J. P., & Davies, T. M. (2018). Peru - Government and society. In Encyclopædia Britannica . https://www.britannica.com/place/Peru/Government-and-society Salazar, X., Núnez-Curto, A., Villayzán, J., Castillo, R., Benites, C., Caballero, P., & Cáceres, C. F. (2016). How Peru introduced a plan for comprehensive HIV prevention and care for transwomen. Journal of the International AIDS Society , 19 , 20790. https://doi.org/10.7448/ias.19.3.20790 UNAIDS. (2016, November 24). Preventing HIV among transgender women in Lima . Www.unaids.org. https://www.unaids.org/en/resources/presscentre/featurestories/2016/november/20 161124_peru World Health Organization. (n.d.). Annex 12. PERU . https://www.who.int/workforcealliance/knowledge/resources/MLHWCountryCas eStudies_annex12_Peru.pdf Department of Global Health Page 6

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World Health Organization. (2012). WHO | Peru. Who.int . https://doi.org//entity/workforcealliance/countries/per/en/index.html Department of Global Health Page 7

Global Fund Assign. 5

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