Where are key and vulnerable populations in the Lusaka Agenda?

Introduction

Since the beginning of 2024, the Lusaka Agenda (LA) has gradually established itself as an essential framework in discussions relating to Global Health Initiatives (GHI). Born of a desire for coordination to achieve Universal Health Coverage (UHC) in countries, it is based on a series of coalitions between international partners aimed at creating a common agenda and setting up a one-stop shop for health financing. This global effort took shape on December 12, 2023 in Zambia, on World UHC Day.

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The LA is the result of a process led by the Future for Global Health Initiative (FGHI), a group of GHIs dedicated to the health and well-being of populations. Key players include Gavi, the Vaccine Alliance, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the Global Financing Facility for Women, Children and Adolescents (GFF). The LA is distinguished by five major transformations it seeks to accelerate to strengthen the evolution of the GHI and the global health financing ecosystem: (1) strengthening primary health care (PHC), (2) catalyzing sustainable domestic financing, (3) improving health equity, (4) ensuring strategic coherence, and (5) coordinating approaches to products and research for development.

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Although African countries such as Zambia, Kenya, South Africa and Malawi have already begun to integrate LA into their health systems, questions remain as to the place given to vulnerable and marginalized populations, such as LGBTI people, sex workers and injecting drug users. Indeed, the positioning of African countries on sensitive issues such as homosexuality raises doubts about the real inclusion of these populations in LA strategies. Doesn’t this state of affairs call into question the very legitimacy of this agenda? In any case, we can legitimately ask the question. The Lusaka Agenda seems, once again, doomed to failure, like so many other attempts to align GHI efforts, as highlighted in the Aidspan article published a few months ago.

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The Lusaka Agenda: A parody of the involvement of communities affected by the three diseases

The elaboration of the Lusaka Agenda was based on numerous consultations (Figure 1), mobilizing government players and international agencies.

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Figure 1: Lusaka Agenda Consultative Processes

However, as seen above, exchanges with key populations and vulnerable communities were often limited, or even tokenistic, fueling criticism that insufficient account was taken of their real needs, particularly for those groups most affected by HIV, tuberculosis and malaria. The term “civil society”, ubiquitous in LA documents, is confusing. Some civil society organizations, although invited to take part in meetings, do not always adequately represent the interests of criminalized populations, notably LGBTI people and sex workers. The Communities delegation to the Board of the Global Fund, for example, expressed its concern at the exclusion of criminalized populations from the LA consultation process.

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The question of the place of LGBTI people in the Lusaka Agenda remains of particular concern, given the continued repression of homosexuality in several African states. This illustrates a persistent tendency to further marginalize these populations in their access to UHC, exacerbating already entrenched social and health inequalities.

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Although some efforts at inclusion were made at the Brazzaville meeting on September 12, 2024, on the occasion of the 74th meeting of the WHO/AFRO Regional Committee, the participation of LGBTI populations and sex workers was virtually absent.

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Many community players criticized the lack of listening and the absence of concrete action in favor of vulnerable populations, reducing the workshop to what was described as a “parody of involvement”.

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The Lusaka Agenda and the Global Fund’s Country Coordinating Mechanisms (CCMs)

There are both similarities and differences between the approaches used by some Global Health Initiatives, including the Global Fund, Gavi and GFF, and those advocated by the Lusaka Agenda, particularly with regard to community participation, taking account of regional priorities and community consultation.

• Community approach: The Global Fund favors an inclusive approach, focusing on key populations and their active participation at all levels. The Lusaka Agenda, while sensitive to these issues, is often perceived as not giving sufficient priority to marginalized groups.
• Regional priorities: While the Global Fund adopts a global approach in its strategies, the Lusaka Agenda focuses more on Africa’s specific challenges. This regional focus, while important, raises questions about the sustainability and global reach of the initiatives taken under the LA.
• Community consultation: Global Fund consultation processes are well structured and formalized, enabling real inclusion of affected populations. Conversely, LA’s processes sometimes lack transparency and meaningful engagement, particularly when it comes to criminalized populations.

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A central concern of the LA is also that it advocates the establishment of a single window for health financing at national level, an initiative which, unlike the Global Fund’s Country Coordinating Mechanisms (CCMs), does not explicitly include a mechanism to bring together government, civil society and key populations. This raises questions about the real involvement of communities in national health programs and, consequently, about the feasibility of achieving UHC. Doesn’t the Lusaka Agenda run the risk of becoming a mechanism of exclusion, facilitating access to healthcare for certain populations while further marginalizing others? Is this a clear desire on the part of governments to ignore and silence key populations?

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Points of vigilance to consider for the rest of the Lusaka Agenda

If the Lusaka Agenda is to play a key role in improving healthcare systems in Africa and in achieving the UHC, several points of vigilance need to be taken into account to ensure genuine inclusion of key and vulnerable populations.

• Strengthen community involvement: It is imperative that the LA takes concrete steps to include key populations, such as LGBTI people, sex workers and injecting drug users, in all stages of the process, from program design to implementation.
• Inclusive and transparent consultations: Formal, transparent and regular consultation mechanisms must be put in place to ensure that the voices of vulnerable populations are heard and taken into account in the development of public health policies.
• Alignment with global strategies: The LA should encourage countries to adopt priorities centered on the needs of populations. For example, it could encourage countries to adopt human rights-based approaches, such as those put forward by the Global Fund, which include Country Coordinating Mechanisms (CCMs) and guarantee the involvement of key populations.
• Advocacy for sustainable funding: It is crucial to ensure adequate and sustainable funding for local initiatives and programs aimed at key populations. Without such funding, efforts to combat HIV/AIDS, tuberculosis and malaria risk running out of steam, leaving the most vulnerable populations without support.

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Conclusion

While the Lusaka Agenda represents an important step towards strengthening health systems in Africa, its success depends critically on its ability to fully integrate key and vulnerable populations into its strategies and actions. Only a concerted, continuous and truly inclusive approach will ensure that these marginalized groups are not left behind, and that equitable and universal access to healthcare is truly achieved.