Mobilizing women at the grassroots to shape health policy: a case study of the Global Campaign for Microbicides

Abstract

Competition to advance issues on public policy agendas is constant. Political scientists agree that professional "policy entrepreneurs" (researchers, academics, and bureaucrats) serve as conduits in this process. Grassroots advocacy has always been part of the political landscape as non-professional people also take on the role of policy advocates or activists, to get specific problems and preferred solutions onto public and policy agendas and motivate policymakers to take action. The contribution of grassroots advocacy to significant policy changes is often under-funded because its impacts are hard to isolate and quantify, and are often most evident in retrospect. This paper examines the contribution of the Global Campaign for Microbicides to the movement to expand the range of HIV prevention options for women and describes how it mobilized hundreds of grassroots policy activists around the world to take coordinated action on this issue. It reviews the Campaign’s accomplishments and highlights some of its strengths and weaknesses. Finally, the paper considers the value of similar efforts on the part of grassroots advocates seeking to influence the post-ICPD and post-2015 development agendas as they are being negotiated. Decisions regarding what kind of advocacy work is carried out during this process, and by whom and how, will inevitably shape the content of these new frameworks.

Résumé

La concurrence pour faire progresser les questions à l’ordre du jour des politiques publiques est constante. Les spécialistes des sciences sociales conviennent que les « entrepreneurs politiques » professionnels (chercheurs, universitaires et bureaucrates) servent de véhicules dans ce processus. Le plaidoyer au niveau local a toujours fait partie du paysage politique car des non-professionnels assument aussi le rôle d’avocats ou de militants, pour inclure des problèmes précis et des solutions préférées dans les programmes politiques et publics, et pour inciter les décideurs à agir. L’apport du plaidoyer de base à d’importants changements politiques est souvent sous-financée car ses résultats sont difficiles à isoler et à quantifier, et sont souvent le plus manifestes rétrospectivement. Cet article examine la contribution de la Campagne mondiale pour les microbicides au mouvement en vue d’élargir l’éventail des options de prévention du VIH pour les femmes. Il décrit comment elle a mobilisé des centaines d’activistes politiques locaux dans le monde pour agir de manière coordonnée dans ce domaine. L’article examine les succès de la Campagne et met en évidence certaines de ses forces et de ses faiblesses. Enfin, il envisage l’utilité d’activités similaires de la part de défenseurs locaux cherchant à influencer les agendas du développement après la CIPD et 2015 alors qu’ils sont en cours de négociation. Les décisions concernant le type de travail de plaidoyer mené pendant ce processus, par qui et comment, façonneront inévitablement le contenu de ces nouveaux cadres de travail.

Resumen

La competencia por promover los asuntos en las agendas de políticas públicas es constante. Los científicos políticos coinciden en que "empresarios políticos" profesionales (investigadores, eruditos y burócratas) sirven como conductos en este proceso. La promoción y defensa (advocacy) a nivel de las bases siempre ha sido parte del panorama político, ya que las personas no profesionales también asumen el papel de promotores de políticas o activistas, con el fin de incluir problemas específicos y soluciones preferidas en las agendas públicas y políticas y motivar a los formuladores de políticas para que tomen medidas al respecto. La contribución de las bases al abogar por cambios significativos a las políticas a menudo es subfinanciada porque resulta difícil aislar y cuantificar su impacto, el cual suele ser más evidente en retrospectiva. En este artículo se examinan los aportes de la Campaña Mundial a favor de los Microbicidas al movimiento para ampliar las opciones de las mujeres para la prevención del VIH y se describe cómo ésta movilizó a cientos de activistas de base mundialmente para que actuaran de manera coordinada al respecto. Se revisan los logros de la Campaña y se destacan algunas de sus fortalezas y debilidades. Por último, se considera el valor de similares esfuerzos por parte de promotores de base que buscan influir en las agendas de desarrollo post-CIPD y post-2015 durante las negociaciones. Las decisiones respecto al tipo de actividades de promoción y defensa que se llevarán a cabo durante este proceso, por quién y cómo, inevitablemente definirán el contenido de estos nuevos marcos conceptuales.

Keywords:

• health policy and planning
• advocacy
• HIV prevention
• microbicides
• reproductive and sexual health

Several political scientists have examined the question of when and how an issue becomes pressing enough to warrant action by policymakers. Kingdon¹ proposed that an issue gains priority when three separate streams of activity converge. First, the issue must be perceived as a problem that would respond to organized action. Second, solutions to the problem must be proposed by experts. Finally, a precipitating event or events must happen at the political level to motivate policymakers to take action. Hafner and Shiffman² refer to this third step as the opening of a political window, which provides the opportunity for “policy entrepreneurs” to link all three streams together and generate decisive action.

Other conceptual models describe this process differently. Incrementalism, for example, describes a process in which policy change results from policy makers adjusting the status quo gradually over time.³ Baumgartner and Jones⁴ proposed a punctuated equilibrium model in which periods of little or no policy change are occasionally interrupted by a sudden burst of public attention to an issue that propels new policy developments.

Despite their differing analyses of the process, all of these models identify a common set of primary actors. These include researchers, academics and bureaucrats, who remain relatively hidden, and publicly visible politicians, such as “prime ministers, political parties, parliamentarians, UN agency heads and leaders of large advocacy organizations, among others”.² Such casting reveals an implicit hierarchical view of the credentials required to address policy problems and offer solutions.⁵

This paper argues that grassroots actors can serve as effective policy activists – taking on a role that parallels that of the professional “policy entrepreneur”. Klugman has coined the term “policy activists” to describe this role, recognizing that “mobilization of those most affected can in itself change the policy environment… to get specific problems and preferred solutions onto public and policy agendas”.⁶

The term “grassroots” is used here to refer to people not part of any political or academic elite and whose engagement occurs at local or regional levels. Their participation in the public policy dialogue may be channelled through non-governmental organizations (NGOs), or may occur when they express individual opinions directly. This paper focuses on the former circumstance, when NGOs operating at state and national levels serve as conduits through which the collectivized involvement of people at the grassroots becomes an audible component of policy discussions.

The question of whether and how grassroots advocates can effectively function as policy activists on issue related to sexual and reproductive health and rights is timely. The intended timeframes for implementing the 1994 International Conference on Population and Development (ICPD) Programme of Action and achieving the Millennium Development Goals, drafted in 2001, are both expiring and the various components of the new post-2015 development agenda are in the process of being debated and drafted. Many advocates have criticized these existing frameworks for their failure to explicitly include sexual and reproductive health and rights as integral to sustainable development, an omission allowing them to be “sidelined in programming, policy and funding”.⁷

A number of factors, including under-investment, competing priorities, political opposition, and mismatches between brave political proclamations and real governmental commitments have undoubtedly contributed to this sidelining. This paper suggests that coordinated pressure on the negotiators shaping the new policy agendas – and particularly pressure from grassroots constituents prepared to hold their negotiators accountable once the frameworks are in place – might help ensure more substantive attention to sexual and reproductive health and rights issues going forward.

Traditional policy entrepreneurs tend to avoid potentially inflammatory topics such as sexual and reproductive health whenever possible, preferring to use their political capital in other areas.⁸ The willingness of grassroots activists to address these issues publicly has been amply demonstrated, but their influence has been limited by insufficient numbers and lack of coordination.⁹ While several large international NGOs engage in advocacy around these issues, they do not always do so as a coordinated bloc or by bringing a common set of well-defined demands to the delegations acting on their behalf. Would this pattern change if more grassroots advocates were systematically recruited, trained and equipped to act as policy activists, using Klugman’s definition?

Could larger numbers of policy activists hold their national delegations explicitly accountable for increasing commitment to sexual and reproductive health and rights in the next generation of public health policy frameworks? This paper uses a case study on the Global Campaign for Microbicides (GCM) to examine the potential feasibility of this option.

Case study: the Global Campaign for Microbicides

Du Toit wrote about the need for “good knowledge brokers: intermediaries, translators, activists and ‘organic intellectuals’ who can work strategically across the divide between policymaking and research”.⁵ Staffed by a small cadre of professional activists, the Global Campaign for Microbicides sought to bridge not only the divide between policy and research but also the divide between professional policy entrepreneurs and those working at the grassroots level to change policy. It did so in an effort to compel professional policymakers and funders to act on the urgent need for better HIV prevention tools for women.

Established in 1998,^* GCM sought to accelerate the development of HIV prevention tools that could be used without a male partner’s active cooperation. GCM focused particularly on microbicides, topical products designed to be applied vaginally or rectally to reduce the risk of HIV infection resulting from sexual exposure. With a relatively small staff and budget, GCM collaborated with ally organizations in women’s health, HIV/AIDS, sexual and reproductive health and rights, and other related fields specifically to:

	generate political pressure for increased investment in microbicide research and greater access to female condoms and other cervical barrier methods;
	promote stronger civil society involvement to ensure that the rights and interests of trial participants, users, and communities are fully represented and respected at all stages of research, development, and product introduction; and
	enable trials to proceed efficiently by addressing emerging challenges such as disappointing research results and political landscape shifts that affect ethical decision making, media coverage, and political and community perceptions of the trials.

Unaffiliated with any product developer or research institution, GCM structured itself as a platform for advocacy and, over its 14 years, recruited 347 partner and endorsing organizations across six continents as collaborators in the implementation of locally appropriate advocacy strategies. At its height in 2007, GCM had 17 staff working out of Washington, DC, Johannesburg, Nairobi, Brussels, Delhi and Ottawa.

Its funding declined, however, in the wake of the global economic downturn and after clinical trial results showed several candidate microbicides to be ineffective. Enthusiasm rebounded in 2010, with the announcement of the first clinical trial results to show microbicide “proof of concept” (evidence that a topically applied product could significantly reduce HIV risk). In July 2012, however, PATH, the organization housing GCM, announced its decision to close GCM,¹⁰ for reasons discussed below.

Defining the problem and proposing solutions

Globally, the vast majority of women with HIV acquired the virus through sex with a husband or boyfriend. Women are about twice as likely to acquire HIV during unprotected sex with an HIV-positive man than vice versa¹¹ and many women cannot or do not insist on male or female condom use. In 1990, Lori Heise (later GCM’s founding director) was conducting a session at an HIV prevention conference when a Ugandan woman asked, “If they can send a man to the moon, why can’t they find a way to protect women [from HIV] and still allow them to get pregnant.” Intrigued by the question, Heise contacted leading scientists at US federal agencies in search of an answer. They told her that such a product was not impossible to create, but that it might not be feasible to test it and was probably not necessary because “women aren’t really at risk” of HIV (L Heise, Director, GCM, Personal communication, 23 August 2006).

Also in 1990, South African epidemiologist and advocate Zena Stein published a commentary in the American Journal of Public Health on women’s need for their own HIV prevention tool. Decades of experience in family planning, she noted, had shown the superior effectiveness of methods that put control over fertility in women’s hands but this lesson was being overlooked with regard to HIV prevention.¹² In 1991, community advocates at the first US Conference on Women and HIV Infection demanded HIV prevention tools “which are woman-controlled and may be used without detection by their sexual partners”.¹³

In the late 1980s, a few researchers began investigating the potential for Nonoxynol-9 (a widely-used spermicide) to function as a microbicide, a hypothesis ultimately rejected in 2000.¹⁴ Research to create novel microbicides started in U.S. and U.K. laboratories in 1992¹⁵ and the first candidate products were ready to enter clinical trials by the late 1990s. But two major barriers slowed their progress: lack of funding and lack of governmental cooperation in the countries best suited to host clinical trials.

In 1999, the US government invested US $28 million¹⁶ in microbicide research and development and more than $200 million in development of an HIV vaccine.¹⁷ Although there was no more evidence to support the likelihood of developing a vaccine effective against HIV than there was for an effective microbicide, vaccines were preferred for several reasons. Preventive vaccines were (and are) generally considered the “gold standard” of biomedical prevention tools, while the concept of preventing disease by applying a product vaginally or rectally was unprecedented. Vaccines are also provider-controlled, rather than user-controlled, making their correct and consistent use more predictable. Vaccines can also be discussed without mention of how, with whom, and under what circumstances people have sex. As in other areas of sexual and reproductive health, policymakers and funders shy away from discussions likely to involve mention of sex and gender-based power differentials. The miniscule level of government funding for microbicides was crippling the progress of research to develop them.

Addressing the barriers to this progress required a two-pronged advocacy effort: one to persuade rich countries to invest in the microbicide effort, and the other to persuade the potential host countries to allow such research. The former was vital because public funding was (and is) the life-blood of microbicide development because the pharmaceutical industry, usually the engine of new drug development, has not seen microbicides as profitable enough to warrant significant investment.¹⁸ Liability concerns have also dampened their interest; since no microbicide is likely to be 100% effective, lawsuits could result from claims of a product’s ineffectiveness. In 2004, only 3% of global funding for microbicide research and development came from the corporate sector, with the remaining 97% supplied by governments and philanthropists.¹⁹ This ratio remained unchanged eight years later in 2012.¹⁷

Low governmental support in trial host countries was an equally critical barrier. To detect potential effectiveness, microbicide trials have to be done in areas where HIV incidence among women is already high. As part of trial protocols, free condoms would always be provided to all trial participants and their use encouraged. Women in the test product arm of the trial would have about the same rate of condom use as those in the comparison (placebo) arm, so any evidence of additional protection in the product arm could be attributed to use of the test product.

Heise and others established GCM in 1998 to make public interest in microbicides visible in potential investor and potential trial host countries. Rather than starting from scratch, GCM enlisted the support of various natural allies, including local and national NGOs working in women’s health, family planning, human rights, and/or HIV/AIDS. To equip this effort, GCM developed user-friendly educational materials on the mechanics of HIV transmission, the status of microbicide research, and the steps being taken to ensure that such research was conducted ethically.

Its organizing approach was nurturing and highly collaborative, assuming from the outset that potential NGO partners were already overloaded with other work. Instead of compounding this by asking endorsing organizations to take on pre-determined tasks, GCM invited them to participate in whatever ways they could. The menu of options ranged from placing a prepared article in their newsletters or website (with locally relevant content added), to circulating GCM’s Petition for Greater Investment in Microbicides, to co-sponsoring educational events. These choices enabled partners and endorsers to engage at a comfortable level and provided them with the tools, training, strategy advice, and motivation to initiate in-country advocacy for microbicides.

Starting in the United States, GCM focused on key legislative districts, asking NGO endorsers to host “Campaign sites” — city-wide NGO coalitions in which members collectively urged their legislators to increase federal investment in microbicide research and development. The US budget for microbicides tripled from US $28 million 1999 to US $92 million in 2004²⁰ and then almost doubled again between 2004 and 2009.²¹ This accomplishment resulted from the convergence of a number of streams in the policy landscape. Increasing media attention to the spread of HIV among women, especially in sub-Saharan Africa, highlighted the urgency with which an HIV prevention tool for women was needed. The steady progress being made in the science of microbicide research and development between 1992 and 2004 lent credence to the idea that such a tool was possible. With these two components (problem identification and proposed solution) in place, GCM joined with numerous other entities, including committed researchers, supporters within government, and other NGOs^* and advocacy groups, in taking the third step of generating the political action necessary to fund pursuit of a solution.

Recruiting more allies

GCM replicated its organizing model and collaboration patterns with partners in Canada, where local and provincial NGOs took up the issue with their Parliamentarians. The country’s microbicide funding levels rose from US$0 in Fiscal Year 2000 to US$4.9 million in 2009.¹⁹

As in the US, the UK government’s interest in microbicides pre-dated GCM and its Department for International Development established a dedicated Microbicide Development Programme in 2001. GC Europe (GCM’s European arm) was launched in London in 2002. In 2004, GC Europe (comprising two staff members) moved into shared office space in Brussels with the International Partnership for Microbicides, the International AIDS Vaccine Initiative, and the Stop AIDS Alliance. This co-location facilitated use of an “inside/outside” approach to influencing European governments. While IPM worked to engage civil servants in key ministries, for example, GCM coordinated local NGO advocacy directed toward elected government officials, thus exerting pressure for funding from two directions.

By 2009, GC Europe had active campaign sites in ten European countries and materials in English, French, Spanish, Dutch and Russian. It had become an integral part of a much larger chorus of advocacy voices (including key scientists and civil servants) that inspired eleven European governments and the European Commission to fund microbicide research. The continent’s investment increased from US $0.7 million in 2000 to US $59.6 million in 2007.¹⁹

High-profile bursts of media attention to an issue, as Baumgartner and Jones⁵ note, can help trigger policy change. A handful of such bursts occurred in connection with microbicides – some engineered by policy activists and others precipitated externally and taken advantage of by GCM.

In 2004, for example, activists, scientists and allies within the European Commission persuaded the Irish government to convene the first EU high-level meeting on new HIV prevention technologies. There, civil society representatives from India, Nigeria, Netherlands, United Kingdom, South Africa, Spain and Belgium stood up and unfurled an enormous scroll of GCM’s Petition for Greater Investment in Microbicides. More than 200,000 signatures, some simply thumbprints, had been collected globally from people demanding condom alternatives. Media attention to this intervention during the meeting expanded its impact.

The media also focused in on HIV prevention research in 2004 when the Cambodian government cancelled a major trial of pre-exposure prophylaxis (PrEP, another new HIV prevention technology) after Cambodian sex worker organizations strongly objected to the terms of trial participation and how they were treated by some researchers.²² Another PrEP trial in Cameroon closed in 2005, also following community opposition.²³ These closures were expensive setbacks for the trial networks. The highly sensationalized press coverage they generated left many governments across Asia and Africa fearful of hosting HIV prevention trials, lest they be charged with collusion in the exploitation of their citizens. GCM seized this chance to show how proactive, authentic engagement between trial communities and researchers could prevent such setbacks.

Another media burst was generated in 2007 by a group of African NGO employees living in London. Supported by GCM, they formed the UK African Working Group on Microbicides to educate their own communities on the issue. They then initiated discussions with microbicide researchers in London to relay their communities’ opinions. This collaboration between the scientists and community members was subsequently profiled in a BBC television documentary about these “unlikely partners”.²⁴

These events illustrate how GCM-recruited grassroots policy activists – working with like-minded allies – made their issue visible on the public policy stage. Rather than diminishing their effectiveness, their lack of professional credentials as policy entrepreneurs allowed them to play a complementary role to those undertaken by other sectors. They spoke as grassroots women (for the most part), representing their communities and their peers.

Generating policy change in developing countries

Large-scale trials to test microbicide effectiveness (past and present) are done primarily in sub-Saharan Africa because of the need for high background HIV prevalence rates. In many such countries, however, fear of research-related human rights abuses are entrenched.²⁵ GCM tackled this head-on, arguing that vigorous community involvement in clinical trial design and implementation – and the transparency that fosters – were both ethically mandatory and the strongest possible safeguard against any future abuses. Such involvement was essential to building a strong sense of ownership and support among African governments and potential trial participants so that the trials could go forward.

As in developed countries, GCM started its work in developing countries by connecting with NGOs already involved in HIV/AIDS and women’s reproductive health and rights. The Society for Women and AIDS in Africa, a network of national NGOs, shared information about GCM with its members in 37 countries and co-sponsored a pan-African conference event with GCM in 1999. This entrée opened the door to collaborative presentations at regional and national conferences in several African countries, and expanded GCM’s credibility and reach. GCM systematically pursued collaboration with transnational networks such as Society for Women and AIDS in Africa, Asian Pacific Council of AIDS Service Organizations, and International Community of Women Living with HIV/AIDS to build its credibility and visibility and to further expand its reach.

GCM assumed that people knew how their own communities worked and how to get things done in the existing political structures. For this reason, it hired indigenous staff and encouraged them to work closely with local NGO partners and organizing networks. GCM staff were expected to revise their materials, budgets and workplans as needed to generate and support authentic advocacy partnerships.

GCM also worked directly with microbicide trial sites and, in 2003, held a three-day consultation with personnel from eight clinical trial sites in four southern African countries. After several such consultations, GCM created a “community of practice” group that used monthly conference calls, an in-person annual meeting, and a web-based clearinghouse to promote resources-sharing and collective problem-solving among clinical trial staff working on community engagement.²⁶

GCM’s involvement with local clinical trial staff complemented its work with community-based organizations. It sent a strong message to those host communities about GCM’s commitment to building the capacity of local people – whether trial employees or policy activists – to ensure that any trials would benefit those hosting it, as well as those sponsoring it.^*

In 2007, GCM decided to focus its work primarily on trial host countries in Africa, where community-based advocacy was urgently needed to secure governmental support for clinical trials. Choosing South Africa, Kenya, and Zambia as its three focus countries, GCM provided dozens of Prevention Research Literacy Trainings in eight African languages, as well as English and French, to build local NGOs’ capacity to conduct their own community-level education and advocate to their policy-makers. This resulted in heightened attention to women’s HIV prevention needs in the national HIV/AIDS strategic plans for South Africa and Kenya and stronger governmental support for microbicide trials in all three countries.

From 1998 to 2012, microbicides went from being an unknown concept to a new HIV prevention tool likely to be introduced in some parts of the world within the coming decade. With its NGO partners based primarily at the grassroots level, GCM helped to make this happen and contributed to substantial changes in accepted norms around effective community involvement in HIV-related clinical trials. It recruited, trained, and supported people affiliated with hundreds of small and large NGOs to serve as grassroots policy activists.

Why was GCM closed down?

The trajectory of NGOs moving from their apex to dissolution within a few years is all too common, particularly among advocacy organizations. Briefly, the factors precipitating GCM’s decline included timing, funding, and (to some extent) operational style. Between its apex in 2007 and its dissolution in 2012, new research findings altered the context within which GCM functioned.

In 2010, the CAPRISA 004 trial results indicated that vaginal use of 1% tenofovir gel conferred moderate protection against sexually transmitted HIV.²⁷ This was the first “proof of concept”, a breakthrough showing that a vaginal microbicide, used correctly, could in fact reduce HIV risk. FACTS 001, a confirmatory trial using 1% tenofovir gel, was initiated in 2011. Subsequent data from other trials on the product’s effectiveness have been mixed but, if the FACTS trial shows high enough effectiveness, regulatory consideration of the first vaginal microbicide could start as soon as 2015.

Also in 2011, the array of other non-condom prevention technologies with demonstrable effectiveness broadened. Pre-Exposure Prophylaxis (PrEP) was shown to reduce the risk of HIV acquisition by up to 75% if taken consistently.²⁸ Daily use of antiretroviral therapy was shown to reduce an HIV positive person’s risk of transmitting the virus by up to 96%.²⁹ An AIDS vaccine has not yet been developed but progress has been made. The vaccine approach retains its appeal because prevention effectiveness is not diluted by inconsistent use, as can occur with condoms, microbicides and HIV medication.³⁰

The field of HIV prevention advocacy diversified in light of these 2011 developments, and the idea of a “narrow” focus on microbicides became less popular. Other HIV prevention research advocacy groups had also created bolder public profiles, built different alliances and competed more successfully among the increasingly limited pool of donors. GCM’s core funding suffered when key donors shifted their funding priorities. The staff of 17 in 2007 had to be reduced to four by mid-2012.

Klugman observes that an advocacy-focused NGO must steadily cultivate and maintain its organizational capacity over time in order to succeed. She highlights the importance of maintaining a strong “adaptive capacity” in a changing policy and programme landscape and the “ability to generate new leaders,” describing these as “less easy to measure but arguably the most important” features of a strong organization, even exceeding more commonly recognized capacities such as fundraising, fiscal management, communications, etc.⁶ When a founding director resigns, transitioning to the next generation of leadership inevitably tests these adaptive capacities. Difficulty at that stage is not uncommon, especially when the shift occurs in the context of external upheaval in field-wide priorities and funding as described above.

GCM’s founding director resigned in 2009, after working with the staff and a transition team to create a streamlined organizational structure and a five-year budget tailored to the new funding environment and diversified landscape of partners. As was the case with the four NGOs described in Klugman’s paper,⁶ GCM’s stakeholders expressed varying opinions after the fact as to why GCM was ultimately unable to continue its momentum between 2009 and 2012. Some attributed its decline and eventual closure solely to a more challenging funding environment, while others saw this factor as compounded by changes in GCM’s organizational vision that affected its adaptive capacity.

In 2011, PATH engaged in a broad consultation with the global health community about GCM’s future and its unique value in the evolving political environment. Those interviewed consistently acknowledged the transformative role that GCM had played in creating a movement in support of HIV prevention tools for women, but also articulated a growing sense that other partners were now better positioned to move the field forward. One significant reservation about this shift, however, was the loss of focus explicitly on women’s needs. As one former GCM board member observed, “If GCM doesn’t have strong positioning… women will be left behind because they won’t be sitting at the table and won’t be part of the negotiating/decision-making process”.³¹ While there are still HIV prevention advocacy entities in the field that do address women’s needs, few make the issue central to their programming, as GCM did. Whether the closure of GCM constitutes a loss to the field is a matter of ongoing debate.

In addition to playing a pivotal role in putting microbicides on the HIV prevention research agenda, GCM built the capacity of hundreds of NGO staff and volunteers to serve as policy activists. Some of them are now running organizations such as the New HIV Vaccine and Microbicide Advocacy Society (formerly Nigeria HIV Vaccine and Microbicides Advocacy Group), the Microbicides Society of India, the US-based National Female Condom Coalition, and International Rectal Microbicides Advocates (IRMA). Convened by prominent former GCM participants, each of these is working with grassroots NGOs. Other former GCM leaders are now serving in an advisory capacity in key research networks and review panels, as well as working with other advocacy organizations.

Moving sexual and reproductive health up on health and development agendas

There is an ethical imperative to bring more grassroots voices on more issues into global and national policy discussions in non-tokenistic and sustainable ways to enable communities to shape policies that affect them directly.³² There is also a pragmatic value in doing so.

For those considering initiating a GCM-type approach to campaigning and advocacy work in sexual and reproductive health and rights, three key lessons from GCM’s experience may be useful:

Set forth a vision and invite people to join it.

Ordinarily, coalition advocacy agendas are negotiated by the founders who represent a range of organizations. GCM reversed this process by articulating a firm, simple vision and then inviting all who supported that vision to join in its realization. Sticking to its original agenda, especially when influential partners wanted to expand or revise it, required discipline and diplomacy. But this adherence preserved the agenda’s intrinsic clarity and energy and assured its supporters that the shared goals would not shift under their feet.

Grassroots-level work and global-stage visibility requires a balancing act.

NGOs employing professional policy entrepreneurs tend to acquire strong visibility with high-level donors. GCM generally preferred to “lead from behind,” sharing public credit with grassroots partners, even when this meant minimizing its own organizational profile. This strategy effectively builds capacity in the field and promotes broader involvement, but it does not produce high visibility or the kind of evidence of an organization’s unique productivity that many funders prefer. NGOs working at the grassroots level need to balance their need for donor credibility and easily documented self-promoting credit for their accomplishments against the need to cultivate and promote the vital work of their grassroots partners.

Put the message in a universal frame.

The topic of microbicides drew public attention and support because it addressed men’s and women’s common reluctance to use condoms. The universal resonance of this problem made it possible for GCM to engage effectively across the globe. A once-popular GCM lapel button read, “With condoms, safer sex is his decision. We want to make it yours”.³¹

This case history demonstrates both the feasibility of mobilizing grassroots policy activists and potential pitfalls inherent in doing so. Klugman identifies the following as indicators of significant progress by an advocacy organization:

	emergence of consensus among a widening constituency around a problem’s definition and its possible solutions,
	through internal and field-wide capacity building, development of readiness for informed and effective engagement with policy makers,
	engagement “that results in increased visibility of the issue in policy processes, resulting in positive policy outcomes” and “shifts in public understanding and visibility of the issues, as the problem definition or potential solutions gain social acceptance over time.”6

As described above, GCM made demonstrable progress in each of these indicator areas and played a significant role in moving microbicides from being virtually unknown in 1998 to the subject of research known by HIV/AIDS policy circles in virtually every country and a topic of sessions at every major HIV prevention conference. The escalating levels of public investment noted above are a concrete measure of the increased priority that the issue acquired in policy processes – an increase to which GCM-trained policy activists contributed.

It is debatable whether GCM outlived its usefulness or closed its doors largely for other reasons. Either way, GCM’s work was highly successful when assessed in terms of Klugman’s indicators. NGOs working to ensure stronger and more explicit governmental commitments to sexual and reproductive health and rights in international development policy now have the opportunity to consider the potential value of using the GCM model in other areas of policy advocacy today. Its demonstrable functionality can be used to convince donors why they need to fund such efforts far more than they currently do.

Grassroots voices can achieve substantial volume and influence when mobilized via well-designed, culturally relevant and competent engagement with local NGO partners. Such partners are responsive when they see the campaign’s goals as potent and central to their own values, priorities and mission. If targeted to influence national delegations participating in global processes, such coordinated policy activism could have a concentrated impact. Creating such a united front might lead to new insights into what is achievable and how to achieve it, both when demanding change and when contributing to making change happen.

Note

I was employed by the Global Campaign for Microbicides from 1998–2010, and served as its Deputy Director from 2006–2010.

Notes

* GCM was initially housed at the Center for Health and Gender Equity (CHANGE), a small NGO in the Washington, DC area. In 2001, GCM moved to the Washington, DC offices of PATH (Program for Appropriate Technology in Health). Although a programme of PATH, GCM retained its own Steering Committee and autonomy with regard to fundraising, budgeting, work-plans, etc.

* GCM worked with a large number of NGOs also actively supporting the advancement of microbicide research and development. Among these were the Alliance for Microbicide Development, Alan Guttmacher Institute, Center for Health and Gender Equity, International Center for Research on Women, International Partnership for Microbicides, National Women’s Health Network, PATH, Population Council, and many others.

* Reports on these initiatives, as well as many other examples of GCM’s work, are available online at http://www.global-campaign.org/EngDownload.htm.