Episode 12: Constructing and Reconstructing Power
Qi Cui has over 18 years of work experience as a senior professional in leading global health programs. She has especially worked to develop alliances with multi-sectoral partners to catalyze investment in health for higher impact and to identify and mitigate mission critical risks. She is currently the Senior Fund Portfolio Manager at the Global Fund to Fight AIDS, Tuberculosis and Malaria and focuses on managing a portfolio of infections disease resilience and health system strengthening programs in the Philippines, Cambodia and Thailand. Previously she served as Program Director at Marie Stopes International in China, where her work focused on sexual and reproductive health and rights for adolescents and young people as well as HIV/AIDS prevention. She joins us from Geneva, Switzerland.
She speaks to us about:
working in China on taboo topics with stigmatized groups at a time when NGO’s where a new concept
her decision to pause her work in program implementation to get more training
her work at the Global Fund
actualizing country ownership and local governance structures
implementing robust and transparent financing measures
mutual accountability
promoting dialogue and public debate
gender discrimination
micro-aggressions
fluid power dynamics
gendered leadership stereotypes
measuring progress over time
the coronavirus pandemic
the need for common decency - and much more.
Editors note:This transcript has been slightly edited for clarity and coherence.
Transcript
Intro: The country does not equal to government agencies only. A country should really represent the different stakeholders and this will lead to a local governance structure we call a country coordinating mechanism. And in this committee or mechanism, there are different constituencies representing government, academic, private sector, the bilateral and multilateral partners and very importantly there are two other constituencies, one is really the civil society and the another are the people and community affected by the diseases. So, this country coordinating mechanism, they will make the decision about where the money should be invested and how it will be invested. The Global Fund actually does not have any country offices.
Safa: Welcome back to the Rethinking Development Podcast. My name is Safa and I will be your host as we speak with and learn from practitioners of all backgrounds and affiliations around the world. In our conversations, we aim to rethink ethical behavior and best practices through the lived experiences and personal reflections of different practitioners. Our guest today is Qi Cui. Qi is currently the Senior Fund Portfolio Manager at the Global Fund to fight AIDS, Tuberculosis and Malaria and focuses on managing a portfolio of infectious disease resilience and health system strengthening programs in the Philippines, Cambodia and Thailand. Qi has over 18 years of experience as a senior professional in leading global health programs. She has especially worked to develop alliances with multi-sectoral partners to catalyze investment in health for higher impact, and to identify and mitigate mission critical risks. Previously, she served as program director at Marie Stopes International organization in China, where her work focused on sexual and reproductive health and rights for adolescents and young people, as well as HIV/AIDS prevention. She initially studied English literature before pursuing two masters degrees in international journalism and international humanitarian action. Qi, thank you so much for speaking with us today.
Qi: Thank you, Safa. Nice to talk to you.
Safa: Thank you. Maybe we can begin by first speaking about your earlier interest in English literature and journalism, what were the reasons you were first interested in those topics and what happened that later you became more interested in pursuing a career in humanitarian and development issues instead?
Qi: Thank you Safa. I would love to say that there is a logical theme for my career and study path. But unfortunately, there is not. So I’m Chinese. Born, brought up and educated in China. And I grew up in an average working class community like most Chinese families in the 1980s. It was also the time when China started its reform and open up policy, which reshaped China almost in every aspect of the society ever since. It also led to a fundamental departure from the traditional norms of group conformity, individualism, and diversity. And such changes actually influenced my education or life or career choices profoundly. So the first choice happened in 1993 when I had to choose which university to go to and which major to take. Instead of following the expectations of my parents to pick some practical topic leading to a stable career like medicine, finance, or teaching, I decided to take something totally unknown, that is English, as I was curious to learn something very different from day to day life, and expected English would be a key to open a door to a brave new world. So indeed, I took a good look at this new or the old world of Shakespeare and Hemingway in my university period. I thoroughly enjoyed it. However, the literature world was kind of too calm for a 20 year old, young graduate to pursue for the rest of her life as a career. I remember during that period, I came across a book written by a very famous, maybe one of the greatest journalists, her name is Oriana Fallaci, and her coverage of war and revolution and her revealing and aggressive interviews were a great inspiration for me. So I thought I want to be like her. Then I decided to learn journalism and to become a reporter with the expectation to explore and present different views from different groups, triggering more discussion, understanding and changes. So after a few years of working as a press journalist, mostly focused on the hard news, like political and economic topics, I started to question myself if any of my reports indeed improved understanding between different groups, or if I was just repeating similar analysis and critiques without any positive impacts on the people’s life. After all, I spent most of my time as journalist speaking in different press conferences, gossiping with other reporters, pressing the interviewee’s for some catchy responses, and rushing to finish articles before a deadline. And then I’d move on to the next topic, which can catch the eyes. So I was in a period of really doubting if my job was real, or really useful. So, in 2002, I got an opportunity to work for an international NGO, that is Marie Stopes. I was immediately attracted by this idea, as that job represent a complete package of new things. The NGO at that time was a new concept for China and the project was a combination of both public health and education and the target group were adolescents and young people whom I felt I could easily relate to. And the project could use my skills in English and communication and writing. So all seemed a perfect fit except one key shortcoming. That is, I had absolutely no idea of the main topic for that project, which was about sexual and reproductive health and rights. So luckily the country director at that time made a very brave decision to take me in and supported me all the way, very generously, and allowed me to learn and develop my knowledge and understanding in this area while I was working with a brilliant team, who were young, innovative and committed to change and eager to share and help me. So I spent five years working with Marie Stopes in China, and we expanded our footprint from the topic of sexual and reproductive health and rights to the HIV/AIDS program. In early 2000s, the HIV epidemic rapidly increased and Marie Stopes was actively involved in many programs, varying from HIV/AIDS information education, or providing care for the people who lived with HIV and AIDS and advocating for access to treatment. So my experience working in this very taboo topic, discussing sexual health and reproductive health and rights, actually really enabled me to work with, at that time, a very stigmatized topic, that is HIV and with even more stigmatized groups, like men who have sex with men, or female sex workers. So that experience really shaped my view of development work, and also my approach to understand and work with marginalized or vulnerable groups. So while I actually learned, improved and thoroughly enjoyed the experience of working in Marie Stopes, when time passed by I felt an increasing urge and need to take a step out of the direct implementation of the programs. I needed a pause to reflect and to learn and to get some systematic training, or probably explore something deeper or broader. So in 2007, I moved to Sweden to study international humanitarian action. At that time I had the expectation that probably I will switch to a totally different career path. However, it seems that destiny had its own plan. In 2009, after finishing that program, I got a job opportunity working for the Global Fund. The Global Fund was not a humanitarian organization in a strict sense. But as we all know, in the early 2000s, the HIV epidemic, particularly in the Sub Saharan African region, was regarded as one of the biggest humanitarian crisis. So the Global Fund was set up in 2002 to really create urgent responses to HIV/AIDS and other deadly diseases affecting most of the population in many low-income countries, that is TB and malaria. So the organization took a very innovative approach to tackle the public health challenges, which was mobilizing huge resources and moving the funds quickly to the country, respecting the country ownership in planning and deciding the program and how to use the funds, and on the other hand, adopting a very strict performance based financing principle and implementing very robust financial and programmatic monitoring measures. So again, like a few years ago, I was very excited by this combination of new approaches. And I was quite impressed by the vibrant and diversified team working at the Global Fund. So, instead of joining the classical humanitarian organizations, I joined the Global Fund and worked there instead. I’ve been covering most of the Pacific and Asian countries in my decade of working for the Global Fund and also expanded my experience and scope of work to some African countries. So that is my story. And I’m afraid there has not been a coherent theme. And rather it is more like kind of improvised jazz with unexpected changes, triggered mostly by my curiosity. That’s it.
Safa: Very interesting and fascinating and it’s such a comprehensive overview of your experiences. And now taking it maybe a few steps back, you mentioned the experience you had in 2002, starting out at Marie Stopes, and at that time the NGO concept was a new concept in China you mentioned, and you are working on taboo topics and with stigmatized groups. In that work, what were some of the challenges you faced in terms of raising awareness or working within the kind of civil society and also maybe with partners, what were some of the issues that had to be addressed and overcome? And what did you find to be effective ways of working around those and navigating those?
Qi: So first, I think I benefited from my ignorance, if I could say that. Since I knew nothing about this taboo, I only knew it was not the topic in the tradition and culture of China to really even talk about. But this did not mean the challenges did not exist. And when I started, I actually learned a lot from the country director. She was, I would say, kind of a role model for female leadership, that is really delivering and tackling some of the challenges in a very calm and open minded way. She was firm and strategic, but she also demonstrated a huge humanity by listening and offering solutions together. So I think this approach really calmed me down and also encouraged me to take up probably one of the most difficult topics to discuss with the educational officials, schoolmasters, or the Teachers Association or the parents’ representatives. And this was actually surprisingly well accepted, it was not like people turned away and regarded this as really taboo — like I don’t or we don’t want to hear it. Rather, they shared their challenges. They had observed the students, the young people from 12- 17 years old, who were naturally encountering all these challenges. And that was almost two decades ago when there was no internet, there was no wide access to information. But people grow up and they would like to know about their body and their sexuality and how to really protect themselves from diseases, and most importantly, to really have confidence about what they feel is right. And all these challenges, the existing establishment did not have tools to address. So instead of being enemies, which I perceived before I started working, they were sharing their challenges and concerns and they wanted us to really provide some practical and feasible skills, training so they could help the students really sail through this turmoil period. And how to really reach this, let’s say, initial openness. I think that is the approach I learned from Lilly, the country director of Marie Stopes, that is to name the issue openly and in a calm way to listen to their challenges, and then explain what is our strength and what we can help with. This does not always solve all their challenges. And in most cases, particularly for this sensitive topic, the initial reaction from the school and from the educational official was, yes, it’s very good, you can help us so please go to do that. So that kind of attitude, in the very beginning, is viewed as easy access, but in the long run is not sustainable because the project will finish in a few years, and if the real stakeholders where not really involved or accept or even be trained and supported in their capacity and skills to address that, then it will just die away. So the second step was that we were expanding our partnership from only adolescents and the students to what we call gatekeepers or the stakeholders to actually discuss how and in what ways they would like to address this, particularly in the very conservative culture and context. So that is the second learning lesson, when we try to really deliver some service which is very right and for the target people, we always need to actually analyze how to get access to them. And when we analyze those stakeholders, they are not only the barriers. Rather, we should work with them and to actually, if possible, transform their attitudes and establish team work, because they will also benefit from the changes. So these two things actually proved successful. And now if we really look backwards, I think that very initial project has triggered a lot of structural changes. I think, in 2007 and 2009, China in the province we had been working with, the educational department organized the teachers and the doctors as well as the representatives from the youth to develop the first ever curriculum, tackling the issues related to the reproductive health, the sexuality and rights and even raised the topic and discussed LGBT issues. So, I do feel a partnership really needs to be based on mutual understanding and also a positivity. I do appreciate there has been various analytical frameworks to really provide critical issues, where we really try to address development or the sexuality or reproductive health related issues. This helps us to analyze where the weakness and the challenges are. However, my practice or experience has brought another perspective. That is, this has to be translated into day to day work and the day to day work means we work with people. And I do believe people can change. So this is the challenge and how we actually work around or try to address the big gaps and challenges. So this has probably changed quite significantly over the decades in the area of SRHR, mostly because of the political changes. However, that work actually really increased my confidence and the approach of really working with marginalized groups and also with perceived taboo topics in a conservative environment, it actually can work. It takes time, and there are ups and downs in the process. But if we believe this is right, and we also believe people can change and that they have the agency but need support to change. Even when we talk about government, this is not a unified one identity, and there are people behind their identity or their titles. That’s where I think the possibility exists.
Safa: That’s very interesting. And it’s very nice to hear that you think that it triggered structural changes, although it takes time and it requires the belief and the effort and the everyday working with people, but that in the end, it can have a structural impact. After your time there, you mentioned you went on to study in Sweden. Were you looking to work in other countries? Was it your plan to get work experience outside of China or is that something that just happened, the opportunity just came up?
Qi: Well, I think it’s a combination of all of this. I had been working for five years and before that I had been working for three years in journalism. And I studied English. So I was actually really caught in the middle of the very fast changing reality. In China there have been so many challenges, and also new things happening almost in every part of the society. And I also benefited from this opening up and when I said NGO was a totally new concept, I had no idea what a NGO is, because where I grew up, like the China at that time, there was only one concept and that is government, which is supposed to take care of everyone from the birth to the death and only after the opening up, there has been another increasing power, that is the business. And that’s represented by the private sector. And gradually the civil society idea, the non government organization, this concept was introduced through different cooperation programs. So all these changes really opened up my view and also increased my interest to compare different societies and different cultures. And as I also said, after a few years working in the field, I felt the need to really step out from this day to day management and implementation work to have a more theoretical reflection and to improve myself systematically in the area of development or management or the civil society. All those were new topics for me at that time, and I also wanted to try something new. As I said, if there was any theme really underlining my career, in and out and left and right, that is my curiosity. So yes, I think it’s a combination of curiosity and the interest of knowing different countries and having a much broader view and understanding at the global level. And also, it came with opportunity. And I still remember, this is not directly linked to the choice of Sweden, but we had a project working on human rights issues for the HIV affected population and the community. And we had a joint workshop where we invited a South African human rights activist who was really inspiring to bring the different experiences working in the human rights and humanitarian areas to address the challenges facing people living with this disease. So that really inspired me to say, look, I want to learn more, and I want to know how the other countries are doing. But I had no plan at that moment to say, yes, I must come back, although that probably is the strongest wish from my family. But I just actually follow the flow.
Safa: I see. Yeah, absolutely. Very interesting. And with that curiosity, eventually, as you say, you accepted a position at the Global Fund. And there are many aspects of your work there. But of course, one of them is developing partnerships, facilitating partnerships, and especially among different sectors, amongst governments, amongst civil society, private sector, all the different areas and groups that are involved. What are some of the maybe challenges you face when it comes to trying to facilitate collaboration or get different actors and stakeholders to work together, especially in a context where they all maybe have their own interests as well, or there’s also some political interests and a political context within the discussions, what have been some of the observations you’ve had or the reflections you have about how to make those collaborations impactful despite any of the political clashes or tensions that maybe happened some times?
Qi: Right. So as I said, what attracted me to the Global Fund was their very new approach to really help the country address the public health challenges. It is different from the traditional bilateral or multilateral program that is between the donor and the recipient. It is actually quite a hybrid model, which we call it country ownership. And we also have a very independent local governance structure and country ownership basically means these few things. Number one, the country does not equal to government agencies only. The country should really represent the different stakeholders. And this will lead to a local governance structure, we call it country coordinating mechanism. And in this committee or mechanism, there are different constituencies representing government, academic, private sector, the bilateral and multilateral partners. And very importantly, there are another two constituencies, one is really the civil society and another is the people and community affected by the diseases. So, this country coordinating mechanism, it will make a decision about where the money should be invested and how it will be invested. The Global Fund, we actually do not have any country offices, we only have offices in Geneva, it is a Secretariat. So, even when the proposal was developed by the country, the Secretariat has no role to really approve it. We will facilitate the review, but the actual review and approval, the power is with an independent technical review panel, which again is a combination of different experts in disease, in human rights, and in the health system. So in this structure, what I found the challenge as well as the opportunity to be is that you have brought in so many different voices that inevitably this will make the process heavy and inevitably, there will be different agendas and the priorities will clash. So how this actually should be managed is always an ongoing challenge. And gradually for the Global Fund, we have actually developed a mechanism that we call country dialogue, that is really to facilitate the open discussion and particularly the participation from the constituency of civil society, as well as the people who are affected by the disease. And in this dialogue, different interests and agendas were requested to be listed openly, and there would be a public debate and deliberation and discussion and negotiation to come up with a list of priorities. So if we just use this as an example, to really summarize what is my experience to deal with partnerships, maybe it can be in three words. One is really the public participation. And second is transparency. And the third is actually agreed consensus on priorities. And when I say agreed consensus on priorities, that probably is the most tricky part because the resources are always limited. And, of course, it can never satisfy everyone’s agenda and needs. So that makes the process of open deliberation and dialogue critical. It will not be viewed or at least it will reduce the perception that the decision was made behind closed doors between the donors and the government. So that is one thing I think I learned and which I still appreciate about the Global Fund approach. And the downside is the process is quite, I think, complicated. And sometimes we are really working under the pressure to conclude the dialogue and agree on the priority list. So it’s never been perfect. Another outstanding challenge and issue probably is the power imbalance. And of course, there have been brilliant analysis for decades from different philosophers and development workers and in the public health areas, to really analyze North to South knowledge sharing and also the resource distribution between different countries. And let’s not forget about gender inequality. All this is actually still heavily affecting this partnership. There are two small examples I can share. One is we all agree in the public health area, particularly in strengthening the health system, that the role of community health workers is critical. And I remember once I visited Sierra Leon and we had a conversation with the community health volunteers to really understand what challenges they were facing, because Global Fund was very famous for very strict financial regulations and requirements. So tons and tons of forms need to be filled in and there will be a third party to actually make a very vigorous validation. So in that conversation, it was a small group, there were five women, and all of them did not have jobs because there were no real job opportunities for them. That’s how come they had the time and they also had the passion to help their neighbours and the village. They were the one to go door to door to really collect data, to distribute the malaria drugs, and also provide the reproductive health services. But surprisingly for that two hour conversation, 90% of the time, the discussion was happening between our team and their leader. That leader was a man who was also coming from the community, very passionate and also very good, eloquently explaining the challenges. But during that conversation, I always had that uncomfortable feeling. That is, when we talk about community health workers and we see that the majority of the work was done by these women, then why was it that even in this dialog which is supposed to be really pro development and supporting this community work, that the women still did not have a voice? We tried to really divert the attention and ask and facilitate so that these women volunteers would give more voices and feedback, but sadly, they always defaulted to their leader. And there might have been a barrier of language, or an uneasiness to talk to foreigners, but that really left me with the impression that the gender or the power imbalance is really entrenched in every part of our work. So when we rhetorically talk about how we should address the gender imbalance in every part of our program, how can we really translate this into this very detailed, let’s say, activity? We should not only be hiring more women, we probably should do more to facilitate these women volunteers to have more voices, to be heard. So that is one thing I find to be a power imbalance. And another thing I find probably quite interesting is that power is actually also a construction and deconstruction process. And that is a combination of different hats. So for example, almost 10 years ago when I led a team to visit a Pacific country and to discuss our investment, when we had the meeting with the Ministers and the different UN agencies, I was quite amused to see they, by default, directed all the questions to my male colleague who happened to be a middle aged, strong, white man, while I was actually the manager. But because I’m Asian, I was young, I was a woman, and I was quiet, no one probably even thought that the team member sitting there (me) might have different perspectives. But after some time into the meeting, when we actually introduced our titles and responsibilities, I immediately saw the change in the dynamic because I represent a lot of resources, so more questions immediately were directed to me, the perceived subordinate role as a woman was replaced with a kind of respect. But this respect was not because of my gender, it was because I was wearing a hat and this hat represented the Global Fund, which comes with huge resources. And then there’s another level of changes. When we actually had the conversation with the local community, in particular representatives from the local churches, and also the people who are affected by the disease, for example HIV, there you would also observe a shift of power in the conversation, because Global Fund has a very strong belief that we should really give more space to the community. And we purposely create bigger space and ask this community to give more voices and ask for their feedback and their concerns with the design of the program. So in that kind of conversation, you will hear the community voice more than the voice from the Ministers or the from the UN agencies. So, from those experiences, I believe that power is not predestined, and it actually is a fluid process and we need to actively acknowledge it and challenge it and also change it.
Safa: Absolutely. What a strong and striking example of the power dynamics that you’re mentioning and we’re talking about, especially how, as your example showed, power dynamics exist within the partnerships and the communities you’re trying to work in, but also amongst yourselves in terms of your colleagues and your partners and how it comes up in all types of different ways and in different contexts. You mentioned the different impressions and the different power relationships that exists in terms of a gender lens, in terms of a resource lens — in your own experiences as a leader, as a manager, as a woman in a position of power, especially as a Chinese woman or your background specifically, have you seen that maybe there are increasingly more women in positions of power? Or what are your thoughts about in the sector generally, the type of diversity and representation that you see or you think exists in positions of leadership and the ability of women, especially from different nationalities and backgrounds, to progress to these type of positions?
Qi: I have a very simple answer to this. I think this sector, or not only the sector of development, I think the whole society should and must make more room and support more women to become leaders. And that is not only an argument, that is a belief I strongly hold. But in this process, I think I recognize a few things. Number one, the space and the leadership is not a given. And this means there should be more opportunities for women to be trained to actually develop leadership. Leadership is not some mysterious charisma only. It is a skill set that everyone is able to develop and to master. So talking about opportunities and the space, that is where the system, the structure can do more. And one very simple thing is, in many organizations, there must be more consideration in recruitment for women. Not only for lower level jobs, but actually really senior managerial and leadership positions. Second, what I recognize is that leadership for women should really try to avoid the trap of the pre-printed stereotype or masculine template. That is our human history, when we talk about a great leader or great leadership, the names most common to our mind are men and there are probably very hidden stereotypes that only by behaving like a man will a woman be a great leader. I think that’s actually quite wrong. And if we really look into history, gender stereotypes are so entrenched in our perception of what can make a good leader. And I told you one example, I worked in Marie Stopes and my boss Lily was a Chinese woman leading an international NGO working on very sensitive topics, she demonstrated a very different way of leading the organization and building a team. She is calm and she has never really used a loud voice or demonstrated the muscles just to preach that what we are doing is right and good so you must submit to this idea. Rather, she sits with different stakeholders and different governments and even with the police and the military. And she will explain and she tries to listen. I think listening is probably a very simple word, but very powerful if we really can master it. She would listen to the different challenges and she would demonstrate understanding. Understanding does not mean agreement in most cases, but she would understand their concerns and their agenda. And she also demonstrated that her way of leading is not ordering others but rather inspiring and working together to find a solution. So I think there is a different type of leadership. And I try to avoid calling it female leadership because again, that falls into that dichotomy of female or male. But I do believe the leadership for women needs a new pathway. And we should actually aim not only for women, but also for men to adopt this new way of leadership. And last but not least, I also wanted to take the opportunity to rethink how when we talk about gender, of course, we can’t avoid this conflict between men and women, but from my background, working in the SRHR area, I think sometimes we should probably think much broader and elastic because gender is actually a quite big, broad spectrum. So when we talk about gender issues, we should not only narrow it down to women's issues, there is also a huge space which we should really explore and support more which is about LGBTQ rights, to understand and give voice to sexual minorities. And these are particularly the groups that are disproportionately effected in the areas I am working in, such as HIV/AIDS. So that is also my small reservation when we talk about gender, I think we need to look broader, not only men or women.
Safa: Absolutely, I think that’s very well said. Those considerations have to be at the top of mind in everybody’s work relationships and their own understanding. You mentioned that at the Global Fund, it’s a hybrid model, and there’s a local governance structure, but I also want to ask you about the part of your work as a Fund Manager where you’re providing investment, you’re providing financing, how do you ensure accountability and transparency and that the funds are used correctly? Or have you ever had experiences where there were maybe issues or challenges around the management of the funds? And in that case, what were some of the ways you dealt with that?
Qi: Yes, that is my everyday headache. And just from the title, and you will sense that it is not the classical development workers job. It is actually a concept brought from investment banking. So when I talk about the Global Fund, we have a very strong gene in our management that is, we are very keen and strong in the financial management and monitoring system. So in the very beginning, when I joined the Global Fund, I really needed to learn a lot, which was so fascinating because the colleagues from the financial department really brought a very new set of perspectives to analyze the program. Not only to say, Okay, this is good, but actually they will use the most boring data to tell you if it’s really good, and they might sound very dour because we are talking about money. And unfortunately, even in this work, money is probably one of the most important tools and their motto is follow the money. Know where money is really invested. If we have a program saying we want to really put an additional 100,000 people into treatment, but if we analyze the budget, half of the budget will go to hiring people, paying for the travel related costs, then naturally you will actually have the question how will this put an additional 100,000 people into treatment? So I think that is a very powerful tool. And for the Global Fund, the request for the financial transparency and the reporting is probably excessively difficult, if I can actually use that terminology, we have been hearing the complaints from day one. This probably is the shortfall when we want to really ensure very transparent reporting. So there are a few layers. First, we call it principal recipients. This is a terrible terminology, but let’s use it and they have a very detailed reporting template. And instead of just them reporting to us, we have a locally hired to agency, usually they are the auditing firms, they will come and validate the expenditure report. And if anything is suspicious, they will notify us and they will conduct a follow up investigation. And a third layer is from the Global Fund, from the inside, although I am working in the front line, the ground management, we also have an independent financial department that it is really doing the checks and balance for every disbursement. And on top of it, we have an independent Inspector General’s office. The head of that office is actually reporting directly to our Board Chair, not to the Secretariat Executive Director. And again in the country, even another layer is the oversight body that we call the country coordinating mechanism, they are requesting the principal recipients and sometimes sub-recipients to really submit the periodical reports. And last but not least, we are performing random investigation audits in different countries and different programs. And when risk is identified, the fiduciary agency is even employed in some exceptional cases, which means every dollar to be paid will need to go through another layer of check. So, what is the advantage for this, of all these layers and layers of check? It is to really reduce the misuse of the fund. But there’s another side of the story. That is, when we put layers and layers, naturally the decision making and the absorption, the money moving speed will be slowed down. And second, the methodology for auditing is based on paper, while the world is moving so fast and particularly there are so many different contexts, you cannot get paper based official receipts for every expenditure. So how to actually reconcile this requirement? And third, this very strong financial management actually poses some negative incentives to the program. In some cases we noticed that when countries design and implement the program, the first thinking is not to see if this program is leading to bigger impact, meaning to save more lives or reduce new infections. Rather, they are thinking if we conduct this activity, will there be a risk that we will be audited if we cannot get the paper-based official receipt? But you know, in many cases particularly like if we have worked with men having sex with men or female sex workers, the ultra rich in this community can’t really track every expenditure in the official receipt. Not mentioning, in some cases, we have to work against the local regulations, such as in some countries, drug use is illegal, but we need to work with the people who inject drugs, for the HIV prevention. All these challenges have actually led to some very significant changes. And I’ll give you one example. In Cambodia, I was requested to really take on the portfolio because there had been previous misuse of funds and very heavy fiscal control measures were introduced. And it was so heavy that it led to almost paralyzed implementation of programs. So when I was brought in, what I discovered was actually really overcautious or risk aversion behavior. The country, the program needed to actually increase the per diem for the program staff to make the local travel from $1 to $2. So for this decision, they need the Geneva team to approve because they were so afraid that if they made such changes, it would be deemed ineligible and then they would need to actually pay it back. This actually really became a huge obstacle because if every action they are going to take is based on if this will become ineligible, then I’m not going to do it, then as a result, no one is going to leave the office to actually go to the field to do the real work. So with this small example, I just tried to give you a flavour of when we have overly heavy hands to the fiscal or paper based financial management, the program implementation stuffers. So we had to actually find a balance. The balance is really to develop a different risk mitigation approach. And living in the real world, this is not just one way or another, we actually need to adjust in different areas with different thresholds and different approval procedures. But ultimately, to start with the changes we need to rebuild the trust. Trust, once destroyed, becomes I suspect you or you do not believe me. Than any changes would not really happen or it will only happen on paper. So that is my experience about the conflict or tension between the financial control vs the program implementation towards impact. And in terms of transparency, Global Fund is one of the top organizations to really disclose most of the documents, including the budget and expenditures on the public website so the donors and the community and civil societies can really reveal, track and challenge us. Last but not least, about accountability. I think accountability is really mutual. Being mutual means we share the risks and we actually hold each other accountable. It should not be the way that I’ll give you money then you do what I tell you. That probably is very wrong. It actually should be changed to yes, we act as an investment bank but we invest in the public health. So, if we have to invest in a joint venture in this country, then I tell you what I can do, that is actually I bring in the money, the resources, and also bring the internationally established guidance, drugs and diagnose kits and from the country, you also bring your commitment and make the upfront commitment and requirement as agreed. And then we actually follow this. Of course, in reality this is not always working. We always need to negotiate and monitor and to actually push each other. Without the upfront agreement on each other’s roles and responsibility, the accountability will become only a one way tool, and that probably will not work.
Safa: Right, that’s very powerful, I think the idea of accountability as a two way street and it being mutual. You also touched on risk aversion and creating a kind of a different risk mitigation approach that is different for each context. And part of what you mentioned that the fund also does is innovative approaches, maybe moving money faster. When it comes to innovative solutions and trying to achieve impact, strengthening health systems. Do you ever maybe feel frustrated about the pace of change or how long change takes or the process? Or what have been your experiences in terms of the time that’s necessary for these processes, these approaches, even if they’re new innovations, to work, to be implemented, to have more sustainable change, and you know, that tension with time?
Qi: Yeah, I guess we all have a dream that what we preach will actually be realized, probably in three years (laughs). That is our funding cycle. No, it is impossible and I think we are frustrated. But on the other hand, we probably are also the slave of the short timeframe. Because the way we are measuring our achievement, also measuring the impact is usually based on the defined duration, like in the Global Fund it is three years. So within three years, we really want to see a big change. Some we can achieve, like put more people on treatment or get more people tested for HIV. But some underlying challenges cannot be changed over time, over 3 years, probably over 30 years. And those underlying things, such as the inequality, the power imbalance, and the right to access primary health care and quality services will actually take a longer time. And I still keep the positive attitude, because I see the changes. And also if we actually look in a little bit longer timeframe you will get more, I think, data to support this positive attitude. There has been a very famous Swedish statistician and physician. His name is Hans Rosling. And he actually developed a very interactive website called Gapminder Foundation. It demonstrates that in the past 15 years or even 100 years, how human society progressed despite all the challenges. And to just gives you very simple data, the life expectancy in India in 1950, the average was 35.5 years old. And the data in 2018 is 69.5 years old. It has literally doubled over 50 years. So, changes happen and change will take time. I feel we are impatient because change does not happen in a linear way. And sometimes we go one step forward, and probably two steps backwards. But that probably is the process when we really want to make fundamental changes in the structure. And coming back to your very concrete question. Are there any changes in the financial model we are working with that can be addressed quickly? I think we are now moving more and more to results based funding. That is another innovative approach to really address the paper-based trail financial measurement to really measure the outcome or impact level. And again, this process will not just happen over three years. This takes time to even get the agreement from the donor community and from the different countries. I’m not talking about the countries who give money to the Global Fund. I am also talking about the country who receives funds and from their system, how they will actually accept it and set a different system to monitor the outcome and monitor impact. So some changes we see very quickly, particularly because of the technology, like the access to the internet and information. When I look back 15 years ago, I was supposed to develop newspaper discussing sexuality. And nowadays you would just laugh at this idea that the newspaper was controlling information flow. Now everyone can get the information if they want. So I also have the kind of rosy, probably very wrong, optimism that the new technology will bring a kind of revolution we have been struggling for for decades, such as the equal access to health. And the data generated from our behaviors and consumptions, like buying which drugs, and at what place people will buy condoms for example, will also give us more accurate analysis and guide the program to have more targeted interventions. And of course, there is again, the downside about data privacy and the data integrity. But as with all new changes, it is actually upon the people how we want to use it. We can’t really stop just because of this fear that it might be misused, hence we should actually not consider it. So that is my perception, and also my hope.
Safa: Mm hmm. Yeah, absolutely. Very interesting. As you say, there are challenges but that can’t stop the process and maybe just changing the timeframes in which we work can help in maybe mitigating some of the challenges or frustrations that come up. Now in the time of the coronavirus pandemic, how has your work been impacted? Or what are your thoughts in terms of the consequences of it, broadly speaking in the sector that you work in?
Qi: Yeah, I think this pandemic has really changed our daily life dramatically, just almost overnight. And it also had raised a lot of questions which have not been answered but have became so urgent. That is, the pandemic actually knows no border. So in order to address this issue, what we need is actually much closer solidarity with different countries rather than isolation. And this approach is not only to combat the pandemic of COVID, but actually also address the other underlying challenges such as social injustice, human rights, access to the quality health for everyone. And second, what I reflect is that COVID, because of the impact coming so quick and broadly, it actually overshadowed and sometimes even crowd out, if I’m only talking about health, those other health programs. In the past two months, we have observed a significant reduction of TB notifications and HIV case testing. So it came with a very heavy price. That is, other people suffering from different diseases actually are not only paying the price of COVID, but also paying the price of not getting access to their other health services. So that is actually a very urgent request for us to think about and to act very quickly on. Because we can’t really sit on our mandate of only three diseases, we must really work on the cross-cutting health system issues, and to help address some other most urgent needs caused by COVID to the health workers and volunteers in the field. And last but not least, this is only an individual reflection, because there have been tons and tons of interviews, articles analyzing COVID and the impact and the responses, but as an individual, I actually started rereading a book, which I read probably 20 years ago by a French novelist whose name is Albert Camus. And he wrote a novel, The Plague, in 1947. And the story, the actions and analysis of people when facing the plague was exactly the same as what we have been through during COVID. And it seems we have not really progressed too much with how we should really respond, but probably that is part of human nature. And I think in that book, which I actually really like, is the attitude at an individual level of how I can embrace the challenge and move on. And he said, there’s no question of heroism in all this. It is a matter of common decency. That’s an idea which makes some people smile, but the only means of fighting a plague is common decency. And in common decency, my understanding is actually showing empathy, taking your responsibility to protect yourself, and also to help your neighbours, your community, and unite to really fight against diseases.
Safa: That’s so well said. And I think it’s a perfect place to wrap up the conversation. I’ve learned so much from you. And there’s so much I’d love to go back and listen to again, thank you so much for sharing your thoughts and your honesty and all the wonderful ideas and contributions you shared. It has been absolutely a great, great pleasure to speak with you.
Qi: Thank you, have a very nice afternoon and thanks for the opportunity to talk to you.
Safa: As always, thank you to our listeners. I really appreciate your attention and value being able to facilitate these important conversations for all of us. As we’re nearing the end of the second season, I’d love to hear from you. I have created a short survey for you to fill out to share your feedback.
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