The majority of African countries with ≥ 10,000 refugees and/or IDPs did not include them in their approved Global Fund proposals for malaria and for HIV. Furthermore, a large proportion of countries with ≥ 10,000 refugees and/or IDPs did not mention them in their malaria and HIV NSPs. This lack of inclusion occurred despite the fact that refugees and IDPs in most of these countries have been settled there for many years, and in some cases decades. Only a minority of those countries both referenced refugees and/or IDPs and specifically included activities in their NSPs and approved Global Fund proposals for malaria and HIV.
A Government's first inclination is to take care of its own citizens. Therefore, refugees will rarely if ever be a Government's first priority. However, those countries that have signed the 1951 refugee convention[6] have an obligation to care for refugees and this includes the provision of health care. IDPs are citizens of their own country. However, they are often oppressed by the Government in power and thus, like refugees, may also not be a priority for NSPs and funding proposals.
Besides legal obligations, Governments have a public health imperative to include refugees, IDPs and other groups, such as economic migrants, in their disease specific strategic plans and funding proposals. Communicable diseases do not respect borders and it is not effective public health policy to provide prevention and treatment programmes to only part of a population residing in the same geographical area.
Refugees and IDPs are often located in isolated and relatively inaccessible areas where Government infrastructure, systems and personnel are marginal. Government health interventions are often poorly implemented for nationals in these remote areas. The inclusion of forcibly displaced persons in funding proposals may have positive direct effects for the host populations as international and United Nations (UN) agencies operating in these locations often have strong logistical capabilities that could benefit all populations. Consequently, the equity of providing interventions to more remote areas of a country, a major problem in many nations where urban and peri-urban populations primarily benefit from such programmes, could be improved.
In many settings, refugee and IDPs compose only a small proportion of the total population of a country. Although they often live in inaccessible and remote areas, there are always surrounding populations from the country that live there as well. Therefore, the relative additional cost in including them in proposals and programmes is marginal, as Governments must also provide such interventions to their citizens already living in these areas. Governments may wish to consider the needs of their own populations first (including IDPs), and then add a component for refugees that is additional to the needs of their own citizens. In this way, concerns about using limited funds for persons other than one's own citizens are negated.
For NSPs, strong and concerted advocacy at global, regional and country levels needs to occur to successfully ensure that refugees and IDPs are included in national disease-specific plans. Improved coordination among Governments, the UN system and civil society during the planning and revision of national plans is sorely needed. The importance of their inclusion has grown considerably with the recent Global Fund Board's decision to move towards funding countries' NSPs in future rounds. Furthermore, since universal access for malaria and HIV control is a declared goal,[7, 8] inclusion of displaced populations is a necessity if the world is to meet these aspirations. The same holds true for the Millennium Development Goals[9]. For malaria, regional meetings are planned to update the current national plans for 2011-2015. Effective advocacy during these meetings would be very useful. Unfortunately, we are not aware of a similar process for HIV NSPs.
Global Fund proposals are made by Country Coordinating Mechanisms (CCMs) that are composed of a wide variety of groups including Government, civil society, and the private sector. UN organisations are often part of the CCM as well. Although in many countries the CCM is dominated by the Government, all groups that constitute the CCM have an obligation to include all persons that reside in a country, and not just the country's citizens. Furthermore, the Global Fund's Technical Review Panel should be obliged to consider these groups in country proposals. The exclusion of the above mentioned groups will limit the effectiveness of the interventions no matter how technically sound the proposals are written for the rest of the population; in essence, proposals that do not consider these groups are not technically sound.
Recently, a small informal working group composed of the Global Fund and UN agencies was formed with the objective to examine how Global Fund monies could possibly be used to address different humanitarian contexts; the Global Fund was not created with this in mind. However, clearly there is a need. Humanitarian emergencies are not simply acute events of a short duration; most last for years and even decades. The divide between humanitarian and development funding is well known and has never been sufficiently addressed. Ultimately, however, the Global Fund is a country-driven process led by the CCMs. Thus, guidance and advocacy need to be directed at the country level. Positive examples include Sudan which has included specific activities for refugees, IDPs and returnees in their malaria NSPs as well as Global Fund proposals.
There are some limitations to our study. Not all NSPs for African countries with ≥ 10,000 refugees and/or IDPs were identified, despite in-country attempts to locate them. For those countries where plans were not found, it is unclear which countries do not have such plans or which were simply not accessible. Tuberculosis was not included in the study because of our experience that refugees, even in remote areas, have free access to Government tuberculosis programmes. We did not have access to those countries that submitted proposals to the Global Fund that may have included conflict-affected persons but were rejected.
Governments, development agencies and donors must recognise the human right and public health imperative as well as the long-term implications of not including persons displaced by conflict into NSPs and funding proposals. In 2001, the UN General Assembly adopted the Declaration of Commitment on HIV/AIDS "recognizing that populations destabilized by armed conflict, humanitarian emergencies and natural disasters, including refugees, internally displaced persons, and in particular women and children, are at increased risk of exposure to HIV infection" and that there is a need to "implement national strategies that incorporate HIV/AIDS awareness, prevention, care and treatment elements into programmes or actions that respond to emergency situations..."[10]. The Political Declaration on HIV/AIDS in 2006 reaffirmed these commitments in the context of achieving universal access to HIV prevention, treatment, care and support for vulnerable groups, including refugees and internally displaced persons[8]. The 2008 Global Malaria Action Plan unambiguously refers to populations affected by emergencies and displacement, and calls for their inclusion into malaria control programmes[7].
This study shows that at present these calls for action are not being heeded. Besides including conflict-affected populations that have been displaced for long periods of time into NSPs and funding proposals, Governments and other actors should ensure that contingency plans for such occurrences are included in these plans and proposals. This inclusion will allow for the flexibility to prioritise and transfer funds to these affected populations in a short period of time if needed. Donors should ensure that such a mechanism exists in their regulations to allow for such contingencies. A concerted effort by numerous actors including Governments, UN agencies, international organisations, donors, civil society and the private sector, that bridge both the humanitarian and development worlds, is necessary if we are to include conflict affected populations in NSPs and funding proposals and reach the lofty aspirations of universal access and the Millennium Development Goals.