At first Global Fund partnership forum, a chance to hear Africa's voice
The Global Fund convened the first in a series of partnership forums in the Ethiopian capital Addis Ababa on 7-8 May, seeking input from both donors and implementers into the next operational strategy for 2017-2021.
The new strategy is expected to improve the mechanics of the Fund's disbursement of some $4 billion annually, which resulted in the 2013 iterative roll-out of the new funding model. In the first year of full NFM implementation, a total 146 concept notes have been submitted, with another 92 expected before mid-2016.
This new strategy is also likely to highlight improved or new approaches used by the Fund and its partners to address key issues raised by both implementers and donors, related to sustainability beyond the lifecycle of a Global Fund grant; integration of human rights monitoring and measurement; better targeting of women and girls with focused interventions; and how to ensure that communities are as engaged in the implementation and monitoring of programs as they are in advocacy.
The goal of the new strategy is, ultimately, to accelerate the end of the three epidemics and help with the proactive identification of, and support for, programs that respect and promote key affected populations (KAPs) and human rights. Its aim is also to help build resilient health and community systems, promote innovative strategies for measuring results, and encourage improved domestic financing to help sustain gains in the fight against AIDS, TB and malaria.
This forum, the first to convene as part of the strategic consultations initiated by the Fund beyond the constituencies to the Board, was an attempt to solicit and cultivate a stronger voice and wider engagement by African stakeholders in the goings-on at the Global Fund.
Global Fund investment to sub-Saharan Africa represents 65% of all disbursements annually.
Below are some of the main themes that emerged as Africa's priorities.
Sustainability means stronger systems
Health care costs are among the major shocks that push people in Africa below the poverty line, requiring them to pay for services that should be free or heavily subsidized. Delegates to the Forum urged more clarity in health system strengthening and better attention to community system strengthening in order to improve the quality and extent of public services available, including better access to medicines and data.
“Investment in health systems emerges as the most critical aspect requiring more focus and planning for sustainability by the Global Fund in its new strategy,” said Dr. Kebede Worku, the minister of health for Ethiopia.
Priorities should include building national health information systems with clear policy frameworks, with relevant indicators for measuring and comparing performance by demographic, district and disease burden, as well as systems that allow for the reporting of community-level data.
Equally, community-based work should receive more support -- both technical and financial -- to ensure greater success. Whether this means more flexibility in the kind of programming they can implement, or better technical assistance to set up the right kind of management structures, more emphasis on communities can ensure their ability to work as effectively as is potentially possible.
Flexibility and adaptability in changing contexts and funding environments
Flexibility was also identified as a priority for programming and investment. New Board chair Norbert Hauser told the more than 130 assembled delegates that the Fund itself needed to evolve and invest more strategically, in line with the post-2015 development agenda but also reflecting an individual country's strengths and shortcomings.
This includes countries now classified as 'challenging operating environments' where acute or chronic conflict, or infectious disease outbreaks like Ebola, have prevented real and lasting impact on service provision and has destroyed health infrastructure.
“These countries bear 17% of disease burden under Global Fund support”, noted Harley Feldbaum, who leads the Strategy and Policy division at the Secretariat.
Countries that are transitioning economically from lower income to middle income also need specialized attention, Feldbaum said, as disease burden is concentrated in middle-income countries. This echoed concerns expressed by many delegates at the Forum about the need to help shepherd countries through transitions that on paper look positive but that can put into sharp relief the inequities that could leave a vacuum in services available to the poor. Just because a country is surging economically and may not globally be eligible for, or requiring of, foreign assistance, it does not mean that all of its citizens are enjoying improved prosperity. A better approach, they suggested, would be investment in health programs that follow a human rights approach.
Human rights and key affected populations
A country's disease burden declines when those who are afflicted with the disease receive the right kind of prevention, treatment and care, delegates reminded the Fund's representatives in Addis. So targeted programming that reaches vulnerable populations is crucial to fight disease.
Most at-risk populations face a prevalence rate multiple times above the national average although data quality on specific populations remains poor, said Feldbaum.
Identifying those populations requires better data and a stronger evidence base that marries epidemiological evidence with qualitative information about human rights and barriers to access. Without them, countries risk incoherence in their policies and gaps in the services they can provide, reducing the impact of both domestic and foreign investment in the disease response.
"A lack of consistency and focus at country level on [key affected populations], gender and human rights from concept note development to grant implementation results in great ideas that wane into simple but not useful programs,” said Nana Gleeson, a member of the Botswana country coordinating mechanism.
How to improve the interaction between the CCM and representatives of key populations is a difficult and sensitive topic but should not be abandoned in favor of expediency. One way to boost those relationships could come from allowing organizations to stand in for individuals, whether it is in development of concept notes or in representation on the CCM.
In countries where certain key populations risk criminal prosecution for being who they are -- as in, for example the 34 countries in sub-Saharan Africa where it is a crime to be gay-- this could also be a safety mechanism, noted Vulindela Musibi of the CCM in Swaziland.
The Fund’s human rights complaints procedure launched in April 2015 could assist somewhat in this regard, but behavior change takes time.
It's about women, and girls
Advocates promoted the Women4GlobalFund (W4GF) platform as a viable approach to strengthen implementation of the Fund’s 2008 Gender Equality Strategy (GES), its Action Plan (2014 – 2016) and the 2009 strategy on Sexual Orientation and Gender Identities (SOGI).
Noting that concerns about targeted interventions for women and girls was one of the more common refrains from the Technical Review Panel following concept note review, the advocates recommended that the Fund’s 2017-2021 strategy emphasize differentiated approaches to case management to reflect gender inequality.
This can include structural barriers to services, including specific community, rights and gender interventions that address gender-based violence and stigma faced by women living with HIV and/or tuberculosis. They advised stricter tracking of the quality and extent of country-level engagement and representation of women and girls in decision-making bodies, particularly of sex workers, transgender women and women who use drugs.
Stronger linkage to sexual and reproductive health programs was also advised, with improved indicators, and the collection of sex- and age-disaggregated data as well as results tracking.
Increasing domestic investments in health
The success of the 2016 Global Fund replenishment will rely on the extent of domestic co-financing commitments from eligible countries. Even in sub-Saharan Africa, which has the largest proportion of lower-income nations of any region, there is a need to see governments contributing their share. African nations excluding Morocco pledged in 2001 to commit to a 15% share of national resources to finance public health by 2015. As of 2012, only six of 43 countries for which data are available, have achieved this goal (2014 Data report).
“Countries need to increase domestic financing to sustain gains made by Global Fund support,” said Ethiopia's Minister Worku.