Reflections on the Global Fund’s 2014–2016 Replenishment

2. ANALYSIS
10 Dec 2013

The Global Fund set itself no small task in seeking $15 billion for the next three years of work to support prevention and treatment programmes that will lead to the vanquishing of AIDS, TB and malaria as leading killers and inhibitors of economic development in the world's poorest countries.

Facing scrutiny about how it measures its impact at country level, its management of fraud and corruption, its reform agenda ahead of the full roll-out of a new funding model, and in the midst of a seemingly ceaseless global economic crisis, the Fund plunged into a very high-profile fundraising campaign. Activists the world over took to social media in support of the replenishment drive, generating worldwide attention for an organisation that has traditionally carried out its mission in a fairly discreet way.

Did the attention pay off? It's hard to say. Pledges from the Fund's traditional coterie of donors came in about as expected, and there were no major surprises or disappointments. Though the target of $15 billion was not achieved, challenge grants from the US and UK governments, as well as the promise of matching funds from the Bill and Melinda Gates Foundation, pulled in a respectable $12.007 billion for the next three years of the fight against the epidemics: a decent-sized war chest.

What was more interesting was the way donors committed to provide funds on behalf of their national taxpayers. The two-minute slot each presenter was allotted by Board chair Dr Nafsiah Mboi during the pledging opportunity in a windowless Washington ballroom on 3 December provided a certain insight into the priorities established over the course of the year during hallway chats, boardroom and parliamentary floor debates.

As an observer of the session arranged around an open rectangle configuration of banquet tables, opened by US Ambassador to the United Nations Samantha Power, Aidspan identified four key themes that will likely be scrutinised by donor country representatives going through this next cycle at the Fund.

Reform

The overhaul of processes and procedures at the heart of the Fund was warmly welcomed by many of the donor agencies, many of whom credited the tireless work of Secretariat Executive Director Mark Dybul for continuing and expanding the work of his predecessor of streamlining a bloated institution and setting it on track to achieve the best-possible results and improve value for money.

As US Secretary of State John Kerry said in his speech on 2 December to open the replenishment conference, reforms at the Secretariat level were one of the drivers of his government's continued support of the Fund.

 “No other international organization has undergone such profound changes in its business model, its management team, and the financial systems that have swept through the Global Fund over the course of this last decade,” he said. “It’s important to underscore the reforms are not cosmetic. They are real. They’re tangible. And they are going to help save more lives, there’s no question.”

But where the Fund has developed and carried out strategies for risk management and data-driven decision-making, many donors reiterated a need for more attention to be paid to similar work at the country level -- and made it clear that they expected the Fund and its personnel to effectuate those strategies.

In pledging their support, donors were insistent that the Fund adhere to a zero-tolerance policy for corruption and make a greater push for national accountability and transparency, particularly among the country coordination mechanisms (CCMs) that are supposed to oversee the implementation of Fund grants.

Human Rights and Gender

Donor after donor reiterated the message delivered by Ambassdor Power in her keynote address: "that there is no sin in being sick, no justification for bigotry, and no license to marginalize anyone based on their HIV status, gender, or sexual orientation." Working to eradicate stigma and reducing the inequity in distribution of resources among men and women will be critical to the Fund's achievement of its objectives and ability to tap future resources from many countries.

Both France and the UK emphasized the need for the Fund to fully implement its gender strategy, with Justine Greening, the UK secretary of state for international development calling the Fund "a key jigsaw piece for moving forward for women and girls".

Support for this objective also came from an unlikely source prior to the launch of the replenishment conference; at a panel discussion hosted by Friends Africa and the Woodrow Wilson Center, Rwanda's first lady, Jeanette Kagame, said that it was imperative that Fund-supported programmes do more to target commercial sex workers, for whom prevalence rates of HIV remain unacceptably high and engagement by the global health community remains unacceptably low.  

But while the Fund has been promoting a general  human rights approach over the last 12 months in a manner that dwarfs previous years, there has been little progress in setting a concrete framework for response to stigma. Equally, the commitment to women and girls has been mostly rhetorical as a 2008 gender strategy was only partially implemented and is being revitalized as a theory rather than a framework for action. Most distressing is the missed opportunity to address head on the challenges to programme implementation derived from the deep and unabiding stigma that exists in many of the countries where the Fund operates.

Domestic co-financing

"Morally and financially responsible investment in our shared future": this was the theme of a second keynote address delivered by UNAIDS executive director Michel Sidibé.

Certainly, the $12 billion raised by the Fund for the next three years will help considerably in achieving the targets of $87 billion needed to truly eradicate AIDS, TB and malaria.

But co-financing by governments to address the problems in their own countries is even more important, and that was a message that many implementing countries present at the replenishment session took pains to make clear they understood.

Representatives from Kenya, Malawi, Namibia and Nigeria in rapid succession outlined the financial support they intended to draw from national resources to bridge the gap in unmet needs among their populations.

Whether it was boosting the number of people on anti-retroviral treatment, sleeping under bednets, or having access to TB tests and first-line drugs, the countries all acknowledged the imperative of supporting their national strategic objectives with ample resources, both in terms of money and trained personnel to strengthen their national health systems.

Equally, whatever the co-financing responsibility, many donors emphasised that the Fund needed to make sure that key populations -- in all countries, including MICs -- remained under the umbrella of coverage: both for prevention as well as for treatment, irrespective of the funding source.

Integration

As Lucica Ditiu of the Stop TB partnership put it at the end of the pledging opportunity, "there's no point keeping people alive on ARV treatment if they are going to die from TB."

This emphasis on integration, both of the response to the three diseases and the global health agenda with other development priorities, aims to be central to strategic planning at both the Geneva and national level over the course of this next cycle.

Integration is manifesting itself in a number of ways as the Fund moves through its next cycle, beginning most visibly with the decision to integrate funding for AIDS and TB programmes in a number of countries. There are also other nuanced and subtle changes under way that will influence the Fund's relationships over time that will help it remain a relevant force, both as a funding mechanism and shaper of policy.

At the first regional new funding model (NFM) meeting in Lusaka, Zambia just weeks before the replenishment conference, Fund representatives repeatedly emphasised the importance of using National Strategic Plans to drive concept note development, ensuring that the Fund's objectives were synced with national ones.

Assiduous cultivation of relationships at the global as well as country level is a new approach for the Fund, which had in the past operated at times in parallel, rather than in concert, with other technical partners.

But with the announcement that it would coordinate with DFID, UNICEF and the (US) President’s Malaria Initiative on the purchase of commodities, beginning with mosquito nets, the Fund is heralding a new era of working with other actors. This is an excellent step forward because it will allow for even stronger negotiation on the lowest-possible unit cost for life-saving drugs and products. Such strength will be inevitably balanced by continued weakness within national procurement systems but this can be tempered by a close working relationship between procurement officers and their national counterparts to help develop indigenous skills that will not be lost to bureaucratic swaddles in red tape or the temptation of corruption.

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