Challenging operating environments (COEs) are countries or sub-regions of countries that the Global Fund characterizes as having weak governance, poor access to health services, manmade crises (such as conflict) or natural crises (such as famine). The Fund’s COE policy affords these countries extra flexibilities to ensure that funding requests can be submitted, and grants can be implemented, despite these difficult circumstances.
As of January 2017, the Global Fund classified the following 25 countries as COEs: Afghanistan, Burundi, Central African Republic, Chad, Congo (Democratic Republic), Eritrea, Guinea, Guinea-Bissau, Haiti, Iraq, Lebanon, Liberia, Mali, Mauritania, Niger, Nigeria, Pakistan, Palestine, Sierra Leone, Somalia, South Sudan, Sudan, Syrian Arab Republic, Ukraine and Yemen. This list of countries is valid for the 2017-2019 allocation period, according to the Global Fund’s Operational Policy Manual.
For the 2017-2019 funding cycle, all of these countries have been invited to submit funding requests that contain questions specifically tailored to COEs. For example, the template asks applicants who are in acute emergency settings, where the context is volatile or often changing, to describe how such change will be managed. In other words, applicants are asked to describe how the scope of the program can be adjusted when circumstances change (whether they deteriorate or improve) as well as the factors that would trigger a shift in approach. This is a new type of funding request, as part of the Global Fund’s differentiated application process.
Aidspan has obtained draft funding requests from six of these COE countries – Eritrea, Liberia, Guinea, Central African Republic, South Sudan and Somalia. Some of these drafts are integrated TB/HIV requests while others are single disease component requests for either HIV or TB. The drafts were circulated as part of a mock technical review panel (TRP) held in Nairobi, Kenya in the first week of May 2017. This article describes some of the specific challenges these COEs are currently facing and the related interventions in their draft funding requests. The final versions of the funding requests discussed below were submitted to the Global Fund during Window 2, for which the deadline was 23 May 2017.
Caveat: Aidspan is cognizant that the content of the funding requests discussed in this article may have changed between the drafts circulated at the mock TRP and the final versions submitted on 23 May 2017. However, the Global Fund does not make final funding requests public until after grant-signing. Further, information coming out of COEs is often extremely limited, making reporting on these countries difficult and infrequent. As a result, Aidspan has not been able to obtain final versions of the funding requests, but deems the draft content worthy of GFO coverage.
Eritrea’s draft HIV funding request states that a major challenge in the country is the extremely low number of skilled health care workers. As a proportion of the total need, current staffing levels are at 9.1% for doctors (general practitioners) and 6.3% for nurses. By comparison, while recent funding requests from both Zambia and Zimbabwe (which Aidspan has previously reported on here and here) highlight shortages in human resources for health, Zambia’s staffing levels are at 49% for doctors and 63% for nurses, and Zimbabwe’s are at 73% for doctors and 88% for nurses
In the context of Eritrea’s immense shortage of professional health cadres, the country prioritizes strengthening community systems so that community groups can fill some of the critical gaps in health service delivery.
Liberia’s draft TB/HIV funding request cites ramifications of the 2014 Ebola outbreak as a significant ongoing challenge. According to the draft request, the country is currently struggling to implement its post-Ebola economic recovery plans. Further, given the country’s need to take financial responsibility for national security following the phased withdrawal of the U.N. Mission in Liberia (with complete drawdown planned for June 2017), the draft funding request states, “It is unlikely that the country can find the adequate resources to invest in the health sector anytime soon.”
That said, the draft request also makes use of Ebola lessons to inform its proposed interventions. To address stigma associated with TB, Liberia prioritizes engaging community leaders and community-based organizations to sensitize people to attend health facilities – a strategy that worked well during the Ebola outbreak.
Guinea’s draft TB funding request notes three potential risks linked to its COE status. The funding request cites the chance of sociopolitical disturbances, the potential reactivation of the Ebola epidemic (or the occurrence of new epidemics) and the possibility of natural disasters as challenging factors.
However, the draft notes that access to TB screening through GeneXpert tests has improved in recent years, with 10 machines currently operational thanks to the shared efforts of the Ebola, HIV and TB programs. The country may be able to continue to leverage structures that sprang up during the Ebola outbreak in order to strengthen its Global Fund programs.
Central African Republic
The Central African Republic (CAR) is in the midst of an on-going civil war, which is the main reason for the country’s classification as a COE. Its draft TB/HIV funding request points to this factor as a severe limitation in service delivery, since the majority of the country is either partially or completely inaccessible due to the conflict (see the figure).
Figure: Distribution of regions of the Central African Republic, according to security level
Source: Draft TB/HIV funding request to the Global Fund, Central African Republic
The draft request notes that the government of CAR, with the support of its partners, has drawn up a National Plan for the Rehabilitation and Consolidation of Peace in the Central African Republic (RCPCA) for the period 2017-2021. It states that this opportunity will allow CAR to improve implementation of its HIV and TB programs, including human rights and gender elements.
Somalia’s draft HIV funding request underscores that the country is currently experiencing the worst drought and famine in over 50 years. This is a humanitarian emergency, meaning that efforts from both government and non-government partners are predominantly focused on addressing issue like malnutrition and maternal and child deaths due to the famine. As a result, there is far less focus on HIV activities. Furthermore, 26% of the population are nomadic and 9% are internally displaced. There are conflicting population estimates ranging from 9-12.3 million. These factors significantly impact the country’s capacity to set realistic targets for its disease programs.
To mitigate these challenges, the country’s draft funding request proposes engaging in regular dialogue with the affected sectors. Somalia also prioritizes bringing in technical assistance or support where needed. The request defines internally displaced women and mobile men as an HIV key population to be targeted with integrated prevention and behavior change programs, with particular emphasis on linking them to essential services and support.
South Sudan’s draft HIV funding request describes the eruptions of conflict in the country in December 2013, and more recently in July 2016. The request notes that these bursts of fighting result in an increase in migrant and refugee populations as people move in and out of the country as the threat of violence fluctuates. This situation is made worse by a fledgling health system and inconsistent and insufficient access to health services. The draft request also cites outbreaks of cholera and measles in different parts of the country as competing health priorities which limit funding as well as attention dedicated to HIV.
As a result, the request prioritizes differentiated service delivery among vulnerable populations, including migrants, internally displaced populations (IDP) and refugees. In particular, the country proposes long-term rapid response team missions of 3–12 months deployed to IDP camps, protection of civilian (POC) sites, and refugee settings. The teams will provide HIV testing services, dispense HIV treatment and conduct health education and adherence counselling sessions.
As a result of the challenges highlighted in this article, many of these countries’ governments are not able to manage Global Fund grants directly. Instead, the majority of them rely on international organizations or U.N. agencies for implementation. In Guinea, the principal recipient (PR) is Plan International; in CAR it is the International Federation of Red Cross and Red Crescent Societies. Grants in Somalia and South Sudan are managed by UNICEF and UNDP, respectively. Among the six countries, Eritrea and Liberia are the only ones where the Ministry of Health serves as PR.