Key Meeting in Dakar: Assessment and Prospects of the Global Fund for West and Central Africa
Author:
Ida Hakizinka and Kafui Essie
Article Type:Article Number: 6
This article is a report on the high-level meeting held in Dakar from December 12 to 14, 2023. Organized by the African Constituency Bureau (ACB) and bringing together 12 countries from West and Central Africa, this gathering served as a crucial platform to assess the successes of the Global Fund's Grant Cycle 6 (GC6) and develop strategies for Grant Cycle 7 (GC7). GC6 made significant progress in the fight against HIV/AIDS, tuberculosis, and malaria, but challenges remain. Discussions underscored the importance of better targeting populations, integrating care, community involvement, and local production of inputs for successful interventions. Debates also highlighted examples of good practices in coordination and leadership, as well as the importance of co-financing and civil society engagement. Finally, the low representation of civil society was discussed, highlighting the need to strengthen its capacities and improve program coordination. The meeting resulted in action plans and recommendations to strengthen health systems and continue the fight against HIV/AIDS, tuberculosis, and malaria in West and Central Africa.
Introduction
Between December 12 and 14, 2023, Dakar, the capital of Senegal, became the epicenter of a crucial meeting for West and Central Africa organized by the African Constituency Bureau (ACB). This assembly, which brought together 12 countries (Benin, Burkina Faso, Côte d’Ivoire, Ghana, Guinea-Bissau, Mali, Niger, Nigeria, Democratic Republic of Congo (DRC), Senegal, Chad, Togo) from the sub-region, provided an exceptional platform to examine the successes and lessons learned from the Global Fund’s Grant Cycle 6 (GC6) and to develop robust strategies for Grant Cycle 7 (GC7), which recently opened. This meeting undoubtedly marks a key moment for strengthening health systems in the region.
Context and Current Challenges
The Global Fund to Fight AIDS, Tuberculosis, and Malaria finances programs to combat these three diseases and strengthen the health system. The Global Fund’s GC6, which took place from 2016 to 2023, allocated several billion dollars to 12 countries in the West and Central Africa region.
It is fair to say that this cycle has been significant in the fight against HIV/AIDS, tuberculosis, and malaria in West and Central Africa. As of December 31, 2022, the overall absorption rate of funds in West and Central Africa reached 75%, showing a 5% increase compared to the previous period. Notably, the region distinguished itself by its efficiency in budget utilization, displaying an impressive rate of 93%. The number of people living with HIV on antiretroviral treatment (ART) increased by 70%, from 11.5 million in 2016 to 19.4 million in 2023. The number of new tuberculosis cases decreased by 22%, and the number of malaria deaths decreased by 29%.
These advancements were a result of collaboration between the governments of the region’s countries, civil society organizations, and Global Fund partners, contributing to the improvement of health and well-being for millions of people. However, despite these successes, challenges persist. The high number of people living with HIV who do not yet have access to ART, the growing threat of drug-resistant tuberculosis, and the persistence of malaria as a leading cause of death among children under 5 remain significant concerns.
Assessment of GC6 and Perspectives for GC7
Dr. Djésika Amendah of the ACB presented a thorough analysis of GC6, highlighting financial gaps and mixed performances in critical areas such as prevention of mother-to-child transmission of HIV, tuberculosis control, and malaria. For GC7, the objective is clear: to strengthen prevention initiatives and improve the scope and quality of healthcare.
Case studies from Chad, Nigeria, and the Democratic Republic of Congo were presented, offering crucial insights into effective strategies in the fight against HIV/AIDS, tuberculosis, and malaria. These knowledge-sharing sessions underscored the crucial importance of developing context-specific strategies tailored to local realities.
Chad: HIV/AIDS Fight
During GC6, the country reported progress in the fight against HIV, highlighting a series of strengths. Since 2020, notable progress has been recorded, marked by an increase in the percentage of people aware of their serological status, from 79% to 85%, and an increase in the percentage of people on antiretroviral treatment, from 59.20% to 63%. These figures demonstrate a clear political will to combat the disease. However, to further improve the situation, measures such as strengthening screening, increasing resources in high-risk areas, and active participation of local communities are advocated for GC7.
Nigeria: Tuberculosis Fight
Nigeria has made significant progress in the fight against tuberculosis, with increased coverage and a notable reduction in cases through private sector involvement. The effective use of funds, surpassing initial targets, reflects successful strategic management. However, better integration of communities remains an area for improvement for future interventions.
Democratic Republic of Congo: Malaria Fight
The DRC faces financial and logistical challenges in its fight against malaria. The majority of funding comes from external sources, and the distribution of prevention inputs is insufficient. For GC7, the objective is to increase funding, improve input availability, and expand territorial coverage.
Mali: Resilient and Sustainable Health Systems
Mali has received a substantial allocation from the Global Fund, aimed at combating HIV, tuberculosis, and strengthening its health system. Despite some successes, the country must overcome delays in implementing activities, as well as a deficit in funding and human resources. Approaches such as anticipating personnel needs and decentralizing funds are considered possible solutions.
Senegal: COVID-19 Response and Health System Strengthening
In Senegal, the C19RM grant prioritized strategic areas such as strengthening surveillance systems and respiratory care. Under GC7, additional resources have been allocated to intensify the fight against tuberculosis and malaria, as well as to strengthen pandemic preparedness capacities.
Togo: Fight against Malaria, HIV, and Tuberculosis
Togo, benefiting from a substantial allocation from the Global Fund, has primarily directed its efforts towards combating malaria, followed by HIV and tuberculosis. Investments have been diversified, but the country faces challenges such as complex administrative procedures and a shortage of qualified personnel.
Overall, the different experiences of these countries highlight the importance of effectively targeting populations, integrating care, involving local communities, and producing inputs locally. Optimal resource utilization and advocacy for greater participation of local governments will prove crucial for the success of future interventions.
Challenges and Solutions in Coordination and Leadership in Grant Implementation
Discussions highlighted challenges related to coordination and leadership in grant implementation. Participants discussed ways to improve program management, increase transparency and accountability, and strengthen the involvement of local communities in decision-making processes. Specifically, discussions focused on improving program management, transparency, accountability, and involving local communities. However, the implementation of additional safeguard policies in some countries was identified as a potential obstacle to grant effectiveness.
Examples of effective coordination and leadership in the implementation of Global Fund grants were shared by countries such as Benin, Ghana, and Nigeria. These testimonies highlighted successful strategies and challenges encountered in different contexts.
In Ghana, challenges in combating the three major diseases resided in multi-party fund management. To resolve confusion and improve decision-making, a conflict resolution framework was established. Moreover, emphasis is placed on the need for intelligent coordination between program managers and key beneficiaries. Despite shortcomings in performance indicator consideration, the country has achieved satisfactory results in malaria control.
Regarding Benin, the Ministry of Health plays an essential role in program implementation, with five main beneficiaries divided among the three diseases. The country has faced challenges related to fragmented management and, for GC7, is considering establishing a unified management unit, thereby promoting coordination and resource optimization. Additionally, Benin has developed intervention plans in response to COVID-19 until 2025.
As for Nigeria, it benefits from active involvement of NGOs and the private sector in managing Global Fund grants. Although governance is shared between the government and NGOs, the Ministry of Health remains the primary implementer. Quarterly meetings and annual assessments are organized to monitor performance indicators. However, challenges such as delays in fund disbursement and administrative burdens call for improved governance and streamlined procedures.
Other topics discussed during the meeting: CCMs, co-financing, and civil society
CCM
During the session dedicated to Country Coordinating Mechanisms (CCMs), examples from Côte d’Ivoire and Burkina Faso illustrated varied and innovative approaches.
In Côte d’Ivoire, the CCM, established in 2002 and reorganized in 2013, highlights the importance of a robust and adaptable internal organization. Disease-specific technical committees and the introduction of the strategic monitoring committee in 2018 demonstrate a commitment to specialization and rigorous monitoring. This has enabled overcoming significant challenges and implementing strategic recommendations. Attention to updating the strategic monitoring plan and advocating for needs not covered by grants is particularly relevant.
In Burkina Faso, there is also a model of CCM composition integrating various sectors, including civil society. This multidisciplinary approach, although facing challenges such as coordination and stigmatization, suggests a path towards more inclusive and representative governance.
These experiences underscore the need for a coordinated and collaborative approach for CCMs.
As highlighted by Professor Niamba in his conclusion, decision-making based on field experience, teamwork, and solidarity is fundamental. The importance given to empirical data analysis and experiential learning is crucial for positively influencing the future of CCMs.
The success of CCMs depends not only on strong and well-organized structures but also on commitment to a participatory and evidence-based approach.
Co-Financing
Guinea-Bissau is a notable example of government commitment to health. For the period 2024-2026, the country has increased its health budget by 6%, bringing public spending in this sector to 10.73%. This budget increase mainly focuses on health personnel salaries and annual government investments. A monitoring committee, in collaboration with the CCM, has been established for domestic expenditure control and monitoring.
It is also important to emphasize the importance of incorporating public financial systems of all funders requiring co-financing by working closely with the Ministry of Finance. Such integration promotes increased transparency, strengthens country autonomy, and improves accountability more effectively.
However, it is crucial to avoid governments’ overcommitment beyond their capacities, highlighting that states should not perceive the Global Fund as a competitive source but rather as a collaborative partner.
And Civil Society in All of This?
Simon Kaboré of RAME highlighted the low representation of civil society in the main recipient of grants, with only one-third of the countries involved. RAME provides technical support to civil society, focusing on assessing gaps in human rights, gender, and community engagement. The network also promotes the effectiveness and sustainability of community interventions.
More broadly, discussions at this level focused on the autonomy of CCMs from the government, actor motivation, support for civil society organizations, and program coordination. CCM structures and leadership vary from country to country, as does actor motivation, which, despite often being voluntary, remains committed. A consensus emerged on the need to strengthen the capacities of civil society organizations and improve program coordination between different ministries and partners.
This session highlighted challenges and advancements in coordination and leadership for the implementation of Global Fund grants. Experiences shared by Ghana, Benin, and Nigeria, combined with contributions from RAME, underscored the crucial importance of efficient governance, active civil society involvement, and the need for strengthened coordination among all engaged actors.
Conclusion
The Dakar meeting concluded on an optimistic note, marked by strengthened commitment to more robust and inclusive health systems. The action plans and recommendations developed at this meeting constitute an essential roadmap for continuous health improvement in West and Central Africa. These plans emphasize the vital importance of collaboration, innovation, and adaptation to the specific needs and realities of each country in the fight against HIV/AIDS, tuberculosis, and malaria.
