The Lusaka Agenda Heats Up the 51st Global Fund Board Meeting

Author:

Ida Hakizinka and Christian Djoko

Article Type:

Article Number: 6

At the 51st Global Fund Board Meeting, a report was presented to members, highlighting points of convergence between the Global Fund and the Lusaka Agenda, as well as aspects requiring further analysis. This article aims to reflect the discussions and conclusions that surrounded this report.

Context:

 

The Lusaka Agenda sparked heated debate at the 51st Global Fund Board meeting, establishing itself as a key topic with its innovative strategies for improving global health initiatives. Launched in December 2023, the Lusaka Agenda is presented by its authors as an ambitious new roadmap for global health. This strategic document aspires to transform the global health architecture by making it more efficient, equitable and sustainable (see our article on the topic). The Global Fund’s potentially decisive role in realizing this agenda is of the utmost importance. Indeed, many of its objectives are closely aligned with those of the Lusaka Agenda, creating a significant strategic convergence for global health efforts. Discussions at the Strategic Committee and Ethics and Governance Committee meetings in March 2024 laid the groundwork for further exploration of this intersection, as well as the associated challenges. In this article, we present the points of convergence identified and the strategic questions raised during these discussions, offering valuable insight into the issues discussed during the Board of Directors meeting held on April 23, 2024 in Geneva.

 

Points of convergence

 

According to the document presented by the Global Fund Secretariat, there are numerous synergies between the Lusaka Agenda and the Global Fund strategy for the period 2023-2028. Indeed, these two frameworks share several common objectives, as illustrated by the synthetic and schematic presentation below (Figure 1) illustrating the convergence between the five major changes of the Lusaka Agenda and the Global Fund strategy.

 

Figure 1: The five key changes of the Lusaka Agenda are integrated into the Global Fund strategy.

 

Areas for further discussion: Committee opinions.

 

Although these points of convergence have been identified, the Strategic Committee (SC) and the Ethics and Governance Committee (EGC) emphasize the need for further reflection and discussion in certain areas.

 

Strategic Committee

SC members stressed the importance of not allowing the collaborative agenda to take precedence over the Global Fund’s core mission of eliminating HIV, tuberculosis and malaria. This caution underlines the need to maintain focus on core objectives while pursuing collaborative efforts.

 

The SC also expressed concern at the lack of civil society and communities’ participation in the development of the Lusaka Agenda, while warning against a reduced reliance on Country Coordinating Mechanisms (CCMs), which provide a unique and important platform for these groups.

 

Another issue addressed by the SC concerned the bottom-up approach to engaging countries to become pioneers in implementing the Lusaka Agenda. Committee members stressed the importance of this approach in ensuring effective and lasting commitment from Pathfinder countries.

 

The Strategy Committee supports the establishment of a joint working group, comprising a limited number of Strategy Committee and/or Board members, as well as equivalent representatives from the Global Fund Secretariat, Gavi and Global Financing Facility (GFF). It also recommends that representatives of civil society and communities be given priority on this group, and stresses that it should have no decision-making powers. The Strategic Committee stresses the need for the GFF and Gavi secretariats to examine this proposal with their own governance before implementing it, highlighting the importance of coordination and collaboration between the different entities involved.

 

Ethics and Governance Committee

 

During these discussions, the EGC recognized from the outset that the Global Fund operates within a global health ecosystem where external discussions and initiatives are frequently introduced. The EGC also expressed concern that some external agendas are presented without alignment with the established governance processes of the Board and its committees, potentially diverting the attention of the secretariat and governance bodies from the agreed strategy. In light of this, the importance was stressed of establishing a clear process for reviewing these external agendas as part of the Global Fund’s governance. Above all, the need to maintain a balance between exploring new ideas and analyses and focusing on the pre-established strategy was emphasized.

 

With regard to the principles of governance, the EGC recalled several fundamental elements. It emphasised the duty of care owed to the organisation, highlighting the importance of commitment to the representativeness and inclusiveness of the Global Fund’s multi-stakeholder Board. In addition, the Committee stressed the importance of maintaining a clear focus and judicious use of time to avoid distraction by external agendas.

 

Finally, with respect to the requirements of the Joint Working Group, the EGC stressed the importance of clearly defining its purpose, its positioning within the Global Fund’s governance structure while preserving the oversight and decision-making authority of the Board and Committees, and the need for clear terms of reference and selection processes consistent with the Global Fund’s principles of inclusive representation.

 

Questions for discussion

 

The Board was asked to consider various aspects of the recent committee deliberations in March 2024, as well as the need to discuss the Lusaka Agenda in the broader context of the Global Fund’s overall strategy. Indeed, several questions and tensions require further attention from governance.

 

Firstly, the question of alignment with and use of national systems needs to be carefully examined. How can this alignment be strengthened while preserving the commitment and essential role of civil society and communities? This issue also raises questions about how CCMs work and how they can be optimized to ensure effective collaboration between the various players.

 

Secondly, strengthening health systems and primary healthcare is of crucial importance, particularly in the context of the fight against HIV, tuberculosis and malaria. Faced with this need, several questions arise: how can we maintain and increase the progress made in the fight against these diseases while at the same time strengthening health and primary healthcare systems? How can the reporting burden on countries be reduced while ensuring that the reports submitted to the Board are sufficient in quality and quantity? This question also highlights the need to strike a balance between data collection and reporting requirements, particularly at different levels of funding.

 

Thirdly, sustainability across the Global Health Initiatives is a major issue. What does sustainability mean to different stakeholders and what strategies and levers should the Global Fund focus on to ensure sustainability? This question raises complex challenges related to the sustainability of health programmes over time and across different contexts.

 

Finally, the evolution of the Global Fund as a model built for HIV, tuberculosis and malaria raises questions about its adaptability to other public health threats. Where is it going in terms of representation on the Board, and how can it broaden its scope while remaining effective in its core mission? These questions are crucial to ensuring the relevance and effectiveness of the Global Fund as global health challenges evolve.

 

Three key questions were put to Board members for their views:

Does the Board have additional reflections to add to the recent SC and EGC deliberations?

 

Does the Board agree that elements of the Lusaka Agenda should be discussed within the context of the full Global Fund strategy?

 

Does the Board have additional guidance for its Committees as they move forward in considering whether and how the Global Fund might take forward more specific aspects of the Lusaka Agenda?

 

Stakeholder Feedback

 

The stakeholders’ feedback on the Lusaka agenda has provided diverse perspectives, reflecting a complex mix of support, concerns, and strategic considerations for the Global Fund. Below are detailed and clear paragraphs summarizing the stakeholders’ feedback, without naming specific stakeholders:

1. Strategic Alignment and Due Care: Stakeholders emphasized the importance of aligning the Lusaka agenda with existing priorities of the Global Fund. There was a common theme of ensuring due care in incorporating external agendas, with a focus on maintaining strategic focus and guarding against potentially distracting agendas. Stakeholders expressed the need for the Global Fund to continue its primary mission of combating HIV, TB, and malaria, while carefully considering the integration of new initiatives.
2. Concerns about Process and Inclusivity: Several voices raised concerns regarding the process by which the Lusaka agenda was being incorporated into discussions. There was frustration over the perception of a top-down approach and the lack of sufficient inclusivity in the consultation process. Stakeholders called for more transparent and participatory processes to ensure that all relevant parties are involved in discussions, particularly emphasizing the role of the non-state actors, including Civil Society Organizations (CSOs) and local communities, recognizing their essential role in public health successes over the past decades.
3. Sustainability and Country Ownership: The feedback highlighted the crucial need for sustainability, which is critical as its supports primary care strategies where diseases like HIV, TB, and malaria are managed, and broader health needs, including non-communicable diseases and reproductive health, are addressed at the primary healthcare level; and stronger country ownership. Stakeholders pointed out the importance of domestic financing and more robust engagement with country governments to ensure that health initiatives are sustainable and tailored to specific national contexts. There was a strong call for the Global Fund to support countries in increasing their health financing capacities, which is essential for long-term sustainability.
4. Risk of Overstretching Resources: Concerns were expressed about the ambitious scope of the Lusaka Agenda potentially over-stressing the Global Fund’s resources. Stakeholders were wary of the risk that focusing on too many new initiatives could dilute efforts against the three core diseases (HIV, TB, and malaria) and impact the Fund’s ability to meet its primary objectives.
5. The Role of the Global Fund in Global Health Architecture: Discussions also touched on how the Lusaka Agenda could be integrated within the broader global health architecture. Stakeholders noted the need for the Global Fund to continue playing a significant role in global health while ensuring that its actions are well-coordinated with other international health initiatives and aligned with overall global health strategies.
6. Emphasis on Practical Implementation: Lastly, there was a consensus on the need for practical and actionable steps forward. Stakeholders urged the Global Fund to focus on concrete implementations that align with its strategic objectives. The feedback called for a balanced approach that integrates new ideas from the Lusaka Agenda without compromising the ongoing efforts against HIV, TB, and malaria.

 

Some stakeholders reaffirmed that the Lusaka Agenda does not directly call for a pooled fund due to donor assurance requirements; it advocates for better alignment and coordination among health efforts. This is seen as essential for enhancing efficiency and eliminating redundant operations, ultimately improving health outcomes across the continent.

 

In addition, there was a letter written , by various representatives and stakeholders of the Global Fund, Gavi and the Global Financing Facility to the Board Chairs of these organizations with specific reference to the Joint Working Group to be constituted across these boards as part of the partnership of these three global health institutions in the context of the Lusaka Agenda. The areas covered in this letter have been incorporated in the article on the Global Fund, Gavi and Global Financing Facility.