The Global Fund in Africa: a deep dive into progress, persisting challenges, and the path to sustainable impact
Author:
Armelle Nyobe
Article Type:Article Number: 8
An examination of the impact of the work of the Global Fund in Africa using the report of the Global Fund’s Office of the Inspector General (OIG) Operational Progress Report (January-August 2024) that was presented at the 52nd Board meeting of the Global Fund in Malawi.
The Global Fund to Fight AIDS, tuberculosis, and malaria plays a pivotal role in improving global health, particularly in resource-constrained settings like many African nations. The Global Fund Office of the Inspector General (OIG) Operational Progress Report (January-August 2024) reveals a complex picture of successes and persistent challenges. While the OIG report showcases impressive gains in reducing mortality rates on these three diseases, a closer examination reveals crucial areas needing significant attention to ensure long-term sustainable impact across the continent.
A symphony of successes: quantifiable progress in Africa
The OIG report highlights undeniable achievements in several African nations. Data-driven analyses demonstrate significant reductions in mortality rates for HIV, TB, and malaria in countries like Malawi, Ethiopia, and Zimbabwe. These are not mere anecdotes; they represent tangible improvements in public health, underpinned by robust quantitative evidence. The increase in access to antiretroviral therapy for HIV, improved TB treatment success rates, and expanded malaria prevention programs all contribute to these remarkable outcomes. As the OIG Operational Progress Report states “There is an abundance of evidence to indicate that Global Fund grants are having a positive impact.”
Examples from African countries
Source: OIG Operational Progress Report (January-August 2024)
Zimbabwe’s success in achieving the 95-95-95 UNAIDS targets exemplifies the power of effective partnerships and a coordinated approach to disease control. Elsewhere, the integration of Global Fund initiatives into national health systems has played a crucial role. As confirmed with some African countries, this alignment with health national priorities is crucial and mandatory to achieving the national objectives.
These successes demonstrate the effectiveness of the Global Fund’s model when implemented effectively and when strong collaborations exist among national governments, local communities and other key stakeholders.
A chorus of challenges: obstacles to sustainable progress
Despite these encouraging results, the OIG report also sounds a cautionary note, highlighting significant challenges that threaten to undermine the sustainability of the gains already made:
The fragility of health systems: The OIG report consistently points to the difficulty of effectively integrating investments in Resilient and Sustainable Systems for Health (RSSH). Many African nations grapple with weak health infrastructure, fragmented services, and a lack of coherent national health strategies. This leads to inefficient resource allocation and hinders the long-term sustainability of disease control programs. Building robust and resilient health systems is not merely an ancillary goal; it is the bedrock upon which any sustainable progress must be built.
The elusive goal of incidence reduction: While significant reductions in mortality have been achieved, reducing the incidence of new infections remains a major challenge. The complexity of HIV prevention, for example, highlights the need for more targeted and sophisticated strategies. Competing priorities within healthcare systems often mean that resources intended for prevention are diverted to address more immediate needs, such as reproductive health services, treatment and care. A shift in focus towards proactive prevention measures is critical for breaking the cycle of infection.
The uncertain landscape of co-financing: The OIG report reveals inconsistencies in securing consistent co-financing from national governments and other partners. This lack of predictable funding jeopardizes the long-term viability of programs. There is a need for improved mechanisms to encourage and support domestic resource mobilization, fostering national ownership and ensuring the long-term sustainability of initiatives beyond Global Fund grants. This is the opportunity to highlight initiatives from Benin and Congo that have a dedicated committee to follow up the cofinancing commitments.
The imperative of transition planning: Many countries lack well-defined transition plans to ensure that progress made with Global Fund support is sustainable after funding ends. The transition from external funding to national ownership requires a comprehensive strategy encompassing capacity building, resource mobilization, and a clear plan for integrating programs into existing health systems. Without careful planning, hard-won gains risk being lost once external support is withdrawn.
Navigating challenging environments: Operating in conflict zones or areas with high levels of insecurity presents unique challenges. The OIG report emphasizes the need for adaptable strategies and flexible approaches to ensure program continuity in these contexts, prioritizing the safety and security of personnel while maintaining the delivery of essential services. Africa is home to 13 fragile countries called Challenging Operating Environments in the Global Fund lingo. The Global Fund has a policy to streamline needed flexibility for grant management in such countries. The African Constituency Bureau advocates for more transparent flexibility and “à la carte” management. Indeed, even if all those countries are facing a stability issue, their realities are not the same: Chad and Guinea Bissau will never be the same.
Data gaps and inconsistencies: While the OIG report provides a wealth of data, it also highlights inconsistencies and limitations in data collection and reporting. Discussions with some countries confirm this reality. Countries reveal gaps in collecting data due to strikes or human resources challenges. Improvements in data quality and the establishment of robust monitoring and evaluation systems are therefore important for assessing the true impact of interventions and for guiding future resource allocation. However, some other countries like Mauritania have succeeded in digitalizing their heath data, which proves it is feasible.
Constituency Feedback
A persistent inability to reach key and vulnerable populations was highlighted, revealing a gap in equitable service delivery. Constituencies raised concerns about the fragmentation of health systems in many countries, where the lack of cohesive national strategies undermines efforts to strengthen healthcare systems and implement effective prevention measures. In cases where such strategies exist, they are often too broad to be actionable or suffer from inefficiencies due to the involvement of multiple uncoordinated entities. These challenges underscored the urgency of designing and implementing targeted strategies that prioritize prevention and cater to the unique needs of underserved populations.
Turning to future planning, the discussion transitioned to the program’s 2025 plan and budget. Flexibility was identified as an essential feature of the plan, ensuring that the program can adapt to changing priorities, unanticipated challenges, and fluctuating resources. Resource allocation emerged as a focal point, with constituencies advocating for a data-driven approach that directs investments toward areas offering the highest impact. Stakeholders emphasized the importance of balancing short-term operational demands with the overarching goal of sustainability. This requires not only optimizing resource use but also making difficult decisions about where to scale back to ensure maximum efficiency and effectiveness.
A central theme of the discussion was risk management. Constituencies emphasized the importance of articulating a clear risk appetite, allowing for strategic trade-offs between accepting, transferring, or mitigating risks. The need to simplify the operational model was also emphasized, as current processes were deemed overly complex and, in some cases, inefficient. A differentiated approach was proposed, wherein resources and efforts are tailored to the specific needs and contexts of different countries and regions. Such an approach would align more closely with the program’s commitment to equity and impact, addressing the unique challenges faced by high-burden or low-resource areas.
Investigation updates provided an insight into the program’s commitment to accountability and transparency. A notable increase in complaints and whistleblower reports was observed, signaling enhanced trust in the mechanisms for addressing grievances. However, these developments also revealed underlying challenges, particularly regarding allegations of human rights violations and the systemic barriers faced by marginalized communities. The program highlighted ongoing efforts to improve reporting mechanisms, support victims, and ensure that allegations are thoroughly investigated and addressed.
Constituencies also expressed concerns about the sustainability of health initiatives, particularly in light of fiscal constraints faced by many countries. While national investments in health were encouraged as a means of ensuring long-term sustainability, it was recognized that achieving this would require innovative financing solutions. Transition financing, aimed at mitigating the potential impact of reduced funding, was identified as a critical area requiring urgent attention. The meeting called for greater efforts to build national capacities and incentivize domestic health investments, recognizing that these measures are essential for sustaining health gains in the face of diminishing external resources.
Technology, particularly artificial intelligence (AI), was highlighted as an emerging tool with the potential to transform operations. AI applications in investigations and audits were noted as promising avenues for enhancing efficiency and effectiveness. Constituencies expressed enthusiasm about these developments while cautioning against potential risks, such as privacy violations or ethical concerns, that may arise with the expanded use of AI.
Stakeholder engagement was another key area of focus. Constituencies underscored the importance of fostering strong partnerships across public, private, and civil society sectors to achieve shared health goals. Engaging community representatives, particularly those from marginalized or vulnerable groups, was emphasized as critical for ensuring that policies are inclusive and grounded in the realities of those most affected by health disparities.
The importance of balancing immediate operational needs with long-term sustainability was a recurring message. Constituencies stressed the need for clear strategic direction, robust stakeholder engagement, and the optimization of limited resources to sustain and amplify the program’s impact. The meeting concluded with a sense of cautious optimism, recognizing both the progress achieved and the challenges ahead, and reaffirming the collective commitment to advancing global health outcomes.
A Call to Action: towards a sustainable future
The Global Fund’s progress in Africa is undeniable, however these achievements are threatened by persistent challenges. To ensure long-term impact and the sustainability of these hard-won gains, the following actions are crucial:
Prioritizing Health Systems Strengthening: Investing in robust and resilient health systems is not a side goal; it is the foundation for long-term success. This requires a holistic and strategic approach, encompassing infrastructure development, capacity building, and the integration of Global Fund programs into national health strategies. In countries like Côte d’Ivoire, we know as a fact that they take 10% of the malaria and HIV grants to reinforce their health system. The country is actively working to establish a comprehensive laboratory system that will address all diseases and not only HIV and plans to expand this RSSH investment to include a supply chain system that is currently focused on individual diseases.
Refining strategies for incidence reduction: Focusing on prevention alongside treatment is crucial. This involves developing targeted strategies for key populations and addressing the challenges of resource allocation within often strained health systems.
Strengthening co-financing and Domestic Resource Mobilization: This necessitates strengthening mechanisms to encourage and support domestic resource mobilization, empowering countries to take ownership of their programs and ensuring sustainability beyond the life of Global Fund grants.
Developing robust transition plans: A comprehensive and well-defined transition plan is paramount for ensuring that progress made with Global Fund support is sustained long-term. This involves capacity building, resource mobilization, and clear strategies for integrating programs into existing national health systems.
Adapting to complex and challenging contexts: The Global Fund must develop flexible and adaptable strategies to manage the challenges of operating in conflict zones and insecure environments, ensuring the safety and security of its personnel while effectively delivering essential health services.
Improving data quality and reporting: Stronger data management and reporting systems are essential for accurate program monitoring and evaluation. This will allow for better evidence-based decision-making and improved accountability.
Conclusion
The Global Fund’s work in Africa has already made a significant difference in the fight against major infectious diseases as Africa bears the bulk of disease burden (over 70% HIV, 24% TB & over 94% malaria) with 73% of The Global Fund investments. Addressing the challenges highlighted in the OIG report, however, is paramount for ensuring the sustainability of this progress and for creating a healthier and more equitable future for all Africans. A collaborative and proactive approach, prioritizing investments in resilient health systems and fostering strong partnerships, is the key to unlocking lasting positive change across the continent.
