In October 2015, the World Health Organization reported that the Millennium Development Goal (MDG) to halt and reverse TB incidence (MDG 6c) was achieved on a worldwide basis, in each of WHO’s six regions and in 16 of the WHO’s 22 high-burden countries. While this progress is commendable, recent evidence suggests the trend may be reversing. The most recent Global TB Report highlights that 10.4 million people fell ill with TB in 2015—800,000 more than reported in 2014. Given that the new Sustainable Development Goals (SDGs) commit the world to ending the TB epidemic by 2030, these statistics are worrying. The Global Fund is the largest external funder of TB programs worldwide, accounting for more than 75% of donor assistance for TB disease programs. This equates to investments of more than $4.7 billion in TB programs in more than 100 countries since 2002. In Uzbekistan, the Global Fund supports training of staff as well the medicine to treat TB so that it can be offered for free to patients who need it across the country. In Bangladesh, Global Fund investments in TB have averted more than 577,000 infections and saved more than 308,000 lives. Despite this considerable effort, the Fund’s 2015 Results Report noted that its TB treatment targets are perhaps overly ambitious. A total of 8.5 million TB patients received treatment between 2012 and 2014, below the benchmark to reach the Fund’s target of treating 15 million TB patients over the 2012-2016 period.  The Global Fund’s new strategy for 2017-2022 contains further targets, aiming to reduce TB incidence by 20% and TB deaths by 35% by 2020 (compared with 2015 rates). Although the Global Fund had a successful replenishment in September, raising nearly $13 billion for the 2017-2019 period, this is just 80% of what is actually required. With limited funds, investments must be made more strategically to reach targets. The Global Fund’s new allocation methodology for 2017-2019 keeps the funding split for TB roughly the same as it has been in the past – 18% of total investment (with 51% for HIV and 31% for malaria). However, small changes to the allocation methodology means there will be a 25% increase to the top 28 countries with the highest burden of multi-drug resistant TB (MDR-TB). Slow (or even reversing) progress alongside ambitious targets and limited funding means rethinking how the Global Fund and its partners can do more to achieve impact towards ending TB. This article outlines three key areas where the response could be improved: TB representation on country coordination mechanisms (CCM), civil society engagement and getting services to key populations. Improve TB representation on CCMs Strong and engaged TB representation on CCMs is critical for ensuring the right priorities go into funding requests and that grants are effectively implemented to achieve targets and save lives. However, a recent study published by the Stop TB Partnership highlights the inadequate representation of TB experts on CCMs. According to the study, just 14% of CCM members have TB-specific expertise, a clear under-representation compared to HIV specialists (Figure). Further, this expertise was concentrated among a small number of CCMs. Only 65 out of the 114 CCMs examined had at least one member with TB capacity. Where TB expertise does exist, the study found it was concentrated among representatives from government and non-governmental organizations. TB representatives for people living with diseases and key affected populations were disproportionately lacking.    

Figure: Distribution of disease expertise among 1201 representatives from 114 CCMs (Stop TB Partnership, 2015)

Ntombekhaya Matsha-Carpentier, Global Fund and Communities Team Leader at the Stop TB Partnership, says that the voice of TB programs has historically been built on very weak foundations. “The advocacy and activism around the Global Fund has been mainly led by the HIV/AIDS community”, she said. “At country level, National AIDS Councils were already familiar with multi-stakeholder functioning that a body like the CCM requires, so naturally the AIDS community was more able to participate actively in CCMs.” It is critical that CCM representation for TB be improved to ensure more effective programming and to accelerate results. Engage civil society With the advent of the Global Fund’s New Funding Model (NFM) in 2014, emphasis on civil society and community participation throughout the grant cycle was significantly elevated. The importance of an engaged civil society continues to be institutionalized with the Fund’s new 2017-2022 strategy. In India – the country with the largest number of incident TB cases - Global Fund investment supports civil society’s role in the National TB Program, engaging communities and community-based care providers in 374 districts where there is low TB case detection or there is limited access to health services. The Global Fund’s Community, Rights and Gender Special Initiative has been a key commitment towards improving civil society engagement in Global Fund processes. The Initiative has fielded more than 100 requests for technical assistance, established six regional communication and coordination platforms, and supported eight networks of key populations through a partnership with the Robert Carr civil society Networks Fund (RCNF). While the CRG Special Initiative review is still ongoing, stakeholders have voiced concerns that it has been weak(er) on TB. For example, the RCNF grantees are all networks of HIV organizations, drawing criticism that the Special Initiative is not well balanced towards supporting TB and malaria communities to engage. In April 2015, the Global Fund issued a call for proposals for strengthening community engagement in Global Fund malaria grants, subsequently appointing several civil society organizations to lead this work. Similar investments in TB communities are limited, though they would make TB grants more efficient and effective. In addition, the Stop TB Partnership CCM study referenced above found that civil society TB CCM membership was particularly lacking. In fact, half of all high-burden countries that are eligible for Global Fund grants have no civil society CCM members who represent TB communities. “The value of community engagement in CCMs is about the lived experience of what it’s like to be affected by TB,” Matsha-Carpentier told Aidspan. “It’s about having people who know what barriers exist to access TB services, and getting guidance from them for solutions.” Prioritize key populations The Global Fund’s commitment to key populations is commendable. Preliminary results from an ongoing resource tracking initiative led by the Fund’s CRG Department indicates that approximately 10% of all funds allocated to HIV and joint HIV/TB programs has been directed towards programs for key populations.  The Fund also has a Special Initiative with the Stop TB Partnership to improve access to technical assistance to improve gender and human rights components in TB grants. However, a recent Global Fund analysis found that out of 49 TB concept notes, only 6 had human rights programs with a traceable budget (see GFO article). In addition, GFO has previously reported that the Fund’s new initiative to intensify human rights efforts will be designed around the seven key interventions to reduce stigma and discrimination and increase access to justice identified by UNAIDS, suggesting they will be largely HIV-focused. According to the Fund, more work will be done in the second half of 2016 to clarify how human rights for TB can be elevated as part of the initiative. Further, investing in multi-country programs is a vital way to reach TB key populations with services. Miners, migrants and refugees are all TB key populations who are often highly mobile and frequently face barriers to accessing TB services as a result. Multi-country programs like the TB in the Mining Sector grant in Southern Africa, or the grant managed by the Intergovernmental Authority on Development to address TB in East African refugee camps, are incredibly important. In the next grant cycle, the Global Fund will no longer be issuing open calls for multi-country grants, instead specifying the regions and priority programs they will be funding. To accelerate impact, the Global Fund’s multi-country priorities should scale up cross-border initiatives that address TB vulnerabilities faced by key populations. Conclusion None of these areas is new for the Global Fund. Efforts in all three areas have been commendable, particularly in the last three years of the NFM. But the WHO’s latest statistics clearly indicate that not enough is being done. As we anticipate the Board’s decisions on multi-country grants and Strategic Initiatives in November, and country allocation letters in December, the Global Fund’s focus on TB must be elevated. If not, the SDG to eliminate the disease by 2030 may prove out of reach.