COVID-19 DISRUPTIONS SHOULD RESULT IN SETTING NEW REALISTIC TARGETS FOR HIV, TUBERCULOSIS, AND MALARIA
Samuel Muniu and Alan WhitesideArticle Type:
Article Number: 2
Moreover, the Global Fund should continue flexible working arrangements
ABSTRACT The advent of COVID-19 has presented challenges for the Global Fund and the fight against HIV, tuberculosis, and malaria. It has exacerbated global efforts to combat the three diseases due to widespread service interruptions. There is a need to set new realistic targets to end the three diseases as epidemics. The Global Fund and other organizations have to learn from the COVID-19 disruptions and continue the flexible working arrangements that lower operational costs by leveraging technology and allowing staff to work both in offices and remotely.
The United Nations (UN) Member States seek to end the epidemics of AIDS, tuberculosis (TB), and malaria by 2030, as captured in Sustainable Development Goal (SDG) 3. This is part of the global targets contained in the 2030 Agenda for Sustainable Development that the 193 UN Member States adopted in a meeting held at the UN headquarters in New York from 25-27 September 2015. The targets were set before the coronavirus pandemic (COVID-19) struck the world in 2019, causing significant loss of lives and livelihoods. As its target, the Global Fund had set a 38% reduction in new HIV, TB, and malaria infections from 2015 to 2022. According to the Strategic Performance Report of 2019, the Global Fund is off track. It reported only a 7% reduction of new infections between 2015 and 2018, and projections indicate just a 16% reduction between 2015 and 2022. To put the rate of decline back on track thus requires an acceleration plan involving increased resource allocations to improve service provision for the three diseases. Hence, the Global Fund was already facing an uphill battle to reduce HIV, TB, and malaria infections, and then COVID-19 struck, thereby exacerbating the situation.
COVID-19 causes widespread service disruption
The pandemic is affecting the performance of not only HIV, TB, and malaria but also of programs addressing other health conditions. A World Health Organization (WHO) survey in 155 countries showed widespread health service disruption due to COVID-19, particularly in low-income countries. The survey, conducted over a three-week period in May 2020, revealed that COVID-19 disrupted non-communicable disease prevention and treatment services. Among the surveyed countries, 53% experienced disruptions in high blood pressure treatment, 49% in diabetes treatment, 42% in cancer treatment, and 31% experienced increased cardiovascular emergencies. This was caused by the cancellation of planned treatment, restricted movements, reassignment of healthcare workers to respond to COVID-19, and rescheduling screening services.
A similar situation regarding service disruption is observed for infectious diseases such as HIV, TB, and malaria. According to a 2021 report on the extent of health service disruption due to COVID-19 in 502 health facilities in 24 African and eight Asian countries, the pandemic has disrupted the provision of HIV, TB, and malaria health services in low- and middle-income countries in the two continents. A comparative analysis of health service provision in these countries from April to September 2019 to that of a similar period in 2020 revealed a reduction in health service provision. For instance, the pandemic has contributed to: reducing HIV testing by 41%, lowering TB referrals by 59%, malaria diagnosis dropping by 31%, and antenatal care visits falling by 43%. Several factors contributed to this, including the reallocation of medical staff and bed spaces to deal with coronavirus emergencies which resulted in the deferral of some treatments and a reduction in the range of services that could be offered. Other contributory factors were people’s fear of contracting COVID-19 in health facilities, and disruptions to public transport which compromised access to health services. This reduction in service provision will eventually increase the rate of new infections in HIV, TB, and malaria.
The ambitious target of ending AIDS, TB, and malaria as epidemics by 2030 would be hard to achieve under normal service provision but now appears to be a fantasy. There has been a reversal of the gains made against the three diseases, and extraordinary measures are required to put the global targets back on track. As an organization, the Global Fund will need to set new realistic targets that factor in COVID-19 interruptions. The new targets should be reflected in its forthcoming strategy that is currently being developed. Also, there is a need for concerted efforts to mitigate the impact of COVID-19 on the three diseases, including increased access to COVID-19 tools and more resources to strengthening health systems.
A need to use and strengthen in-country systems
Almost all governments have instituted measures to contain the spread of coronavirus, including travel bans and restrictions on freedom of movement. For international organizations, such as the Global Fund, the restrictions on movement and closure of international borders have greatly affected operations that require an in-country visit. For example, the Global Fund’s Office of the Inspector General (OIG) had to suspend its approved 2020 Workplan due to COVID-19 related disruptions. Specifically, the OIG was forced to cancel or defer three audits scheduled for 2020 that required fieldwork and instead opted to implement audits that did not require travel. This was due to restricted international travel and, most importantly, protecting OIG staff from contracting COVID-19 while conducting fieldwork. Figure 1 shows countries’ restrictions in place regarding international travel arrivals since the pandemic started until mid-May to date.
Figure 1: International travel controls during the COVID-19 pandemic, 18 May 2021
Source: Obtained from Our World in Data
Consequently, the OIG published fewer audits and investigations in 2020 (13 audit reports) than the 24 audit, investigations, and review reports published in 2019. This is despite an increased risk of fraud and misuse of resources arising from the haste to procure and distribute COVID-19 related health commodities on an emergency basis at the country level. For example, there have been reports of some countries engaging in corrupt practices, such as price inflations and embezzlement of funds, during the procurement of medical supplies for the COVID-19 response (see GFO issue 385 from August 2020 on how the misuse of COVID-19 funds undermines the fight against the COVID-19 pandemic).
As a change of tactics, the OIG is adopting remote country auditing and investigations by leveraging data analytics, enhanced technology, and reliance on in-country structures to implement its 2021 workplan. At the country level, the OIG will work with existing in-country institutions such as Supreme Audit Institutions (SAIs), the constitutionally mandated national institutions to audit public resources, to conduct the 2021 audit of grants. Adopting remote auditing means that the OIG will depend on SAIs to conduct fieldwork while the OIG staff follow up using electronic methods such as video conferencing. Remote audits have the advantage of allowing auditors to collect and share data from all over the world without international travel, thereby saving time that can be utilized to write high-quality audit reports. The use of in-country SAIs is beneficial as they have the legal mandate and local knowledge, and better understand their country context. Importantly, they can follow up on audit findings and recommendations.
The OIG should use a similar approach to investigations. In-country investigative institutions such as anti-corruption agencies should be prominently involved in future investigations into suspected malpractice in implementing Global Fund grants. For these in-country institutions to function well, the Global Fund and partners need to strengthen these organizations’ capacity, thereby making them more reliable and of a consistently high standard. The future of audits and investigations will rely on strong in-country structures that are publically accountable.
The future is in remote working and having meetings through web conferencing
Most governments issued mandatory working from home directives as a way of keeping people safe. This was the case in Switzerland, where the Global Fund has its headquarters. From 16 March 2020 to 6 June 2020, the Swiss government issued a directive indicating that people should work from home. Following a spike in coronavirus cases, the Geneva Canton issued another mandatory working from home directive on 2 November 2020 and has been in effect since then. Thus, since the Global Fund did not return to its offices between June and November last year, Global Fund staff have been working remotely, including holding virtual meetings, since 16 March 2020.
Also, since COVID-19 was declared a pandemic, the Global Fund Board has shifted from physical to virtual meetings. The two Board meetings held in May (43rd Board meeting) and November (44th Board meeting) 2020 were both held via video conferencing. This year’s Board meeting (45th Board meeting) in May 2021 was also held online. These virtual meetings were shorter, as they occurred over two afternoon sessions, compared to the physical meetings that had morning and afternoon sessions. COVID-19 containment measures have forced many organizations, not just the Global Fund, to work remotely and resort to web conferencing for meetings. The major challenge with virtual meetings is having strong internet connectivity to facilitate smooth communication, and poor connectivity has often been a source of some frustration for some countries and meetings’ participants.
Thus, COVID-19 has revolutionized how people work by giving rise to remote working and virtual meetings. Indeed, remote working has become a way of life, although it does not necessarily eliminate the need for organizations to have physical offices. COVID-19 has provided an opportunity to test remote working, and the future lies in a mixed approach where employees might spend a few days in the office to stay in touch and the rest of their time work from home. Also, organizations no longer need to set aside huge budgets to facilitate the movement of people worldwide to attend a meeting or even to invest in the expensive infrastructure of office space since employees can participate in meetings from the comfort of their own homes.
Remote working is one way of improving productivity for people who work better in total silence. It provides an opportunity to work away from a noisy and distracting office environment, although that may not be applicable to people coming from a family with young children. Besides allowing staff to work from any location globally, remote working enables people to manage their schedules and save time wasted in commuting to workplaces. It is also a better way to strike a balance between work and home life as it provides a person with more time to plan and have control of both work and household chores. Since it seems remote working and having virtual meetings are the future way for employees to engage, there is a need for the Global Fund and its partners to invest more in web-conferencing systems. If anything, this might be cheaper and less time-consuming than the physical meetings.
The disruptions caused by COVID-19 have provided valuable lessons to organizations, including the Global Fund, on the need to adopt flexible work arrangements that can reduce operational costs. There is a need to strengthen in-country systems to eliminate the need for country visits, to the extent possible. Also, there is a need to leverage technology to promote remote working and virtual meetings. If anything, some of these approaches may result in increased efficiencies, cost-effectiveness, and savings. But the main message for the Global Fund is that it must now revise its target rates and dates for eliminating HIV, TB, and malaria, as well as be prepared to continue to exercise flexibilities in grant implementation.