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GFO Issue 256



David Garmaise

Article Type:

Article Number: 3

Emerging powers will play an ever-larger role in the global health arena

ABSTRACT The Global Fund will need to adapt to fundamental changes in the development and global health landscape, says Executive Director Mark Dybul. In his report to the Board, Dybul described several initiatives designed to help the Fund adapt. He also discussed initiatives to improve the impact of grants; to make better use of data to measure impact and plan programs; and to enable the Fund to respond to emergency health situations. Finally, Dybul provided an update on the creation of an integrated platform for the Fund’s financial information.

There will be fundamental changes in the environment in which development and global health have operated for more than 50 years, the Global Fund’s executive director, Mark Dybul, told the Board to open its 32nd meeting on 20 November.

This is a world where emerging powers play a bigger role in the global health arena and where traditional, large-scale external investments remain important in some countries – but where there is a strong shift to increased domestic resources.

In his report, Dybul said that the Fund must determine what role it should play in the “development continuum” and assess what kind of Fund it wants to be in 15 years. How the Global Fund evolves and adapts to the changing landscape will influence how it is able to ensure impact in the fight against AIDS, TB and malaria.

In his report, Dybul also discussed initiatives to improve the impact of grants; to use data to measure impact and plan programs; and to enable the Fund to respond to emergency health situations. Finally, Dybul reported on the current status of the Secretariat’s finance step-up project involving the creation of an integrated platform for the Fund’s financial information. We report on these items below.

Regarding the development continuum, Dr Dybul said that some trends can already be discerned. For example:

  • A number of countries are transitioning from low-income to middle-income status. Already, middle-income countries (MICs) account for 70% of the world’s poor, 66% of HIV cases, 76% of TB cases and 54% of malaria cases.
  • MICs are better positioned to invest domestic resources for health. However, the resources invested are often insufficient and some populations are being left behind.
  • While some MICs and regions are making remarkable progress against the diseases, others are falling back.

To prepare the groundwork for its next strategy, the Global Fund has convened a Development Continuum Working Group, chaired by Anders Nordström, the Swedish ambassador for global health. The working group will examine questions such as:

  • How should the Global Fund support populations left behind, and engage countries where political will or financial support may be lacking?
  • How can countries be best supported as they transition from Global Fund support?
  • How can the Fund best operate in challenging operating environments?

The working group is expected to submit a report and recommendations to the Board in March 2015.

Currently, movement along the development continuum is largely defined by gross national income. But this system has its limitations, Dybul said, particularly in relation to health programs. As a result, the Global Fund will join GAVI, the World Bank, WHO, UNAIDS, UNDP, UNICEF and UNITAID in developing a new framework called the Equitable Access Initiative to integrate progress along the continuum specifically related to health.

The panel is expected to meet in early 2015 to develop a workplan, and again in early 2016 to make final recommendations on a framework.

Dybul said that this framework will guide not only how technical partners and funders work with countries but also how they can anticipate their needs and accommodate them. This will require a look forward, to determine what it takes to progress, but also a look back at what systems have already been put in place to assist countries. Dybul said that the Global Fund is pursuing “several strands of work” to develop and strengthen these systems, including:

  • the Rwanda results-based financing pilot, with its emphasis on national systems, which the Fund hopes can be tried in other countries;
  • the Fund’s new innovation hub which will focus on improving procurement and supply chain management, financial and risk management and program quality
  • the piloting of some “cash on delivery” models.

With support from the Gates Foundation, the Fund and its partners are tracking cash-on-delivery strategies in different sectors, the results of which will feed into the pilots.

Key to supporting countries as they graduate from Global Fund support is access to the lowest possible prices for commodities, Dybul said. Again with support from the Gates Foundation, the Fund is exploring the possibility of creating an electronic market exchange that will become a clearinghouse for information on the prices and sales of health products.

Improving impact

As part of a special initiative on improving value for money, the Global Fund and its partners have been working in several countries on a process to strategically prioritize interventions to maximize the impact of grants. This process of allocative efficiency will require changes to the mix of interventions in a grant and to the proportion of the budget assigned to each intervention. To date, the countries involved are Armenia, Bangladesh, Belarus, Ethiopia, Jamaica, Kazakhstan, Kyrgyzstan, Moldova, Mozambique, Sudan and Ukraine.

A separate report on lessons learned from the new funding model (NFM), also prepared for the Board meeting, described the outcomes of an allocative efficiency exercise conducted in Sudan. Prevention services among men who have sex with men went from 0% of spending in 2013 to 21% of the budget in the HIV concept note submitted in August.

Prevention services among female sex workers went from 8% to 17%. To compensate, budgets for other items, such as management support, were reduced. In Sudan, programs for the prevention of mother-to-child transmission of HIV went from 7% of the 2013 spending to 0% in the concept note budget because it was decided that PMTCT would be funded through the national budget instead.

Dybul said that achieving allocative efficiency will require attention to several challenges, beginning with a new focus on modelling for TB and malaria, and an ever-greater commitment to better data collection, management and analysis.

Putting data to use

The Global Fund is working to ensure comprehensive data from country to global level is available to measure impact, Dybul said, including encouragement of countries to increase investments in monitoring and evaluation systems. Partner organizations are mapping the resources that are available in countries to do M&E, while also assessing needs that can be covered by grant resources and those that can be covered elsewhere. In some countries, where there are gaps in data, the Fund is providing additional money through special initiatives.

Since 2012, the Global Fund and its partners have supported 20 countries to do epidemiological and impact analyses. In Nigeria, for example, an analysis completed in August 2014 examined the total number of people in need of services, current coverage, how services are packaged, and service availability – both nationwide and by state. The analysis also looked at what interventions were working.

In 2013 in Tanzania, through a health systems strengthening grant, the Global Fund reinforced the District Health Information System (DHIS). By March 2014, the DHIS platform had been installed in all the 165 districts in the country. Currently, DHIS is being extended to all hospitals to improve reporting and analysis of mortality data.

Health emergencies

To respond to health emergencies, the Global Fund has adopted a country-by-country approach. This requires a more nuanced understanding of the political, economic and social context in each country, Dybu said, and responding with flexibility.

In war-torn Syria, the Global Fund has worked with partners to develop delivery routes for antiretrovirals, to place more emphasis on vulnerable and internally displaced populations, and to prioritize testing and prevention of mother-to-child transmission of HIV.

In South Sudan, Dybul said, the main focus is on delivering essential medicines. In addition, there have been advances in strengthening health systems, better reporting and verification of programmatic results, and enhanced verification of antiretroviral stocks.

In Somalia, where the health system is barely functional, the Fund is disbursing grants to  principal recipients UNICEF and World Vision to support the rebuilding of infrastructure, training of medical staff and integrating the disease-specific programming into primary health care services, while contributing to health activities that prioritize maternal and child health.

In Pakistan, the only federal country in the world without a central ministry of health, the Global Fund is channeling its investments into provincial health and disease strategies.

Consolidating financial information

In early 2014, the Secretariat completed the migration of all financial information – covering 1,800 purchasing transactions and over 1,000 grants – into a new Enterprise Resource Planning Tool. “All of our financials are now in one single integrated data platform and are updated in real time,” Dybul said.

The Secretariat has also developed an online financial dashboard that includes status of contributions, grant expenses and disbursements, and operating expenditures. This tool, which allows a user to view the data in a variety of ways and to look at different levels of detail, will soon be made available to Board members, which should facilitate and improve oversight by the Board.

The Report of the Executive Director (GF-B32-02) is now available at The report on New Funding Model Lessons Learned (GF-B32-09) is also available at the same site.

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