In his second annual report to the Global Fund Board since taking office in early 2019, Peter Sands began his address to the meeting by hailing the recent success of the Sixth Replenishment Conference in Lyon, where the Fund raised $14 billion.
Sands said it is now up to all to turn the Replenishment campaign hashtag #StepUpTheFight into reality. Invoking the Global Fund’s responsibility to donors and taxpayers to use the money to maximum effect, and to those affected by and vulnerable to the diseases, he said this was “both an extraordinarily exciting opportunity and a daunting responsibility”. At the same time the Executive Director acknowledged that $14 billion is not enough “to sweep away all our challenges.”
Mentioning his own “immensely steep learning curve,” Sands set the tone for his remarks by referring to the inspiration he has received from the courage and determination of those directly affected by the diseases to fight for their rights. He quoted Connie Mudenda from Zambia, an HIV activist who made a moving appearing (along with her child) at the Replenishment Conference in Lyon, who said what was needed was “to take luck out of the equation and instead put justice in its place”.
Progress against 2019 priorities
The five priorities the Executive Director (ED) set out in his first annual report, one year ago, were: (i) supporting a successful Sixth Replenishment, (ii) driving impact from the current grant cycle, (iii) preparing for the next cycle of grants, (iv) enhancing efficiency and effectiveness, and (v) investing in people.
Citing the record amount achieved at the Replenishment, Sands said this success was driven by the Global Fund’s having a track record of delivering results, a “robust” investment case with ambitious goals, intense mobilization of the whole global Fund Partnership, “superb support from France and President Macron (who hosted the Sixth Replenishment), and a well designed and well executed Replenishment campaign.
He also mentioned other ‘record’ facts, including 21 new or returning donors, private sector pledges above the target of $1 billion (at $1.04 billion) with 16 donors of which 8 are new or returning, plus 11 new private sector partners pledging in-kind contributions and co-investment opportunities.
Within the section on ‘driving impact’ (ii), Sands said continued impact would require “a huge effort” from all partners, and drew out some main themes that focus on current challenges the Fund faces, including reducing new infections, the quality of treatment, new treatment regimens, faster coverage of new infections, and dismantling legal barriers that exist in some countries and effectively bar patients from accessing treatment and care.
He remarked that across all three diseases the Fund continues to make better progress on reducing mortality than on reducing incidence, necessitating a scale-up in effective prevention; that the Fund is making slower progress on the underlying policy and socio-economic determinants of the epidemics than on factors that respond to bio-medical interventions; that progress is uneven on delivering more people-centred care and in reinforcing underlying systems for health; and that varying levels of political leadership in countries means varying degrees of commitment to domestic resource mobilisation and policy changes needed for enduring systemic impact.
In ‘preparing for the next cycle of grants’ (iii), to prepare a stronger platform for the next cycle of grants, the Secretariat is working with the Technical Review Panel, finding a workable approach for the RSSH roadmap, prioritizing sustainability, transition, and co-financing; turning recommendations from the Office of the Inspector General’s advisory report on grant implementation in West and Central Africa “into concrete actions” (see separate article in this issue), focusing on CCM Evolution (see separate article in this issue), and on making timely decisions on the funding allocation methodology and catalytic funding.
Sands also discussed the Fund’s approach to investing in people (a leadership development program, gender equity in salaries, and new measures and processes in place to handle bullying and sexual harassment) and enhancing the efficiency of grants (investment in technology, an accountability framework that for the first time puts in place 52 processes with associated metrics).
Priorities for 2020 and beyond
In setting out the six priorities for the Secretariat for 2020, the ED began with the need to invest the $14 billion recently pledged for “maximum impact” in the new grant cycle, and to show “sharp acceleration in progress towards SDG3” [the health-related Sustainable Development Goal]. (This means “not only doing more of the same,” he said, “ but grasping the opportunity to do things differently,” including transforming multidrug-resistant TB treatment, and HIV prevention for young girls and adolescents. “There is no time to waste,” Sands stated, saying that more than 70% of new grants will be signed by the end of 2020.
Encouraging “the entire Global Fund Partnership” – the Secretariat, CCMs, technical and bilateral partners and others – to translate the “unprecedented” financial resources now secured (which would allow for an increase in overall country allocations of 23% to $12.71 billion, and an increase in catalytic funding of 11.3% to $890 million) into programs that will deliver maximum impact, Sands said technical partners especially need to “step up and sustain,” and that more coordination and accountability was needed in technical assistance.
Explaining that 2020 is “the base to give results for the next Replenishment,” Sands said that “expectations will be high, and the results need to be good enough.”
The six priorities for 2020 are: (i) Actively support countries to develop high impact grants for the next 3-year period (as above); (ii) Delivering maximum impact from current grants in their final stage; (iii) Begin planning and consultations for the next Global Fund Strategy; (iv) Reinforce capabilities and impact on key strategic priorities including sustainability and transition; (v) Improve efficiency and effectiveness; and (vi) invest in people.
For reasons of space and time limitation Sands said he could not describe in detail priorities for the next grant cycle, much less how they vary by country setting or disease burden. In his written report, he offered some personal observations on the three disease components and on resilient and sustainable systems for health (RSSH):
For HIV, the ED called for a sharp reduction in new infection rates, particularly among adolescent girls and young women (AGYW), entailing significantly scaling up and strengthening prevention programs for AGYW; scaling up and reinforcing comprehensive programs for key populations (with a focus on prevention); achieving a step-change in the effectiveness and scale of prevention programming for men in high-burden settings; implementing a strategic mix of differentiated HIV testing approaches; further enhancing differentiated ART delivery; integrating TB preventative treatment at scale in countries with high HIV/TB co-infection rates; and accelerating the adoption of optimal ARV regimens.
For TB, Sands called for “a massive reduction” in the gap between the number of people falling ill with TB and those who are diagnosed and treated. This would involve sustaining and accelerating the momentum in finding and treating missing people with TB (leveraging new catalytic funding); scaling up and strengthening the diagnosis and treatment of multi-drug-resistant (MDR) TB; and scaling the provision of preventative treatment.
For malaria, the Fund will want to see additional countries eliminate the disease, and see a reversal in the current trend of increasing cases in the highest-burden regions. To do this, priorities would include: accelerating coverage of effective vector control; expanding access to quality basic healthcare through community-based health workers; enhancing the sophistication of transmission reduction strategies; developing further regional initiatives (such as the successful Regional Artemisinin Initiative in the Greater Mekong); responding rapidly to resurgence, reinforcing community engagement to improve access and use of long-lasting insecticide-treated nets (LLINs); and supporting countries that are close to elimination “to cross the line”.
In the next grant cycle, Sands said, he anticipates a significant step-up in the scale and quality of the Global Fund’s investments in RSSH, consistent with the RSSH Roadmap. He cited ways in which RSSH investments help combat the diseases (e.g. overcoming health systems constraints by strengthening supervision to enhance health-care workers’ performance), and stated that investing in RSSH will help countries accelerate their progress towards the broader goals of SDG3. The Global Fund’s priorities in this area would include: ensuring that Global Fund investments are integrated into robust and well-prioritised plans for strengthening systems for health; helping countries address supply-chain weaknesses and accelerate progress towards creating people-centred supply chains [see separate article in this issue]; enabling countries to enhance their ability to capture, manage and use data for better decision-making (he called for “a transformational change in the way we capture and analyse data”); and supporting countries in improving the performance of health workers to deliver more and better quality care (beyond paying health workers’ salaries, and including helping countries develop career structures, training and certification schemes).
Sands emphasized two “crucial” considerations in supporting countries to build RSSH: working in coordination with other development partners and within the parameters of nationally-led strategies; and remaining focused on how such investments translate into lives saved and infections/cases averted.
Also within the priorities for 2020, Sands discussed Human Rights and Gender Equality, and Sustainability and Transition [see separate article in this issue], which was “not a secret topic,” he said. Sustainability, transition and co-financing “should be deeply embedded in the way grants are designed and priorities are set,” Sands remarked, adding that domestic resource mobilization is “crucial,” and that the Fund would need “to have some tough conversations with the countries,” in part about co-financing but also their engaging civil society, and removing legal and human-rights barriers where they exist, which will be “key” for transition. “We ask governments to finance populations they don’t want to see,” he said.
Sands added that there was “a mismatch between expectations and what the Secretariat has been able to deliver” in the areas of RSSH, human rights, market shaping, and domestic resource mobilization. These are key strategic priorities that “should be seen in the next strategy,” Sands said.
In the category of improving efficiency and effectiveness, the ED emphasized in his written report the need to be realistic about operating expenses, saying that the current $900-million cap no longer reflects the reality of what the Secretariat is being asked to do. Saying that the need to fund ‘surge’ capacity for the new grant-making cycle as well as investing in strategic priorities is creating “acute pressure” on operating expenses, he cited four factors that are driving the new reality: (1) a significant increase in projected grant volume, (2) the changing mix of grants (prevention, reinforcing health systems and reducing gender and human-rights related barriers to health are more expensive to operate than commodity-based grants), (3) an increasing emphasis on the Fund’s catalytic role beyond grant-making, and (4) limited scope to fund more investments through efficiency savings.
Under the topic of investing in people, the ED noted the high level of commitment within the Secretariat, but also acknowledged frustrations among staff, including “over-complex processes”. He mentioned the need to strengthen leadership and to make it more productive.
In his final remarks in his written report to the Board, Sands drew attention to the need to recognise that the context in which the Global Fund operates has changed: “In the SDG era, there is far more focus on the interdependence between different goals, and the need to build systems that underpin sustainability.” He pointed out that the Fund has already transitioned from its original mandate of “simply saving lives” to “saving lives and ending the epidemics”. Now, he said, the Fund “must be prepared to frame our goals of ending the epidemics of HIV, TB and malaria within the broader [SDG3] agenda of delivering health and well-being for all.”
There are opportunities and risks in this evolving context, Sands said. Opportunities lie in the recognition that ultimately the Global Fund will not defeat the epidemics unless it helps countries build strong systems, especially for primary health care. The risks, he said, arise from the potential to lose focus – he emphasized the necessity that “we must not lose our clarity of purpose,” all the while remaining “acutely aware of the broader SDG3 agenda”. He also pointedly remarked upon the need to support the development of the overall system for health and the progression towards more people-centered delivery, but that “we must be careful not to diffuse our resources to the detriment of our core mission.”
Finally, Sands warned (as he often has before) against the threat of complacency, saying there was “no middle ground” in the fight against HIV, TB and malaria. “If we are not winning, we are losing,” he said, “and losing against any of the three diseases will drag down every aspect of the SDG agenda.”
Board Document GF-B42/05 (Report of the Executive Director) is expected to be available shortly at https://www.theglobalfund.org/en/board/meetings/42/.
Editor’s note: This article is dated 15 November, which is when this article was uploaded into our automated system. The article was not published until after the conclusion of the 42nd Board meeting, on that day. This respects our agreement with the Global Fund concerning when we publish articles that are based on the content of the Board papers.