As the Global Fund announced in a press release published on their website, funding allocations for the next cycle will be the highest ever made to recipient countries. The total amount available for country allocations in the 2020-2022 cycle is $12.71 billion, including $890 million for catalytic investments for the period, beginning in January 2020. This represents a 23% increase compared to the previous three-year period.
Figure 1: Geographic distribution of Global Fund allocations
The allocation for West and Central Africa represents a substantial increase as the region will receive $780 million more during the 2020-2022 cycle compared to the previous one. The table below shows that 10 out of 23 countries in the region have seen their allocation increase by more than 60%, with some significant increases exceeding 100%: The Central African Republic (126.3%), Congo Brazzaville (102%), and Gabon (128.4%).
Figure 2: Francophone countries’ allocations comparison between 2017-2019 and 2020-2022 funding cycles
Only 3 countries within the Global Fund francophone countries have seen a decrease in their grants: Mauritius, Rwanda and Tunisia.
When allocations are broken down by disease, it is clear that increases have been primarily allocated to the malaria response, particularly in high-incidence countries such as those in the Greater Sahel (Chad, Mali, Burkina Faso, Mauritania, Niger and Senegal). Allocation letters for countries with large increases in grant size contain specific recommendations from the Global Fund in terms of activities to be funded: expanded coverage of seasonal chemoprevention for Sahel countries, as well as programs that take a regional approach and strengthen coordination between ministries and programs in the countries concerned. In addition, the Global Fund highlights the need to strengthen health systems throughout.
In order to achieve this, the allocation letters outline the Global Fund's preference for “integrated and focused actions (including activities that treat co-infection and provide a full and consistent range of services, such as prenatal care).” Finally, the Global Fund recognizes that “investments supporting the capacity of systems necessary to obtain impact and guarantee sustainability (in terms of laboratory, supply chain, health information systems, community-based monitoring, community mobilization, advocacy and human resources for health at community level”) are a priority which must be reflected in proposals submitted by recipient countries.
Necessary (but not necessarily sufficient) conditions for concept notes to achieve success
The 2020-2022 cycle is the third round of the new funding model, which is based on: a transparent and inclusive dialogue open to all actors involved in the response to epidemics (and beyond, where possible), taking into account barriers to access to health care (in particular discrimination linked to gender and human rights), with gradual commitment of recipient countries to fund national budgets.
The pace and requirements of this exercise make the process very difficult to carry out. The TRP noted various recurring shortcomings in its report on the 2017-2019 period: analysis of the epidemiological situation is often too weak, a lack of methodology for identifying priorities and justifying them in the concept note, too little focus on integrated interventions, even though many joint HIV-TB concept notes were submitted in the last cycle. For these reasons, the 2017-2019 TRP made recommendations for the current period:
- Improve priority setting by increasing focus on prevention and reducing incidence;
- Strengthen cross-cutting programming for resilient and sustainable systems for health (RSSH);
- Strengthen community systems; and
- Place more emphasis on program sustainability, mobilization of national resources and preparing for the transition from Global Fund support
This is of course extremely wise advice and has been informed by weaknesses in previous requests. However, a certain number of changes are required to achieve this, some at intellectual-paradigm level, others in terms of form and method, which are useful to outline here, as these changes are not always visible in the current process of developing requests.
Improving priority setting
TRP members concluded (in a report after the 2017-2019 term) that they did not always have a strong sense of the scientific and evidence-based logic behind the selection of particular activities over others, and did not observe the link between the priorities set out in the country's national strategic plan (NSP) and those of the funding request.
This raises questions about the content and format of certain NSPs, which should allow for a hierarchy of priorities, as well as providing budget estimates to allow the plan to be financed in its entirety by health donors. The structure of funding cycles requires that NSPs are updated or newly developed before funding requests are written, and that some of the same stakeholders are involved to ensure the logic and continuity of discussions. Subsequently, it is useful for members of the committee drafting the request to have a methodology for discussing and deciding priorities. It is important to agree on the criteria underlying what is selected and what is left out.
The investment case and the allocation letters are clear on this: it is about optimizing resources and maximizing impact with the investments made. In other words, countries must set out to minimize the effects of epidemics in order to eliminate them within a limited budget. The implication of this statement is twofold: costs must be minimized (integrating actions to meet several health objectives at the same time, reducing operating and coordination costs (particularly in countries where grants are managed by international organizations, which the Office of the Inspector General’s May 2019 Advisory Review on West and Central Africa showed had lower long-term impact than national/state implementers), and increase the output of activities implemented through a more targeted approach (better suited to the target group and the regions covered).
Focusing on prevention and reducing incidence
TRP members recommend focusing more on prevention and incidence reduction. They believe that this is the most effective approach to move towards ending the epidemics by 2030. We know that the number of people newly infected with HIV is double the number on treatment; we also know the frightening number of people with latent tuberculosis (one third of the world’s population). Finally, the number of malaria-related deaths has increased over the past three years, demonstrating that prevention strategies, in particular chemoprophylaxis campaigns, have not been carried out effectively.
This emphasis on prevention and on reducing incidence, however, presents methodological limitations, which one must be aware of in order to overcome them quickly. In fact, it is traditionally difficult to attribute a drop in incidence to a particular prevention activity, particularly in terms of HIV, which is linked to behavioral factors, perception of one's vulnerability to the virus, as well as various other recognized factors. Given the impact indicators selected by the Global Fund, and the need to provide quantified results to show the direct impact of investment, it is to be expected that measuring the effect of prevention strategies will be difficult.
Strengthening cross-cutting programming for resilient and sustainable systems for health and strengthening community systems
The Global Fund is asking countries to move from supporting the system (notably through payment of salaries) to strengthening it in a sustainable manner. Cross-cutting programming for the three diseases, and beyond, therefore requires a preliminary knowledge of the weaknesses of the system, a detailed study of the potential cross-cutting sectors, as well as multisectoral and multi-donor dialogue. These are areas that are still rarely covered. The Global Fund RSSH roadmap presented to the Board of Directors in May 2019 sets out priorities that appear to be relevant to the institution but are not necessarily reflected at country level. However, this step is crucial for coherent and sustainable programming.
The most obvious example of cross-cutting programming today is the development of integrated strategic plans and cross-cutting community strategies. Several countries have produced, or are in the process of developing, integrated NSPs, such as Benin and Mali. 13 community strategies have also been developed since NFM1, reflecting the integration of types of activities and epidemics: community health workers are involved in all activities (prevention, awareness, screening and sometimes dispensing treatment) and in all health disciplines (HIV, TB, malaria, vaccinations, maternal and newborn health, etc.).
Integration can also take the form of cross-cutting planning for the supply of health products, laboratory capacity, or human resources training. This requires "systemic" planning and thinking, which is still far removed from the current siloed approach to management. Finally, there is a need to ensure that this work is funded (through cross-donor dialogue, given that these areas are funded by the Global Fund, GAVI, Unicef, UNFPA, the Bill & Melinda Gates Foundation), which appears to be more complex than initially envisaged.
Increasing the focus on sustainability of programs and mobilizing national resources
The majority of donors now operate co-financing policies by asking beneficiary countries to participate in funding programs. There are various approaches taken (some donors ask the country to honor its commitment before releasing the funds, others are prescriptive about what should be co-financed), and the pressure that these commitments place on countries is rarely calculated. However, without carrying out an exhaustive inventory of the current share of health financing by the state budget, the level of debt, commitments with various partners, as well as an assessment of what has been financed in NFM1 and 2 and to what extent commitments have been respected, we do not have a clear picture of the situation. We know that the commitments given by African states do not meet the need (and are far behind the Abuja commitments) but we do not know what this commitment to co-financing represents and the pressure it places on national budgets. This is why before any discussions around the commitment of beneficiary countries to cover co-financing, it is necessary to assess in depth the landscape of health financing in each country, to identify the sectors or activities that will be most effective in terms health indicators.
The challenges around improving the effectiveness and efficiency of health systems are huge, and this weighs heavily on the impact achieved in the response to epidemics. The two go hand in hand, to the extent that we must now consider health system efficiency to get closer to meeting Sustainable Development Goal 3. Will it be possible, as the TRP recommends, to meet this challenge through the next allocation cycle?
This is Executive Director Peter Sands' wish, as he wrote in his report to the Global Fund Board in November 2019: “As we start thinking about refreshing our strategy, we must recognise that the context has changed. In the SDG era there is far more focus on the interdependence between different goals, and on the need to build the systems that underpin sustainability. We have already transitioned from the Global Fund’s original mandate of simply saving lives to one of saving lives and ending epidemics. Now we must be prepared to frame our goals of ending the epidemics of HIV, TB and malaria within the broader agenda of delivering health and well-being for all. There are opportunities and risks in this evolving context. The opportunities lie in the recognition that ultimately we won’t defeat the epidemics unless we help countries build strong systems, particularly for primary health care, and in the way we can collaborate more effectively in supporting countries and communities. Equally important are our efforts to deepen our partnerships with key bilateral partners to ensure we maximise our collective impact.”