The introduction of the new funding model (NFM) has raised some concerns in the Middle East that it fails to consider the sweeping population movements and refugee crisis around the region and their impact on public health, particularly with respect to higher incidence of TB.
This was the key message at a regional meeting held on 2-5 March in Jordan, attracting representatives from all 15 countries classified as part of the Middle East and North Africa (MENA) by the Global Fund.
“They consider the income level and the disease burden – countries like Jordan, Lebanon and Iraq will not be eligible”, El Tayeb Elamin, UNAIDS regional adviser for MENA in Cairo, told Aidspan. “This does not take into account the rapidly changing region and population mobility including refugee influx to those countries.” Iraq will however be eligible for transitional funding of $10.7 million for TB.
According to the Health Ministry of Jordan, a total of 109 TB cases have been detected among Syrian refugees since 2011, among them at least four cases of multi-drug resistant TB (MDR-TB).
Millions of people have been displaced or forced to migrate in the aftermath of the Arab uprising that began in Tunisia in 2008 and swept across the entire region, culminating with the continued conflict in Syria that has lasted for three years and sent over two million people fleeing their homes.
The regional displacement has overburdened health systems struggling to cope with the complications of mass population movements, which include the outbreak of communicable diseases like TB, polio, measles and meningitis.
Jordan was in 2010 on track to achieve complete elimination of TB, in line with the Millennium Development Goal of reducing the global TB burden. But because of the high burden of TB among Syrian refugees, some of those successes have been mitigated. Prevalence in Jordan is now estimated at around 9.9/100,000: a rate unseen in Jordan since 2000, and considerably higher than the last recorded rate, in 2011, of 7.7/100,000, according to WHO.
A similar trend has been observed in Iraq where the estimated TB prevalence was at an all-time low in 2000 at 62/100,000 but rose to 74/100,000 in 2011 following years of armed conflict.
Jordan’s Health MinisterAli Hyasat used the meeting to implore that the Global Fund reassess its eligibility criteria, noting that despite the glut of Syrian refugees currently in Jordan, estimated at 600,000 by the Jordanian government, the country is no longer able to receive grant support.
Countries hosting refugees should be able to use Global Fund support to minister to the needs of these vulnerable populations, he said, because of the public health implications both for the displaced populations and their hosts if disease is allowed to spread unchecked.
The meeting co-hosted with the World Health Organization and UNAIDS aimed to help eligible countries prepare to develop concept notes under the NFM. Eligibility under the new financing mechanism replacing the decade-old rounds-based approach was streamlined in November 2013 to invest a greater share of the Global Fund’s resources in countries with the highest burdens of disease and least ability to pay – which has, in turn, eliminated the Global Fund as a potential source of financial support for many countries in the region, among them Jordan and Lebanon.
There has been some reprieve for some upper-middle income countries (UMICs) that are able to demonstrate a severe or extreme disease burden to be eligible for the general pool, and a high burden to be eligible for the targeted pool.
The presence of the Syrian refugees has put “enormous pressure” on Jordan, King Abdullah said in November 2013; he noted that the established figure of 600,000 refugees only considers those who have been classified as such by UNHCR and does not take into consideration an equal number of people hosted in communities by extended family. The approximately 150,000 Syrians residing in the Zaatari refugee camp, receive health support from UN and other international organizations. Zaatari, now the fourth largest city in Jordan, has been considered a concern for the spread of TB , with 40 cases reported since 2011.
Jordan is also the semi-permanent home to 30,000 refugees who fled Iraq following the fall of Saddam Hussein in 2003 . Another two million Palestinian refugees, most of whom have become citizens, also call Jordan home.
The Syrian refugee crisis has also put immense pressure on Lebanon, which has absorbed more than 900,000 people since 2011. Another 250,000 Syrians have fled to Iraq, which remains shorn of much of its public health infrastructure in the aftermath of the conflict there and continues to battle political and ethnic instability.
For Alaa Mokthar, head of Egypt’s National TB Control Program , although the number of refugees in Egypt was increasing, there has yet to be a noticeable impact on the number of reported cases of TB – a challenge to the fears expressed by a number of health experts that rising poverty and sprawling slums would threaten the country’s gains towards a national goal of TB elimination by 2019.
“Fortunately, the disease burden amongst the Syrian refugees is almost the same as among the Egytian population”, says Mokthar. “Therefore, it does not present an epidemiological problem, but rather a number problem. We have to treat more people with the same funds.”
The UN Office for Coordination of Humanitarian Affairs estimates that Egypt plays host to some 135,000 Syrian refugees, as well as tens of thousands more from Libya and Sudan. Others place those figures much higher. Egypt will, however, continue to receive Global Fund support, at least through 2016; its NFM allocation, released on 12 March, will be $7.0 million for HIV and $11.1 million for TB.
Joseph Serutoke, the Global Fund’s regional portfolio manager for MENA told Aidspan that the Fund was aware of the refugee crisis in the region and was looking at ways to respond within the existing funding structure.
“What we are looking at is a way of dealing with it within the existing grants. We are also calling for people to apply for regional grants to deal with the crisis that is not dealt with by individual country grants.” At the 31st meeting of the Global Fund Board in Jakarta on 6-7 March, some $200 million was set aside for regional programs; another $30 million was placed in a humanitarian emergency fund under a separate envelope for special initiatives.
Some participants at the Jordan conference, however, were dubious that such grants would work in the diverse and sprawling region with a low level of participation from civil society.
“It is not clear through what institutions those regional grants could be administered”, said El Tayeb Elamin of UNAIDS.