Recognizing that the Eastern European/Central Asian region is alone globally with a steady increase in HIV prevalence and growth of MDR-TB, the Global Fund has, in consultation with an array of local, regional and international partners, developed new guidance to promote domestic financing and strategic priority setting.
The impetus for the guidance, beyond the expanding burden of disease, is the practical reality that EECA countries are among the most likely to 'graduate' into income classes that would make them ineligible for Global Fund support, particularly as the new funding model (NFM) reorients resources towards those countries with the lowest incomes and the highest burdens of disease.
Two principles define the investment guidance: alignment with other partners' policies, plans and strategies to achieve disease-specific targets set at the country level; and differentiation and ownership to reflect the need to tailor priorities to specific national contexts.
What this means, essentially, according to Dr Steve Fabricant, an independent consultant in health economics and policy, is that the Global Fund is trying to define, for its own work, how to support different countries at different stages of economic development -- with a finite amount of resources.
Equally, however, Fabricant told Aidspan in an e-mail while providing latitude for countries to set their own priorities, the guidance also reinforces the Fund's emphasis on harm reduction and ARV treatment programs for key populations, as well as prioritizing adequate support for TB. Future guidance would do well to include what Fabricant called "a clearer indication of the relative priority given to future requests for support for health system strengthening”.
For representatives of the region's civil society groups, the guidance comes at a critical time, as it will help to help leverage the new requirements for transparency and inclusion in country dialogue to help develop concept notes.
Andrey Klepikov, the executive director of the International HIV/AIDS Alliance in Ukraine said the investment guidance sets ambitious regional targets based on the funding available in each country. But he notes that for countries like Ukraine, which was classified as significantly over-allocated under the initial rounds-based approach, the size of the envelope announced in March for HIV funding represented a significant decline from previous levels.
The risk is that projections of future funding contained in the investment guidance could create the wrong impression that there will not be further cuts in assistance to countries in the region; for example, he notes that the HIV envelope for Ukraine under the NFM will mean 50% less Global Fund support for the country from 2015.
"The investment guidance should be a tool that, when applied correctly, may avoid further cuts in funds available to respond to the particular needs of key population groups: men who have sex with men and people who inject drugs," he said.
Klepikov also expressed disappointment that the guidance seemed to deprioritize the needs specific to reaching men who have sex with men. "I’m actually surprised to see so little attention to MSM in the strategy. Clearly, from the Ukrainian perspective I have to state that similarly to other countries of the region, the HIV epidemic situation with MSM is worrisome," he said. "It is projected that, should there be no increase in the level of response, MSM will begin to drive the HIV epidemic in Ukraine by 2020. So without prioritizing prevention and treatment services, we risk a crisis scenario."
Nor did the guidance address the silent challenge of Hepatitis C that is confronting the region, primarily due to how rife it is within a major target group for Global Fund-supported programming for HIV and TB: people who inject drugs.
"The investment strategy should not only mention the issue, but actually propose a way to directly and indirectly address this issue, and be among the key stakeholders prioritizing cost-effective funding solutions in addressing Hepatitis C issues," Klepikov said.
For Ivan Varentsov, a Moscow-based independent HIV expert, it is not only the priorities that give pause.
"My concern is about the targets determined in this guidance with respect to domestic co-financing and especially about the timeframe given to achieve these targets," he said.
The document projects that by the end of the current allocation period -- 2017 -- the region's lower/lower-middle income countries are expected to start covering at minimum 60% of funding for ARV treatment, diagnostic services and adherence support; the same holds true for TB. For middle income countries, that number rises to 75% and for upper middle income countries, 100% -- targets that, for all intents and purposes, mean that by 2017, no upper middle-income country will be eligible for Global Fund support for HIV or TB treatment.
When ten of the 18 countries in EECA that are receiving Global Fund grants are fully or partially dependent on those resources to purchase ARV drugs, the implications for the future prompt concern.
"Taking all this into account I strongly doubt that given targets are realistic and achievable within the prescribed timeframe," Varentsov said. “It is also not clear how the Fund expects certain EECA countries to find this money within their national budgets in three years; the investment guidance doesn’t cover this issue".
According to Varentsov, the investment guidance should be updated with evaluations by the Global Fund of countries' ability and willingness of countries to pay, in order to harmonize the targets with the practical realities on the ground, and "extend the targets for at least one more allocation period".