17 Nov 2015

In the past week, I travelled from Mbabane in Swaziland to Geneva in Switzerland. When I was a boy, growing up in Swaziland, we frequently got mail that had been sent, initially, to Switzerland. In the 1970s, no one knew where Swaziland was. Today, the little Southern African kingdom has one of the highest HIV prevalence rates in the world. Part of the answer to this crisis may lie in Geneva since this is where the Global Fund to Fight AIDS, Tuberculosis and Malaria is headquartered. I was there as a guest to attend the Fund’s Board Meeting on 16-17 November. The Global Fund is one of the major partners in the response to the three diseases, and without its support millions of people would be sick or dead.

The Board meeting was held in a plush conference venue at the Starling Hotel. The delegates, as many women as men, from all over the world did not quite fill the space, but there was, at times, a sense of urgency and enthusiasm. The pre-meetings on the 15th comprised a mixture of information exchanges and constituency gatherings. Because I was there with an Aidspan “hat,” most constituency meetings were closed to me. The briefings, though, were models of efficiency. Crisp presentations on, for example, the funding model, followed by short questions from the audience, and thoughtful answers from the panels.     

I formed a number of initial impressions. Perhaps the overarching one is that the Global Fund is a technical response to the diseases, including, in Southern Africa, the AIDS catastrophe. We heard about how things should work in an ideal world.

My perspective, having just been in Swaziland and South Africa, was different. There is no ideal world. Thanks to “El Nino,” Southern Africa is facing the worst drought in decades. Driving through the Highveld, it was deeply concerning to see how little grass there was for this time of year. There were dust devils dancing across the ploughed fields, carrying away the precious top soil. Hunger and poverty are set to deepen. In addition, in the short time I was in the region the Rand lost about seven percent of its value against the major global currencies. Economic growth may well stagnate and this too will drive poverty.

What does this have to do with the Global Fund and the Board meeting? The Fund is one of the major funders of HIV, malaria and TB in the region. It may also define some of the conversations and the agenda for those parts of the world, and people that care about health. The meeting was structured on a very – and perhaps too – tight agenda; board members sat in the center of the room with their teams and observers in rows of chairs around the outside of the room. A third tier of attendees were in an overflow room where the proceedings were shown on a big screen.

One of the key issues is around money: how much there is. There was general acknowledgement that the amount of money going to development assistance is stagnant or falling. The Sustainable Development Goals which kick into action in 2016 have only one health goal, which means that the diseases the Global Fund focuses on are falling off the agenda, at least in comparison to the Millennium Development Goal era. Furthermore, the meeting took place against the backdrop of the terrorist attacks in Paris and the migrant and refugee crisis in the Mediterranean. It was noted that money previously targeted to development may be reprogrammed because of this.

For the Global Fund, the crucial question is how much money will be raised during the replenishment scheduled for 2016. If it is not successful, then the Global Fund activities will have to scale down.  This means the messaging is crucial. One of the interesting comments made about the allocation model was that it should be a public health response, not a political one. Of course all this will depend on how much money there is. The bigger picture is around sustainability and transition. This was discussed and one of the concerns was that when transition takes place it is the marginal groups who may be forgotten.

Gender, human rights and social issues were brought up, but less than I would have expected, again a clear indicator that this is a technical response to disease. Also interesting was the recognition of the importance of health system strengthening especially in certain more challenging countries. The issues of corruption and fraud were raised, but the problem was that that there was no willingness to name and shame individual countries in the meeting.

The board meeting is something of a circus. For most items on the agenda, what I heard were speeches, not discussion. Is this the best way to govern the response to these killer diseases? This I cannot answer as this is the first meeting I have attended. How was it for me? My experience tells me that process may be product! In my view, though, the meeting was far too restrained. Swaziland ignites passion, Switzerland does not!

Professor Alan Whiteside is an Aidspan Board member.

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