The cancellation of Round 11 by the Global Fund has had a significant impact on programmes to fight AIDS, TB and malaria including, in particular, programmes being implemented by civil society organisations (CSOs). Programme scale-up and even some essential life-saving interventions that were planned by countries were halted.
These are some of the findings of two surveys that were undertaken recently. One survey was conducted in March 2012 by the Open Society Initiative for Southern Africa (OSISA) and the Open Society Foundations (OSF) in three countries: Swaziland, Malawi and Zimbabwe. A final report on this review was released in late July.
The second survey was conducted by UNAIDS as a rapid internal data collection exercise to explore ways to support countries in managing the repercussions of declines in expected funding. The agency surveyed 91 UNAIDS country coordinators in December 2011, immediately after Round 11 was cancelled. Eighty-two offices responded. No final report on this survey has been published. However, a draft internal report was disseminated to partner organisations. In addition, a summary of the findings was presented at a session held on 25 July at the International AIDS Conference in Washington, DC. (The presentation was not made by UNAIDS. The session was held in the Global Village and was not part of the official programme.)
Editor’s Note: This article provides brief summaries of the findings of these two surveys. Much has occurred since the two surveys were conducted, particularly the UNAIDS one. The Global Fund has instituted significant reforms, the Fund’s revenue situation has improved, and the Fund is expected to launch a new funding opportunity (using a new model) in the coming months. All surveys have their limitations. The OSISA/OSF survey was conducted primarily in only three countries. The UNAIDS survey results reflected only the opinions of UNAIDS country coordinators at the time the survey was conducted – i.e. right after Round 11 was cancelled. Nevertheless, we feel that it is important to bring to the attention of our readers what various organisations have said about the impact of the decision to cancel Round 11.
The OSISA/OSF survey found that because of diminished funding, including the cancellation of the Global Fund’s Round 11, countries like Swaziland, Malawi and Zimbabwe are concentrating on safeguarding supplies of medical commodities. In the process, they are shifting budgets away from human rights programming, community mobilisation, community programme design and delivery, politically sensitive programmes for most-at-risk populations (MARPS), and community systems strengthening (CSS) – with adverse effects on civil society organisations (CSOs).
The report quotes Khanya Mabuzo, deputy director of the National Emergency Response Council on HIV and AIDS (NERCHA), as saying that in Swaziland all HIV prevention programmes, except for the prevention of mother-to-child transmission (PMTCT) and male circumcision, have been halted until 2013.
The report said that Malawi has had to postpone plans to switch existing HIV patients to newer, better tolerated drugs. In Zimbabwe, planned HIV and TB policy dialogues have had to be cancelled; and the national TB programme will be negatively affected because it was established with money from the Global Fund and is wholly financed by the Fund.
The report said that had Round 11 not been cancelled, it would have been “a watershed moment” in southern Africa. Some countries, including Swaziland, were planning to include interventions for sex workers and men-who-have-sex-with-men (MSM) in Global Fund proposals for the first time. In Swaziland, there were plans to include activities addressing the HIV prevention needs of a small community of injecting drug users.
In addition, Round 11 funding would have supported community-based NGOs to provide treatment literacy and adherence support; implement community education, mobilisation and prevention efforts; and address barriers to treatment, care and support. A new funding window would have allowed countries to fill critical gaps in HIV and TB treatment, diagnostics and the provision of other commodities; to scale-up prevention interventions such as PMTCT and male circumcision; and to strengthen health systems.
All of the CSOs interviewed reported that organisations within their networks had been affected by the declines in expected funding, and have had to cut programmes, retrench staff and, in some cases, close down completely.
The report argues that, due to funding constraints, CSOs are unlikely to see much relief in the future. They will have problems finding new donors because of the way the Global Fund’s Transitional Funding Mechanism (TFM) is structured; and because of the impact of the decline in expected funding on Phase 2 renewals of existing grants.
The report said that grant renewals have been negatively affected by the funding situation. In Zimbabwe, for instance, under a recently approved agreement for Phase 2 of a Round 8 HIV grant, significant cuts were made to the budget that had originally been approved for Phase 2. For example, funding for behaviour change communication in communities and schools were reduced by more than half; budgets for institutional capacity building and for strengthening PLWHIV networks were lowered by 27%; and funds for programmes to support orphans and vulnerable children suffered a 17% cut.
The report made several recommendations, including that the Global Fund Board should issue a new call for applications as soon as possible that emphasises the importance of investing in “critical enablers” such as programmes to address human rights and barriers to accessing services; and that the Global Fund should develop a specific strategy on how CSOs will be supported.
According to the draft report of the UNAIDS survey, funding shortfalls, including the cancellation of the Global Fund’s Round 11, raise serious doubts about the ability of many countries to reach the 2015 targets set at the 2011 United Nations High Level Meeting on AIDS.
The 2015 targets include: reducing sexual transmission of HIV by 50%; reducing HIV transmission among people who inject drugs by 50%; ensuring that no child will be born with HIV; increasing universal access to antiretroviral therapy to get 15 million people onto life-saving treatment; and reducing TB deaths in people living with HIV by 50%.
Many UNAIDS country coordinators believed that countries might face service disruptions over the next few years if there were no new Global Fund money before 2014. The coordinators said that programmes for key populations and those managed by community groups might very well be worst affected due to the current crisis because, in most countries, these programmes are funded predominantly through the Global Fund. Specifically, 58% of coordinators were concerned about PMTCT service disruptions, and 62% were worried about a disruption to HIV-TB services.
In addition, at the time of the survey, many of the coordinators feared that services for MARPs would be hit badly: 79% of services for men who have sex with men and 79% of services for sex workers were perceived to be at moderate or high risk of not having the resources to scale up.
The UNAIDS Country Coordinators also reported concerns around funding for community groups and said that the critical role that communities play in prevention, treatment, care and support might be severely hampered.
The report provided numerous examples of the possible impact of the cancellation of Round 11 on individual countries. The following are three such examples:
Although Uganda’s health systems strengthening proposal was approved in Round 10, the HIV component was not. A Round 11 submission would have covered PMTCT, antiretroviral therapy and care, and services for sex workers and men who have sex with men.
In Djibouti, treatment coverage currently stands at 21%. Its new strategic plan for 2012–2016 includes plans to increase national coverage to 80% by 2015, but the country was relying on Round 11 success to achieve this.
In Pakistan, Round 11 was to have been an opportunity to increase services for transgender people. The target was to reach 60% of the estimated 43,000 transgender people in the country.
Since the beginning of 2012, several reports have been issued on the negative impacts of the decision to cancel Round 11. These include:
"Don't Stop Now: How Underfunding the Global Fund to Fight AIDS, Tuberculosis and Malaria Impacts on the HIV Response," 24 January 2012, International HIV/AIDS Alliance (see GFO article);
“Lives in the Balance: The Need for Urgent HIV and TB Treatment in Myanmar,” Médecins Sans Frontières;
Quitting While Not Ahead: The Global Fund’s Retrenchment and the Looming Crisis for Harm Reduction in Eastern Europe and Central Asia, May, 2012, Eurasian Harm Reduction Network; and
The Global Fund: Progress at Risk, July 2012, Action (Global Health Advocacy Partnership).
Peter van Rooijen, Executive Director of International Civil Society Support, told GFO that what is important about these reports is that they all point in the same direction: (a) there are serious impacts to cancellation of R11, and (b) there are substantial funding gaps. “Whether countries would have been successful in Round 11, or not, is not the point,” Mr van Rooijen said. “More importantly, these studies point to the planned potential for important life saving interventions and scale-up that have been halted due to the cancellation.”
Mr van Rooijen said that although the situation may be partly alleviated by the Transitional Funding Mechanism (TFM) and by an accelerated introduction of the Global Fund’s new funding model, “the point is that the Global Fund Board and Secretariat never monitored or reviewed the impacts of the decision to cancel Round 11. This was a serious omission.”