How to improve Global Fund governance
Kafui EssieArticle Type:
Article Number: 6
Africa needs to be better represented to achieve more balance between the regions
This article is a reflection against the backdrop of a plea for better representation through two additional seats for Africa on the Board of Directors. It is a question of efficiency, value for money, and equity.
The Global Fund has an inclusive governance system. However, it is it equitable? Can we save more lives with a better representation of Africa which, after all, receives more than 70% of Global Fund monies?
The African Constituencies are requesting two additional voting seats on the Global Fund Board. The Board currently comprises 28 members: ten donors, ten implementing voting members and eight non-voting members. Among the implementers are two Africa Constituency voting members, one for Eastern and Southern Africa (ESA) with 22 countries and the other for Western and Central Africa (WCA) with 24 countries. There are three seats for non-state organizations, and five other government constituencies representing other regions of the world like the Eastern Mediterranean region(EMR), Eastern Europe and Central Asia, Latin America, and Western Pacific.
It’s about efficiency, value for money and equity
The WCA and ESA Constituencies together are home to about 1.2 billion people which includes 70% of people who live with HIV (PLHIV), 23% of people affected by TB and 96% of malaria cases worldwide. These two Constituencies encompass 21 low-income countries, 18 lower-middle-income countries and one high-income country (South Africa). This high burden of disease associated with lower income is one of the reasons why the two African regions receive more than 70% of Global Fund resources.
But while Africa receives 70% of the resources it only accounts for a mere 20% of implementers. In practical terms, this composition makes constituency engagement and governance complex. How do people decide on agenda items and positions that reflect the views of all their constituencies? How impactful and effective are decisions made in a governance model whereby those who receive 70% of the money and are responsible for a similar proportion of results get as much space as those who receive, for example, 5% of the resources? Is this distribution of seats equitable?
This question of equity is not only a matter of moral or fair sentiments. It translates into lives saved or missed opportunities.
South Africa and South Sudan: worlds apart yet the same voice
To give you a practical example of constituency engagement and position, let’s look at the ESA Constituency. At its southernmost tip is South Africa with the richest economy in sub-Saharan Africa and home to seven million PLHIV. At the northern end of the ESA constituency is South Sudan. Its population of 11 million is barely 35% higher than the total number of PLHIV in South Africa. The South Sudanese gross domestic product (GDP) per capita of $1,072 is about 15% of that of South Africa’s $6,777, according to World Bank data. South Sudan has emerged from decades of civil war and became independent in 2011; and the young country is still very much in a nation-building stage with civil war flaring up every so often. South Africa has existed since 1910 and has a stronger institutional framework (even if it is often tested).
How likely is it for those two countries to have the same priorities and focus? These are only two countries out of 22. How easy it is for a single person (even with an effective Secretariat) to meaningfully represent all of them and adequately bring their issues to the table?
Consider the Global Fund’s market-shaping discussion, a pivotal dialogue with implications not only for Africa but also for global health security. However, practical responses to this multifaceted issue are likely to be different in South Africa and South Sudan.
In South Africa, the focus is rightfully on bolstering domestic production of critical healthcare essentials such as antiretroviral medications (ARVs), vaccines, and various health commodities. This approach aligns with the country’s capacity and resources, allowing it to effectively meet the healthcare needs of its population. Conversely, South Sudan faces an entirely distinct set of challenges. It lacks a robust pharmaceutical production industry, rendering local manufacturing of health-related products an unattainable goal in the three-year Global Fund cycle. Instead, the nation grapples with the intricacies of the Additional Safeguard Policy. Here, the top priority is the development of systems robust enough to earn the Global Fund Secretariat’s trust, particularly when it comes to relying on the country’s Ministry of Health or other local entities as Principal Recipients of Global Fund grants. Up to this point, only United Nations agencies have held this role in South Sudan.
Note that market shaping is just one of the twenty or so topical issues discussed at Global Fund Board meetings. It is important to adequately support all countries and not only those that are easy to support.
Critics of an increased and improved representation of African governments claim that Africans are better heard through the seat of Communities and Civil Society Organizations. How can civil society organizations (CSOs) represent entire countries and national governments? Rather, the CSOs work complements that of governments who are legally entrusted with the care of their people and must be at the table to discuss various issues like the policy framework, law-making, sustainability and transition, manufacturing regulation, and other public national level issues.
Other critics claim that the EMR seat represents Africa because that constituency includes North African and Middle East countries. This raises questions on two points: North Africa’s circumstances are different from those of ESA/WCA constituencies in many ways, including epidemiological ones. Second, it would be highly unusual for countries in the Middle East, outside the African continent, to be considered African representatives.
Africa wants the Board to appoint two more voting seats for Africa to have an equitable representation in governance. Better representation will help improve the voice of Africans and the quality of Board decisions, and it will cascade down to operational decisions made by the Secretariat; thus, it will likely provide value for money for donors.
The Global Fund aims to eliminate HIV, TB and malaria as epidemics by the end of 2030. Our partnership, together with stakeholders in countries, is off-track for all three diseases for several reasons. Among them are the COVID-19 pandemic and its consequences of general paralysis, turmoil, and delayed activities; the fragility of many countries where the Global Fund invests with its consequences of conflicts and population displacements which reduce efficient programming, and climate changes. Admittedly, the Global Fund can do little against those world problems. However, observers wonder about the extent to which the disproportionately small space the Global Fund allows Africa within its governance and decision-making processes contributes to missed targets.
Ultimately, the true reward lies in saving more lives, and this can be achieved by affording Africa the opportunity to contribute more substantially to the strategies and decisions of the Global Fund. The whole partnership would benefit from this decision.