LIVELY DEBATE AMONG STAKEHOLDERS REGARDING THE REVISED GLOBAL FUND STRATEGY FRAMEWORK

Author:

Arlette Campbell White

Article Type:

Article Number: 4

ABSTRACT On 15 June, the Global Fund Strategy Committee held an extraordinary meeting to discuss the revised Global Fund Strategy Framework which took into account stakeholders’ views on the proposed Strategy revisions following the Sixth Partnership Forums health earlier this year.

On 15 June 2021 the Global Fund Strategy Committee (SC) held a virtual Extraordinary Meeting to discuss their recommendations to the Extraordinary Board meeting to be held on 22 July 2021. Its aim was to review and recommend to the Board the Strategy Framework presented in Annex 1 of GF/ExtraordinarySC01/02.

Based on discussions during the Sixth Partnership Forums of March-April 2021, the Strategy Hub produced an updated draft Strategy Framework and Explanatory Paper. In this article, we provide you with a synthesis of the wide-ranging views of a number of stakeholders on the revised draft.

Controversy still remains over where to place Pandemic Preparedness and Response

Stakeholders acknowledged the hard work of the Strategy Development team in incorporating feedback received and, on the whole, welcomed many elements of the current Strategy Framework as presented in the Explanatory Paper. In particular, all appreciated:

• The centrality of people and communities within the primary goal of the Strategy Framework.
• The inclusion of a contributory objective to maximize the engagement and leadership of the most effective communities to leave no one behind, recognizing that communities are critical to how the Global Fund works.
• Maintaining reinforcing objectives on maximizing health equity, gender equality and human rights, and people-centred health systems.
• The emphasis on equity in the updated vision and mission.

Everybody supported some elements of the Framework, including strengthened approaches needed to remove structural barriers for the realization of the Global Fund’s core mission; but some still had concerns about the positioning of Pandemic Preparedness and Response (PPR). In the view of many, the Explanatory Paper had inadequately addressed concerns expressed by the Board and in other consultative processes. in particular, unease was expressed ahead of, and during, the 45th Board Meeting on the PPR’s position or placement within the new Strategy. Many believed that there is a need for further discussion on aspects of the Strategic Framework to strengthen the language and ensure that all partners have the same understanding of the future direction that the Global Fund plans to take. Communities hoped that the upcoming discussions at the Extraordinary Strategy Committee and Board Meetings would resolve some of these issues.

In the revised Strategy, PPR is reflected as follows:

Figure 1. Overall view of Strategy Framework

From this, it can be seen that the evolving direction of ‘Contribute to Pandemic Preparedness and Response’ is now placed below ‘Mobilizing Increased Resources for Health’.

Nonetheless, for some activists this was insufficient and there were feelings that some outstanding critical issues concerning PPR had still not been addressed.

Stakeholders stressed the need for the Global Fund to prevent PPR becoming a separate competitive stream for resource mobilization by developing one investment narrative. These actors argued that through strengthening and leveraging the existing HIV, tuberculosis (TB) and malaria programs and supporting them to achieve disease elimination, PPR capacities will be further developed. The Private Foundation Constituency’s ‘Illustrative Theory of Change’ showed how national malaria program implementation – as supported by the Global Fund – can more intentionally improve malaria outcomes while building PPR capabilities. With regard to TB, contact tracing, treatment, prevention, and other components, including early and timely diagnosis using GeneXpert, not only enables TB case notification but can also be used for early infant diagnosis, and HIV viral load and coronavirus testing. This is a clear example of how one function can be used to support multiple tests and mitigate the risk of other pandemics.

On the COVID-19 response, stakeholders noted that the label of ‘evolving’ does not indicate that the Global Fund’s role in PPR is concluded and that the Global Fund can act as it sees appropriate through the next Strategy. While this point has been clarified, it will be important for the Secretariat to develop a framework that will clearly articulate how it will actualize this particular ‘evolving’ objective and any other that will arise in the future

Among those who felt comfortable supporting the revised framework, some noted that high-level discussions about the future of global health architecture have intensified following the release of the Independent Panel for Pandemic Preparedness and Response (IPPPR) report. It was noted that the IPPPR report contained recommendations relevant to the Global Fund, particularly the inclusion of the COVID-19 Response Mechanism (C19RM) as an example of effective PPR financing. A strong narrative on PPR, therefore, was felt to be instrumental in positioning the Global Fund to meaningfully contribute to global health security (GHS) and secure the financial resources needed to achieve its mandate to end the three diseases.

Next steps for the Strategy narrative: stakeholder priorities

The stakeholders noted that they hoped to see a well-articulated narrative that provides clarity on how the Strategy will be implemented at country level, as well as demonstrating how the Global Fund will pursue and strengthen an integrated, holistic and public health approach in the linkages between the five objectives and the primary goal to end HIV, TB and malaria (HTM), and their comorbidities, contributing to universal health coverage.

Outstanding concerns

People wanted the following issues to be clarified in the narrative:

• Addressing weaknesses in the delivery of the previous Strategy such as failings in programming to address human rights barriers, ensure gender equality and build strong community systems across all levels of the Global Fund, as frequently highlighted by civil society and communities and noted in numerous Technical Evaluation and Reference Group (TERG) and Technical Review Panel (TRP) reports.
• Operationalizing the focus on people and communities: while members welcomed the stronger focus on and recognition of communities and the urgent need to address structural barriers in the goal and objectives of the Strategic Framework, they also felt that the centrality of communities was not fully reflected in the Explanatory Paper. For example, the ‘strategic shifts’ and ‘partnership enablers’ were not framed in ways that would allow the effective operationalization of these objectives.
• Maximizing Health Equity, Gender Equality and Human Rights: Addressing barriers to these are central to ending the three diseases, but stakeholders did not clearly see how this would materialize unless there are shifts beyond the few countries implementing the Breaking Down Barriers initiative. They reiterated the need for the narrative to include details on how the new Strategy will provide for:

• Improved key performance indicators (KPIs) measuring the removal of human rights and gender-related barriers, including for key populations.
• Global Fund leveraging its resources to support decriminalization and other major barriers.
• Restoring and boosting regional grants which make effective use of regional expertise and are critical for civil society to do difficult human rights-related work that cannot be done safely by local organisations, including in non-eligible countries.
• A reassessment of the sustainability, transition and co-financing policy in light of COVID-19.

• Making dual track financing a requirement, rather than a recommendation.
• Contributions to PPR are the result of activities under other objectives: some continued to be concerned about the inclusion of a separate objective on PPR, believing this to be unnecessary since it is not – and should not be – a separate workstream for the Global Fund. The Global Fund already contributes to PPR and this contribution is the result of the work to end the three diseases, strengthen health systems and work with communities. Improving what is already being done through a public health approach is the way that the Global Fund will best contribute to PPR. The ongoing work on PPR would therefore be more accurately reflected as sub-objectives under the primary goal and contributory objectives.
• Topics that need to be clarified in the strategy narrative: stakeholders called for clarity of language and clearly defined terminology to ensure that everyone understands the aspirations of the Strategic Framework and how it will be operationalized. Among the topics that need further clarification are: Community systems strengthening; PPR; Gender equality; Inclusive Global Fund Partnership Model; Country ownership; NextGen market shaping; Innovation; and Affected communities.

 

Articulating the distinction between People-Centred Integrated Systems for Health and Pandemic Preparedness and Response

Many believed the narrative would benefit from further distinction between systems for health and PPR, in terms of eligible investments. While some of the examples provided in the Explanatory Paper are clear – such as the strengthening of integrated surveillance systems to improve national capacity to collect and deploy disaggregated data – others are less so. As an example, they highlighted the fact that strengthening laboratory systems is an eligible investment under the current guidelines for resilient and sustainable systems in health (RSSH) but has been provided as an example of what the Global Fund might do under PPR.

Secondly, many actors also argued for the narrative to specify what the Global Fund will not do. While they appreciated the growing ambition reflected under PPR and the Strategic Shifts, they were also mindful of the findings of the Strategic Review 2020 (SR2020) report that “there is an urgent need to specify more clearly what the Fund does (and doesn’t) do as part of the RSSH agenda ― including in its response to COVID-19 and ongoing in the broader GHS context, climate change and other global health challenges such as antimicrobial resistance.”

On a third and related point, although people were supportive of the PPR objective being framed as ‘evolving’ to take into account the ongoing discussions concerning global health architecture, they felt it would be important for the Strategy narrative to clearly articulate the Global Fund’s role in the broader GHS landscape. Ideally, its role should be guided by its core mandate and comparative advantage, and a reflection on lessons learned. To that end, they supported the findings from the SR 2020 report that the next strategy should give equal weight to the Global Fund as a partner, working within its own mandate with other independent institutions for the achievement of broader objectives such as universal health coverage (UHC) and the Sustainable Development Goals (SDGs), or indeed as part of the response to COVID-19. Stakeholders that remained concerned about the placement of PPR noted that the best way to address invisible and potential risks is to address the current and present risks, i.e., by working every day with every community and with innovation to eliminate the three diseases, they believe that the Global Fund can develop the capacities, skills set, tools and experiences, enthusiasm and will, to address GHS, not as an abstract goal but as a real and tangible threat.

Regarding UHC, some people placed importance on this as an ultimate goal. Although recognizing that it is critical that Global Fund’s primary goal is clearly focused on the three diseases, communities also believe that UHC provides the foundation for ending the three diseases by 2030 and for keeping them under control even after 2030. Therefore, this point should be clearly highlighted within the Strategy Framework or narrative, such as adding ‘towards achieving UHC’ after ‘End AIDS, TB and Malaria’.

Health systems

The Strategy Framework acknowledged the importance of health systems. Indeed, the Strategy mentioned community systems, data and laboratory systems, market-shaping associated with procurement and supply chain as areas of health systems related to the three diseases. Those areas are important not only for HTM but also for pandemic preparedness; and RSSH should therefore be duly recognized as being critical.

Several recommended that the clarity on the importance of health systems translates into standalone RSSH grants at country level. Such standalone grants are necessary for cross-cutting interventions that are not specific to one disease; an example is building a data system that provides reliable routine granular data for the three diseases and the whole system. Earlier investments in data systems in some countries were leveraged for timely monitoring and decision-making in the fight against COVID-19. These investments helped protect the gains in the earlier fight against HTM.

Many felt that the Global Fund should rethink its Challenging Operating Environments Policy and, given RSSH’s prominence towards ending HTM, strongly consider giving more leverage to countries to have separate RSSH grants which will ensure increased visibility of RSSH work.

Engagement and leadership of most affected communities

Everybody welcomed and had indeed advocated for the centrality of communities, human rights and gender equality in the Strategy Framework, including discussion about the incentives that would be needed to drive the integration of community, human rights and gender equality in grant requests.

Health Equity, Gender Equality and Human Rights

Activists were looking for a strong strategy narrative that continues to recognize human rights and gender equality as critical components of the Fund’s investments and underpin effective, sustainable programming. The narrative could, however, be strengthened with a clearer description of the actions to be undertaken by the Global Fund. Communities also wanted to see commitment to improving the collection and use of disaggregated data, and strengthened uptake of gender data, to support efforts to remove structural barriers that drive inequality and poor health outcomes. Finally, they requested greater clarity in the narrative on the levers available to the Global Fund to challenge laws, policies and practices preventing equitable access to HTM services.

Mobilizing increased resources for health

Developed country stakeholders in particular noted that, while they look forward to working with the Global Fund partnership to identify and mobilize new and innovative financing for health, they continue to emphasize their support for an independent review of the Global Disease Split. While adjacent to Strategy narrative discussions, ensuring that disease split allocations are responsive to needs is a crucial component of realizing the Strategy’s vision.

Monitoring and evaluation

The Global Fund has made strenuous efforts to strengthen M&E systems, and subsequent improvements in results reporting are welcome. Again, with reference to the SR2020 Report findings, those interested affirmed support for strengthened approaches to Monitoring, Evaluation and Learning, including robust KPIs that cover impact, outcomes, and accountability for performance. Prioritized discussion of the M&E framework together with Strategy development, including efforts to endorse actionable, measurable performance indicators from the outset of implementation, were welcomed. Members felt that a strong M&E framework will continue to be key to transparency, accountability and demonstrating results.

Country ownership

Some people articulated the need for the Global Fund to move beyond rhetoric to action. Countries feel extremely pressured to respond to the demands and complex requirements of the Global Fund Secretariat conveyed by the Fund Portfolio Managers, with little understanding and sensitivity to the stressful situation and stringent capacities and resource constraints faced by countries experiencing the COVID-19 pandemic. There is an increasingly high risk that countries do whatever is necessary in order to have their grants approved and are then unable to successfully implemented them and achieve the expected results.

The Global Fund partnership model

Stakeholders felt that the partnership model is a strong basis to move forward in articulating partners´ relationship at each level (not only global, but also at regional, sub regional, country and local level) to ensure aid alignment, efficiency and effective and sustainable investments and results. The Strategy narrative should describe further those aspects related to complementarity, roles, accountability and technical assistance.

Conclusion

It is very clear that, despite the Global Fund’s efforts to revise the draft Strategy to reposition PPR, no consensus has yet been reached on where it should be placed or how much weight should be given to it. Indeed, a very real concern of stakeholders is that attention to PPR means less attention (and maybe less funding) to the existing three diseases. Other stakeholders believe that working through the three diseases is the best way to approach PPR.

Read article 9, an interview with Jorge Saveedra of the AIDS Healthcare Foundation, for his argument on the expansion of the Global Fund mandate and PPR.