THE AFRICAN CONSTITUENCY BUREAU SUPPORTS COUNTRIES TO WEIGH IN ON THE NEXT GLOBAL FUND STRATEGY DEVELOPMENT
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Download PDF The Global Fund to fight AIDS, Tuberculosis, and Malaria is developing its post-2022 strategic plan. The Global Fund has requested input from partners, implementers, and other stakeholders to help identify emerging challenges and opportunities that will be critical for its next strategy. The Africa Constituency Bureau (ACB), which supports the representation of 46 African countries in their engagement…
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ABSTRACT The Africa Constituency Bureau, which supports the representation of 46 African countries in their engagement with the Global Fund, convened virtual meetings of the representatives of those countries to discuss key challenges and achievements during this current strategy and collect input for the next strategy.
The Global Fund to fight AIDS, Tuberculosis, and Malaria is developing its post-2022 strategic plan. The Global Fund has requested input from partners, implementers, and other stakeholders to help identify emerging challenges and opportunities that will be critical for its next strategy. The Africa Constituency Bureau (ACB), which supports the representation of 46 African countries in their engagement with the Global Fund, convened a series of virtual meetings of the representatives of those countries to discuss key challenges and achievements, and collect input for the next strategy.
Sub-Saharan African countries receive 72% of the Global Fund funds. These countries form two constituencies: West and Central Africa (WCA) and East and Southern Africa (ESA). Most countries use English or French as their official language. Fourteen countries participated in the francophone cluster of WCA & ESA: Burkina Faso, Cameroon, Central African Republic, Chad, Congo, Côte d’Ivoire, Gabon, Guinea, Guinea-Bissau, Madagascar, Mali, Niger, Senegal, and Togo. Their representatives met on 25 June 2020. Seven countries participated in the anglophone cluster: Eswatini, Ghana, Kenya, Mozambique, Namibia, Nigeria, and South Africa on 26 June 2020. Though Portuguese is the official language of Guinea-Bissau and Mozambique, they joined the francophone and anglophone clusters respectively. As only 21 countries participated in the two calls, ACB resolved to call the other CCM (Country Coordinating Mechanism) secretariats separately for their views.
Dr Zweli Mkhize, the Global Fund Board Member for the ESA constituency and South Africa’s Minister of Health, as well as Dr Nduku Kilonzo, the Strategic Committee member, participated in the meeting for the anglophone cluster. Prof. Pascal Niamba, Chair of the ACB Board and Ethics and Governance Committee (EGC) member, and Dr Mele Djalo, Strategic Committee Member, participated in the meeting for the francophone cluster.
Logistics challenges
Language and time differences posed logistics challenges for the virtual meetings, but the most significant logistic issue was the inconsistent internet connection that hampered fluid communication. As it was difficult to ensure that all participants heard the discussion, the ACB requested that each country share a summary of their contribution via email within a week of the meeting. The ACB has also obtained funding from the British development agency, DFID (Department for International Development), to provide a secure platform for virtual meetings for all CCMs who work with them.
Challenges of grants implementation during this strategic period
Participants emphasized the importance of the four current strategic objectives and insisted that they should not be disregarded. They then discussed challenges and associated solutions. Those challenges are rarely new or unique to specific countries. However, they are influenced by the country context.
Weak health systems
Weak health systems are a huge problem in sub-Saharan Africa. This could be due to security issues (civil war or terrorism in fragile states), economic problems, or poor governance.
Health system weaknesses include inadequate infrastructure, insufficient human resources in quantity or quality, poor data systems, and fragile supply chains. Some participants explained that a weak health system directly affects the grants’ performance and the ultimate goal of saving lives. For instance, a weak supply chain system often results in Antiretroviral (ARV) stock-outs that disrupt patients’ treatment. Several countries experienced stock-outs of ARV or tuberculosis (TB) medications in recent years. This has been extensively documented in audits by the Global Fund’s Office of the Inspector General.
Participants of the meeting insisted on the importance of data quality as a pillar for good program planning and performance. High quality data is needed for effective grant management as well as to test, treat, and retain patients in treatment. The WCA participants discussed the low proportion of HIV-positive persons who know their status and the region’s lack of progress with regard to meeting the ambitious 90-90-90 UNAIDS goals. (The targets are that by 2020, 90% of all people living with HIV know their HIV status, 90% of those who tested positive are on treatment, and 90% of those on treatment have viral suppression.) (See more on that target in an article in this issue).
Service delivery to key and vulnerable populations
Delivering services to key and vulnerable HIV populations remains a challenge in most participants’ countries because of criminalization and stigmatization. Key populations for HIV include drug users, sex workers, men who have sex with men (MSM), whose activities are often criminalized. In this context, programs to identify and provide them with services are often challenging. Vulnerable populations to HIV include adolescent girls and young women; the highest rates of new HIV infection are found among them in sub-Saharan Africa.
Participants acknowledged that without appropriate management of the key population issue, the HIV epidemic could not be controlled.
Strong country leadership and multi-sectoral engagement needed
Some participants deplored the lack of leadership in the coordination and integration of the three disease programs in the national health system. While no participant mentioned a lack of country ownership explicitly, many described situations where their health ministries are sub-recipient of international non-governmental organizations; thus, they are “just like simple executants.” When this occurs and the Global Fund Additional Safeguards Policy is also in place, it is unlikely that there would be increased capacity and involvement of the State. This is even less likely if the situation has lasted for many years without a clear exit strategy. These countries also acknowledged poor financial, procurement, and supply chain management. Shoring up the gains in the fight against the three diseases is impossible without strong national leadership.
CCM members from several countries in WCA, particularly Guinea and Congo, lamented the low absorption of the grant funds that coexist with unmet needs. Participants pointed to the lack of collaboration among governmental bodies. The fight against the three diseases, as they explained, requires a multi-sectoral approach that involves not only the ministries of health and finances, but also other ministries. For example, they explained that the need to work with the ministry of education – to engage girls in school, the ministry of social affairs and protection – to empower women, the universities – to conduct research, and the private sector – a major provider of malaria and non-malaria treatment in malaria-endemic countries. Despite the wide representation offered by the CCM, those other sectors are not always present in the CCM. A strong state leadership could create avenues for deliberation and collaboration.
The COVID-19 pandemic threatens existing gains
The COVID-19 pandemic affected service delivery for AIDS, TB, and malaria as well as other disease programs.
Countries had to devise innovative ways to address the disruption that accompanied COVID-19 prevention measures and revise their service delivery systems. For example, Benin did not cancel the mosquito nets distribution campaign. Instead, the country provided health workers with personal protective equipment (PPE) and adopted a procedure of distribution that maintained social distancing. Senegal’s HIV programs revised the system for dispensing medicine to reduce the exposure of HIV patients in health centers. Patients received ARV medications for at least three or four months, instead of the usual single month.
Some participants mentioned that their countries are unlikely to meet their co-financing commitments partly because of COVID-19.
Some positive highlights during this strategic period
One of the current strategic objectives is to reinforce health systems. The Nigerian CCM representative highlighted an important win related to the health system: the country has obtained a standalone Resilient and Sustainable System for Health (RSSH) grant to strengthen its supply chain, data system, and human resources for health. The advantage of a standalone RSSH grant is that it could ease the coordination and effective implementation of the RSSH interventions.
Ethiopia also plans to submit an RSSH standalone funding request in August for the same reason. As Meseret Yenehun, Ethiopia CCM Secretary, said, “it is better to have a standalone RSSH grant in Ethiopia for better coordination and visibility.” Few other countries obtained a standalone grant and funds for RSSH are usually part of HIV, TB, and malaria grants. She added that program heads have a tough time influencing other agencies and directorates to implement the interventions/activities.
Also, when the RSSH indicators perform more poorly than the specific disease indicators, the low performance of RSSH brings down the rating of the whole grant. A low rating of the grants results in funding for the country as the Global Fund provides performance-based grants.
Dr Mele Djalo, from the WCA constituency, highlighted the CCM evolution pilot project in which approximately 20 countries participated. It began in 2018 and lasted for a year. The project, coordinated by the Secretariat, aimed to improve the level of maturity of CCM performance in four areas: overseeing grants, ensuring links with national structures, engaging key stakeholders and strengthening CCM functioning. She explained that the project pilot gave the CCM in Niger an opportunity to strengthen its structures and oversight.
The Global Fund Secretariat had announced plans to scale up the CCM evolution project in 2020.
Looking forward to the next Global Fund focus next strategy
Dr Zweli Mkhize drew participants’ attention to non-communicable diseases that are spreading in the region and affecting aging persons living with HIV.
Participants discussed the idea that health issues require a multi-dimensional approach. Although CCMs provide a great microcosm with several stakeholders, the CCMs alone do not hold the answers, especially in Africa. Input from other sectors, State and non-state principal recipients will enrich the discussions.
The ACB recommended that countries in each sub-Saharan African region (East, central, southern, and West Africa) engage with each other to develop an approach that will be consolidated at the constituency level. Some of these discussions will feed the Partnership Forum Preparations that will happen by December. Dr Mele Djalo said those consultations “represent a unique opportunity to make our voice heard.”
