The Global Fund Strategy’s evolving objective of Pandemic Preparedness and Response
Article Number: 3
A response too far?
ABSTRACT The topic of pandemic preparedness and response has been a controversial issue during the 18 months leading up to the development of the Strategy Framework and now the draft Narrative. This article provides you a view for and a view against. What is clear is that it is not as simple as Pros and Cons, and the opposing views are not actually that contradictory.
The Global Fund Strategy Framework, endorsed by the Board on 22 July, included a fifth ‘evolving objective’, ‘Contribute to Pandemic Preparedness and Response’ (PPR). At one time included as a full objective with the other four, the many virtual and online consultations, including the 6th Partnership Forums held earlier this year, have resulted in PPR being positioned at a lower level than the main objectives.
Nonetheless, the placement ― indeed, the inclusion ― of PPR in the forthcoming Strategy continues to be a bone of contention among the different stakeholders. The Global Fund Observer (GFO) has published several articles on this topic in issue #397 (The Global Fund Must Expand Its Mandate to Other Pandemics, Says the AIDS Healthcare Foundation) and issue #399 (Lively Debate Among Stakeholders Regarding the Revised Global Fund Strategy Framework). The arguments for expanding the Global Fund’s mandate to include PPR were the subject of a panel debate at the International AIDS Society (IAS) annual meeting in July (Pandemic Response, Preparedness, and Prevention: The Pros and Pros for the Global Fund) and an Open Letter to the Board (Former Global Fund Board Members Urge the Strong Placement of Pandemic Preparedness and Response in the New Strategy) which arrived after the end of the Board meeting and so could not be considered or discussed by the Board prior to their endorsement of the Strategy Framework, on which the draft Strategy Narrative is built.
In this article, the GFO considers how the evolving objective of PPR is justified within the draft Strategy Narrative and summarizes the conflicting views of stakeholders.
Evolving Objective: Contribute to Pandemic Preparedness and Response
The draft Strategy Narrative, still embargoed for external circulation, outlines the plans for this fifth objective as described under the Global Fund 2023-2028 Strategy Framework.
Figure 1. Evolving objective ‘Contribute to Pandemic Preparedness and Response’
The Global Fund’s arguments for this inclusion are simple. The COVID-19 (C19) pandemic has been the largest single obstacle to the Fund’s mission of ending the three diseases. The pandemic is further weakening already overstretched health systems, reducing economic growth, constraining domestic resource mobilization, and will be the largest single cause of death from infectious disease throughout the world in 2021. It has severely disrupted critical services, not just for the three diseases but also those of other key programs, meaning that countries are even less likely to meet global and national health targets.
The Fund keenly feels that it is essential to help countries effectively respond to this health crisis as a prerequisite to getting HIV, TB, and malaria (HTM) and broader Sustainable Development Goal (SDG) targets back on track. This would also help countries to better prepare for future pandemic threats and lessen the risk of them further upsetting progress against HTM and high-level global health goals. As the largest multilateral provider of grants in global health and the only multilateral agency specifically created to fight pandemics, the Global Fund partnership is uniquely placed to support countries in preparing and responding to pandemics.
The Strategy Narrative concludes that there are significant synergies to be gained by integrating PPR across the Global Fund partnership’s work. It considers this evolving objective to be holistic, building directly from and having synergy with the Strategy’s primary goals and mutually reinforcing contributory objectives.
The Executive Director’s position on PPR
As noted in our special Board issue of the GFO on 12 May (The Proposed New Strategy Framework Provokes Lively Debate), Peter Sands would like the Global Fund to become the ‘go-to’ mechanism for C19 and any future pandemics. He wants to position the Fund at the centre, and one of his arguments for doing so is that, if Global Fund does not take this on, it may not be able to raise enough funds through the upcoming Seventh Replenishment (although to date there is no evidence of this from any donor).
As a reminder of Peter Sands’ view on PPR, we reproduce some of his speech below:
|“The Global Fund was created as a mechanism to respond to pandemics; specifically, AIDS, then encompassing TB and malaria. We have learned more than any other organization in the world about how to do that. However, we have never really focused on the preparedness aspect and arguably we should have done. C19 has been our biggest setback and knocked us back against the three diseases. We didn’t anticipate the risk and didn’t do much to mitigate its impact.
“The biggest danger for the coming nine years (up to the 2030 SDGs) is if we do not deal with the impact of C19. This is not about refocusing our mission but about protecting our communities from the effects of C19’s effects.
“Today we have talked about C19 as a ‘game changer’ – most organizations can only react to one game before they go bust or they devolve into different institutions, or new institutions are created. We need to recognize the scale of the changes around us: are we thinking boldly enough about the changes that need to be made?
“We are at a terrible moment in our history, the worst setback we have ever faced in the story of the Global Fund. It is okay to say it is not easy and that we need time to debate on what and how to do it. If it were easy, we would be missing the point. It ought to be hard to work out what the right thing is to do and how to carve a path through this storm. I welcome people’s passion because it really matters to millions of people that we get this right.”
Peter Sands, speaking at the Board meeting on 12 May 2021
Arguments in support of expanding the Global Fund’s mandate to include PPR
The International AIDS Society in July 2021 had held a panel session on Pandemic Response, Preparedness, and Prevention: The Pros and Pros for the Global Fund. One of the IAS panelists was Professor Stefano Bertozzi from the UC Berkeley School of Public Health. He was the last director of the World Health Organization (WHO) Global Programme on AIDS (GPA) before it transitioned to become the Joint United Nations Programme on HIV/AIDS (UNAIDS). He directed the HIV and TB programs at the Bill and Melinda Gates Foundation and it was in this capacity that he sat on the Global Fund Board for four years representing the Private Foundations’ Delegation.
Bertozzi feels that the Global Fund is a model for global organization governance divided as it is between donors, developing and developed countries, civil society, non-government actors, representatives of those affected by the diseases, charitable and private foundations, and the private sector. This in itself uniquely positions it to address a global health threat that impacts people in all these groups.
“We clearly need new financing mechanisms for routine expenditures as well as emergency funding for when pandemics strike”, Bertozzi says. “Establishing a new funding mechanism would be more expensive as it would have to have its own infrastructure; but who could provide a ‘home’ for it? WHO might seem to be an obvious choice but it has never managed a similar program so lacks the requisite experience. Meanwhile, the current mechanism works well and is responsive to country needs and requests.”
When the Global Fund was being established, Bertozzi initially argued against it as a separate standalone organization because he thought the new entity should be a solely AIDS-focused funding stream combined with GPA/UNAIDS for the same reason ― not to create another organization to address HIV/AIDS. However, once this had become a new and separate entity (the Global Fund) to cover all three diseases and avoid being caught up in politics ― as would have happened if the new funding mechanism had been merged with GPA/UNAIDS ― then the rationale was clear. To date, says Bertozzi, the Fund has done a better job of resisting political pressures than other UN bodies.
“The Global Fund is ‘pretty much the Goldilocks in the governance of global organizations.’ A role model for others.”
Bertozzi understands the concern that stakeholders may have of the Global Fund losing its focus if it were to add another disease to its mandate but he does not believe that the inclusion of PPR would diminish funding to the three diseases. However, if the alternative is to create a different fund, he feels there is a likelihood that resources will be diverted to it that might otherwise have gone to the Global Fund. Looking at expanding the mandate to include COVID-19 and PPR purely from the efficiency perspective, it makes sense in the context of providing a broad PPR function, when there is a pandemic – with a clear focus on infectious diseases and a distinctly global problem which may or may not prevail (he gives the example of pandemics that were expected to be much bigger, like Zika, but in the end were not as much of a problem as anticipated).
Bertozzi says there needs to be discussions at the Board level based on a clear steer from those who give the Board members their instructions. Given the Board structure, governments together easily form the majority of the Board and may take a more sympathetic, broader view of supporting PPR. The private sector and foundations may also have this wider perspective, as might some of the non-government organizations (NGOs). The key lies in who makes the decisions with respect to what government representatives say and vote for. Accordingly, discussion regarding the mandate’s expansion needs to be elevated to a higher level than that of the actual representatives sitting on the Board. Advocacy and decision-making should be dictated by senior government officials’ directives to their country representatives on the Board.
“(The Global Fund) is not broken, it does not need to be fixed: but decisions have to be made that might not correspond to the interests of the currently involved parties.”
The Board has a fundamental problem regarding governance because of conflicts of interest on the part of Board members representing one or another of the three diseases. Therefore, for example, it is easier for them to believe that the inclusion of PPR would be more of a threat than a benefit to HIV. It would be unusual for someone actually working on HIV to support the broader view of what benefits all four diseases. The Global Fund should be governed by the people most involved and most interested – implementing partners make up a third of the Board. But Bertozzi is concerned about marginalizing the donors, marginalizing governments, and marginalizing civil society and the voices of the people most affected by the three diseases.
Any decision on PPR does not concern the three diseases’ expectations in their indirect effects. This decision, Bertozzi feels, needs to involve a broader constituency and a different level of decision-making.
Arguments against expanding the Global Fund’s mandate to include PPR
Mick Matthews currently works for the Global Network of Sex Work Projects (NSWP) which upholds the voice of sex workers (SWs) globally and connects regional networks advocating for the rights of female, male, and transgender SWs. He worked at the Global Fund for several years as the Senior Civil Society Officer which was, he says, “a fight every day”. By his own admission, he is not very diplomatic, not good at compromise, and is key population (KP)-focused. An ideal person, therefore, to represent NSWP on the Communities’ Delegation to the Board, and as a member of the Delegation’s management group.
Matthews’ major concern is that COVID-19 puts considerable additional pressure on Global Fund beneficiary countries. Making the decision to push the Global Fund in a particular decision that expands its mandate is a political and funding decision, says Matthews. “There is no evidence that there will be more pandemics (although there may well be) and COVID-19 won’t stay at the level it is now; there will be a downturn after vaccines become widespread”.
Matthews is concerned that, if PPR becomes a major part of an expanded Global Fund mandate, the end result will be a more broad-based organization that will not include KPs in the governance structure because it will become “all about governments”. All KPs are criminalized so they do not fit into that broader health model in the same way as they do for HTM programs.
“The COVID-19 Response Mechanism (C19RM), version 1, in 2020 was a disaster for KPs. All the funds went to governments and didn’t filter down to KP organizations and networks. Phase 2 is better thanks to the efforts of the Community, Rights, and Gender (CRG) team to ensure that KPs and community-led organizations have been included in the Funding Requests (FRs). But the amount and intensity of efforts supporting country partners are not sustainable.
“Also, the Fund has instituted shortcuts to make C19RM FRs function as an emergency grant – it wants to get money out as soon as possible to show donors that it can do so. There is too much money going to corrupt country-level governing structures who do not have the capacity to deal with it and as a result, these shortcuts will not help the money reach the people who need it”.
Matthews is not the only person who is uncomfortable about this. A KP representative working on C19RM funding applications told GFO that ‘The Global Fund pushed for shortcuts and essential processes are then shortened – I am not convinced that this is the right way to go’.
Another concern is where the money goes at the community level, partly driven by a misunderstanding of the definition of what constitutes a community, as we have seen in the peer reviews of C19RM applications (Community-Based, Rights and Gender Interventions Fail to Feature Strongly in Global Fund COVID-19 Mitigation Proposals). “Community health workers (CHWs) do a great job but are not the only frontline workers”, says Matthews, “So any support that does filter down to the community level goes to CHWs. KPs and civil society/community-based organizations and others working with other KPs do not get access to the money”.
“We know that the Board recently made a decision to increase the C19 fast-track (FT) funding level to $700 million. Where is the evidence that the existing FT money is actually making a difference? People buy into this emergency argument and a lot of the Board want the Global Fund to expand its mandate to take on PPR – now an ‘evolving objective’, new phrasing to soften its meaning and appease the anti-PPR-ers – but this is mere semantics, playing with words. The Board has been very clear that Global Fund work on COVID-19 should support and mitigate the Global Fund’s work on HTM”.
“As a result of COVID-19’s impact there has been a 20% reduction in services for SWs and people who use drugs (PWUD) so we need to recoup these losses. But the Global Fund wants to be a panacea for all the world’s health problems by adding PPR to its mandate. If this happens, then these KP programs for populations like men who have sex with men, SWs and PWUD, will never be able to catch up”.
Matthews echoes civil society concerns that, as the Global Fund moves forwards with its plans to contribute to PPR, it must be careful not to lose the principles of community involvement, KP engagement, a focus on human rights, addressing criminalization, and gender equity. Every region represented at the 6th Partnership Forums in March had noted the need to do better regarding equity, human rights, and gender, noting that key inequalities persist across income, geography, age, and sex, perpetuating barriers to accessing quality prevention, care, and treatment and health outcomes. This was the complaint even before COVID-19 made itself felt and the Global Fund had accepted the need to improve performance in this area.
|We have to do better for key populations and for community, human rights, and gender. If the Global Fund takes its eye off the ball because of COVID-19, key populations will suffer and it won’t be the Global Fund we all want it to be.|
Of course, the C19RM places a special emphasis on community-led monitoring and community-led responses in developing COVID-19 impact mitigation and HTM adaptations. Nonetheless, this was the weakest area of the C19RM applications across the board, and in spite of the Global Fund’s specific instructions to do so, few countries managed to develop suitable community, rights, and gender (CRG) and gender-based violence interventions.
“The Global Fund has already said that, administratively, it is too difficult to have a separate funding mechanism for key populations: but the C19RM, a separate funding mechanism, was not too much,” Matthews points out. “Moreover, the Global Fund is a partnership organization so why can’t it partner with an NGO funding mechanism to manage small grants using the Global Fund financial architecture and standards to channel funding directly to community organizations?”.
On 1 September, WHO launched a flagship global data hub in Berlin, the WHO Hub for Pandemic and Epidemic Intelligence, in an attempt to create an ‘unbreakable chain’ of disease surveillance to prevent future outbreaks escalating into pandemics.’ The initiative, announced earlier this year and launched in collaboration with the German government, is a key pillar in WHO’s efforts to stem holes in the world’s pandemic preparedness, laid bare by the coronavirus.
Speaking at an event in Berlin featuring a host of influential scientists on Wednesday, Dr. Tedros Adhanom Ghebreyesus – director-general of the WHO – stressed that the hub is part of the organization’s “commitment to keeping the world safer” after the “defining crisis of our time. Viruses move fast, but data can move even faster,” he said. “With the right information, countries, and communities can stay ahead of emerging risks, and save lives.”
It is as yet unclear whether or not this hub’s activities will be limited to only providing information. However, it seems highly unlikely in the near future that it would be able to perform the role currently occupied by the Global Fund. So, the debate about the pros and cons of the Global Fund’s expanded mandate remains legitimate. And, while there are valid perspectives on both sides of the argument, currently, given the clear global levels of under-investment in health and the need to raise more financing, the case for the Global Fund taking on this role is likely to win the day.