Time to prioritize – let’s get it right this time round

Author:

Christian Djoko

Article Type:

Article Number: 3

A successful workshop to help West and Central African countries prepare for the new funding cycle

ABSTRACT This article is a brief report on the UNAIDS Technical Support Mechanism Global Fund Round 7 2023-2025 Funding Request Preparation Workshop held in December 2022 in Saly Portudal, Senegal. The article highlights two key elements that should be at the heart of future funding requests to the Global Fund: prioritization on the one hand and human rights and gender equality on the other.

From 5 to 9 December 2022, the Joint United Nations Programme on HIV/AIDS (UNAIDS) sponsored an important workshop in Saly Portudal (Senegal) to assist countries to prepare their funding requests for the 2023-2025 grant application cycle. Organized by the UNAIDS Technical Support Mechanism (UNAIDS-TSM), the workshop brought together delegations from Francophone countries in West and Central Africa (as well as Guinea Bissau and Madagascar) planning to submit funding requests for the next cycle, as well as independent expert consultants.

The overall objective of the workshop was to share the latest technical guidance and best practices in HIV programming, gender and human rights, and community engagement in a way that allows countries to assess where they are in their national HIV response. It aimed at helping them to identify and address gaps and went through the new Global Fund country application processes. Specifically, it was to:

1. Ensure that each country delegation, together with prospective consultants, can clarify the current status of its HIV program, identify key gaps in the service cascade and areas requiring priority investments.
2. Ensure that each country/consultant understands what is new in the upcoming Global Fund application cycle and how it affects the country.
3. Develop a common understanding of the important technical areas of concern to countries and strategies to address them, based on lessons learned in the countries.
4. Develop a greater awareness of the technical resources available to countries at all stages of the cycle (in the form of tools, guidance, and technical expertise), at global, regional and national level, and how to access them.
5. Provide an opportunity for country delegations to begin thinking about their Global Fund funding applications, using the information and resources made available during the workshop.

To say the least, it was a success. The various presentations, clinics, and formal and informal exchanges between participants were enlightening and informative. Considering that most workshops are held in English and that this is often a barrier, many participants expressed their satisfaction at being able to participate in such a large-scale workshop in French.

Among the many themes discussed during this workshop, the issues of prioritization, human rights and gender equality particularly dominated the exchanges.

Prioritization

The issue is far from new, but in the context of a difficult global economic situation and the limited success of the recent Global Fund replenishment, the question of prioritization has gained importance. It has attained more importance than in the past and is now an essential component of national strategic plans (NSPs). In practical terms, it is the mechanism for aligning the priorities of national disease plans with the goals and objectives of the Global Fund Strategy. In effect, it involves making choices, but more importantly, trade-offs about what to prioritize and how to allocate resources to deliver services to those who need them most (equity) and to achieve maximum impact from investments. Moreover, the fact that there are competing needs for limited resources creates a need to prioritize the strategies and actions needed to achieve goals over a period of time. If funding requests are poorly prioritized, there is a high risk that the 2030 goals will not be met.

While all workshop participants readily agreed to work on meeting the prioritization requirements in Global Fund applications, the reality is that it is far from a straightforward exercise. In his presentation on “Prioritization in Global Fund Applications,” Marc Péchevis, Technical Director of the UNAIDS Technical Support Facility (TSM), highlighted the difficulties that often plague the prioritization process.

• The lack of a common definition and understanding of what is meant by [‘prioritization’ and the lack of clear guidance from the Global Fund on how to prioritize: this may result in an inability to describe and document prioritization processes.
• Data gaps: Synthesis of epidemiological studies, program reviews, other key elements may not available when countries begin to develop their NSP.
• A frequently highly “charged/sensitive” political environment.
• Inclusive national dialogue is not well understood; there is little involvement of a wide range of stakeholders, but especially key and vulnerable populations, community groups, and women’s networks.
• Lack of alignment: Donor and country priorities and/or the process are often misaligned as prioritization does not always consider what others are doing

However, these difficulties are far from insurmountable. During his presentation, Marc Péchevis shared some criteria (taken from the Global Fund guide) that should help refine prioritization when writing the Grant Cycle 7 applications.

• Epidemiology ¾ disease trajectory, populations and geographic areas of focus
• Magnitude of the gap to be filled
• Effectiveness and scale of intervention
• Equity of the intervention
• Cost and effectiveness of the intervention
• Health system capacity
• Funding opportunities
• Sustainability

In addition, the various stakeholders involved in preparing applications for the next funding cycle must constantly overcome or work around the constraining factors that tend to mitigate the impact of prioritization processes, which start with the beginning of prioritization in the NSP and are carried through into funding request development: see below.

Figure 1. Favorable and constraining factors affecting prioritization

Source: UNAIDS-TSM

It is important to emphasize that there is no magic formula or solution for prioritization. While it is true that the Global Fund cannot impose a top-down approach on a country as to what should ultimately be prioritized, it is also important that Country Coordinating Mechanisms (CCMs) organize genuine and inclusive national dialogues. Such a democratic process is part of the success of NSPs in general and the prioritization exercise in particular.

Human rights and gender equality

The issue of human rights and gender equality is also a central component of funding requests for Round 7. The Global Fund has made this a key element of its Strategy 2023-2028. In Global Fund parlance, core program elements are key evidence-based interventions and approaches to achieve the ambitious goals set out in the global strategies to fight HIV, TB and malaria.

Figure 2. Human rights and gender equality as one of three core objectives of the Global Fund Strategy 2023-2028

Source: Global Fund Strategy Framework 2023-2025

In fact, the issue of human rights and gender equality was already one of the Global Fund’s major concerns, as evidenced by the Breaking Down the Barriers initiative or the Global Fund’s Technical Review Panel’s 2020-2022 Observations Report. Too often, the latter report says, the interventions proposed in the current round of funding (NFM3) were insufficient, compartmentalized, and placed in the prioirtized above allocation request (PAAR) or beyond the allocated amount. When included, services for transgender and gender-variant people were still incorrectly linked to services for gay men. Disaggregated data and intersectional gap analyses on the broad determinants of poor health are not available. These include inequities related to race and indigenous/ethnicity in access to services (see page 10 of the Report).

With this in mind, the Report (see page 6) emphasizes the need to prioritize sustained optimal coverage of high-impact interventions for key populations and adolescent girls and young women, with greater investments to address gender and human rights barriers, including legal barriers such as criminalization. And the Report lays out guidance for donor countries regarding gender equality and human rights (page 29):

Box 1. Guidance for applicants for future funding requests Strengthen the identification and response to significant socio-economic, ethnic, racial and other inequalities. Integrate interventions to address human rights and gender-related barriers throughout programs, and to leverage multisectoral partnerships to improve the impact of programs. This might include working with government ministries, departments and agencies working beyond health, such as justice ministries, to address access to justice for key and vulnerable populations, and to consider opportunities for decriminalization. Deploy a cross-cutting approach toward social determinants and health promotion as well as gender. Regularly collect, update, analyze and use disaggregated data to identify intersectional gaps and inequities. Disaggregation should consider socioeconomic status, age, gender, race, indigenous and ethnic background, education and other epidemiologically relevant demographics. The resulting analysis should be used to propose relevant interventions, with corresponding budget set aside in the allocation budget. Ensure that legal, gender, stigma and key population assessments, disaggregated data, and human rights and gender analysis inform programming. Interventions to address barriers identified through human rights and gender assessments should be included in the allocation budget. Use a comprehensive gender lens to ensure that services are well focused on the needs of all genders, including to address and mitigate gender-based violence. The TRP would like to see enhanced and more precise geographic focus, and layering of evidence-based interventions to address the needs of key and vulnerable populations. Accompany analysis of human rights and gender-related barriers with corresponding interventions and metrics to monitor outcomes as well as appropriate allocation budgets. Analyze and mitigate financial barriers to access, especially among economically-disadvantaged populations, including removal of user fees, or integration of HIV, TB and malaria services in universal health coverage schemes, to achieve greater equity, mitigate poverty and improve access to services. Undertake activities that facilitate legal reforms to decriminalize key populations with a view to bring about greater equity for all people, leaving no one behind.

All in all, we will have to do more with less money. More than ever, this requires a good prioritization exercise. In any case, this is what is expected of countries in the framework of Grant Round 7, which has now begun.

Table 1. Dates for GC7 Funding Request submission and process

Window	Closing Date	TRP Dates	Notes
1	20 March	24 April-5 May	Strongly recommended to countries whose grant cycle ends in December 2023
2	29 May	3-17 July
3	21 August	25 September-6 October	Recommended to countries whose grant cycle ends in 2024