VOICES OF THE PEOPLE I: EECA AND LAC PARTNERSHIP FORUMS
Arlette Campbell WhiteArticle Type:
Article Number: 5
Two regions meet virtually to discuss their commonalities and divergences to provide input into the next Global Fund Strategy
ABSTRACT The Global Fund launched its sixth Partnership Forums with a global opening, followed by the first of three regional meetings, each held over several days. In this first meeting, two regions ― Eastern Europe and Central Asia, and Latin America and the Caribbean ― met virtually to discuss their achievements as well as their challenges, gaps and constraints; and made recommendations for the direction of the forthcoming Global Fund Strategy.
The Global Fund convened the sixth in a series of Partnership Forums that took place virtually between 2 February and 15 March 2021. Three Partnership Forums were convened with representatives from across the globe to actively contribute their regional expertise to help develop the aims and areas of future focus for the next Global Fund Strategy from 2023 onwards.
The first Partnership Forum brought together the regions of Eastern Europe and Central Asia (EECA) and Latin America and Caribbean (LAC) for plenary meetings and breakout sessions over two days. Although at first glance these two regions may seem to be diverse in culture and language, they have been placed together because, in terms of overall income levels, the regions are similar. Although LAC has more high-income countries, these are quite small and the region is predominantly composed of upper middle-income countries. Likewise, although it has more low-income countries, EECA comprises mostly upper middle-income countries (according to World Bank classifications). Moreover, most of those receiving Global Fund support are planned to be transitioning out of it based on the Global Fund eligibility criteria ― a process that has now been threatened by the impact of COVID-19 on these countries’ health systems and the amount of domestic resources available for health that have been directed towards the pandemic.
The Global Fund asked participants to review inputs, evidence and guidance received on strategy development and to identify the most pressing challenges and opportunities in: the fight against AIDS, tuberculosis (TB) and malaria; building resilient and sustainable systems for health (RSSH); promoting and protecting human rights and gender; and mobilizing resources. Participants also reflected on how these aims have been or may be affected by COVID-19 and broader changes in the health and development landscape.
The joint EECA/LAC Forum showed many commonalities – most especially the repeated emphasis in all sessions on more community focused interventions – which resulted in some very similar recommendations. However, there were also divergences in emphasis and priorities, an understanding of which will help the Global Fund Secretariat to adjust expectations and make informed decisions.
Note that the Partnership Forums resource center contains a plethora of useful information through background notes and other documents that formed the background basis for the discussions.
What have the EECA and LAC regions achieved so far with Global Fund resources?
To provide the overall background, Figure 1 shows the results to date of Global Fund supported programs in the two regions.
Figure 1. Achievements to date in EECA and LAC*
Source: Global Fund Strategic Information Analysis. *does not include disbursements for multi-country grants. 1.4 million lives saved through the GF partnership represents 4% of the global figure. 600,000 people on antiretroviral therapy represents 3% of the global figure. 125,000 people with TB treated represents 2% of the global figure. 500,000 mosquito nets distributed is 0.3% of the global figure. 4.9 billion USD disbursed is 11% of the global figure.
Progress towards the 2030 Sustainable Development Goals (SDGs)
The most important of these goals for our work is SDG 3 (ensure healthy lives and promote well-being for all at all ages) which has two relevant targets: (1) Target 3.3: by 2030, end the epidemics of AIDS, TB, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases; and (2) Target 3.8: achieve universal health coverage (UHC), including financial risk protection, access to quality essential health care services, and access to safe, effective, quality and affordable essential medicines and vaccines for all.
Unfortunately, both regions are off-track to meet the HIV, TB and malaria targets for 2030. While impressive gains have been made, significant shortfalls remain, especially in reducing the number of new infections. Moreover, COVID-19 threatens to reverse the extraordinary gains made by the Global Fund Partnership: health and community systems are overwhelmed, with treatment and prevention programs disrupted and resources diverted to deal with the pandemic.
HIV: progress, challenges and priorities
The HIV epidemic is growing in EECA, with a 72% increase in new HIV infections since 2010; and the incidence : prevalence ratio is the highest globally. By comparison, there has been a 21% increase in new HIV infections since 2010 in Latin America and a 29% decrease in the Caribbean. However, the increase in Latin America was driven largely by Brazil, a country that does not receive Global Fund support.
In both regions, key and vulnerable populations (KVPs) and their partners remain disproportionately affected. In EECA they accounted for 99% of new HIV infections in 2019, with 48% of all new infections among people who inject drugs. They accounted for 77% of new HIV infections in Latin America and 60% in the Caribbean in 2019, with gay men and other men who have sex with men (MSM) and transgender individuals particularly affected.
In EECA, there is a need to rapidly expand antiretroviral therapy (ART) coverage which remains the lowest globally; addressing this is vital for sustainability in the region. On the positive side, EECA has recorded progress on prevention of mother-to-child-transmission and pediatric treatment, with 94% of pregnant women with HIV now accessing ART.
There are large prevention coverage gaps in both regions that need to be addressed by further scaling up and better targeted programs, such as pre-exposure prophylaxis (PrEP) and addressing structural drivers.
Both EECA and LAC see a need to increase the scale and strengthen integration of human rights interventions in order to address stigmatization, discrimination, criminalization and violence, which are barriers to KVPs accessing HIV services.
Tuberculosis: progress, challenges and priorities
While the World Health Organization (WHO) European Region is on track to reach the 2020 milestones of the End-TB Strategy, 83% of estimated TB cases are in EECA high prevalence countries where incidence is four times the European Union average. LAC is also off track to meet End TB targets: although mortality decreased 11% between 2015-2019, incidence is estimated to be slowly increasing.
EECA has the highest multi-drug resistant (MDR/RR)-TB rates among WHO regions: 17% among new, 52% among previously treated, TB cases. In the WHO Americas region TB treatment success is ~76%, while success of RR/MDR-treatment is ~56%; but TB treatment gaps persist.
The percentage of new TB patients with known HIV status is increasing across the EECA region but there is still a gap in TB screening and TB preventative treatment (TPT) among persons living with HIV (PLHIV). Scale up of TB care and prevention measures for KVPs in many countries in the region has been suboptimal. Of deaths attributed to antimicrobial resistance, one-third are from DR-TB globally but EECA bears an increasing global burden of DR-TB. In LAC there has been a slow uptake of new tools (e.g., rapid molecular tests), as well as a gap in TB screening and TPT among PLHIV; and the proportion of HIV-positive TB patients who died remains high at 20%.
Participants in both regions agree that the Global Fund must support more efforts that focus on finding and treating missing people with TB and MDR-TB.
Another key message in both regions is the need for the Global Fund to engage with and support communities to ensure the sustainability of TB responses. This is particularly important in LAC where the TB incidence is ~100 times higher in people deprived of their liberties and indigenous communities; hence, community systems are critical for sustainability and for reaching the most vulnerable but remain limited and must be scaled-up.
Malaria: progress, challenges and priorities
The WHO European region, which includes EECA, has been free of malaria since 2015.
The picture in LAC is very different. It is currently off track to meet the 2030 targets, with a 7% increase in malaria incidence from 2010-2019 and a 4% increase in malaria deaths; but it should be noted that 55% of all new reported cases were in Venezuela and 11% were in Colombia.
Although overall results are disappointing, there has been some progress towards elimination: seven endemic countries were on schedule to reduce incidence by more than 40% in 2020. Of countries that have received Global Fund support in the past, Paraguay (which received support until 2018) was certified as malaria-free in 2018. Accelerating progress will require optimization of strategies and innovations both in delivery of available interventions and in new tools and approaches, as well as increased financial investment.
An important issue to take account of in planning is that drug resistance is impacting the future of malaria and needs to be addressed. Vector resistance to pyrethroids was confirmed in 26% of collection sites surveyed in 2019.
Another message to emerge from the discussions on malaria is that regional collaboration is seen as crucial to eliminating malaria in LAC.
Resilient and sustainable systems for health (RSSH): progress, challenges and priorities
COVID-19 has presented significant challenges to health systems and domestic resource mobilization in both EECA and LAC; but its real impact is still unknown.
Community systems are also seen as critical in both regions, especially for reaching the most vulnerable/last mile populations. In this respect, the Global Fund is a key partner and is regarded as uniquely positioned to assist in strengthening community responses.
EECA made significantly faster UHC coverage progress between 2010-2019 than from 1990-2010; however, as a sub-region within the WHO European Region, it is unlikely to meet 2030 goals at the current rate of progress. Between 2000 and 2015, the largest concentration of out-of-pocket health spending in EECA shifted from low-income to middle-income countries; and high care-seeking from the private sector in high-burden middle income countries means that attention must be placed on strengthening engagement and implementation with the private sector.
LAC participants in the Forum emphasized that RSSH investments are increasingly important for achieving sustainability in the region. Between 2010 and 2015, the WHO Americas was the only region that saw improvements in both financial service coverage and financial protection. Despite progress in domestic expenditure for health, UHC financing gaps are vast: Between 2005 and 2015, public health expenditure as a proportion of gross domestic product (GDP) increased in all countries; but not one of the Global Fund-supported countries achieved the recommended spending level of 6% of GDP on public health expenditure for UHC.
Equity, human rights and gender
Key inequalities persist in EECA and LAC across income, geography, age and sex, perpetuating barriers to accessing quality prevention, care and treatment and health outcomes.
It was noted that Honduras, Jamaica, Kyrgyzstan and Ukraine – i.e., two countries in each region – are part of the 20 focus countries in the Global Fund’s Breaking Down Barriers Initiative which provides intensive support to address barriers to health. Participants wanted to know if and when this Initiative would be rolled out across all countries.
HIV-related deaths increased 14% more among women than among men in EECA between 2000-2019 (+20% for men, +34% for women). By contrast, in LAC HIV incidence has increased at a vastly higher rate among men and boys since 2000. But in both regions, while men are more likely to contract TB than women, they are less likely to access services.
Like other breakout groups, the group that considered RSSH concluded that community systems are critical to making progress, particularly for reaching key populations and the most vulnerable.
Both regions shared concern over the observed high levels of discriminatory attitudes, especially relating to issues of stigma, and the importance of overcoming human rights-related barriers to reducing new infections, improving treatment outcomes and achieving 2030 targets.
COVID-19 and Global Health Security
As of January 2021, all EECA countries except Turkmenistan had reported COVID-19 cases. Ukraine became officially the most affected country in absolute numbers, making up 26.3% of reported cases.
COVID-19 is having a catastrophic impact on the most vulnerable communities and threatens progress against HIV, TB and malaria in both regions. Latin America has some of the highest COVID-19 death rates in the world, compounded by both the increasing displacement in Central America and the Venezuelan migrant crisis.
In LAC (excluding Venezuela), COVID-19 has contributed to an expected average 7.9% decline in GDP in 2020.
About $25.2 million funding for EECA and $16 million for LAC was approved through the Global Fund COVID-19 response mechanism (C19RM) to reinforce national responses, mitigate the impact on HIV, TB and malaria programs and support urgent improvements in health and community systems.
LAC participants pointed out that the Global Fund has the opportunity to lead as an ambassador for an inclusive global health security (GHS) vision, based on solidarity and equity for communities. The Global Fund’s extension of support to Venezuela is an example of its contribution to GHS through its investments. Participants from EECA added that building resilience through stronger preparedness will be key for maintaining essential health services in prioritized health system action plans.
How the Global Fund can strengthen its impact
In EECA the first recommendation is to keep an overall focus on supporting interventions for key populations, with more attention to prevention and testing. In order to do this, there must be stronger support to address criminalization of KVPs and ensure their access to HIV services. This also calls for the availability and use of more robust data to guide and monitor interventions.
The EECA’s second recommendation is to increase support to communities, a recurring theme throughout all sessions. This is also the priority for the LAC region which suggested that such support should include: increasing engagement of vulnerable communities in the HIV response; promoting social contracting initiatives as part of the transition packages; strengthening support to regional networks; increasing alternative financing and technical resources targeting communities; and strengthening Country Coordinating Mechanism (CCM) monitoring and accountability.
Building on the lessons learned from Venezuela, the LAC region recommended that the Global Fund increase its response in challenging environments and fragile settings.
On the subject of increasing sustainability initiatives and transition preparedness, there is some concern that the LAC region is not yet prepared for transition. Participants in the region recommended that the Global Fund reconsider transition eligibility criteria specific to regions and continue to encourage increased domestic investment with a people focus without leaving anyone behind.
Participants in the EECA region had four additional recommendations for the Global Fund: First, prioritize innovations such as PrEP and digital services. Second, assist in the design and implementation of improved costing and financing mechanisms to ensure comprehensive HIV services. Third, acknowledge that poverty is a major factor that influences access to HIV services, especially for internal and external migrants, and reflect this in increased funding to address the structural drivers of disease. Fourth, build stronger partnerships by encouraging bilateral cooperation and experience change between countries.
Breakout sessions on TB in both EECA and LAC concluded that there is a need to strengthen and apply accountability for performance. To do this, it is recommended that the Global Fund introduce and apply grant conditionalities to ensure accountability for implementation performance. To improve accountability for co-financing and allocative efficiency of funding through community-led monitoring, the Global Fund should support countries in updating guidelines and respecting international commitments for TB prevention and care, and support gender, stigma and human rights assessments and legal reviews in relation to TB-affected communities.
As in virtually all other topics, participants in both regions recommend increasing community involvement in integrating TB into primary health care and in monitoring.
More cross-border initiatives are also recommended; in particular: expanding the Global Fund’s Breaking Down Barriers approach, perhaps to entire regions; supporting multicounty initiatives to target vulnerable groups (like migrants and indigenous communities); and developing plans for delivering TB services, specifically for mobile populations.
Malaria in LAC Region
The LAC Forum recommended four priorities: (1) the Global Fund should maintain its investment in malaria in the region; (2) enhance sub-regional approaches, coordination and cross-border collaboration; (3) expand and strengthen community level involvement; and (4) plan for a progressive transition from high investments in supplies, diagnostic, treatment and investigation towards more systemic approaches including moving from vertical to integrated systems approaches.
Integration and systems for health
The two regions had different recommendations for integration and systems for health.
EECA had three recommendations, the first being to synchronize and engage with health reforms and UHC processes at country level by institutionalizing the role of civil society/CSS within RSSH; and as a watchdog to keep health systems accountable, inclusive, and equitable.
Learning from the COVID response, EECA participants recommended that the Global Fund contribute to structural reforms (at national and local levels) by strengthening and capacitating systems including health information management, procurement and supply management, laboratories, and epidemiological surveillance. This requires a review of the role of CCMs/national health governance structures to ensure their commitment and contribution to health systems reform within a framework that will sustain and institutionalize the role of civil society/community in health systems and UHC (including decision making and implementation via social contracting). Participants also noted the need to persist with reforms of the justice and penitentiary systems alongside health systems reform to ensure alignment in human rights-based responses and development of an enabling legal environment.
The third EECA recommendation was for the Global Fund to promote and support the widening of service coverage and integration of services (including prevention) as part of the UHC package of essential services in primary health care.
From the LAC perspective, the priority is for the Global Fund to go beyond being a contributor to become a leader and serve as a catalyst to create a common vision for health systems, just as it has done to strengthen community systems where the Global Fund has played a leadership role to create/support this strategy beyond the three diseases. At the national level, the Fund should play a leadership role in improving governance and strengthening systems to ensure that KVPs are effectively integrated and empowered, and that cross cutting and systemic challenges that will affect the three programs’ capacity, quality and sustainability are identified and addressed by each country and its partners. This means that the Global Fund should use its political and financial leverage to bring about changes to laws, policies and practices that criminalize/stigmatize KVPs. It should also continue to press for the involvement of KVPs in national processes as these processes can empower, support and strengthen these groups to be better advocates and service providers.
In order for communities to maximize their contribution (data, service provision, advocacy), LAC participants recommended that the Global Fund invest directly in affected communities and KVPs. This would call for more consideration to including community-generated data within national information systems. If governments criminalize or do not recognize KVPs, there are no official data and therefore no prioritization, whereas communities have more autonomy and freedom to collect such data but need the necessary technical/financial support to do so.
The LAC region would also like to see the Global Fund use its influence in dialogue with development partners and other stakeholders to integrate and complement policies and services. For example, investments made in the response to COVID-19 should be integrated so as to also benefit the response to TB, HIV and malaria.
Whatever the recommendations and priorities, progress is heavily reliant on having the necessary resources; and in both regions, there is a need to mobilize more resources. Unsurprisingly, participants pointed out the need to ensure greater commitments from domestic financing. In turn, this requires increased monitoring of country contributions with verifiable measures (such as government expenditure on health as a percentage of actual total government expenditure). It was noted that the response of governments to the COVID-19 pandemic showed their willingness and ability to respond when they understood the social and economic impact; and the same urgency and determination needs to be applied to the health sector more generally.
LAC participants recommended that the Global Fund increase investments in sustainability interventions that support social contracting for when countries transition from Global Fund support. They also recommended that the Global Fund invests in national and regional networks which can support domestic resource mobilization (especially post-transition). At the same time, the Global Fund should increase its engagement with the private sector as donors (including multinationals), intensify the focus on global security and health agendas, continuing to emphasize the SDGs and UHC outcomes relating to poverty, social exclusion, gender, and the link to human rights, KVPs, the three diseases and COVID-19. Finally, LAC participants urged the Global Fund to strengthen coordination among international development partners at global and national levels.
EECA participants made similar observations but also recommended that the Global Fund should avoid premature transitions until countries can ensure program sustainability through domestic resource mobilization. They also recommended that the Global Fund consider employing conditionalities/co-financing requirements to incentivize domestic resource mobilization; and that this should be accompanied by direct investment to capacitate and empower civil society and communities to advocate for domestic resource mobilization. This will require the Global Fund to guide country-specific decisions on the allocation of domestic resources to health/diseases, based on human rights principles (balancing health and law enforcement interventions), and assess the level of domestic investment in health to direct reallocations from justice/law enforcement to health. Finally, EECA participants urged the Global Fund to mobilize additional resources for expansion to meet extra streams of work (such as COVID-19) and secure commitment from Global Fund donors for increased investments to meet its expanded mandate.