Bobby Ramakant, India: May 2011
The Global Fund to fight AIDS, TB and Malaria (the Global Fund) has contributed significantly over the last decade in accelerating India’s response to TB, HIV and malaria, saving lives and preventing infections. However a lot more needs to be done as it is clearly not enough. If the Global Fund and India do business as usual, currently unreached populations are unlikely to benefit.
“Over the last ten years the Global Fund has focussed on strengthening the national programmes in India”, according to Dr Nevin Wilson, Director, International Union Against Tuberculosis and Lung Disease (The Union), South East Asia office, New Delhi. He continues, “they poured money into national programmes, provided infrastructure, trained people, built capacities, provided drugs, supported processes, and national TB programmes (NTPs) are much more functional now with the Global Fund intervention than they were 10 years ago. The problem is that NTPs are still not able to use all the money that the Global Fund gives them. There is a significant proportion of the population that NTPs still don’t reach. Most of these unreached populations are the most vulnerable, most socially marginalised, and the most poor. I think it is stretching management to imagine that NTPs will ever reach these unreached populations, they won’t”.
The Union is a Principal Recipient (PR) of the Global Fund round 9 grant in India and is implementing one of the largest advocacy, communication and social mobilisation (ACSM) programmes around the world.
Reaching the unreachable
So what should the Global Fund do to support programmes that truly reach and serve the currently unreached populations? “The Global Fund needs to invest in the sector for people from these populations who currently can’t seek services. Poor people when they are not well go to a particular service and will continue to go there when they are not well. You cannot expect them for TB alone that they will suddenly become aware and go to a public service” said Dr Wilson.
According to estimates, about 70-80% of people in India go to a private sector health facility when ill. May be a combination approach of strengthening sectors where people currently receive services from and meaningfully engaging community-based organizations in providing services where government programmes cannot reach might work.
“The Global Fund needs to invest in the community. This is where the last mile is. If you have got 60% case detection we have to find the other 40% and it is not going to be found by the NTPs on their own. It can only happen if other sectors get the investment. The challenges are there in terms of standardisation, among others, but I am sure we can find answers to that” said Wilson.
Although India has the highest TB burden in the world, more than 2.3 million people living with HIV (PLHIV) and alarming malaria rates, it might not be eligible for the Global Fund grants anymore because of the virtue of being classified as a middle-economy country. “I don’t know whether the Global Fund will consider India as an eligible country or not, but India should remain as one of the countries high on their agenda at least for TB being the highest burden TB country globally” said Dr KS Sachdeva, Chief Medical Officer (CMO), Revised National TB Control Programme (RNTCP – India’s NTP), Central TB Division, Ministry of Health and Family Welfare, Government of India. India’s NTP is also a PR for Global Fund grants.
“I think the Global Fund’s reporting mechanisms are too stringent and get too much into micro-details. It takes a lot of time for reporting and leaves very little time for actual programme implementation. Significant time is invested in documentation or answering the queries. The Global Fund should not micro-manage the grant” said Dr KS Sachdeva.
For Dr Wilson, “one important thing that the Global Fund needs to do less of is micromanaging. The Global Fund is increasingly becoming a micromanager and they are double managing financial and technical processes”. He continues, “Global Fund now wants us to again and again clarify these processes through multiple mechanisms. The same thing happens to finance. Now I understand that the Global Fund operates in terms of the business mechanism which is lending money to a high risk entity. When a bank lends money it ensures that the credit rating of the person bank is lending money to is very high. Here the Global Fund gives the money and the risk is very high. That situation is not going to change and when it changes then we will not need the Global Fund anymore”.
Solutions?
So what is the solution? “India is a setting for mismanagement, financial incapacity, and also for high burden of TB, poverty, low literacy, low education… that is why we need the Global Fund. So the Global Fund needs to build systems that will help local managers audit their work and carry it out with integrity. We need to think of a way that it will align with best practice. It will not always be what you can do at Wall Street. We should be able to do it locally in countries like India and those in Africa” said Dr Wilson.
“The Global Fund can do a little less with all the middle men so that the grant reaches the community it is meant to reach the most. The Global Fund has lots of paper work, system and structure, that are meant to protect against corruption and prevent misusing. It has now become evident that this system is not preventing against corruption or misusing. So this is one area the Global Fund can look into it and simply the process so that people who are meant to get the funds receive it” said Loon Gangte, from the Delhi Network of people living with HIV (DNP+) and International Treatment Preparedness Coalition (ITPC), South Asia.
“There are many other models like ITPC Collaborative Fund which disburses money to affected communities regardless whether systems exist or not because it is our job to find a way to transfer money. I am the coordinator for South Asia ITPC Collaborative Fund and countries like Bangladesh not only provide antiretrovirals (ARVs) but also have started producing ARVs. With the small advocacy money we gave, they lobbied with the government and pharmaceutical companies. Nepal doesn’t produce ARVs so this is a good model that can be replicated. So the Global Fund should look at these models and minimise all middle men, reduce paper work, enhance programme efficacy, optimise the funding and let money reach where it is meant to” said Loon Gangte.
“We are about to receive support as a sub-recipient (SR) of the Global Fund grant to Solidarity and Action Against The HIV Infection in India (SAATHII)’s ‘Pehchaan’ project. Not enough has been done to address the needs of Transgender and Hijra communities and most of the resources that have been allocated to sexual minorities have been invested in scaling up men who have sex with men (MSM) programmes. We need to scale up investment on programmes that address the needs and challenges of Transgender and Hijra populations as well” said Ranjit Sinha, Secretary, Association of Transgender and Hijras in Bengal (ATHB).
“The Global Fund should invest more money into health systems strengthening (HSS) besides three diseases (TB, HIV and malaria). HSS also includes practical approaches to lung health (PAL), programmes to address TB and diabetes, silicosis and TB, TB and tobacco use, TB-HIV co-infection, strengthening TB laboratory capacities among others” said Dr KS Sachdeva (NTP).
He continues, “apart from the public private mix approaches already used in RNTCP, we also need to see how civil society can be more and more roped in especially in difficult geographic terrain. May be we have to allow the civil society to set up infrastructure there to complement the NTP because if civil society doesn’t have an infrastructure in these remote areas, then it will not work”.
“The structure of the Global Fund has to be more expanded to ensure that the communities are represented as well as civil society and not controlled by the Governments of the north” said Anand Grover, UN Special Rapporteur on Right to Health and head of HIV/AIDS Unit of Lawyers’ Collective. Anand Grover is a senior Supreme Court lawyer in India.
“Our goal in TB control is ‘early detection, complete treatment’ but for TB to be eradicated from our population we need more than early detection and complete treatment. We need social change. And social change cannot be dictated by specific interventions like poverty reduction. Poverty reduction is an outcome of social change” said The Union’s Dr Wilson.
Engaging with communities
The Global Fund needs to simply its processes to build in-country competence to manage the grant and implement programmes effectively. The need to engage affected communities as equal partners with dignity in this process is a clear mandate expressed above by the government, non-government and community representatives above. The affected communities need to be in the centre of India’s response to HIV, TB and malaria, and not merely on the receiving end.
