What should the Global Fund be doing more of?

Bharathi Ghanashyam, India: May 2011

As a part of the Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund) consultation project, the Biennial Partnership Forum 2011, an inclusive online debate was initiated to find answers to some key questions. The answers are expected to contribute towards constructing a more robust roadmap for the future of the Global Fund.

The responses have been wide-ranging – in both suggestions and observations. They reflect the voices, expectations and hopes of affected communities, programme administrators and other stakeholders. They also indicate that the Global Fund has become a symbol of hope – stakeholders would like to see its scope go beyond just funding country programmes. Regardless of whether or not this is feasible, or fits with the Fund’s scope, the exercise has succeeded in revealing some very real gaps that need to be addressed. The summary of the responses is available at: www.citizen-news.org/2011/04/global-fund-consultation-topic-1-lives.html

It is important to appreciate here how the Global Fund is structured, and how it is different from other funding agencies. Andreas Tamberg, Fund Portfolio Manager, says:

“The Global Fund is a unique, public-private partnership and international financing institution dedicated to attracting and disbursing additional resources to prevent and treat HIV and AIDS, TB and malaria. This partnership between governments, civil society, the private sector and affected communities represents an innovative approach to international health financing. The Global Fund’s model is based on the concepts of country ownership and performance-based funding, which means that people in countries implement their own programmes based on their priorities and the Global Fund provides financing on the condition that verifiable results are achieved.”

The Country Coordinating Mechanisms (CCMs) were established by the Global Fund to drive country level activities, and ensure that there is equitable representation from all sectors. Manohar Elavarthi, Vice Chair of the CCM in India, corroborates this:

“Before the Global Fund was established, we were operating in a traditional world of funding where it was typically bilateral and did not allow space for participation from key stakeholders who would benefit from the funds. The Global Fund in a sense changed much of this. For the first time, we have an agency that allows for this very vital participation through the CCMs. There are other unique elements to the Global Fund as well. It encourages the use of generic drugs, allows for administration by local officials and most importantly optimizes on the resources available by lowering administrative and manpower costs.”

That the Global Fund has touched lives and made a difference is evident from the figures (see box 1), working in close collaboration with other bilateral and multilateral organizations to supplement existing efforts in dealing with the three diseases.

The need to revisit priorities

Given the Fund’s evident successes, why is there a need to revisit the funding patterns, or examine whether the Fund should increase or decrease its activities? It is important to view this through different lenses. Within the Fund there are questions as to whether systems and processes have become too complex. To quote from the Fund’s ‘An Agenda for a More Efficient and Effective Global Fund’ (2010):

“Increased political attention to health, with substantial new resources, has given rise to a proliferation of actors and initiatives and a far more complex global health landscape. The Paris Declaration on Aid Effectiveness and subsequent Accra process have highlighted the need for the Global Fund, along with other donors, to harmonize their efforts and align them more effectively with countries’ own systems and regulations. This need has become particularly acute as AIDS, TB and malaria programs in many countries have rapidly scaled up from demonstration projects to fully-fledged national programs. In such a dynamic environment the Global Fund has had to remain a flexible, innovative and learning organization.”

Viewing it from a stakeholder perspective, expectations are varied, and some fall in with the above. Dr Mohammed Rafique, Country Team Leader at CARE India, says: “Since the Global Fund bases its funding on local programmes and does not initiate or implement parallel programmes, it is very important to understand local contexts. It is also vital for the Global Fund to recognize that the different political climates of different countries make it impossible for one solution to fit all problems, and thereafter allow for those differences and respond to them accordingly.”

Dr D Behera, Director, LRS Institute of TB and Respiratory Diseases, and CCM Member says: “The Global Fund has done a commendable job of providing vital funding for TB programmes in India, but the demand for uptake of funds for TB is rather limited. The reasons why India continues to grapple with the problem of large incidence of and deaths from TB lay elsewhere and are not within the purview of the Fund. We have to regulate the private sector, as this is the first point of contact for patients. When they come into the government programme, most often it is already too late. How can we pull these linkages together?”

Subrat Mohanty, Project Coordinator, Project Axshya, International Union against Tuberculosis and Lung Disease (The Union), adds: “The Global Fund has been supporting the India TB Programme since Round Two through various rounds. It has been a historic moment for TB care and control in India to have two civil society principal recipients - The Union and World Vision India - along with the Central TB Division to have joined together in the Global Fund Round Nine to support India’s effort to TB care and control. A lot depends on how effectively access to full treatment and awareness on the disease is spread across the country – an area where the usefulness of civil society collaboration and roles for sectors like the media become apparent.”

Linkages – vital to impact

While the above statements might reflect the situation with regard to TB, this also applies to AIDS and malaria. Treatment is vital to saving lives but can the Global Fund help to enable the other linkages? These are important linkages to overall public health, without which real impact is difficult to achieve. Andreas Tamberg says: “At the end of the 1990s, public health experts identified a number of highly effective interventions to prevent and treat AIDS, TB and malaria. New knowledge about the scale of epidemics and a deeper understanding of the complex causal links among poverty, development and disease, pushed international issues of public health to the centre of the world’s development agenda.”

In the coming years, it will be important to translate this understanding into action. That linkages with other sectors are equally important is evident from the fact that responses to the online consultation attracted a significant number of respondents commenting on the need for more effective measures to prevent diseases. Other demands include collaborative programmes such as training for health workers, health and community systems strengthening, and the scaling-up of laboratory services.

In addition, the CCM is a vital hub for effective functioning of the Global Fund in each country. Most respondents were of the opinion that the Fund’s activities would be better served with greater representation from non-government entities: “While government representation is very important, it should not result in all the other voices becoming less vocal. It is absolutely imperative for a Global Fund representative to anchor the CCM meetings,” appealed one respondent eloquently.

However, there is a risk that non-AIDS diseases are less well addressed by the Fund. For example, the India CCM has very little representation from the TB sector, and the emphasis seems more in favour of AIDS. One can rationalise that when AIDS is addressed, TB also gets attention. AIDS and TB can be twinned of course, but only to a limited extent - 80 percent of people living with HIV might develop TB at some time, but the reverse might not be true. It is vital to look at TB as a separate entity and give it special emphasis in certain contexts, and this merits greater representation from the TB sector.

In its World Malaria Report 2008, the WHO estimated there had been 10.6 million cases of malaria and 15,000 deaths from the disease in India during 2006[1]. By its very name, the Global Fund concentrates on HIV/AIDS, TB and malaria. The response to malaria however is seen as minimal. Mr Nirod Kumar Bhuyan, Project Officer at the LEPRA Society and CCM India member, says: “Malaria is underrepresented in the CCM and the Government of India does not give adequate importance to it despite the fact so many people suffer from malaria in India. Much more needs to be done, and the Global Fund has a vital part to play in this.”

In conclusion

Global Fund-supported programs have saved so many lives (see box 2 above), by enabling countries to deliver expanded key services. The emphasis has been on service delivery, and whilst numbers are important for meeting the Millennium Development Goals, huge efforts and sustainable commitments in terms of funding are also required, for programmes and country specific responses that go beyond the numbers. In addition, there should be more civil society involvement, increasing emphasis on malaria, and further involvement, politically and financially, from central government.

The consultation revealed some significant gaps, and it remains to be seen how the Global Fund will rise to the full spectrum of challenges.

[1] The Hindu 17 June 2010: www.hindu.com/2010/06/17/stories/2010061754161100.htm