“Against this grim backdrop, there is still much to be proud of in how the Global Fund partnership has responded to the crisis” says Peter Sands
As is customary, the Board meeting began its 46th session with the report by the Executive Director Peter Sands, who reviewed the Secretariat's activities over 2021. He began his speech with a gloomy assessment, regretting the devastating effects of COVID-19 and the damage to HIV, tuberculosis (TB), and malaria (HTM) progress. Nevertheless, he also noted that the Global Fund had played a key role in the countries in which it invests, saving more lives than ever before. He reviewed the objectives set at the May 2021 Board in the six areas of COVID-19 mitigation, the launch of the grant cycle NFM3, and enhance efficacy and effectiveness,
The source of information for this article is the documents for the Board meeting held on 8-10 November 2021, stakeholders’ feedback, and Board discussions.
Mitigate the impact of COVID-19
In 2021, thanks to the donors’ generosity, the Global Fund has secured pledges of $3.73 billion to date, including $3.5 billion from the United States, $154 million from Germany, $50 million from Switzerland, and $30 million from the Netherlands. Sands acknowledged that this envelope represents by far the largest ‘off-cycle (i.e., outside the Replenishment process) resource mobilization ever achieved by the Global Fund. He underlined that, combined with the $261 million raised in 2020, total ‘off-cycle pledges during the Sixth Replenishment period, at $4 billion, dwarf the Fifth Replenishment record of $232 million.
In terms of the COVID-19 Response Mechanism (C19RM), to date $3.1 billion has so far been awarded to 103 countries and 13 multicounty programs to help countries respond directly to COVID-19, mitigate the impact on HTM services, and make urgent improvements to health systems. The Executive Director emphasized that this amount of funding, across so many countries and across such a diverse set of needs, had required major efforts and is an immense achievement. Thanks to this, the Global Fund has become the largest provider of grant support to lower-middle-income countries (LMICs) across all the non-vaccine components of the COVID-19 response, including diagnostics, therapeutics (including oxygen), personal protective equipment (PPE) and community, human rights, and gender-related interventions.
As of 20 October, the Global Fund had awarded $690 million for diagnostic tests, $648 million for therapeutics, including $477 million for oxygen equipment and supplies, and $171 million for other therapeutics. Together with investments in clinical care infrastructure and human resources, this amounts to $755 million in support of the Therapeutics Pillar of the Access to COVID-19 Tools (ACT) Accelerator (ACT-A), $512 million for PPE to protect health workers, $119 million for community-led interventions.
The Executive Director acknowledged the risks and challenges associated with these new funds. He also expressed concerns that funding for C19RM has now been exhausted. As of 20 October, the Global Fund has $231 million left to deploy, but has $287 million of expected funding requests under review and $1.02 billion of unfunded demand.
Launch the next cycle of grants
Peter Sands was very satisfied with the implementation of the new cycle. As of October 2021, $11.6 billion of Technical Review Panel (TRP)-reviewed allocations had been recommended by the Grants Approval Committee (GAC) and resulted in 230 Board-approved grants, alongside four Board-approved catalytic multi-country grants. In addition, 95% of catalytic matching funds ($325.5 million) and 68% of catalytic multi-country funds ($156 million) have also been approved by GAC and become grants.
Nevertheless, the Executive Director stated that there is a need to accelerate implementation and all partners’ efforts given the performance to date of only 33% fund utilization against budget (4% of the total three-year envelope of $343 million) and 66% achievement of programmatic milestones. Country allocations are on average 23.4% higher than in the previous cycle and C19RM allocation will make these even larger.
Despite the COVID-19 disruptions, the following achievements were noted:
- 94% of grants for the new grant cycle were signed on time.
- Disbursement levels were higher than ever before after the first six months of the new cycle. Pooled Procurement Mechanism (PPM) volumes for HTM (excluding C19RM) in 2021 are up 34% compared to 2020, and 65% compared to 2018
The Executive Director also reflected on the specificities of the grants signed that reflect the Global Fund’s evolving priorities. For example, direct and contributory investments in resilient and sustainable systems for health (RSSH) have increased from $2.7 billion in the last cycle to $3.3 billion in the new cycle, and now represent 25.2% of the total grants under NFM3. Direct RSSH investments, including significant interventions in health management systems, human resources for health and health product management, now represent 11.2% of total country allocations. Investment in community system strengthening has increased sharply, by 139%.
Other examples of increased investment include support to tackle human rights barriers in HIV and TB, up 126% and 65% respectively, and investments in community-led monitoring (CLM), up 288% (with further investment in CLM amounting to over $27 million, via C19RM).
Drive for efficiency
Sands underlined four specific achievements relating to efficiency and effectiveness:
- The use of the Business Continuity Plans (BCPs), first established in 2020, to ensure a structured approach to deprioritizing or deferring certain activities to ease workload pressures or release resources.
- The revision of the budgeting and forecasting process to enable more effective prioritization of annual and cyclical investments, and more flexible reallocation of resources throughout the year. The OPEX budget for 2022 recommended by the Audit and Finance Committee for Board approval was such an output
- The completion of three major internet technology (IT) projects: the upgrade of the financial and procurement system to Oracle Fusion Cloud, the multiple enhancements to the Grant Operating System (e.g., Grant Entity Data, C19RM functionality, and the migration to Microsoft Azure).
- The publication of the Operational Framework on the Protection from Sexual Exploitation and Abuse, Sexual Harassment, and the Related Abuse of Power (PSEAH). Through this, the Secretariat aims to prevent and better address such infringements across the entire Global Fund partnership. In 2021, the PSEAH Coordination Unit was established within the Ethics office, revised codes of conduct for staff, implementers and suppliers, CCMs, and governance officials, completed PSEAH training for senior managers, key staff, and government officials, and strengthened the capacity for investigations and victim support, in conjunction with the Office of the Inspector General (OIG).
From a financial perspective, the Global Fund continues to drive down OPEX as a percentage of pledged funds, with Secretariat costs for the current cycle at 5.1% of pledged funds. Incremental OPEX for C19RM is even lower. Since C19RM leverages core infrastructure and processes, the Fund is delivering C19RM well within the budgeted OPEX of 3% of C19RM total funds.
The new approach to independent evaluation, also presented to the Board for approval, provides a much stronger platform for rigorous, independent assessments of impact to enable learning and accountability.
Invest in people
Sands acknowledged that COVID-19 has created unprecedented workloads for the Secretariat, while staff also deal with acute challenges in their personal lives. Several measures have been taken, such as deprioritization of certain activities, streamlined processes, and new recruitments: 284 new staff have been hired, 15% more than were recruited in 2020.
The Secretariat continues to monitor staff mental health and satisfaction: in the Pulse Survey conducted in March 2021, 96% of respondents indicated they had been kept sufficiently informed, and 84% said they felt well supported by their team. However, only 47% believed there was sufficient staff in their team to handle the workload. A new Pulse Survey has been launched and its results will be available later this month.
A key issue that has been addressed by the Secretariat is Diversity, Equity, and Inclusion (DEI). Led by the DEI Working Group, activities such as mandatory training on topics like ’dignity and respect at work’ and ’unconscious bias’ have been rolled out, and an independent assessment of the DEI maturity of the Global Fund has been commissioned. The key findings of this assessment have been shared with staff and are now being used to shape the DEI strategy, priorities, and plan.
Finalize the next Strategy and prepare for implementation
The new Strategy is the fruit of many thousands of hours of discussion involving hundreds of stakeholders. Sands described it as “a far more ambitious, detailed and actionable strategy than we have ever had before”.
The Executive Director underlined that the approval of the Strategy Narrative represented the culmination of over 18 months of debate, analysis, and consultation, guided and led by the Strategy Committee (SC) and the Board itself, involving over 350 individuals via the Partnership Forums, some 5,500 individuals through the Open Consultation and hundreds of people across the Secretariat, technical partners and other stakeholders.
The Secretariat has designed the process to be conducted from Strategy approval to implementation. Grants based upon the new Strategy will start in January 2024 with funds from the upcoming Seventh Replenishment. While it might appear that there is ample time prior to this, many decisions need to be taken in 2022 to determine priorities/approaches in the grant-making process in 2023. A timetable was presented to the SC for discussion before going to the Board.
Figure 1. Global Fund Strategy Development Timeline
Prepare for the Seventh Replenishment
Key steps have been conducted such as refreshing the Global Fund brand’s visual identity and the launch of the 20th Anniversary campaign, both in June 2021. In line with the rebranding, the campaign to celebrate the Global Fund’s 20th Anniversary was centered on the theme 'Change the Story’ and comprised multiple events.
The Secretariat is currently developing financial estimates for the campaign. While the numbers are not yet finalized, it should not come as a surprise that the estimates of financial resources required to achieve the Sustainable Development Goal 3 (SDG 3) target of ending the three epidemics by 2030 will increase significantly. Since COVID-19 has led to reversals across all three diseases and the 2030 deadline remains unchanged, the required trajectories for reductions in deaths and infections have steepened significantly. Getting back on track toward achieving SDG 3 will inevitably require more money.
Plans for 2022
Sands outlined the next six month’s objectives which focus on the same objectives as 2021, mainly because of the long-term characteristics of these challenges. These cover the need to reduce gaps to be able to meet the 2030 targets, implementation of C19RM funds and monitoring impact on health systems, the development of the Investment Case to prepare the 7th Replenishment and continue to improve internal efficiency.
Get back on track in the fight against HIV, TB and malaria
- On HIV, the Global Fund aims to reduce incidence, with a particular emphasis on prevention, and strengthening interventions to protect adolescent girls and young women in the 13 priority countries.
- On TB, case finding is the main priority, with a particular focus on 20 high-burden West and Central African countries, in order to close the widened gap between those contracting TB and those diagnosed.
- On malaria, the Secretariat will ensure COVID-19 does not impede the timely implementation of campaigns or case management through community health workers. The Global Fund wishes to work with partners to optimize the early roll-out of the new malaria vaccine RTS,S.
To reduce the gaps widened by the COVID-19 disruptions, Sands identified several possibilities:
- Deployment and uptake of innovations, building on the lessons learned from the response to COVID-19, through ACT-A.
- Power of communities in reaching those left behind and tailoring services to their needs. Scaling up community-led interventions, including community systems for health and CLM, is critical to the success of the new Strategy.
- Tackle the resurgence in human rights and gender-related barriers as a result of the pandemic through projects such as the Breaking Down Barriers initiative.
Continue to mitigate the impact of COVID-19 in 2022
Implementing the C19RM Monitoring and Oversight Framework, including periodic Pulse Surveys and Spot Checks, is a key priority to ensure maximum impact both at system level and in the capacity to mitigate the negative effects on the three diseases.
Sands plans to determine the Global Fund’s role in the next phase of global COVID-19 support. In 2021 the Global Fund has been the primary provider of external grant support to LMICs for all non-vaccine components of their pandemic. The latest ACT-A strategy and budget envisages a need for a further $16.4 billion for non-vaccine support over the next 12 months (with another $7 billion for vaccines). If this money is forthcoming, which is far from certain, it would be logical for the Global Fund to be a significant channel for the deployment of non-vaccine support, since it has demonstrated its capacity to deploy resources swiftly and effectively.
The Fund must work with partners to ensure equitable access and effective deployment of new antivirals, most notably Molnupiravir. If the early trial results for Molnupiravir are confirmed, then it could potentially be a game-changer in the fight against COVID-19 since it appears to reduce hospitalization by around 50%.
Drive the Secretariat’s efficiency and effectiveness in 2022
In 2022, Sands plans to improve efficiency and effectiveness through better adaptation of the Fund’s operating model, new technology, and better oversight of grant implementation through the revised performance rating approach and refined Principal Recipient reporting process, including Pulse Checks and supply chain and health service Spot Checks.
After its validation at this Board meeting, the risk management tool and the operational risk management framework will help revise the Risk Appetite Framework and lessons learned from the pandemic.
Finally, the Secretariat will reinforce measures against unethical and unacceptable conduct across the partnership, with a particular focus on rolling out strengthened approaches to PSEAH and the Policy to Combat Fraud and Corruption across the partnership.
Keep on investing in people in 2022
In 2022, priorities will be broadly similar to those for 2021, with a focus on managing workload pressure through periodic reprioritization of activities and initiatives, continuous streamlining of processes, and the addition of surge resources where necessary, and promoting and protecting the wellbeing of the staff by working with staff and teams across the organization to build a more pervasive culture of wellbeing, with a particular focus on mental health.
Prepare the operationalization of the next Strategy in 2022
The new Strategy begins in 2023, and its new grant cycle in January 2023, hence, preparation for this needs to start now. In 2022 the Secretariat will:
- Ensure that parameters for the 2024-2026 grant cycle, such as the allocation methodology and eligibility criteria, are aligned with and support the new Strategy.
- Make decisions on catalytic funding to provide extra support and stimulus to critical priorities within the new Strategy.
- Establish the overall approach to performance management for the partnership, including refined Key Performance Indicators.
- Implement the new approach to independent evaluation before the Board for approval.
Prepare a successful Seventh Replenishment in 2O22
Sands positioned the Global Fund’s Replenishment narrative within the broader agenda of addressing COVID-19 and protecting the world from future threats. The rationale for the Replenishment must demonstrate that continuing the fight against the earlier HTM pandemics, ending COVID-19, and preparing for future pandemic threats are not distinct, competing priorities, but should be seen as complementary dimensions of an overall effort to make everyone safer from infectious disease.
The Global Fund will have to convince donors that the best way to protect their own people, as well as to reduce global health inequities, is to turbocharge the fight against the existing pandemics, including both HTM and COVID-19. As the last two years have demonstrated, the systems, infrastructure and capacities put in place to fight existing infectious diseases are the best foundation for pandemic preparedness and response.
Reactions from the Constituencies
All Constituencies acknowledged the overwhelming effort made by the Secretariat and the Committees to maintain business and fight COVID-19 at the same time as developing the new Strategy, and work on the allocation and disease split framework. They extended their appreciation to the Fund for so effectively managing the C19RM to support countries to mitigate the impact of the pandemic on HTM services.
They expressed their support to the six priority workstreams for 2022, ensuring a maximum impact on the current grant implementation, while preparing to best implement the new Strategy. They highlighted the crucial step of operationalizing the new Strategy and called on the Secretariat to focus attention on working through the changes that will be required, at several levels, to implement the ambitious new Strategy.
They all underlined that the changes that this Strategy implies will be reflected in the Global Fund’s Business Model and translated throughout the funding cycle, as well as in the Replenishment’s Investment Case, so as to be attractive and gather support.
Several constituencies also wished to see lessons learned regarding the Global Fund’s response to COVID-19: the grants’ agility and flexibility to design, review and approve proposals, always strengthening M&E and risk management with partners at country level, is a good example of a more tailored and country-centered approach to be replicated for the next cycle.
Finally, several constituencies expressed their satisfaction and support to Operational Framework on PSEAH and Related Abuses of Power.
The Board Document GF/B46/07, Report of the Executive Director, should be available shortly at https://www.theglobalfund.org/en/board/meetings/46