Shifting the power to the people
After our article in March’s Global Fund Observer entitled To risk or not to risk: that is the question, we continue to explore the question of the appetite of major donors for risk in all its forms. Our article (Racism in the aid sector) in this issue, based on the recent British Parliament report on racism in aid, showed how the general conduct of donors with aid-recipient countries is systemically based on Western standards and often tends to be patronising and paternalistic; whereas bad practices and the need for capacity building are the prerogative of poor countries.
While the Global Fund’s Challenging Operating Environments Policy was intended to provide fragile countries with the framework for the dialogue and discussion necessary to remove barriers to implementation, it has mostly been useful in removing bottlenecks created by additional safeguards.
On the other hand, the bottlenecks linked to truly contextual difficulties are rarely addressed and almost never resolved by innovative measures. Among these recurring barriers, we can cite several. Firstly, the delivery of treatment and medicines in areas where the security situation does not allow for the presence of implementing agencies. Then there is the response to the health needs of forced population displacements, including the provision of medical services, which is still barely addressed by the Global Fund in country programmes (although some attempt is made to redress this this through multicountry programmes such as the Middle East Response grant). This is especially notable when it comes to the situation of refugees who are often not taken into account in the countries’ health funding envelopes. Then there is the response to the phenomenon of violence, which affects young girls and women more severely in circumstances of political instability and economic deprivation. This is also poorly addressed by the Global Fund, even though it is a generator of sexual violence (and therefore of HIV transmission and unwanted pregnancies), psychological distress and devastation from a social perspective.
How can an empowering programme be developed for fragile states?
First: Strengthen the health system on a long-term basis by aligning the various health donors
The addition of a health system strengthening (HSS) envelope for the NFM3 grant cycle has allowed countries and donors alike to reflect on how the Global Fund can contribute to strengthening the health systems of the countries it supports. Using the national health development plan as a starting point, stakeholders present at the country dialogue have been able to identify funding gaps, evaluate the investments already made by the Global Fund in previous grant rounds, and propose a contribution.
In some COE countries, HSS funding supports their governing objectives and is aligned with the national vision, which Gavi, the Vaccine Alliance, also supports. In Mali, for example, the Global Fund grant and the Gavi grant accompany health sector reform by supporting its first pillar, community health. The two donors have supported the development and implementation of an integrated minimum package of services, the process of redefining the profile and responsibilities of community health workers and their recruitment, equipment, deployment, and payment. To avoid duplication, Gavi and the Global Fund have even signed a memo aimed at harmonising their procedures, optimising costs by financing a common programme management unit (PMU) and rationalising investments between the country's regions. Follow-up meetings with the PMU are common to both donors, and in the long run, if this is the wish of each stakeholder, one can envisage the future development of a procedural manual, common audits, and risk management policy that is accepted by both donors. Other issues are also common to both donors, such as activities in the regions, open financial advances, and the reporting of receipts. It is likely that that these activities are the same or very similar for other donors.
In COE countries, this type of communal approach should be the norm, with donors and government ministries adhering to this discipline of alignment. Planning must be thought out over a five to ten years’ period, with durations extended or spread over several funding cycles. Only in this way will gaps and duplication be avoided and good governance develop.
Second: Respond to unexpected events and emergencies
A health system must be made as resilient as possible to the many shocks to which it might be subjected; take, for example, the Democratic Republic of the Congo (DRC), a country which currently has 12 diseases with epidemic potential. The health system faces simultaneous epidemics each year: cholera, which is seasonal; measles, which has been present in the sub-region for more than five years; yellow fever; typhoid; Ebola; and now COVID-19. It also has to deal with population movements linked to the conflict that is still active in the eastern regions of the country, and the volcano Nyiragongo (Goma), considered to be one of the most dangerous in Africa, that awakens about every 20 years.
There have been recent floods in the Central African Republic (CAR), Côte d'Ivoire, South Africa and Sudan which have severely impacted service provision.
Chad and Niger are facing increasing droughts, with temperatures approaching 50 degrees Celsius during the dry season. At the same time these countries are having to deal with recurring epidemics of cholera, measles, meningitis, and chronic malnutrition that affect children and pregnant women in particular. In these contexts, investment is necessary to deal with a range of scarcities including a shortage of human resources, insufficient medicines and medical equipment, and inadequate infrastructure to deliver services especially in rural areas. In the short-term, donor support must be geared to deal with these shortages and in the longer term, to supporting the country to implement its national health development plan.
Recent experience has shown that donors, including the Global Fund, must anticipate and plan for emergency scenarios. This is what emergency preparedness is all about, and it is one of the new objectives of the next Strategy. However, this poses the question of how to organise emergency preparedness in COE countries. It may be easier to deploy the Emergency Fund, which is intended to respond to acute and temporary emergencies (the latest being Ukraine), than to plan and attempt to implement emergency preparedness to cope with emergencies in the COE countries. This is because an early response to such emergencies is needed to minimise the dire consequences on the population. Bear in mind that maternal and neonatal mortality rates in Chad and Niger are among the highest in the world and have been increasing for the past five years. The incidence of malaria in the DRC and more generally in the French-speaking African region has also been increasing for the past three years, while prevention actions are massive and costly.
Actors in COE-rated countries told us about their difficulties: they range from the simplest obstacles (not being able to handle cash for programme activities and the impossibility of payment by mobile money in areas that are too remote for connectivity) to critical situations for which forceful operational decisions are required. One of the most common situations is related to the difficulty of accessing the population in areas where security is no longer assured.
Delays are a recurring problem; and are linked to a lack of anticipation and to the cumbersome procedures that accompany implementation. One of the worst is the abuse of “No-Objection notices“ by the Global Fund Country Team when activities have been planned and validated by the Secretariat at grant-making and there is no policy that requires them to receive further ‘permission’; yet this request for an additional No-Objection occurs all too frequently. Even fiscal agents have been known to ask for No-Objections so that they are additionally ‘covered’ (a kind of ‘double indemnity’) and these No-Objections often lead to weeks if not months of delays while permission is sought.
Another is the cumbersome and time-wasting reprogramming process. Little use so far has been made of rolling reprogramming, whereby a good programme is above all a flexible programme. This would mean that instead of many weeks spent reprogramming once a semester/trimester, activities that are not implemented in one month are either rolled to the next, postponed even further or cancelled, and the savings made are then spent on other activities that can take their place as in the CAR example below. This is an example of grant flexibility use that was unforeseen: the repeated use of unspent programme funds on important activities that have arisen but were not originally planned for. In CAR, for example, this allowed the funding of community-based monitoring.
Another example is the response package for gender-based violence, which is on the rise in Mali linked to growing insecurity in certain areas. To guarantee programme delivery in areas that were considered too risky, the Mali team contracted six international organizations present and already working in the centre and north of the country. Thanks to this partnership, these regions’ populations have access to life-saving malaria, HIV and TB prevention and care programmes. Of course, a higher-than-usual risk appetite had to be negotiated, and the usual Local Fund Agent checks could not be conducted. On the other hand, the non-government organizations (NGOs) agreed to commit to reporting on their activities according to the methodology they use with other donors, and the results seem encouraging. The Global Fund has stepped out of its comfort zone by negotiating on terms that are not usual, and it can now be satisfied that it is covering the needs of millions of additional people in a country where those needs are immense. On their part, the NGOs recognise that this experience has increased their capabilities because of the use of the Global Fund's tools and the expansion of their activities.
Before the next grant funding cycle begins, it is important to identify and analyse the operational difficulties faced by implementers. The grant flexibilities listed by the participants at the African Constituency Bureau’s Lomé workshop in June show that the majority of the solutions address procedural issues, but not the operational difficulties, which are constraining the achievement of results. Authorities in the COE countries therefore need to look at the bottlenecks, analyse them in the context of the operational objectives, discuss them with the implementing actors financed by the Global Fund and other donors, and propose a list of solutions. It is this list that should be discussed with the risk management professionals in the Global Fund who should then provide the formulae that will allow implementation to proceed according to plan.