Voices of the People II: Sub-Saharan Africa and MENA 1 Partnership Forums
The Global Fund convened its 6th Partnership Forums in a series of ‘virtual’ consultations. Different stakeholder groups from a number of subregions came together to exchange their experiences and formulate recommendations that will steer the development of the next Global Fund Strategy from 2023 onwards.
The second set of meetings in the Sixth Partnership Forums covered Western, Central, Eastern and Southern Africa (Sub-Saharan Africa/SSA) and the Middle East and North Africa (MENA 1), the latter representing Algeria, Djibouti, Egypt, Eritrea, Mauritania, Morocco, Somalia, Sudan and Tunisia. Participants from six other countries in the MENA II region attended the third Partnership Forum with the Asia and the Pacific region and this is reported on separately (Voices of the People III ).
The Global Fund asked participants to review inputs received on strategy development and 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. Breakout sessions were based on the topics that had emerged from the evidence gathered on Strategy development throughout 2020. Participants also reflected on the effects of COVID-19 and broader changes in the health and development landscape.
The Partnership Forums resource center contains useful information through background notes and other documents that formed the basis for discussions.
What have SSA and MENA 1 regions achieved so far with Global Fund resources?
Figure 1 shows the results to date of Global Fund supported programs in the two regions.
Figure 1. Achievements to date in Sub-Saharan Africa and MENA I
Progress towards the 2030 Sustainable Development Goals (SDGs)
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. COVID-19 threatens to reverse the gains: health and community systems are overwhelmed, with treatment and prevention programs disrupted and resources diverted to deal with the coronavirus pandemic.
HIV: progress, challenges and priorities
Progress towards 2030 targets in SSA is, at best, moderate. Eastern and Southern Africa (ESA) saw the largest decrease in new infections since 2010 (38%) but sustained momentum is required if the HIV targets are to be reached. West and Central Africa (WCA) has a smaller HIV burden but lags behind its targets despite a 25% reduction of new infections. Eswatini stands out as the only country in the world to surpass its HIV targets. Gender dynamics must be addressed to reach targets: in 2019 adolescent girls and young women were 2.5 times more likely to contract HIV than their male peers in ESA and 2.3 times more in WCA. Strengthening the integration of human rights interventions to address violence towards women and girls and discrimination as barriers to HIV services must be addressed if the regions are to make better progress. Prevention coverage gaps and the structural drivers of infection need to be addressed to improve incidence reduction. Key and vulnerable populations (KVPs) and their partners remain disproportionately affected – 28% of new infections in ESA and 69% in WCA. The prevention of mother-to-child transmission and pediatric treatment gaps also remain to be addressed. In WCA, only 58% of pregnant women living with HIV received antiretroviral therapy in 2019.
The MENA 1 region is off track to meet 2030 targets with a 22% increase in new infections since 2010. KVPs and their partners remain disproportionately affected, representing 97% of new HIV infections. To make better progress, countries in the region need to strengthen the integration of human rights interventions and scale up prevention programs, addressing punitive laws, stigma and discrimination as barriers to services and, in particular, tackling the social determinants that drive increasing incidence.
Tuberculosis: progress, challenges and priorities
Despite some progress in SSA – the World Health Organization (WHO) Africa region saw a 16% incidence reduction and 19% death reduction from 2010 to 2019 – the region is off track to reach 2020 End TB targets. The reduction in the death rate is largely attributable to the rise in antiretorviral therapy (ART) coverage (from 24% to 70%). Nonetheless, some TB mortality is due to late diagnosis and suboptimal quality of service. This region has the highest TB-HIV co-infection rates among WHO regions. The scale up of TB preventative treatment (TPT) is a challenge – delivery and reporting need to be strengthened. TB care and prevention measures for KVPs have not been scaled-up to the extent needed to have impact; and undernourishment and HIV coinfection remain the top risk factors attributable to TB cases. To achieve better progress in addressing TB, SSA countries need to focus more effort on finding and treating missing people with TB/drug-resistant TB (DR-TB) through more and enhanced engagement with the private sector and communities. While there has been progress, an estimated 51% detection gap still persists; and treatment coverage notifications are lagging behind, especially for children.
MENA 1 is off track to meet 2030 targets – although between 2010-2019 the WHO Eastern Mediterranean region saw a 3.5% incidence and 11% death reduction. The treatment success rate is high at 91% but gaps persist in TB screening and TPT among people living with HIV. There has to be greater focus on finding and treating the missing people, especially from high risk and vulnerable groups – 75% of people with HIV-associated TB are unreported. In the Eastern Mediterranean region, the proportion of HIV-positive patients who died during TB treatment was 10% compared to 2% of all new and relapse cases.
Malaria: progress, challenges and priorities
For SSA, progress towards 2030 targets is mixed: Botswana, Cabo Verde, Ethiopia, the Gambia, Ghana, Namibia and Togo have achieved the 2020 Global Technical Strategy (GTS) milestone target of a 40% incidence reduction; and Zambia and Zimbabwe made good progress, with 33% and 30% respectively. In contrast, Burundi, Comoros, Eritrea and Eswatini saw increases in incidence of more than 40%. Ten out of 11 High Burden High Impact countries are in SSA. Accelerating progress will require investment in new approaches and better data quality and reporting. Drug and insecticide resistance is impacting the future of malaria; in ESA’s high transmission countries, vector resistance was confirmed in all reporting countries. Domestic resource mobilization is crucial to address the financing gap.
MENA is off track in meeting the 2030 targets; malaria incidence in the Eastern Mediterranean region increased by 15% and deaths by 16% between 2010-2019. However, Algeria was certified malaria free in 2019. Humanitarian emergencies, population displacement and fragility have impacted malaria progress together with climate change, with frequent floods recorded.
Resilient and sustainable systems for health (RSSH): progress, challenges and priorities
Unsurprisingly, across both regions COVID-19 is presenting significant challenges to health systems and domestic resource mobilization, the impact of which is still unknown.
Countries in SSA are off-track to meet 2030 targets; the WHO African region has the lowest UHC Service Coverage Index (SCI) value of all regions. Data quality remains a key challenge. The Global Fund has invested in data in SSA as a priority; for example, in the District Health Information Software (DHIS) 2, and Zensyis in Rwanda. Community systems play a crucial role in reaching the most vulnerable. National strategies for community health workers (CHWs), community-led monitoring and social contracting represent key opportunities. Quality of care varies across the region and is a large and challenging area of Global Fund and domestic investment. It is estimated that 36% of all health expenditure was out-of-pocket in 2017 in SSA and TB households were disproportionately affected by catastrophic health expenditure. Private sector engagement is critical since 30% of households use the private sector for treatment for children with a fever, according to a 2015-2019 survey.
MENA 1 is off track to meet the 2030 targets: the UHC SCI value in MENA is 68.52 (out of 100), an increase from 66.8 in 2015, putting MENA just slightly above the global average. It is estimated that 34% of all health expenditure was out-of-pocket in 2017; 13.5% of the population faced catastrophic health expenditure at the 10% threshold just above the global average.
Equity, human rights and gender
Throughout SSA key inequalities persist across income, geography, age and sex, perpetuating barriers to access to quality prevention, care and treatment and health outcomes. The Global Fund aims its funding to address equity barriers and human rights barriers, including by working in partnership with community and civil society organizations to reach underserved populations. Of the 20 countries that are part of the Global Fund’s Breaking Down Barriers initiative, 11 are in SSA. Gender dynamics must be addressed: there is 2.7 times higher HIV incidence in women aged 15-24 years than in men of the same age. In WCA, women and girls accounted for 58% of new infections in 2019; while in ESA they account for 60%. Overcoming human rights barriers is key: in WCA, gay men and other men who have sex with men make up 21% of new HIV infections. Key populations are often stigmatized, and there are challenges in addressing social norms and behavior.
In MENA 1 stigma and discrimination are barriers to health services that must be addressed by the Global Fund in the next Strategy. The Strategy must also take account of women living with and affected by HIV in the region who are particularly vulnerable to gender-based violence and stigma. The Global Fund must better address the region’s human rights barriers, including punitive laws and policies, that impact women and KVPs, as well as expanding support to stronger dvocacy efforts.
COVID-19 and global health security
Across SSA, COVID-19 has negatively impacted the most vulnerable communities and progress against the three diseases. In South Africa, monthly TB notifications fell by 50% between March and June 2020. ~$616.7 million for SSA had been approved through the Global Fund COVID-19 response mechanism (C19RM) as of January 2021. While the death toll from COVID-19 in SSA is lower than initially projected (see our article on the lack of research on COVID-19 in Africa ), vulnerable populations are disproportionately impacted. Accessibility to health services is an issue for the most at-risk: in a recent SSA study 15.9% of people aged 60 years or older reported travel times longer than two hours to access any health facility. Lessons learned from the Ebola pandemic demonstrated that investments in preparedness capabilities, especially health surveillance and capacity building, are essential for fending off and, when necessary, dealing effectively with infectious disease outbreaks (see the article in this edition of the Global Fund Observer on Rwanda’s preparedness to fight COVID-19).
For MENA 1, COVID-19 is putting a strain on the most fragile health systems. ~$3.3 million for the region had been approved through the C19RM as of January 2021. The importance of preparedness was underscored when the recent Middle East respiratory syndrome outbreak demonstrated the effectiveness of investments in this area. The most vulnerable are disproportionately affected, exacerbated by internal displacement and the flow of refugees, putting additional pressure on already fragile health systems.
How the Global Fund can strengthen its impact
Delivering outcomes against HIV
To strengthen impact and deliver outcomes against HIV, participants made several recommendations. One was to scale up work on adolescents’ and women’s rights by including more youth participation and directly allocating funding to community level interventions to develop capacity and systems.
Participants called for increased support to better integrate HIV programs with national health systems (including sexual and reproductive health and addressing teenage pregnancy); to be accompanied with improvements in data recording and reporting.
To eliminate barriers to accessing HIV services – and health services generally – participants called for the next Strategy to better recognize the needs of children and people with disabilities, and the need to increase support for adolescents, women and KVPs to access justice for human rights violations and the review of laws that constitute barriers to accessing health services.
Delivering outcomes against TB
The main recommendations were that the Global Fund should: strengthen monitoring and evaluation support; allocate more funding and leverage increased funding to TB programs from domestic resources and other donors; strengthen its coordination of other actors to avoid duplication and maximize efforts; strengthen community systems and evidence-based community activities; and fund the development and adoption of new tools.
Furthermore, there was a general feeling that TB-HIV co-financing has not been effective; hence participants want the Global Fund to apply pressure for contributors – governments and others – to fulfill commitments made in this area. With the current environment and challenges presented by COVID-19, participants also expressed concerns that funds for TB, human resources and other health programs were being diverted to the fight against Covid-19.
Delivering outcomes against malaria
To strengthen the impact against malaria, participants made three principal recommendations. First, strengthen community ownership/participation in malaria programs by increasing investment in: service delivery decentralization, community-led responses (in turn calling for an expanded range of trained CHWs), community systems, and making malaria commodities available at that level.
Second, strengthen research and service delivery by supporting: research and introduction of new tools, including increased funding of indoor residual spraying interventions in high burden areas and research into vaccines and drugs to address resistance issues; the use of real-time data including community driven data; and the increased local manufacture of malaria commodities.
Third, the Strategy must scale up programs for KVPs. To ensure that fragile populations such as displaced persons and people in war zones receive appropriate malaria services, it was recommended that the Strategy call for adequate support and funding for cross-border collaboration.
Integration and systems for health
Participants made recommendations on: RSSH, community systems strengthening (CSS), addressing the social determinants of health and improving quality of care. Establishing RSSH is a complex area but suggestions included: build civil society capacity, de-incentivize exploitation in the form of unpaid CHWs, ensure that investments in civil society actually go to civil society and not elsewhere, map and share how communities have used RSSH investment in the responses against specific diseases, and make direct and ring-fenced investments in RSSH.
For CSS, the recommendations included: investment in CHWs, programs for adolescents, monitoring, social accountability mechanisms, advocacy, and fighting stigma.
To address the social determinants of health and improve quality of care, participants felt that the Global Fund needs to recognize the peculiarities that the two regions have in their different communities. Although both regions have refugees, those refugees are not found everywhere and hence there is a need for a differentiated service delivery models. While there was, again, a call for institutionalizing community health systems, there was also a call for increased transparency and for accountability for performance.
Adapting to a changing environment
Recommendations were made on global health security (GHS); climate change and the environment; challenging operating environments (COEs); and responding to COVID-19. The Global Fund can best contribute to GHS by focusing on complementarity and leveraging partnerships for GHS while it continues to support the disease programs; by strengthening – but not supporting – health systems; and by increasing community engagement and community-driven interventions.
To better adapt to climate change and the environment, stakeholders recommended that the Global Fund: support social protection intervention measures that address natural disasters (for example: cash transfers, sanitation and shelter); improve public health infrastructure and building resilient development strategies to strengthen ecosystems; increase community resilience to COEs; and establish a funding stream that goes directly to the UN agencies assisting displaced persons and refugees.
To better deal with the needs in COEs, participants recommended that the next Strategy should allow for more flexibility and make provision for a more timely response to emergency situations.
COVID-19 has shown the need to invest in emergency preparedness and disaster risk reduction, including building resilience within country health systems and communities. It has also highlighted the need to ensure that marginalized communities are not further marginalized when a pandemic occurs.
Equity, human rights, gender, and KVPs are cross-cutting themes. To further support progressive change in these areas, participants made many suggestions but the most important recommendations in this area were for the Global Fund to shift Country Coordinating Mechanism (CCM) evolution to allow communities more decision-making power and to directly fund the entities implementing and doing the real work on equity, human rights, gender and KVPs. This would mean investing in differentiated and context specific interventions.
Strengthening impact by country context
Participants’ recommendations covered: data driven programming at all levels; sustainability, transition and co-financing; and managing risk as potential barriers to impact.
The Global Fund was asked to strengthen all data-driven programming by: supporting the development of electronic management systems; ensuring that countries have costed plans for electronic health systems including collaboration and integration, as some partners are not using DHIS 2; and investing in integrated community systems/data.
The composition of and challenges facing KVPs vary from one country to another. Participants recommended that more attention be paid to understanding those communities within the country context.
To strengthen sustainability, transition and co-financing, the Global Fund was asked to support fiscal space analysis and continue its advocacy for increasing domestic health financing. However, the Global Fund should consider the impact of COVID-19 (possibly among other crises) on a country’s eligibility and ability to transition; and bear in mind that increasing domestic financing for health is not just for the three diseases.
Stakeholders recommended that the Global Fund be less risk averse and pay more attention to mainstreaming innovations. This calls for greater flexibility, including upholding country ownership so that countries can adapt their approaches and priorities as their needs evolve, including flexibility in the grant management cycle.
Partnerships to support effective implementation
To strengthen partnerships, participants recommended: strengthening community, civil society engagement and leadership of responses; improving the partnership model to strengthen program effectiveness; and adapting and strengthening CCMs.
For the first recommendation, the Global Fund could: establish a special funding track for communities and civil society; expand partnerships beyond disease components, strengthening systems for health; and engage more with country stakeholders through the disease Plans.
Participants recognized that the CCM model provides opportunities for diverse stakeholders to participate in decision-making processes, which is a real strength. This mechanism also provides a way for the Global Fund to facilitate progress on human rights, gender, and community aspects; also a strength. However, CCMs can sometimes be overly bureaucratic at the expense of programs. Also, the engagement of CCMs with civil society and KVPs varies across countries and is not meaningful in some countries; and RSSH representation on the CCM is not strong because RSSH involves many parties and CCMs may not have the breadth of knowledge and experience of health systems.
Participants recommended that the next Strategy advocate and lobby governments, donors and regional bodies to increase their financial support for health; and examine the possibility of leveraging innovative financing, for instance prepayments and risk pooling, loan buy-downs, debt swaps and targeted levies.
This article is a mere snapshot of the main highlights of the common and cross-cutting priorities and recommendations made by stakeholders but does not in any way capture the full extent of the varied and wide-ranging discussions that took place at the pre-regional and country stakeholder consultation meetings and at the Partnership Forums.