Voices of the People IV: Africa calls for investments in health systems at the sixth Global Fund Partnership Forums
The Global Fund to fight AIDS, Tuberculosis and Malaria organized the 6th Partnership Forums for the Africa region from 15 to 18 February 2021. The Forums, entirely virtual due to the COVID-19 restrictions, reviewed input received on Strategy development to date and collected the perspectives of a wide range of stakeholders. The Strategy is a roadmap to guide the Global Fund towards the year 2030. The virtual Partnership Forums were launched with a global opening on 2 February, followed by three regional events. A global closing session will take place on 15 March.
Articles on EECA & LAC (Voices of the People I), Africa and the Middle East and North Africa I (MENA I) (Voices of the People II) and the Asia & Pacific with MENA III (Voices of the People III) meetings can also be found in this issue of the Global Fund Observer, together with an article on the Global Fund Advocates Network (GFAN) discussions (Voices of the People V).
In addition to the plenary sessions, discussions were organized around breakout sessions. The breakout sessions covered: Delivering outcomes against the three diseases; Integration and systems for health; Adapting to a changing environment; Equity, human rights, and gender; Key and vulnerable populations (KVPs); Civil society engagement and leadership of the response; Strengthening impact by country context; Partnerships to support effective implementation; Resource mobilization; and Market shaping, Procurement, Supply-chain and bringing innovations to scale.
Participants in the Partnership Forum
Participants represented African governments, civil society organizations (CSOs) and communities of people living with or affected by the three diseases. Among more than 150 invitees, less than 20% of them represented government implementers from Sub-Saharan Africa who manage approximately 70% of the Global Fund grants in this region. This region is represented on the Global Fund Board by two constituencies, Eastern and Southern African (ESA) and West and Central Africa (WCA). The constituencies are supported by the African Constituency Bureau which acts as their Secretariat. The African Constituency Bureau was formally launched in 2017 because, while African governments recognized that the Global Fund has provided valuable support to the African continent to save millions of lives, despite the Global Fund’s participatory approach in its decision-making ‘African voices were not adequately heard in global health discussions’.
Among the Forums’ attendees were Dr. Zweli Mkhize, South Africa’s Minister of Health and Board Member for ESA, Dr. Lia Tadesse, Minister of Health for Ethiopia, Dr. Brigadier General Gerald Gwinji, the alternate board member for ESA from Zimbabwe, and Professor Pascal Niamba, the Chairman of Burkina Faso’s Country Coordinating Mechanism (CCM) and Board Member for WCA.
African constituencies’ top priorities
In order to help African representatives to collect the inputs of the different countries and represent them effectively during the development of the Global Fund Strategy, the African Constituencies Bureau organized 20 regional consultative meetings on different topics with nominees designated by their CCMs. Those representatives were members of governments, civil society and communities. The collected insights from the consultative meetings were supplemented with commissioned thematic research to obtain evidence-based materials.
The findings of the consultative meetings and the research, presented as the key priorities, are reflected in a news article, the advocacy campaign AfricanVoice4GF, and related position statements.
The African Constituencies’ highest priorities are for the next Strategy to: (i) focus on HIV, tuberculosis (TB) and malaria as the Global Fund’s core mandate; (ii) strengthen resilient and sustainable systems for health (RSSH), including community systems, which would then contribute to Global Health Security; (iii) address human rights, gender and equity; (iv) reorient partnerships to optimize the Global Fund’s ability to achieve its ambitious mission amid unique challenges; and (v) support the West and Central Africa region, which is particularly lagging behind, to improve its performance.
Focus on HIV, TB and malaria
The three diseases remain a priority as 67% of people living with HIV, 25% of TB cases and 92% of malaria cases, globally, are in Sub-Saharan Africa. In the past two decades, the region has received substantial investments from the Global Fund. These investments, together with those of other partners and governments, have helped to significantly reduce mortality from those diseases in the region. For example, from 2010 to 2020, there was a 40% decrease in AIDS mortality in ESA, according to the Joint United Nations Programme on HIV/AIDS (UNAIDS).
Nevertheless, in spite of the considerable investments in SSA and notable declines in mortality, the region is still off-track to reach the United Nations Sustainable Development Goal (SDG) target 3.3 of ending the HIV, TB and malaria epidemics by 2030. These targets were also designed before the COVID-19 pandemic that has significantly affected health service delivery in this and other regions. Thus, it is unlikely that these epidemics will end without consequent and sustained investment in responses to these diseases and the health systems through which the disease programs are delivered.
Strong health systems are essential to end the epidemics
The African Constituencies called for investments in health systems that are nested within countries’ health plans and systems for sustainability. They strongly recommended that the Global Fund consider standalone grants to strengthen health systems when a country context makes it possible, as used to be the case under earlier Global Fund application rounds. It is not clear to the Constituencies why this is not still the case; currently, interventions to strengthen RSSH are usually included in the disease grants. While this practice limits the number of Principal Recipients and reduces management costs, it often leads to ‘suboptimal performance because the disease programs are not best placed to implement/manage broader health systems strengthening interventions', as the Global Fund Technical Evaluation Review Group (TERG) has asserted. The Global Fund’s Technical Review Panel (TRP) explained that when the disease programs submit funding requests in different funding application windows (there were eight windows for the grant cycle 2020-2022), with RSSH activities split between diseases, it becomes difficult to evaluate those RSSH interventions.
The Global Fund divides its resources into the three diseases so that 50% is allocated for HIV, 18% for TB and 32% for malaria. Countries themselves currently have the responsibility for deciding how much of the three diseases’ allocations go towards RSSH, and the amount or grant for RRSH is included within the disease grant. The split at country level depends on the burden of the diseases and other available funding. For example, WCA spends 56% of its Global Fund grants on malaria; the sub-region was home to about 68% of malaria deaths worldwide in 2019, according to the World Health Organization (WHO) malaria report. Standalone RSSH grants, not attached to any disease program and with its own document, would allow countries to manage designated RSSH funds, within the country’s allocation, separately from disease programs. These RSSH grants could be used to strengthen data systems or procurement and supply chain, for instance. Such resources could be supplemented with government co-financing and other donors’ funding. To prove the feasibility of the concept, the Global Fund could set up a pilot project for standalone grants in a similar way as it has piloted the CCM Evolution Project, before rolling it out to other countries. This pilot would look at why separate health system strengthening grants had not worked well previously and ensure that mechanisms to address the identified weaknesses of separate RSSH grants would be built into the pilot project design.
Financing is an important component of health systems. African governments need to invest more of their domestic resources to help fund the fight against the three diseases and strengthen the underlying health system. However, while governments may acknowledge the need to make more effort to meet their Abuja declaration pledge to set a target of allocating at least 15% of their annual budget to improve the health sector; at the same time, this comes as an almost insurmountable obstacle to resource-poor African countries. Only four or so countries meet the Abuja declaration and 18 of them spend less than 5%. Moreover, given the impact that COVID-19 has had on diverting spending from other health priorities, the likelihood of countries meeting the Abuja Declaration has receded even further into the distance.
The Constituencies recommended that the low-income African countries spend their co-financing on health system strengthening following the Global Fund Sustainability, Transition and Co-financing policy. To overcome the challenge of accounting for co-financing commitments, governments ideally need to develop national health accounts as part of health systems strengthening for their countries, or use their public finance management system. Currently, many countries spend their co-financing on purchasing commodities, partly because it then becomes easier to provide proof of meeting co-financing commitments.
Procurement and supply chain
Procuring and distributing health commodities like mosquito nets, anti-retroviral (ARV) medications and laboratory reagents is an essential function of health systems. The Global Fund spends 40% to 90% of the grants on purchasing health commodities depending on the country, according to the Office of the Inspector General (OIG). The COVID-19 pandemic and its associated supply-chain disruptions highlighted the danger of sourcing most health commodities from outside the continent. The Constituencies recommended that the Global Fund procure more health commodities from Africa whenever possible and support the regulation and quality control of drugs at the sub-regional and country levels.
Community systems, including community health workers, are an important part of the health system. For increased efficiency and synergy, they should be linked to the formal health system to deliver services to the community, and to refer people in need of care to the formal system. While many countries are supporting the improvement of the capacity of community workers, still more work has to be done to ensure better linkages between formal facility-based health care and that offered within the community. Improving these linkages is a significant factor in attaining better adherence to treatment, care and support programs and less lost-to-follow-up of individuals on medication.
Address human rights, gender and equity
Reducing human-rights and gender-related barriers to access to prevention, care and treatment for the three diseases is vital to end these epidemics. In Sub-Saharan Africa in 2019, adolescent girls and young women accounted for 59% of new HIV infections while representing only 10% of the population, according to an article in the Lancet. Key populations and their sexual partners accounted for 27% of new HIV infections in ESA and 69% in WCA. This higher prevalence among KVPs requires that countries address human rights, gender and equity issues, including the structural drivers of the epidemics, that make some groups more vulnerable to contracting HIV.
The notion of equity also applies to remote geographical areas and income categories. Affordable and quality health care to the last mile should reach the poor and hard-to-reach population groups. Thus, the African constituencies recommended that the Global Fund Strategy encourage countries in Africa to use their co-financing to fund user-fee waivers and support insurance premiums for poor and vulnerable populations with the objective of reaching universal health coverage (UHC) by 2030.
The African Constituencies called for the Global Fund to reorient its partnerships in several areas by defining its principles of ’country ownership’ and ’partnership’. One of the areas where Africans call for a reorientation is related to the provision of technical assistance (TA).
The Secretariat has long-term TA provision contracts with UNAIDS and WHO, among others. The most common practice, said many country representatives in the consultative meetings, is that these agencies, on behalf of the Secretariat, lead the needs identification, the recruitment of TA providers, and the evaluation of their work. Most often, the TA providers are international non-government organizations (INGOs) or consultancy firms; and, although they sometimes work with locally-appointed TA providers, the present system does not encourage national staff working on the Global Fund grants in their countries to ‘own’ the process and results of TA. Several participants stated that some TA providers are unfamiliar with the country context and this results in inappropriate or unworkable recommendations.
African countries also recommended the creation of a mechanism to allow them to evaluate and give feedback on the Global Fund processes and procedures as well as the staff they interact with. In addition, the constituencies suggested that program managers, through the CCM, should have access to the Global Fund Ombudsman services in the case of any dispute with the Global Fund Country Team.
Support the West & Central Africa region and other fragile countries in improving performance
Challenging Operating Environments (COEs) are ‘countries or regions characterized by weak governance, poor access to health services, and man-made or natural crises’ as stated by the Global Fund Board. About two-thirds of the Global Fund’s COE-designated countries are in WCA. Also, most WCA countries are low-income which correlates with weak infrastructure and human resources. Thus, some financial assurance processes that are easily applied in other settings, such as mobile money payments or asking for three quotations from providers, become difficult in some areas in COEs where there is an absence of good phone networks or when only one provider exists who also does not know how to write.
African constituencies recommended that the Secretariat apply greater flexibility in implementing the Global Fund’s procedures and processes in COE countries. The OIG review of WCA made the same recommendation earlier in May 2019, even indicating that some of those flexibilities are already available under the COE policy but are not always implemented.
This call for flexibility should not be confused with a call for lax accountability. On the contrary, it is a call for increased programmatic accountability. Achieving better program results in COE countries often requires an increase in risks, as suggested earlier by the Risk Management Report to the Global Fund’s 44th Board meeting.
The complementarity of civil society organizations, communities and governments
African Constituency participants stressed the importance of communities being at the center of Global Fund-supported activities. Participants from ESA and WCA governments emphasized the complementarity of governments, civil society and community organizations. They explained the important role that efficient and accountable governments play in service delivery to the communities. Some activities are essential functions of the state, such as allocating national resources or passing laws. Other activities, such as outreach to marginalized communities or additional accountability for resources at the facility level, are better led by communities. They added that one cannot replace the other, thus both sides should not be in competition. Rather, each side’s unique role should be acknowledged
.Editor Note: There are signs that the Global Fund designated TA activities are seeking to involve more local institutions. For example, the Differentiated Service Delivery (DSD) Strategic Initiative (SI),with overall guidance provided by UNAIDS and WHO, has selected several INGOs who will work with national TA providers in ten designated countries to pilot DSD projects or strengthen existing ones. This SI will be evaluated by a firm selected by the Secretariat to undertake an independent evaluation. In this way, there will be an exchange of experiences between INGOs and local institutions, and capacity-building of local institutions where required; and lessons learned for feedback into improving national DSD delivery.