As stated in the preceding article, the 39th Global Board meeting approved six key policies – eligibility, Global Fund approach in non-eligible countries experiencing health crises, risk appetite framework, board leadership selection process, Country Coordinating Mechanism (CCM) code of conduct, CCM policy and CCM evolution including funding for it – all largely favorable to the African Constituencies. Even with the above key issues in the bag, the African Constituencies cannot rest on their laurels. There still is more work ahead to be done, if the world is to see the back of the three epidemics come 2030. This article discusses some key policy issues needing to critical attention to ensure epidemic control of HIV in 2020, halving malaria in 2023 and to ensure we remain on course to eradication of the three epidemics in 2030.
First, the elephant in the room for the next board and committee meetings is the 2020-2022 grant allocation methodology. This will be the policy that will device the methodology for distributing Global Fund resources in the 2020-2022 funding cycle. African Constituencies need to prioritize strategizing for this process to ensure the correlation between disease burden and fund allocation is not compromized. Key actions will include mapping current disease burdens and comparing with funding allocations to identify any gaps between the two.
The poor performance and absorption of resilient and sustainable systems for health (RSSH) grants clearly shows that a lot more work needs to be exerted on this front. RSSH being an area of strategic focus in the Global Fund’s 2017-2022 strategy, this poor performance does not bode well and will clearly be a lost opportunity especially given we are fast approaching the mid-point of the strategy. It’s critical to revisit the current approaches being employed to implement RSSH grants. Focusing on high impact catalytic RSSH interventions that yield greater impact would be a worthwhile hypothesis in the toolshed. Strengthening the capacity of implementers is equally critical. Further interrogation of RSSH implementation is equally critical, and the rapid assessment by WHO is welcome, which, it is hoped, will result in prudent course-correction.
Tackling the malaria resurgence is critical, if malaria is to be halved by 2023. The world witnessed tremendous progress in reducing the malaria burden between 2000 and 2015; deaths fail by more that 60% with seven million lives saved, six countries certified as having eliminated malaria,12 countries attaining zero malaria status and over 40 countries having fewer than 10,000 cases of malaria. However, progress thereafter seems to have stalled and we are now witnessing a resurgence. 2016 saw a reversal of the positive trend with more than 216 million cases in 91 countries, an increase of 5 million from 2015 largely due to dramatic increases in resistance for a number of insecticides used to treat malaria, resistance towards some of the malaria drugs, plateauing and in some cases declines in funding, climate change, losses of habitat and biodiversity caused by deforestation, as well as the large numbers of mobile and displaced persons and refugees. Combating this deadly disease requires not just more money but scientific innovations that will ensure our tools for prevention, detection and treatment of malaria evolves with the evolving environmental conditions. The malaria fight also need precision, based on data.
Finding the TB missing cases remains another strategic focus. More than 10 million people around the world get sick every year with TB, and 40 percent of them, including 600,000 children, fail to be diagnosed, treated, or reported by health systems. Finding the people missed by health systems is a major challenge, as is the growing problem of drug-resistant TB. The 2030 Agenda for Sustainable Development has set ambitious targets of ending the TB epidemic by 2030 and achieving universal health coverage. 95 percent of new TB cases and 98 percent of all TB deaths are in low- and middle-income countries, of which Africa constitutes 26 percent mainly in Nigeria and South Africa. With the UN high level meeting on ending TB slated for September 26 2018 fast approaching, its critical to put the spotlight on this deadly disease which, according to WHO in 2015, surpassed HIV as the leading cause of death. TB is also the leading cause of death in people living with HIV. We need a dynamic, multi-sectoral approach that ensures actions and investments match the political commitments.
Perhaps more specifically on the HIV front, three key issues stand out. With a dismal 42-35-25 attainment of the HIV testing and treatment cascade, ensuring West and Central Africa (WCA) catches up on the path towards achieving the 90-90-90 goals should be high on the agenda, and is critical to attaining epidemic control in the region.
Reversing the vulnerability of adolescent girls and young women (AGYW) to HIV infection is another critical issue. Over 360,000 AGYW get infected with HIV annually i.e. 20 percent of all new infections. In sub-Saharan Africa, where nearly two-thirds of all new HIV infections in 2016 occurred, more than twice as many AGYW were infected as young men. In the rest of the world, more young men were infected than young women. PEPFAR has been implementing the DREAMS initiative for some time now, and is scheduled to evaluate the initiative. This will be a critical learning point. From the Global Fund ecosystem perspective, the TERG report on AGYW points to the key recommendations which are reproduced in the text box above verbatim. Needless to say, its critical to triangulate lessons from both initiatives and ensure cross-fertilization of ideas.
Sub-optimal absorption of funds continues to haunt the African constituencies, particularly in the WCA region – Eastern Europe and Central Asia (EECA) and South East Asia (SEA) have highest absorption – and around RSSH interventions (54%). Given this poor absorption rate, over $1.1billion was unutilized at the end of the 2014-2016 grant implementation cycle and ploughed into the 2017-2019 funding cycle. Clearly, this picture has to change if goals are to be attained. One option is to have a deep dive into this situation to identify the actual bottlenecks. Another is to have a GSM-like mechanism to provide on-going TA to implementing countries.
Finally, the need for more funding is another elephant in the room. With Global Health resources projected to plateau, the need to tap into non-traditional sources of funds remains imperative. Innovative financing, blended financing, loan by-downs, Debt2Health, public private partnerships (PPPs), consumption levies, etc. are all means to ensure domestic financing continues to increasingly compliment global health resources. Equally important is ensuring that available funds are put to their optimal use, entailing efficiency, investing in rigorously proven interventions and curtailing mismanagement and misuse of funds, including corruption and graft. In all these ventures, African countries owe their citizenry prudence; countries should not be burdened with unsustainable debts nor should taxation cripple economic growth. And then there is the coming 6th replenishment of the Global Fund to be hosted by France. African must play its part to show-case the impact of the Global Fund, to champion for more funding and to contribute to the fund.
The Global Fund mechanism remains central to achieving HIV epidemic control in 2020, halving malaria in 2023 and eradicating the three diseases in 2030. Its success in contributing towards achieving these goals depends pretty much to how it succeeds in the African region – it cannot succeed without deliberately ensuring these issues are critically addressed. Africa has to play its part to ensure the issues are not just tabled on the decision-making processes but tabled with strong and rigorous evidence. Delving into these issues through policy research to interrogate and unpack them, and ensure consensus building around the African position means our work is already cut out for us. The African leadership should not be left out in all these processes.