The Global Fund to fight AIDS, Tuberculosis, and Malaria is developing its post-2022 strategic plan. The Global Fund has requested input from partners, implementers, and other stakeholders to help identify emerging challenges and opportunities that will be critical for its next strategy. The Africa Constituency Bureau (ACB), which supports the representation of 46 African countries in their engagement with the Global Fund, convened a series of virtual meetings of the representatives of those countries to discuss key challenges and achievements, and collect input for the next strategy.
Sub-Saharan African countries receive 72% of the Global Fund funds. These countries form two constituencies: West and Central Africa (WCA) and East and Southern Africa (ESA). Most countries use English or French as their official language. Fourteen countries participated in the francophone cluster of WCA & ESA: Burkina Faso, Cameroon, Central African Republic, Chad, Congo, Côte d’Ivoire, Gabon, Guinea, Guinea-Bissau, Madagascar, Mali, Niger, Senegal, and Togo. Their representatives met on 25 June 2020. Seven countries participated in the anglophone cluster: Eswatini, Ghana, Kenya, Mozambique, Namibia, Nigeria, and South Africa on 26 June 2020. Though Portuguese is the official language of Guinea-Bissau and Mozambique, they joined the francophone and anglophone clusters respectively. As only 21 countries participated in the two calls, ACB resolved to call the other CCM (Country Coordinating Mechanism) secretariats separately for their views.
Dr Zweli Mkhize, the Global Fund Board Member for the ESA constituency and South Africa’s Minister of Health, as well as Dr Nduku Kilonzo, the Strategic Committee member, participated in the meeting for the anglophone cluster. Prof. Pascal Niamba, Chair of the ACB Board and Ethics and Governance Committee (EGC) member, and Dr Mele Djalo, Strategic Committee Member, participated in the meeting for the francophone cluster.
Language and time differences posed logistics challenges for the virtual meetings, but the most significant logistic issue was the inconsistent internet connection that hampered fluid communication. As it was difficult to ensure that all participants heard the discussion, the ACB requested that each country share a summary of their contribution via email within a week of the meeting. The ACB has also obtained funding from the British development agency, DFID (Department for International Development), to provide a secure platform for virtual meetings for all CCMs who work with them.
Challenges of grants implementation during this strategic period
Participants emphasized the importance of the four current strategic objectives and insisted that they should not be disregarded. They then discussed challenges and associated solutions. Those challenges are rarely new or unique to specific countries. However, they are influenced by the country context.
Weak health systems Weak health systems are a huge problem in sub-Saharan Africa. This could be due to security issues (civil war or terrorism in fragile states), economic problems, or poor governance.
Health system weaknesses include inadequate infrastructure, insufficient human resources in quantity or quality, poor data systems, and fragile supply chains. Some participants explained that a weak health system directly affects the grants’ performance and the ultimate goal of saving lives. For instance, a weak supply chain system often results in Antiretroviral (ARV) stock-outs that disrupt patients’ treatment. Several countries experienced stock-outs of ARV or tuberculosis (TB) medications in recent years. This has been extensively documented in audits by the Global Fund’s Office of the Inspector General.
Participants of the meeting insisted on the importance of data quality as a pillar for good program planning and performance. High quality data is needed for effective grant management as well as to test, treat, and retain patients in treatment. The WCA participants discussed the low proportion of HIV-positive persons who know their status and the region’s lack of progress with regard to meeting the ambitious 90-90-90 UNAIDS goals. (The targets are that by 2020, 90% of all people living with HIV know their HIV status, 90% of those who tested positive are on treatment, and 90% of those on treatment have viral suppression.) (See more on that target in an article in this issue).
Service delivery to key and vulnerable populations
Delivering services to key and vulnerable HIV populations remains a challenge in most participants’ countries because of criminalization and stigmatization. Key populations for HIV include drug users, sex workers, men who have sex with men (MSM), whose activities are often criminalized. In this context, programs to identify and provide them with services are often challenging. Vulnerable populations to HIV include adolescent girls and young women; the highest rates of new HIV infection are found among them in sub-Saharan Africa.
Participants acknowledged that without appropriate management of the key population issue, the HIV epidemic could not be controlled.