The Global Fund to fight HIV, TB and malaria invest in countries following a step-by-step process. It decides on the Global Disease Split using epidemiology and income category to obtain a formula-derived allocation per country. Then, the Global Fund conducts “qualitative adjustments”.
What is the qualitative adjustment?
Qualitative adjustments are refinements to formula-derived amounts (FDAs) to account for epidemiological, programmatic and other factors insufficiently addressed through the allocation formula, to maximize the impact of Global Fund resources in line with the Strategy. For the 2020-2022 allocation period. The qualitative adjustment itself goes through two phases.
Phase 1 consists in adjustments for key populations (KPs) for HIV. In other words, at this stage, the Global Fund reduces the formula-derived allocation for countries with a high prevalence to give to countries with low prevalence but a concentrated epidemic in Key populations.
Phase 2 adjusts for key programmatic factors and other contextual considerations like whether the countries is a Challenging Operating Environment, the program effectiveness in the previous cycle, the absorption.
All changes and rationale are reported to the SC, and all changes greater than $5 million and 15% are reported to the Board.
What does the qualitative adjustment aim to achieve?
Through qualitative adjustment the Secretariat redistributes resources from countries favored by the formula-driven allocation (those with a high burden of disease and lower ability to face the epidemics) and with or without bottlenecks in grant implementation towards others with lower disease prevalence but higher concentration of the disease in key populations. Some of the receivers are in our constituencies: they are countries that showed stellar performance in the past like Rwanda, or other like Central African Republic trying to rebuild from a recent past of conflict. Most receivers are not in our constituencies but our constituencies are convinced of the need to save lives in danger wherever they may be.
Different epidemics in sub-Saharan African and outside sub-Saharan Africa
In sub-Saharan Africa, HIV epidemic is concentrated among AGWY and women
Figure 1: distribution of new infections and population in sub-Saharan Africa
Source: UNAIDS – Confronting inequalities
AGYW (age 15-24) who represent only 10% of the population account for 25% of new infections.
In addition, in ESA, HIV is a disease of women: about 60% of people living with HIV are women (with small variation depending on the country according to the UNAIDS).
The situation is quite different outside our constituencies
Figure 2: Distribution of new HIV infection and population outside sub-Saharan Africa
Source :UNAIDS – Confronting inequalities.
As we miss pregnant women with timely care mostly in our constituencies, we then miss their children: 90% of the 800 000 children with HIV who are not on treatment are in sub-Saharan African (Reference UNICEF).
Figure 3: Distribution on pregnant women living with HIV not on treatment by region, 2020
In West and Central Africa although the prevalence of HIV is much lower in general, it remains high in key populations and their partners.
Figure 4: Distribution of new HIV infections by key populations among those age 15–49 years, western and central Africa, 2020
Malaria in West and Central Africa: Malaria
According to the World Malaria Report 2021, 95% of the malaria cases occur in the WHO African region and 2% in the WHO South East Asia region. We expect that the formula and the associated qualitative adjustment will follow the evidence and address the situation.
What happened during the last qualitative adjustment?
Our constituencies analyzed the results of the qualitative adjustment for the 2020-2022 cycle for countries for which the change was at least 15% of the allocation or 5 million. We acknowledge all countries are not listed in this report, so the below analysis is partial. But our analysis remains insightful considering the parallel with the plans for this cycle.
The final results of the qualitative adjustment appear to
significantly reduce the allocation for most countries in southern Africa. For example, South Africa through qualitative adjustment got 92 million less (16%) than it would have in step 1, according to the report.
Significantly reduce the total allocation for countries in Central Africa
Mainly redistribute within Eastern Africa, and Western Africa with much smaller final change.
Some countries gained some resources in step 1 (HIV key populations) but were more steeply adjusted downward in step 2 (for malaria, absorption, others). Other countries moved in the opposite situation: Key populations adjustment resulted in moderated decreases in step 1 but performance and other factors made for steeper gains in step 2. Those changes were not limited to our constituencies as countries like Indonesia received downward adjusted allocations.
Overall, our issues with the qualitative adjustments and propositions are
Table 1: issues with the current methodology and propositions
· The single largest group of new infections in ESA, which are the adolescent girls and young women (AGYW) are ignored.
· Children not on treatment are ignored; the majority are in WCA and ESA; they do not appear to be included in the coverage indicators since those children are not identified yet.
The step one should include key and vulnerable populations in particular AGYW and children
· There is no cap on the amount or percentage change that can happen to the formula-derived allocation, so that the Secretariat can significantly change the results of the formula
We propose a cap of 10% on the change at the step 1
· Some changes applied are not clearly explained and as such appear arbitrary and not evidence-based. Such changes will be less damaging if they can be explained with reasonable or quantifiable redistribution criteria. For instance, each criteria like absorption, COE, international NGO and UN agencies cost can have a weight so that countries receiving more do not feel like they have received a favor and those “losing” do not feel like they are being penalized.
We propose a clear rationale for step two with a weight for each element of decrease.
As this redistribution takes place, it remains important that the Secretariat does not try to overturn the formula-derived allocation. Also, it needs to consider the specificities of the region where it invests.
After voting, the members of the SC agreed on the following, The next workplan plan of the strategy committee will take into consideration the African constituencies comments, the full report will be provided in December 2022 and the grant allocation will be fair as much as possible with African countries.