Prospects for the Sustainability of Global Fund Grants

A meeting of the Cluster-Based Learning Network (CBLN) of the African Constituency Bureau (ACB) for West and Central Africa (WCA) was held in Dakar, Senegal on 12 – 14 December 2023. It brought together 12 countries from West and Central Africa (Benin, Burkina-Faso, Côte d’Ivoire, Ghana, Guinea-Bissau, Mali, Niger, Nigeria, DRC, Senegal, Chad and Togo) and 30 delegates from the sub-region. The meeting, supported by L’Initiative, enabled participants to address issues such as (i) the sustainability of Global Fund grant outcomes, including domestic resource mobilization for health and government co-financing for the next cycle, (ii) the implementation of RSSH grants and activities, including the alignment of resources from the C19RM mechanism and the Pandemic Preparedness Fund, and (iii) Experience and lessons learned in HIV, TB and malaria (HTM) prevention and care for people living with or affected by the diseases in countries with Challenging Operating Environments (COEs) and non-COE countries in the region, and issues around governance, coordination and leadership in the implementation and oversight of Global Fund grants (including Country Coordinating Mechanisms).

The meeting, attended by representatives of Country Coordinating Mechanisms (CCMs) and Principal Recipients (PRs), gave participants a better understanding of their operating environments. In the process, countries with COEs and those under the Additional Safeguards Policy (ASP) had the opportunity to explain to those who are not classified in these categories, the difficulties associated with these two policies. The two policies, which often tend to be confused, are risk mitigation measures designed to ensure the sustainability and integrity of the Fund’s investments. While the COE policy applies to countries experiencing “chronic” instability (armed conflict, chronic drought, etc.) and gives greater flexibility to the countries concerned, the ASP aims to reduce the risk of financial mismanagement.

Country Coordinating Mechanisms

The CCMs were created to bring together all the stakeholders involved in Global Fund grants in a country such as the public sector, communities, the private sector and technical and financial partners. The aim was to bring their representatives to the table so that their voices are heard, and their problems reflected in funding requests and grant implementation. During the debates, participants noted that the diversity in the leadership of these entities – public sector, private sector and civil society – provide a multi-sector and multi-disciplinary dimension, which in the participants’ opinion, makes the CCMs a platform a model for duplication in other sustainable development fields.

CCMs provide an excellent opportunity to share responsibility for country ownership of Global Fund policies, and to ensure coordinated implementation of Global Fund grants and in the process help foster partnership, accountability and sustainability. Click & Tweet! Côte d’Ivoire’s CCM is often cited as an example in this regard (see Box 1 below)

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Box 1. Côte d’Ivoire’s Country Coordinating Mechanism Côte d’Ivoire’s Country Coordinating Mechanism (CCM) is an inspiration in terms of governance, country ownership, and funding management. Côte d’Ivoire has shown exceptional leadership in funding the CCM. The Ivorian government provides the CCM with a sum of around 200,000,000 FCFA per year and employs nineteen staff; while the GF budget of 300,000 Euros over three years, i.e. 196,782,000 FCFA covers recruitment of just three staff. Going forward, Côte d’Ivoire’s CCM plans to serve as a multi-sectoral platform for other diseases that fall outside the ambit of the Global Fund.

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The institutional anchoring of CCMs also gave food for thought. Some CCMs anchored at the Prime Minister’s Office or the Presidency of the Republic in their country felt that this positioning enables them to have a better grasp of health issues linked to HTM than they would have if they were anchored at the Ministry of Health, for example. Other CCMs anchored in the Ministry of Health appreciated their proximity to implementing actors.

Challenges faced by CCMs

The CCMs concured that once the funding requests have been submitted, they are completely sidelined when contracts are signed, which makes for an uneasy relationship with the country’s PRs. The inadequate integration of interventions across the HTM programs was also identified as a challenge by some CCMs.

On another note, civil society involvement in CCMs is still low, according to Simon Kaboré, Executive Director of the Réseau Accès aux Médicaments Essentiels (RAME). On this issue, he pointed out that a study carried out by the Global Fund’s Francophone Africa Regional Platform in 2019-2020 in the West and Central Africa region, revealed that only one in three PRs is community-based (local NGO), a trend that is also felt in service delivery. The other PRs are from the government or international NGOs and institutions.

Tackling HIV, TB and Malaria

A review of grant performance in West and Central African countries, presented by a Global Fund team at a Cluster-Based Learning Network meeting, showed improved performance in the fight against HIV, tuberculosis and malaria. The overall absorption rate for West and Central Africa as of  31 December 2022 stood at 75%, which was a 5% increase compared with the previous cycle. The region also stood out in terms of its budget utilization rate (93%) (see Figure 1 below).

Figure 1

These results indicate an increased capacity in the WCA region to use funds effectively if this positive trend is maintained. Significant improvements in absorption were observed across all interventions, with the exception of infrastructure, non-health equipment and human resources for health, which require further attention.  At the same time, there was a low absorption rate of funds allocated to the Covid-19 response, which even though they helped to strengthen health systems, remains relatively low at 31%; the reasons behind this gap often include issues related to tender procedures and the acquisition of inputs, administrative red tape and so on.

Slow Progress in the Fight against HIV

On the 95-95-95 targets for 2025, the countries of the sub-region are lagging behind with only five countries in Africa (Botswana, Eswatini, Rwanda, the United Republic of Tanzania and Zimbabwe) having fulfilled the 95-95-95 targets, none of which are in West and Central Africa. Prevention of mother-to-child transmission appears to be a major challenge in the sub-region (see Box 2 below).

Box 2. Chad’s Fight Against HIV  Chad in Central Africa is classified as a COE and under ASP. In Grant Cycle 6 (GC6), the country reported some progress in the fight against HIV. Since 2020, the country has made significant progress on the 90-90-90 front, marked by an increase in the number of people who know their HIV status from 79% to 85%, and in the number of people on antiretroviral treatment from 59.20% to 63%, which demonstrates a clear political will to put an end to the disease.  Chad shared that 40% of new infections are in children, indicating a high rate of contamination, due in part to discontinuity of care for HIV positive women, inadequate follow-up of people living with HIV, and gaps in testing. “According to available data, Chad has around 110,000 people living with HIV, including 7,000 HIV-positive pregnant women, and 1,300 new cases of pediatric infection”. Looking ahead to Grant Cycle 7, it is recommended to strengthen screening of the contacts of people living with HIV, increase resources in gold-mining and other mining areas, convert some specific prevention of mother-to-child transmission centers into comprehensive care centers, involve local communities in the fight against HIV to decentralize patient care, and improve access to resources for stigmatized people (notably homosexuals). In addition, the country is planning to expand activities on the Differentiated Service Delivery approach to keep mothers and children in the continuum of care.

 

To achieve better results in West and Central Africa, countries are calling for a demedicalization of HIV services, which are overly centralized at the national and regional levels of the health pyramid. Click & Tweet!

Tackling Malaria and Tuberculosis

Malaria and tuberculosis, on the other hand, lack funding.  According to the Stop TB Partnership, the global funding gap for TB is USD 249.98 million, and the cost of inaction is estimated at USD 1,000 billion.

For malaria in particular, in addition to the funding gap, countries noted that malaria control resources are inadequate. In most participating countries, insecticide-treated bednets account for around 2/3rd of program funding. The free distribution of these nets does not guarantee that they will be used, as evidenced by the gap between possession and use, indicating a certain level of wastage. This problem takes on added importance considering the rising costs of treated nets in a context of insecticide resistance and high transport costs. Many participants felt that a better targeting (pregnant women and children under five) might be more fruitful. These enriching exchanges once again demonstrated that learning from the field remains the best way to overcome the three diseases.

Exiting the Additional Safeguards Policy

Predictably, any meeting with representatives of the countries affected by this measure cannot be concluded without a passionate plea to get out of the policy. Countries have the impression that being placed under the ASP is tantamount to being admitted to death row, as the chances of getting out are extremely slim, even if the case of Côte d’Ivoire proves that this is not an impossible mission. Many countries, such as Guinea-Bissau, Congo and Burkina Faso, consider this classification unfair, as they have been placed under the ASP without being found “guilty” of misappropriating Global Fund resources or mismanagement.

Countries welcomed the African Constituency Bureau’s request for the OIG to audit this provision, which dates back to 2004 and has not been subject to any amendment. It is hoped that the Global Fund will better appreciate risk and consider country contexts. Similarly, countries recognized the importance of a good internal control system to reduce financial risks. Countries also called for skills transfer and capacity building.

The meeting closed with the adoption of a roadmap, the first activities of which will begin in January 2024.

Armelle Nyobe