Global Fund ObserverNEWSLETTER

Issue 343: 3 October 2018

GFO is an independent newsletter about the Global Fund.

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CONTENTS OF THIS ISSUE:

1. NEWS: Global Fund will ‘donate’ $5 million to Venezuela to provide treatment for HIV

BY DAVID GARMAISE

The Global Fund Board, responding to a proposal developed by the Secretariat in consultation with partners and civil society, has approved an exceptional $5.0 million donation to Venezuela as a “short-term humanitarian response” to the economic and health crisis in that country. The bulk of the funds will go to the purchase of ARVs. The rest will support civil society organizations to provide oversight and monitoring of the delivery of ARVs to patients. The funding is exceptional, as it is the first time Venezuela is receiving Global Fund support, and because the support is a ‘donation’ rather than a grant.

2. NEWS: U.N. General Assembly’s high-level meeting on TB called on leaders to reaffirm commitment to end tuberculosis by 2030

BY TINATIN ZARDIASHVILI

The United Nations General Assembly held its first High-level Meeting on Tuberculosis, to reaffirm Member States’ commitments to accelerating collaborative efforts to end the disease. Member States endorsed the ‘Political Declaration on TB’ calling for accelerated and concerted efforts against the disease.

3. NEWS: First OIG audit of Niger’s Global Fund grants applauds progress and calls for improvements

BY ADÈLE SULCAS Niger has made significant progress against HIV, TB and malaria in a ‘challenging operating environment’, but the Office of the Inspector General, in its first-ever routine audit of Niger’s

Global Fund grants, found problems in the supply chain, in the use of data, and in the coverage, quality and coordination of supervision.

4. NEWS: OIG audit of Global Fund grants to Myanmar reveals gaps in service delivery and supply chain management despite good results in other areas

BY DAVID GARMAISEA new audit of grants to Myanmar by the Office of the Inspector General shows that the country is making good progress in its fight against the three diseases, thanks in part to increased financial commitments from the government and initiatives to extend health care coverage. However, there are increasing concerns about how Myanmar can best plan for sustainability, optimize resources and bridge gaps in service quality.

5. ANALYSIS: Countries need better data for accurate forecasting of funding gaps in Global Fund grants

BY DJESIKA AMENDAHIn funding requests submitted to the Global Fund, countries provide estimates of future needs and gaps in funding, though many countries lack reliable and accurate data to project the future resources they will need. This situation begs the question of how future resource needs and gaps are calculated, and calls into question the reliability of such estimates.

6. FEATURE: Tanzania National Coordinating Mechanism aspires to become best-practice model for Global Fund’s CCM evolution initiative

BY ARLETTE CAMPBELL WHITETanzania, recently selected by the Global Fund Secretariat as one of the 18 countries to pilot the Secretariat’s 18-month CCM Evolution Initiative, has already forged ahead with its own plan to evolve its CCM, the Tanzania National Coordinating Mechanism (TNCM). The first TNCM retreat held in August this year has set the tone for transforming the TNCM into an effective management agency, by developing a transformation plan that will be integrated with that of the pilot CCM Evolution Initiative workplan.

7. OF INTEREST: Gates Foundation’s second ‘Goalkeepers Report’ tracks progress towards the Sustainable Development Goals

BY ADÈLE SULCAS In 2017, the Bill & Melinda Gates Foundation published its first Goalkeepers Data Report, tracking progress on 18 Sustainable Development Goals indicators (for the 17 goals) and analyzing promising approaches to achieving those goals. This year’s report is the second; the Foundation will publish one every year until the SDGs’ target date of 2030.

8. EDITOR’S NOTE: OIG explains why Sri Lanka appears twice in country list for audit report on Global Fund Transition Management processes

In GFO 342, an article on the OIG’s audit of Global Fund Transition Processes reported on the OIG’s inclusion of ten countries in the sample of countries reviewed for the audit. Here we clarify why one country, Sri Lanka, appears twice in that list.

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ARTICLES:

1. NEWS: Global Fund will ‘donate’ $5 million to Venezuela to provide treatment for HIV

The bulk of the funds will be paid into the PAHO Strategic Fund to purchase ARVs

The money will come from funds designated for portfolio optimization

David Garmaise 2 October 2018

The Global Fund will donate 5.0 million U.S. dollars to finance the procurement of critical health products for Venezuela, which is in the midst of a severe economic and health crisis.

This funding is exceptional for several reasons. First, Venezuela does not meet the grant eligibility requirements for upper-middle-income countries, but the Global Fund is making an exception in this instance. Second, because it is the first time Venezuela is receiving support from the Fund, and third, because the support comes in the form of a donation rather than a grant.

The Global Fund Board approved the funding on 24 September using electronic voting. In so doing, the Board endorsed a 24-page proposal developed by the Secretariat in consultation with partners and civil society and recommended by the Strategy Committee.

“The decision is the culmination of a concerted and unyielding effort by Venezuelan and global activists to push the Global Fund to show leadership in supporting countries in crisis,” ICASO and ACCSI said in a news release. ACCSI, or Acción Ciudadana contra el SIDA (Citizens Action Against AIDS) is a human rights organization in Venezuela.

In the box below, we summarize the highlights of the Board’s decision. In the balance of this article, we provide some background information; we describe the proposal endorsed by the Board, including implementation arrangements, risk considerations and sources of the funding; and we present some reaction to the decision.

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The Global Fund’s donation to Venezuela - in brief

The Global Fund will donate $5.0 million to Venezuela to provide treatment for people living with HIV. This is the first time that Venezuela has received support from the Global Fund.

$4.9 million will be paid into the PAHO Strategic Fund to purchase ARVs. These funds will supplement funds that organizations in Venezuela have received from other donors to

procure ARVs for the existing cohort of patients.

The remaining $100,000 will be used to support CSOs in Venezuela to monitor the delivery of ARVs to patients. These funds will be channeled through UNAIDS.

Because the $5.0 million is a donation and not a grant, implementation arrangements will be different from the Global Fund’s standard practice. The OIG will not be able to provide the usual degree of assurance concerning how the funds are spent.

The $5.0 million will come from funds that the Audit and Finance Committee has designated as being available for portfolio optimization.

Reaction to the decision from civil society and other organizations has been positive.

Background

Previously, Venezuela had not received any support from the Global Fund because it was deemed to be ineligible under the Fund’s Eligibility Policy. (Since 1997, Venezuela has been classified as an upper-middle-income country by the World Bank every year except 2014 when it was classified as high income. Under the Eligibility Policy, high-income countries are not eligible for Global Fund support. Upper-middle-income countries are only eligible if they meet a certain threshold of disease burden.)

Venezuela has been in a severe economic crisis since about 2015 due to falling oil prices. Oil accounts for 95% of the country’s export earnings. Venezuela has been hit by hyperinflation. According to BBC News, in July 2018 the annual inflation rate reached 83,000%. Prices have been doubling every 26 days, on average. This has resulted in many Venezuelans struggling to afford basic items such as food and toiletries.

The economic crisis precipitated a crisis in Venezuela’s public health system. GFO reported in October 2017:

“Essentials like soap and gloves have vanished from hospital floors. Life-saving medications are sometimes only available on the black market and cost half a month’s wages. Food is scarce, and people are dying ––dying of starvation, dying of AIDS, dying of long-eradicated diseases like diphtheria.”

The Global Fund was first approached about the possibility of providing assistance to Venezuela on 6 June 2016 when the board of the Venezuelan Network of Positive People (RVG+) wrote   to the Fund asking it to make an exception to its rules in order to provide urgent humanitarian aid for HIV and TB. Since then, civil society organizations (CSOs) have been relentlessly pushing for the Global Fund to provide assistance.

Although the Global Fund expressed concern about the situation in Venezuela and said that it was prepared to support a regional response, the Fund did not agree to provide direct assistance to Venezuela –– until now.

In May 2018, the Board adopted a policy (the Fund refers to it as an “approach”) on the provision of exceptional funding to countries in crisis that do not meet the Global Fund’s

eligibility criteria (see GFO article). This policy paved the way for the decision to support Venezuela financially.

Immediately after the policy on exceptional funding was adopted, the Secretariat launched an assessment of the situation in Venezuela. Meanwhile, in June 2018, the Pan American Health Organization (PAHO) and UNAIDS undertook a technical assessment of the critical gaps in programming for HIV, TB and malaria.

Also in June, PAHO and UNAIDS developed a Master Plan (Plan Maestro para el fortalecimiento de la respuesta al VIH, la tuberculosis y la malaria en la República Bolivariana de Venezuela desde una perspectiva de salud pública) which has been endorsed by the Venezuelan Ministry of Health, for the strengthening of the response to the three diseases. The plan covers a three-year period. To facilitate decisions by donors on potential funding, the interventions in the plan are prioritized.

Proposal details

According to the proposal developed for the Board, the Master Plan estimates that the cost to strengthen HIV, TB and malaria programs, and to ensure continued treatment and diagnosis, for a three-year period, is $122.0 million. Most of this cost, approximately $100.0 million, is for HIV; just over half of the HIV costs are for ARVs. The estimated costs for TB and malaria, respectively, amount to $5.1 million and $16.0 million.

Editor’s note: The Master Plan has not been released publicly. All references in this article to the contents of the Master Plan are based on information contained in the proposal prepared for the Global Fund Board.

The proposal said that the Global Fund considered the needs of all three diseases in Venezuela. “However, in view of the limited funds available,” it said, “and the fact that the government has made a procurement of anti-TB drugs to cover the needs until July 2019, and that there are sufficient anti-malarials for the highest-burden malaria state (Bolivar), the Strategy Committee and the Secretariat recommended that all of the limited funds available be directed to the HIV response.”

The Secretariat concluded (and the Strategy Committee agreed) that the health situation in Venezuela meets the criteria for funding contained in the policy on exceptional funding.

The proposal prepared for the Board said that the funding represents “a short-term humanitarian response.” The Global Fund acknowledged that the available funding is insufficient to meet more than a fraction of the total need. “More fully addressing the health needs of the Venezuelan people

“The economic crisis in Venezuela has severely impacted the country’s health system and the provision of services…. Stock-outs and shortages of key essential commodities including ARVs, anti-TB drugs, anti-malarials, diagnostics and key prevention commodities for HIV and malaria, have had a significant impact on the lives of people living with or affected by the three diseases.”

– Proposed Funding to Address the Health Crisis in Venezuela, Board Document GF-B39-ER10

will require additional commitments from other donors and partners in the near term, and ultimately a resolution of the economic and political situation so that the Venezuelan government can provide for the health of its people,” the Fund said.

The Board decided that of the $5.0 million donation, $4.9 million will be used to purchase antiretrovirals (ARVs) through the PAHO Strategic Fund; and that the remaining $100,000 will be used to support civil society organizations (CSOs) in Venezuela to provide oversight and monitoring of the delivery of ARVs to patients.

The Strategic Fund is a regional pooled procurement mechanism for essential medicines and health commodities that procures on behalf of member states. The fund, which has been operational since 2000, currently has 33 participating countries.

The Global Fund has received no official request for assistance from the Government of Venezuela. However, in March 2017, the government officially requested help from the United Nations to regularize the supply and distribution of medicines.

According to the proposal prepared for the Board, the $5.0 million donation will provide support for an initial 12-month period. This is consistent with the policy on exceptional funding adopted earlier this year. That policy set a ceiling of $20.0 million for support (for all countries combined) provided during the 2017–2019 allocation period.

“The Secretariat anticipates that there will be a continuing need for funding beyond the initial 12 months and $5.0 million,” the proposal said, “but notes that any additional funding would be conditional upon an assessment of the impact of this proposed investment and subject to additional Board approval and the availability of funds.”

The $4.9 million will supplement other funds that organizations in Venezuela have received from other donors to procure ARVs for the existing cohort of patients. The $4.9 million will be channeled directly to PAHO for procurement through the Strategic Fund. The Government of Venezuela has been using the Strategic Fund to procure medicines since 2010.

The $100,000 for CSOs will be routed through UNAIDS to strengthen the capacity of CSOs to continue to advocate for people living with HIV; to monitor access to care and treatment and the delivery of ARVs at the national and sub-national levels; and to strengthen the CSOs’ coordination with the National AIDS Program.

The Global Fund will enter into a contribution agreement with UNAIDS, which has agreed not to charge any overhead or direct costs. Under the agreement, UNAIDS will support CSOs to prepare reports and analyze stock levels at distribution sites. UNAIDS will also, as needed, perform checks at central or regional warehouses to verify stock levels after the ARVs are delivered. UNAIDS will provide three quarterly reports on these activities, prepared with input from CSOs. The Global Fund expects that this support will facilitate the establishment of a mechanism for CSOs to work with the National AIDS Program on the oversight of drug delivery in Venezuela that will endure beyond the period of the $5.0 million donation.

The proposal prepared for the Board noted that the Secretariat does not anticipate that the health situation in Venezuela will improve in the near or medium term.

Implementation arrangements

The proposal emphasized that the $5.0 million is a donation and not a grant. Exceptional funding, such as that which the Global Fund has provided to Venezuela, requires implementation arrangements that are different from standard practice. For example, there will be no country coordinating mechanism or local fund agent providing oversight.

In addition, the Office of the Inspector General (OIG) will not be able to provide the usual degree of assurance, through audit or investigation work, with respect to how the funds were spent. For instance, the funding arrangements do not provide the Global Fund unrestricted right of access to books, records, personnel or sites relating to the funded activities, including as required under the OIG Charter.

PAHO has not agreed to grant the Global Fund access to its books, records, or sites, or those of its suppliers. UNAIDS has not agreed to grant the Fund access to its books and records. Nor has UNAIDS guaranteed its collaboration for accessing sites and personnel. However, UNAIDS has agreed to ensure Global Fund access to the books and records of any contracted CSOs receiving money from the Fund.

Given the exceptional circumstances of this funding, the proposal said, “the OIG does not have any objection related to the lack of access rights in this case.”

The proposal prepared for the Board stated that the Global Fund will enter into a contribution agreement with PAHO, under which PAHO will be responsible for procuring ARVs through its Strategic Fund and delivering the commodities to the port of entry.

The PAHO office in Venezuela will, in coordination with the Venezuelan government, clear the ARVs through customs and facilitate the transfer and delivery of the ARVs to the central warehouse. The National AIDS Program will be responsible for ensuring delivery from the central warehouse to Venezuela’s 51 dispensary sites.

PAHO will also support the National AIDS Program and the Ministry of Health to quantify their ARV needs and develop procurement and distribution plans. To support PAHO’s ongoing efforts and collaboration with respect to the Global Fund’s donation, the Fund has agreed that PAHO may receive $208,250 of the approved funding of $4.9 million. At the same time, PAHO has agreed to waive its standard 13% overhead charge.

The proposal said that neither PAHO nor the Global Fund will have any legal agreement with the government of Venezuela, and that PAHO’s responsibility for the commodities extends only to delivery to the central warehouse.

Risk considerations

The proposal pointed out that the requirement to provide a rapid and efficient response in the context of the crisis in Venezuela entails significantly higher levels of risk and lower levels of assurance. By approving the $5.0 million donation, the Global Fund has accepted these risks. They cannot be fully mitigated under the proposed implementation arrangement, the proposal stated.

For example, accountability for the proposed investment is limited to the procurement and delivery of commodities to port, customs clearance, delivery of commodities to the central warehouse, and some downstream monitoring activities. Distribution of the ARVs to

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“The proposed implementation arrangements with PAHO and UNAIDS, while different from traditional grant arrangements, are considered by the Secretariat to be the most effective arrangements possible and likely to deliver the expected outcomes in the crisis context in a rapid and efficient way. Both PAHO and UNAIDS have in-country presence, established working relationships with government counterparts and civil society, and have the capacity to provide oversight over the proposed investment.”

– Proposed Funding to Address the Health Crisis in Venezuela, Board Document GF-B39-ER10

intended beneficiaries will be the responsibility of the government, which will have no formal obligation to complete the distribution.

Sources of the funding

According to the proposal, there is no dedicated source of funds within the 2017–2019 allocation period for non-eligible countries in crisis. Therefore, the $5.0 million will be taken from available sources of funding identified by the Audit and Finance Committee (AFC).

These available sources of funding come primarily from efficiencies achieved in the implementation of existing grants. Normally, these efficiencies are used to finance interventions on the register of unfunded quality demand (UQD). These are “above-allocation” interventions that have been deemed to be technically sound by the Technical Review Panel but for which a source of funding needs to be found. The Global Fund refers to this process as “portfolio optimization.”

In July 2018, the AFC undertook a review of available sources of funding and declared that $144.9 million was available for portfolio optimization.

At the same time, the Secretariat undertook a thorough review and prioritization of the interventions on the UQD Register. Through the Grant Approvals Committee, the Secretariat decided to award $127.7 million of the available $144.9 million to fund interventions in the UQD Register that it deemed to be critical and time-sensitive.

(The total value of all interventions in the UQD register is about $3.0 billion.)

When the Secretariat put together the proposal to donate $5.0 million to Venezuela, it assessed the proposed donation against the unfunded needs of countries currently receiving Global Fund support as expressed by the interventions in the UQD Register.

According to the proposal, the Strategy Committee and the Secretariat weighed the trade-offs involved in investing in eligible countries versus providing support for Venezuela. They concluded that while there remain clear gaps in the portfolios of eligible countries, the most critical and urgent needs for 2018 and 2019 are able to be filled with the $127.7 million in awarded funds.

The Strategy Committee and the Secretariat further reasoned that because the first grants emerging from the 2017–2019 allocations had only been implemented for about seven months, there will be considerable opportunities to identify additional efficiencies in the next year or two. This should allow for additional interventions in the UQD Register to be funded at later dates.

In addition, the proposal states, many countries will benefit from the newly negotiated ARV framework agreements, which will result in additional efficiencies that can be reprogrammed. (These agreements are essentially multi-year commitments by 14 pharmaceutical companies to supply large volumes of HIV medications at set prices. The Global Fund stated that the agreements signed in July 2018 will result in savings of $324.0 million by the end of 2021.)

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Consequently, the proposal stated, the Strategy Committee and the Secretariat are comfortable recommending the use of $5.0 million from available funding for portfolio optimization to support the proposed response to the health crisis in Venezuela.

At the same time, the proposal stated that in future, weighing of support for countries in crisis against UQD needs may be more challenging.

Reaction

Reaction to the donation from the Global Fund has been generally positive.

In the news release issued by ICASO and ACCSI, Alberto Nieves, Executive Director of ACCSI, said that “while the crisis in Venezuela continues and deepens, this support is an important display of global solidarity in time of extreme need. We are happy that our community monitoring is being taken seriously and we commit to continue to monitor the situation.” 

And Javier Hourcade Bellocq, a member of the Latin American and Caribbean delegation to the Board said, “It took a long time to have the Board come to this decision and we acknowledge that this is only a small step to address the crisis in Venezuela, but it is a move that shows the leadership of the Global Fund.” 

The news release also quoted Mary Ann Torres, Executive Director of ICASO, as saying, “We are grateful to see that the advocacy effort by many organizations has come to fruition with this decision that will save lives. We will continue supporting our partners in the country to ensure transparency and accountability.” 

Finally, Jorge Saavedra, Executive Director of the AHF Global Public Health Institute at the University of Miami, is quoted in the news release as saying that “the role and voices of international civil society and people living with HIV inside Venezuela were instrumental to convince the Board that some countries facing extreme health crisis, irrespective of the World Bank’s assigned income classification, need exceptions.”

Amanda Glassman, from the Center for Global Development (CGD) in the U.S., told Aidspan, “We were pleased to see the Global Fund allocate modest resources to address HIV in Venezuela and the implementation arrangements seem appropriate given the circumstances. Our worry,” Glassman added, “is the ability of PAHO, government and CSOs to deliver the medicines to patients –– the experience with vaccines has apparently been mixed, and it is worrisome to see such major interruptions in service delivery.”

In addition, Glassman said that “the resurgence of malaria –– particularly among indigenous groups –– is also a huge issue and could be dealt with somehow.”

On 21 September 2018, Glassman co-authored a blog (with Roxanne Oroxom, also from the CGD) on the situation in Venezuela.

Tamara Taraciuk Broner, a Senior Researcher in the Americas Division of Human Rights Watch, told Aidspan that the donation by the Global Fund “is an important step to address

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Venezuela’s humanitarian crisis and the impact it is having on patients with infectious diseases that have been on the rise in the country.” Taraciuk added, “It is critical to continue pushing for measures that will provide aid to Venezuelans, and also to redouble the pressure on the Venezuelan government so it accepts additional aid that is desperately needed.”

Last May, Taraciuk published an article on the need for the Global Fund to take bold action with respect to the situation in Venezuela.

Regional response

The decision by the Global Fund Board to donate $5.0 million to Venezuela includes a call for relevant partners, donors and other stakeholders to further support a regional response to the health crisis.

According to the proposal prepared for the Board, the Global Fund’s policy on non-eligible countries in crisis has generated interest from other donors and partners. As a result, the Secretariat, together with partners in the region, is planning an initial donor roundtable to be held in early October 2018 to discuss the HIV, TB and malaria situations –– and, possibly, some broader health systems issues –– as well as to develop a coordinated support mechanism, and to determine ways to support the country and the region affected by the influx of people leaving Venezuela.

GFO has written extensively about the situation in Venezuela. The most recent article, from 12 May 2018, is available here.

The full text of the Board decision, Document GF-B39-EDP11, will likely be posted shortly on the Global Fund website here. However, if the Global Fund follows past practice, the proposal prepared for the Board, Document GF-B39-ER10, will not be posted. Although the Fund has regularly posted papers prepared for in-person Board meetings (once the meetings have been concluded), it has not been in the habit of posting Board papers related to electronic decisions.

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2. NEWS: U.N. General Assembly’s high-level meeting on TB called on leaders to reaffirm commitment to end tuberculosis by 2030

Political declaration sets ambitious targets for investment and progress monitoring

Tinatin Zardiashvili 2 October 2018

On September 26, in New York, the U.N. General Assembly hosted a first ever high-level meeting (HLM) on tuberculosis under the key theme - “United to end tuberculosis: an urgent global response to a global epidemic”. The purpose of the meeting was to provide a platform

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for high-level leaders to reaffirm their commitment to accelerate efforts towards the goal of ending the TB epidemic by 2030.

Up to 40 Member States, represented by heads of state, health ministers, parliamentarians and city mayors, attended the meeting along with leaders of civil society organizations, TB survivors, business and research organizations, international development agencies and donors such as WHO, UNICEF, the World Bank, the Global Fund to Fight AIDS, TB and Malaria, UNITAID, and the Bill & Melinda Gates Foundation, among others.

The main outcome of the HLM was Member States’ endorsement of the ‘Political Declaration on TB’, committing them to greater efforts and investments towards the Sustainable Development Goals’ target of ending the TB epidemic by 2030.

The resolution calls for increased political commitment at the national, regional and global levels, and for increased investments in TB programs, research and innovations, with ambitious targets to treat up to 40 million patients by 2022 and mobilize sufficient and sustainable financing to enable timely prevention, screening, diagnostics, treatment and care for all people affected by TB.

The declaration states that “while the World Health Organization declared tuberculosis a global emergency 25 years ago, it is still among the top ten causes of death worldwide”.

Although all UN Member States have already committed to end TB by 2030, through their endorsement of the “End TB Strategy” adopted at the World Health Assembly in 2014, progress in the fight against the disease has been slower than hoped, making the 2030 target, which is aligned with the Sustainable Development Goals, difficult to attain. This was confirmed by WHO’s latest annual Global Tuberculosis Report , released on 18 September 2018, in time for the High Level Meeting. The report states that 1.6 million people died of TB in 2017 (including 300,000 deaths among HIV-positive people) while the annual financial gap in financing treatment and services for TB was estimated at $13 billion.

Drug-resistant TB is already a public health crisis and a rising threat, with almost half of drug-resistant tuberculosis cases, the TB report says, found in three countries: India (24%), China (13%), and Russia (10%).

The report also stressed the sizeable deficit in funding of TB-related research, amounting to $1.3 billion. According to the report, in 2017 an estimated 10 million people developed tuberculosis, and 4 million people with tuberculosis remained undiagnosed and untreated. Two-thirds of this global tuberculosis case burden of 10 million cases was found in eight countries: India (27%), China (9%), Indonesia (8%), the Philippines (6%), Pakistan (5%), Nigeria (4%), Bangladesh (4%), and South Africa (3%).”

The meeting included a plenary segment for general discussion and two multi-stakeholder panels on how to scale up efforts to improve access to treatment and prevention services and financing and process, research and commitment to innovations.

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The core themes of the HLM discussions and the meeting’s expected outcomes were drawn from civil society hearings that were organized in preparation for HLM, in June 2018. Around 400 participants from civil society and the private sector, parliamentarians, NGOs, academia, medical associations and patients voiced their opinions and discussed potential solutions. The summary of the hearing informed the ‘Key Asks from TB Stakeholders and Communities’ document describing expected outcomes of the meeting, which are to:

1. Reach all people by closing the gaps in TB diagnosis, treatment and prevention2. Transform the TB response to be equitable, rights-based, and people-centered3. Accelerate development of essential new tools to end TB4. Invest the funds necessary to end TB5. Commit to decisive and accountable global leadership, including regular UN

reporting and review.

The director-general of WHO was requested to develop the Multisectoral Accountability Framework by 2019, to measure progress against targets. The U.N. Secretary General, with support of the WHO, will commission progress reports at national and global levels for 2020. The next high-level meeting on TB, planned for 2023, will provide a comprehensive review of results.

Since 2002, the Global Fund has invested more than US$6.2 billion in the fight against TB and now represents about 65 percent of the international funding response to TB.

Some stakeholders were dissatisfied with the meeting’s outcome. Health Gap along with seven other TB-related NGOs issued a joint statement on 26 September, called ‘ What is Missing from the United Nations Political Declaration on Tuberculosis?’ saying that “the declaration falls short in its response to the leading infectious killer worldwide and the leading cause of death for people with HIV around the world.”

The NGOs collectively commit to taking 12 “concrete steps” in pursuit of ending the TB epidemic, including an appeal to the Global Fund “to launch immediately a reprogramming and fundraising initiative to ensure high-TB burden countries modify their Global Fund-funded TB and TB-HIV programs to reflect the newest WHO treatment and prevention guidelines rather than old and outmoded approaches.”

In an email to Aidspan, the Global Fund’s Head of Communications, Seth Faison, responded to the Health Gap Declaration with the following comment:

“The Global Fund fully supports action that increases and expands programs aimed at ending TB. It is critically important to support efforts in high-TB burden countries to find and treat the missing cases, and to adopt the most effective and up-to-date treatment and prevent guidelines. We strongly encourage reprogramming that makes TB treatment and prevention more effective, and we welcome work by all partners to raise more money to fight TB.”

For more information on the UNGA’s High-level meeting on TB, see also:

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- The ‘Key Asks from TB Stakeholders and Communities’ preparatory document for the HLM

- The modalities resolution adopted in April, 2018, which defined the scope, format and agenda of the HLM

- The videos of opening and plenary segments here- The electronic versions of the country statements can be downloaded from Paper

Smart Services- The Global Fund’s 19 September statement, ‘More Urgency, New Funding Needed

to End TB’- The Global Fund’s 26 September statement, ‘Global Fund Supports Brave Commit-

ments to Ending TB’

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3. NEWS: First OIG audit of Niger’s Global Fund grants applauds progress and calls for improvements

Main issues are fundamental gaps in supply chain and supervision

Adèle Sulcas 2 October 2018

In the first ‘routine’ audit by the Office of the Inspector General (OIG) of Global Fund grants to Niger, the OIG found that Niger has made “significant progress against the three diseases,” with the quality of all three disease programs having improved over the last two years despite a challenging operating environment.

Fundamental gaps remain, however, in the areas of the supply chain and in supervision, leading to the disruption of services or issues with service delivery to patients.

These are some of the key findings in the OIG’s report, which was made public on 3 September 2018.

The audit covered grants active across all three disease components between January 2016 and December 2017. It aimed to assess the effectiveness, in particular, of supply chain mechanisms, program data processes and mechanisms, oversight over grant activities and performance, and financial controls over the TB grant (the HIV and malaria grants were considered ‘low risk’; see ‘Previously identified issues’ below).

The OIG called out three specific issues in the supply chain: weak oversight over quantification and forecasting activities, that improvements are needed in supply chain management mechanisms, and that drugs quantification was not informed by available data. The OIG also underscored the need to strengthen supervision arrangements.

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Niger’s achievements, the OIG report said, include progress in reducing disease burdens and improving access to services: malaria deaths decreased by 30% between 2010 and 2015, and PMTCT of HIV services are accessible in 186 health centres and district hospitals. In addition, the OIG noted improved financial controls, after the Global Fund put in place a number of safeguards following the discovery of financial irregularities in 2014.

Table 1: Global Fund grants in Niger

Component Grant no. Principal recipient Grant period Signed amount(EUR million)

HIV/AIDS NER-H-CISLS

Intersectoral coordination of the fight against STIs/ HIV/ AIDS (Coordination Intersectorielle de Lutte contre les IST/VIH/SIDA)

July 2015-December

2017

14,486,006

January 2018-December 2020 (new

grant)

13,395,464

TB/HSS NER-T-SCF

Save the Children Federation, Inc.

January 2016-December

2018

28,682,344

Malaria NER-M-CRS

Catholic Relief Services – United States Conference of Catholic Bishops

May 2016-December

2017

32,778,373

January 2018-December 2020 (new

grant)

44,567,826

Total 75,946,723

Note: Grants included in the audit were those active up to December 2017; new grants were not included

During the audit, the OIG team visited 17 integrated health facilities for HIV and/or PMTCT, 10 sites for TB, and 12 for malaria, all within the three regions of Niamey, Maradi, and Tahoua. They also reviewed three central warehouses, two regional warehouses, and hospital and health-facility warehouses and pharmacies in 14 districts. The audit’s geographic scope covered three regions, corresponding to 63% of the country’s HIV burden, 45% of the malaria burden, and 40% of the TB burden.

Ratings

The OIG rated three “objectives” according to its four-tiered rating scheme (effective; partially effective; needs significant improvement; ineffective):

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Objective 1: Supply chain mechanisms in providing medicines to patients for the three diseases procured through GF programs “needs significant improvement”. The OIG cited “fundamental gaps in the quantification, forecasting and stock monitoring processes”.

Objective 2: Program mechanisms to provide adequate quality of services to patients and reliable data for decision-making were rated “partially effective”.

Objective 3: Financial systems and processes, including controls in place over grant funds and sub-recipient management, were rated “partially effective”.

Niger country context

The Global Fund had committed $248 million, and has disbursed $220 million, to Niger since 2004, across all three disease components. The three Principal Recipients (PRs; see Table 1 above) work with 10 sub-recipients, including national entities under the Ministry of Health.

Niger is one of the least developed countries in the world (ranked 187 out of 188 countries in UNDP’s development index), which makes its progress against all three diseases especially noteworthy.

Key issues and risks

The OIG specified the following key issues and risks in Niger’s Global Fund grants:

Inadequate oversight over quantification and forecasting of health products Weak use of data Lack of national strategy including an absence of national guidelines for the supply

chain Coverage, quality, and coordination of supervision activities to be improved Transparency and competitiveness issues.

The OIG noted that Niger and partners have made major efforts to address some of the supply chain challenges, such as a World Bank-financed supply chain diagnosis; technical assistance funded at the central medical stores level to support health commodities’ management and logistics management; and pharmacists appointed by Niger’s health ministry in all eight regions to improve order verification and supervision of facilities.

However, despite these efforts, “the supply chain has fundamental gaps and efficiency challenges which adversely impacted the availability of drugs and treatment of patients.”

We summarize some of the key issues below:

Inadequate oversight over quantification and forecasting activities

Despite many layers of oversight (by PRs, the Local Fund Agent, and the Global Fund’s country team) weaknesses and errors in quantification and forecasting were not identified and corrected, the OIG said. Issues such as incorrect assumptions about buffer stocks, delayed ordering with unrealistic delivery dates, and a failure to exclude expiring drugs from

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available stocks during forecasting of needs all contributed, the OIG report states, to treatment disruptions and waste, with recurrent stockouts and the expiring of essential HIV and TB commodities.

Weak use of data

The OIG said programmatic data had shortfalls, particularly for HIV and malaria: there were many cases of missing or non-updated patient registers and other databases. For health procurements, all PRs in Niger use morbidity data to determine the quantity of medicines needed, rather than adjusting it based on consumption and stocks data, which is available but is not extracted and used from the tools and reports of the health facilities.

Lack of national strategy for supply chain

The absence of an overarching framework document to guide supply chain processes has resulted in “confusion and divergent practices,” the OIG said, including “arbitrary ordering” and “siloed and uncoordinated distribution by the PRs”. These issues have had a knock-on effect, resulting in delayed deliveries, which have contributed to stockouts, expiries, and missed opportunities for cost efficiencies.

Coverage, quality and coordination of supervision

The number and coverage of supervisory activities are inadequate, the OIG said. The OIG also noted that there is limited coordination between supervisions conducted by grant implementers and regional health directorates, and that increased coordination is needed. While supervision guidelines and tools are well-designed, the OIG said, they are not used at the regional or district levels. This impacted the delivery of activities including adherence with MDR-TB testing and malaria treatment protocols, the quality of HIV care, and weakened prevention of mother-to-child transmission.

Progress on previously identified issues

In 2013, a regional report on the effectiveness of external assurance for West African countries included Niger as a sample country, Niger has never before had a routine country audit. An OIG investigation in 2014 highlighted non-compliant expenditures of almost $17 million between 2005 and 2012, of which $2.4 million was deemed by the OIG to be refundable to the Global Fund. The OIG considered the misuse of grant funds to be due to “weak internal controls and inadequate oversight of SRs by PRs”.

The OIG’s audit found that measures taken since to mitigate similar risks have been effective – including replacing two out of three PRs with international NGOs, instituting a Zero Cash Policy, and using the Global Fund’s Pooled Procurement Mechanism for the purchase of HIV and malaria commodities - and its review of the financial control framework indicated “low residual financial risk” for the HIV and malaria grants. For this reason, the audit’s review of financial controls included only the TB/HSS grant.

Agreed management actions

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The Secretariat will work with the Government of Niger and partners on three agreed management actions (AMAs):

1. To develop and implement an overarching guidance document that describes the supply chain network

2. To conduct a root cause analysis of bottlenecks to the implementation of quality supervisions across the three diseases

3. To review and revise data collection tools, rationalize data reporting requirements and indications, and develop a plan to rolling out and training on the revised tools and requirements.

All the AMAs are ‘owned’ by the Head of Grants Management, and all are due to be completed by 31 December 2019.

For a table detailing the AMAs, see page 17 of the OIG report.

The full report of the OIG audit of Niger’s Global Fund-supported grants is accessible on the Global Fund website, as well as the OIG investigation report from 2015.

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4. NEWS: OIG audit of Global Fund grants to Myanmar reveals gaps in service delivery and supply chain management despite good results in

other areas

Audit shows significant progress in program impact and financial management

David Garmaise 1 October 2018

Myanmar has made significant progress in its fight against HIV, TB and malaria, thanks in part to increased financial commitments from the government and initiatives to extend health care coverage. At the same time, there are gaps in service delivery and issues related to supply chain management.

These are some of the key findings from an audit of grants to Myanmar conducted by the Office of the Inspector General (OIG). A report on the audit was released on 7 August 2018. This article provides a summary of the OIG’s findings.

The audit, which covered the period from January 2016 to December 2017, examined all six active grants implemented by two principal recipients (PRs): Save the Children and the United Nations Office for Project Services (UNOPS). See Table 1 for details.

Table 1: Grants included in the audit

Component Grant no. Principal recipient Signed amount($ million)

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HIV MMR-H-SCF Save the Children $118.0 m

MMR-H-UNOPS UNOPS $99.0 m

TB MMR-T-SCF Save the Children $24.4 m

MMR-T-UNOPS UNOPS $97.0 m

Malaria MMR-M-SCF Save the Children $28.3 m

MMR-M-UNOPS UNOPS $75.2 m

Total $441.9 m

Notes:

1. All of the grants listed in Table 1 ran from January 2013 to December 2017.2. The signed amounts shown in the table include funding that was awarded from the 2014–2016

allocations. The grants have since received additional funding from the 2017–2019 allocations.3. For the three UNOPS grants, the Ministry of Health and Sports (MOHS), through the national disease

programs, implemented the grants as a sub-recipient (SR).4. The links in the table are to the grant pages on the Global Fund website.

The audit focused primarily on the HIV and TB grants. The malaria grants are being reviewed as part of another audit that the OIG is conducting on the Regional Artemisinin-resistance Initiative (RAI). The findings from the RAI audit will be included in a forthcoming OIG report on regional and multi-country grants.

The audit included site visits to selected health facilities, treatment centers, warehouses and stores. Due to travel restrictions and security concerns in parts of the country, site visits were limited to seven out of the 15 states and regions, which represented 59%, 63% and 32%, respectively, of HIV, TB and malaria patients in June 2017.

In addition to good programmatic performance and increased governmental financial commitments, the audit identified two other key achievements: (a) effective collaboration between government and other stakeholders in implementing interventions; and (b) improved financial controls.

Table 2 provides a high-level summary of the audit findings.

Table 2: Myanmar audit findings at-a-glance

AREA 1: Adequacy and effectiveness of the implementation arrangements –– particularly the supply chain, use of community workers, data management, and provision of services to ensure efficient and sustainable achievement of grant objectives

Rating: Partially effective

OIG comments: The implementation arrangements have supported the delivery of HIV, TB and malaria medicines, commodities and other services to intended beneficiaries. Nevertheless, there is a need to optimize the utilization of resources to enhance impact and maximize cost efficiency.

AREA 2: Effectiveness of systems, processes and controls in place to ensure quality of service to intended beneficiaries

Rating: Partially effective

OIG comments: Despite conflicts in parts of the country, good progress has been made in addressing the HIV, TB and malaria epidemics in the last few years. Programmatic achievements

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include significant increase in antiretroviral therapy, relatively high TB treatment success rate, and material decline in malaria cases. However, while investments made have supported the scale up of interventions across all three diseases, access to quality services, especially around HIV testing among key populations, viral load monitoring and infection control at health facilities, remain a challenge.

AREA 3: Adequacy and effectiveness of sub-recipient management and assurance mechanisms in safeguarding Global Fund resources

Rating: Partially effective.

OIG comments: The overall assurance framework has improved since the last OIG audit (in 2014). There are defined procedures, controls and systems to ensure effective management of Global Fund resources. However, oversight and assurance over programs require moderate improvements.

The OIG has a four-tiered rating scheme, as follows: Effective; partially effective; needs significant improvement; ineffective.

Key issues and risks

The OIG identified the following key issues and risks:

Services and the supply chain are fragmented, meaning they are being managed separately for each disease, with little opportunity for integration;

There are challenges with respect to how services are being delivered;

There are limitations in the plans for transitioning treatment services from NGOs to the government; and

There are limitations in assurance and oversight by principal recipients (PRs), the country coordinating mechanism (CCM) and the local fund agent (LFA).

Below, we briefly describe each issue and risk.

Fragmentation

The OIG provided the following examples of fragmentation in services:

The Global Fund supports over 17,000 malaria health volunteers but this network has not been used to support HIV or TB services.

Only 22% of methadone maintenance treatment centers provide integrated HIV services, despite the high HIV prevalence among people who inject drugs.

In addition, because of legislative barriers, none of the over 1,600 community outreach workers funded by the grants who provide HIV prevention services for key populations were undertaking HIV testing.

Fragmentation also affected supply management, the OIG said, with different supply chains for implementers of each disease program. In many cases, warehouses for all three programs are close to each other, and distribution routes substantially overlap. For example, the OIG noted, in Yangon alone there are 13 central or regional warehouses covering the three disease programs within a 21-km radius.

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The OIG also observed that efforts to develop an integrated logistics management information system amongst health partners and the government have seen limited movement.

Service delivery

The audit revealed the following difficulties:

25% of facilities visited by the OIG had expired kits at the testing site at the time of the visit, which could have resulted in those kits being used.

38% of the facilities visited did not test in accordance with approved HIV testing guidelines.

Key populations, such as people who inject drugs, are not yet effectively reached with services. Less than half of the people who inject drugs reached by prevention programs were tested for HIV, even though HIV prevalence among this population is over 28%.

Despite the fact that TB infection-control guidelines were disseminated to facilities offering both TB and HIV services, the OIG noted, health workers were not screened for TB at least annually in 46% of the facilities it visited.

Transition planning

The OIG said that plans to transition treatment of over 26,000 patients on antiretroviral therapy (ART) from NGOs to government providers have not yet addressed the risks associated with the transition.

The National AIDS Program is already facing storage constraints at the central level, the OIG said, and there is some doubt about the ability of the current governmental supply chain system to absorb the increase in patient numbers.

In addition, the OIG noted, an assessment of the human resource requirements of this shift had not been done at the time of the audit. Finally, the OIG said that the transfer plan lacks a description of how patient tracking and tracing, which are necessary components of a successful transition, will be done.

Oversight and assurance

The audit found that supervision by the PRs was not carried out consistently due to security challenges as well as the workload associated with grant-making. When supervisory visits to health facilities did take place, the OIG said, written feedback was not consistently provided to the visited sites.

In addition, the OIG said, a large proportion of the recommendations provided by auditors and by PRs themselves remained unaddressed at the time of the audit. Finally, the OIG observed, oversight by the CCM was limited: Only one oversight visit was conducted in all of 2016 and 2017.

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Progress on previously identified issues

The last OIG audit of grants to Myanmar was conducted in 2014. The main weaknesses identified concerned financial and supply chain management. The current audit noted improvements in financial management, largely due to the strengthening of internal financial controls at the SR level. In addition, the OIG observed, there has been some improvement in supply chain management, including better storage conditions for commodities and a significant reduction in stock-outs and expiries.

Agreed management actions

To address the latest audit findings, the Global Fund Secretariat has agreed to:

Work with the PRs, the MOHS and relevant partners to conduct supply chain assessments to identify key areas of fragmentation and define areas for potential integration;

Work with relevant stakeholders to finalize (a) an enterprise architecture blueprint for health information system interoperability; and (b) an integrated community case management policy and strategy to address integration and quality issues at the community level; and

Ensure that a comprehensive ART transition plan is developed.

The full OIG audit report on Myanmar is available on the Global Fund website.

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5. ANALYSIS: Countries need better data for accurate forecasts of funding gaps in Global Fund grants

Unfunded gaps are often calculated using unreliable data

Djesika Amendah 2 October 2018

Applications for Global Fund grants require countries to state the resources needed for them to meet their targets for HIV, tuberculosis and malaria programs, and to state their anticipated domestic and donor funding, including their Global Fund allocation for the duration of the grant. Subtracting the total anticipated domestic and donor funding from the resources they need gives the gap in funding for each disease component.

Using the example of HIV, we aim to describe how countries calculate the resources they need for their fight against the diseases, and the related challenges they face due to the scarcity or the poor quality of their country and program data.

Wide variation in unfunded gaps in High Impact Africa countries

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A recent GFO article focusing on High Impact Africa countries presented the funding distribution between domestic and external sources for the three diseases in the 2015-2017 grants, and their associated funding gaps. (High Impact Africa and Asia countries are a group of 23 priority countries which together account for approximately 70% of the global burden of disease for HIV, TB and malaria, and receive two-thirds of all Global Fund investments). For HIV specifically, domestic financing accounted for 3% of total expenditures in Mozambique but for 48% in Kenya, in the 2015-2017 allocation period. This wide range gives rise to a similarly wide range in individual countries’ funding gaps for HIV, from 4% in Mozambique to 49% in Cote d’Ivoire (Figure 1).

Figure 1: Anticipated resources, gap in amount and percentage for select High Impact Africa countries

Cote d'Ivoire DRC Ethiopia Kenya Mozambique Sudan Tanzania Uganda Zambia Zimbabwe0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

0%

10%

20%

30%

40%

50%

60%

49%

26% 25%23%

4%6%

11%

31%34%

26%

Total anticipated resources Gap % Gap

Source: Aidspan policy analysis department

The resource needs calculation

We use HIV as a disease-component example to illustrate how these resource needs were calculated. First, the country adopts a health target usually formalized in a National Strategic Plan. Second, a team of experts gathers data on the current demographic, HIV epidemic (e.g. incidence and prevalence by age-group) and cost of prevention and care.

Using mathematical modeling, the team forecasts the future population by age group and gender, future HIV incidence and level (or number) of persons living with the disease. Then, the team uses the forecasts of population and HIV epidemics with assumptions on future trends of costs of health commodities to project the resources needed.

The health target is often based on the relevant recommendation from the World Health Organization (WHO) or, for HIV, the Joint United Nations Programme on HIV/AIDS (UNAIDS).

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For instance, UNAIDS recommended in 2014 that all countries adopt its ‘90-90-90’ target by the year 2020. This target means that 90% of people living with HIV know their status, 90% of those who are HIV positive are on antiretroviral therapy (ART) and 90% of those on ART are virally suppressed. Some countries adjust these targets to suit their country context: Kenya adopted 90-90-90 but decided on an earlier target date of 2019. The latest WHO recommendation in the care and treatment of persons living with HIV is “test-and-treat”, i.e. people who test positive for HIV start treatment as soon as possible after diagnosis, regardless of their CD4 count. (In 2013, the WHO recommended that adults living with HIV start treatment when their CD4 cell count falls to 500 cells/mm³ or less – a level at which their immune systems are still strong). Some countries such as Togo still follow that recommendation, which itself was an improvement over an earlier (2010) recommended CD4-count threshold of less than 350.

For any country to reach the UNAIDS 90-90-90 target (or any other target it chooses), it is important to first forecast the estimates of the population (for instance the number of children, adolescents and adults by gender and age group) to determine the number of children, women of reproductive age, and men who would potentially need HIV prevention and treatment services.

The second step is to forecast HIV impact in terms of levels (the number of people who live with HIV), HIV incidence (percentage of new infections per year), and HIV prevalence, disaggregated by age-group and gender, when possible. The third step is to use historic, current and forecasted population and HIV data as well as costing data (e.g. costs of HIV test kits, ARVs, laboratory costs, health professionals, community mobilization and other components of service delivery) as input (or predictor) variables in a mathematical model, to obtain projected resource needs.

UNAIDS and several countries use a software called ‘Spectrum’ for their projections.

Kenya example of resource needs calculation

When the Ministry of Health in Kenya adopted the 90-90-90 target, development partners published a policy brief that estimated resources needed.

The policy brief forecasted the number of Kenyans who will be living with HIV in 2019 using 2013 data. Then, the brief projected that 1.4 million patients would need ART by June 2019, up from 871 000 patients in 2016 when the forecast was first made. This higher number of people living with HIV (PLWH) on ART translated into an increase in the needs for health commodities, personnel, space and other utilities, but the brief focused on the health commodities, which are the main cost driver in HIV treatment programs.

The brief used consumption data to forecast the ARV needs, and morbidity data to forecast the laboratory commodities. In terms of quantification, consumption data is superior to morbidity data, which is used when consumption data is not available. For the viral load tests, the policy brief used population and target estimates in the absence of more reliable program

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data. Cost data originated from procurement files, the Global Fund, and PEPFAR (the US President’s Emergency Plan for AIDS Relief). Then, the policy brief estimated resources needed, available funding, and the associated gap.

Reliable data on population targets and unit costs is needed but is not always available

As the Kenyan example indicates, a wide range of reliable data is necessary to project future resource needs. This data originates from several sources. Population and behavioral data (e.g. distribution of the population by sex, age group, and location) comes from national censuses or representative surveys such as Demographic and Health Surveys (e.g. the number of children desired by women, HIV-related behavior). Morbidity and beneficiaries data (e.g. sex, age and geographical location of people who receive health services) comes from the routine Health Management Information System (HMIS) or its equivalent. Other service utilization data comes from the program (e.g. number of people treated for HIV, number of ARVs consumed, laboratory reagents consumed). Unit costs of HIV treatment (e.g. ARVs, laboratory, personnel) originate from procurement records.

The Global Fund programs generate some of the data needed using implementers’ own monitoring and evaluation information; the quality of this data is subject to debate. The Secretariat, in the Global Fund’s annual report 2017 , asserts that quality data exists, especially in High Impact countries. On the contrary, in the same year, the Office of the Inspector General (OIG) deplored the “lack of accurate and reliable data” in a published report on supply chains in fifteen countries, thirteen of which were High Impact countries in Africa and Asia. The OIG highlighted the inadequacy of data used for quantification and forecasting of health commodities. For example, health commodities consumption data could not be linked to the number of patients treated in 10 out of the 15 countries reviewed. All the countries audited (except one) mainly use morbidity data for quantification and forecasting as no other reliable data is available.

These diverging opinions illustrate a quality issue. For example, the OIG report affirmed that patient registers are not used in some facilities across several countries. In addition, it is possible that those data are mainly collected for reporting purposes and not demanded by program managers to improve service delivery. An Aidspan study found similar results earlier this year.

Other studies have also highlighted the lack of publicly available data in sub-Saharan Africa, where the Global Fund invests about 65% of its monies.

To circumvent the absence of reliable data at country level, modeling uses data published by others from similar countries, or regional estimates.

Using erroneous data for projection results in inefficient resource allocation

Using erroneous data to estimate future resource needs has a cascading negative impact down the service delivery chain. It results in inefficient resource allocation and subpar service delivery.

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For instance, overestimating the number of PLWH leads to overestimation of their needs, in particular expiries and wastage of ARVs. On the other hand, underestimating PLWH leads to unmet needs (illustrated by stock outs of health commodities) and to suffering by those who need care and services.

The Global Fund should strategically invest in health system and data

The data required for reliable projection reinforces the need for the Global Fund to invest and catalyze domestic and other partners’ resources to improve the quality and availability of data in countries where the Fund invests. Indeed, in its current strategic plan, the Global Fund aims to strengthen health systems, particularly to “[s]trengthen data systems for health andcountries’ capacities for analysis and use”. The Global Fund needs partners’ support and implementing countries’ embrace of ‘country ownership’ to reach this objective.

Djesika Amendah is the Senior Policy Analyst at Aidspan.

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6. FEATURE: Tanzania National Coordinating Mechanism aspires to become best-practice model for Global Fund’s CCM evolution initiative

18 pilot countries are included in the first phase of the Global Fund’s “evolution approach”

Arlette Campbell White 1 October 2018

When the Global Fund Secretariat, through its CCM Evolution project, invited embers of the Tanzania National Coordinating Mechanism (TNCM) to stakeholder consultations in 2017, it captured the attention of TNCM stakeholders. The consultations resulted in the launch of an ambitious and innovative process to transform the TNCM into an effective and efficient organisation with the capacity to maximize its management of all health-donor funds for the three diseases and health system strengthening.

A driving force behind the desire for reform is Tanzania’s recognition that, after more than 15 years of Global Fund support and the investment of nearly US$1.8 billion (second only to Nigeria in the total amount of Global Fund investment), programmes have not performed as well as expected. This is in addition to the even greater resources provided by the US President’s Emergency Fund for AIDS Relief (PEPFAR). The development, management, implementation and evaluation of disease programmes still face the same familiar challenges and bottlenecks from year to year. Hence, the best health outcomes are unlikely to be attained until the framework for programme delivery has improved. Without essential, well-functioning management components in place, Tanzania is unlikely to improve its health performance and maximize the most effective and efficient use of donor support.

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Three decades of experience with CCMs have provided a wealth of information on their weaknesses and opportunities for improvement, leading the Global Fund to acknowledge that CCMs cannot continue to operate in the same way if countries are to better implement the Global Fund Strategy 2017-2022.

Development of the Global Fund’s “evolution approach”

As a result, in 2017 the Global Fund Secretariat conducted a series of consultations on CCM evolution (the CCM Evolution Project), to examine how CCM functionality and performance could be improved. Data collection, analysis and a series of consultations with multiple stakeholders identified the need to strengthen the quality of engagement of CCM members, clarifying expectations for CCM oversight and strengthening CCM linkages to national bodies, tailored to country context. At the 38th Board meeting in November 2017, updates were provided on the key findings to date, options and next steps. The Board agreed that the Secretariat would evaluate options based on potential cost and impact to discuss with the Secretariat’s Committees in March 2018 and at the 39th Board Meeting in May 2018.

The May 2018 Board meeting approved the first phase of “an evolution approach”, called the CCM Evolution Initiative, endorsing the consultations’ findings on the three main changes needed to evolve CCMs: (1) differentiate CCMs according to context into Standard CCMs, Transition Preparedness CCMs and CCMs in Challenging Contexts; (2) improve CCM performance in key areas, including the approval, introduction and enforcement of a Code of Conduct; and (3) introduce CCM maturity levels (functional, engaged, and strategic) tailored to different types of CCMs.

Specifically, the Board approved the revised ‘Guidelines and Requirements for CCMs’ (now renamed the ‘CCM Policy’), the Code of Ethical Conduct for CCM members, and funding to support the first phase of implementation for CCM evolution in selected countries for 2018-2019. The Board then discussed the proposed four options concerning the level of ambition the Secretariat should have regarding CCM Evolution, and each level’s recommended funding.

The level of ambition is the extent of the scope and number of countries the Secretariat can actively support to integrate operational changes. The Board accepted the Strategy Committee’s recommendation of a phased roll-out of the Intermediate option and allocated US$3.85 million to be made available to implement activities in 2018 and 2019 through piloting the Initiative in 18 targeted countries, of which Tanzania is one.

Table 1: 18 countries participating in first phase of CCM Evolution Phased Approach

Standard CCMs Transition preparedness CCMs

CCMs in challenging contexts

BeninBurkina Faso*

AlbaniaColombia

BurundiCongo (Democratic

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CameroonLesothoMalawi*MozambiqueNepalPapua New GuineaTanzania*Uganda

GuatemalaRomania

Republic)HaitiNiger

Tanzania’s readiness for CCM reform

In addition to the CCM Evolution Initiative, other events influenced Tanzania’s readiness for TNCM reform. Firstly, Tanzania was one of several countries reviewed by the OIG for its 2016 global CCM Audit, the findings of which were central to the Global Fund’s decision to move forward with CCM evolution.

In early 2017, TNCM performance (along with that of many other countries’ CCMs) was assessed by an independent team, as part of the early activities carried out during the research and data collection phase of the project. Likewise, in 2017, the Health Economics and HIV and AIDS Research Division (HEARD) of the University of KwaZulu-Natal, supported by the Bill & Melinda Gates Foundation (BMGF), conducted exploratory research on Global Fund processes in Tanzania.

This assessment provided lessons learnt and an analysis of the gaps and challenges that will provide invaluable information as Tanzania proceeds to evolve its CCM. Finally, selected TNCM representatives attended CCM Evolution workshops in Ethiopia (2017) and Malawi (2018). Transformation was thus a key issue for the TNCM’s new dynamic Chairman, Professor Faustin Kamuzora, Permanent Secretary (Policy and Coordination of Government Business), who no longer wanted to see ‘business as usual’ when it was clear that this had not produced optimal results. And the time was ripe: not only was there a new Chairman but newly elected TNCM members would be in place by the end of 2018.

The finalization of HEARD’s research coincided with the Global Fund’s move to assist CCMs to reassess their roles and develop into more effective mechanisms. Tanzania is keen to make the most of this opportunity to bring about changes that will ultimately improve health outcomes. Being one of the 18 pilot countries represents a unique opportunity for Tanzania to develop a best-practice model on how to successfully transform a CCM.

The starting point for reform is the country’s supervision of Global Fund processes. Good management, at a CCM level, implies that the TNCM has to function well and proactively; plan for and manage problems and risks rather than react to them; be assertive, professional and competent in dealings with the Global Fund; and establish and maintain a favourable programme delivery environment. Once this has been achieved, Tanzania will be in a much better position to tackle programme-level issues.

Gates Foundation support for TNCM’s 18-month transformation period

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As a result of the assessment’s recommendations on how the TNCM could improve its management of Global Fund processes, the Secretariat requested BMGF to support transformation over an 18-month period. This requires the development of a transformation plan to improve TNCM operations and performance so that it becomes an efficient and proactive organisation capable of providing real leadership, governance and oversight to health program implementation.

The first action for TNCM was to build consensus for reform among committee and program stakeholders. To do this, the TNCM held its first ever residential retreat in August 2018 for TNCM members and alternates, together with implementing partners. Over 50 participants attended, comprising a balanced representation of Government and non-government programme delivery managers, Principal and Sub-Recipients (PRs and SRs), the Local Fund Agent, civil society and faith-based organisations, academic institutions; and key development partners. The presence for three days of two Permanent Secretaries demonstrated the importance attached to the transformation process.

The retreat aimed to achieve agreement on a way forward that would contribute to the development of a transformation plan. Participants were presented with management and planning tools that could help the planning process and keep the momentum for change. The tools included: the evaluation methodology of appreciative inquiry to reflect on recognised performance and implementation issues; SWOT analysis to arrive at solutions to address threats and weaknesses while taking advantage of strengths and opportunities to upgrade the TNCM’s performance; a theory of change, using the SWOT analysis to populate it and address major concerns; and stakeholder analysis to win support, gain resources and achieve consensus. Participants considered these tools to be useful, and the same tools could potentially be used by other CCMs embarking on an evolution process.

The four major enablers to evolve CCMs to the highest functional level, that of Strategic Engagement, were discussed; and participants felt that three of four enablers were now in place — having the right leaders, an effective CCM Secretariat, and strong support and active engagement from the Global Fund Secretariat. It was recognised that there needed to be a formal transformation plan which, in addition to the changes sought, should also include work on the fourth enabler: having sufficient financial resources.

The enablers are intended to support the four “improvement areas” identified by the Global Fund: functioning, linkages, engagement, and oversight.

The TNCM now has to review the 18-month CCM Evolution workplan provided by the Global Fund and develop and implement its own transformation plan in such a way that it is consistent with the CCM Evolution activities planned for Tanzania.

If the momentum for change is maintained, as the first country to take ownership of the CCM Evolution Initiative and move beyond the minimum required by the Global Fund, Tanzania could be in a position to provide a model for other countries’ successful CCM evolution.

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For more information on the CCM Evolution initiative, see also:

“ Global Fund Board approves CCM Evolution initiative at an intermediate level of ambition but with a phased-in approach” from GFO 336 (12 May 2018)

The Global Fund’s CCM-related document from its 39 th Board Meeting: “CCM Evolution: CCM Code of Conduct, CCM Policy and Level of Ambition”

The Global Fund’s CCM Evolution description on the CCM page of the Fund’s website

The Global Fund’s CCM Policy

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7. OF INTEREST: Gates Foundation’s second ‘Goalkeepers Report’ tracks progress towards the Sustainable Development Goals

The 2018 report focuses on youth population growth, occurring mainly in Africa

Adèle Sulcas 3 October 2018

The Bill & Melinda Gates Foundation undertook, in 2017, to publish a ‘Goalkeepers Report’ every year until 2030, charting the world’s progress towards the Sustainable Development Goals, which have 2030 as their target date.

The co-chairs’ introduction to the report (and on the ‘Goalkeepers’ page on the Foundation’s website), is entitled ‘Is Poverty Inevitable’? They go on to explain that usually they express their optimism “by highlighting some of the recent mind-blowing developments in the human condition,” such as the fact that more than one billion people have lifted themselves out of poverty since 2000.

On this occasion, though, they present a more sober picture: “To put it bluntly,” they write, “decades of stunning progress in the fight against poverty and disease may be on the verge of stalling.”

The reason for this, they say, is that the poorest parts of the world are growing faster than anywhere else – more babies are being born “in the places where it’s hardest to lead a healthy and productive life.”

Sometimes, though, “optimism requires being candid about the hard problems that still need to be solved,” the introduction says.

The crux of the Goalkeepers 2018 report rests on current population numbers and projections: Africa’s population is predicted to increase by 51% between their 2017 baseline and 2050,

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while all other regions in the world are projected to experience population declines of between 6% and 41% in that same time period.

Africa’s youth population is booming; the rest of the world is shrinking, the report says. (This is what was referred to at AIDS 2018 by Unicef and others as the imminent ‘demographic bulge’, making new and more effective HIV prevention tools for the increasing youth population at risk more critical than ever.)

Nearly 60 percent of Africans are under the age of 25, compared to 27 percent of Europeans; the median age across Africa is 18, compared to 35 in North America (or 47 in Japan).

However, the co-chairs also say that the development of human capital is the key to unlocking a successful future for Africa, by investing in young people’s health and education.

“If young people are healthy, educated, and productive,” they say, “there are more people to do the kind of innovative work that stimulates rapid growth,” which ultimately would be extremely good news for the economy, at all levels.

The report’s conclusion and ‘global data’ section includes some global health data on: HIV, TB and malaria (pages 44-45), as well as vaccines, stunting, maternal mortality, under-5 mortality, neo-natal mortality, neglected tropical diseases, family planning, universal health coverage (UHC), smoking and sanitation.

There is also a separate section on HIV, comprising a ‘future scenarios’ view of Zimbabwe’s HIV epidemic.

To read Bill & Melinda Gates letter, and to download the Goalkeepers Report 2018, click here.

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8. EDITOR’S NOTE: OIG explains why Sri Lanka appears twice in country list for audit report on Global Fund Transition Management

processes

In an article that appeared in GFO 342 (19 September 2018) on the Office of the Inspector General’s audit report on Global Fund Transition Management processes, we stated that:

“The audit was based on a sample of ten countries that either are already receiving transition funding for 2017-2019 or are projected to have ‘transition components’ from Global Fund support by 2025. The ten countries are:

- Albania, Cuba, Sri Lanka, Turkmenistan, and Paraguay (ineligible for funding allocation since 2014-2016 and receiving transition funding 2017-2019);

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- Sri Lanka (projected to become ineligible for funding in 2017-2019 due to upper-middle income [UMI] status);

- Kosovo (projected to become ineligible based on country move to UMI status in 2020-2022);

- Malaysia, Romania and Costa Rica (projected to become ineligible due to move to high-income status.”

One astute GFO reader noticed that the sample of ten countries in fact comprises nine countries, with Sri Lanka appearing twice. This was not an error but – we realize – readers may benefit from further clarification: The first mention of Sri Lanka refers to its malaria disease component; the second mention refers to its HIV and TB disease components. (See page 23 of the audit report for a full table of the countries included in the audit sample).

The OIG offered Aidspan the following further explanation:

“A country or a disease component may transition from Global Fund support either voluntarily or because they become ineligible based on the Global Fund Eligibility Policy and/or have received their final allocation based on discussion with the Global Fund.

“The Eligibility, and STC policies look at transition at the disease/component level. So disease components in country may transition during different periods. One key factor in the eligibility policy is the disease burden (which is assessed at each disease level) so if the malaria burden is at a lower level, it will transition before TB or HIV which may be a relatively high level compared to malaria.” 

We thank the OIG for the clarification.

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________________________________________________________________

This is issue #343 of the GLOBAL FUND OBSERVER (GFO) Newsletter. Please send all suggestions for news items, commentaries or any other feedback to the GFO Acting Editor at adele.sulcas@aidspan.org. To subscribe to GFO, go to www.aidspan.org.

GFO Newsletter is a free and independent source of news, analysis and commentary about the Global Fund to Fight AIDS, TB and Malaria (www.theglobalfund.org).

Aidspan (www.aidspan.org) is a Kenya-based international NGO that serves as an independent watchdog of the Global Fund, aiming to benefit all countries wishing to obtain and make effective use of Global Fund resources. Aidspan finances its work through grants from foundations and bilateral donors. Aidspan does not accept Global Fund money, perform paid consulting work, or charge for any of its products. The Board and staff of the Fund have no influence on, and bear no responsibility for, the content of GFO or of any other Aidspan publication.

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GFO Newsletter is now available in English and French. The French-language edition becomes available within one week after the publication of the English edition.

GFO Acting Editor: Adèle Sulcas (adele.sulcas@aidspan.org). Aidspan Executive Director: Ida Hakizinka (ida.hakizinka@aidspan.org).

Reproduction of articles in the Newsletter is permitted if the following is stated: "Reproduced from the Global Fund Observer Newsletter, a service of Aidspan."

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Copyright (c) 2018 Aidspan. All rights reserved.

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