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What can the Global Fund do more of?

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As a part of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) consultation project, the Biennial Partnership Forum 2011, an inclusive online debate was initiated to find answers to some key questions. The answers were expected to contribute towards constructing a more robust roadmap for the future of the Global Fund.

The responses have been wide-ranging ā€“ both in suggestions and observations. They reflect the voices, expectations and hopes of affected communities, programme administrators and other stakeholders. They also indicate that GFATM has become a symbol of hope and stakeholders would like to see its scope go beyond just funding country programmes. Regardless of whether or not this is feasible, or fits in with the scope of GFATM, the exercise has succeeded in revealing some very real gaps that need to be addressed. The summary of the responses is available at http://www.citizen-news.org/2011/04/global-fund-consultation-topic-1-lives.html.

It would be valid to begin here by directing some thought towards how the Global Fund is structured and how it is different from other funding agencies. Andreas Tamberg, Fund Portfolio Manager, GFATM says: “The Global Fund is a unique, public-private partnership and international financing institution dedicated to attracting and disbursing additional resources to prevent and treat HIV and AIDS, TB and malaria. This partnership between governments, civil society, the private sector and affected communities represents an innovative approach to international health financing. The Global Fund’s model is based on the concepts of country ownership and performance-based funding, which means that people in countries implement their own programmes based on their priorities and the Global Fund provides financing on the condition that verifiable results are achieved.”

The Country Coordinating Mechanisms (CCMs) established by GFATM to drive country level activities ensure that there is equitable representation from all of the above sectors. Manohar Elavarthi, Vice Chair of the CCM India, corroborates this: “Before the Global Fund was established, we were operating in a traditional world of funding where it was typically bilateral and did not allow space for participation from key stakeholders who would benefit from the funds. The Global Fund in a sense changed much of this. For the first time, we have an agency that allows for this very vital participation through the CCMs. There are other unique elements to the Global Fund as well. It encourages the use of generic drugs, allows for administration by local officials and most importantly optimizes on the resources available by lowering administrative and manpower costs.”

That the Global Fund has touched lives and made a difference is evident from the figures, which speak for themselves (see box at the end of the article). The Global Fund works in close collaboration with other bilateral and multilateral organizations to supplement existing efforts in dealing with the three diseases.

The funding for India is as follows:
Total approved funding as of May 2011
Funding for HIV/AIDS: USD 1,927,801,421
Funding for HIV/TB: USD 14,819,772
Funding for malaria: USD 101,650,559
Funding for TB: USD 352,466,229
(Source for figures: Global Fund)

The need to revisit priorities
Then why is there a need to revisit the funding patterns, or examine whether the Global Fund should increase or decrease what it is currently doing? It is important to view this from different lenses. Within the Global Fund there are questions as to whether systems and processes have become too complex. To quote from the Global Fund’s An Agenda for a More Efficient and Effective Global Fund: “… increased political attention to health, with substantial new resources, has given rise to a proliferation of actors and initiatives and a far more complex global health landscape. The Paris Declaration on Aid Effectiveness and subsequent Accra process have highlighted the need for the Global Fund, along with other donors, to harmonize their efforts and align them more effectively with countries’ own systems and regulations. This need has become particularly acute as AIDS, TB and malaria programs in many countries have rapidly scaled up from demonstration projects to fully fledged national programs. In such a dynamic environment the Global Fund has had to remain a flexible, innovative and learning organization. It has consistently worked to adapt its processes in response to changing circumstances and to effectively use data and operational experience to bring about organizational improvement and increased operational efficiency and effectiveness…”

Viewing it from a stakeholder perspective, the expectations are varied, and some fall in with the above. Dr Mohammed Rafique, Country Team Leader at CARE India, says: “Since the Global Fund bases its funding on local programmes and does not initiate or implement parallel programmes, it is very important to understand local contexts. It is also vital for the Global Fund to recognize that the different political climates of different countries make it impossible for one solution to fit all problems, and thereafter allow for those differences and respond to them accordingly.”

Dr D Behera, Director, LRS Institute of TB and Respiratory Diseases, and CCM Member says: “Global Fund has done a commendable job of providing vital funding for TB programmes in India, but the demand for uptake of funds for TB is rather limited. The reasons for why India continues to grapple with the problem of large incidence of and deaths from TB, lies elsewhere and is not within the purview of the Global Fund. We have to regulate the private sector as this is the first point of contact for patients. When they come into the government programme, most often it is already too late. How can we pull these linkages together?”

Subrat Mohanty, Project Coordinator, Project Axshya, International Union against Tuberculosis and Lung Disease (The Union), adds: “The Global Fund has been supporting the India TB Programme since Round Two through various rounds. It has been a historic moment for TB care and control in India to have two civil society principal recipients – The Union and the World Vision India – along with the Central TB Division to have joined together in the Global Fund Round Nine to support India’s effort to TB care and control. A lot depends on how effectively access to full treatment and awareness on the disease is spread across the country ā€“ an area where the usefulness of civil society collaboration and roles for sectors like the media become apparent.”

Linkages ā€“ vital to impact
While the above statements might reflect the situation with regard to TB, the situation is true of AIDS and malaria as well. Treatment is vital to saving lives but can the Global Fund help to enable the other linkages? These are important linkages to overall public health, without which real impact is difficult to achieve. Andreas Tamberg says: “At the end of the 1990s, public health experts identified a number of highly effective interventions to prevent and treat AIDS, TB and malaria. New knowledge about the scale of epidemics and a deeper understanding of the complex causal links among poverty, development and disease, pushed international issues of public health to the centre of the world’s development agenda.”

In the coming years, it would be very important for the Global Fund to translate this understanding into action. That linkages in other sectors are also important is evident from the fact that the responses to the online consultation had a significant number of respondents pointing towards the need for more effective measures to prevent diseases. Other demands include collaborative programmes such as training for health workers, health and community systems strengthening and the scaling-up of laboratory services.

The CCM is a vital hub for effective functioning of the Global Fund in each country. Most of the respondents to this story were of the opinion that the purpose would be well served if there was greater representation from non-government entities. “While government representation is very important, it should not result in all the other voices becoming less vocal. It is absolutely imperative for a Global Fund representative to anchor the CCM meetings,” appealed one respondent eloquently.

The India CCM, on the face of it, has very little representation from the TB sector and the emphasis seems more in favour of AIDS. One can rationalise that when AIDS is addressed, TB also gets attention but AIDS and TB can be twinned only to some extent because, while 80 percent of people living with HIV might develop TB at some time, the reverse might not be true. It becomes vital to look at TB as a separate entity and give it special emphasis and this merits greater representation from the TB sector.

In its World Malaria Report 2008, the WHO estimated there had been 10.6 million cases of malaria and 15,000 deaths from the disease in India during 2006.[1] By its very name, the Global Fund concentrates on HIV, TB and malaria. The response to malaria however was seen to be minimal. Mr Nirod Kumar Bhuyan, Project Officer at the LEPRA Society and CCM India member, says: “Malaria is underrepresented in the CCM and the Government of India does not give adequate importance to it despite the fact so many people suffer from malaria in India. Much more needs to be done and the Global Fund has a vital part to play in this.”

Some statistics
* 3 million people currently on antiretroviral treatment for HIV.
* 7.7 million people on effective TB treatment under the internationally approved TB control strategy (DOTS).
* 160 million insecticide-treated bed nets distributed to protect families from malaria.
Additional results in treatment, prevention and care include:
* 150 million people reached with HIV counseling and testing.
* 142.4 million malaria drug treatments delivered.
* 2.7 billion condoms distributed.
* 5 million basic care and support services provided to orphans and vulnerable children.
* 160.4 million people reached with community outreach services.
* 12.3 million people trained to deliver services for prevention and treatment of AIDS, TB or malaria.
(Source for figures: Global Fund)

In conclusion
Global Fund-supported programs have saved so many lives by enabling countries to deliver significantly expanded key services (see figures above ). The emphasis has been on service delivery. Numbers are important but meeting the Millennium Development Goals for HIV, TB and malaria will require huge efforts and commitments in terms of funding, programmes and country specific responses that go beyond the numbers. The consultation has revealed some of the more severe gaps. It remains to be seen how the Global Fund will respond to the challenges.

[1] Source: The Hindu 17 June 2010 http://www.hindu.com/2010/06/17/stories/2010061754161100.htm

Bharathi Ghanashayam

First published in www.healthdev.net

Written by JournalistsAgainstTB

May 16, 2011 at 5:19 pm

Posted in TB and Media

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