Credit Tommy Trenchard / Oxfam
On 10 November, the Global Fund for the first time tapped a new Emergency Fund that is designed to provide quick financing to fight HIV, TB and malaria in emergency situations. In this case, Liberia, a country seriously affected by the Ebola outbreak, will use US$1.6 million to expand a mass distribution campaign of mosquito nets. The move follows the World Health Organization’s declaration of the Ebola outbreak as a public health emergency of international concern, and a realization that existing grants could no longer meet needs on malaria. Because initial symptoms can be similar, Ebola is complicating and delaying the diagnosis and treatment of malaria and malaria cases are adding to the burden on Ebola facilities.
The Emergency Fund aims to prevent disruptions in treatment and essential services when standard funding channels, including the reprogramming of existing grants, cannot react fast enough. The Ebola outbreak in West Africa showcases the extra challenges faced by countries like Guinea, Liberia and Sierra Leone, post-conflict states each with unique challenges in building effective health systems. With health workers and patients deeply afraid of becoming infected, systems are not operating well and disease programs are being seriously affected. Together with partners, the Global Fund is actively exploring whether there is an additional need for artemisinin-based combination therapy (ACT). The Global Fund has informed Ministries of Health that they can use Global Fund resources for presumptive therapy of malaria, consistent with WHO guidelines.
The Global Fund is working with experienced emergency-response partners. With US$30 million, it may be applied to other emergencies such as famine, natural disasters or refugee crises. The Emergency Fund is limited to short-term and time-bound funding, covering the specific disease emergency until longer term financing can take over.
“This funding gives us the capacity, within our mandate to fight HIV/AIDS, tuberculosis and malaria, to be able to release funds when an emergency situation arises and when people’s lives are being put in danger by the disruption of treatment and services,” said Mark Edington, Head of Grant Management at the Global Fund.
Finding a Way to Defeat TB
Tuberculosis, one of the oldest diseases known to mankind, killed more than 1.5 million people in 2013, even though it is entirely curable. Leaders, health experts and civil society activists meeting recently in Barcelona at the annual Union Conference on Lung Health called for an approach that aims to defeat the disease, by working with affected communities and focusing on vulnerable groups such as miners and prisoners.
“We have to concentrate on vulnerable groups and hot spots,” said Aaron Motsoaledi, Minister of Health for South Africa. “In South Africa we are targeting particular areas and not using a one-size-fits-all approach.” Miners in South Africa represent the highest TB rates in the world. Incidence of TB is 70 times higher among prisoners than in the general population.
Incidence of TB is falling at an annual rate of 1.5 percent, far too slowly. “I don’t think TB has been prioritized to the extent that it needs to be,” said Amy Bloom, senior technical adviser at USAID. “In the United States we don’t see TB and we don’t hear about it. People ask me: is there still TB in the world?”
Even in South Africa, deaths from mining accidents attract far more attention than TB fatalities, said Motsoaledi. “In 2009 there were 80 deaths in mines from accidents while 1,100 miners died from TB. The problem is that TB is a very slow and silent disease. HIV awakens a lot of fear, like Ebola, but we are unable to do that with TB.”
Mark Dybul, Executive Director of the Global Fund, said that if slow rates of decline in TB incidence continue, it could become challenging to advocate for funding for tuberculosis, estimated to be US$2 billion short of what is needed. “We need a paradigm shift, away from seeking coverage and control to going for elimination by focusing on hot spots of disease and vulnerable groups and by investing for impact,” said Dr. Dybul. “TB cases are not all over, they are concentrated in a number of countries. You have to go where the infections are.”
More Concept Notes
Many countries have recently submitted concept notes to the Global Fund, a critical step in applying for funding. The Technical Review Panel considers strengths and weaknesses of all funding applications, and reviewed 39 concept notes in September, of which 31 were approved for grant-making. The remaining 8 concept notes will require additional work, and the TRP will review revised versions in future submission windows once they are ready.
The TRP provides regular feedback to applicants to help them develop stronger proposals and make a compelling case for funding. In September, the third window for review in 2014, the TRP noted that a large number of applications were grounded in evidence and had a sound strategic focus, in line with national strategic plans.
To build upon recommendations developed after the first two windows in June and July, the TRP has produced 6 new suggestions to help countries build the strongest case for funding:
One: Prioritizing Funding Requests
The TRP noted improved clarity and communication of priorities in the concept notes. It strongly urged applicants to separate the allocation request from the above allocation request, noting that when the split between the two is not clear it is a challenge for the panel to assess the application and to recommend incentive funding or unfunded quality demand.
When applicants can clearly describe why certain geographic regions, modules and interventions have been included in either the allocation or above allocation request, that will make a more compelling case.
Two: Identifying the Right Interventions
Many applicants presented situational and programmatic gap analysis well, but at times did not make the best use of their findings for intervention selection and budgeting. For example, if low detection levels of TB are acknowledged in a concept note, the case for funding is strengthened if strategies for increasing case detection are also proposed.
If applicants are not sure which activity is best suited to address issues that have been identified in the concept note, the TRP encourages applicants to consider piloting interventions and/or under taking operational research that can inform future planning.
Three: Including Gender-sensitive Programs
The TRP welcomed the identification of key populations and issues of gender-based violence as a priority by applicants. However, the panel noted that adequate programming for these groups was at times lacking and should receive attention in future submissions.
The TRP encourages greater emphasis on gender-sensitive programming. Applicants are expected to address gender-specific health problems and barriers in accessing services for women, girls, men and boys. More attention should be paid to HIV prevention and treatment programs for adolescent girls and young women and to deal with gender-based violence.
The panel encourages technical and civil society partners with expertise in gender issues to engage with Country Coordinating Mechanisms (CCMs) during country dialogue to identify the best interventions and make sure they are adequately budgeted for.
Four: Improving Presentation of Funding Landscape for the National Program
The TRP encourages applicants to better present the funding landscape with the main sources and focus of funding from national and other donors, thereby identifying remaining funding gaps. Additional information that illustrates how the Global Fund complements the overall picture is valuable in helping the TRP assess this issue.
The development of co-financing plans with other donors is being encouraged, in order to maximize the impact of Global Fund funding.
Five: Thinking ahead for Sustainability of Programs
All applicants are encouraged to consider how best to plan for long-term sustainability. For example, increased government investment in programs and activities focusing on key populations is recommended as well as promoting government collaboration with community-based organizations and NGOs.
Six: Adequately Addressing Health Systems Strengthening Needs
The TRP reminds applicants that health system capacity is a foundation for success in all health programs, including those addressing the three diseases. Applicants are particularly encouraged to describe how health systems strengthening investments are addressing existing health system weaknesses, while seeking technical collaboration from partners to help ensure a robust and holistic response.
The TRP encourages maximizing health systems strengthening, from Global Fund or other sources, in order to integrate programs into national health efforts; bolster human capacity; improve national supply chain management and strengthen monitoring and evaluation systems.
Where appropriate, applicants are urged to explore ways of integrating disease-specific interventions with reproductive, maternal, new-born and child health.
In addition, the TRP made a number of technical recommendations:
One: HIV Programs Should be Comprehensive
The panel encourages expanding access to antiretroviral treatment for key populations, adolescents, children and women and to better prevent mother-to-child transmission of HIV. The TRP is also looking for comprehensive programs adequately covering testing and treatment continuum, whereas expanded access to HIV testing also ensures timely referral, inclusion and retention in treatment with appropriate indicators to properly monitor treatment outcomes.
Interventions for key populations should make best use of the available data (size estimation, modes of disease transmission, barriers to services, etc.) and where lacking should plan for data generation.
Two: Increasing access to TB services for all patients, including those with MDR-TB
The panel found that concept notes were consistent with international standards and aligned with national strategic plans but were lacking a clearer link between programmatic gaps, priorities and proposed activities. More attention is needed to ensure increased access to comprehensive and good quality basic tuberculosis services along with detection and treatment of drug-sensitive and drug-resistant strains of the disease.
Three: Increased TB and HIV program coordination needed
While some concept notes showed a high degree of integration and collaboration between TB and HIV programs, the panel concluded that some did not go far enough in advancing the degree of coordination and collaboration. In particular, diagnosing, identifying and treating patients through integrated service delivery between TB and HIV programs remains an area requiring more deliberate elaboration in the concept notes.
Four: Stratify the Risk and Link with Interventions in Malaria
The TRP recommends that all countries should be using or establishing systems to generate the best data to stratify risk in specific administrative areas so that prevention and treatment interventions are appropriately linked to these risks, adequately planned, deployed and monitored.
Five: Focusing more Attention on Community Systems Strengthening
The panel stresses the importance of community systems strengthening, especially in helping to apply a client perspective to the development of policy and service delivery.