The conclusion of the Global Fund's 32nd Board meeting since its inception in 2002 demonstrated a healthy maturation of the organization with signs of adherence to a systematic way of doing business. But lingering questions about impact, about equitability and about resource management remain, accompanied by concerns about the gaps in capacity and flexibility that the model has yet to overcome.
Most of these concerns were encapsulated in the lengthy and lively discussion that followed the presentation on 21 November of progress and lessons learned about the new funding model: the upfront allocations to countries of financial resources based on their burden of disease and ability to pay for their own response to AIDS, TB and malaria.
NFM lessons learned... or needing to be learned
Board delegations emphasized the need for greater simplicity within the NFM's processes and procedures. Equally they demanded that concept notes to apply for a country's share of the more than $12 billion in funds available through 2017 be based on more and better data, more rigorous analysis of needs and a more sound application of the Global Fund's methodology and ethos to national priorities -- balancing the needs of the most vulnerable against the responsibility to a wider population.
The theme of 'more' reverberated throughout the meeting: more emphasis on human rights, gender, community strengthening and key populations; more human resources in country to provide durable technical assistance to increase local capacity; more money overall to respond to the interventions laid out in countries' national strategic plans. How to find more, however, remained elusive.
Among the challenges highlighted by the TRP were the struggles countries are having to operationalize what they have identified as gender or community-level barriers to access to services.
The discussion around disease burden and controlling the spread of epidemics seems to have pivoted, one participant noted, away from high-burden countries to high-burden populations. Perversely, another said, it seems that the Global Fund's focus and resource commitment to those very key populations has been somewhat of a disincentive for national governments. This has meant that governments have been reluctant to providing costed support for activities that target them.
What this has translated into, in many countries, is domestic resources not being directed towards the highest-impact interventions.
And so, as the TRP noted, the Fund is caught somewhat in a dilemma, trying to fund critical programmatic gaps so that impact is based very clearly on the basic provision of essential services while having very little room to incentivize innovation because of the limitations on funding.
This dilemma has been compounded by a number of decisions that, while derived from the best of intentions, would seem to be undermining the ability to achieve the Fund's overall goal: investment for impact to reduce the spread of AIDS, TB and malaria.
The encouragement of countries to develop their full expressions of demand in order to tap into incentive, or above-allocated funding, are not achieving their purpose, the TRP said. More than that, it is not favoring strategic investment decisions for impact across the portfolio, setting up an "unrealistic hope of resources that may undermine real prioritization and lessen the drive to mobilize domestic and other funding".
Continued alarm over the state of middle income countries
Nowhere is this drive to mobilize domestic and other funding more acute than among the middle-income countries bracing to transition away from Global Fund support. In a paper released to coincide with the Board meeting, Open Society Foundations warned of the need to consider the implications that the reorientation of the Global Fund's allocations methodology are causing for key populations in those countries.
"The main way that New Funding Model is at odds with human rights is that it abruptly curtails funding for the populations most systematically subject to human rights abuses. A failure to protect these groups from abuse will be disastrous for HIV program effectiveness, and also undermines years of Global Fund investments," the paper concluded.
Analysis of investments sought for future allocations
Board delegations were also keen to develop a more grounded understanding of the NFM as it was rolling out, asking for analyses on a range of topics in time for the next Board meeting. Among the issues of greatest interest were the value of the technical assistance being provided, which one participant noted succinctly would indicate whether the investment in TA helped improve the quality of the concept notes being developed and approved. Also topping the wishlist were investigations into the extent to which gender, human rights and community system strengthening were being integrated not only into the development of concept notes but into programming as well.
How well the joint concept notes for countries with high co-morbidity between HIV and TB were being articulated and resulting into quality programming that did not sacrifice one disease for another was also identified as an area that required further study.
Finally, many delegations sought clarity on how the Global Fund was articulating its approach to health system strengthening -- particularly within states that are fragile, emerging from conflict or suffering from chronic instability. The conflation of poverty, conflict and epidemic disease are having ruinous effects for the countries stricken by Ebola, more than one delegate noted, and highlighted the yawning gaps in human resource, infrastructure and health systems.
As one delegate soberly noted: "Ebola tells us that all progress made can be wiped out by a major disease epidemic".