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Issue 252: 02 October 2014

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CONTENTS OF THIS ISSUE:

1. NEWS: Morocco's quiet revolution over AIDS and human rights

In Morocco, the election of five representatives of key populations to the country coordinating mechanism marks a turning point in the recognition of the rights of those people most at risk of being infected with HIV: groups that have traditionally been victims of stigma and discrimination.

2. NEWS: Some hiccups but mostly smooth sailing for Latin America and Caribbean under NFM

As countries in Latin America and the Caribbean move through the new funding model (NFM) process, sustainability beyond the life of the Global Fund grant is at the heart of strategic planning.

3. NEWS: First grants under the full NFM rollout are about to be signed

History will be made shortly as the first two grants under the full NFM roll-out are signed. Both grants are from a Moldova HIV concept note. In a separate development, the Fund’s newly established Emergency Fund has received an application to provide HIV and TB services to Syrian refugees in Jordan and Lebanon. 

4. NEWS: Regional pitch to fight TB in Syrian refugees rejected by Global Fund

An expression of interest for a $10.18 million regional initiative to develop a harmonized response to a TB crisis among Syrian refugees scattered across neighboring countries was rejected by the Global Fund.

5. NEWS: Civil society in Malawi elbows its way in to find a seat at the table for HIV policymaking

Civil society groups are stepping up their engagement in policymaking in Malawi, to ensure that their voices are not just heard during country dialogue but are contributing to a way forward to fight HIV. 

6. NEWS: Global Fund pledges swift response to any Ebola-related requests from Liberia, Sierra Leone or Guinea

The Global Fund will respond to requests from Liberia, Sierra Leone and Guinea to be more flexible in reprogramming grants should this be needed to support the continued response to the Ebola epidemic. The countries may ask for a greater investment in health systems strengthening, as poor infrastructure, a shortage of trained health workers  and weak systems are driving the spread of the outbreak.

ARTICLES:

1. NEWS: Morocco's quiet revolution over AIDS and human rights

Robert Bourgoing 29 September 2014

In July 2014, in a meeting room in the Moroccan capital Rabat, a young Moroccan woman stood up and addressed an audience composed of senior representatives from international organizations and government -- including the Ministry for Islamic Affairs and the prison system. “I am Karima El Kaoudali," she said in Arabic, "and I represent the sex workers of Morocco.”

The new representatives of key populations in Morocco’s CCM. From left to right: Abderrahim Elhabachi (PLWHA), Haj Driss Benattabou (IDU), Mohamed Lamouri (MSM), Hassan Haliba (IDU), Karima El Khaoudali (CSW), Yassine Eloulidi (MSM) and Othman Akhrif (PATB)

Karima El Kaoudali's bravery was matched equally by two other young men who also stood up during that meeting: one, a member of Morocco's gay community; the other, a representative of people who inject drugs.

Bearing witness to the courage of these three young people is driving a perceptible and noteworthy shift in the way Boutaina Selma El Omari works, coordinating the Global Fund’s Program Management Unit at the Ministry of Health -- and the way Morocco will, going forward, be developing its proposals for Global Fund support for HIV.

The three advocates were meeting with other members of Morocco's new country coordinating mechanism (CCM), representing disease-affected populations in a way that has never before been seen -- not in Morocco nor in most parts of the Middle East and North Africa region, explains El Omari.

The selection of 5 voting members (out of 33) to represent vulnerable and most-at-risk populations (the other two represent people living with HIV and affected by TB) was a complex and sensitive project that had to be conducted independently, under the supervision of a notary, recalls Boutaina El Omari: “There is no association representing those groups because it’s illegal [homosexuality, prostitution, drug use]. So we had to work with civil society groups that collaborate with them. All thematic NGOs were involved in the process.”.

The Global Fund, common sense and the King

Morocco's human rights landscape is evolving for a number of reasons, many of which could have a positive effect on the way the country responds to its HIV epidemic. The right to access health services, the right to respect for human dignity, the right to discretion and privacy: all are becoming normative in the traditionally conservative Kingdom, which was among the only countries in the region that did not experience any upheaval during the Arab Spring.

And while the nearly $38 million allocated to Morocco under the Global Fund's new funding model (NFM) for TB and HIV is a modest sum, the requirements accompanying the disbursement of those resources are also helping to fuel this quiet rights revolution.

"The ground was ready" for the new requirements placing key populations at the heart of the proposals to support the national HIV response, says Mustapha Ouchrahou, the permanent secretary of the CCM. "It's the culmination of many years of work -- within the CCM and in the field."Mustapha Ouchrahou, CCM’s Permanent Secretary

It's also indicative of the new approach to HIV that has taken root within the health ministry, adds El Omari. "Since the beginning of the epidemic, the ministry has understood the need to work with these groups," she says. For one simple reason: two thirds of new infections recorded in Morocco are within key populations. Prevalence among men who have sex with men is estimated at 5%, among sex workers 8%, and among drug users around 10% compared to a generalized rate of under 1% nationwide.

With the concern that the spread of disease from key populations to their clients and loved ones could undermine that progress, a series of legal protections for human rights has been enshrined in the Moroccan constitution in 2011. Equally, the HIV national strategic plan 2012-2016 was complemented by a new national strategy on rights and HIV: two documents that envisage the end of stigma and discrimination against all vulnerable populations.

Dr Mohamed Belekbir (center), coordinator of the Global Fund-supported HIV sensitization program for imams and ulemas in Morocco

Religious leaders, who have considerable influence on public opinion, have also weighed in -- and favorably.

Mohamed Belekbir has carried out sensitivity and awareness training about HIV for imams and Muslim legal scholars known as ulemas for more than a decade. 

The program, which receives Global Fund support, is founded in Koranic teachings: a foundation that lends immediate credibility to the training and has provided a jolt to the fight against discrimination.

"People say that, prior to 2004, religious leaders were propagating fear and misinformation about HIV," says Belekbir. "Those who were infected were considered sinners and AIDS was a punishment from God. There really was a change [in attitudes] after 2004."

According to him, none of the innovations -- not the representation of key populations in the CCM, the human rights legislation in the Moroccan constitution, or the support for HIV awareness training among the clergy -- would have been possible before the 1999 ascension to the throne of King Mohamed VI.

Morocco's evolution on human rights and HIV is setting a new regional standard, adds Belekbir. "Everyone is interested in the Moroccan model."

Boutaina El Omari confirms: "we are trying not to compare ourselves but when we attend international conferences, we can see we are light years ahead of [our regional counterparts]. We feel like sometimes, people think we are exaggerating".

A first step forward, as one of the powerful

"Initially, I was shocked because of what I saw in the eyes of the other CCM members --whether it was empathy, or pity, or intolerance," says Karima El Khaoudali, recalling the bombshell she dropped after being appointed to serve on the reconstituted committee. "But I haven't let it get to me; in fact, the weight of my responsibility is driving me forward, and the people I am representing are more of a motivation than a brake."

For Driss Benattabou, the "openness of spirit" with which he and other representatives of key populations have been welcomed by the other CCM members overrides any lingering concerns about being open about his past injected drug use.

"We have not felt marginalized; if anything, we have turned it around and sort of surprised them with how comfortable and present and strong we are about advocating for our rights," he says. "It's not what they would have expected from people who are so marginalized, so stigmatized in society."Representatives of key populations in Morocco’s new CCM. From left to right, standing: Abderrahim Elhabachi (PLWHA), Yassine Eloulidi (MSM), Othman Akhrif (PATB) and Hassan Haliba (IDU). Sitting : Mohamed Lamouri (MSM), Karima El Khaoudali (CSW) and Haj Driss Benattabou (IDU)

For all their confidence in the gravity of their roles in the CCM, however, it can be difficult sometimes, says Abderrahim Elhabachi, newly installed as the representative of people living with HIV in the CCM. "Sometimes, when we want to say something in front of senior people, it's a bit intimidating," he says ruefully. "So you have these ideas but it's hard to translate them into words."

It's those ideas that are the most important, replies Hassan Haliba, Benattabou’s alternate on the CCM. Ideas and experience of discrimination, he emphasizes, and how that discrimination affects people's ability to access information, or services, are valuable elements to bring to the table in a way that professionals, be they doctors or academics, cannot.

Morocco's CCM: an ‘incubator for human rights’

The advances made by Morocco should not eclipse what is left to achieve in terms of human rights and HIV. Now that a legal framework is in place and the Ministry of Health has shown itself disposed to leading the way to implementing those laws nationwide, and reaching all people, it is up to the judiciary and security forces to get in line -- a dicey proposition sometimes. Notes Benattabou, "society is on board and is mostly accepting, but government, and all that is considered 'official' has not shown itself to be so tolerant."

 Zineb Nasser, Peer Educator and nurse at the Association Sud Contre le Sida in Agadir, with Safa, a 22 year old CSW who undergoes her first voluntary test for HIV.Benattabou's counterpart representing the gay community in the CCM, Yassine Eloulidi, agrees. "The CCM is a microcosm of Morocco as a whole. When we join the CCM we have a responsibility to work on ourselves as well, to not wait for others to accept us but to assert ourselves with strong ideas about the best way to reach our constituencies."

Morocco is not trying to please donors by rushing into something that doesn’t take into consideration the particular context of the country, its laws and its societal conventions, explains El Omari, who coordinates Global Fund programs at the Ministry of Health.

The reason the Moroccan model is an incubator and role model for the region is because its revolution was started from within, she insists, and because ultimately, its goals are relatively modest yet urgent, when considering the threat that the concentrated HIV epidemic represents for the entire population.

"All we want is for anyone who lives with HIV, whether it is a drug user, a sex worker, a man who has sex with men, all we want is for them to be considered equally," she says. "A Moroccan who has the right to health."

Read this article in French. Lire l'article en français.

[This article was first posted on GFO Live on 29 September 2014.]

To comment on this article, click here.

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2. NEWS: Some hiccups but mostly smooth sailing for Latin America and Caribbean under NFM

Lauren Gelfand 29 September 2014

Six concept notes in and another eight on deck for October from the region

Countries from Latin America and the Caribbean have submitted six concept notes under the new funding model (NFM) as of end-September, with another eight expected in the October submission window, according to a calendar shared with Aidspan.

Three of the first six notes submitted were returned following a review by the Technical Review Panel; the revisions are expected to be completed in time to catch the November TRP window.

A reprogramming of funds to support Guyana's HIV program was approved, as was a Cuban concept note for HIV. Grantmaking for this disease component is expected by the end of the year, according to the Secretariat's LAC regional manager Silvio Martinelli.

Haiti, which in June submitted a joint concept note for HIV and TB, was asked by the TRP to revisit its proposal and pay more attention to the relationship between the two diseases and ensure better connectivity of programs. To support the region's poorest nation, which suffers from the highest burden of disease for HIV, TB and malaria, technical assistance will be provided by France, the United States through its PEPFAR vehicle and the Pan-American Health Organization (PAHO).  Haiti is also scheduled to participate in a mock TRP for francophone countries prior to the November submission window. The mock TRP is not a Global Fund-supported event but coordinated by technical partners.

Paraguay has also been asked to resubmit its HIV concept note in November.

Three new regional programs have also been asked to submit concept notes in February 2015, among the handful of expressions of interest that were picked from more than 40 submitted in April.

The regional candidates include a network of transgender people, REDLACTRANS; the International Coalition of Women (ICW-Latina) and an HIV program within the Caribbean Community (CARICOM) called PANCAP.

PANCAP's submission would support the continuation of existing regional activities.

LAC's relatively modest share of the $14.67 billion allocated for the period 2014-2017 does not mean that it cannot be a regional leader in best practice, insisted Martinelli. For example, Panama is submitting a joint proposal for HIV and TB in October, based on a recommendation from the Secretariat. The high level of transaction costs incurred by engaging two principal recipients means that money that could be going to activities was being swallowed by administration. As a country with a small allocation (a total of $7.9 million) and high capacity, Panama could provide a way forward for other countries in a similar situation, he said.

Sticking points for some of the countries entering and going through the NFM process caused some delays in submission, Martinelli noted. "We were going to have seven [concept notes] submitted in July and went down to three. We had two big meetings to help develop roadmaps to get the concept notes underway, but some have found the process more difficult than anticipated."

Challenges identified in a survey of CCMs from the region included hiccups with the new technology and the online submission requirements. Other challenges included integrating the new requirements for eligibility for CCM members including the participation of key populations, particularly for malaria.

Data collection and analysis also gave some countries more trouble than others; Paraguay's resubmission is predicated on a lack of solid data to justify the prospective interventions. Some technical assistance and workshops are forthcoming, in order to assist in focusing interventions on 'hot spots', mapping and population size estimates.

"The old system did not put so much focus on evidence and data on key populations and hotspots; the new system requires this much more," said Martinelli.

Overall, according to Martinelli, there is general satisfaction with the allocations as there is a "good correlation between income level and burden [in the region] for the most part".

Most discussions now center on sustainability of programming beyond the life of Global Fund grants. "Discussions about elimination are more and more common, particularly for malaria; we are also moving towards EMTCT (elimination of mother-to-child transmission of HIV), and in a couple of countries TB elimination is also starting to be in sight," he said.

Much of this can be attributable to the fact that Global Fund resources represent a small contribution to the national budget. Most country governments pay for medicines in full or for a great part, so where the Global Fund can be most useful in the region is in helping to draw attention to key populations, which are normally politically unattractive, un-funded and shunted aside in society and in the government budget.

"It's a scenario where, in less than 10 years, hopefully, all other regions can find themselves at least in the same position," he said. "In most countries, the percentage [of domestic financing] is already met, so what we are trying to do is to get them to do a little bit more, to get more engaged and impactful in the response: especially the politically unattractive part of the response."

[This article was first posted on GFO Live on 29 September 2014.]

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3. NEWS: First grants under the full NFM rollout are about to be signed

David Garmaise 30 September 2014

Application submitted to the Emergency Fund to deal with Syrian refugee crisis

The first two grants under the full rollout of the new funding model (NFM) should soon be approved for signing by the Global Fund Board. Both grants emanate from an HIV concept note submitted by Moldova during the first window on 15 May 2014.

The concept note took just four months to work its way through the system, reaching the second and final review by the Grant Approvals Committee on 18 September. The Moldova disbursement-ready grant agreement documents were scheduled to be sent to the Board before the end of September.

Meanwhile, the first application to the Global Fund’s Emergency Fund, established as a special initiative under the NFM to fight the three diseases in emergency situations, was received in mid-September. It is designed to respond to the TB challenge posed to Syria's neighbors by the massive influx of refugees fleeing the nearly four-year old crisis in the country.

The above information was contained in the Global Fund’s NFM Progress Update for September.

Concept notes

The Global Fund is still anticipating that about half of the 280 concept notes expected to be submitted during this allocation period will be reviewed by the Technical Review Panel in 2014, and that these notes will represents 68% of the total allocation, prior to any incentive finding awards. This prediction comes despite a general trend among CCMs who have delayed submission of their concept notes. 

CCMs were asked to “register” for a particular review window so that the Secretariat, the TRP and the GAC could plan their workload. However, CCMs are not committed to the windows for which they registered. The Secretariat says that for Windows 1-3, these shifts have resulted in a “slippage rate” of about 47%.

See the table for a summary of the number of concept notes submitted in the first three windows for 2014, and the number of notes expected in the last window of 2014 and in the four windows for 2015.

Table: Concept note submission schedule, showing approximate value of submissions

Window

Submission deadline

Concept Notes reviewed, screened or expected

Approximate value

1

15 May 2014

10 notes reviewed

$0.92 billion

2

15 June 2014

23 notes reviewed

$1.80 billion

3

15 Sep. 2014

41 notes being screened

$3.22 billion

4

15 Oct. 2014

67 notes expected

$3.97 billion

Totals for 2015

141 notes reviewed, being screened or expected

$9.88 billion

5

15 Jan, 2015

46 notes expected

$1.72 billion

6

15 April 2015

33 notes expected

$860 million

7

15 Aug. 2015

4 notes expected

$580 million

8

15 Oct. 2015

3 notes expected

$78 million

Totals 2014-2015 combined

227 notes reviewed, being screened or expected

$13.12 billion

Notes:

1. A number of concept notes have not registered for any window yet and so are not included in this table.

2.The numbers expected for Windows 4-8 are tentative and are subject to change.

There is only one other window in this allocation period: 15 April 2016.

Application concerning Syrian refugees

An application for a grant drawing on funds in the Emergency Fund has been submitted, following the failure of an earlier attempt to address the Syrian refugee crisis through the submission of an expression of interest for a regional grant (see GFO article). The expression of interest, which was submitted by a cluster of UN and international agencies, was seeking $10 million. At the time, both the applicants and the Global Fund indicated that the Emergency Fund might be a better channel for the request. The size of the Emergency Fund is $30 million.

Concerns raised by NGOs

In a covering note for a discussion paper released on 29 September, the Developed Country NGO delegation expressed concern about what they termed “significant confusion and contradictory information being received about core elements of the NFM". The delegation was referring to the need for concept notes to be comprehensive and inclusive, building on fully costed and prioritized national strategies.  

The discussion paper recommended that the Global Fund and technical assistance providers offer clearer, more consistent and more encouraging messaging.

Other items

The September progress report provided an update on the planning for two of the special initiatives approved by the Board as part of the NFM. One was the Emergency Fund; the other was the Principal Recipient Grant-Making Capacity Building Fund.

The progress report also provided an update on the Key Populations Engagement Pilot, an initiative launched in 2013 to support the greater involvement of key populations and representatives of people living with the diseases within CCMs. Some of the 10 countries involved in the pilot have made good progress, while others are struggling to find a suitable mechanism to implement the pilot.

In addition, the progress report revealed that the Secretariat has agreed the program split for 47 applicants, up from 40 at the time of the August NFM update.

[This article was first posted on GFO Live on 30 September 2014.]

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4. NEWS: Regional pitch to fight TB in Syrian refugees rejected by Global Fund

Lauren Gelfand 25 September 2014

An expression of interest for a $10.18 million regional initiative to develop a harmonized response to a TB crisis among Syrian refugees scattered across neighboring countries was rejected by the Global Fund.

The pitch was determined ineligible because it was submitted by a cluster of UN and international agencies led by the International Organization for Migration (IOM): a violation of the eligibility requirements for regional proposals that limit regional organizations to those that are legally registered entities that are not UN, multilateral or bilateral agencies.

Such eligibility requirements would seem to illustrate the rigidity in the Fund's policies, even when it comes to fragile states, Aidspan was told by one member of the submitting team, and its continued failure to grasp the need for flexibility when confronted with a crisis scenario that does not fit neatly into standard protocols.

The pitch was among more than 40 submitted in May to capture a portion of the $200 million set aside for regional initiatives by the Fund's Board. Only 16 of the 43 regional proposals received were invited to submit concept notes, following their review by the Technical Review Panel.

In submitting the proposal, IOM and partners the UN High Commissioner for Refugees, the World Health Organization, the UN Development Program and the national TB programs in Syria and six of its neighbors, aimed to develop a coordinated response to the widening TB burden among Syrians displaced by four years of conflict.

More than 2.4 million people have been displaced, the vast majority of whom are either residing in organized camps or informally in host communities in Jordan, Lebanon, Turkey and Iraq. Only Iraq remains eligible for Global Fund support under the new funding model (NFM), worth some $10.7 million in transition funding.

The regional TB initiative would have primarily directed funds to support national TB programs in Syria's neighbors, either in service delivery to the refugee populations or technical assistance to the workers within the health system. Part of the problem is that the TB burden in Syria is higher than in its neighbors; Jordan, for example, was on track for TB elimination but its prevalence rate has trended higher due to the influx of Syrian refugees.

Another problem is that countries now hosting the influx of Syrian refugees have made clear that their communicable disease strategies -- and attendant budgets -- did not contain provisions to respond to the health needs of refugee populations. Iraq, itself undergoing yet another security crisis and a widening of its own TB burden, has made abundantly clear in conversations at the highest levels that there is just not enough money to diagnose, and treat, the refugee TB caseload.

Mitigating the possibility of a spread of MDR-TB crossing borders with the displaced populations is another goal of the $15 million project, for which UNDP -- current principal recipient for Global Fund TB programs in Syria, Iraq and Gaza -- would have been the PR.

Most of the funding would have come from the Global Fund's pool of resources for regional projects; UNDP had committed to investing $1.5 million in co-financing. The remaining $3.5 million would have been raised from other sources under the UN's Regional Refugee Response Plan, according to a copy of the EoI shared with Aidspan.

In the rejected proposal, the participating agencies acknowledged the concern expressed by the Global Fund about the refugee crisis in the region and its efforts to find ways to respond.

"We are submitting this EOI through the regional proposal channel as one possible channel available to access Global Fund resources," the letter from the agencies said. "We are nevertheless fully aware of the particular nature of this proposal that is addressing an emergency situation and may also possibly be suited for support from the Global Fund Humanitarian Emergency Fund. We are, therefore, available to discuss with the Global Fund the best funding alternatives to deal with the regional TB risks caused by the Syrian refugees’ crisis."

In a statement to Aidspan, the Global Fund's director of communications, Seth Faison, said: “The Global Fund is designed to support country programs. We cannot take applications for funding from multi-lateral organizations. For regional initiatives, we have limited resources and we have to prioritize eligible applicants. The situation in Syria is serious, and it makes sense to explore potential funding through our Emergency Fund, which was created to address the three diseases in emergency situations where standard channels may be hindered.”

While there is some degree of optimism that this alternative funding possibility could respond to the immediate needs of the TB program for Syrian refugees in the region, the concern is that it is a short-term, rather than durable, solution and support mechanism, Aidspan understands.

[This article was first posted on GFO Live on 25 September 2014.]

To comment on this article, click here.

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5. NEWS: Civil society in Malawi elbows its way in to find a seat at the table for HIV policymaking

Owen Nyaka 17 September 2014

Participating in country dialogue is a first step -- over many hurdles

Malawi's ability to control the spread of HIV will be undermined by the structural barriers that prevent access to services by key populations: this was the message delivered to stakeholders participating in country dialogue to develop the southern African nation's HIV concept note.

Malawi is one of the countries targeted by the Global Fund under the new funding model (NFM) seeking to drive a greater share of resources to those countries with the highest burdens of disease. With some $475 million allocated until 2017, the country should continue to provide anti-retroviral therapy to some 420,000 people annually, while also expanding prevention, treatment and care options for others.

Civil society is keen to ensure that those 'others' are drawn from all populations -- especially key populations of MSM, commercial sex workers and miners -- with services and activities specifically tailored to their particular needs.

For now, getting representatives of key populations to even be present for the policy- and decision-making discussions, is the first hurdle.

"We have seen increased involvement by key populations in developing our national strategic plan (NSP) for HIV," said Gift Trapence, executive director of the Centre for the Development of People (CEDEP) and a newly elected member of the country coordinating mechanism (CCM).

But the progress on the policy side has not been matched by similar strides on the legislation side.

Sodomy laws remain on the books in Malawi: one of 34 countries in sub-Saharan Africa to continue to enforce anti-gay legislation. By  keeping these laws active and enforceable, the country imperils any progress being made to control HIV, according to Trapence. In driving men who have sex with men (MSM) underground, these laws will ultimately contribute to spreading the epidemic, not curbing it.

"The laws reinforce discrimination and stigma," Trapence told Aidspan. "Some health workers think that they cannot condone something which is illegal -- and this also affects service providers who offer friendly services, like the distribution of condoms and lubricants. We need the policies and the laws to be harmonized, since they do not speak to each other."

Another hurdle comes with the data challenges confronting Malawi, including the lack of population-level data disaggregated by sex. According to Trapence, data collected has failed to count MSM, transgendered people or sex workers, meaning that there is no clear estimate about the population size. This has fuelled some push-back against efforts to focus the NSP on key populations; those opposed say that the numbers are too insignificant to warrant special attention.

The Global Fund's own push to disaggregate data comes at a critical moment for Malawi, said Trapence, which is beginning to develop its own set of health indicators, supported by a nationally representative sample size. These data will be the foundation of the NSP and will drive the HIV concept note, which should be submitted in October.

"We have an opportunity to have indicators that will be reported annually for key populations; what we need now is programs to reach them," he said, including prevention activities that respond to both the human rights challenges facing key populations and the structural barriers preventing them from accessing services.

"We cannot talk about the 'three zeros' -- zero deaths, zero infection and zero discrimination -- if we leave some groups behind when they have high HIV prevalence rates," he said. "We must see comprehensive programs targeting key populations in the concept note being submitted in October".

[This article was first posted on GFO Live on 17 September 2014.]

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6. NEWS: Global Fund pledges swift response to any Ebola-related requests from Liberia, Sierra Leone or Guinea

Lauren Gelfand 25 September 2014

Requests must be in line with mandate to fight three diseases and invest in health system strengthening

The Global Fund has committed to a swift response to any requests from Liberia, Sierra Leone or Guinea for flexibility in reprogramming grants in order to assist in the management of the Ebola outbreak, which has killed more than 2,900 people and risks infecting up to 1.4 million more by early 2015.

It is probable that the three countries most badly affected by the epidemic will ask for a greater investment in health systems strengthening, as poor infrastructure, a shortage of trained health worker and weak systems are contributing to the spread of the outbreak.

"We recognize the urgency of the situation, as the outbreak is changing fast," Seth Faison, director of communications for the Global Fund, said in a statement to Aidspan on 25 September.

"We are actively exploring ways to support the response in affected countries, with re-programming, training, protective gear, and steering resources where they are needed most."

The acute needs in the three countries, all of which are among the world's poorest and in varying phases of post-conflict reconstruction, underscore the importance of investment in health systems, according to George Shakarishvili, the Fund's senior advisor for HSS. In these West African states, this investment should include human resources for health, improved routine data collection, more efficient logistics and supply chain management and an overall expansion and rehabilitation of health care infrastructure.

Already, the Liberian Ministry of Health and the country coordinating mechanism in Sierra Leone have signaled their intent to issue a formal request for flexibility and possible reprogramming of grants.

"We do not foresee re-programming that would affect our overall disease split. HSS is a major concern, and we will continue to explore all ways to advance it," Faison's statement said. " Where we see flexibility to re-program grants to support work that is related to the three diseases, and also connected to others, we will actively engage in it."

Activities under Global Fund-supported programs have already been affected by the outbreak. Among them are high-impact interventions including a mass distribution campaign in Liberia of long-lasting, insecticide-treated (LLIN) nets that had been set for November 2014, which has been postponed.

Travel restrictions -- including a curtailing of international flights into the country -- have postponed country team visits, and field visits by in-country implementers have also been put off.

The countries' progress through the new funding model (NFM) process, including country dialogue and concept note development has also slowed due to the immediate needs of responding to the epidemic.

In an 8 September response to the Secretariat's reporting to the Board on the situation, as it relates to the Global Fund context, the Communities delegation issued a statement, a copy of which was shared with Aidspan, that "strongly recommend[ing] that the Fund allows for, and encourages, training of personnel and country implementers to be able to manage cases of Ebola".

The delegation also urged an investment in data collection and analysis to determine the impact on treatment for HIV, TB and malaria of the epidemic, including the numbers of patients unable to access the treatment they need due to the closure of health clinics. Many clinics have been turned into isolation units for Ebola sufferers, and even they are reportedly turning infected patients away for want of beds.

"The Ebola outbreaks demonstrate the need to invest more in health and community system strengthening. This is a humanitarian and public health emergency with an impact that goes beyond those infected. It needs our immediate and strategic attention," the delegation's statement said. 

One possible way the Fund could get more involved in the Ebola response was proposed in an August editorial by development economist Jeffrey Sachs.

If donors were to expand the remit -- and the budget -- of the Global Fund beyond the fight against the three diseases to become a global health fund for low-income countries, it would help the poorest countries "establish basic health systems in every slum and rural community, a concept known as Universal Health Coverage (UHC)," Sachs wrote.

The outbreak of Ebola has already claimed the lives of more than 2,900 people. The US Centers for Disease Control and Prevention warned on 24 September that at current rates of transmission, as many as 1.4 million people could be infected by 2015. 

Read this article in French. Lire l'article en français.

[This article was first posted on GFO Live on 25 September 2014.]

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This is issue 252 of the GLOBAL FUND OBSERVER (GFO) Newsletter.

We welcome suggestions for topics we could cover in GFO. If you have a suggestion, please send it to the Editor of GFO (see contact information below).

GFO Newsletter is an independent source of news, analysis and commentary about the Global Fund to Fight AIDS, TB and Malaria (www.theglobalfund.org). GFO is emailed to nearly 10,000 subscribers in 170 countries at least twelve times per year.

GFO Newsletter is a free service of Aidspan (www.aidspan.org), a Kenya-based international NGO that serves as an independent watchdog of the Global Fund, and that provides services that can benefit all countries wishing to obtain and make effective use of Global Fund financing. 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.

GFO Newsletter is now available in English and French. Articles are also available in Russian and Spanish.

Aidspan Editor-in-Chief: Lauren Gelfand (lauren.gelfand@aidspan.org)

Aidspan Executive Director: Kate Macintyre (kate.macintyre@aidspan.org)

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