“End It for Good,” is the rallying call for the Global Fund’s Fifth Replenishment conference, to be held in Montreal, Canada on 16-17 September 2016. Millions of lives have been saved and infections averted, and tremendous progress has been made in the fight against AIDS, TB, and malaria. Yet, there is still no greater global health challenge for humanity. As a partnership, the Global Fund is balancing precariously, and teetering atop a tipping point. Push ahead one way and we beat the epidemics, with re-energized action and a much greater resolve for results on the frontlines of disease treatment and prevention. Slip the other way, and the three diseases may spring back even stronger with climbing incidence, deaths, and drug resistance.
Much progress has been made in recent years to evolve the Global Fund into a more effective and efficient partnership with governance reform, a sharper strategic focus, and a streamlining of process to improve grant management. But, with the scale of the challenge that remains, a combination of the very best strategy and plans, the most efficient processes and all the funding asked for will not be enough to succeed as intended. Here are three priorities for leadership, management, and front line workers to move on – together – so that the partnership, as a collective of responsible individuals, can “End It for Good.”
1. Personal accountability for results
Better systems are needed to recognize and promote the importance of people management, including individual recognition and individual accountability for progress towards measurable performance targets to prevent and treat disease. It should be clear who is personally responsible for rolling out treatment and prevention coverage with progress rewarded or corrective personnel action taken. Performance contracts with meaningful targets initiated and managed by private, government, or civil society principal recipients should be the norm. Senior leaders at the Global Fund, Board members and members of country coordinating mechanisms should set an example by further promoting and overseeing a performance-based management culture, and taking on challenges of their own to be more helpful in addressing complex barriers to treatment or prevention coverage. Active diplomacy on human rights issues is one of the most pertinent examples of where the partnership has an ongoing role to play in promoting rights protection, denouncing violations, and negotiating inclusiveness with key decision makers.
Health care and community workers should know that their daily achievements are recognized as crucial to success in the global challenge. “End It for Good” will require measuring and rewarding success tangibly and with positive encouragement, so individuals on the frontlines are motivated to increase the number of people and adherence in prevention and treatment programs. Innovative public awareness campaigns are still important to educate and encourage citizen engagement and individual adherence to protocols.
2. Front-line action
The Global Fund needs to find ways to re-energize the people responsible for treatment and prevention of the diseases in every remote corner, or in every marginalized community on earth.
As part of funding for health system strengthening, we need to support the communities and individuals leading the response on the ground. This is about increasing the number of health and community outreach centers and the efficiency of supply chain management. And it is about improving performance and increasing numbers of trained workers. For example, in South Africa, the Treatment Action Campaign estimates that the country requires 200,000 community health workers, set starkly against the current workforce of 30,000 and the health ministry’s target of 40,000. If reaching this number is not possible, then increasing the effectiveness of a smaller workforce must be taken on. More progress can also be made by supporting innovative and focused ways to reach marginal communities. Funding key populations networks can be used more strategically so best-placed implementers can reach and retain the attention of their communities. Ending stigma, discrimination, marginalization, and criminalization of these groups is a crucial linchpin. With the new strategy, catalytic funding will be available to increase results where there are clear needs for focussed interventions including empowerment of women and girls for HIV prevention.
3. Faster research and development
Trying to change the course of an epidemic without a cure or a vaccine is an unprecedented ambition in global health.
There are increasing reports that knowing one’s status and accessing treatment will not be the social vaccine we thought it was. While treatment as prevention (TasP) initially promised to prevent new infections, evidence from countries where this should be happening already paints a different picture. For example, despite being very close to achieving the 90-90-90 targets (90% of all people living with HIV know their status, 90% of all people diagnosed with HIV are on treatment, and 90% of all people on treatment achieve viral suppression), Botswana still has unacceptably high community HIV incidence rates of 3.1%. In South Africa, recent results from the TasP study showed no material effect of test-and-treat on reducing new HIV infections in the general population. These two examples remind us that we cannot treat our way out of the epidemic. We need a vaccine. We need a cure.
The Global Plan to End Tuberculosis highlights the ambition of a global movement to end TB once and for all, and then warns that without a dramatic change, targets will not be achieved in 150 years, let alone by 2030. One reason is the slow pace of trials and approval for more effective drug regimens to combat strains of drug resistance. Though there has been much progress, and lives saved through diagnostics and treatment, vaccine development is the key to end TB for good.
Similar to the challenges in AIDS and TB, malaria will not end as a public health threat, it will not be eliminated, until there is further progress in research and development, including the introduction of an effective vaccine alongside stepped-up prevention and treatment coverage. Spreading of resistance, in this case of malaria parasites, threatens to increase risk and transmission. There are some alarming reports of malaria resurgence where we had expected malaria eradication.
Across the three diseases, ambitious leadership in research and development is needed to find ways to speed up trials and approval of an effective vaccine to be rolled out quickly. We need leadership towards a cure. Who is accountable for this?
Success of the collective starts with the individual. Those involved in the fight against AIDS, TB, and malaria are rightly proud of their achievements in saving lives – 17 million since the Global Fund’s founding. Behind such success are heroes to be celebrated or remembered. Let’s step up progress in research and development, push ahead with front-line action and take on personal accountability for results, so that collectively “End It for Good” is not a dream but a rallying call that succeeds.
David Stevenson is President of AEDD13 Development Initiatives, and former Chair of the Global Fund Strategy Committee, a position to which he was appointed when he was a Board member representing Canada and Switzerland.