On April 9, the Board of the Global Fund to Fight AIDS, Tuberculosis and Malaria unanimously approved two temporary, extraordinary measures to enable flexibilities within current Global Fund grants in order to ensure continuity of programs, and to provide additional direct support to countries for their responses to COVID-19.
A background document provided to the Board described these two decisions as “time-bound, limited scope measures to respond to an unprecedented public health emergency that threatens to entirely derail the fight against HIV, TB, and malaria and to build resilient systems for health”.
Given the urgency of the situation and the “exceptional circumstances” of the global pandemic, the Board’s leadership and the Board committees’ Coordinating Group agreed to an expedited decision-making approach for the April 9 decisions. Both decisions are limited in duration, remaining in force until 30 September 2020, with one of three elements of the ‘flexibilities’ decision in place until 30 June 2021.
The ‘flexibilities’ decision (GF/B42/EDP10) makes provision for extended deadlines in the case of supply chain disruptions (this is the element valid until June 2021), to mitigate the impact of program delays, and support the rapid integration of already-approved portfolio optimization funds into grants (foregoing the usual separate step of Board approval for integration of funds). The decision also allows for limited exceptions to Quality Assurance (QA) policies.
The second decision (GF/B42/EDP11) sets up the COVID-19 Response Mechanism (C19RM), which will provide up to $500 million of direct, additional support to countries implementing Global Fund grants, in part for measures to combat the pandemic and “to ensure the continuity of the fight against HIV, TB, malaria”.
The C19RM will add up to $500 million to the earlier $500 million made available to countries for their COVID-19 responses announced by the Global Fund on March 4. (The March 4 provision enables countries to use up to $500 million in savings or reprograming within existing grants, up to 5% of the existing grants’ amounts.)
The C19RM will support “the rapid deployment of funds to support implementer countries’ COVID-19 responses”, in coordination with partners; finance interventions consistent with World Health Organization (WHO) guidance on COVID-19 and national Strategic Preparedness and Response Plans (including control and containment interventions such as personal protective equipment, diagnostics, treatment, communications and other WHO-specified guidance); and finance interventions across the 5th and 6th replenishment periods.
The $500 million available under C19RM is made up of $180 million already approved by the Audit and Finance Committee for portfolio optimization (out of $300 million of previously available funds), and up to $320 million of additional funds, which will no longer be available for portfolio optimization (the Fund assesses portfolio optimization to be a lower priority at the moment for in-country partners compared to their need to respond to COVID-19).
C19RM funding process
The C19RM funding of up to $500 million is new funding for which countries must apply. While the Fund says this additional support will be through “rapid deployment” of funds, the Secretariat has not yet specified the exact process that countries will need to undertake to apply for these funds. In response to a request from the Global Fund Observer for more information, a Global Fund spokesperson said in an email that the Fund was “working on operationalization, and will share information as soon as possible”.
The Response Mechanism will enable countries to request funding for “control and containment, to mitigate the impact on HIV, TB and malaria and to support systems for health, including laboratory networks, supply chains, and community-led response.” The decision point also specifies that the C19RM enables the Fund to mobilize additional resources from “private and public donors willing to support the most vulnerable countries as they fight COVID-19”, as stated in the Fund’s news release. It is not yet known whether this means there will be specific COVID-19-related resource mobilization.
Board constituencies offer inputs
Immediately before the electronic voting on the two decision points regarding flexibilities and the C19RM, some Board constituencies offered comments to the Board. The constituencies raised concerns including the necessity of involving communities and civil society in the design and delivery of funding requests, as well as key and vulnerable populations; the availability and cost of COVID-19-related products; the role of the Country Coordinating Mechanism; and the decision-making processes involved in the C19RM, particularly in relation to technical partners; and regular reporting to the Board on the use of the C19RM.
A revision to the C19RM decision point requesting the Secretariat to “further operationalize the investment and management modalities for C19RM” added language on including working with partners to deliver critical technical assistance, ensuring the appropriate involvement of the Country Coordinating Mechanisms, and aligning with the Global Fund’s underlying principles of gender equity and human rights. The same sub-point undertakes to provide regular reporting to the Board on the operationalization of C19RM, including grant totals for C19RM by country, component, regional and global totals, as well as the purpose of funding (specific COVID-19 interventions, risk mitigations activities for a disease, community or health systems strengthening).
The Secretariat has acknowledged that COVID-19 will disproportionately affect “the poorest, the most marginalized and the most vulnerable” and has in principle agreed that the engagement of communities and civil society in understanding how best to adapt existing HIV, TB and malaria programs to the COVID-19 context will be important.
Constituencies also raised a concern around the potential negative impact that exceptions to the Fund’s Quality Assurance Policy could have on recipients in the short and longer term, and requested the Secretariat to explore innovative ways to ensure its quality assurance and use the provision for exceptions only when there are no other alternatives. The background paper provided to the Board suggests that exceptions would be made only where sampling and quality control may not be physically possible due to the unavailability of those services as a result of COVID-19, and where a delay as a result of the inability to quality assure would have a negative program impact such as, for example, an implementer’s missing an insecticidal net distribution campaign.
Rosmond Adams, Director of the Pan Caribbean Partnership against HIV and AIDS (PANCAP) and the Communication Focal Point of the LAC constituency on the Global Fund Board, was strongly supportive of the Board’s decisions to provide further support to the overall COVID-19 response. On the ‘flexibilities’ decision, Adams told the GFO, the LAC constituency urged that “all measures are put in place to ensure that checks and balances are adhered to whilst allowing for this flexibility”, and called the new response mechanism “highly commendable,” while calling for a focus on vulnerable populations, including people living with HIV/AIDS.
Berry Nigobora, Programme Director at African Men for Sexual Health and Rights, and a member of the Developing Country NGO Delegation to the Board, said, “We are glad that the Global Fund recently adopted a decision to step up the fight against COVID-19, which includes a human rights-based approach and clear directive to invest in community-led interventions.”
He also said that those affected by COVID-19 may also be affected, though without governments’ intention to harm, by the range of measures imposed such as quarantine, social isolation, and other restrictions that may further increase the vulnerability of people living with HIV and key populations.
“For most of them,” Nigobora said, “home may not feel like home, or be suitable, due to stigma, family rejection and other forms of violence. The lockdown measures may mean an increase in domestic violence against people living with HIV, TB survivors and key populations. Further to that, the lockdown implies more often than not a discontinuation of access to physical and mental health services at shelters or drop-in centres that are closed as a result of lockdown and curfew measures. We are committed once again to making civil society and community a watchdog and monitors of how these measures will not leave anyone behind, and defeat the trajectory of ending the three diseases as well as human rights violations and gender-related inequalities that have been for so long the underlying causes.”
Basis for the Board’s decisions
The background document provided to the Board before electronic voting on April 9 described the context for the two decisions in vivid terms, saying that as the COVID-19 pandemic spreads across the globe, it threatens to derail HIV, TB and malaria programs and to have “significant to catastrophic impact” on the low- and middle-income countries where the Global Fund provides support. It also said the C19RM decision was built on the fact that “fighting COVID-19 and reducing the negative impact of the pandemic on HIV, TB, and malaria programs and systems for health are inseperable and urgent objectives for the Global Fund.”
As of April 14, when the Fund published its most recent COVID-19 situation report, 55 countries and two multi-country grants (in 103 separate decisions) had taken up the possibility of reprogramming or using savings within their existing grants. The Fund said that most countries had requested less than the 5% limit, and that almost all the funds approved to date - $70 million – have used savings from existing grants. The Fund also said that the number of requests and the dollar amounts of the requests have increased greatly since March, and that requests are now coming in from all regions.
The Global Fund Board's decision points described in this article are GF/B42/EDP10-11: COVID-19 Response for Business Continuity and Country Support.