In 2014 the Global Fund to Fight AIDS, TB and Malaria started implementing its new funding model (NFM). The NFM aims to re-allocate its resources away from middle-income countries towards those with the highest burdens of disease and the least ability to pay. For the countries of Eastern Europe and Central Asia (EECA) - the single most-affected region in the world by the spread of multi-drug resistant TB (MDR-TB) – a loss of eligibility for Global Fund funding is bad news.
Since its founding in 2002, the Fund has been a key donor and supporter of HIV and TB programs in EECA. Global Fund investments have supported countries in their development of enabling environments and have helped strengthen their health and community systems allowing the region to show progress against HIV and TB. In particular, the Fund has been very supportive, both administratively and financially, of civil society in EECA where civil society organizations implement Fund-resourced programs.
As a result, TB advocates and CSOs are now very aware that it is mostly the work they are doing within vulnerable communities that will be most affected by the eventual withdrawal by the Fund from the region -- and, most worryingly, how this will affect the spread of disease.
Research recently completed by RESULTS UK (http://www.results.org.uk) and Global Health Advocates France (http://www.ghadvocates.eu) on behalf of the TB Europe Coalition (http://www.tbcoalition.eu/) shows that views on the ground are less than optimistic on whether domestic funding for TB will be enough to fill the gap once the Fund leaves the region:
“For our country, the exit of the Global Fund is impossible, because the government will not be able to cover the needs of TB services that are now funded by Global Fund” (respondent from Kyrgyzstan)
While respondents acknowledge how important it is for all stakeholders to prepare for the phasing-out of Fund support, there are significant obstacles to making this path an easy one. The majority of people interviewed, who represented a broad spectrum of TB stakeholders and CSOs in EECA, responded negatively to the question on whether governments were likely to increase domestic TB funding. Most frequently, it is suggested that government TB spending will likely be constrained by budget restrictions and other priorities of state funding.
As to the outcomes of the donor phasing-out, the CSO-based work with hard-to-access populations was believed to be the area of work most severely affected:
“Patients (especially the ones with MDR-TB and XDR-TB) will not be able to access necessary TB treatment, without referral and motivation services currently provided by CSOs. As a result, their treatment adherence will be low, the number of newly registered TB cases will decrease, as the CSOs will not be able to continue their work as before when they were funded by the GF”(respondent from Kyrgyzstan)
Transition to government funding may also unfavorably affect most of the programs previously supported by the Global Fund, such as harm reduction, work with sex workers, men having sex with men (MSM) and some aspects of prison-based work. According to the research, these activities, typically implemented by CSOs, are unlikely to be funded by national governments.
Phasing-out of Global Fund funding may also lead to increased TB and HIV prevalence rates with recipient countries being ‘punished for their success’:
“If you have been investing in a country, have managed to keep HIV and TB prevalence relatively low, and you take that funding away, the loss of funding may also result in rates going above 5% of the population. You are wasting the previous investments. Countries who had already registered some success, are being punished for doing that.” (an independent expert)
Some participants believed that transition into TB funding may affect the quality of TB drugs:
“In Uzbekistan, there is one state organization that is responsible for centralized procurement of all drugs. The donor exit and increasing the role of the state may lead to a re-distribution of spheres of influence in TB drug procurement. The state will try to save money and procure more quantities of cheaper TB drugs of worse quality. The state procurement will also be hard to be controlled for international quality standards. Weakening of quality controls and exit of international donors may lead to creating new non-transparent procurement schemes in the country“(respondent from Uzbekistan)
There is a clear need to support countries in conducting the gap analysis of TB funding, and to systematically assist countries to develop their TB funding transition plan before the Global Fund phase-out. While the prospect of transition into domestic funding was always on the agenda, the real transition mechanisms are not in existence in most countries. The country dialogue should now become more active, more robustly supported by donors, and involve groups implementing Global Fund programs at country level and a wide range of country stakeholders. Donors’ assistance in planning the TB funding transition is crucial in making this process effective.
Participants also believed that the EU institutions may have a bigger role to play in influencing and mitigating the consequences of the donor phase-out. While the role of the EU was generally acknowledged as ‘not clear’ in the EECA region, consistent policies and a sustainable step-by-step approach needs to be demonstrated by EU institutions to become more effective regional players influencing the policy making processes. Control over directing the EU spending in EECA needs to be reinforced:
“EU does have a role, but it is not completely clear. EU does not do enough. There is a lot of rhetoric coming out of EU, but they do not do a lot. They should play a stronger role and use their political leverage and financial instruments to ensure the transition of funding to national governments’ responsibility.” (an independent expert)
At the governance level, a multi-disciplinary approach and involvement of communities with the disease in decision-making should remain a priority for both domestic and international support for TB response. Funding should be made available for institutional support of TB advocacy networks and other regional coalitions that would represent the interests of patients and communities affected by the TB epidemic.
Interestingly, the findings of the RESULTS, GHA and TBEC study resonate with the views expressed by Michel D. Kazatchkine, the former Global Fund executive director, and now a UN Secretary General‘s Special Envoy on HIV/AIDS in Eastern Europe and Central Asia, expressed in his recent Huffington Post blog:
“Although new technologies are now available to diagnose TB and test for TB drug susceptibility / resistance, the reality is that less than 50 per cent of the estimated new cases of MDR-TB are diagnosed across the region. And only half or less of those patients in need of treatment are actually treated and cured. Those who are not treated remain contagious and they also die. This nothing short of a crisis, one we have to stop neglecting.”
Tuberculosis is at a crisis point in EECA and it is a crisis that can no longer be ignored. Kazatchkine’s post ends with the hope that the issue begins to receive the attention it deserves at international forums such as at the 45th Union World Conference on Lung Health in Barcelona.
Sveta McGill is a Health Advocacy Officer at Results UK. All opinions in this commentary are her own.