The recently adopted Global Fund Strategic Framework 2017-2022 sets important parameters for the partnership to support countries in ending the three epidemics. The new strategic framework will strengthen systems for universal health coverage in line with the Sustainable Developments Goals. It focuses our efforts on those countries and populations with the greatest needs, and challenges us to find tailored (i.e. “differentiated”) approaches. It puts resilient and sustainable systems for health, based on human rights and gender equality, at the core of the Global Fund’s agenda. If we take our joint vision to end the epidemics seriously, these principles have to guide the Global Fund’s future work.
We now need to find modalities to translate the principles into programming. Drafting the next strategy in detail and refining the Global Fund’s allocation methodology are crucial next steps. What considerations and questions should guide us on this path?
A focus on flexibility, sustainability, and systems
We have to bear in mind how increasingly diverse the epidemiological, systemic, and financial needs of countries truly are. If we were to create the Global Fund today, would we really institute the same procedures for Nigeria and Nepal, for South-Sudan and South Africa? We need to tailor the Global Fund’s support to individual country contexts, both in terms of what is funded as well as how grants are managed. This requires more flexibility in our systems.
We are on the right track in allocating funding where the need for external support is greatest: 92% of the allocation for 2014-2016 is focused on low- and lower-middle income countries, 95% on countries with a high to extreme burden of disease. We should continue in this direction.
With respect to the allocation methodology for the next period, we argue for refinement, not revolution. The reports by the Technical Review Panel and the Technical Evaluation Reference Group provide valuable insights on what has worked and what has not. The allocation methodology can certainly be improved, especially with regards to the qualitative adjustments. But can we really expect to find a “magic formula” which covers all relevant dimensions and, at the same time, is easily understood by country stakeholders?
The real challenge is how to tailor our support to the countries experiencing significant changes in their allocation, i.e. previously “under” or “over-allocated” countries and countries gradually transitioning out of Global Fund support. This requires a focus on building country systems able to absorb the allocated funding, rather than simply reducing funding if systems show symptoms of being overburdened. It also requires increased attention to programmatic and financial sustainability, which is a joint responsibility of implementing countries and the Global Fund. While the allocation methodology provides a general framework, solutions to specific challenges need to be developed on a country-by-country basis. The Secretariat should be entrusted with the necessary flexibility to do so.
This also applies to those elements in the allocation methodology that go beyond the “indicative funding.” These funds could be used more flexibly to respond to specific country (and multi-country) needs not reflected adequately in the formula-based allocation, such as humanitarian emergencies or malaria elimination efforts. While making sure that strategic priorities – such as human rights, women and girls, key populations and health and community system strengthening – remain integral to the core programming of the Global Fund, such flexible funding lines could also be used to set incentives for catalyzing progress in these areas. This should, of course, not a mean a separate “Fund” for each of these priorities, but certainly more leeway for the Secretariat – with accountability for the results.
Leaving the silos behind
Health systems strengthening is pivotal to success. The next Global Fund Strategy should provide a clear direction on how the Global Fund will contribute in this regard. But again, concrete solutions must be found for each individual country. Global Fund support for health systems will of course look very different in countries with concentrated epidemics as compared to countries scaling up services in generalized epidemics.
If we want to extend and sustain our gains, we need to develop and promote a more systemic perspective. This perspective is still lacking in too many country dialogues and country coordinating mechanisms. Too often, we still see a focus on disease systems rather than the health system as a whole. Could a combined allocation envelope encourage stakeholders to engage with a more comprehensive view? Will we use the preparation for the next implementation period to rethink our approach to in-country structures and systems? Will we still need concept notes in places where sound and costed national strategies already exist?
Shifting our thinking
Hopefully, soon we will no longer talk about how the Global Fund can best use country systems but rather how countries are using the Global Fund to achieve impact. This shift will not happen overnight. But increasing the flexibility, sustainability and systemic orientation of the Global Fund partnership now will be crucial for making it happen.
Reinhard Tittel-Gronefeld is Head of the Division for Health, Population Policies and Social Protection at Germany’s Federal Ministry for Economic Cooperation and Development (BMZ). He has been involved in Global Fund governance since 2011, first as the Board Member of the (former) Germany-Canada-Switzerland Constituency. He is currently the Alternate Board Member for the Germany Constituency and a member of the Finance and Operational Performance Committee, and will serve in these positions until his retirement in March 2016.