Donors must balance urgent health threats with sustainability of health systems

The world’s most powerful countries and most important providers of overseas development assistance, meeting this week, are likely to pledge, collectively, about $14bn for the next three-year funding period of the Global Fund to Fight AIDS, Tuberculosis and Malaria.

This fundraising cycle, called “the replenishment”, culminates in a pledging conference to be held on October 10 in 2019 in Lyon, France, hosted by President Emmanuel Macron. It will be attended by leaders of the G7, representatives from the rest of the 60+ countries that have contributed to the fund, as well as headline figures from the world’s leading private sector and non-governmental funders of global health programmes (the Bill & Melinda Gates Foundation, Product (Red), and SA’s own Nando’s, among others).

While most major donors have already announced their pledges, the US and France — consistently the two biggest donors to the fund because its inception — are expected to make big-bang pledge announcements on the final day.

The Geneva-based Fund is now 18 years old and the biggest funder globally of countries’ own national programmes to fight the three diseases (more than $41bn disbursed so far). In late September, it published its annual results report, in which it says that its grants have supported programmes that have saved 32-million lives. The target of “at least $14bn” for the upcoming Replenishment is slated to save 16-million more, through grants for 2020-2022.

The results attributed to the Global Fund from 2018 alone are staggering: 18.9-million people on antiretroviral (ARV) therapy for HIV, 719,000 HIV-positive mothers receiving medicine to keep them alive and prevent transmission of the virus to their babies, 5.3-million people treated for TB, and 131-million mosquito nets distributed. Clearly the needs are vast, and the Fund’s mandate — “Accelerating the end of AIDS, tuberculosis and malaria as epidemics” — was a response to a particular moment in time.

At the beginning of the aughts, developing countries were reeling from rapidly increasing numbers of HIV infections and related deaths, and from endemic malaria, and tuberculosis, whose incidence (and deadliness) was increasing along with rising HIV infections, given the greater susceptibility of HIV-positive people to TB. The 100+ countries that the fund now finances to fight these diseases could not — in 2001, or most likely, ever — themselves finance national programmes to effectively conquer them, and they had no access to affordable antiretroviral medication for HIV.

This was the catalyst for the fund’s creation by then UN secretary-general Kofi Annan, with initial funding of $1.3bn from the Group of 8 (G8), to get money rapidly “on the ground” to enable countries to fight their own public health battles. The founding principles were “country ownership”, transparency, and accountability — all in the context of a fundamental partnership approach to making the money work. And “affect” mattered, above all.

But now, in this age of global integration, the Sustainable Development Goals and a trend away from “siloed” approaches to development, does the fund still present to its donors a value proposition that is relevant?

Recently repositioning its role in the context of Sustainable Development Goal 3 (health and wellbeing for all) — like most global health organisations — the fund has shifted the way it describes how it assesses itself: “In the fight to end AIDS, tuberculosis and malaria as epidemics, the Global Fund partnership measures our progress against the targets set in the global plans for HIV, tuberculosis and malaria and in Sustainable Development Goal 3”.

And there is a strong argument to be made for effective primary healthcare as a prerequisite for effective disease-specific programmes.

But the persistence of the severity of the three pandemics, which remain the three biggest infectious diseases killers worldwide, means the fund has chosen not to change its mandate. As the 2018 results report says, while enormous progress has been made against the three diseases, huge challenges remain: the resurgence of malaria and growing insecticide resistance in many parts of the world, the terrifying rise of multidrug-resistant (MDR) TB (especially in SA), large proportions of “missing” TB people whose disease is undetected, untreated and therefore highly transmissible, still shockingly high rates of HIV infection among adolescent girls and young women, in particular, in sub-Saharan Africa, largely due to hard-to-tackle gender inequality.

At the same time, in the context of the zeitgeist — universal health coverage (endorsed on September 23 by the UN’s General Assembly) and the “global goals” (the SDGs), the Global Fund to Fight AIDS, Tuberculosis and Malaria and other donors have a tricky line to toe to find the balance between these urgent threats and the long-term sustainability needed by all countries for their health systems. The bottom line is that more money is needed to enable countries both to offer UHC and continue to fight specific epidemics.

So, while remaining focused on AIDS, TB and malaria, the fund is trying to ensure that its financing has an enduring effect on health system strengthening, which will further support a country’s overall efforts to provide better comprehensive care for its people. (The Fund’s holistic approach more or less guarantees an element of this in any case — grants that are approved usually involve a comprehensive set of interventions, including training, hardware and infrastructure if needed.)

It is also placing increasing emphasis on “co-financing” — where countries commit, at the time of grant signing, to contribute a certain percentage of the proposed budget themselves.

So far, the five G7 countries that have already announced their pledges for this Replenishment have increased their amounts by 15% or more relative to three years ago — clearly the fund has traction, and credibility. Hopefully the final numbers will reinforce donors’ commitment to millions more lives saved.

• Sulcas is editor of the Global Fund Observer. She is a former employee of the Global Fund to Fight AIDS, TB and Malaria.