From 9 to 10 July 2019, the West and Central Africa constituency of the Global Fund held a sub-regional meeting in Saly, Portudal, Senegal, organized by the African Constituency Bureau with funding from Expertise France through Initiative 5%. The meeting was attended by 50 delegates from 23 countries, technical and financial partners, as well as Global Fund constituencies’ members. The objectives set for this meeting were to: (i) share the OIG advisory report with the constituency’s member countries; (ii) allow the constituencies to contribute and integrate comments into the discussions of Global Fund bodies; (iii) provide updates to the participants on the 3 diseases and (iv) identify priorities in WCA for the next Global Fund’s 2020-2022 allocation period.
The meeting served as a framework to delve into the consultative report of the Office of the Inspector General, in order to gather feedback from the constituency’s member countries.
The OIG advisory report highlights some of the multiple socio-economic, security and political challenges facing the region that undermine the performance of Global Fund grants to fight HIV, Tuberculosis and Malaria. It can be noted, in particular that 70% of the countries in the region recorded a low utilization of past allocations; due to high fragility and instability with 18 of the 23 countries having experienced major crises in the last decade; weak health systems with human resources for health being 3 times lower than the rest of Africa; Health financing does not generally honour the Abuja Commitment to reach 15% of national budgets due to a very limited fiscal space and a high regional funding gap of 50% across the three diseases, while the Global Fund is the largest funder in the region (55% for TB, 45% for malaria and 32% for HIV).
With regard to the operational procedures that may partly account for the underperformance of the programme, Global Fund representatives made a review and update of Global Fund policies, guidelines and processes such as the Additional Safeguard Policy (ASP); the Treasury Policy subject to conditions; the improvement of regional coherence and the working methods in the WCA region; the high out of pocket (OOP) expenditures incurred by users; the unavailability of granular data. Other issues were also reviewed such as access to health services by minimizing out-of-pocket expenses for health service users and ensuring the availability of granular data. The Global Fund presented the operational improvements envisaged as part of the grant implementation arrangements to ensure that the 6 principles are incorporated into the conceptualization of grants for the next implementation cycle. These include in particular: (i) the key role of the Health Ministry in each State; (ii) the implementation arrangements and the clear and formal reporting links between the various levels; (iii) the mandate and competence of the responsible institutions; (iv) the existence of a stakeholders’ network; (v) the balanced approach to risk management; (vi) and finally, the identification of grant management capacity building measures in the Technical Assistance (TA) plan. He also pointed out that the Secretariat would work closely with countries to develop action plans that clearly define the responsibilities of the Global Fund, country stakeholders and partners.
Some notable progress has been made for malaria and HIV though falling short compared to other regions. The region has not done well on TB.
With regard to malaria, the region has achieved a 31% reduction in deaths between 2016 and 2020, while the incidence rate has reduced by 23%, with case management being 87% against target and coverage for Long Lasting Insecticide Nets (LLINs) being 72% in 2016, representing 215 million people who have access to bed nets.
On the HIV front, the WCA region has registered a 27% reduction in AIDS related deaths between 2010-2017 with new infections falling by 12% during the same timeframe. However, while ART coverage increased by 29.2% during this period, the region is lagging behind the rest of Africa on all targets vis-à-vis the treatment cascade.
TB is the component where the region is notably lagging behind. Between 2010 and 2016 the region had an increase of 5% in TB deaths, thereby increasing its global contribution to total TB deaths from 7% to 9% during the same period. The TB incidence rate increased by 10% while the TB missing cases have risen by 8% since 2010.
In terms of priorities for the future, presentations from technical and financial partners laid emphasis on the following:
• On HIV:
- Reduce gaps and eliminate mother-to-child vertical transmission.
- Prevention among young women whose prevalence currently exceeds 3% in some African countries such as Cameroon.
- Fight against stigma and discrimination against infected people.
- Improve the quality of programs (Only 25% of countries in the region have an adequate program, unlike the East African countries that record 40%).
- Strengthen the use of the community monitoring system and fine-tune it to reduce the gaps
- Build the capacities of youths to transform them into forces of change
- Take the opportunity of Universal Health Coverage (UHC) to improve access to and use of health services.
• On tuberculosis:
The main challenges that need to be addressed are: the persisting high burden of TB and TB/HIV co infection; low treatment coverage (52% of missing TB cases); Multidrug-resistant tuberculosis; and low domestic financing.
• On malaria:
The update focused on three pillars: (i) Ensuring universal access; (ii) accelerating efforts towards elimination; (iii) Transforming surveillance into intervention.
Ending malaria will require a comprehensive strategy that includes vector control measures and rapid diagnosis and treatment, especially at the community level. It will be necessary to change course and improve the malaria control approach, especially in countries with the highest disease burden. Targeted initiatives and approaches to scale up high-impact interventions in the course of eliminating malaria will be required.
A follow-up meeting is scheduled for September 2019 where the Global Fund will present its action plan for the region but also and especially, the country action plans resulting from the country evaluation it is planning to carry out.
The meeting ended with the adoption of recommendations for partners, the Global Fund (Board and Secretariat) and the governments in the sub-region.
The meeting acknowledged the intense effort made by the Global Fund in supporting health systems and increasingly scaling up treatment to patients in the region. Nevertheless, increasing efforts in coordinating interventions in the field, together with a stronger leadership at country level are necessary in order to address the serious issues such as the financing and management of grants, the prevention of new cases and a better access to treatment for all.
There is an urgent need for the Global Fund to further strengthen current successful interventions, ensure flexibilities vis-à-vissome of the policies, practical strategies, effective implementation mechanisms and concrete monitoring structures to ensuring further streamline our response to the epidemics in WCA region.
We request Heads of States from our region, the Global Fund and all cooperating and technical partners to urgently take adequate measures to make the partners’ investments more strategic and cost effective.
We fully endorse the findings and recommendations of the OIG and in addition:
We urge Western and Central African Governments
1. To consider health as a fundamental priority in budget allocations even within the current context of insecurity and fragility of countries, in accordance with the 2001 Abuja Commitment signed by all parties;
2. To prioritize marked increases in Domestic Resources Mobilization (DRM) by employing innovative mechanisms including through private sector involvement to strengthen and expand effective interventions in the fight against the three epidemics;
3. To ensure prepayments and pooling mechanisms, such as insurance schemes, are in place to minimize out of pockets (OOP) expenses and user fees made by patients that are often catastrophic;
4. To increase State leadership through ownership of Global Fund’s investment management and intensify the effort to synergise all the investments in health provided by international and national sources;
5. To ensure the development of integrated malaria pre-elimination and/or elimination plans taking into account the private sector, community actors, gender and human rights issues, including evidence-based efficient innovative aspects such as differentiated approaches, funding, digitalisation of health services, health products, etc.;
6. To take responsibility for the implementation of supply chain transformation plans developed from audits conducted by the Global Funds, given that the access to essential medicines is key to achieve the UHC;
7. To improve definition, need identification, coordination, evaluation and country leadership of Technical Assistance (TA) and leverage local expertise first, including ensuring resources are dedicated for TA;
8. To Ensure the involvement of civil society in the process of mobilizing additional domestic resources and in their use
We call upon the Global Fund’s partners
9. To take all necessary measures to ensure that the needed resources are made available in the WCA region coupled with creating necessary procedural flexibilities in order to further enhance absorption to support countries in implementation;
10. To identify long-term RSSH Technical Assistance interventions to address priority health system weaknesses that require long term efforts in a coordinated fashion;
11. To strengthen technical support for the decentralization of care by, among other options, reinforcing the Differentiated Service Delivery (DSD) approach;
12. To streamline collaboration with health partners to ensure issues such as domestic resource mobilization, RSSH, etc. are effectively managed;
13. To promote a better coordination and harmonized alignment of interventions in countries to ensure that technical support responds effectively and in the long term to country needs (7,9,11)
We urge the Global Fund Secretariat
14. To undertake all the necessary measures to disseminate the policies and procedures of the Global Fund and more specifically for the Challenging Operating Environments (COEs) and their impact on the grants via the distribution of a briefing note in French on these procedures and their use;
15. To introduce flexibilities on the COE policy in order to simplify the grant’s implementations in these fragile contexts and provide a rationale in the case of non-use of procedures for eligible countries (PFM accountability);
16. To urgently review the risk mitigation measures currently implemented in the region and develop exit plans for additional safeguarding measures with measurable criteria and a timeframe at the commencement of each cycle;
17. To ensure mechanisms are put in place for local Principal Recipients (PRs) to manage grants in the long term;
18. To formalize Country Teams’ visits: agendas, terms of references, action plans, consensus on defining and implementing recommendations, level of involvement of CCMs;
19. To ensure CSOs have the resources to play their watchdog role of systematic and real time community monitoring;
20. To Involve countries in the evaluation of the Global Fund Country Teams in their performance on past and current grants in order to anticipate and capitalize on good practices in supporting countries.
21. Strengthen communication and exchange of experiences between countries to improve the qualitative and quantitative absorption of GF resources
22. To Train the GF Country Teams on topics as HSS and promote the recruitment of more French speaking persons in transversal departments with obligations for foreign PRs to respect the systems.
We call upon the Global Fund’s Board
23. To urgently put on the agenda of committees a general discussion on risk appetite and make the necessary adjustments to the risk mitigation measures in an effort to ensure a right balance between fiduciary and programmatic risks;
24. To urgently put on the agenda of the SC and AFC Committees the follow-up of the recommendations of the OIG report on the WCA region and ensure a trackable WCA Action Plan is in place with a very specific timeline and scheduled updates on implementation of recommendations;
25. To urgently integrate the recommendations of the OIG into discussions on qualitative adjustments to ensure that they no longer penalize WCA countries with respect to their absorption rates that currently happens to be superior to
26. To urgently Revise the risk mitigation framework in all countries concerned with flexibility plans over the next 2 years
27. To Strengthen the GF support for strengthening the health system or Resilient and Sustainable Health System (SSRP) while involving community intervention strategies.