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Institut Veolia Environnement

The Global Fund to fight HIV/AIDS, Tuberculosis and Malaria Five-year Evaluation Policy Challenges

Dominique Kerouedan

Abstracts

The five-year evaluation of the Global Fund to fight HIV/AIDS, TB and malaria (GFATM) was carried out by a Consortium of several universities and institutions, led by a consulting firm based in Washington DC. The evaluation focused on three study areas: (i) organizational efficiency and effectiveness of the Global Fund, (ii) effectiveness of the Global Fund partner environment, (iii) system effects of the Global Fund and impact of increased funding on the level of response to the three diseases. The findings can be summarized as follows: the Global Fund has been successful in mobilizing additional funding and attracting new players. However, the demand-driven model used for allocation of funding is poorly adapted to epidemiological profiles with regard to population, persons at highest risk, and number of persons affected by the disease. The partner environment of the Global Fund, involving UN technical partners and institutions cooperating in development, has failed to produce planned results due to the weak institutional capacity of recipients and health systems overall, as well as little synergy and coordination between international partners. Increased financial resources have allowed the rapid expansion of prevention and care services for the three diseases. Spectacular results have been achieved against malaria in Eastern African countries, but little progress has been made in the collective effort to slow down the spread of HIV/AIDS. In preparation for the upcoming Replenishment Conference of the Global Fund and prior to any further decisions to expand the use of innovative financing instruments for development, the author of this article calls the attention of policy-makers to the need to ensure the development of accompanying strategies to increase the effectiveness and impact of these instruments at country level.

Aspects politiques liés à l'action du fonds mondial de lutte contre le VIH/Sida, la tuberculose et le paludisme

L’évaluation à cinq ans du Fonds mondial de lutte contre le VIH/SIDA, la tuberculose et le paludisme (GFTAM) a été menée par un consortium de plusieurs universités et institutions, piloté par un cabinet de conseil basé à Washington DC. Cette évaluation s’est concentrée sur trois domaines d’étude : (i) l’efficacité organisationnelle du Fonds mondial, (ii) l’efficacité et la performance du système de partenariats du Fonds mondial, (iii) les effets systémiques du Fonds mondial et l’impact de l’augmentation des financements sur la maîtrise des trois maladies. Les résultats se résument comme suit : le Fonds mondial a su mobiliser des financements additionnels et attirer de nouveaux acteurs. Cependant, l’allocation des financements repose sur un modèle fondé sur la demande qui n’est pas adapté aux profils épidémiologiques en termes de population, de personnes les plus exposées, ou de nombre de personnes atteintes par ces maladies. Le système de partenariats du Fonds mondial, impliquant des partenaires techniques de l’ONU et des institutions de coopération au développement, n’a pas eu les effets escomptés, en raison de la faible capacité institutionnelle des bénéficiaires et des systèmes de santé, et d'une synergie et d’une coordination insuffisante entre les partenaires internationaux. Si l’augmentation des ressources financières a permis une expansion rapide des services de prévention et de prise en charge des trois maladies, avec des résultats remarquables pour le paludisme dans les pays d’Afrique de l’Est, l’impact de l’effort collectif sur la réduction de la propagation du VIH/SIDA reste faible. En amont de la prochaine conférence de reconstitution des ressources du Fonds mondial, et à la veille de décider d’élargir l’utilisation d’instruments de financements innovants du développement, l’auteur de cet article souhaite attirer l’attention des politiques sur la nécessité d’élaborer des stratégies d’accompagnement de ces nouveaux instruments afin d’améliorer leur efficacité et leur impact au niveau des pays.

Aspectos políticos del fondo mundial de lucha contra el Sida, la tubercolosis y la malaria

La evaluación quinquenal del Fondo Mundial de lucha contra el SIDA, la tuberculosis y la malaria (FMSTM) fue realizada por un consorcio de diversas universidades e instituciones, encabezado por una asesoría con sede en Washington DC. La evaluación se centró en tres áreas de estudio: (i) eficiencia y eficacia organizativa del Fondo Mundial, (ii) eficacia del compromiso de los asociados del Fondo Mundial, (iii) efectos sistémicos del Fondo Mundial e impacto de la ampliación del financiamiento en el grado de respuesta a las tres enfermedades. Las conclusiones pueden resumirse de la manera siguiente: el Fondo Mundial ha tenido éxito a la hora de movilizar fondos adicionales y atraer a nuevos actores. Sin embargo, el modelo basado en la demanda utilizado para asignar las ayudas no está bien adaptado a los perfiles epidemiológicos con respecto a la población, las personas de más riesgo y el número de personas afectadas por la enfermedad. El entramado de asociados del Fondo Mundial, incluidos los asociados técnicos de la ONU y las instituciones de cooperación al desarrollo, no ha obtenido los resultados esperados como consecuencia de la escasa capacidad institucional de los receptores y de los sistemas de salud en general, así como por la poca sinergia y coordinación entre los asociados internacionales. La ampliación de los recursos financieros ha permitido una expansión rápida de los servicios de prevención y cuidado en las tres enfermedades. Se han conseguido resultados espectaculares contra la malaria en los países de África Oriental, pero se ha avanzado muy poco en el esfuerzo colectivo para frenar la propagación del VIH/SIDA. Ante la próxima Conferencia de Reposición del Fondo Mundial y antes de tomar ninguna otra decisión para extender el uso de los nuevos instrumentos financieros para el desarrollo, el autor de este artículo llama la atención de los responsables políticos sobre la necesidad de garantizar el desarrollo de estrategias de acompañamiento que aumenten la eficacia y el impacto de estos instrumentos a nivel de país.

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Editor's notes

Originally published in Med Trop 2010; 70:19-27

Full text

1The Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM) is a worldwide public/private partnership formed in 2002. Its aim is to contribute to achieving Millennium Development Goal 61 by attracting and disbursing additional public and private resources to prevent and treat three diseases that kill over 6 million people worldwide each year2. The initiative’s context brought forward by UN Secretary-General Kofi Annan in 2001 is provided by the Millennium Declaration (1), the work done by the WHO Commission on Macroeconomics and Health (2), the UN General Assembly Special Session on HIV/AIDS3, the Abuja Declaration by African Heads of State to earmark 15% of national budgets for health (3), and the Genoa G8 meeting in 2001. The aim of these commitments is to consolidate a high level of political will and to boost national and international funding for health and the fight against these diseases in developing countries (inset 1). The Global Fund Executive Secretariat is based in Geneva, and the organization has no country-level presence. The Local Fund Agent (LFA) is a private country-level audit bureau responsible for providing technical and financial monitoring of program implementation by the principal recipient signing the grant agreement, with oversight by the Country Coordinating Mechanism (CCM). The LFA is a local or regional firm appointed by international bureaus selected at the time the programs were launched in 2002 under the Global Fund LFA competitive bidding process. At that time, the LFAs were Crown Agents, KPMG and Price Waterhouse Coopers. The LFA system has been the subject of a separate evaluation.

  • 4  Global Fund Secretariat presentation to the GFATM Partnership Forum in Dakar in December 2008.

2At the end of 2008, the outcome was as follows4: the Global Fund accounted for a quarter of global funding for the fight against AIDS, and two-thirds of that was for tuberculosis and malaria.

3It contributes to funding ARV access for nearly half of all patients receiving treatment in middle-income and low-income countries. In the period 2002-2009, 620 grant contracts were signed with 140 countries. During this period, $16.2 billion of grant aid was approved, and $8.8 billion actually paid. The breakdown across the three diseases was: 55% for AIDS, 29% for malaria and 16% for tuberculosis. Africa received 57% of this funding (www.theglobalfund.org). This continent is also the source of over 70% of new HIV infections (www.unaids.org).

4In 2006, the Global Fund Board requested ‘a first major evaluation of the Fund’s overall performance against its goals and principles after completion of at least one full grant funding cycle (five years)’. Three evaluation studies were commissioned by the Global Fund Technical Evaluation Reference Group (TERG), whose members are top-level experts on the three diseases, as well as representatives from the community, universities, governments and nationalities from every continent. Its ex-officio members include representatives of Stop TB, UNAIDS and Roll Back Malaria. The TERG is independent of the Global Fund Secretariat, and reports directly to the Global Fund Board. The TERG set the evaluation terms of reference, ensured the independence and methodological quality of the evaluations, and monitored the quality of the reports. A Secretariat team of two was available to the TERG to provide practical assistance. The purpose of these studies was to analyze three key aspects of Global Fund performance: (i) institutional and organizational, (ii) partnership efficiency and performance, and (iii) the impact of funding on disease burden.

Global Fund evaluation methodology

Evaluation questions

5The key questions can be summarized as follows on the basis of the three study areas (inset 2).

The evaluation was conducted by Macro International (inset 3)

6The evaluation method and process were similar to those used for traditional evaluations: a review of documentation, interviews at international headquarter level, country-level interviews and visits, training sessions, and the set up of technical and evaluation steering groups. Analyzing the impact has raised many methodological questions, which we invite you to read (5).

INSET 1

The guiding principles of the Global Fund are based on: (i) taking a global approach to combating these diseases, (ii) country-level definition of the strategy for controlling these diseases with input from national public, private and community contributors working within the Country Coordinating Mechanisms (CCMs), (iii) a balance between the three diseases and between regions, (iv) funding allocation based on program performance measured with indicators selected within the Global Fund monitoring and evaluation system developed jointly by a number of partners (9), (v) national implementation supported and monitored financially and technically by the Local Fund Agents (LFAs).

INSET 2

Study Area 1: Does the Global Fund as an organization  (Board, Secretariat, TRP, LFAs) through both its policies and operations, reflect the core principles, including acting as a financial instrument rather than an implementation agency, and furthering country ownership? In fulfilling these principles, does the Global Fund as an organization perform in an efficient and effective manner? This study was conducted in 2007, and the report was published the same year.

Study Area 2: How effective and efficient is the Global Fund partnership system in supporting HIV, malaria, and TB programs at the global and country level? What are the wider effects of the Global Fund partnership on health systems? This study was conducted in 2007 and 2008, and the report published in June 2008.

Study Area 3: What is the Global Fund’s contribution to reducing the burden of AIDS, tuberculosis and malaria? What has been the overall reduction in the burden of the three diseases? This study was conducted in 2008 and 2009, and the report published in March 2009. In reality, it is the collective funding effort made by the Global Fund, the World Bank, PEPFAR and the (US) President’s Malaria Initiative that is analyzed across 18 countries covered by the impact study.

INSET 3

The evaluation studies were conducted over the period 2006-2009 by an evaluator appointed on the basis of an international bidding process. The evaluator who was awarded the contract - Macro International - is a consulting firm based in Washington DC. The evaluator brought together a consortium of different universities and service providers for each study area. These included Johns Hopkins University, Harvard School of Public Health, Washington University, Axios International, Development Finance International (DFI), Macro International, the Indian Institute for Health Management Research, African Population and Health Research Centre, and a department of the WHO (the Health Information Systems Department, which did most of the analysis of the findings for study area 3).

  • 5  These reports produced by the 18 countries covered by the impact study are not available on the Gl (...)

7The evaluation reports (4 and 5) and the summary report for all three study areas (6) are available at http://www.theglobalfund.org/​en/​terg/​evaluations/​5year/​. In addition to these documents, each country participating in the impact study produced its own evaluation report5. We will begin with the submission of the evaluation results, before moving on to suggest a number of points for discussion. Only the results for study areas 2 and 3 are presented and discussed here, since the organizational structure of the Global Fund Secretariat was changed nearly three years after publication of the first study as a performance enhancement measure, rendering the majority of observations no longer relevant.

8The aim of the analysis offered here is not to criticize, as we are convinced that the Global Fund is a worthwhile route to funding the process of combating pandemic, on condition that funding are supported by relevant strategic mechanisms.

9Our aim is: 1) to bring the relevant information and discussion to the attention of the French-speaking audience concerned; and 2) to alert policy-makers to the need to support global funding (i) through a strategic vision of the fight against AIDS, (ii) through a national and international expert evaluation suitable for a new public development aid governance structure and architecture, (iii) through initiatives to strengthen country-level capabilities in terms of performance administration, management, measurement and monitoring, and (iv) through effective mechanisms for promoting synergies between countries and fund providers to support health systems and the sector as a whole. The global fund evaluation reports contain many lessons for those who advocate the use of innovative funding for health or other sectors. It would be counterproductive to reinvent the wheel, especially since we have limited resources at present.

The evaluation study results

Study to examine Global Fund partnerships at the global and country levels

10The observations and recommendations made by the evaluators focus on a number of themes relating to the expectations of the global fund partnership at the global level and how it is expressed within the Country coordinating mechanism (CCM). The following issues are addressed in particular: (i) the place of the Global Fund within the architecture of international aid, (ii) the ability of countries to manage Global Fund grants, (iii) the communication with countries and partners, (iv) the required expertise, and (v) Global Fund project performance measurements.

11The evaluator recognizes the ability of the Global Fund to attract and disburse very large volumes of funding at the global level in the period from 2002 to 2007. From this point of view, one of the founding goals of the Global Fund was achieved during this period. The most important concept regarding the place of the Global Fund within the wider architecture of international aid is that it should remain a funding institution and not become a technical agency. This presupposes that: (i) the strategies prepared by individual countries and adopted to combat the three diseases are relevant and that the funded initiatives are both effective and efficient, and (ii) the partnership with the United Nations agencies (the technical benchmark for the diseases), the stakeholders within individual countries and the development aid agencies, is working for the benefit of delivering the Fund’s programs.

12The Global Fund must respect and facilitate the adoption of strategies by country stakeholders and ensure that the priorities identified by the CCMs align more accurately with the actual needs of countries. The Global Fund must develop a communications strategy that conveys a clearer understanding of its principles and mechanisms among those approached to support its work. The GF is invited to develop a ‘global partnership framework’ that would define the precise roles, responsibilities and remits of partnership members. The evaluators also stress the need to strengthen the capacity of sub-recipients of the Global Fund funding, not only in terms of training or funding provided via these organizations and/or associations for technical activities, but also in terms of developing the institutional and managerial capabilities of public, private and denominational partners, regardless of whether these are based in the capital or throughout the country. This would seem to be a fundamental recommendation if countries are to succeed in decentralizing the process of treating these diseases in the widest sense. Technical assistance for countries should not be limited solely to the development phase of the funding proposal submitted by the country: there is a substantial need for technical and managerial expertise all along the Global Fund funding implementation process.

13Although the evaluator recognizes the contribution made by Global Fund programs to rekindling the interest of countries and national managers in program performance, the performance system as designed by the Global Fund is identified as an issue. In practical terms, the program monitoring/evaluation indicators are, in most cases, input and process indicators; the basic data used to measure progress over time are either not present at the country level or are relatively unreliable; the system encourages the generation of quantitative results, sometimes at the expense of quality, which could in turn limit the impact of prevention and treatment initiatives.

Study to examine the impact of joint funding on disease reduction

Since the services are spread relatively thinly, the likely impact is hard to measure

14The impact study report and the evaluation results summary report stress the fact that the money attracted and disbursed by the Global Fund, PEPFAR, the World Bank and the (US) President’s Malaria Initiative has extended the coverage of prevention, screening and treatment initiatives for all three diseases, and has had some effect on malaria and AIDS-related mortality in some countries, although the impact on reducing the incidence of AIDS is not clear because of:

  • health information systems that are deficient to the point where they do not enable collection of the data required to measure impact indicators, or even to track the prevalence of HIV infection in sentinel groups (pregnant women and blood donors) and high-risk groups (sex workers, drug users, sexually-transmitted infection (STI) patients, etc.). On this basis, the evaluator recommends that countries and the international community strengthen health information systems and the monitoring/evaluation capability of the health sector in order to facilitate country-level management of the sector and pave the way for future external evaluations.

    • 6  One-third of Global Fund funding allocated to AIDS is focused on HIV prevention and screening

    the very modest results achieved by additional funding for AIDS prevention. A detailed reading of the chapter devoted to AIDS in the third impact study once again reveals a relative failure in prevention and behavior change strategies, where higher levels of funding6 have not led to a reduction in HIV incidence, or even to significant behavioral changes in most of the countries observed. This is partly due to the fact that prevention campaigns targeting the general population have been conducted in places where higher-risk groups should have been the priority targets. The reports state that, despite the progress made over time, initiative coverage still falls short of need. Blood and transfusion screening and safety were not analyzed.

Funding allocation is not based on the level of disease burden

15The evaluators working on the third Global Fund study area observed that there are significant disparities in the way funding is allocated between countries with similar epidemic profiles, when considered from the point of view of population or number or people infected with HIV. In the period 2003-2006, Zambia received USD 11 per person, per year. The Democratic Republic of Congo received little funding overall, while Rwanda, Haiti and Cambodia received the highest levels of aid per HIV-positive person.

16Some countries with concentrated epidemics, such as Kyrgyzstan and Moldavia, have received amounts disproportionate to their epidemic status: USD 500 per HIV-positive person. In January 2008, Zambia received $100 million from the Global Fund for a population of 11 million. The evaluator also found that less educated people in rural areas benefited less from the funding provided.

17The impact study conducted into tuberculosis reveals no significant change in the countries studied; a situation the authors explain by referring to the fact that the anti-tuberculosis programs in these countries were already efficient and effective. In the case of malaria, the analysis reveals convincing results in terms of initiative coverage (provision of mosquito nets and insecticide impregnation), but little progress in ACT availability and distribution. The impact of the joint effort to combat malaria is very obvious in countries like Ethiopia, and can be seen in the reduction achieved in mortality rates of children under five years old. In overall terms, the anti-malaria program is the one that presents the best results, with particular emphasis on the countries of East Africa, where morbidity and mortality levels are demonstrably lower; a trend which seems to be connected to control of the climate variable. The fact that this region was also subject to drought in 2009 is a cause for future vigilance.

The effects of Global Fund funding on health systems

18Despite being asked to do so, the evaluators have not described the structural effects of Global Fund funding on health systems in terms, for example, of laboratory services, the diagnosis of opportunistic infections, the biological benchmarking structure, the health sector finance structure in place in countries such as Rwanda, etc. Only the negative systemic effects hypothesis has been explored.

19In answering this question, the evaluators have chosen to look at what the mother and child health services have been able to provide over the evaluation period, compared with the period prior to the introduction of global initiatives (pre-2003). The evaluator shows that in the countries analyzed (with specific focus on Zambia, Rwanda and Malawi), funding for maternal healthcare had also risen, but proportionately less so than funding for AIDS, and that maternal healthcare services remained effective, even though the coverage of initiatives was found to be insufficient to achieve MDG 5 of reducing maternal mortality by three-quarters by 2015. It does not appear that funding the fight against the three diseases has been achieved at the expense of other health expenditures. Furthermore, observed over the period 2003-2006, infant mortality has not worsened in those countries evaluated, where funding for the fight against the three diseases was significant. We note that the decrease in malaria-related infant mortality as a result of the success achieved by these programs in East Africa may in part explain the good results seen in this area of healthcare in this part of the continent. In overall terms, the evaluator confirms that the provision of more money for the three diseases has not prevented health systems from continuing to supply effective maternal and infant health services, and that there have therefore been no negative systemic effects as a result of (additional) funding for these diseases in these countries. We will show that the approach adopted by the evaluators imposes a number of limitations on the ability to answer fully the question regarding the systems effects of Global Fund funding.

20Conversely, the evaluators observed a form of donor substitution in favor of the fight against tuberculosis, illustrated by the fact that bilateral funding was withdrawn when the global initiatives to combat tuberculosis first appeared and, to a degree, took over that fight. Conversely, it does not seem that in countries where national accounts are available for healthcare services, that government funding to fight the three diseases had diminished, even though the quantity of external funding is undeniable, and may account for up to 70% of total funding. The increase seems to be earmarked more in favor of AIDS and malaria, than tuberculosis, for example. The evaluator observes that, where data are available, the countries of West Africa have received much less money than those of East Africa, “due partly to the fact that their epidemics are less widespread” (5). We note that it was not until the end of the ninth call for projects in 2009 that, for the first time since the creation of the Global Fund in 2002, the amounts approved in favor of West and Central Africa exceeded those approved in favor of Southern Africa.

Basic health systems have widespread shortages

21Furthermore, according to the impact study, the district health assessments conducted showed that health centers have a shortage of everything: water, medical staff, protocols, directives, medication, laboratory reagents, equipment and logistics resources, although in some countries where HIV tests are available, there are no hemoglobin measurements, or glycemia or urine tests (5).

The Global Fund evaluation five-year summary report

The summary of the three evaluation study areas covers 9 findings (inset 4)

22On the basis of these observations and recommendations, the Global Fund Secretariat has put in place a series of provisions and - in some instances - has even responded in advance of the analyses and recommendations. The performance-based funding system has been revised and the Secretariat has prepared a Partnership Strategy which was approved by the Global Fund Board at its meeting in Ethiopia in November 2009. The Global Fund has also joined in the work done by the Joint Platform for health systems strengthening, whose other members include the World Bank, WHO and the Global Alliance for Vaccines and Immunisation (GAVI), in accordance with the recommendations made by the Taskforce on Innovative International Financing for Health Systems7. The Global Fund has also taken the initiative of setting up a working group to examine ways of making the transition from a demand-based model to a more rational model in which the allocation of Global Fund funding is based more squarely on the situation at country level (7).

23The discussion that follows offers an analysis of the relevance of some of the responses offered by the Global Fund on the one hand, and of the challenges not addressed by the evaluation on the other.

INSET 4

- The Global Fund has mobilized impressive amounts of funding to support its goal of fighting AIDS, tuberculosis and malaria.

- The collective effort made has resulted in increased coverage and availability of prevention and treatment services, although its impact on reducing the burden imposed by these diseases has yet to be seen.

- The failings seen in basic health systems are holding back the extension of AIDS, tuberculosis and malaria prevention and treatment services; in those areas where basic health services operate more effectively, the effects of programs to combat these diseases are more evident.

- The Global Fund promotes fairer access to resources and services for women, the poorest in society, sexual minorities, those with the least education, rural populations, etc., but access to services by the most vulnerable population groups must be taken into consideration more closely when measuring grant performance.

- Until now, the system used to measure the performance of Global Fund programs has focused on the outcomes achieved by the projects themselves, but considerable effort has yet to be made by the international community in order to ensure the more widespread strengthening of health information systems that would enable more effective monitoring and evaluation of programs, both quantitatively and qualitatively.

- The Global Fund has succeeded in involving a broadly diverse base of national and international stakeholders, but this partnership model relies too heavily on goodwill, and should be structured around concrete commitments from the various parties involved. This commitment should extend to include strategies as well as health systems and the mobilization of technical support.

- At the country level, the role of the CCMs has consisted essentially of working together in the project funding submission phase. It is now important to develop the scope of the CCMs by focusing on their role of providing management, monitoring and technical expertise throughout the process of implementing programs funded by the Global Fund, and by adding real strength to the process by which individual countries adopt and push forward the fight against these diseases.

- The Global Fund has not developed a risk management strategy with regard to administering the various levels of the very extensive funding it handles, and is exposed to the risk of poor funding application and misappropriation.

- The Global Fund governance model should be revised in such a way as to reposition the institution within the global architectural framework of health development aid, as well as within the public/private partnership that forms its structure. These revisions should extend to redefining the roles and responsibilities currently undertaken by the Global Fund Secretariat in Geneva, which may be better undertaken by partners. It is the responsibility of the Global Fund Board to guide the Secretariat on issues regarding the strengthening or limitation of its missions, whether in terms of funding, health policy or development aid, in order to position the Global Fund more centrally within the context of the international development aid architecture.

Discussion of the results of the Global Fund evaluation

Limitations of the study examining the effectiveness of Global Fund partnerships

24The contribution made by study area 2 of the Global Fund evaluation in analyzing the effectiveness of its partnerships is relative, since it repeats in 2008 the observations made in 2003 and 2004 (8) regarding the governance of CCMs, the low-level capacity of sub-recipients, and the need for technical expertise, etc.

25The evaluators observe that basic health services are short of most basic materials, except for tests, training, directives and AIDS medication. If basic commodities, like hemoglobin and urine testing, are not available in health centers where expensive tests are available, then why would it not be correct to talk about systemic effects in favor of AIDS at the expense of more everyday illnesses?

26With this in mind, it would have been reasonable to expect the evaluation steering committee to ask itself why the countries have not made much progress more than five years after the initial studies’ findings were shared, and to bring forward new recommendations, especially in terms of governance. Study area 2 therefore suffered clearly from having been unable to go beyond what was already known in order to contribute something new to these discussions. From this point of view, the thoughts and contributions made by the countries themselves to the evaluation are not clear: despite the interviews that we know were conducted at the country level, readers of the evaluation reports have no idea regarding the thoughts and proposals of those working on the ground at the local level. The contribution of this study will ultimately be to encourage the Global Fund Secretariat to develop a partnership strategy clearly specifying the respective roles, responsibilities, and remits of each partner. What happens in the future will show whether this document and the resources that will accompany implementation of its recommendations will be precise enough to facilitate partnership governance at the global scale and at the country level in such a way as to improve the efficiency of Global Fund programs.

The limitations of the evaluation on systemic effects

27In addressing this issue, the evaluators chose to consider whether funding the fight against the diseases is achieved at the expense of funding for other health system initiatives, including mother and child healthcare. Hence, has the question regarding the systemic effects of Global Fund funding been properly asked?

28In providing massive funding for the fight against these diseases, the underlying assumption was that improving the ability to control them would de facto strengthen health systems. Does experience do anything to dent this assumption? To what degree does the evaluation attempt to answer this question? In the literature, responses vary (9-11). To arrive at an answer, it would be essential to analyze the repercussions of Global Fund funding or innovative funding such as that provided by Unitaid (www.unitaid.eu) on country-level systems for the provision and distribution of medications (for example).

29More globally, in environments where there are more and more patients and fewer and fewer medical staff (12), and where severe shortages of equipment and funding are the norm - which is the case in the majority of African countries - we must recognize that only a little is needed to keep political attention and existing resources focused in favor of a handful of closely-monitored programs. To what extent does the Global Fund evaluation put forward practical proposals regarding the effects imposed by the lack of medical staff on the ability to achieve MDG 6? To what extent do the systemic effects of Global Fund funding impact on the treatment of cardiovascular disease or chronic diseases such as diabetes and cancer, which are increasingly prevalent in countries where AIDS is not a national public health priority? These issues still need to be explored.

Challenges not addressed by the evaluation

Regarding the relevance of national and international strategies to combat the three diseases

30At the time the Global Fund was set up, the main assumption was that existing country-level strategies to control AIDS, tuberculosis and malaria were relevant and supported technically by UNAIDS and the WHO, and that increasing the coverage of initiatives (facilitated by the availability of additional funding) would ultimately restrict the spread and effects of these three pandemics.

31Everybody who works on the front line knows that things are not that simple. The joint funding impact evaluation analyses should have focused the minds of the evaluators, the evaluation steering committee and the Global Fund Board (to whom these analyses were intended) on the issues surrounding the relevance of its strategies, and particularly its AIDS prevention strategy.

32The independent evaluations conducted by UNAIDS in 2002 (13) and again in 2009 (14) hammer home the message of how urgent it is to manage the AIDS pandemic more effectively.

33That is not what we see. At its Board meeting of May 2009, the Global Fund was questioned about its responsibility to invest strategically in the fight against AIDS (15). Some Board members asked for further work to be done to clarify their analyses. At the Board meeting held in Addis Ababa in November in the same year, the focus was no longer on evaluation, but rather on the conference on rebuilding Global Fund resources and the desire for the commitment of billions of dollars in a tense atmosphere of global financial crisis. Although we understand the justifiable necessity to maintain or increase the level of funding raised in order to move forward towards universal access, we favor the revision of country-level strategies to make them more targeted, more specific and more effective in response to determining factors and country-level situations yet to be analyzed; thus raising the risk that financial preoccupation could once again take precedence over strategic efficiency. This is all the more essential since a series of crises are destabilizing development aid efforts: the global crisis among healthcare professionals, the global financial and economic crisis, demographic growth, and climate change. Despite the appeals made by the World Bank to maintain the level of aid, particularly in favor of social sectors, the continuation of funding for the therapeutic treatment of AIDS remains a very serious concern (16). The report published by the World Bank in April 2009 was already warning that AIDS prevention and treatment programs were being affected by the crisis (17). The first observations to emerge from a survey conducted in March 2009 among 69 countries offering 3.4 million people basic antiretroviral treatment indicated that 8 of these countries were already very short of this type of medication, or were experiencing other problems that posed a risk of AIDS treatment suspension. A total of 22 African, Caribbean, European, Central Asian and Pacific countries anticipated difficulties of this type during the year. Between them, these countries accounted for more than 60% of people worldwide receiving treatment for AIDS. HIV prevention programs were also compromised. In 34 countries together accounting for 75% of people living with HIV, the prevention programs targeting high-risk groups (especially sex workers and intravenous drug users) had already been impacted.

Regarding the identification of bottlenecks to efficient use of Global Fund funding

34None of the Global Fund evaluation studies reveal what we believe to be a major obstacle to the provision of funding and the extension of services: the low level of health sector capacity in tender management. This is a long-standing obstacle to the use of funding at levels equivalent to the loans and donations made by the World Bank, the French Development Agency and the European Commission, and is recognized by the European Court of Auditors to slow down the use of funding (18). Truly practical procedures must be introduced to remove this obstacle, although this is not commented upon by the evaluators, which is all the more surprising given that purchases can account for more than 50% of the funding provided by the Global Fund.

Is it up to the Global Fund to strengthen health systems?

35In response to the assumptions made regarding the systems effects of Global Fund funding, we believe that the evaluation did not ask the most important question: is it the duty of the Global Fund to strengthen health systems, since its vocation was to extend and accelerate initiatives specifically targeting the three diseases? At inception, the mandate of the Global Fund was to act quickly and massively to counter the pandemics and achieve MDG 6. That being the case, the steering committee and evaluators should have asked the question: how can we act fast to expand access to prevention and treatment in those areas where health systems are weak? It follows that in order to gear up quickly in terms of scale and speed, parallel systems of management, procurement, training, health information and program monitoring must, in the first instance, be implemented only where justified. This would certainly not have prevented countries from acting with the support of other international institutions, all of which are partners of the Global Fund (specifically the World Bank and the European Commission) to strengthen health systems at the same time as the Global Fund provided support for specific activities. But we did not see that happening. This discrepancy, which is the cause of the imbalance seen today, reflects primarily a failure of the Global Fund partnership model, both at the global level and the country level. It also reflects the lack of interest among policy-makers and publicly-funded development aid institutions: the bilateral initiatives undertaken by the European Commission and France in West and Central Africa have shrunk substantially as a result of the majority of their funding being allocated to global health initiatives (especially those run by the Global Fund, GAVI Alliance and UNITAID). This precisely overlooks the fact that it is via these initiatives that the fight against the diseases is predominantly planned and funded. At the same time, World Bank funding for health systems is also diminishing. All these choices have resulted in an imbalance in favor of the diseases, to the point where they account for an equivalent, and in some cases larger, proportion of health ministry budgets in several Sub-Saharan countries (18 and 19). It is, however, recognized by the European Court of Auditors that the funding instruments of the European Development Fund (including variable tranche budgetary aid packages8 and sector-targeted aid) are applied to fund health system strengthening initiatives (18); a sector in which the European Parliament wishes to see a stronger exercise of political will from the European Union and the Commissioners for External Relations and Development (20). These financial instruments (general budget support and sector budget support), which are preferred by the World Bank, the United Kingdom and even the French Development Agency, are equally well suited to systemic approaches. It is therefore important to work on the basis of synergy at global and country levels, which was the insistent recommendation of the 2005 Paris Declaration on Aid Effectiveness and Harmonisation9 and the EU Code of Conduct on Complementarity and the Division of Labour in Development Policy (21).

36The logical outcome is that current collaborative efforts between the WHO, the World Bank, the GAVI Alliance and the Global Fund to address the issue of strengthening health systems must be extended to include the contribution of the European Commission, which provides high levels of funding in Africa and the Caribbean and Pacific (ACP) zones most affected by the AIDS pandemic, and must certainly extend to include British cooperation. Our view is that global public/private partnerships whose current and future innovative funding may form part of these discussions on the strengthening of health systems are neither mandated nor best placed to become leaders in terms of health system strengthening. We must not lose sight of the fact that this responsibility lies primarily with the countries themselves, supported by the WHO and development partners that have recommended the kind of systemic approach that is more the remit of bilateral aid.

Regarding the identification, mobilization and funding of technical expertise to support Global Fund projects

37The need for health sector technical expertise is a universal issue for fund providers: the European Court of Auditors deplores the absence of a policy to cover expert resources and the strengthening of country-level capacity in the context of European public funding of development aid (22); we are witnessing a decline in the provision of French technical assistance to support the health sector in Africa (23); there is a lack of training and development facilities for this type of expertise, both nationally and internationally (24). The second study area of the Global Fund five-year evaluation stresses the fact that the ‘technical assistance’ issue should be tackled collectively as part of country-level and international partnerships. We view as vital that new expertise be brought forward at country and international levels, and that this expertise be tailored to support the new health sector funding instruments of developing countries (25). We believe that as major donors to the Global Fund with seats on its governing board, France and the European Union have a particular responsibility in this respect, especially towards French-speaking countries, which found it harder to access information, guidelines and funding during the period 2002-2009. The ‘Backup Initiative’ technical assistance model introduced by the GTZ (website: http://www.gtz.de/​en) to support Global Fund programs at the country level may inspire these developments. All partners agree that this is a vital issue, but to which extent do they discuss it in purely practical terms? What are the partners proposing? Where in Europe and Africa are the future global health experts being trained?

Equity of access to resources, information and knowledge

38The evaluators are fairly clear on the fact that the distribution of Global Fund resources relative to population size or to the number of people affected by HIV is not rational. We note that the Global Fund is no exception in this respect, since authors comment on the fact that funding is not evidence-based and speak of global health misfinancing (26). Furthermore, the evaluation does not answer this question: have all these grants brought about any reduction in user fees, or any reduction in health-related poverty? Finding the answer could provide an excellent research project.

  • 10  Commented upon verbally in evaluation steering committee sessions and visible on reading the evalu (...)

39A more subtle disparity that may strike French-speaking readers of all these evaluation reports regards the differences between West & Central Africa on the one hand, and East and Southern Africa on the other, which emerges when one reads between the lines. The report on the third study makes it clear that the countries of West Africa received less funding than those of East Africa, “due partly to the fact that their epidemics are less widespread”. It remains to be seen whether the difference in the spread of the epidemic in itself justifies this unequal distribution of Global Fund resources between two parts of the same continent. This issue deserved more research work and analysis. There are clearly ‘pet countries’ that receive conspicuous attention from many fund providers. These include Zambia, Mozambique and Uganda. No doubt they have learned how to deliver and demonstrate the required performance. From the point of view of public health, we believe it equally fair and justified to take a closer interest in the countries experiencing difficulties. These studies should also have focused on examining whether the less impressive results hinted at by the evaluators in West and Central Africa10 were related to any lack of access to resources (information, knowledge, expertise and funding).

40Ever since the beginning of the AIDS pandemic, the French-speaking countries of Africa have found it more difficult to access information, documents, guidelines, bibliographic references, research findings, and so on, since all these documents were originally (and sometimes only) published in English, regardless of whether they were prepared by the WHO, UNAIDS, the Global Fund or any other partner. The calls for clinical research projects launched by the EDCTP program funded by the European Commission11 have remained in English for too long, making access to them unfair for French-speaking African research teams over several years, when this European funding is supposed to benefit research teams throughout the continent. The grant agreements issued by the Global Fund are drafted in English, even where they are used in French-speaking countries. The program monitoring/evaluation guide is a very valuable technical resource for those active at the local level, but it is available only in English (27). The Global Fund five-year evaluation reports are available only in English. Why deprive so many French-speaking local workers and universities of the opportunity to access the knowledge and learning that could be obtained by reading these documents in detail? The same applies to Spanish speakers and Portuguese speakers, among others.

41As the European Commission, France, Germany and the World Bank reduced their investment in the West African health sector throughout the first decade of the 21st century, the countries of eastern and southern Africa have benefited from more recent political commitments and massive development aid funding from Britain, the American presidential PEPFAR program, and private funding from the Bill and Melinda Gates Foundation, as well as very large contributions from the European Commission (Zambia) and the Global Fund to fight AIDS, Tuberculosis and Malaria.

42We consider that it is vital that a retrospective study into this unequal distribution of resources be conducted at the earliest opportunity so that measures can be put in place to limit the risk of its continuation.

43There is an urgent need to reconsider the overall distribution of resources available to support the health sector throughout the African continent, and at the global scale. We see this as one of the component parts of analyzing the architecture and effectiveness of aid.

Conclusions

44The evaluation raises, and in some cases fails to raise, a number of issues that the Global Fund Board would do well to consider. The most important for the community of fund providers is that surrounding the real country-level impact of the sums attracted and committed, which are totally unprecedented. With this in mind, it is important to be very clear about the position of the Global Fund’s public/private partnership stakeholders, at least regarding the following issues, which have a direct bearing on funding:

    • 12  Presentation by the Executive Director of the Global Fund to the Global Fund Board in Addis Ababa (...)

    the revision of AIDS prevention strategies, without omitting to provide broad-based funding for every element of prevention, such as safe blood and transfusion, the diagnosis and early treatment of STIs and the prevention of mother to child transmission of HIV through a commitment to improve the level of use of maternal health services, all effective and efficient intervention strategies, although they receive little funding from individual countries and the international community, especially the Global Fund, whose earmarked funding for HIV prevention is 4% for blood safety, 6% for the diagnosis and early treatment of STIs, and 15% for the prevention of mother/child HIV transmission12.

  • the strengthening of health systems in all their aspects, but especially basic health services, in order to facilitate the expansion and decentralization of prevention and treatment services for the three diseases.

  • the training, mobilization and funding by countries and the international partner institutions of the Global Fund of high-level technical and managerial expertise in order to support: (a) an improvement in the sub-recipients’ capacity to implement Global Fund programs, and (b) the country-level implementation of new health sector funding methods, including innovative funding.

  • practical methods for synergy-based co-operative working between country-level contributors in accordance with the provisions of the EU Code of Conduct on Complementarity and the Division of Labour in Development and the Paris Declaration on Aid Effectiveness and Harmonisation 13.

45The performance and success of Global Fund funding in achieving MDG 6 will depend on the consideration and practical commitments given by Global Fund partners in all these areas as part of in-depth Board discussions, bearing in mind the partner commitments restated at the G8 meeting in Italy to pay more attention to the effectiveness of initiatives (28). Their discussions will be all the more productive and useful in supporting existing or future innovative funding at the global scale, whether for health or other sectors, such as food security, climate change, etc.  France and Europe must demonstrate that they are equal to the challenges raised by the revolutions now underway in the architecture of international aid (29), assume their rightful place and exert their influence (30) to extend in a new form their respective, historically-concerted and recognized contributions to the epic challenge of international health cooperation.

We are grateful to Dr. Jean-Marie Milleliri, Global Fund expert on the WHO inter-country team for Central Africa, for his valuable advice.

We are grateful to Gisèle le Cabellec and Institut Veolia Environnement for facilitating the translation of this paper from French into English.

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Bibliography

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Annex

Dominique Kerouedan, MD, MPH, MSc., PhD, BA Law, with 25 years experience in developing countries, on long-term or short-term assignments in urban and rural areas, in relation to HIV/AIDS control, health systems strengthening, policy design and strategy evaluation, working for various institutions, including UN agencies, bilateral French and German technical cooperation agencies, as well as USAID, the European Commission, the World Bank, the Global Fund to fight HIV/AIDS, TB and Malaria, etc. Her fieldwork has been mostly in Africa over the last 20 years (Rwanda, Gabon, Congo, Mali, Niger, Côte d’Ivoire, Centrafrican Republic, Senegal, Eritrea, Algeria, Morocco, Madagascar, etc.).

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Notes

1  The Millennium Declaration sets out the 8 Millennium Development Goals, number 6 of which is to ‘Combat HIV/AIDS, malaria, and other diseases’

2 http://www.theglobalfund.org

3  UNGASS (United Nations General Assembly Special Session) http://www.ua2010.org/fr/UNGASS

4  Global Fund Secretariat presentation to the GFATM Partnership Forum in Dakar in December 2008.

5  These reports produced by the 18 countries covered by the impact study are not available on the Global Fund website

6  One-third of Global Fund funding allocated to AIDS is focused on HIV prevention and screening

7 http://www.internationalhealthpartnership.net

8  The grant agreement specifies the rate at which non-targeted budgetary aid tranches are paid. The variable tranches are supposed to be paid in addition on the basis of the performance of social sectors measured using indicators defined in cooperation with the country concerned.

9 http://www.oecd.org/dac/effectiveness

10  Commented upon verbally in evaluation steering committee sessions and visible on reading the evaluation reports for certain countries.

11 http://www.edctp.org,  European and Developing countries Clinical Trials Partnership (website in English only).

12  Presentation by the Executive Director of the Global Fund to the Global Fund Board in Addis Ababa on November 9, 2009. http://www.theglobalfund.org/en/board/decisions/

13  http://www.oecd.org/dac/effectiveness

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List of illustrations

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References

Electronic reference

Dominique Kerouedan, « The Global Fund to fight HIV/AIDS, Tuberculosis and Malaria Five-year Evaluation Policy Challenges », Field Actions Science Reports [Online], Commentaries, Online since 17 December 2010, connection on 01 August 2014. URL : http://factsreports.revues.org/635

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About the author

Dominique Kerouedan

M.D., M.P.H., M.Sc., PhD, Sciences Po Paris - Paris School of International Affairs, E-mail: dominique.kerouedan@sciences-po.org

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Copyright

Creative Commons Attribution 3.0 License

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