Global Fund ObserverNEWSLETTER

Issue 340: 22 August 2018

GFO is an independent newsletter about the Global Fund.

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CONTENTS OF THIS ISSUE:

1. NEWS AND ANALYSIS: Advocates’ network report underscores critical need for Global Fund to ‘get back on track’ to end epidemics

BY CHARLIE BARAN

A new report from the Global Fund Advocates Network released at AIDS 2018 makes the case that the global responses to HIV, TB, and malaria are currently ‘off track,’ and that increased funding is needed to ‘get back on track’ and meet the various global disease targets for 2025 and 2030. The report outlines some key financial and political imperatives for addressing the epidemics adequately.

2. NEWS: France will host the conference for the Global Fund’s Sixth Replenishment

BY DAVID GARMAISE

France has been selected as the site of the Replenishment Conference expected to be held in Autumn 2019. This article summarizes the outcomes of the Fifth Replenishment Conference in 2016; describes the steps leading up to the Sixth Replenishment Conference; and reports on the appointment of Françoise Vanni as Head of External Relations, the unit responsible for the replenishment campaign. Vanni replaces Christoph Benn who served for many years in that position. Finally, the article provides highlights from the Resource Mobilization Update submitted to the Board in May.

3. NEWS: Global health leaders discuss ‘ending’ AIDS in context of universal health coverage

BY CHARLIE BARANSome of the leaders of the world’s most influential health organizations, and of governments grappling with the challenges of reaching universal health coverage, discussed in a special

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session at AIDS 2018 how the ‘elimination’ of HIV and achievement of universal health coverage should be addressed.

4. ANALYSIS: The Global Fund explores the use of impact bonds and social success notes

BY CHERYL TOKSOZAt its last Board Meeting, in May 2018, the Global Fund opened a formal consultation process to develop a more structured approach to innovative finance within the organization. The Global Fund is considering several different approaches to innovative finance, many of which would require a change in organizational policy and the way that it interacts with its partners and the countries it services. Aidspan is taking a deeper look at the different innovative financing instruments over a series of three articles. This second article describes outcomes-based financing and discusses the pros and cons of mechanisms such as impact bonds and social success notes.

5. COMMENTARY: International AIDS Economics Network meeting in Amsterdam focuses on sustainability of global response to HIV

BY ALAN WHITESIDERenowned health economist and Aidspan Board member Alan Whiteside describes the International AIDS Economics Network meeting held in the runup to AIDS 2018 in Amsterdam last month. The sustainability of the AIDS response in the context of ‘shrinking donor funding’ was in the spotlight, at this pre-meeting as well as at the main conference.

6. ANALYSIS: Domestic financial contributions to HIV, tuberculosis and malaria responses remain low

BY ANN ITHIBUA new analysis by Aidspan shows that domestic contributions by low- and lower middle-income countries to their HIV, TB and malaria responses accounted for around one third or less of their funding to tackle these diseases over the 2015-2017 period. The analysis also quantifies the projected gaps in overall funding for the 2018-2020 period - 24% for HIV, 49% for TB, and 44% for malaria - unless domestic and international commitments increase.

7. NEWS: Global Fund grant to Ukraine finds treatment success for multidrug- resistant TB with two-pronged approach

BY IVAN VARENTSOVRenowned health economist and Aidspan Board member Alan Whiteside describes the International AIDS Economics Network meeting held in the runup to AIDS 2018 in Amsterdam last month. The sustainability of the AIDS response in the context of ‘shrinking donor funding’ was in the spotlight, at this pre-meeting and at the main conference.

8. ANNOUNCEMENT: Aidspan’s Board: a new member, a new Chair, and a farewell

BY ADÈLE SULCASAidspan’s Board sees some changes in 2018, and with regret and appreciation sees the departure of one of its founding Board members, Dr James Deutsch.

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ARTICLES:

1. NEWS AND ANALYSIS: Advocates’ network report underscores critical need for Global Fund to ‘get back on track’ to end epidemics

Advocates outline concerning trends in HIV, TB and malaria financing, call for action

Charlie Baran 21 August 2018

“If the world only maintains current levels of investments and programming against [AIDS, TB, and malaria], global targets for 2025 and 2030 will be unattainable.” This is the alarm sounded in a new report by the Global Fund Advocates Network (GFAN): Get Back on Track to End the Epidemics. The report, which was released on 25 July at the International AIDS Conference in Amsterdam, and is available online, claims that, “flat or declining funding from international donors, with an assumption of progress through greater efficiencies and increased domestic investment…will drive the world off-course in its attempts to control and end the epidemics.”

Citing concerning epidemiological trends (slowing or too-small reductions in infections and deaths from AIDS, TB, and malaria) and data showing that even current levels of international assistance for the three diseases will be insufficient to reach global targets, the report calls for the global community to “get back on track.” For GFAN, getting back on track means substantially increasing the contributions of donor (and implementer) countries for disease control efforts, much of which could be done through expanded pledges to the Global Fund in next year’s replenishment drive. The centerpiece of the report is a bold, yet well-documented, statement of need for global financing for the three diseases over the 2020-2022 period, which will be funded through the Sixth Replenishment (see image below). For the Global Fund in particular, the report argues that donors need to increase pledges by at least 22% over the prior replenishment, which was launched in Montreal in September 2016, and covered the 2017-2019 period.

Image 1: Global financial need to get back on track. From Get Back on Track to End Epidemics

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A note about the above graphic: Days after the report was published, the Stop TB Partnership presented updated calculations of need for the global TB response. At the 2018 International AIDS Conference, Stop TB stated that, in fact, $65 billion is needed for TB responses for 2018-2020, representing a doubling of the current level of investment. According to these new figures, at least $14 billion is needed per year starting in 2020, with at least $1.6 billion being channeled through the Global Fund. GFAN issued a press release reflecting these updated figures at the conference.

‘Hazards in the global epidemic response’

To illustrate its claim that the world is off track in its efforts to meet the Sustainable Development Goals of ending the epidemics of HIV, TB, and malaria by 2030, the report highlights six concerning trends.

Adolescents and young women face too much risk

At the top of the list is the fact that the largest-ever generation of adolescents and young women (recently referred to at AIDS 2018 as the “demographic bulge”) is facing a host of threats to their health and overall well-being and security. More than 350,000 adolescent girls and young women are still becoming newly HIV-infected in low- and middle-income countries each year. These infection rates stand in contrast to the falling rates among many other populations, “signaling potential for resurgence of HIV epidemics as cohorts of young people expand.” If the world fails to get a handle on controlling HIV in these populations, the report argues, then the entire project of ending HIV is unlikely to come to fruition within the next 12 years.

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Speaking at a press conference organized for the report in Amsterdam, Maurine Murenga, Global Fund Board Member for the Communities Delegation, said: “There are some really scary data in this report – not only scary in terms of the figures, but also in terms of an epidemic that is growing. We need many, many more resources to address this. If we don’t cap it now, then it’s going to be worse. Everyone needs to top up!”

Key and vulnerable populations continue to be left behind

Another key threat to success is the abiding neglect by health systems of key and vulnerable populations for all three diseases. The report cites new data from amfAR: the foundation for AIDS research which describes that 80% of new HIV infections outside sub-Saharan Africa and 25% of those within sub-Saharan Africa are occurring among key populations and their sexual partners. People living with HIV and other key populations are also at substantially elevated risk for acquiring and dying from TB. And migrants—an ever-growing global population—continue to have some of the highest risk levels for HIV, TB, and malaria. But despite their growing profile in global health discourses, key populations are still not receiving appropriate levels of funded interventions for the three diseases, and are at particular risk for being left behind in some middle-income countries where donors such as the Global Fund are rapidly exiting, leaving them to fend for themselves against often unfriendly governments.

Human rights under attack

A corollary to the neglect faced by key populations is the increasing regularity with which human rights are being attacked. As the report highlights: “Leading global measures of human rights have reported worsening rights-related situations in every region of world.” The report acknowledges the central role of human rights to the achievement of the SDGs, those which are health-related and otherwise. While there is an unfortunate global trend against respect for universal human rights, the report does point to the Global Fund as a key influencer in support of human rights, through its requirements that recipient countries respect peoples’ rights and support non-discriminatory approaches to health.

Drug resistance is up, access is threatened

Two of the other top-line ‘hazards’ relate to medicines: drug resistance is on the rise at the same time that access to medicines is under threat. The two hazards are indelibly linked. At the same time that some corporate and government entities are seeking to “extract maximum profits” for life-saving drugs, the report argues, efforts to mitigate increasing resistance to some essential medications are not being sufficiently developed or implemented. This combination represents a major challenge to current efforts to control the epidemics, let alone the necessary scaling up for which the report calls.

International aid is plateauing/declining, just when it needs to be increased

Finally, the international assistance equation is evolving out of sync with global need. As many countries with major epidemics of HIV, TB, and malaria transition from low- or lower-middle income into higher economic classifications, the rationale donors use to make

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investments becomes weaker. There is a sense of punishing success in this arrangement. Reducing donor investments in middle-income countries just as they are approaching tipping points in controlling their epidemics threatens to set back their progress, with potentially “disastrous results,” as the report argues. The report highlights the unfortunate reality that “over 70% of people living with the three diseases live in countries with over-burdened health systems.” Regardless of income classification, and in spite of growing domestic investment in many countries, low- and middle-income countries remain largely dependent on international aid to combat their epidemics, as described in the table below.

Table 1. International aid in low and middle-income countries. From Get Back on Track to End the Epidemics.

In 2017, in low- and middle-income countries, international aid accounted for

Disease Percentage of spending

International assistance

Total spending

HIV 40% $9 billion $17.9 billion

TB 16% $1.1 billion $6.9 billion

Malaria 69% $1.9 billion $2.7 billion

A plan to get back on track

The report calls for “immediate action” to get back on track, and lays out five plans for doing so, each targeting a specific stakeholder group. Because the report describes these plans with exceptional brevity and pointedness, we have chosen to reprint the original text for GFO readers.

1. Donor governments and implementing countries should recognize the urgency and peril of the situation and mobilize resources without delay. The technical partners have estimated the total funding need for AIDS, TB and malaria at US$46 billion annually, of which GFAN estimates that at least US$14.55 to US$18 billion should be invested through the Global Fund for the Sixth Replenishment (2020-2022). This would reflect a minimum increase of 22% compared to the US$11.9 billion announced pledges at the Fifth Replenishment (2017-2019). This requires donor governments making increased pledges—as early as possible—to the Global Fund’s imminent replenishment for 2010-2022.

2. Policy experts and decision makers must acknowledge, articulate, and draw attention to the ways in which HIV, TB and malaria efforts are off-track and update strategies to bring epidemic responses back on course to ending the three epidemics.

3. Global technical partners, notably WHO, UNAIDS, and the Stop TB and Roll Back Malaria partnerships, must re-examine current progress and challenges and recalculate current epidemic trajectories and global resource needs.

4. The Global Fund, given its record of success and central role in financing epidemic responses, should be ambitious in setting replenishment targets for the 2020-2022 funding cycle and be forceful in communicating the costs of inaction.

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5. Advocates should boldly demand increases in international aid for health, including for programs against HIV, TB and malaria, and should press all governments to build resilient and sustainable systems for health and commitments to health for all.

A report with legs

While the authors of many advocacy documents cross their fingers and hope that others will make use of the statistics and arguments they present, GFAN took this a step further with the Get Back on Track report. Rather than simply write and release the report, GFAN has made available a suite of supporting documents for advocates to use to expand the utility and impact of the report. On the report’s webpage readers will find pre-made templates for a press release and social media posts, as well as graphics, images, power point slides, and ‘key talking points,’ to be used at their own discretion. In addition, the executive summary is provided in French, Spanish, and Russian. Although not detailed in this article, data-heavy ‘spotlight’ sections on each of the three diseases are also included in the full version of the report, which may serve as further ammunition for advocates seeking to build their cases with this report.

The report and supporting documents represent a poignant and coordinated effort to influence the Global Fund’s Sixth Replenishment drive, which begins early next year. This is in alignment with GFAN’s mission to support advocacy around increasing donor pledges for the imminent, as well as past, replenishment drives.

Mike Podmore, executive director of UK-based STOPAIDS, and Global Fund Board Member for the Developed Countries NGO Delegation, provided some context for the role of this report when he spoke at the press conference. “In previous replenishments there was an established part of the traditional advocate-donor dance, where donors always started the discussion by saying, ‘The financial and political context is very challenging, so an increase is unlikely. We will be lucky to maintain current funding.’

“They try to lower expectations, and then we proceed to ignore that and ask for what is actually needed to end the epidemics,” Podmore said. “This time the circumstances really are a bit different because, depressingly, funding pessimism has more substance. Not only is the political context in many key donor countries hugely challenging, but the stark gaps for funding the three diseases seem to be widening. This report is an antidote to that pessimism, and a call to action.”

Further reading:The Get Back on Track report and associated materials can be found here: http://www.globalfundadvocatesnetwork.org/campaign/get-back-on-track/#.W3NpRX4nZTbMore information on the Global Fund Advocates Network can be found here: http://www.globalfundadvocatesnetwork.org/More information on amfAR: The Foundation for AIDS Research can be found here: https://www.amfar.org/Further discussion of the “demographic bulge” and why HIV prevention among young people is of major concern can be found in The Lancet, here: https://www.thelancet.com/pdfs/journals/lanhiv/PIIS2352-3018(16)30058-3.pdf

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2. NEWS: France will host the conference for the Global Fund’s Sixth Replenishment

The conference is expected to be held in Autumn 2019

David Garmaise 21 August 2018

Last May, the Global Fund announced that France will host the Fund’s replenishment conference in 2019. The conference is the formal platform for donors to announce their pledges for the Sixth Replenishment, which covers the period 2020–2022. This is the first time that France will host a Global Fund replenishment conference.

“As one of the founding partners of the Global Fund, France is demonstrating great leadership and sustained commitment in global health,” said Peter Sands, the Fund’s executive director. “We are extremely grateful to President Macron for leading efforts to renew and expand our impact, to the benefit of millions of people.”

A date for the conference has not yet been set. A spokesperson for the Global Fund Secretariat told Aidspan that it would likely be in Autumn 2019.

The last replenishment conference –– for the Fifth Replenishment, covering the period 2017–2019 –– was held in September 2016 in Montreal, Canada. By the end of that conference, $12.9 billion had been raised. Since then, the Global Fund has received additional commitments of £100 million from the U.K . plus a matching contribution of £50 million from the Bill & Melinda Gates Foundation.

The U.K. pledge, which is part of an undertaking by the U.K. to spend £500 million a year until 2021 to tackle malaria, brings to £1.2 billion the amount the U.K. has committed for the Fifth Replenishment. The pledge from the Gates Foundation means that the foundation has now committed $665 million for the Fifth Replenishment.

Following the Fifth Replenishment conference, the Global Fund also received pledges from Liechtenstein (100,000 Swiss francs); Portugal (€112,000); Uganda ($1.5 million) –– as well as Debt2Health (two initiatives, denominated in different currencies: €13.8 million and $3.2 million).

(The Global Fund records pledges in the currencies in which they are made [“source currencies”]. The Fund’s pledges and contributions spreadsheet can be downloaded here. The spreadsheet is updated periodically; the latest one is dated 18 June 2018. The Fund also converts all pledges to U.S. dollars at the spot rate in effect when the pledges are received. The pledges and contributions spreadsheet shows the pledges for 2017–2019 in their source currencies only; it does not show the U.S. dollar equivalents. This explains why we have used several different currencies in this article.)

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France pledged €1.08 billion for the Fifth Replenishment. This was the third-largest pledge, behind the U.S. and the U.K. In terms of cumulative pledges since the Fund was launched in 2002, France is the second-largest donor after the U.S., having committed more than €4.2 billion.

The Global Fund Secretariat has informed Aidspan that the Sixth Replenishment will follow a schedule similar to the one used for the Fifth Replenishment. The replenishment campaign will be formally launched at a Preparatory Replenishment meeting which is expected to be held in the first quarter of 2019 (site to be announced). The replenishment target will be revealed at that time or shortly thereafter.

At the 22nd International AIDS Conference, held on 23–27 July 2018 in Amsterdam, it was noted that donor funding for HIV has been declining since 2012 (development assistance for HIV dropped $3 billion, Devex reported ); and that the Global Fund’s Sixth Replenishment will be a decisive moment for the near-term future of AIDS funding (see GFO article).

New Head of External Relations

Within the Global Fund Secretariat, the responsibility for coordinating replenishment efforts lies with the External Relations division. The longtime head of the division, Christoph Benn, officially left that position in June 2018 (though he is remaining on staff for a few months as a senior advisor). The new head of External Relations, Françoise Vanni, is scheduled to take up her position on 3 September.

In a news release, the Fund said that Vanni has more than 20 years of leadership experience in resource mobilization and advocacy, most recently as Director of External Relations and Communications for the United Nations Relief and Works Agency in the Middle East, where she oversaw a broad portfolio that included dozens of institutional and private donors. Vanni’s career has included stints as country representative in Angola and Cuba for Médecins du Monde; executive director of Agir Ici, an NGO in France which she transformed into Oxfam France; communications chief for UNICEF in Mexico; and campaigns and policy director for Oxfam Great Britain.

Resource Mobilization Action Plan

The Secretariat submitted a costed Resource Mobilization Action Plan 2018–2019 to the Audit and Finance Committee (AFC) in early July; the plan was reviewed by the AFC that same month.

The Secretariat provided the Board with a Resource Mobilization Update at its May meeting. The following are some of the highlights from the update:

Spain has not pledged since the Third Replenishment in 2008–2010. At the Fifth Replenishment conference in Montreal in 2016, Spain indicated that it planned to announce its pledge “at a later date” (see GFO article). Parliament was presented with a proposal to contribute € 100 million, but the crisis in Catalonia has (hopefully temporarily) sidelined the proposal. The Secretariat believes that the recent signing of

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Debt2Health agreements involving Spain signals continued interest in the Global Fund and a willingness to engage.

Discussions continue with four emerging economies in Latin America –– Argentina, Mexico, Brazil and Chile. The primary objective is to secure ongoing engagement and broad political support for the Global Fund and its mission. This could translate into financial contributions in the medium- to longer term.

The Secretariat has adopted a new engagement strategy for China. The approach is structured around three pillars: (1) seeking synergies with China’s international development strategy, including its Belt and Road Initiative; (2) setting up tripartite cooperation among the Global Fund, China, and African or Asian implementing countries (e.g. co-investment in providing technical assistance); and (3) promoting frequent communications at different levels, including engaging with the private sector.

Three new Debt2Health swaps are being negotiated (Germany –– El Salvador; Germany –– Papua New Guinea; and Spain –– Guinea Bissau).

The Global Fund Secretariat is currently developing an Investment Case document for the Sixth Replenishment. As in past replenishments, the document will estimate the investment needs for the three diseases. The Investment Case is expected to be completed in January 2019, prior to the Preparatory Replenishment meeting.

This is the first of a series of articles GFO will carry in the run-up to the replenishment conference in late 2019. The Resource Mobilization Update is available here (look for Document GF/B39/24).

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3. NEWS: Global health leaders discuss ‘ending’ AIDS in context of universal health coverage

Special session at AIDS 2018 brings together Dr Tedros, Peter Sands, and country ministers

Charlie Baran 21 August 2018

From left: Robert Matiru (UNITAID), Khuat Thi Hai Oanh (Supporting Community Development Initiatives), Peter Sands (Global Fund), David Sergeenko (Government of Georgia), JVR Prasada Rao (Global Commission on HIV and the Law). Photo: Charlie Baran.

“Half of the world’s population lacks access to quality health services” and “the world is not on track to reach HIV targets” were two of the opening remarks by World Health Organization Director General Dr. Tedros Adhanom Ghebreyesus (known as Dr. Tedros) during a satellite session at the International AIDS Conference last month in Amsterdam. Dr. Tedros’s objective in the session was to link the dual challenges of ending the HIV epidemic and achieving universal health coverage (UHC), which was the focus of the session, entitled, “Eliminating AIDS epidemics on the road to universal health coverage.”

The high-level session, which took place directly before the opening ceremony of the conference on Monday, 23 July, encapsulated well one of the major themes of the conference, as noted in GFO 340, that the success of the global HIV response will be tied closely to the success of UHC.

Dr. Tedros described a six-point plan for synchronizing the HIV response with the drive for UHC. First, UHC needs to be informed by the evolution of the HIV and viral hepatitis responses. Second, national HIV strategies must be integrated into national health-care programs, with the foundation of these programs being stronger systems with a major focus on primary services. Third, countries need to define the quality HIV services to be included in UHC plans. On this point, Dr. Tedros emphasized that, “All people must have access to

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HIV services no matter who they are.” Fourth, UHC needs to be people-centered. This point harkens to the third principle of the WHO’s UHC call to action of 2017: “Together on the Road to Universal Health Coverage.” Fifth, health systems must have a package of services which are free at point of service, thereby reducing the barrier of out-of-pocket payments. And sixth, “To end the epidemics, we will need new technologies and interventions.”

Dr. Tedros was followed by three presenters with more country-level perspectives, coming from South Africa, India, and Georgia. The first was Aaron Motsoaledi, South Africa’s Health Minister. Mr. Motsoaledi remarked that, “The concept of UHC has arrived at the right time.” He described how South Africa, which has the largest HIV epidemic on earth, functionally has two parallel health systems. “A private one which is superior to any in Europe. And a public one which, just like any other in Africa, is marred by huge inequalities.” From his perspective, the drive for UHC will help diminish the disparity between his country’s health systems.

The next speaker, JVR Prasada Rao of India, continued on Mr. Motsoaledi’s theme of two health systems. According to Mr. Rao, a commissioner with the Global Commission on HIV and the Law, “UHC doesn’t include the private sector.” He appeared to be referring to the fact that the global UHC movement is largely led by governments, NGOs, civil society, and multi-lateral institutions, but does not yet have strong engagement from business or the private sector. This is a problem for Mr. Rao because in India 60% of health services are accessed through the private sector. He described a situation where, just as in South Africa, people who are more privileged have access to the private health system, which offers better quality care, while others are left to suffer the public health system. The distinction itself can inhibit access to services. As Mr. Rao described, “In some developing countries the health system itself is an instrument of stigma for poor people.” Shrinking the gulf between the two will be critical, according to Mr. Rao.

Georgia’s Minister of Internally Displaced Persons from Occupied Territories, Labor, Health, and Social Affairs, Dr. David Sergeenko, spoke next. Universal health coverage is the national policy of Georgia, having been initiated in 2012 and operational since 2013. Dr. Sergeenko allowed that while his country is fairly small, it is nonetheless a great example for other countries to study. While most of his remarks focused on his country’s efforts to control hepatitis C virus (HCV) and HIV, he was able to point to some of the overall benefits of UHC. For example, since 2012, out-of-pocket payments by patients, as a proportion of total health expenditures, have gone down significantly, just as patient visits to public health centers have nearly doubled, signaling more well-visits and treatment-visits, two key indicators of improving health outcomes (see Figure 1).

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Figure 1. Universal health care program, Georgia; out-of-pocket expenses.

Peter Sands, the new Executive Director of the Global Fund, spoke next, and brought a global perspective back to the conversation. His remarks followed two major themes: the connection between ending HIV and achieving UHC, and the resources needed to do both. As discussed in GFO 339, Sands reflected: “I think there is a false dichotomy between, ‘should we do UHC or end the epidemics’. We will not succeed in ending the HIV epidemic if we do not build a UHC platform.” Mr. Sands made it very clear that the two go hand in hand from now on. But he acknowledged one of the most lamented risks of UHC, that the marginalized people whom the HIV response has fought to keep at the center, may be left behind by UHC. This cannot be allowed, said Mr. Sands. “A UHC platform that does not include key populations, is not universal.”

Dr. Khuat Thi Hi Oanh, who runs Supporting Community Development Initiatives (SCDI), followed Mr. Sands. In a playful yet poignant jab at the session organizers, Oanh opened with: “I feel really special being the only woman and only civil society on the panel.” SCDI is a Vietnamese NGO that promotes the well-being of vulnerable and marginalized communities. She echoed Sands’ concern about key populations: “The people most affected HIV, TB and HCV are the most likely to be left behind by UHC.” She argued that people living with HIV are desperately in need of UHC, because they are “dying from many other things, such as HCV and overdoses.” Nonetheless, she thinks that the HIV response has much to offer the UHC movement: “I would like to call on my fellow HIV activists to use our experience and know-how and wisdom for UHC.”

Dr. Oanh wrapped up her presentation with a reflection on history, and an idea for how to set up the UHC movement for success. “We don’t want another Alma Ata,” she said referring to the 1978 global health summit that called for universal health coverage by 2000. This year is the 40th anniversary of that aspirational summit, whose main call to action has not nearly been realized to date. “We are 18 years late!” lamented Dr. Oanh. She did boldly articulate one decision that could provide some urgently needed financial and political scaffolding for the UHC movement. Turning to Peter Sands and addressing him directly, she said: “If you can make [supporting UHC] a Global Fund policy, it would have a great impact.”

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While the Global Fund Board – not the Executive Director – sets Global Fund policy, Mr. Sands’ comments in this session and elsewhere do suggest that he would support such a policy at the Fund.

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4. ANALYSIS: The Global Fund explores the use of impact bonds and social success notes

Outcomes-based financing approach could reduce the risks associated with innovation

Part 2 of a 3-part series

Cheryl Toksoz 21 August 2018

In the beginning, there was performance-based funding. It was the outcomes-based mechanism of choice for the Global Fund and forms the foundation on which the Global Fund’s grant architecture was built. The idea was simple. Release funding in tranches, whereby recipients were required to reach specific targets before the rest of the grant would be disbursed. That focus on results, which has been baked into the Global Fund process, is a primary driver of its success.

In recent years, a variety of innovative financing tools, including results-based financing, have surfaced to help channel resources to achieve greater social outcomes. Perhaps the most prominent example of this movement is the emergence of social and development impact bonds (SIBs and DIBs) that seek to mobilize private sector capital to fund proven social programs, with a promise to be paid back by the government if these programs successfully achieve desired social outcomes.

Impact bonds are one area that the Global Fund is exploring in its efforts to expand its work in innovative finance. It currently has projects in the very early stages of development in South Africa and Fiji and the organization hopes to be able to offer it as part of the toolkit it is creating to support its innovative finance program.

“The instrument, in terms of use in development, is still relatively new,” said John Fairhurst, the Global Fund’s Head of Private Sector.  “Like others, we are very much building the sense of where these approaches can add the most value.”

Impact bonds: How they work

In an impact bond, private investors provide upfront capital to service providers to deliver an intervention or program to a population in need. Upon the achievement of a set of agreed-upon results, the investors are then repaid by an outcome funder; in a SIB, the outcome funder is the government, while in a DIB, outcomes are financed by a third-party organization, such as a foundation or donor. In South Africa and Fiji, the Global Fund is supporting the design phase of setting up the impact bond.  And although the Global Fund’s role would change depending on the project and country context, Fairhurst said that it is unlikely the Global Fund would be an investor or guarantor in an impact bond project. Sponsoring design and being an outcome funder are two possible roles for the organization.

 Projects funded by SIBs or DIBs are subject to frequent performance reviews by the outcome funders and the risk capital providers. Although course corrections can be made as activities

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are performed, there is a possibility that outcome funds may not be paid if targets are not achieved. This does not mean the activities are not performed as these are funded by the risk funders.  When these instruments are well-designed, then outcomes would be paid through the life of the project as it progresses—not just at the end.  One benefit of this approach for the Global Fund is that it will get earlier warning of off-track performance through the outcome funding. 

In January, the Brookings Institution reported that six impact bonds have been contracted in low- and middle-income countries and that another 24 were either in early or late stage design. Across the impact bonds both contracted and in design, health is the most predominant sector, with 11.

Probably the most well-known impact bond is the Educate Girls DIB, where a multinational bank gave a girls’ education non-profit in India enough funds to scale their program to three new villages. Under the contract, a large education philanthropy will pay back the initial investment plus interest after three years based on the number of girls who have been enrolled in school and their learning gains. Second-year results from the DIB show enrollment at 88 percent of the target and learning progress at 50 percent of the target with another year of intervention to go.

Although these results are promising, impact bonds are not the easiest instruments to put in place. They demand a considerable time commitment and a steep learning curve from those engaged in the contracting process. And since they are relatively new and involve a wide variety of actors, some consider impact bonds to be too slow or unwieldy for the relatively small sizes of the investments to date. In fact, Fairhurst says that the design stage alone can take nine to 12 months. However, it is the most important part of the process as it is when core elements of the impact bond are clarified, including the definition of outcomes, their costing, and the legal structure that will be used.

Betting success on a note

Another instrument that the Global Fund is exploring is the use of the Social Success Note (SSN), an innovative pay-for-success financing mechanism that addresses the investment gap for small- and medium-sized social businesses. Created by the Rockefeller Foundation and Yunus Social Business, the first SSN pilot was launched in April.

SSNs are very similar to impact bonds, but are designed to help social businesses access scale capital while not being diverted from their social mission by the need to meet burdensome investor demands for returns. There are, however, a few differences between impact bonds and the SSN model, under which, for example, outcome payers are only responsible for paying a return based on performance; they do not have to cover the original investment, making it more attractive to potential outcome payers. The SSN also has a simpler structure than an impact bond to reduce transaction costs and time. In addition, complex impact metrics are avoided in favor of simple key performance indicators.

In the SSN pilot, the UBS Optimus Foundation is providing a $500,000 loan to Impact Water, a social enterprise, to expand its work installing low-cost UV-based water purification systems in schools across Uganda. Schools pay approximately $1,000 to Impact Water to install the system.

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Impact Water will pay back the loan after five years and the rate of interest will go down if certain outcomes are achieved. If Impact Water achieves the agreed-upon targets, the Rockefeller Foundation will pay up to $200,000 to both pay off some of Impact Water’s interest and pay UBS a performance-based return on its investment. 

Although time-consuming and a bit cumbersome, Fairhurst believes innovative instruments like impact bonds and SSNs are an exciting area for the Global Fund and may provide the organization with flexibility to use its resources in a variety of ways. “We think it has real potential in some key areas, such as where it can de-risk innovation for the public sector, create new forms of contracting mechanisms, or where there is a misalignment of incentives in a diverse group of stakeholders—such as around regional and cross-border issues.”

The Global Fund is reviewing a number of innovative finance approaches that could help it to achieve greater impact.

- The first article in this series in GFO 339 described the background and rationale for the change in policy and discusses the pros and cons of development cooperation mechanisms, such as debt swaps and blended finance.

- In the final article in this series, the Global Fund Observer will describe innovation and cost-reduction incentive mechanisms, and discuss the pros and cons of instruments, such as challenge funds and prizes, advance market commitments and seed funding.

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5. COMMENTARY: International AIDS Economics Network meeting in Amsterdam focuses on sustainability of global response to HIV

Experts look at economic tools to get ‘best bang for the buck’

Alan Whiteside 21 August 2018

The International AIDS Economics Network (IAEN) held a two-day pre-conference in Amsterdam on 20th and 21st July, ahead of the 22nd International AIDS Conference. The theme was ‘Sustainable AIDS Response Results in the Era of Shrinking Donor Funding’. This was timely given the context of shrinking international funding for development assistance for health (DAH), and specifically, the HIV and AIDS epidemic. The meeting would not have been possible without support from a number of donors and the very hard work of the steering group, ably led by Dr Steven Forsythe of Avenir Health.

The topics included funding trends, costing, costs and cost-effectiveness, sustainability, and the economics of HIV testing. This meeting is important as it assumes that AIDS funding needs advocacy, and one way to obtain it is to show that it makes sense to spend resources here. At the same time, participants recognized these resources are finite and so looked at economic tools to get the ‘best bang for the buck’. They include modelling and cost-benefit and cost-effectiveness analyses. 

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The importance of the topic was indicated by the keynote speakers the meeting was able to draw for the opening. Ambassador Deborah Birx, U.S. Global AIDS Coordinator and U.S. Special Representative for Global Health Diplomacy, and Mark Dybul, Georgetown University Medical Center, and former head of the Global Fund, spoke on the first day.

All the presentations were interesting and had varying levels of technicality. Some big questions were raised. Health economist Charles Birungi asked, “Long-term liabilities of HIV financing = debt sentence? The fiscal impact of HIV in Uganda”. As we saw in the rest of the AIDS 2018 conference, the current best practice is to treat people as early as possible once they have tested HIV-positive and ensure they adhere to antiretroviral treatment. Barring significant scientific advances, an 18-year- old in Malawi could require drugs for 40 years or more. This has a cost, and the person receiving the treatment may not be able to afford it.A deeply interesting presentation by Gavin George of the Health Economics and HIV/AIDS Research Division of the University of KwaZulu-Natal entitled “An examination of men’s wealth- and age-disparate partnerships in South Africa: A nationally representative cross-sectional survey” addressed the ‘sugar daddy’ syndrome. George used data from the National HIV Communication Survey of South Africa to assess this. He concluded:

Comparatively wealthier men in both urban and rural areas are no more likely to en-gage in age-disparate partnering than poor men.

Whiles age-disparate relationships are characterized by transactional sex, the relation-ships are not the sole domain of wealthier men.

HIV prevention messaging highlighting the risk posed by the economically advan-taged ‘sugar daddy’ may not be accurately representing the risk posed by older men across the economic spectrum.

This is not to say ‘transactional sex’ is not a driver of HIV, but rather that sugar daddy/sugar baby relationships may be over-emphasized. It feeds into another question that, to my mind, has never been properly answered. Where in poverty-stricken communities does the money for the ‘sugar’ come from?Annie Haakenstad of Harvard’s TH Chan School of Public Health illustrated the dependence of many countries on DAH. She concluded, “Some countries may be able to spend substantially more of their domestic resources on HIV/AIDS relative to current spending. Some of the countries with the highest burden of HIV/AIDS and the most dependence on DAH may not be able to spend much more, however.” The question that arises from this is: which can, which can’t, and what should the global response be? As suggested elsewhere in the GFO, in an article discussing the ‘Risky Middle’ category of countries, this is both a political economy issue and a human rights issue.

Writing in the International Health Policies Newsletter on the meeting, Mit Phillips of Médecins Sans Frontières noted “Excellent presentations on political economy … However, the difficult choices that would be in real life the consequence of such theoretic modelling and investment comparisons were rarely touched upon, and nobody questioned the shrinking international and overall funding as a given. Some people were perhaps happy that sustainability was finally taking centre stage again, after 20 years of ignoring the reality of poor countries and weak health systems” (click here for more on this).    

Economists are going to be increasingly important in the response to HIV and AIDS. Decisions made on a technical basis may not be popular. The reality is that as international funding decreases, this will evermore be how the world operates.

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PowerPoint presentations from this pre-conference will soon be available on the International AIDS Economics Network website at www.iaen.org. 

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6. ANALYSIS: Domestic financial contributions to HIV, tuberculosis and malaria responses remain low

Global Fund’s high impact African countries still depend mostly on donor funds

Ann Ithibu

A new analysis conducted by Aidspan shows that domestic contributions by low- and lower-middle income countries to their HIV, TB and malaria responses accounted for 16% for HIV, 36% for TB, and 36% for malaria, for the 2015-2017 period. Countries will experience huge gaps in funding for the 2018-2020 period unless domestic and international commitments increase.

The analysis, which aimed to assess the domestic contributions to the health sector and to the three disease programs, focused on 13 ‘high-impact’ African countries, as classified by the Global Fund.

High Impact Africa 1 countries: Cote d'Ivoire, Democratic Republic of Congo (DRC), Ghana, Nigeria, South Africa, and Sudan

High impact Africa 2 countries: Ethiopia, Kenya, Mozambique, Uganda, Tanzania, Zambia and Zimbabwe

The countries each have a high burden of one, two or all of the three diseases. Investments in these 13 countries account for nearly half of the Global Fund investments for the 2017-2019 funding cycle. Countries are a mix of low, lower-middle and upper-middle income countries, as classified by the World Bank.

Data for this analysis came from three databases – the World Health Organization (WHO), the World Bank, and the Global Fund - as well as from grant application documents, particularly the funding landscape submitted to the Global Fund by the sampled countries.

The funding landscape reports disease-specific expenditures for the period 2015-2017, total funding needs, and anticipated funding for 2018-2020. Funding landscapes information was available for 11 of the 13 countries, except for Ghana and South Africa. In fact, obtaining data for this analysis was difficult and for some segments of the analysis, some countries were dropped because of incomplete data.

Three main sources of funding for health expenditure

Funds for national health expenditures come from three main sources: general government revenues, external sources (via governments or NGOs), and households (out-of-pocket payments, or OOP).

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Governments that prioritize the health sector are more likely to allocate more resources to it. Prioritization is reflected in the proportion of the general government expenditure directed towards the health sector. The 13 countries spent an average of 7.4% of government expenditure on health. The proportion ranged from 1.22% in Mozambique to 18.1% in Sudan. Thus, all but one – Sudan – failed to meet the minimum target of 15% agreed on by the African Union Heads of States in the Abuja Declaration.

The WHO separates health expenditures into ‘current’ (e.g. expenditures for remuneration of personnel, rent payment, purchase of medications, reagents, and other health commodities) and ‘capital’ (e.g. funds for building construction, equipment).

In our sample, the proportion of current health expenditures funded by government revenues ranged from 8% in Mozambique to 54% in South Africa in 2015. In contrast, funding from external sources was highest in Mozambique (85%) then Uganda (40%) and lowest in South Africa (2%) and Sudan (2%). It is clear that external funding remains vital to the health sector in most low-income countries.

The third source of health funding, OOP expenditures, was extremely high in Nigeria (72%) and Sudan (63%), far more than the global average (18.1%) and sub-Saharan average (36.25%), in 2017. High OOP payments acted as barriers to access to health services and are often associated with catastrophic and impoverishing spending.

Cote d

’Ivoire DRC

Ethiopia

Ghana

Kenya

Moza

mbiq

ue

Nigeria

South A

frica

Sudan

Tanzania

Uganda

Zambia

Zimbabwe

36 37 38 36 337

72

8

63

2641 28 26

26 39 15 26 19 85

10

2

2

37

40

2424

22 1627 35 33

8 17

54

31 3513

37 21

Health financing, by source (%) (2017)

Out-of-pocket expenditure as % of CHE

External health expenditure as % of CHE

Domestic general government health expenditure % of CHE

Figure 1: Health financing by source (2017) (CHE: Current health expenditure)

Sources of funding for HIV

About $8.2 billion was available to finance the HIV national strategic plans from all sources in the 2015-2017 period, based on data reported by nine countries; Uganda, and Nigeria did not have available data so are excluded from this analysis. Of this amount, only $1.3 billion, about 16%, came from domestic sources. This average percentage conceals wide discrepancies: Mozambique covered 3% domestically, both DRC and Zimbabwe 4%, while Sudan reported the highest domestic contribution at 23% of their total HIV funding.

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The Global Fund accounted for 24% of the total funding for HIV while other donors together accounted for 60%. Global Fund contributions to HIV expenditures were highest in Sudan (68%) and lowest in Zambia (15%). In eight of these countries excluding Sudan, these lower Global Fund proportions may be related to the presence of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), one of the largest sources of HIV financing alongside the Global Fund.

DRC Cote d'Ivoire Ethiopia Kenya Mozambique Sudan Tanzania Zambia Zimbabwe 4% 11% 7%

48%

3%

23%11% 12%

4%

71%72%

63%

34%

72%

9%

73% 73%

48%

25%17%

30%18% 25%

68%

16% 15%

48%

HIV funding, by source (%) (2015-2017)

Domestic resources External resources (excluding Global Fund)

Global Fund resources

Figure 2: Sources of HIV funding for the period 2015-2017

Note:1. Uganda did not report funding from the Global Fund hence was excluded from this

analysis2. By the time of this analysis, the Board was yet to approve Nigeria’s TB/HIV funding

request (see GFO article)3. Kenya did not report funding from external sources for 2015 and 2016.

Sources of funding for TB

Approximately $385 million was available from all sources to finance the TB national strategic plans for the 2015-2017 period, based on data reported by six countries: Cote d'Ivoire, DRC, Kenya, Mozambique, Sudan and Zimbabwe. Of this amount, $137 million (36%) was from domestic resources. Domestic contributions, as a percentage of the total funding, were lowest in DRC (0%) and highest in Zimbabwe (53%). The Global Fund was the single largest source of TB funding for these six countries and accounted for 48% of the available funding. Global Fund’s contributions ranged from 33% in Zimbabwe to 88% in DRC.

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DRC Cote d'Ivoire Kenya Mozambique Sudan Zimbabwe 0%

35% 43%

9%

37%53%

12%

2%

21%

34%

0%

14%88%

63%

36%

57% 63%

33%

TB funding, by source (%) (2015-2017)

Domestic resources External resources (excluding Global Fund)

Global Fund resources

Figure 3: Sources of TB funding for the 2015-2017 period

Note: 1. Ethiopia, Uganda, Tanzania and Zambia did not report Global Fund spending for the

2015-2017 period and therefore were excluded from this analysis.

Sources of funding for Malaria

Based on data reported by seven countries, excluding DRC, Ethiopia, Mozambique and Zambia, $3.6 billion was available for malaria in the same time period. Of this total amount, $1.3 billion (36%) was from domestic resources. However, this amount is strongly influenced by Nigeria which accounts for 70% of the total domestic resources for malaria. Domestic contributions were below 10% in four of the seven countries – Kenya (4%), Zimbabwe (4%), Uganda (6%) and Tanzania (7%) – and above 40% in the remaining countries – Sudan (43%), Cote d'Ivoire (45%) and Nigeria (52%). Global Fund contributions ranged from 26% (Kenya) to 58% (Zimbabwe).

Cote d'Ivoire Kenya Nigeria Tanzania Uganda Sudan Zimbabwe

45%

4%

52%

7% 6%

43%

4%

0%

54%

12%

38% 47%

2%

38%

55%41% 35%

55% 47% 55% 58%

Malaria funding, by source (%) (2015-2017)

Domestic resources External resources (excluding Global Fund)

Global Fund resources

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Figure 4: Sources of malaria funding for the 2015-2017 period

Note:1. DRC did not report any data for the period 2015-20182. Ethiopia, Mozambique and Zambia did not report Global Fund spending and were

excluded from the analysis

Large funding gaps expected in the 2018-2020 period

The sampled countries will require in total $15 billion, $1 billion and $6 billion for the 2018-2020 period to fully fund the HIV, TB and malaria national strategic plans, respectively (see Table 1, below).

Estimated available funding from all sources – domestic and international – reported by the countries, amounts to $11 billion (HIV), $708 million (TB) and $3 billion (malaria) creating a funding gap of 24% (HIV), 49% (TB) and 44% (malaria). Figure 5 shows HIV resource availability and total resource needs for individual countries. Increased domestic and international donors commitments are required to close the funding gaps.

Table 1: Funding needs and availability for the 2018-2020 period

Disease component

Total funding needs for the strategic plan

Total anticipated resources (including Global Fund)

Funding gap

$ %HIV (n=10)1

15,273,732,460 11,554,366,788 3,592,839,967 24%

TB (n=10)2 1,390,247,055 708,224,7173 682,022,338 49%Malaria (n=10)4

6,271,467,727 3,037,578,04715 45,655,571 44%

Note: For grants denominated in euros, a conversion rate of 1 euro = 1.1675 US dollars was used.

Note:1 2 Nigeria excluded from analysis: HIV and TB funding landscape not yet available3 Global Fund allocations for Ethiopia missing4 DRC excluded from analysis; they did not report any data for the period 2015-20185 Global Fund allocations for Tanzania and Zambia missing

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Cote d'Ivoire DRC Ethiopia Kenya Mozambique Sudan Tanzania Uganda Zambia Zimbabwe0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

536 619 666

2,869

1,348

28

1,6701,711

9531,1361,054

839 890

3,707

1,401

29

1,882

2,490

1,447 1,535

Domestic resources External resources (non-Global Fund)

Global Fund resources Total funding needs

US$

(m

illi

ons)

Figure 5: HIV resource availability and total funding needs for the period 2018-2020

Domestic contributions remain largely unchanged in the current allocation period (2018-2020) when compared to the previous (2015-2017). Of the total estimated available funding for the period 2018-2020, domestic contributions account for 16% (vs. 8% for 2015-2017) for HIV, 26% (vs. 32%) for TB and 39% (vs. 37%) for malaria. Proportions may change as more funding becomes available.

Table 2: Comparison of sources of funding for the 2015-2017 and 2018-2020 period

Sources of funding

Disease component 2015-2017 2018-2020

HIV Domestic resources 16% 16%External resources (excluding Global Fund)

60% 65%

Global Fund resources

24% 18%

TB Domestic resources 36% 26%External resources (excluding Global Fund)

16% 34%

Global Fund resources

48% 40%

Malaria Domestic resources 36% 39%External resources (excluding Global Fund)

26% 25%

Global Fund resources

38% 36%

Conclusion

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Significant funding gaps are expected in the 2018-2020 period if domestic and international resources remain at their current levels. International sources such as the Global Fund are less likely to fill these gaps; in fact, international assistance is on the decline – HIV assistance diminished by more than 20% between 2013 and 2016 according to the International AIDS Society-Lancet commission (see GFO 339’s article on Peter Sands’ call for more funding from implementing countries).

The onus, therefore, is on the implementing countries to increase their share of funding their disease responses. Countries can raise additional health financing by increasing tax revenues, budgetary reallocation (from low-priority expenditures) and debt relief (which frees up additional domestic resources that can be invested in health). All these depend on political will, hence the need for increased advocacy at the country and regional levels (such as through the African Union). Countries also need to ensure that available resources are utilised optimally, including using savings from increased efficiencies to help reduce the gaps.

Author’s note: - Tracking financing to HIV, TB and malaria programs is difficult due to the lack of

accurate, complete and timely data available. Countries have taken strides to improve the quality of health financing data, such as the NHAs and disease-specific efforts such as the NASAs. More needs to be done to improve the frequency and outputs of these existing tools. Accurate and timely data is necessary to monitor and track health financing and its efficiency.

- The funding landscape documents are part of a downloadable package of grant application (funding request) documents available on the Global Fund website. To access the documents, visit the Global Fund website at https://www.theglobalfund.org/en/. Under the ‘Where We invest’ page, click on the country of interest to access the individual country pages. The application documents are available at the bottom of the Country Overview page.

Aidspan will publish a follow-up GFO article in September 2018 assessing how implementing countries intend to address these funding gaps for the 2018-2020 period and beyond.

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7. NEWS: Global Fund grant to Ukraine finds treatment success for multidrug-resistant TB with two-pronged approach

Combining social and medical support achieves better treatment outcomes

Ivan Varentsov 22 August 2018

According to the WHO, Ukraine remains a country with a high TB burden, and in 2014 it became one of the five countries with the highest burdens of multidrug-resistant tuberculosis (MDR TB) in the world. The TB epidemic in Ukraine is marked by the spread of multidrug-resistant and extensively drug-resistant tuberculosis (XDR TB), relatively high MDR TB

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mortality and one of the lowest TB treatment success rates in the region of Eastern Europe and Central Asia – 72% in new TB cases and 38,6% in patients with MDR TB (WHO, 2016). Currently the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) is supporting the implementation of programs to fight tuberculosis in Ukraine within a new country HIV/TB grant for 2018-2020, as well as through catalytic funding. The current program, which started this year, is being based on the previous three-year project, “Investing for Impact against Tuberculosis and HIV”, which had been implemented in Ukraine in 2015-2017 and was completed, with success, at the end of last year.

One of the three key implementers of this project was the Alliance for Public Health (the Alliance), which was responsible for a number of program components, in particular for providing medical and social support to ensure adherence to MDR-TB treatment. Implementation of this latter component achieved high success rates (up to 80%).

Key success factors and outcomes

One of the key factors contributing to the success of this project component was the use of the DOTS approach (Directly Observed Treatment Short-course) in combination with social support for patients, which included the delivery of psychosocial services and training in treatment adherence. This project was implemented in all regions of the Ukraine and performed strongly in all of them.

Apart from the Alliance, other partners involved in implementation included the Public Health Center of the Ministry of Health of Ukraine and the Ukrainian Red Cross Society. The Red Cross Society, which has a wide network of branches covering all the regions of Ukraine, and also has the required number of visiting nurses, was responsible for the DOTS and social support components of the project.

Before patients were released from hospitals, they were asked if they would like to be involved in the project at the outpatient stage of treatment. If the person agreed, information about the patient was given to a relevant branch of the Red Cross Society, where a supervisor was assigned to receive that patient’s TB drugs, attending to the patient daily. If the patient did not miss any doses, he would receive food parcels twice a month.

The efforts of the Alliance and its partners to provide medical and social support to patients and establish their adherence to MDR TB treatment within this project continued the work that had been started in 2013 with the implementation of the previous Global Fund TB grant from Round 9. In 2013, just over 100 patients were enrolled in the support program.

Treatment success rates were very high, at 86%, while the treatment success rate for patients with similar conditions who also received treatment within the Global Fund project but were not covered with DOTS or by social support from the Red Cross, was 44% (according to the Alliance).

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'Figure 1: Multidrug-resistant tuberculosis treatment outcomes in Ukraine are significantly improved due to people oriented approaches'. 

Source: Analytical statistics guide "Tuberculosis in Ukraine", 2016. Official website of the SI "Public Health Center of the MoH of Ukraine".

According to one staff member from the Alliance, one of the reasons for such high treatment success rates was the approach the program used to select patients: at first patients for whom good treatment outcomes were expected were enrolled in the program – ‘treatment-naïve’ patients, patients with repeated TB cases (if the previous TB case was cured) and patients whose first treatment courses had failed. Further, starting from 2014, all patients eligible for the treatment regimens procured within the Global Fund project were enrolled in treatment. After 2015, the patients who received treatment within the state budget were also enrolled in the program.

In 2014, the treatment success rate for the 500 patients covered by the project was 79%, and in 2015 it was 75%. The target for patient coverage in the three years from 2015 to 2017 was 9,300 patients, and was overachieved – the actual number of patients with MDR TB covered by the program was 9,420. (Treatment success rates for the patients enrolled in 2016 will be available later in 2018.

According to Eugenia Geliukh, the program’s project manager, the program can be credited with improving the overall MDR-TB treatment success rates in the country: In 2012 it was 34%, in 2013 it was 39%, and in 2014, 46% (WHO Tuberculosis country profile).

Ensuring sustainability of the TB response in Ukraine

“In three years, we fully piloted the DOTS model combined with social support of the patients and proved the efficiency of this project in Ukraine,” says Andrey Klepikov, Executive Director of the Alliance for Public Health. “Our main message to the government is to make sure that, considering the existing evidence base and taking into account the ongoing processes of transition of TB programs from Global Fund support to domestic funding, this component will also be taken over by the state.” Klepikov suggested that

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treatment success rates would be halved if, after the withdrawal of Global Fund support, the government supported only drug procurement, without the social support component.

This aspect is crucial as in recent years there has been a rapid transition of the TB response to domestic funding. Until 2017, procurement of half of the second-line drugs to treat multidrug-resistant forms of TB in the country was covered by the Global Fund; starting in 2018, the government took over the procurement of all TB and MDR-TB drugs. Moreover, it is planned that by the end of 2018, 90% of XDR-TB treatment will be covered by domestic funds. The remaining 10% will be procured by the Alliance within Global Fund programming (133 schemes with delamanid).

0

10

20

30

40

50

60

70

80

90

100

Transition plan to the state budget, %Proportion of TB drugs procured for state budget and GF/APH fund-

ing in 2015-2017 and 2018

Susceptable TB MDR-TB XDR-TB

State budget GF funding/Alliance State budget GF funding/Alliance 2015-2017 2018

'Figure 2: Transition plan to the state budget, %  Proportion of TB drugs procured for state budget and GF/APH funding in 2015-2017 and 2018'.  

Source: Alliance for Public Health

So far, the equipment for rapid TB diagnostics, supplies and reagents are mainly procured with financial support from the Global Fund and other donors. According to the new Global Fund grant agreement, to implement the 2018-2020 HIV/TB project, every year the procurement of equipment will incrementally be covered from the state budget. Currently, a National TB Program concept has been approved in Ukraine, and it is expected that this year the Parliament will approve the National TB Program for 2018–2021.

Within the new grant, in 2018, support for patients who receive treatment will remain the responsibility of Alliance, in eight regions of the country, with no Red Cross Society involvement. However, it is planned that the social component will also gradually be taken over by the government. In 2018, it is projected that social support for 20% of patients receiving support from NGOs will shift to the Ministry of Ukraine’s Public Health Center. Financial support for this activity will still come from the Global Fund, and the Alliance provides technical support to the PHC within this component. Starting from 2019, 50% of

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patients will receive support from within the state budget and in 2020, it is expected that 80% of the patients will receive support from the state.

TB treatment approach based on results-based financing model

The Alliance also has implemented a pilot MDR-TB treatment project using a results-based financing (RBF) model. In 2017, the Alliance applied this approach when implementing opioid substitution treatment programs in the Odessa region, within the same Global Fund grant, and decided to adapt it to TB treatment based on the DOTS model. The main goal of the project was to reduce treatment costs per patient per year, and to hand over the implementation of DOTS and social support for TB patients to the primary-care level of the state healthcare system.

“Involvement of the Red Cross Society or other NGOs in DOTS implementation is an interim solution,” says Eugenia Geliukh. “Such projects can be implemented only as long as donors support them. As soon as donors stop financing those activities, NGOs will not be able to continue them at their own expense. At the same time, delivery of treatment services through primary healthcare centers (PHCCs) is in line with the concept of the healthcare reform which is currently going on in Ukraine.”

Within the project, Alliance signed contracts with 14 PHCCs in the Odessa region to implement DOTS and provide social support to patients receiving treatment. The specific mode of providing DOTS services was defined by each PHCC.

Within the pilot project using the RBF model the cost of treating one MDR TB patient for one year was UAH 9,000 (compared to UAH 13,000 for the Alliance project) with the same outcomes. Treatment success rates for the MDR TB patients are not yet available as they have not yet completed their treatment. But for the patients with drug-susceptible TB, the average treatment success rate was 93%, compared to the 35–40% registered in some Odessa region districts before the pilot project implementation started.

This project was not included in the new program supported by the Global Fund for 2018–2020. Moreover, within the new program the government made a decision to go back to DOTS provision by NGOs and not by state-run primary healthcare institutions. But the city of Odessa became interested in the pilot project’s results. The annual budget of UAH 2,2 million (which is equivalent to $85,000) is allocated within the Odessa city HIV/TB program for 2019–2020, to cover up to 700 people with DOTS through primary healthcare centers. In 2019 half of these funds are expected to be covered by the city budget, and in 2020, 100%.

“In the end, the results-based financing model has been accepted and supported with municipal funding,” said Andrey Klepikov, executive director of the Alliance for Public Health. “It is a great victory for ensuring sustainability and transition. And civil society will remain one of the key players in our national TB response, becoming more and more recognized by the Ukrainian government.”

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8. ANNOUNCEMENT: Aidspan’s Board: a new member, a new Chair, and a farewell

Adèle Sulcas 22 August 2018

Aidspan’s Board of Directors held its most recent biannual board meeting in Amsterdam, at the start of AIDS 2018, the IAS international AIDS conference in late July. The Aidspan Board undertook three changes to its composition at, and shortly after, the board meeting.

Joining the Board is Dr Jesse Boardman Bump, executive director of the Takemi Program in International Health and lecturer on global health policy at the Harvard T.H. Chan School of Public Health. Dr Bump leads the global health field of study in the Master of Public Health degree. He brings extensive experience and interest in the development of health systems and the implications for development assistance, as well as a focus on advancing health for people in low- and middle-income countries, while helping their governments understand and manage the complex political economy of donor policies.

“Accountability and transparency are fundamental to equitable and effective development cooperation,” Dr Bump told Aidspan. “Aidspan’s reporting and analyses uphold these principles when agencies cannot or will not.” Dr Bump’s own research examines the historical, political, and economic forces that are among the fundamental determinants of ill health. His work also addresses the most significant contextual factors that shape institutions and the approaches they embrace.

Isaac Awuondo, who has been an Aidspan Board member for more than four years, was elected as Aidspan’s Board Chair.Mr Awuondo is the Group Managing Director of Commercial Bank of Africa (CBA Group), the largest privately held commercial bank in Kenya with a regional focus, also operating in Tanzania, Uganda, Rwanda and Ivory Coast. Mr Awuondo sits on the Boards of several public and private organizations, including as Chair of the Kenyan Airports Authority, as a Board member of WWF Kenya, and as Trustee of the Zawadi Africa Education Fund, an educational charity supporting disadvantaged girls in four African countries.

Finally, longtime Board member Dr James Deutsch, the Director for Biodiversity at Paul G. Allen Philanthropies, has stepped down from the Board. Dr Deutsch joined the Board when Aidspan was created in 2002, under the leadership of Bernard Rivers, and leaves after 16 years of service and support to Aidspan to pursue other interests.

Aidspan’s Executive Director Ida Hakizinka said, “We are of course sad to see James go but appreciate his long and dedicated years of service to Aidspan. We are also delighted to welcome Dr Jesse Boardman Bump, who brings to Aidspan wide-ranging public-health expertise and a strong commitment to improving the health and health systems of developing countries. And we are honored to have Isaac as our new Board Chair, with his extensive financial and governance experience. Aidspan extends a heartfelt thanks to each of these three exceptional individuals.”

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Aidspan’s Board comprises Professor Alan Whiteside, a health economist; Dr Djalo Mele, President of the Country Coordinating Mechanism in Niger, and Aidspan Executive Director Ida Hakizinka, in addition to Dr Bump and Mr Awuondo.

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________________________________________________________________

This is issue #340 of the GLOBAL FUND OBSERVER (GFO) Newsletter. Please send all suggestions for news items, commentaries or any other feedback to the GFO Acting Editor at adele.sulcas@aidspan.org. To subscribe to GFO, go to www.aidspan.org.

GFO Newsletter is a free and independent source of news, analysis and commentary about the Global Fund to Fight AIDS, TB and Malaria (www.theglobalfund.org).

Aidspan (www.aidspan.org) is a Kenya-based international NGO that serves as an independent watchdog of the Global Fund, aiming to benefit all countries wishing to obtain and make effective use of Global Fund resources. Aidspan finances its work through grants from foundations and bilateral donors. Aidspan does not accept Global Fund money, perform paid consulting work, or charge for any of its products. The Board and staff of the Fund have no influence on, and bear no responsibility for, the content of GFO or of any other Aidspan publication.

GFO Newsletter is now available in English and French. The French-language edition becomes available within one week after the publication of the English edition.

GFO Acting Editor: Adèle Sulcas (adele.sulcas@aidspan.org). Aidspan Executive Director: Ida Hakizinka (ida.hakizinka@aidspan.org).

Reproduction of articles in the Newsletter is permitted if the following is stated: "Reproduced from the Global Fund Observer Newsletter, a service of Aidspan."

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