Lessons Learned in Lilongwe: A Very personal set of reflections
It has felt like since the last Replenishment wrapped up in September of 2022, the Global Fund community has been girding its loins for the next Replenishment; the hardest one yet.
That’s something we’ve heard before and been able to still find ways to find the right messages in time. At times, we have found unlikely or unexpected champions to build political will. Even faced with insanely impossible to plan for confluence of events (war in Europe, royal funeral, a global pandemic), we’ve been able to find the best possible outcome. But what we face this time is unique – we face a funding crisis when there’s no economic crisis.
There’s no global economic downturn forecasted. There’s no G7 country in recession. The fiscal crises in implementing countries are real, driven by combinations of foreign exchange challenges and debt. While the fiscal crises in donor countries are also very real, shaped by domestic cost-of-living pressures and external threats that demand strong responses, they are largely an issue of choices.
The choice to fund refugee and migrant issues at home via already strained and historically small Official Development Assistance Budgets. The choice to spend less and less on international development compared to growing GDPs. Obviously, country contexts are more complex than that, but it is, ultimately important to remember – and remind governments – that the stagnating health and ODA budgets are a choice and not some intractable and unknowable force pushing good people to make difficult decisions.
At this Global Fund Board Meeting the focus was on decision points related to the policies that would enable programming after the next Replenishment. Yet, like pretty much every other Board meeting I have attended since the last Replenishment, it felt at times, and particularly in the lead-up to it, like a meeting of the Pessimists Club. Pretty much every person at the table said at least once something like: “We have to use innovation to drive efficiencies so we can do more with less, there will be some difficult trade-offs, and we have to be realistic.”
European colleagues were ringing alarm bells loudly about the cost of living and fiscal crisis – and were worried that nobody is hearing them say that this is a real problem and challenge to the Replenishment. American colleagues are trying to rise to the challenge presented by the recent election, with ideas on how to manoeuvre around what will be difficult political leadership in the White House. They also have to say goodbye to their colleagues on the Board, who, knowing the system of political appointments in the US, know they are likely attending their last Board Meeting. Countries who have been strong supporters are facing elections, the consequences of which could still take several very different paths with few certainties. Others believe the way to solve the Global Fund’s problems is to use the money they contribute to buy products made in their countries.
All this matters because the reasons this Replenishment will be the hardest one yet are quite different: we have enjoyed a certain level of political solidarity over the past 20+ years history of the Global Fund. Our world and resources have been growing with successively higher Replenishments. What we face now is low (or at least lower) levels of political solidarity and a desire to adjust the global health architecture in some way that means different things to each person and yet they use the same words as if the solutions were simple (can you say “Lusaka Agenda”).
It’s no longer that the impact of the Global Fund isn’t understood in most capital cities: it is. It’s not that those who sit at its Board aren’t keen allies: they are. It’s not that there aren’t allies to communities and civil society on the Board – there are, many. In fact, most happily trip over themselves to align with either or all the Communities and NGO delegations on issues at the Board table. Although I would point out that some ask for more focus on CSO and Communities when talking human rights or about key and vulnerable populations (KVPs), or when discussing transition, but when discussing allocation, still support a comparatively anemic set of Catalytic Investments at the lowest funding scenario.
And it’s not just money: it’s also the system. Donors don’t really want to hear about the impact of their dollars invested in the Global Fund – we and the Global Fund Secretariat have done a VERY good job of that. Parliaments and MPs know the impact of the Fund across party lines and officials can see us coming a mile away. However, what they do want to hear more and see more of is how the Global Fund is “driving innovation and efficiencies”, how it is collaborating with other actors in the Global Health architecture (other multilaterals closely connected like Gavi, but also bilateral and other global actors like the World Bank for e.g.). In other words, they want reasons to spend less dollars, not reasons to save more lives.
Significant changes were approved at the Board Meeting last week in Malawi. The Communities and the two NGO delegations sought assurances and clarity again and again on how to ensure support for KVPs in countries transitioning out of the Global Fund, with clear calls for direct funding to CSOs and CBOs. Our Board Members and Alternates all walked in the first day of meetings in doctors’ white coats that had been decorated by Malawian CSOs reminding the room that Communities are Experts. The decisions (which you can read more about when we finish our full Board Meeting report) did increase the share of funding going to malaria and TB, with important caveats: only if we raise a significant amount of money above and beyond what is considered the duty of care and the cost of continuing to provide essential HIV services. This is to reflect the reality that HIV is chronic, and that keeping people alive will require life-long medical interventions.
These board discussions show the ways in which the Global Fund continues to evolve, continues to change to meet the challenges of the moment. Equally important, it is, with its complex but comprehensive mechanisms, often at the forefront of transformative change. It is imperfect, yet a respected thought leader both in process and actions – particularly as it relates to championing the meaningful inclusion of communities and CSOs – that many other actors within the Global Health architecture should aspire to.
There is opportunity in how we approach this replenishment and the next few years. There are possibilities in terms of the work that a fully funded Global Fund can do, as part of the broader partnership it works within. In malaria we face stark challenges – and yet, as a partnership in the past we have met them with more nets, more treatment and more lives saved. It’s unclear if the fight can be won by more of the same, but it’s clear that more of the same is saving more lives. With TB, shorter treatments and the possibility of new vaccines beg for the highest level of investment and collaboration between governments and global institutions. And in HIV, we need to see faster guidelines and procurement for diagnostics and therapeutics for co-infections such as Female Genital Schistosomiasis (something we heard a lot about in Malawi as the burden there is high). We also need real vertical transmission elimination. And we need to convene global health actors like Unitaid, the Medicines Patent Pool and the Global Fund to be ready to provide Lenacapavir – the new twice yearly injectable PrEP option, whose early studies showed incredible, almost vaccine-like, results.
Simply put: our systems must be funded and ready to bend the curve as we near 2030.
The Global Fund is by no means the only or even necessarily the most important actor in any of those diseases in every place they persist. Yet, there is opportunity in how we talk about the work of the Global Fund this replenishment and over the coming years. There is no doubt that multilateral health institutions have helped to bend the curve against all three diseases, to differing degrees and at different times, precisely because it has sought to work in partnership with others. At times it is difficult to isolate its influence and direct responsibility for change and imperfect implementation. But it has been crucial actor in the roll out of key innovations over its two decades. Just an example from my early years as an advocate, the deployment at scale of GeneXpert machines to fix “sputum” microscopy, that was literally bending the floors of labs in sub-Saharan Africa from the physical weight of the samples waiting to be tested. Insecticide treated nets alongside partnerships with the private sector to distribute them far and wide accompanied by public education campaigns. Working with and learning from other actors to pool procurement, reduce prices and shape markets so that HIV treatment options could be available quicker and faster to more people. Now, many millions receive essential services to prevent and protect others from infection.
I have at times been accused of being overly optimistic about Global Fund replenishments; to the point that some may tire of my assertions that we’ve always done it before when it felt impossible, we can do it again and we have to at least try or “they” win (who “they” is, is admittedly questionable).
As I said earlier and as GFAN has spelt out in our report “How to Close a Funding Gap” earlier this year, this is the choice we must make. Do we choose to let fiscal crises, deficits and mercurial political landscapes stall our endgame in the fight against HIV, TB and malaria? Or, do we use the goodwill that emerged at the Board meeting from the ashes of the impossibly difficult decisions that were made and catapult ourselves, with optimism, into the 8th Replenishment; leave realism behind and fight like hell for the things we know changes lives.
I hope there’s a curve at the corner of your mouth or a little twinkle in your eye, because I think you all know my answer and I am counting on our collective and collaborative GFAN approach to do it.
– Katy