I mentioned in my last blog that I would be attending a meeting in Geneva to discuss the New Funding Model (NFM) of the Global Fund to Fight AIDS, Tuberculosis and Malaria, well I am just back from a fascinating couple of days getting to understand the new model. The meeting was a great opportunity to mix with a wide range of individuals and agencies and community representatives who are committed to ensuring that the Global Fund remains a major source of strategic investment in the fight against malaria, tuberculosis and AIDS.
For those not familiar with the Global Fund, the website (here) provides a huge amount of useful information, including links which allow you to see how money has been used to good effect in the past. Since its launch, there have been 10 rounds of funding which have allowed countries to bid for resources in support of their national response. There was a high level of concern when Round 11 funding was cancelled in November 2011 (see here).
The Partners Consultation meeting was an opportunity to hear more about how the Global Fund will operate in future and to understand better the transition process from the previous funding mechanism to the new. The NFM is intended to ensure that the poorest countries and those with the greatest burden of disease have more chance of securing crucial funds to support the fight against the three diseases.
The Board of the Global Fund has been discussing new ways of providing funding which respond to past criticisms of the funding rounds based system of grant allocation. Of particular concern with the previous mechanism of funding was the huge amount of effort and time put in to developing funding bids which, if they didn’t meet the required standard, would fail to secure needed funding. The process could be a major distraction for hard pressed health planners struggling to use limited resources to provide a wide range of health services. Another criticism was that the very high level of ambition expressed by some countries could lead to significant funding and a welcome scale up of some services, but with negative consequences for other parts of the health service. For example, if staff were drawn away from maternity and child health services in order to staff HIV services, or to attend training on malaria or TB. With many of the countries most affected by AIDS, TB and malaria having limited numbers of doctors, nurses and other health workers (see here and here), increasing activity in one area can easily led to a decrease of activity in another key service. This opportunity cost of different programmes competing for limited human resources, was sometimes over looked. Mark Edington and Abigail Moreland (pictured above) are two of the key members of the Global Fund team working to ensure that the New Funding Model addresses those concerns. They did a great job fielding questions about the new model and noting down ideas which could help strengthen the approach.
The Partner Consultation drew together a number of individuals and agencies who are equally keen to ensure that the new model works. There was very strong representation from the communities affected by the three diseases, and the meeting opened with a statement from Civil Society groups, who had met the previous week in Amsterdam (here) and had developed a clear list of asks for Mark Dybul, the new executive director of the Global Fund. The Global Funds has significantly improved the lives of many poor and marginalised groups, and these communities want to protect the gains made and ensure further progress.
There is a very tight timeline for rolling out the new funding model, and the production line of new guidance documents is only just beginning to deliver the first papers that will guide the process. The draft documents shared at the meeting give an early indication of some of the key elements of the new approach.
I have tried to summarise my views on the New Funding Modality (as I understand it) in terms of the good news, and potential challenges, and have set these out below:
The Good News
Those countries facing funding shortfalls for their national response to the three diseases in the period 2013-2014 will be able to apply for new funds or to re-programme existing commitments. This could mean new money for up to 50-60 countries.
A maximum of 9 countries will test out the new funding modality (these countries will be known as the early applicants). These countries will be able to bid for a set level of funding, indicated at the outset, but will also be able to express what their full demand for funding would be if they were able to secure more funding than is initially on the table. This element of the approach is intended to keep levels of ambition high.
In addition, a set of 40 to 50 ‘interim applicant’ countries will be identified who will be able to apply for bridging funding to cover anticipated shortfalls in funding for current Global Fund financed programmes. Additional funding might include things like replacement insecticide treated bed nets for malaria prevention, when nets previously provided by the global fund are nearing the end of their functional life.
For other countries, not in these groups, there will be no new funding until after the next replenishment of the Global Fund, however there will be scope to negotiate reprogramming of existing funds, and they will be encouraged to develop national strategic plans to address the three diseases, in preparation for future bids.
Each country will be given an ‘Indicative Funding level’ which is the volume of funds they might reasonably expect to apply for based on their level of need (disease burden) and on the capacity they have to fund a national response. There will be more money available for poorer countries. This is really good news in terms of promoting greater equity in access to funds to fight the three diseases and will favour poorer countries with higher disease burdens.
Indicative funding will provide a guaranteed minimum level of funding for a 3 year period, which countries know should be approved subject to a sufficiently robust application. This will remove the risk of significant time wasting in grant applications which has been a problem in the past.
The move away from the round based application process should allow more time for grant applications and allow them to be synchronised with national planning cycles. Having said that however, for the ‘early applicant’ countries, tight deadlines set for the completion of the concept notes is likely to mean that the process of application will still feels highly pressured and demanding in this early phase.
The Concept note application process is intended to lead to ‘grant ready’ funding – avoiding the problem of funding being approved subject to lots of conditions, which was a fault of the previous system. If this can be achieved, that would mark significant progress.
But there will inevitably be challenges with any new funding mechanism. The ones that I identified include the following:
The concept note process still seems to encourage single disease applications, although combined applications for all three diseases will certainly be possible. The problem with lots of single disease applications, each requiring its own application process, will be the same as for the previous funding mechanism, in that the opportunity to address some of the key system challenges, such as lack of doctors, nurses and health workers and limitations of the drug purchasing and distribution systems in ways which will benefit the whole health service may be lost. This is a problem that it should be possible to resolve and the Global Fund team are working on solutions.
The requirement that the concept note include a ‘Full Expression of Demand’ in addition to the bid for the indicative funding is intended to maintain a high level of ambition in countries response to the three diseases. Whilst ambition is good if we want to develop and expand services, it is also important to plan realistically, bearing in mind the limited resources available to deliver the wider range of health services that populations need. We do not want countries to bid for so much funding that it will draw health workers away from other critical areas of healthcare. Any tendency to encourage countries to bid for more than they can realistically and effectively spend is something to guard against.
There will inevitably be teething problems with the new funding model. However, the Global Fund is consulting and listening, and this is a real opportunity to improve on what has been a hugely important funding instrument for tackling the scourges of AIDS, TB and malaria. I, like many others at the meeting, will be keen to find out which countries volunteer and are selected for the early implementer phase. I hope that these countries can demonstrate how the new model can help build stronger health services which tackle the three diseases but also strengthen capacity to deal with the many different health challenges that every country faces.