Fix-the-Fund: Health Systems Strengthening & Global Fund

[Guest guest]

January 24, 2006

Dear Members of the Global Fund Board:

We write to you as individuals and organizations committed to defeating AIDS, tuberculosis, and malaria. We believe it is critically important that the Global Fund retain its Health Systems Strengthening (HSS) proposal category. We urge you to ensure that HSS remains a category in Round 6 and beyond, and to take the steps necessary to enable the success of HSS proposals.

There is much debate as to whether the Global Fund is the right mechanism to finance health system strengthening or whether this area represents an inappropriate expansion of the Global Fund’s mission. We are convinced that financing HSS proposals will not expand the Fund’s mission; it will enable the Fund to achieve it. We believe that not only is the Fund the right mechanism for health system strengthening, but it is crucial that the Fund engage in this task.

Many countries are experiencing difficulties and delays in scaling up AIDS, tuberculosis, and malaria programs because they depend on national health systems that are too weak to effectively deliver on these new demands. The multitude of Round 5 requests for funds to support health workforce strengthening, for example, reflects the recognition of African health ministers that, as stated in their October 2005 Gaborone Declaration on a Roadmap Towards Universal Access to Treatment and Care, “the human resources for health crisis affecting the continent is a severe impediment to health system strengthening and a constraint to accessing prevention, treatment and care.”

The HSS category enables the Fund to support activities that are tied to the needs of the entire health system and the full range of national health goals, not only needs and goals specific to one disease. This financing capacity is important both to address the health system needs necessary to scale up AIDS, tuberculosis, and malaria interventions and to ensure that the Fund’s activities do not inadvertently harm health systems. Providing support for disease-specific programs without also supporting the underlying systems risks reducing the capacity of those systems to deliver other vital health services.

The HSS category should encourage Global Fund applicants to locate their AIDS, tuberculosis, and malaria programs in existing systems wherever possible instead of creating a new, parallel infrastructure. This integrated approach to health system strengthening is more sustainable than a vertical approach, and avoids duplications, health system distortions, and inefficient use of resources. It also meets the expressed goal of African Union health ministers, who committed themselves to “the development of an integrated health care delivery system” in the Gaborone Declaration.

The health worker crisis is one of the most prominent of the health system deficiencies that the Global Fund will need to address if it is to fulfill its mission. Health worker wages and working conditions do not meet their basic needs or those of their patients, so many migrate, leaving behind a demoralized workforce too small to meet health needs.

There are other such issues as well. For instance, even if a country has the resources to offer HIV, tuberculosis, and malaria services, the impact will be severely restricted if people lack financial access to any health services. The impact will also be limited where managers lack basic skills in areas like financing, supervision, and monitoring and evaluation. A health system requires strong financial management to ensure that funds reach the proper destination, and an effective procurement and distribution system to ensure that medicines and other essential supplies reach their destination quickly. The Global Fund can help by, for example, supporting community health insurance schemes as it is for Rwanda, training mangers, and improving inventory control systems.

Retaining a separate category for HSS is the best way to meet these needs. It will encourage countries to take a systemwide, integrated approach to scaling up health interventions and is the best way to support systemwide strategies, such as Malawi’s Emergency Human Resource Programme and Rwanda’s health insurance program, that are required to scale-up AIDS, tuberculosis, and malaria services.

The Global Fund’s experience with HSS proposals thus far has been both disappointing and encouraging. Thirty countries applied for HSS assistance from the Global Fund in Round 5, demonstrating that the Global Fund’s HSS category is helping fill a significant gap in international funding and that many countries believe the Global Fund is an appropriate mechanism to help fill this gap. They recognize that the Global Fund is an appropriate mechanism for activities that require long-term external support, as many health system strengthening activities will need. Already, for example, the Global Fund is a major financer of anti-retroviral therapy, which will require long-term external support. And the Fund’s results-based financing will help ensure that grants for health system strengthening translate into positive health outcomes, successes that will attract additional donor support.

However, only three of the Round 5 HSS proposals were approved. Fortunately, the Global Fund, the World Health Organization, and other partners can take steps to ensure that the next round of HSS proposals is far more successful. WHO and the Fund’s Technical Review Panel have outlined many of these steps. We urge the Fund and other partners to take such the necessary measures, including immediately beginning to work with countries that applied for but were denied HSS funding in Round 5 to develop Round 6 proposals. We ask the Fund to consult national stakeholders, including health workforce representatives, when making decisions that will most directly impact Global Fund applicants.

Health system strengthening has been a neglected area of international health spending, even though strong health systems are vital for the success of a broad array of health programs, including those to fight AIDS, tuberculosis, and malaria. The Global Fund took the enlightened step of permitting Health Systems Strengthening proposals in Round 5. This process should continue, expand, and improve. The need is too great, and the Global Fund’s potential contribution to save lives in the short and long term too significant, for the Fund to follow any other path.

Sincerely,

Organizations

Action Group for Health, Human Rights and HIV/AIDS (AGHA) (Uganda)

Addis Development Vision (Ethiopia)

Africa Action (USA)

African Council for Sustainable Health Development (ACOSHED) (Africa)

African Council of AIDS Service Organizations (AfriCASO) (Africa)

AIDES Federation (France)

AIDS for AIDS International (USA)

AIDS Law Project (South Africa)

AIDS Law Unit, Legal Assistance Centre (Namibia)

American Medical Students Association (USA)

Campaign for Female Education (CAMFED) (Zimbabwe)

Christian Health Association of Kenya (Kenya)

Churches Health Association of Zambia (Zambia)

Coordination Council of the All Ukraine PLWH Network (Ukraine)

Copilarie pentru toti (Women and Children Living with HIV/AIDS) (Moldova)

Credinta PLWHA (Moldova)

Delhi Network of Positive People (DNP+) (India)

East, Central and Southern Africa (ECSA) Health Community (Africa)

East European & Central Asian Union of PLWH Organisations (Eastern Europe/Central Asia)

EQUINET: Regional Network for Equity in Health in East and Southern Africa (Africa)

European AIDS Treatment Group (EATG) (Europe)

Freedom Foundation (India)

Gay Men’s Health Crisis (USA)

Global AIDS Alliance (USA)

Global Network of People living with HIV/AIDS (GNP+) (Global)

Grupo Português de Activistas sobre Tratamentos de VIH/SIDA (Portugal)

Health Gap (USA)

Healthpartners (Kenya)

Interagency Coalition on AIDS and Development (ICAD) (Canada)

International Community of Women Living with HIV/AIDS – Namibia (Namibia)

International Council of HIV/AIDS Service Organizations (Global)

International Council of Nurses (Global)

International Planned Parenthood Federation (Global)

Joint Clinical Research Centre (Uganda)

Journalists Against AIDS (JAAIDS) (Nigeria)

Kenya AIDS International Prevention Project Group (KAIPPG) Kenya (Kenya)

Kenya AIDS International Prevention Project Group (KAIPPG) International (Kenya/International)

Kenya AIDS NGOs Consortium (KANCO) (Kenya)

Kenya Network of Women with AIDS (KENWA) (Kenya)

Latin American and the Caribbean Council of AIDS Service Organizations (LACCASO) (Latin America & Caribbean)

Latin American Network of People Living with HIV and AIDS (RedLa+) (Latin America)

Lawyers Collective HIV/AIDS Unit (India)

Manipur Network of Positive People (MNP+) (India)

Movement of Men against AIDS in Kenya (MMAAK) (Kenya)

Mozambican Youth National Council (Mozambique)

National Union of the Organizations of People Affected by HIV/AIDS (Romania)

Osservatorio Italiano sulla Salute Globale (Italian Global Health Watch) (Italy)

Partners in Health (USA)

Physicians for Human Rights (USA)

Pinoy Plus Association (HIV+ organization) (Philippines)

Positive Malaysian Treatment Access & Advocacy Group (MTAAG+) (Malaysia)

Public Services International (Global)

Southern African Development Community (SADC) (Africa)

Southern African Network of AIDS Service Organizations (SANASO) (Africa)

Tanzanian Essential Strategies Against AIDS (TESAA) (Tanzania)

Thai AIDS Treatment Action Group (TTAG) (Thailand)

The AIDS Service Organization (TASO) (Uganda)

Treatment Action Campaign (South Africa)

The Uganda Treatment Access (Uganda)

Zimbabwe Activists on HIV and AIDS (Zimbabwe)

Health Leaders [affiliations for identification purposes only]

Dr. Uzodinma A. Adirieje, OD, MNIM, AIPM

Programmes Director, Afrihealth Information Projects/Afrihealth Optonet

Association, Nigeria

Ilaria Bianchi, M.Sc Health Management

Freelance Consultant

Italy

Dr. Asma Bokhari

National Program Manager, National AIDS Control Program

Pakistan

Lincoln Chen, MD, MPH

Director, Harvard Global Equity Initiative

Co-Chair for Coordination of Joint Learning Initiative on Human Resources for Health

USA

Don de Savigny, PhD

Head, Health Systems and Interventions Unit, Swiss Tropical Institute

Basel, Switzerland

Cephas Epaalat

Commonwealth Nurses Federation Board Member for East, Central and Southern Africa (Kenya)

Dr. Oladipo J. Folorunso

Community and Family Health Initiative

Abuja, Nigeria

Jim Kim, MD, PhD

Former Director, Department of HIV/AIDS, World Health Organization

Division of Social Medicine and Health Inequalities, Brigham and Women's Hospital

Department of Social Medicine, Harvard Medical School

USA

S. Lawrence, MD

Edyth H. Schoenrich Professor of Preventive Medicine

Associate Dean for Professional Practice and Programs

Director, Center for a Livable Future

s Hopkins Bloomberg School of Public Health

Baltimore, MD, USA

Professor London, MD

Health and Human Rights Programme, School of Public Health and Family Medicine

University of Cape Town Health Sciences Faculty

South Africa

Marina Madeo, MD

Health & HIV/AIDS Advisor, Italian Development ation, Embassy of Italy - Addis Ababa

Ethiopia

Oteba Olowo

International Health Specialist

Principal Pharmacist, Ministry of Health

Uganda

Mataka

Alternate Board Member, Developing Country NGOs

The Global Fund to Fight AIDS, Tuberculosis and Malaria

Zambia

Dr. Max Meis

Health Advisor, Christian Health Association of Malawi

Malawi

Saleh Meky

Minister of Health

CCM Contact for HIV/AIDS

Eritrea

Mugyenyi, MD

Director, Joint Clinical Research Centre

Uganda

Joia S. Mukherjee, MD, MPH

Medical Director, Partners In Health

Assistant Professor, Harvard Medical School (Cambridge, MA, USA)

Dr. Musoba

Consultant, Public Private Partnership in Health,

Kampala, Uganda

Françoise Ndayishimiye, MD

Alternate Board Member, Communities Living with the Three Diseases

The Global Fund to Fight AIDS, Tuberculosis and Malaria

(Responsible of the Civil Society Component in the Permanent Executive Secretariat of the National AIDS Counsil (SEP-CNLS Burundi)

Burundi

Dr. Triphonie Nkurunziza

Chairperson, Burundi CCM

Minister, Ministry of the Presidency in Charge of Combating AIDS

Burundi

Dr. Ogbe Oritseweyimi, MBcHB, MPH

Planning, Research and Statistics, National Primary Health Care Development Agency

Abuja, Nigeria

F. Picazo

Former Senior Economist (Health), Human Development, East and Southern Africa, The World Bank

Resident Mission South Africa

The World Bank

Simonetta Pirazzini

Geographic Liaison Manager, Country and Regional Support Department

UNAIDS

Nana Poku

Director of Research, Commission for HIV/AIDS and Governance in Africa

Economic Commission for Africa

Addis Ababa (Ethiopia)

Hélène Rossert-Blavier, MD

Vice Chair Emerita, Board of the Global Fund to Fight AIDS, Tuberculosis and Malaria Director General, AIDES Federation

France

Bjorg Sandkjaer Demography Officer, Commission for HIV/AIDS and Governance in Africa Economic Commission for Africa

Addis Ababa (Ethiopia)

Dr. Sewankambo

Dean, Faculty of Medicine, Makerere University

Kampala (Uganda)

Uwintwaza

Secrétariat Exécutif Permanent du Conseil National de Lutte contre le Sida (SEP-CNLS Burundi) (Responsible for the youth response in the fight against HIV/AIDS)

Burundi

Waldman, MD, MPH

Director, Program on Forced Migration and Health;

Professor, Clinical Population and Family Health,

Columbia University Mailman School of Public Health

Mr. Stanislas Whannou

Secretary-General, Ministry of Public Health

Contact 1, Burundi CCM

Benin

, MD

Assistant Professor, Section of Infectious Disease and International Health, Dartmouth Medical School (Hanover, NH, USA)

Monisha Arya, MD, MPH

Fellow, Infectious Diseases, Division of Infectious Diseases, Beth Israel Deaconess Medical Center (Boston, MA, USA)

Holly Atkinson, MD

President, Physicians for Human Rights

Assistant Professor, Department of Public Health, Cornell University Weill Medical College (New York, NY, USA)

Carol J. Baker, MD

Professor, Pediatrics, Microbiology & Immunology

Head, Section for Infectious Diseases, Department ofPediatrics, Baylor College of Medicine (Houston, TX, USA)

Lucy Bradley-Springer, PhD, RN, ACRN, FAAN

Director, Mountain Plains AIDS Education and Training Center

Associate Professor of Medicine, University of Colorado Health Science Center

Professor and Co-Director, Center for Health Disparities Research, University of Pennsylvania School of Nursing (Philadelphia, PA, USA)

Mardge Cohen, MD

Director of Women's HIV Research, CORE Center (Chicago, IL, USA)

Joyce Fitzpatrick, PhD, MBA, RN, FAAN

Ford Professor of Nursing, Case Western Reserve University (Cleveland, OH, USA)

Warner C. Greene, M.D., Ph.D.

Director, Gladstone Institute of Virology and Immunology

Professor of Medicine, Microbiology and Immunology

University of California, San Francisco (USA)

T. Haase, MD

Regents’ Professor and Head, Department of Microbiology

Director, Minnesota Division, Great Lakes Regional Center for AIDS Research, University of Minnesota, Twin Cities (Minneapolis and St. , MN, USA)

Holzemer, PhD, RN, FAAN

Director, WHO Collaborating Center, Department of Community Systems

Director, International HIV/AIDS Nursing Research Network

Professor and Associate Dean for International Programs, University of California, San Francisco (USA)

Mayer, MD

Professor of Epidemiology and Psychiatry Emerita, Columbia University

Director of International Core, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute

Director, Brown University AIDS Program; and Professor of Medicine and Community Health, Brown Medical School (Providence, RI, USA)

Helen Miramontes, RN, MSN, FAAN

HIV/AIDS Consultant

USA

Bruce G. Trigg, MD

Medical Director, Sexually Transmitted Disease Program, Region 1,3,T

New Mexico Department of Health (Albuquerque, NM, USA)

Volberding, MD

Professor and Vice Chair, UCSF Department of Medicine

Chief, Medical Service SF Veterans Affairs Medical Center

Co-Director, UCSF-GIVI Center for AIDS Research

USA

Other

Bettina T. Schunter

HIV and AIDS Project Officer (Pakistan)

Aleksandrs Molokovskis

HIV Prevention Programme (Kekava, Latvia)

Coordinator TIDES Foundation Community Review Panel member from the Baltic States

Terry White

Consultant to the All-Ukraine PLWH Network

Policy Advisor to the East European & Central Asian Union of PLWH Organisations

Ukraine

CC: Global Fund Secretariat

Global Fund Technical Evaluation Reference Group