Letter |

MSF letter to the Global Fund to Fight AIDS, Tuberculosis and Malaria

A call to keep the Global Fund effective at saving lives in all developing countries through its 2017-2021 strategy.

Dear Board of Directors and Members of the Secretariat,

On behalf of Médecins Sans Frontières (MSF), I am writing to share our reflections and concerns regarding shifts in the policies and funding model of the Global Fund to Fight AIDS, Tuberculosis and Malaria, and their potential impact on the fight against these three diseases.

The impact of the Global Fund’s support has been widely recognised, including by MSF teams treating patients with HIV, TB and malaria in multiple and diverse geographical settings. The Global Fund has helped avert millions of deaths and untold suffering by supporting evidence-based policies and programming, and has been a critical vehicle in increasing access to HIV, TB and malaria treatments, as well as care and prevention across the globe over the past decade. Despite these significant achievements, much more work remains to be done to combat the three diseases. While 15 million people are on HIV treatment today, this is still less than half of all people living with HIV.

The response to TB, and especially multidrug-resistant TB (MDR-TB), shows a striking lack of urgency, with less than half the estimated cases of MDR-TB diagnosed successfully. In terms of malaria, there are still unacceptably high numbers of cases in countries such as Democratic Republic of Congo and Central African Republic.

Upcoming progress by the Global Fund will largely be decided by the level of ambition of the Global Fund Strategy 2017-2021. However, a number of decisions and reforms over the past few years raise questions about the future direction of the Global Fund’s ambitions.

In 2012, after funding shortfalls and the cancellation of Round 11, MSF raised its concerns to the Global Fund Board regarding the urgent need to address funding gaps in countries’ efforts, and the risk that some reforms could compromise the Global Fund’s core principles such as demand-driven country leadership and a clear focus on results for patients and people.

Today we remain concerned that several of the reforms adopted over recent years to accommodate reductions or stagnation in donor contributions touch upon the core mandate of the Global Fund, and that the essential features that have made the Global Fund successful to date might be lost. It puts into question whether the Global Fund can continue to keep people in need at the centre of its strategic objectives.

The Global Fund was created as a strategic tool, with a mandate and modus operandi tailored to increase effectiveness and scale, overriding the limitations of existing efforts. Now, however, we see indications that the Global Fund is adopting similar trends seen among traditional donors, including: deprioritising service delivery focused on addressing diseases; shifting the focus towards institutions and systems without assuring a direct impact on people’s health; and making decisions based on the availability of resources, rather than on people’s health needs.

Global Fund spokespeople often say that the world has changed and the Global Fund should adapt. However, the fact remains that it is now both possible and feasible to significantly curb the spread of death and suffering from the three diseases. The extent of people’s needs and the necessity of not delaying our response to the epidemics are also evident. But instead of strengthening our resolve to ‘finish the job’, global ambition and solidarity appear to be wavering.

The Global Fund remains the main funding tool to effectively battle AIDS, TB and malaria – indeed in many countries where we work, it is the only tool. It is not hyperbole to say that the choices made around the Global Fund’s strategic role will determine the futures of millions of people.

In order to address these concerns, to improve support to countries, and to continue to place people at the centre of the equation, MSF urges stakeholders deliberating on the 2017-2021 strategy to:

1 - Commit to increase the pace of scale-up and maintain an ambition to save lives. The Global Fund should take care not to squander the investments and successes to date against the three diseases.We are concerned about the slowdown in disbursements in 2014, and urge the Global Fund to take necessary measures to reverse this.

Saving lives must remain a priority; this is both a moral responsibility and a practical measure, with evidence showing that saving lives and preventing new infections are intrinsically linked. Support for scaling up access to lifesaving services must remain at the core of the Global Fund’s strategy.

2 - Prioritise outputs and outcomes over the call for sustainability. Some actors are calling for a balance between financial sustainability and ambition. While there has been tremendous progress in fighting the three diseases, we are nowhere near a ‘maintenance’ approach.

On the contrary, efforts will need to be stepped up over the next five years. Neither donor nor domestic investments will be sufficient if infections and avoidable sickness and deaths are allowed to increase. The Global Fund should strengthen its support to patient-centred service delivery. This includes interventions involving recurrent costs such as human resources and commodities, coupled with strengthened support to ‘last mile’ delivery to avoid stock-outs or shortfalls.

3 - Adjust the funding model without narrowly defining country eligibility and restricting country demand. A funding allocation model based on blunt economic categories or disease level thresholds fails to capture true patient needs, while hiding the country’s real demand.

Such a model also risks pitting affected populations in different countries against each other and risks undermining the Global Fund’s leverage to fight these diseases. Significant unmet needs remain in low-income and high-burden countries, but also in many middle-income countries which are trying to combat MDR-TB or to increase their HIV service coverage. Domestic funding should support an expanded response to those needs, and not replace a drop in international funding, which would reduce the country’s ability to scale up services to those not yet reached. This risk is increased because countries which cross income classification lines face higher prices for medical commodities to improve diagnosis and treatment.

Proposals to focus on a small group of high-burden countries, while deprioritising the others and asking them to share an even smaller pot of funds, are equally problematic. Providing high-burden countries with the necessary funding should not come at the expense of defunding countries with critical needs.

Other proposals appear to aim to exclude countries from obtaining funding for certain interventions. Decisions about which areas to fund should not be imposed from above, but rather follow country’s context-specific and inclusive assessments of needs. Adjustments to the current model should aim to provide more context-specific flexibility and account for countries’ real-time assessment of needs and capacities.

The Global Fund should encourage country-led proposals and plans to reflect needs-based and realistic but ambitious plans, regardless of the pre-defined funding allocation. Proposals to focus on a small group of high-burden countries, while deprioritising the others and asking them to share an even smaller pot of funds, are equally problematic. Providing high-burden countries with the necessary funding should not come at the expense of defunding countries with critical needs.

Other proposals appear to aim to exclude countries from obtaining funding for certain interventions. Decisions about which areas to fund should not be imposed from above, but rather follow country’s context-specific and inclusive assessments of needs. Adjustments to the current model should aim to provide more context-specific flexibility and account for countries’ real-time assessment of needs and capacities.The Global Fund should encourage country-led proposals and plans to reflect needs-based and realistic but ambitious plans, regardless of the pre-defined funding allocation.

4 - Pursue a market-shaping role responsibly. MSF recognises and appreciates the Global Fund as a critical player in ensuring access to medicines for populations around the world. However, the Global Fund must ensure that any expansion of role and influence in market shaping is done in a manner that builds upon successes, ensures transparency, accountability and buy-in, and avoids unintended consequences that undermine access to medicines.

This includes clarifying and strengthening its approaches to pricing and addressing intellectual property barriers to ensure the lowest sustainable prices for patients in all low and middle-income countries. MSF remains concerned that the Global Fund is not adequately transparent and accountable for its market shaping and procurement strategies, and is reluctant to tackle the most sensitive political and commercial barriers that undermine access to affordable medical tools.

5 - Raise and mobilise additional resources as a priority. The Global Fund should not take the resource limitations expressed by donors as a given, nor should it allow its ambitions to be pre-empted by their current loss of resolve. Gaps between what is feasible to achieve and the available resources pledged must remain at the core of the Global Fund’s resource mobilisation strategy. To fulfil its mission, the Global Fund should prioritise reflections on how to attract, manage and disburse additional resources more effectively and efficiently to obtain concrete results.

MSF encourages the Global Fund Secretariat and Board to consider these points in their upcoming deliberations during the Board retreat. We hope the Global Fund will reaffirm its commitment to fund a global effort to support all developing countries in combating the three diseases.

The discussion must be focused on how to be more effective as a key strategic instrument to achieve this goal, not on how to further ration its funds, pitting people in low and middle-income countries against each other in the process.

We remain at your disposal for further discussions on these issues.

Yours sincerely,

Jérôme Oberreit
Secretary General, Médecins sans Frontières

Read more on the Global Fund's Market Shaping Strategy, Procurement for Impact Programme and E-Marketplace