barry coleman - Mar 01, 2006

The questions posed in the forum are very straightforward. In the case of this week's discussion they amount to: What should we do?

Creating capacity in health (mobility) as an intervention (to counter lack of health personnel?): I suppose most of us who work in the field of creating capacity in public health (especially in Africa, where we work) find the environment frustrating. Reading about GF disbursements in areas in which we doubt, often with good reason, that the intervention will be effective can add to that frustration.

Could highly increased health worker mobility contribute to impact? For example, our field is the sustainable mobilisation of public health workers. We have had some success. In Zimbabwe, where our team runs all the MoH's viable vehicles, we have managed to assist the ministry in getting more than half the available public health workers permanently mobile. We noted the other day the work done by Imperial College at the University of London that revealed a falling rate of HIV infection in Zimbabwe. It would be rash to ascribe causes to this important event, but it would be just as rash to rule out the possibility that a very high rate of mobility among health education workers was not a contributory factor.

But at the very least, would it not be worth considering? Supposing it were true. Then we would be duty- and morally-bound to consider committing serious funding to getting all appropriate public health workers wholly mobile in every country (shall we say) in sub-Saharan Africa. This would cost about $200m and would take five years.

We have other statistics. In one district of Zimbabwe, every single public health worker --16 in all -- is permanently mobile. In the first year of total mobility, malaria death rates in that district fell by 20% in that district (Binga) while they rose in the comparator district, Gokwe North.

Academics could point out that there could be a range of factors. But again, supposing it were true.

Then, as the correspondent from Nepal/UK, Tshering points out, we should turn our attention to this kind of capacity-building in public health service delivery.

Learning from past interventions on other diseases (e.g. polio): Should we learn from the decisions we have taken in the past? We have not yet been defeated by polio, but one cannot help but wonder if we would have been wiser to have built public health service capacity to the point at which it could have dealt with all preventable diseases rather than attempt to isolate them and thus have to garner truly astonishing levels of financial resources and still not be sure of the outcome.

So it is most certainly my view that the GF should look at ways to work with partners to build capacity. We are some way from this. A couple of weeks ago we had a series of meetings with a Government Ministry of Health in Africa who want to emulate Zimbabwe's success with mobility. This ministry happens to be part of an adminstration that is well thought-of by the international community. And yet, in spite of impressive disbursements by the GF, they cannot find an immediately obvious route to the funding they need -- and this for an intervention that, by keeping motorcycles and other vehicles running normally however difficult the conditions, actually saves money!

I apologise to fellow correspondents if this simply reads like an application for funding. It most certainly isn't that -- we are a bit too long in the tooth (too advanced in years) to use a ploy like that! No -- we want to be in the discussion and to add to the body of knowledge -- and we can only usefully contribute when it comes to things we know and understand. In any case, frustration is simply a normal, everyday part of the environment in which we all work. And as we know, in this environment there are self-evidently much (tougher) things to deal with.

Barry Coleman

Tshering - Mar 01, 2006

I have read and agree with what other colleagues have been contributing towards this fruitful discussion. There is no doubt the Global Fund will take this forum as their ears and refer to these contributions while implementing projects.

What diseases and interventions should be funded? Regarding fund distribution, the “one size fits all” theory should not be applied. Funding needs to fight disease would be different from country to country. There have been several discussion previously in the forum about where money should be spent and how. One of the main points raised was the hope that funds would reach all those who are really in need. We know that many developing countries are facing threats and suffering from all these three diseases. Interventions should include both prevention / protection and curative/ treatment programmes, to fight these diseases.

How can funding be sustained, accessed and accepted?: However, as many people pointed out that financing towards “CAPACITY BUILDING” is important in developing countries. I would strongly support financing towards public health capacity building as this is only sustainable way of funding. Once people are capable of understanding problems, interventions for tackling diseases usually develop locally, in ways that will be acceptable and accessible. “Let's give the fishing technique rather than fish all the time”.

Rationale for balancing grants accross regions, interventions and diseases: Regions: HIV/ AIDS is sweeping towards Asia and there is little doubt it will overtake Africa. HIV/AIDS in Asia has been a silent killer where people die without reporting or being diagnosed. Due to strong cultural, social and political influences on health and diseases, people are happy to die without disclosing. There is need for great awareness about HIV/ AIDS through comprehensive health promotion in every sector. TB has been there for centuries and will remain until and unless people have healthy living standards. Malaria: most dangerously, drug resistant Malaria will kill millions. Apart from fighting disease, the time has come to fight peoples' attitude towards disease and behaviour that causes vulnerability. It is a universal truth that all these three diseases are preventable and two are curable, but people have been ignoring them until they become major issues. If we delay any longer, some African countries will have completely annihilate populations. More teachers die than can be trained by governments to teach (or protect) future generations.

Interventions: The time has come for Attitude/ behaviour change programmes for entire populations- Very often the most educated personalities stick back to negative traditions, or doctors and other health professionals discriminate against the sick, negatively affecting societies.
We need to focus on Human Resource Capacity Building but what kind of people do we need? Do we need more Doctors and Nurses or health promoters who understand different factors that contributes towards vulnerability to the diseases – such as social and economic factors?

Knowledge sharing: We do know that there are several success stories in the world in fighting these diseases. The time has come to learn from those and share experiences and knowledge on how one place managed to control and prevent disease than another, rather than looking for funding all the time.

The next forum should focus on discussions about what kind of intervention was used and how it was used to eradicate or minimise such prevalence of the diseases. Learning from others as an evidence would be more useful than designing completely new wheels. My personal opinion is that the Global Fund could put money towards sharing information amongst those who are fighting the same diseases. We need more success stories from different corners of the world. This will give hope to those who have been failing their initiatives in the country and getting frustrated.


Thanks.
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Looking forward to participating in fruitful global discussions any health realted topics.

ccmindo - Mar 07, 2006

In my opinion, the purpose of GF funds is to help Indonesia to be able to tackle the three diseases: HIV/AIDS, TB and Malaria. This should not only be seen at the end of the GF project only. But that it should be seen as to strengthen the Indonesian themselves in term of commitment, capacity and resources to tackle these three diseases by themselves in the long term.

Therefore the main actions GF should take is to ensure that the commitment, capacity and resources of the relevant Indonesian institutions namely GO, NGO, academics, professions, private enterprise, communities etc. could be strengthened according to their roles. Why? because to tackle these three diseases will definitely take a very long time, especially for Indonesia. Therefore, the indicators for this GF project should be properly balanced between conventional diseases control/epidemiology indicators (such as case findings, treatment, incidence, prevalence etc.) and institutional capacity building indicators among the Indonesian players. When the GF project ended, it should be ensured that these Indonesian players are ready and should be able to sustain the program in terms of capacity, manpower and resources. Too many projects in Indonesia are considered success because were seen only at the end of the project using the project indicators but after that....its collapsed! The project managers, staff, consultants etc. were gone for another project. In other words it's just only for the sake of the project.

This is my short opinion. I would very much welcome any critics or comments to my opinion. Thank you.

Firman Lubis
Indonesia CCM Member

Wei GUO - Mar 03, 2006

We think that the question is not just how they balance between those three diseases. Building on the observations, we think that there are several balancing problems:

1. The three diseases are quite different. One needs a broad, social, economic, legal, etc approach, the others do so much less. Therefore, any mechanism that are set up e.g. CCM become very time consuming because you have to have three sets of participants and processes.

2. The fact that it is only for those diseases means that the wider picture is forgotten - e.g. addressing only HIV/AIDS without having any assurance that related issues such as STDs, FP, VaW are addressed means that the response may be less cost effective.

3. From my experience there seems to be no effective assurance that "coordination" is not mistaken for "power and money". That is, a lot of money goes to CDC, which therefore uses all the money on its own channels, no matter how illogical - e.g. even if it has to do with outreach to sex workers, work with adolescnets etc - typical outreach work where NGOs and NPFPC would be better placed. That is the fund can actually decrease the capacity of the country, because those organizations which get money also get the mandate, no matter how illogical.

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Message by KRISI
Before I post I would like to pose a question: As a whole what would be more important to focus on, the suffering and holistic cares of those infected at this time, or stopping the spread any further from now on?

This sounds like a simple question but it is not, since healthcare and treatment for those infected is a different approach to the way you fund the education and prevention. These are two entirely different catagories, before you debate over who is in more need you should direct what is in more need the education to prevent and cure or to help those already infected.

Dr. Saka Mohammed Jimoh - Mar 03, 2006

While I agree with high risk groups and voulunerable children, I think GF should look at approaching the intervention using PMTCT the maternal and child unit can be a good approach for intergrated activites. most especially Malaria and HIV/AIDS.
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Dr. Saka Mohammed Jimoh

Mina - Mar 02, 2006

The extent to which national strategies and programs succeed in addressing the challenges posed by the HIV epidemic, will to a great degree, be influenced by the ability of communities and governments at all levels and in particular local government which is closest to people and communities, to complement and reinforce each other.

In many countries, structures and mechanisms for effective interaction between these groups are not well established or lacking all together. External funding in significant amounts can either facilitate and support a coherent response, reflecting national/local needs and realities or not. Technology driven verticle interventions, which do not adequately take into account the need to also invest in building national/local capacities to manage an effective and coordinated response (short term and long term) will have limited impact.
The issues raised by the HIV epidemic are complex and approaches will vary depending on the stage of the epidemic in a country or region. As has been noted "one size does not fit all".

There is evidence showing that the dimensions and course of the HIV epidemic are significantly influenced by local conditions and factors, and that "interventions" aimed at controlling the epidemic are best optimised by relating actions to relevant local factors. Such an approach requires time and does not necessarily respond to tight deadlines imposed by funding organisations. Social and cultural factors, fear, stigma, shame, discrimination influence the prevalence and trend of the epidemic. And efforts to design and implement policies and programs need to reflect this reality. Efforts to significantly scale up services towards universal acces to prevention, care, treatment and services to support the growing number of orphans and vulnerable youth will need to build on foundations that enable local and national organisations and groups to more effectively manage services that are responsive to local needs and realities.

For this to happen, the current "implementation gap" between policies and national AIDS Plans will need to be tackled in constructive and pragmatic ways. Funding mechanisms may need to reconsider some of the current practices and procedures to ensure that they are perhaps more flexible (e.g. timelines) and responsive to realities on the ground.

Timothy Mbugua - Mar 02, 2006

The interventions on the three diseases, in my opinion, should continue as it is given that in Africa for instance, AIDS is today the biggest killer and in other parts of the world it is claiming a huge number of the productive population.

Rationale for Behaviour Change & OVC programmes in countries witnessing high HIV prevalence and high mortality rates: When it comes to interventions on treatment, I suggest that emphasis should now move from awareness and sensitization particularly in countries with high prevalence, to working on measures that can lead to positive and quantifiable behavioral change. For instance, even in the remotest part of Africa people know about AIDS because of the high number of those who are dying in their midst and they also know how it is spread. The major issue now is how to make them change the risky behaviors that continues to increase the infection rate.

Orphans and vulnerable children: Another issue on interventions is that there is still ineffective and inadequate emphasis and support for orphans and vulnerable children especially in Africa where AIDS has created over 12 million orphans. Only 1 million orphans and vulnerable children (about 7%) are expected to benefit from the current (round 1-5) fundings being disbursed by the GF. More action needs to be taken to increase the level of support to this group. This is strengthened by the fact that in 2004, UNICEF and UNAIDS produced a document called “A Framework for the Protection, Care and Support of Orphans and Vulnerable Children Living in a World with HIV and AIDS.” The framework concluded with one of the key actions to be taken being to include the prioritization of the support of the OVC and their families in the national policies, actions and plans. Leaders and policy makers in governments and international institutions were asked to contribute towards this goal by committing at least 10% of their HIV and AIDS funding to protection, care and support for orphans and vulnerable children. GF could also take an affirmative action and ensure that all proposals on AIDS have a certain percentage of resources going to support the orphans and vulnerable children.

Supporting Capacity Building in Community Based Organizations, NGOs and Government agencies: Because of the close proximity with the people they serve, the CBOs can make a significant change in addressing the AIDS scourge. Yet most of them lack adequate capacity to be able to function successfully. GF should consider capacity building for these organizations. Indeed, as more and more support is generated to fight these diseases, the issues of capacity of the organizations (including the government departments) that are expected to lead the fight become critical. The civil society in general, can complement government efforts particularly where the later lacks enough capacity or is overstretched and this should be encouraged.

Dr. Saka Mohammed Jimoh - Mar 02, 2006

Well, never too much

I strongly believe that more should be spent on PREVENTION. Let's look and analyse the cost implication of the intervention methods, and choose those with greater impact. We need more research on preventive methods for all these diseases, prevention in local terminology (local ownership); use of approriate technology that is accessible and affordable by all and that is also applicable in all levels of health care system is paramont.
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Dr. Saka Mohammed Jimoh

kokoi - Mar 01, 2006

After reading all the posted reply, I have decided to participate again. In own view ,(all I have shared are from my previous experience and reading)
1. Global fund may review evidences on current trend in disease causation and the impact indicators (rates & ratios) in order to established a more appropriate policy in giving grant across the three diseases. A more wholistic approach in the review of every proposal stressing on the actual needs and evidenced-based studies.
2. Policy on standards and benchmarks should be reviewed to fit into the objective of grants.
3. Global fund should see to it that Grants to different types of interventions should be evidenced based and should focus on "unmet needs" rather than targetted accomplishments.
4. On the different kinds of recipients economic indicators, degree of cooperation and the anticipated effect of grant should be carefully evaluated. It is equally important to look into the burden of problem or diseases to the recipients.
5. Different region applied different "reforms" in their health care delivery system. It is then critical to consider the different reforms initiated by the diferent country before giving grants. The effect may have synergistic effect or may hinder the reforms or maybe the reforms maybe totally dependent on the grant hence sustainability is affected.
6. Lastly Global fund should strengthened its own Policy making bodies by making more evidenced based generated policy and m,ore importantly results of M&E on previous grant(success or Failur) should play the key role before approval of proposal. To me then, "Equity" in giving grant could replace the word "balance"

Jerry - Mar 01, 2006

It seems that The Global Fund should begin using barometers connected to Climate Changes, flooding, food shortage caused by weather condition, waste management, excess rain and high temperatures. Each item causes Public Health issues whereby the Fund should diversify its funding toward these issues.

A clear Public Health policy can define a sustainable program linking the Environment with tuberculosis, malaria and HIV/AIDS.

bintu - Mar 01, 2006

I am glad a discussion has been opened regarding the disbursement of Global Fund's grants. Please excuse my language, but I think it is realistic to consider areas where HIV/AIDS is not prevalent, since prevention is better than cure, especially now that AIDS has no known cure. I feel that it is unrealistic for people to lobby for the funds' distribution to be geared towards South East or Southern Africa or Asia. Please rethink (your suggestions), as there are under-populated countries in the world, where, when disease is prevented, it will be good because the population will be sustainable, say, a country with a population of 6 million and below.

I believe funds should be distributed to credible NGOs in countries and communities, who are interested in training personnel to help in the prevention of these diseases, since investing in health staff to increase in-depth knowledge may bring viable results.

Thanks,
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bsesay

nitya - Mar 01, 2006

The Fight Against HIV and AIDS in Nepal now depends on the UN System in Nepal as they have taken the responsibility over the management of the fund. Since the UN took over the Management Support Agency in Nepal, there was a big hope that things would see a drastic change. But no such things have happened yet. It may be because of the political crises in Nepal that the fight against HIV/AIDS is lost in the shadow of gun-battle going on since a decade. In such a situation, the Global Fund needs to put tremendous efforts in Nepal to protect the future generation from catching HIV/AIDS. Simply handing over the MSA to UN System in Nepal would not help realize the intended goal of the Fund. To balance the funds, the Global Fund must make realistic programs and make interventions suitable to a country like Nepal, mired in perpetual ocnflict.

The Global Fund had delayed disbursement of funds to Nepal since the creation of the Global Fund in early 2002.

The government missed the deadlines repeatedly but it does not mean that the Global Fund should punish those urgently in need of care and treatment.

A timely monitoring is important to ensure whether or not the funds are utilized. Journalists be encouraged to take up field reporting where situation is critical. The officials from the Global Fund should visit recipient countries from time to time to ensure that they are doing a good job. Then the Global Fund would bring desired changes in the lives of affected people in a country like Nepal.
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Nityananda

tarigwafa - Feb 28, 2006

The Global Fund is not the only funding organization present in the scene . Many other funds work in the same areas where the Global Fund plays . For the balanced distribution of funds , I think we have to ensure the following takes place:
1) Strong collaboration with all funding agencies working in the same area of a certain region or country .
2) Actual or semi-actual estimates of the burden of the three diseases and distribution of the funds proportionally between the diseases depending on these estimates .

With best wishes

Dr.Tarig Dafallah Elhassan
HIV/AIDS State Coordinator
Ministry of Health - SUDAN
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Tarig Dafallah

Dr. Saka Mohammed Jimoh - Feb 28, 2006

The allocation of funds across regions , between diseases or types of inteventions should be based on a full scale intial asssessment of country capacity to manage and to provide services, their credibity, corruption levels, and their commitments to fight the diseases and move forward.

We can also learn from previous country success stories and best practices; What works well in a country or community.

By and large GF should channel the funds through credible NGOs in countries and communities.
The intervention methods should proportionally spread across both preventive and curative processes targeting the most vulnerable or high risk category in the country.

In many local NGOs these strengths and opportunities exist, and I believe GF can identify such in each state and use them as channels to provide interventions.
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Dr. Saka Mohammed Jimoh

thayer - Feb 28, 2006

It seems to me that one of the most important elements is to take into account the spending intentions of the other large donor organisations such as the Gates Foundation. It is very important not to duplicate.

Personally, I also feel that the health and safety of children should be considered as a very high priority.