Feb 24, 2006

Message from Tom Mboya Okeyo, MoH- Kenya

My contribution this week is a Case study on Kenya (powerpoint presentation available on request). It demonstrates that without the Global Fund, PEPFAR, MSF, Clinton Foundation, the number of people on ART in Kenya by end of January, 2006 would have been only 5000 instead of 65,000. In the next six months, additional 15,000 Kenyans - will be started on ART bringing the total to 80,000 by end June 2006 (drugs in place paid for with Global Fund resources). Therefore, ensuring impact requires development and maintenance of strong partnerships at all levels.

The Global Fund needs to urgently commission studies to develop communication strategies to deflect threats/fears among some development agencies that it could drive them out of business (i.e. the International Development Assistance in health business). The Global Fund must be seen as an asset stimulating collective action to ensure impact.

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--- A complete copy of Dr. Okeyo's interesting presentation " A CASE STUDY ON KENYA " is available on demand. Please request it from the moderators via e-mail - to send an e-mail, please click on the 'Email' icon below. Included below are a few highlights from his presentation:

Ensuring Impact – demands Investing in effective and efficient Partnerships at all levels

Overview of Kenya’s Experience:

1.2 million adults and 100,000 children are living with HIV/AIDS
203,425 people require to be on ART today but only 65000 are on ART as at end 31 Jan 2006 (30% of people eligible)

This means 70% of people eligible for treatment have no access
Why? - Inadequate funding, lack of health workers, inadequate health infrastructure, stigma and high levels of poverty together stand on the way to realization of Universal Access.

Remedies:
1. Funding requirements for a comprehensive National response is estimated to be US$ 350 million in 2006 in Kenya. Total available funding from Government, Global Fund, PEPFAR, DFID, the World Bank, private sector and NGOs is US$ 160 million. Funding Gap isUS$ 190 million.
To bridge this gap requires at least doubling the current funding levels by all donors and the Government, and increasing efficiency and effectiveness in the use and application of available funding.

2. Investing in Health Human Resource in Kenya:
-Provision of Quality health services is a labor-intensive business which requires qualified health workers. Investment of US$ 50 million per year for five years is required to have in place a reasonable number of health worker workforce able to deliver quality health care (Prof Jeffrey Sachs and Dr James Nyikal Kenya Health Human Resource Study 2004).

-A recent risk-based audit of health human resource in Kenya demonstrates evidence of acute shortage of health workers due to retrenchment, embargo on employment, staff suspensions, natural attrition and rising patient population especially HIV/AIDS and TB associated.
-There is a general state of apathy – the increased funding has increased workload with no concomittant investment in increasing staff numbers, Motivation and Quality.

3. Affordable Commodities and low-cost technologies:
Drugs, medical supplies and medical equipment are major factors contributing to the high cost of health care.
-Legislative reforms to facilitate use of high quality generic drugs, standardize medical equipment in the health sector could reduce health care costs.
-Increased investment in low-cost prevention technologies like vaccines, condoms, school health education, VCT and community mobilization to fight stigma and discrimination could also reduce health care costs.
-But, business practices guided by pro-rich policies are making access to basic commodities and technologies for care and prevention difficult in resource poor countries such as Kenya.

4. Human rights, stigma and discrimination and gender equity

-Targeted Information, Education and Communication to promote health-seeking behaviour increases efficiency and effectiveness in the use of investments in drugs, medical supplies and reagents.
-In 2004 following an effective ART campaign, 36,000 more Kenyans enrolled for ART
-However, stigma and discrimination contributes to low utilization of VCT services especially in rural areas
-Investing in Community Organizations led by women is a feasible strategy to fight stigma and ensure gender equity.

Universal Access Targets and Milestones, Kenya

Key Milestones........................................2010 Target......Current Status

People tested and counseled per annum...........2 million.......453,017
Transfused blood is safe................................. 100%.............99%
Pregnant women accessing PMCT services.........80%..............30%
People on ART...............................................203,254..........65,000
TB patients accessing
compréhensive HIV care services.....................100%.............20%
Orphans schooling ..........................................90%...............30%
( due to free primary education policy).
% Government budget allocated to M.of Health...15%...............9%


Financing Framework for Anti-retroviral Treatment
Source of funding..............Number of Patients.........Cost in Khs in 000s
Government and Global Fund.....22,000................................1,487,860
PEPFAR ...................................28,000................................1,893,640
Others (NGOs, pvt sector, etc)...15,000................................1,014,450

TOTAL..................................... 65,000................................4,395,950
No. of People on ART if there was no GF, PEPFAR, MSF, Clinton Foundation etc 5000 Mainly Household and private sector financed.

THANK YOU.

Dr Tom Mboya Okeyo

Ministry of Health, Kenya.

Carrr - Feb 24, 2006

To achieve real sustained impact in malaria control (as well as for AIDS and tuberculosis) there needs to be a concerted push to streamline, simplify and harmonize procedures and practices to improve the effectiveness of country-led responses and reduce the burden placed on countries.

Fighting these diseases requires a harmonized approach, i.e. the Three Ones. The “Three Ones”, require that partners go beyond achieving consensus by taking actions to harmonize their approaches and ensure mutual accountability for impact. The "Three Ones" requires that partners harmonize their actions by subscribing to:
• One result oriented strategic and operational plan
• One national coordinating mechanism for implementation support
• One monitoring and evaluation system

Fighting these diseases calls for multiple players and significant resources - both financial and human - working together. Working in partnership maximizes the deployment of available resources, avoids duplication and fragmentation of efforts, and engages each partner's core competencies - allowing each player to do what they do best.

The RBM Partnership Secretariat was just involved in a workshop in Zambia to facilitate the identification and resolution of various planning and implementation bottlenecks. All of the national partners active in the fight against malaria were brought together in the planning process to review the 2006 Zambian National Action Plan, compare actual vs. expected results for the current malaria transmission season, conduct a SWOT (strengths, weaknesses, opportunities, and threats) analysis of current RBM implementation, and use these findings to update the National Action Plan. Each partner was able to add their activities to the plan, so that now there is one National Action Plan with buy-in from all the partners coordinated through the National Malaria Control Programme. We expect that this will dramatically increase implementation of RBM scale up activities this year in Zambia.

At the end of March, the RBM Partnership Secretariat and the Global Fund will co-host a meeting with the Principal Recipients of GF grants from 15 West and Central African countries. The purpose of the meeting will be to identify and resolve planning and implementation bottlenecks and harmonize partner support to these countries. We hope to ensure that countries are able to maximize the use of current resources and leverage further resources for RBM scale up activities necessary to attain a 50% reduction in the malaria disease burden by 2010.

We feel that working together to harmonize partner support to countries is a key to better implementation at the country level.
_________________
Mr. Richard M. Carr
RBM Partnership Secretariat (RPS)
Technical Officer, Country Support Development (CSD)
Room L 253, hosted by WHO, Geneva
Tel: +41 22 791 3518
Fax: +41 22 791 4824/1587
e-mail: carrr@who.int
web: http://rbm.who.int/partnership

Stéphane P. ROUSSEAU - Feb 21, 2006

There is one particular body that have well proven to be paramount to the smooth running of the whole GF process – and yet – is not an integrated part of the in-country Global Fund architecture: that is the Technical Working Group (TWG). The latter being defined as "a pool of country-based technical experts" from Government, local and international NGOs, UN agencies, bilateral agencies, independent experts and naturally people living with the disease so as to ensure technical decision are realistic and appropriate. Unlike the CCM it does not strictly need to be representative of all constituencies, it needs first and foremost to be technically competent, motivated and manageable. Many countries have already established TWGs, but there is no real standard on the latter, and they may work at very various level of efficiency. One may then recommend that TWG be formally part of the in-country GF architecture with specific requirements alike was done for the CCM (but with very different requirements) .

TWG should not play a mere technical advisory role to the PR, rather they should be directly responding to the policy-making and supervisory CCM and provide technical advices to the latter and warn of projects bottlenecks when appropriate.

Among the very critical role TWG can play in the process are the following:
Ø Actual preparation of the proposal (strategy, policy and technical aspects). Unlike written in the book, it is not the CCM that writes the proposal but the technical experts (with people concerned, PLWHA) in the background. Prevents the “reinventing of the wheel”.
Ø guiding the PR and SR in its technically-related decisions.
Ø preparation of the Procurement Guidelines.
Ø preparation of the Procurement Work Plan (policy, specification++)
Ø preparation of the Monitoring & Evaluation Plan (indicators notably)
Ø assisting the assessors when they come.
Ø advising the CCM on the trends of the projects.
Ø Assisting in the writing of the various reports
Ø Identify the weaknesses and bottleneck in the implementation and advise the PR on how to remedy
Ø Draft the Terms of Reference of the Technical Assistance needed, etc

Naturally, all these are extremely time-consuming and demanding tasks and for these TWG to function efficiently, organization/agencies should formally accept that their experts will contribute actively to these TWG. In other words it should be clearly understood by the experts that their participation is part of their core work, and represents an active contribution from their recruiter to the GF-funded projects.
It is therefore not a simple and easy thing to develop a functioning TWG, but it very likely to be worth the investment.
For a number of reasons, the CCM is not the place to discuss technical details, and yet the PR cannot have all the technical expertise required to cover all the technical questions it encounters.

Last but not least should TWG become part of the GFATM in-country architecture, countries should be advised to adopt/adapt any TWG already existing rather than creating new ones from scratch solely for the GFATM purposes. Ideally, these TWG should not be following only GF-funded project but all relevant activities in the country.

I believe good functioning TWG – that follow closely the development of the GF-funded projects -- will likely answer most of the two questions asked in this forum session. Indeed for the question b, I do not think that Global Fund should get more closely involved at the country level, it should rather ensure/assist/nurture the local partnership function efficiently, notably within… Technical Working Groups! 

Kind regards to all.

Stéphan
Manila, Philippines

basmakh - Apr 10, 2006

The Global Fund should always ensure additionality with other partners involved in fighting the epidemic diseases, ie. The Donors and Government. To make sure that at the country level Donors are funding programs which are complimenting each other .Taking into consideration that sustainability of the response in fighting against the three diseases is very important .

Stéphane P. ROUSSEAU

kaizer - Mar 10, 2006

Its a welcome development that a forum like this was created for all concerned individuals to make their contributions. Its a very difficult thing to entrust an individual or a group one hardly knows with funds meant for projects,why because most times the funds end up being diverted for personal use.What with the situation of the receiving countries which are bedevelled with corruption from the highest places.
It should be clearly seen that you cant entrust a hungry cat with a fish for safe keeping,no matter the grammer involved the fish is good as gone.The developing world has all sorts of problems which range from poverty to diseases,ignorance etc.and this has almost led to a situation of everyman for himself,no body cares about his neighbour anymore but for what he can make for himself. I dare to say here that its only GF that can decide how the funds can be judiciously spent. If a proposed project is found worthy,apart from investigating the receiving body a staff of the organization (GF )should be attached to the body to ensure proper disbursement .
I personaly believe anything short of this would continue to make some people rich at the expense of others. Here in Nigeria treatment for tuberculosis is free and how many people know this, TB is still on the increase in the country and still claiming lives. You'd be surprised to find how much WHO has spent on the so called campaigns, still an ordinary man on the street does not know this. If there is any fund to be disbursed for any project, there should be a staff attached to ensure proper disbursment pending the time things improve. Thanks

Ole Skovmand - Mar 05, 2006

The Global Fund is doing a unique and very good work in accumulating economic support for the control of the three diseases. But when it comes to transfer these moneys to national programs, it is disastreous slow process that delays national programs for months and often means that money for mosquito control are not available before the rainy season is over. For the moment, this process is getting worse. The well intended Paris convention of 2005 stated that national ownership is a first priority, which in principle is fine, but with the current practise develops into enormous delays. During the discussions in a working group under the Roll Back Malaria Partnership last week, a private company complained a about a stock of 36 mio dollers long termed impregnated nets because fund release are slow. UNICEF had reserved a great part of this, but money are stocked in national ministries of finance that on one side had headaches of following the complicated rules for fund transferring and on the other side have great interest in not doing it too quickly since the fund transfer also is used to temporarily boost the dollars reserves of the country. The ministries of health's have often not enough impact to change things on a national level, and it would be better if the Global Fund could set up procedures and demands that assures a much faster transfer to the national health campaigns. Typically, the procedure is like this: the national program develops a program and ask for support from Global Fund and obtains it after program review: absolutely OK. Then the funds are transferred to the national ministry of Finance that immediately converts it into local currency and set the dollars on the national reserve. 6 months later, the money are transferred back to dollars and used to pay for the equipment for the campaign as originally planned - but that delay often means it is too late for the yearly campaign and it is deeply discouraging for the national campaigns that cannot make a proper planning and implementation. The politics of national ownership, transparency and accountability has developed a problem of delay that Global Fund has to do it's best to solve.
_________________
Ole Skovmand
Intelligent Insect Control
France

kamundulio - Feb 27, 2006

It is an honor to be part of this discussion.

I have a thought. I have watched NGOs, governments and other entities either waste funds or get dismayed at wastage of the same by their partners.I keep wondering why these funds keep getting dished out anyways.But that is not the issue right now.

I believe the GF has mechanisms and the capacity to do this. Is it possible for you to screen these NGOs and whoever else you are working with?l know you could be doing the screening. But why don't you make it tighter? For instance, when an organization requests for funding, can you get to ask other people about them and their claims of objectives set.l know you have technical groups in your working regions. But why is it there are problems when it comes to transperancy with some organizations recommended by these members of the groups?

The GF could actually set out their own contacts. This would help in funding organizations that are transparent and those that actually deliver.

The GF goals are not dreams. These are actually achievable. But a lot of input in terms of screening needs to be done. Also a note on your technical teams. You don't want somebody there for over 4 or 5 years. People get comfortable and at some point too comfortable. Even 3 years is better. These comfortable members would be the dead weight that GF needs to shed to achieve more transparency.

Maria Wanza
Trans World Radio
Nairobi, Kenya
_________________
Greater power, greater responsibility

Heath - Feb 24, 2006

Greetings,

A) Architectural--If I accurately understand the role of the Local Fund Agent, it seems that the LFA would be the entity responsible for discovering programme strengths and weaknesses. In turn, the LFA and others could reasonably anticipate future challenges. "Technical Working Groups" as described above by Stephane' would complement the role of the LFAs and contribute to keeping PRs and CCMs well informed of anticipated challenges and possible solutions. If such an arrangement constitutes a modification or change, it might be one worth considering.

B) I think the GFs current country-level partnership initiatives are excellent ways to maximize the use of local resources in recipient countries. It seems to me that these initiatives encourage sustainability.

rosminiday - Feb 23, 2006

To ensure that the GFATM budget has an impact on the country program, we should develop a new system for financing to ensure the budget is used in a proper way. As in my country (Indonesia), the Principal Recipient (PR) is the Ministry of Health (MoH). The budget is not entering the existing system in the MoH. We establshed a Programme Management Unit and hired a Financial Officer, accountant and staff.

In each province and district which the GFATM finances support , a Programme Management Unit should also be established.

However, the technical staff implementing programmes are mostly government employees. To make the GFATM work more closely with the country, the Fund Portfolio Manager should routinely visit the country, say every 6 months to see the progress of the program and also to see how the CCM works.

Timothy Mbugua - Feb 22, 2006

The achievements that GF has made in a short span of time need not be gainsaid. However, for greater impact to be achieved, there is need for a holistic approach to the whole issue of health and health financing especially in the developing world. One of the key bottlenecks that need to be addressed is scarcity of health personnel particularly doctors and nurses. In many countries one doctor is expected to attend to thousands of patients. The GF need to network with other like minded organizations and institutions like the World Bank, WHO, UNAIDS and UNICEF to identify areas in which they can complement and reinforce each others effort in addressing this issues, otherwise no matter the amount of funds allocated to drugs and treatment, without the doctors and the nurses to undertake administer them the anticipated impact won’t be achieved.

The GF architecture including Country Coordination Mechanisms (CCM), Principal Recipient (PR), Local Funding Agent (LFA), Technical Review Panel (TRP), need to be more fine-tuned and their respective functions and roles well specified to avoid friction and unnecessarily overlapping of duties. For instance, the according to the GF regulations grants are approved for various countries but it only sign contract with the PR. Besides, in legal and contractual terms the responsibility to implement and report rest with the PR and not the CCM, government or the LFA, yet the CCM is the body that is meant to oversee the process of selection and disbursement. The roles of CCM, PR and sub recipient need to be well defined. Closely related to this, is where the CCM in some countries have been dominated by one group to the detriment of the others. Some CCM have been dominated by the government effectively elbowing out other players. Another problem noted is where the CCM outsource technical support in for instance proposal writing. There are cases where the engaged consultant may produce the proposal without adequate consultation and participation of the CCM and other and stakeholders. This may lead to ownership problem and affect implementation. The Global Fund can work more closely with country-level partners (including government, civil society, business private sector, private foundations, and multilateral agencies) to ensure implementation challenges like these are addressed in an accountable and effective manner.

T.K. Mbugua

kokoi - Feb 21, 2006

Still I want to deal first with specific areas in project and program implementation these are;
1. Capacity and capability of implementors should be take into consideration. In most cases programs and projects implementation are having problems because of personnel's limited knowledge on managing a project. What the global fund can do is to look in the proposal the Training Needs Assessment (TNA) of implementors.

2. In reviewing proposals, statement or plan on sustaining the program should always be included. Some grant can cause a degree of dependency on partner agencies or government thus failed to sustain. Global fund should look into a well developed a "Weaning Process" in the proposal and this should be a part of policy in approving a grant. Meaning the GF can always start the funding but sustainability after the completion of timelines of every project should always be the responibility of partner agencies or governments.

3. Monitoring and process evaluation should be done by GF along with regular stakeholder meeting towards improvement of service and implementation of project.

4. Careful and thorough review of existing policies and guidelines should be done inorder to adapt to the trend of everchanging needs as determined by evidence - based studies.

tarigwafa - Feb 21, 2006

Dears ; Administrator and Memebers
I was involved for the two past days in a workshop titled " THE ROAD TOWARDS UNIVERSAL ACCESS TO AIDS PREVENTION ,TREATMENT AND SUPPORT " By UNAIDS in Sudan.The GF has given a greater part of the discussion during these couple of days ,because it's the only fund in the scene and all other partners are shading including the National support from the country .
In my opinion, I think GF has to keep pressures on its target countries gevernments to put a considerable amount of local resources paralelled to its contribution.

Greetings to Amna ;GF representative in SUDAN for giving us a comperhensive look about GF in SUDAN during the workshop.
Greetings to ALL.

Dr.Tarig Dafallah
Gezira State AIDS Coordinator
Wad Madani - SUDAN

Ben Karenzi - Feb 20, 2006

1. The Global Fund should always ensure additionality with other partners involved in fighting the epidemic diseases, ie. World Bank (MAP), PEPFAR, Bilateral partners. This is better addressed at country level coordination mechanisms. Governments have to play a leading role in this.
2. The Global fund should aim at consolidating good work through performing grants. Rather than look for or jump to new proposals, it is important to consolidate ongoing performing projects. I would propose, therefore, serious consideration of "third phase" financing of ongoing well performing projects in addition to seeking out new projects.

Feb 20, 2006

Message from Grace Kyeyune
Sent: Monday, February 20, 2006

Thank you so much for availing me this chance to discuss about the way the impact of the Global Fund could be improved. There is a lot of knowledge to be derived from our indeginous resources e.g. the medicinal plants accessed by approximately 80% of Africans in health care (Nutritional and for therapy).

A number of HIV, Malaria and T.B debilitated patients in Uganda are known to be accessing a diversity of biomaterials which still require, authentication, documentation and research to comfirm their therapeutic contributions, i.e. role in immunoboosting, or curative properties. Subsequently these could provide leads to antiretrovirals or other interventions that are safer. The Global Fund clearly shies away from this kind of research and this is a real shame.

No wonder the scourge of AIDS has overstayed with us. Personally I have lots of formulars that would be very helpful just requiring validation. likewise the Institute of Natural Chemotherapeutics Research
Laboratory (Ministry of Health in Uganda) that I'm heading would have a lot to offer if it chances any form of funding.

Dr Grace Nambatya Kyeyune (PhD Chemistry)
DIRECTOR OF RESEARCH
NATURAL CHEMOTHERAPEUTIC RESEARCH LABORATORY
MINISTRY OF HEALTH