Joint statement of 4 implementer constituencies

EECA, EMR, LAC and SEA Constituencies Common statement for the 36th Global Fund Board:

HIV Epidemics Data from UNAIDS fact sheet "How AIDS changed everything" (2014):

As we move from Millennium Development Goals (MDGs) to the Sustainable Development Goals (SDGs), accelerating progress towards ending HIV, tuberculosis and malaria is critical. Although there was due cause for celebration after the HIV targets for MDG 6 were exceeded[1], there was and is also necessary concern over the fragile nature of gains made to date. While the world celebrates declining rates of new HIV infections and deaths from AIDS, in Eastern Europe and Central Asia (EECA), the only region in the world that did not achieve the 6th Millennium Development Goal and new infections and AIDS-related deaths continue to grow. While in Middle East and North Africa and EECA region have lowest access to antiretroviral treatment. Middle East and North Africa have highest number of AIDS related deaths relative to amount of HIV in the regions.  Faced with rapid transition to domestic funding, these two regions are not adequately financing programming for the HIV care continuum (including prevention, testing, linkage to care and retention) in particular for stigmatized and criminalized key populations.

Globally, between 2000 and 2014, the rate of new infections decreased by 35%[2] while in EECA it grew by 30%[3] over the same period. Between 2010 and 2015 new infections grew by 53% in EECA[4]. AIDS related deaths declined globally by 41% between 2004 and 2014[5] but increased by 27% in EECA between 2005 and 2014[6]. High rates of co-infection plague the region, with tuberculosis cases increasingly linked to HIV infection and opiate use[7] and hepatitis C virus approaching 80% prevalence amongst PWUD in many countries. The EECA region has the highest rates of multi-drug resistant tuberculosis (MDR-TB) in the world[8].

While still far from reaching targets for access to prevention, testing, treatment, care and support, the countries of EECA , EMR, LAC and SEA regions (most of which are in middle income categories according to the World Bank classification) are faced with rapid transition to domestic funding as they lose eligibility for financial support from the Global Fund. The Global Fund’s eligibility criteria still do not take into account of governments’ limited willingness to pay for programming targeting stigmatized and criminalized populations.

Syria and Libya are examples of inappropriately-scheduled already-transitioned countries. As the conflict in the Syrian Arab Republic entered its sixth year, it continued to trigger massive levels of displacement, with 6.5 million internally displaced persons (IDPs), and over 4.8 million refugees in the neighboring countries (Egypt, Iraq, Jordan, Lebanon and Turkey). The conflict in Libya continued to have severe consequences for civilians, with approximately 350,000 IDPs, over 300,000 returnees and an estimated 100,000 refugees and asylum-seekers in need of protection and humanitarian assistance. The complex humanitarian situation in Yemen continues to be alarming, some 180,000 people have fled the country mostly to Djibouti, Ethiopia, Somalia and Sudan, and further afield.   An estimated 82 per cent of the 27 million people residing in Yemen is in need of humanitarian assistance, including 2.2 million IDPs and almost 950,000 IDP returnees.  [9]

As a country in transition, the sectarian violence that dramatically increased in much of Iraq since 2014 has displaced more than 2.5 million people. This, combined with the quarter of a million refugees fleeing to northern Iraq from the conflict in Syria, have put a great strain on a health system that had been making modest progress in its recovery from the prolonged crisis of the past decade. The frequent mobility and the cramped living conditions of those displaced are a particular challenge for the country’s tuberculosis (TB) programme.[10]

Iraq is home to one of the highest TB rates in the region, with about 15,000 new cases annually. The Iraqi health system has been badly affected due to the long years of war and sanctions. The current TB crisis threatens to wipe out the progress made since 2008. Patients who fled their homes have stopped their treatment, case detection is disrupted, and the deteriorating conditions in which displaced communities survive have fueled the rapid spread of the disease. Interruption of TB treatments, which normally require over six months of close monitoring, is now likely to lead to an increase in multi-drug resistant (MDR) strains of TB. It is much more difficult and longer to treat MDR patients and it implies a higher burden for the government. The cost of treating MDR-TB is about ten times the cost of regular TB. It is a regional issue as countries receiving refugees from Iraq are now exposed to the spread of TB. Domestic spending on the health sector has decreased dramatically as funds are re-directed to deal with the conflict in large parts of the country. According to the Ministry of Health, currently 75-85 percent of the health budget pays for salaries and recurring costs.10

Tunisia has also been struggling with refugee crisis from Libya and other North African countries while it is in process of transition out of Global Fund.

In the WHO Region of the Americas, about 112 million people in 21 countries and territories are estimated to be at some risk for malaria, with 20 million at high risk (reported incidence >1 per 1000 [Figure A]). P. vivax is responsible for more than 70% of reported malaria cases in the region, although P. falciparum malaria comprises more than 50% of cases in French Guiana (France) and Guyana, and essentially 100% of cases in the Dominican Republic and Haiti (Figure F). Belize, the Dominican Republic, Ecuador, El Salvador and Mexico are in the pre-elimination phase and three countries are in the elimination phase (Argentina, Costa Rica and Paraguay). The remainders are in the control phase.

The number of confirmed malaria cases in the region decreased from 1.2 million in 2000 to 390 000

in 2014. Three countries accounted for 77% of cases in 2013: Brazil (37%), Bolivarian Republic of Venezuela (23%) and Colombia (17%). Between 2000 and 2014, decreases of more than 75%

in the incidence of microscopically confirmed malaria were reported in 15 of the 21 countries and territories that had ongoing transmission in 2000 (Argentina, Belize, Bolivia [Plurinational State of], Brazil, Colombia, Costa Rica, Ecuador, El Salvador, French, Guiana [France], Guatemala, Honduras, Mexico, Nicaragua, Paraguay and Suriname). In Haiti, it is not possible to discern clear trends, because of differences in diagnostic testing and inconsistent reporting over time. However, diagnostic and surveillance systems have improved in recent years. The region reported 79 deaths due to malaria in 2014, an 80% decline compared with deaths in 2000. Brazil accounts for almost half of the deaths due to malaria in the region. (*)

Regarding TB, globally, most of the estimated number of cases in 2015 occurred in Asia (61%) and the WHO African Region (26%); smaller proportions of cases occurred in the Eastern Mediterranean Region (7%), the European Region (3%) and the Region of the Americas (3%). The Region of the Americas achieved the target of 50% TB prevalence reduction, as well as the target of a 50% reduction of TB mortality; and the TB treatment coverage achieved higher levels of above 75%.

In 2015, the total TB cases notified were 230.519 in the Region of Americas, with the highest percentage of TB patients with known HIV status (82%). The estimated incidence (including HIV+TB) was 268.000 (250.000–287.000) and the estimated incidence of MDR/RR-TB was 11.000 (10.000–12.000).

Among the six WHO regions, the highest treatment success rates in 2014 were in the Western Pacific Region (92%) and the Eastern Mediterranean Region (91%), and the lowest (at 76%) were in the Region of the Americas (due to high levels of loss to follow up and missing data) and the European Region (due to high rates of treatment failure and death, influenced by the high frequency of MDR/RR-TB). There were particularly large differences in the Region of the Americas where the treatment success rates for HIV-positive TB patients were 56%compared with 77% among HIV-negative patients.

Overall, the proportion of MDR/RR-TB patients in the 2013 cohort who successfully completed treatment (i.e. cured or treatment completed) was 55. Loss to follow-up was highest in the WHO Region of the Americas (25%).

Globally, the 87 236 children who started on TB preventive treatment in 2015 represented 7.1% (range, 6.9–7.4%) of the 1.2 million (range, 1.18 million to 1.26 million) children estimated to be eligible for it. Higher levels of coverage were achieved in the WHO Region of the Americas (best estimate 67%; range, 63–71%) (**)

By the end of 2015, in Latin America and the Caribbean, there were an estimated 2 million [1.7 million–2.3 million] people living with HIV, an estimated 100,000 [86,000 – 120,000] new HIV infections, and an estimated 50,000 [41,000 – 59,000] AIDS-related death. Approximately 55% [50 – 57] of people living with HIV have access to antiretroviral therapy, although variation between and within countries exists. The number of HIV infections among children were estimated in 2100 [1600 – 2900]. (***)

The bulk of the cases, nearly 75%, are spread among four countries: Brazil, Colombia, Mexico and the Bolivarian Republic of Venezuela. Approximately 60% of people living with HIV in the region were men, including heterosexual men and gay men and other men who have sex with men. HIV prevalence among general adult population was estimated to be 0.4%. Central American countries, with 7% of Latin America’s population, accounted for 9% of people living with HIV in 2013.The epidemic is mostly concentrated in urban settings, along commercial routes and in trading ports. Most vulnerable key populations to HIV in Latin America include transgender women, gay men and other men who have sex with men, male and female sex workers and inject drugs users. Latin America continues to be a region with a high antiretroviral coverage. Regarding the Caribbean, five countries account for 96% of all people living with HIV in the region: Cuba, the Dominican Republic, Haiti, Jamaica and Trinidad and Tobago. Haiti alone accounts for 55% of all people living with HIV in the Caribbean. While the Caribbean region is home to only 0.7% of the global total of people living with HIV, infection rates remain high. The overall HIV prevalence in the region is 1.1% [0.9–1.2%], with the highest prevalence of 3.2% [3.1–3.5%] found in the Bahamas. Haiti alone accounted for 59% of all AIDS-related deaths in the region. (****)

Vulnerabilities faced by Caribbean countries

According to the Caribbean Regional Strategic Framework for HIV and AIDS 2014-2018, Caribbean countries, including Jamaica, share special vulnerabilities common to small island developing states (SIDS), which constitute severe and complex challenges to sustainable development and to sustaining the gains in AIDS, TB and Malaria in the absence of responsible transition.  These include:

• High levels of exposure to frequent and devastating natural disasters. Because of the small land mass, high population density and limited resources for disaster preparation and recovery, natural disasters often have disproportionate and long-lasting economic, social and environmental consequences. The six countries of the OECS rank among the top 10 most disaster prone countries in the world, measured in terms of disasters per land area or population. All Caribbean countries are listed among the top 50 hot spots for natural disasters.
• Vulnerability to climate change and sea-level rise. The Caribbean islands and low-lying continental entities are vulnerable to the adverse effects of climate change and sea-level rise, which are expected to worsen and, therefore, present a serious risk to the sustainable development of the region.
• Many Caribbean economies face high and rising debt-to-GDP ratios that jeopardise prospects for medium-term debt sustainability and growth. Average debt exceeded 76 percent of GDP in 2014 with rates of over 100 percent in Jamaica and St Kitts and Nevis.  A number of Caribbean states are unable to finance their high debt, while Antigua and Barbuda, Jamaica and St. Kitts and Nevis have moved ahead with debt restructuring.
• Additionally, the Caribbean has recently been plagued with new diseases such as Chikungunya and Zika which place increase burden on national health budgets.

Vulnerability as a criteria for development assistance

The challenges Caribbean countries face in transitioning should not be seen as a dereliction by their Governments, instead they should be viewed as special vulnerabilities that confront these Small Island States. These vulnerabilities place significant pressure on their economies which currently do not have the fiscal space to facilitate responsible transition from external donor funding within narrow timeframes being proposed by the Global Fund. 

In reviewing its Development Cooperation, Japan concluded that per capita income levels alone do not capture the severity of each issue, such as the development challenges of the individual countries and their special vulnerabilities[11]. For the future Japan’s development cooperation aims to achieve “quality growth” accompanied by: “inclusiveness” in which no one is left behind and everyone can benefit from the fruits of development.  This aim mirrors UNAIDS mantra, “No one left behind”.  We are reminded that the Global Fund’s new Strategic Framework is fully aligned with the Sustainable Development Goals embraced by member states of the United Nations in September 2015, with a holistic and multidisciplinary approach that seeks to reach those most in need, reduce inequalities, and support sustainable transition across the development continuum as countries move toward self-sustainability. We therefore call upon the donors of the Global Fund to provide the Secretariat with the latitude to work with and support countries to venture onto a path of sustainability, which can only be achieved through responsible transition.

There is a need to continue increasing Global Fund investments in middle income countries as HIV prevalence is growing and high burden on MDR-TB exists and most at risk populations affected by the three diseases are poverty stricken; it’s crucial to address their needs and ensure timely access to health services.. For example, Iraq, Iran, Chile, Venezuela, Algeria, Malaysia, Russian, Bulgaria, Serbia, Bosnia and Herzegovina, Macedonia, Montenegro, Romania and the Central African Republic all receive less than one fifth of expected development assistance for health. Many countries would benefit significantly from additional Global Fund investment in order to sustain low HIV and TB prevalence.  External funding for some regions – such as Eastern Europe and Central Asia and Latin America and the Caribbean – has fallen, whilst it has increase in a smaller sub-set of countries in other parts of the world.

How transitions are currently being managed:

1. Transitions are implemented ad hoc. There is no consensus on the best model for guiding countries through a responsible transition. A variety of frameworks and criteria has been put forward by several different sources.
2. Transitions may threaten key populations. There is uncertainty about how to ensure key populations are not cut off from services through a transition. Key populations programming is often heavily donor-funded and not eagerly absorbed by governments.

Transitions need to be based on the following sets of principles: (1) transparency and predictability, (2) good practice, (3) human rights and (4) flexibility:

1. Transparency and predictability – discusses how we might better anticipate which countries will move to self-reliance and when.
2.  Good practice – looks at the available literature on good practice for transitions, sharing models and frameworks which others have developed to guide countries and donors in this process.
3. Human rights – asks important questions about how transition impacts vital key populations and human rights interventions.
4. Flexibility- the GF should properly define technical and financial sustainability components to protect and improve achievements.

Recommendations:

1. As Government Constituencies we need realistic time for country policy change and development of domestically-funded AIDS, TB and malaria responses that are evidence-based, focused on key populations and are gender, age and ethnicity responsive.
2. The Global Fund should provide technical support for countries to develop realistic plans and mechanisms for sustainable transition over the next 5 to 10 years to ensure Health System Strengthening and enhancing National Programs to achieve Sustainable Development Goals by 2030.
3. A support mechanism should be available to countries which have become ineligible for Global Fund support and finished their last grants, but have not been able to undertake any sort of structured transition planning process. Global Fund should have mechanism to safeguard key populations in countries which fail to transition successfully.
4. Advocacy investment is needed to support efforts to reduce stigma and sensitize law-makers, law enforcement and health care providers regarding legal protections of rights of key populations. Legal frameworks should be adjusted to enable social contracting of NGOs for low threshold prevention, testing and linkage to treatment and other services.
5. Global Fund should change eligibility that correspond with the Strategy 2017-2022 for ending epidemics and leaving no one behind and funding allocation should be in correspondence with  available information in national AIDS spending assessments[12]; HIV sub-accounts of national health accounts; public expenditure reviews, United Nations General Assembly Special Session (UNGASS) country progress reports; and other reports – to examine countries’ levels of domestic effort, taking into consideration epidemic size, resource needs, fiscal capacity and space, and amount of external assistance for HIV.
6. Catalytic Investments for the 2017-2019 Allocation Period should be increased in particular the amount dedicated for priority area  for HIV 1.1 Key Populations Sustainability and Continuity the amount of 50 million US$ is not enough to address the challenges in countries that made exit out of the Global Fund without proper transition. “No one left behind” implies the inclusiveness of the largest proportion of target populations living in Middle and Upper Middle Income Countries; such as people affected by TB and poverty – stricken.
7. Together with the catalytic funding, the Global Fund should increase its support through regional initiatives. Establishing regional networks of technical groups and enhancing multicountry or inter-regional cooperation are highly recommended. The proportion of funding should be larger for multi-country approaches and strategic initiatives related with diseases elimination, in order to sustain achievements, due to the fact that the New Strategy 2017-2022 vision of ending the epidemics entails a greater effort to protect the gains and support countries already moving into elimination phase by applying the catalytic funding in the most appropriate way. Cuba has been the first country in the world certified for elimination of HIV mother-to-child transmission and others in the Caribbean will follow soon, it is critical and smart investment to document best practices in elimination and accompany those countries that are close to accomplish the goal.
8. Emergency fund under Catalytic Investments for the 2017-2019 Allocation with total amount of 30 million US$ also need to be increased as there are emerging countries in Middle East and North Africa suffering from conflict and refugee crisis’s where TB and HIV prevalence is increasing : Syria, Iraq, Jordan, Lebanon, Libya etc.  Establish mechanism that ensure the oversee of the in country absorption capacity and the level of performance in the implementation to use funds available for catalytic investments to further ensure scale-up, impact and paced reductions in funding.
9. Enhancing KPI’s to reflect successful transition and ensuring achievement of SDGs by 2030 are recommended, and funding for independent monitoring of performance should be considered.
10. We need to slow-down the current rapid transition in middle income countries (a ‘freeze’ on rapid scale-down of support) and approach it carefully through practical interventions.
11. There are specific countries where small funding would make a great difference in our regions. It would be good we say that instead of non-zero allocation we opt for some very focused/targeted grants (like up to 100K) and NGOs rule, applying the incentivizing component.
12. We acknowledge AFC recommendation on transferring 1.1 billion USD to the next programming cycle. In the meantime the Board shall request Secretariat to ensure flexible approach avoiding non-utilization in current allocation.
13. Countries transitioning may not only fall behind in supporting key population, rules in several countries do not permit community organizations to be funded ( note for ourselves: INO is example for this )
14. With transition , CCM , the dialogue making body between stakeholders, only of such kind may wither away, transition needs to take this into account., Countries can be
15. Incentivisation is a way for addressing to these two issues may be considered and countries agreeing to address these two issues may be eligible for additional funding or increased duration of funding