Global Fund-supported programmes’ contribution to international targets and the Millennium Development Goals: an initial analysis
Ryuichi Komatsu a, Daniel Low-Beer a b, Bernhard Schwartländer a
Various international partners have committed to efforts to reach treatment and prevention targets for HIV/AIDS, tuberculosis (TB) and malaria. These targets contribute to the Millennium Development Goals (MDGs) adopted by countries at the United Nations Millennium Summit, particularly Goal 6 to combat HIV/AIDS, malaria and other diseases. Global resource needs in 2006 are estimated at US$ 14.9 billion for HIV, US$ 3.1 billion for TB and US$ 2.8 billion for malaria.1 Many funding partners are involved globally in addition to substantial domestic financing, including loans and out-of-pocket payments for prevention and treatment.2–4
The Global Fund to Fight AIDS, Tuberculosis and Malaria is one of the largest funders to support low- and middle-income countries in fighting these diseases, which are critical to achieving health-related MDGs.3–12 As of mid-2006, the Global Fund has approved proposals worth US$9.6 billion, of which US$ 5.5 billion is approved and committed in 132 countries. Based on these approved proposals, a total of 333 programmes have been funded, US$ 4.1 billion worth of grant agreements signed and over US$ 2.4 billion disbursed to the recipients. Over half of funding goes to fund HIV/AIDS programmes; nearly 30% goes to fund malaria and 15% to TB programmes. Financial contributions through the Global Fund are estimated at 21% of international funding commitments for HIV, 67% for TB and 64% for malaria.1
It is important to link financial inputs to programmatic outputs, then to link results by Global Fund-supported programmes to international targets, and over time to assess progress towards the MDGs. To date, the results have been presented in relation to Global Fund-supported programme targets, but not to wider international goals. Based on a recent Global Fund progress update,13 this paper relates the Global Fund-supported programmes results to international targets as well as presenting a framework to further track progress against international targets.
Present results and future targets for Global Fund-supported programmes were compared against international targets. Current results and targets for Global Fund-supported programmes also were compared. Results for Global Fund-supported programmes were reported from 333 grants in 127 countries and aggregated. Five-year targets from the proposals approved for the Global Fund’s Proposal Rounds 1 to 4 (2002–2004) were aggregated to 2009. International targets for programmatic service delivery were taken from targets agreed-upon by major disease-fighting partners.
Results of programmes
Grantees periodically report their results to the Global Fund Secretariat as a basis for performance-based funding. Programmes choose indicators for which data may already be collected, generally from standard sets of indicators agreed upon by major partners.14 The indicators should reflect progress in the service delivery areas approved in the proposals. The Global Fund Secretariat asks grant recipients to include at least some selected service delivery indicators of people reached by services (known as the top ten indicators), such as the number of people treated on antiretrovirals (ARV), the number of new smear-positive TB cases detected under the DOTS strategy and the number of insecticide-treated nets (ITNs) distributed.14 The reported data are verified by local agents who act in countries on behalf of the Global Fund to ensure accountability (Table 1). The data are then compiled at the Secretariat (grantee-submitted reports are available at: http://www.theglobalfund.org). The indicators on the same service in a country were assessed for overlap, as different grants may separately report on the same service or report overlapping services in a country. For example, one indicator may report on the number of pregnant women on ARV and another on all adults on ARV. Some programmes report national figures due to the large amount and integrated nature of Global Fund support filling financial gaps in national programmes. In particular, national ARV figures are taken for countries where the support is essential for ARV treatment (laboratory/infrastructure support, training, drugs/commodities or management) on a national scale, the programme is performing well and raises no significant data quality issues, and significant financial resources contribute to the national effort (disbursement over US$ 10 million). ARV figures are also verified with other major donors to assess consistency and overlap supported dually by the Global Fund and an aid programme sponsored by the United States of America, the President’s Emergency Plan for AIDS Relief (PEPFAR).15,16
Targets of Global Fund-supported programmes
The targets of Global Fund-supported programmes were projected based on the presently approved and agreed-upon proposals, from Round 1 to Round 4. Proposals are made for five years, with a few exceptions. The targets regarding ARV, DOTS, and ITNs were extracted from board-approved proposals. All approved proposals are available on the Global Fund web site (http://www.theglobalfund.org). Proposals are funded only for the initial two years, and the remaining years are contingent on adequate performance; this analysis included all years of proposal lifetime. As of May 2006, 5 out of 140 grants were recommended by the Secretariat to be discontinued for Phase 2 funding. The timing of the start of programmes also was taken into consideration, as it took 11 months on average from proposal approvals to sign grant agreements and initiate funding disbursement. The targets are presented as cumulative until the end of 2009. It is not the Global Fund Secretariat that decides the targets; the country sets targets based on the targets it sets for its programmes, which may include inputs from the country and other donors.
International targets for ARV
As the MDGs were decided before the global ARV scale-up era, they do not include ARV. This scale-up is an indicator set by the United Nations General Assembly Special Session on HIV/AIDS, a key international goal. By 2005, the “3 by 5” initiative led by WHO and UNAIDS provided the major international target for ARV scale-up. This initiative resulted in a level of ARV scale-up which was not considered possible before the initiative started in 2003, but met only half of the international target.15 For the future target from 2006 to 2009, we used the projected number of people on ARV considered for the UNAIDS resource estimates in 2005.4 This is estimated to reach 9.8 million people on ARV by 2010 and to cover 68% of ARV needs, defined as people living with HIV two years before death.
International targets for DOTS
The internationally publicized targets for TB control are to detect 70% of new sputum smear-positive cases and to treat 85% successfully under DOTS programmes. WHO estimated 3.9 million new smear-positive TB cases occurred and a case detection rate of 53% as of 2004;3 these were used as the 2004 targets. For the 2005 targets, the case detection rate was set at 70% and 3.9 million new smear-positive TB cases were assumed. These numbers include high-income countries, but no adjustment was made since cases from these countries are relatively few in number. From 2006 to 2009, the number needed for each year was calculated based on the target numbers of new smear-positive TB patients treated for 2006 and 2010 published in The global plan to stop TB, 2006–2015.17 The estimated international targets were accumulated since mid-2004 to be comparable to targets and results for Global Fund-supported programmes.
International targets for ITNs
The Abuja target, set by the African Summit on Roll Back Malaria in 2000, calls for protecting 60% of populations at high risk for malaria, namely children under 5 years of age and pregnant women, with ITNs in sub-Saharan Africa.12 Assuming that one ITN is needed to protect one high-risk person (this is a conservative estimate, as an ITN is often used to cover one mother and one child), the number of ITNs needed to cover 60% of the population living in malaria risk areas was calculated. The at-risk population was estimated for WHO deriving from the MARA map exercise.18 This country-specific information was extrapolated using population projections19 and aggregated for three sub-Saharan African regions covered by Global Fund grants. Accordingly, Global Fund targets and results on ITNs were presented only for sub-Saharan African regions in comparison with international targets. Re-treatment for insecticide and replacement of worn-out nets were not considered.
A comparison of Global Fund-supported results to international targets is shown in Table 2. Aggregated results from Global Fund-supported programmes reached 544 000 people for ARV, 1.4 million for DOTS and 11.3 million for ITNs by June 2006, an increase from 384 000 people on ARV, 1 million for DOTS, and 7.7 million for ITNs by 2005. ITNs for sub-Saharan Africa numbered 5.1 million by 2005 and 6.3 million by mid-2006. International targets for ARV were 3 million by the end of 2005 (the “3 by 5” target); ARV delivered by Global Fund-supported programmes contributed 13% of the “3 by 5” target, which was 29% of actual global results of 1.3 million people on ARV. Cumulative estimates for DOTS treatment were 3.8 million by the end of 2005; the share of this provided by Global Fund-supported programmes was estimated at 26% of the international target by 2005, and 29% by mid-2006. In addition, international ITN targets were estimated for sub-Saharan Africa at 69 million ITNs by the end of 2005, and the contribution by Global Fund-supported programmes was 7% of the estimated international target for 2005 in sub-Saharan Africa and 9% by mid-2006.
Global Fund-supported programme targets by 2009 were to provide 1.6 million people with ARV therapy and 3.5 million people with DOTS treatment, and to deliver 100 million ITNs (Table 2). International targets for ARV were calculated as 8.3 million people on ARV out of an estimated international 12.4 million people needing treatment in 2009. Global Fund-supported programmes aimed to deliver 19% of this 2009 international target. International cumulative targets estimated for DOTS were 12.3 million in 2009. The proposed targets for Global Fund-supported programmes aim to contribute 28% of the international target by 2009. International ITN targets were estimated for sub-Saharan Africa at 76 million ITNs by 2009. The aggregated targets for Global Fund-supported programmes in the sub-Saharan African region were 64 million ITNs, or 84% of the international target, by 2009. This shows that the targets of programmes supported by the Global Fund should contribute significantly towards an impact on malaria. If one ITN covers more than one person, the actual coverage would be higher, but this target does not account for needs to re-treat ITNs once the insecticide loses its effectiveness or to replace worn-out nets.
Global Fund-supported programmes also show progress in reaching targets set by countries (Fig. 1). These targets by Global Fund-supported programmes were set at 350 000 people on ARV, 700 000 receiving DOTS therapy and 5 million ITNs by the end of 2005. The corresponding results reported by these programmes totalled 384 000 people on ARV, 1 million receiving DOTS treatment and 7.7 million ITNs. By June 2006, these figures increased 42% for ARV (544 000), 43% for DOTS (1.4 million) and 47% for ITNs (11.3 million).
Table 2. International targets and targets and results for Global Fund-supported programmes for ARV, DOTS and ITN
HIV, TB and malaria result in an annual loss of well over five million lives and enormous burdens of illness and economic impacts on households, communities and countries. The achievement of international goals to control of HIV, TB and malaria by 2015 would result in approximately 50 million lives saved, based on calculations of 31.1 million HIV infections averted,20 14 million lives saved from TB17 and a total of 2.5–5 million direct malaria deaths averted by 2015 if mortality is halved by 2015 from a baseline of 1 million direct malaria deaths per year.21 Overall, Global Fund-supported programmes contribute substantially to international targets, but these require considerably greater financing and service delivery, particularly for HIV, to achieve international targets by 2015. By mid-2006, Global Fund-supported programmes contributed 18% of ARV targets, 29% of treatments needed to achieve the international target for DOTS, and 9% of ITN distribution needed to achieve international targets for malaria.
Data used in this exercise have inherent limitations. First, countries select indicators and set targets. Some grants use indicator definitions that are not perfectly consistent with other grants or are not standardized with international definitions. Second, future targets do not guarantee results, though the results so far have reached grant targets overall.13 Third, despite safeguards installed to verify reported results and extensive analytical exercises to validate and cross-check indicators, errors might still take place. A preliminary analysis of on-site data quality verification showed that 70% of indicators were within a 10% error margin, and that errors were not biased in one direction with both over- and under-reporting.22 Uncertainty ranges around data have not been assessed to date. Importantly, the results and targets are due to country programmes and efforts, where the Global Fund provides financing alongside other donors. Global Fund financing, due to its gap-filling nature, is an integral part of country programmes supported by several sources. Finally, international targets need to be updated as new targets are agreed upon or operationalized. Despite these limitations, the analysis presented herein is the best estimate currently available, and provides a first assessment of the programmatic output of Global Fund-supported programmes against international targets.
Global Fund-supported programmes have provided substantial contributions to ARV treatment for the “3 by 5” target. Programmes have also demonstrated the effectiveness of country-driven targets, as overall grant-financed programme targets for ARV treatment have been reached. Global Fund-supported programmes contributed 29% of global results of 1.3 million people on ARV for “3 by 5” but only 19% is targeted by 2009. We have the opportunity to save millions of lives through future investments in effective prevention measures; such investments should lead to substantial savings by reducing the future number of people needing AIDS treatment. Between 2005 and 2015, it is estimated that 31.1 million HIV infections could be averted globally if an effective package of prevention, testing and treatment activities is funded and implemented.20,23 Further analysis regarding prevention efforts is needed to assess contributions towards the MDGs.
The international targets for TB control are to achieve a 70% case detection rate in all high-burden countries and an 85% rate of successful treatment by scaling up quality programmes under DOTS; these interim targets seek to halt increases in and begin to reverse burdens by 2015.24,25 Globally, 1.7 million new smear-positive cases of TB were provided with treatment under the DOTS strategy in 2003.3 Global Fund-supported programmes reported a 29% contribution to international increases in case detection to date. By 2009, 28% of cumulative treatment is projected to be provided by Global Fund-supported programmes; almost 41% of the target for TB treatment will be provided by Global Fund-supported programmes in the year 2009. Once fully implemented, the Global Plan to Stop TB17 is expected to provide treatment to 50 million people in the next decade and, overall, to save 14 million lives. The HIV pandemic has caused a significant negative impact on TB control, particularly in sub-Saharan Africa. Unless efforts to control the HIV and TB epidemics are dramatically scaled up, MDG targets to halve TB are unlikely to be reached.
In malaria-endemic areas of sub-Saharan Africa, populations at high-risk number 115 million, and 69 million ITNs would be needed to achieve the Abuja target. Two million ITNs were distributed in 2000, 3 million in 2001, 5 million in 2002 and 13 million in 2003.12 Global procurement reached 25 million ITNs in 2005.26 Global Fund-supported programmes have distributed 11.3 million ITNs by mid-2006, with 6.3 million distributed in sub-Saharan Africa. To understand the actual usage of ITNs, population-based surveys are needed. Partners, such as UNICEF (the United Nations Children’s Fund) and the US Agency for International Development-funded MEASURE DHS (Monitoring and Evaluation to ASsess and Use REsults, Demographic and Health Surveys) project, conducted surveys in many grant-funded countries in 2005. Correct ITN use results on average in a 50% reduction of uncomplicated malaria episodes and 5.5 deaths per 1000 children per year in malaria-endemic sub-Saharan Africa.27 Global Fund-supported programmes also procure malaria drugs to further prevent deaths. To reach the MDGs for malaria control, nearly US$ 30 billion will be needed from 2006 to 2015, roughly US$ 3 billion per year. Macroeconomic models showed reducing malaria burdens by 50% by 2015 would have annualized net benefits of US$ 3–10 billion.28 Investments in malaria control are likely to pay off directly in terms of economic returns in malaria-affected countries.
Future results against the international targets depend on programme performance; in the past, 75% of grants achieved an adequate or excellent rating. These grant-funded programmes are still at a relatively early stage of implementation, with the average age of grants less than two years (22 months). Experience has shown that performance of programmes, particularly malaria programmes, tends to lag in the first 18 months of rapid scale up due to procurement bottlenecks or limited management capacities, but once such obstructive factors are alleviated, performance can quickly catch up towards targets.13,29 Studies have found that absorptive capacity of countries with limited resources seems less restrictive than predicted,30 and we also see no sign yet of limits to absorptive capacity. To achieve and maintain the future international targets for TB and malaria, additional funding will be required to re-treat bed nets with insecticides and replace worn-out bed-nets, and to considerably accelerate TB control programme scale-up. It will be important to track the increasing contributions of these grants to global targets in coming years.
In conclusion, country programmes have demonstrated the ability to deliver significant outputs using support from the Global Fund and technical partners. The world’s worst-affected countries are showing their ambition to meet international targets, but efforts need to increase substantially to approach the international targets and MDGs. This study is not about impact on diseases, and it needs to be complemented by a systematic evaluation of impact as part of the Global Fund Five-Year Evaluation31 that includes data triangulation. Because the largest 15 countries receive 50% of disbursed funding,22 further detailed analysis of different resource contexts in country may also yield useful insights. The Global Fund mechanism with the current level of financing, though important, is not yet a sufficient scale to achieve a major impact on the three diseases. ■
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