GFATM GDF Identify GFATM and GDF implications district

GFATM & GDF

• Identify GFATM and GDF implications – district, national, global levels – current, expected • How to address concerns: – short term solutions – longer term solutions • Data needs to study/document the extent/nature of these impacts? • Existing human, technical & financial resources, organizational structures to be harnessed? New resources/efforts? Discussion Objectives

• Awareness of the burden and cost of disease associated with poverty – – – Commission on Macro Economics of Health HIPC Millennium Development Goals Access to drugs for neglected diseases Amsterdam Conference on TB & Sustainable Development • Awareness of the need to reject ‘business as usual’ – demand-led not supply-led – results-based – public-private partnerships Why a GDF & GFATM?

• 50 years since TB treatment developed BUT • 39 months to reach the global targets The Need for Urgency

• A novel approach to secure access to high quality drugs to accelerate DOTS expansion, addressing four needs: – – The need for more resources for TB drugs The need for high quality TB drugs The need for efficient procurement systems The need for standardised products • An initiative of the Global Partnership to Stop TB • Housed in WHO and managed by Stop TB partnership secretariat. • Aims to provide free drugs for 10 million people with TB by 2005 • Needs $250 million over the next 5 years • Initial funding from Canada, Netherlands & US What is the GDF?

• Now – Grants of first line drugs, to support DOTS expansion – A direct procurement mechanism for countries and NGOs, for use in DOTS programmes – A web-based tool for placing orders and tracking shipments • Future – A list of ‘prequalified’ manufacturers of quality TB drugs – Diagnostics – Second line drugs • Other Possibilities – Anti malarials? – Products for TB-HIV? What does the GDF offer?

• Processed over 50 applications from countries, NGOs, states and public-private partnerships • 33 countries approved for support, and 1 pending • 2 countries buying drugs through the GDF using their own resources • Drugs ordered for 21 countries and delivered to 11 • Drugs committed for over 1. 6 million patients • Drug prices down ~30% • Average drug cost per patient (inc freight): Progress so far: Outcomes ~$11

Countries approved for regular GDF support Countries approved for emergency GDF support Countries under consideration for GDF support

• Link demand, supply and monitoring, to facilitate increased access whilst ensuring rational use – Link supply of drugs to objective assessments of technical soundness and operational feasibility – Monitor drug use, treatment outcomes and drug resistance • Use grants of drugs to catalyse improvements in quality of health service provision – Link grants of drugs to programme performance – Encourage partners to provide additional technical and financial assistance, – Catalyse improvements in planning for DOTS expansion, monitoring, and drug management • Establish a ‘virtual organisation’ through a partnership of agencies – Contractual or collaborative (no fee) partnerships, coordinated by a small secretariat – Competitive bidding process, to identify organisations that provide efficient, quality and low cost services, and create an effective partnership chain. • Use product packaging to simplify logistics, promote rational use, and enhance patient acceptability and compliance – Standardised catalogue of TB drugs – Fixed dose combinations and patient treatment packages GDF Lessons • Diverse funding base – Donor grants to GDF – Direct procurement - countries and NGOs use own resources – Donors/lending agencies (eg WB/GFATM) for support to countries

Instruction to disburse Trustee (The World Bank) The Global Fund Reporting Grant agreement Local Fund Agent (LFA) CCM Reporting Principal recipient(s) (PRs) Reporting Sub-recipient GFATM Fiduciary & Reporting Sub-recipient

Total amount disbursed to grantee USD First ‘advance’ payment will depend on initial programmatic requirements* The GF will approve long term programs but commit funding for short term (~2 years) Future disbursements tied to evaluated indicators Subsequent disbursements will be authorized based on submission of financial and programmatic progress reports* Outcomes Program implementation Financial management 0 Board approval ”in principle” Grant agreement 12 Frequency and amount of subsequent disbursements to be determined upfront based on programmatic milestones and resource needs 24 • GF decision on future funding based on assessment of outcomes & financial accountability *Benchmarks: First disbursement could amount to about one third of the first year financial request; Financial and programmatic progress reports would commonly be provided on a quarterly basis GFATM Result-based Time (months)

• Over 300 proposals submitted by ~100 countries • 17 technical experts reviewed ~150 proposals • 2 nd GFATM Board meeting approved 1 st round of proposals in April 2002 • US$ 616 million immediately committed over two years in 40 countries for proposals totaling US$ 1. 6 billion GFATM Outcomes

Country split based on total year budget requirements* Percent, 100% = USD 490 million Americas Western Pacific China Mongolia Vietnam Honduras**41 Panama 0. 6 48 2 10 $60 Total South East Asia 5 9 DPR Korea 71 India 6 Indonesia 13 Sri Lanka Thailand $104 TB Approvals by Country *HIV/TB combined proposal **HIV/TB/Malaria combined proposal Source: 2 nd Board meeting, New York Moldova* 12 $42 Total Eastern Europe Africa Ethiopia 27 Ghana 6 Rwanda* 15 South Africa*165 Zambia 60 Total $272

Nearly 50% of requested resources are for commodities and products, therefore the Global Fund is particularly vulnerable to the potential risks of sub-optimal procurement Percent of two year commitment to approved Others Data/information proposals systems Human 100% = US$ 616 million resourc es Outreach services Logistics / supplies Training / supervision Products and commoditie s Provision of Drugs & Health Commodities

Approved Under review Rwanda South Africa Sri Lanka Thailand Vietnam DPR Korea India Indonesia Moldova Zambia Benin Cambodia Guatemala Mali Mozambique Swaziland Yugoslavia Nigeria Philippines Uganda Eritrea Not received Global Fund China Ethiopia Ghana Honduras Mongolia Panama Not received Under review Angola Armenia Bangladesh Burundi CAR Cote d"Ivoire Djibouti DR Congo Gambia Global Drug Facility GFATM and GDF Haiti Kenya Kyrgystan Liberia Mauritania Myanmar Niger Pakistan Approv ed Rep. of Congo Sierra Leone Somalia Sudan Tajikistan Togo Uzbekistan Yemen

GDF & GFATM Comparison

• Sustainability – Sustainability is not the same as self sufficiency – Sustainability is not limited to finances; outcomes, processes, structures, human resources – How long will the GDF/GFATM need to provide support? – How long will the GDF/GFATM be able to provide support? what happens after the GFATM & GDF? • Additionality – Additionality is not limited to new resources; new partners, new outcomes – How can we reduce the extent to which the GDF & GFATM displace existing resources? • Distortion – How much will the GFATM influence national health priorities? – How much work will the GFATM add to existing health systems; applications, implementation • Absorption – How much additional funding can countries utilise (health workers and financial systems)? Issues for GDF/GFATM

• Increased financial resources available to address: – Health priorities, in general – TB (&TB/HIV), in particular • Empowerment of countries: – to set priorities – to lead a coordinated, collaborative effort of all partners (e. g. , through CCM mechanism) GFATM - Implications (Positive)

• Issues related directly to GFATM country proposal development & award implementation • GFATM funds - additional & catalytic, not a replacement • Perception: GFATM is the entire solution • Macroeconomic impact of GFATM on national economies GFATM - Implications (Unintended)

• Macroeconomic impact of GFATM on national economies GFATM - Implications (Unintended)

• GFATM funds - additional & catalytic, not a replacement • Perception: GFATM is the entire solution GFATM - Implications (Unintended)

• Managing increased expectations and demand for services • Human resources requirements • proposal development process • program implementation • financial & program management • Sustainability - what steps to take & when to take them at end of 5 yr period? Implications: country level

• Programmatic capacity -- All levels, for TB, TB/HIV and overall health services • Laboratory TB diagnostic capacity • TB Drug management capacity • Integration of public/private sector efforts • Potential role of TB programs in the delivery of INH preventative therapy, ARVs New interventions (TB & HIV) to increase TB case-finding/treatment

• GFATM Secretariat, permanent staff • Staffing of fiduciary, monitoring & evaluation GFATM-specific activities • Intersection of GFATM and GDF with STOP TB • International technical assistance proposal development and implementation • Impact of GFATM on GDF - increased GDF staff needs & associated drug International management needs. Level: • Increased Donors: Intersection of GFATM with other Human on-going programs

Proposal development Proposal review • Stop TB can • GDF TRC provide very members important ensure technical common assistance to standards CCMs as they develop GF • Stop TB can proposals provide additional expertise, and situational analyses • GLC can review proposals for second line drugs Agreement of grants • GF and GDF should ensure no funding redundancie s • Stop TB can support procurement assessments with, e. g. , inputs from DM meeting Programme Monitoring implementati & evaluation on • GDF can procure DOTS meds for recipients with the "approve to buy" process • Stop TB can help to harmonize M&E data gathering and reporting • GLC can provide access to low cost second line drugs • Stop TB can continue to provide TA to ensure good operations Collaboration between the GF, STB, GDF &

• Applications & Review – assist countries/CCMs prepare high quality applications – technical review (TRP, TRC, GLC) – pre-delivery country visits for GDF • Implementation – Organisationally join CCM – Technical assistance • Monitoring – annual monitoring visits How can TB consultants support

• GDF & GFATM are necessary but not sufficient for reaching the global control targets • There are many potential pitfalls with any new initiative, particularly when large sums of money are involved • The extent to which the GDF and GFATM have a positive impact will depend on the extent to which they gain popular support from all stakeholders • The global TB community has an opportunity to maximise the potential of Conclusions these new initiatives