A group of African parliamentarians raised a red flag on Tuesday at the UNITE Global Summit when they told representatives that they felt neglected by the Global Fund to Fight AIDS, Tuberculosis and Malaria, which funds billions of dollars of health services in their countries.

“Do African parliamentarians only get involved when we have to make an appeal, when it suits our colleagues?” asked Tanzanian MP Neema Lugangira in her remarks at a session titled “The Global Fund Post 7th Replenishment – The Role of Members of Parliament and Domestic Health Financing.”

Lugangira said that she was asked to make a fundraising appeal via video on behalf of the Global Fund to the United Kingdom parliament over the summer believes her intervention added value and played a key role in convincing the UK government to provide a more than $1 billion grant. However, despite being in New York in September during Global Fund’s Replenishment event at which donors pledge money for the next three years, she was not invited to attend.

Global Fund instead hosted 18 heads of state and governments and many high-level officials from civil society and the private sector at the 400-person event in the city.

Lugangira said that “some of my colleagues in Tanzania were surprised I was not invited” because of the video she provided and her deep commitment to public health in Tanzania.

“When it is time for the glorious moment, we are not invited,” she said.

Lugangira said that Global Fund could generate increased matching domestic financing and distribute its funds more effectively if it worked closely with parliaments, the way it works with civil society.

“Civil society was not chosen by our UK parliamentarians to record a clip and make an appeal to parliament. It was me, a member of the African parliament,” she stressed. “It is powerful when you hear the voice of an African parliamentarian representing her people.

“Don’t just use us when it suits you. Include us across the entire chain” Lugangira continued. “Parliamentarians should be involved at all levels and be recognised for the impact and power we have.”

‘Confused and surprised’

Lugangira had been asked to speak during a panel hosted by the fund that was meant to celebrate the nearly $16 billion it raised in the fall and to examine the positive impact that the more than $55 billion it distributed over the past 20 years has had on health and saving lives.

In Tanzania alone, the Global Fund has invested $3 billion to tackle issues of HIV, TB and malaria between 2002 and 2022. Currently, the fund has four core grants in the country totalling $608 million.

According to Lugangira, since the fund became involved in her country, there has been a 68% decrease in HIV and people with the virus and a 68% increase – from 18% to 86% – of individuals with HIV enrolled in treatment programs.

But after Lugangira and several other parliamentarians criticised the Global Fund for failing to properly leverage local lawmakers and called on it to shift its paradigm, Scott Boule, the Global Fund’s Senior Specialist for Parliamentary Affairs, said he was left “confused and surprised.”

“At least one MP sort of implied a feeling of being only utilised when the Global Fund needs to raise funds,” Boule said, “Global Fund is supposed to be a partnership.”

‘You handcuff us’

Some parliamentarians also expressed concerns over the Global Fund model, which involves establishing a Country Coordinating Mechanism (CCM) committee to help distribute funds. Boule said Global Fund mandates that CCMs have broad representation, including from the government, but also from civil society, such as members of the communities that are impacted by the three core diseases.

In some countries, parliamentarians sit on the CCMs, but in many countries they are not asked to do so. Moreover, parliamentarians have been ineligible to receive money to help fund their role on these committees.

Zimbabwe’s Ruth Labode is one of those MPs. She is a member of her country’s CCM but said she rarely attends meetings due to lack of transport and funding. She only goes when parliament is in session and she has to be in the capital city for work anyway. Otherwise, “it’s too costly” to take part, she told Health Policy Watch.

“The CCM has decided not to fund parliamentarians for meetings while they fund members from the civil society, private or any other sector,” Labode said. “The lack of funding shows that the Global Fund is not committed [to the parliamentarians]. It does not think it needs parliamentarians. And yet, when the time comes for replenishment, they are quick to find parliamentarians to lobby for their purpose.”

She told Boule during the discussion that “it is about time you advocate for a parliamentary seat on every CCM in every country… If you told them to have a seat for a parliamentarian, it would happen overnight”.

Another complaint was that many parliamentarians are not educated about the work of the Global Fund or its accomplishments, which could help them push for further domestic health financing.

“You cannot mobilise resources when you are not informed,” said MP Peter Njume from Cameroon. “You work [directly] with the government and then expect us to ask them to be accountable. But parliamentarians are not involved.

“You talk about the importance of democracy,” Njume continued. “We represent democracy, but you handcuff us, you make us become vulnerable and helpless. How do you want us to function?”

“To own this agenda, we need to be well informed and educated,” Lugangira similarly added.

Njume requested that the Global Fund earmark financing for a parliamentary education program.

‘Healthcare financing is a political decision’

Global Fund’s Alex Winch acknowledged that “the financing of healthcare is a political decision.”

A specialist on Global Fund’s Advocacy, Health Financing Team, he said it is important to understand that the vast majority of the fund’s resources do come from governments prioritising money.

“Eighty percent of funding comes from the G7 and the European commission,” explained Boule. “Eleven percent comes from other governments around the world. And 9% comes from the private sector.”

To date, the Global Fund is providing 30% of international financing for HIV, 76% for TB and 63% for malaria. The fund gives more money for the battle against TB and malaria than anyone in the world. In addition, about a third of its funding is now going to reward strengthening underlying health systems.

The funding has been effective, at least according to the data. Life expectancy, for example, has increased as a result. In sub-Sahara Africa alone, average life expectancy jumped from 52.3 in 2002 to 66.7 in 2019, in large part because of the fund’s efforts.

During 2021 in countries and regions where Global Fund invests, some 12.5 million people were reached with HIV prevention services; 670,000 mothers living with HIV received medicine to keep them alive and prevent transmitting HIV to their babies; another 5.3 million people were tested for TB; 110,000 were given treatment for drug-resistant TB; and 133 million mosquito nets were distributed to protect families from malaria, amongst many other efforts.

“All of this is made possible by our replenishment,” Boule told Health Policy Watch. “Every third year, we raise funds for the subsequent three years.”

Replenishment this year was held on 21 September in New York. Some 47 public and 27 private sector donors pledged $15.7 billion out of the target of $18 billion that the organisation had set to raise for the 2023-2025 period.

Boule said that efforts were continuing to try to fill the gap.

‘We are de-investing in health’

But Zimbabwe’s Daniel Molokele said that while the results are stunning, he believes African governments have become too “dependent” on the Global Fund, which puts 72% of its money towards the continent.

“I don’t think it is good for Africa, this over-reliance on the Global Fund,” Molokele said.

He said that Global Fund’s filling the gap lets off the hook governments who then do not have to commit to fund health in their own countries. In Zimbabwe, he said, domestic health financing dropped several percentage points in the last year.

“We are de-investing in health,” Molokele said.

Boule explained that recipient countries are required to provide a certain percentage of matching money to receive a grant from the Global Fund, though he said that the fund is often more flexible with low-income countries about achieving their targets.

He said that despite the economic challenges the world is facing in the aftermath of COVID-19 and as the war is raging in Ukraine, the fund did see around a 30% increase across the board in domestic health financing from recipient countries.

‘It was ambitious’

Another concern raised from the floor came from French MP Jean-Francois Mbaye, who expressed “disappointment” that his country invested $1.6 billion towards a goal it thought was $18 billion but that fell short

“It was ambitious,” Boule admitted to Health Policy Watch. “We did raise $15.7 and that is by far the largest amount we ever raised.”

The gap came from some of Global Fund’s largest donors not increasing their gifts by the 30% that the fund expected.

“The United States, Germany, Japan, Canada and the European Commission all did increase by 30%,” Boule said. “France increased by 23% and Italy increased by 15%.

“The only country amongst our largest donors that went down was the UK, although it still pledged $1.2 billion,” Boule continued. “So we very much had strong support from our donors, and in particular, our largest donors.”

On the other hand, faltering exchange rates, and hosting the replenishment seven months after the start of the Ukraine war amid rising interest rates had a negative impact.

To illustrate if the pledging session had been held on February 23, 2022, which is the day Global Fund had its preparatory meeting, because of exchange rates, it would have raised around $857 million more.

In general, Winch said that achieving funding in the current fiscal environment is becoming increasingly more challenging.

He cited a recent report by the World Bank that highlighted how even more countries will find it hard to invest in health or in even sustain existing levels of health investment. He said that “an uncertain global macro-economic environment threatens domestic financing for health.”

‘We need to crowd more resources into health’

Boule said that he plans to take some of the parliamentarians’ concerns back to Geneva, such as providing resources for parliamentarians to sit on CCMs and perhaps developing a fixed parliamentary position on the committees.

“I wasn’t aware of the point that Honorable Ruth Labode was making from Zimbabwe, that other members of the CCMs received some sort of support and she did not,” Boule said.

He also said he would be interested in finding ways to better involve parliamentary feedback as another means to ensure that the fund is asking the right questions and distributing resources in an optimal way.

“Our good results are due to a lot of African political leaders, including parliamentarians, really building and sustaining political will to prioritise health,” Boule said. “It is even harder now with food insecurity, debt crisis and rising interest rates. But we are making the point that even now we need to crowd more resources into health.”

Image Credits: Maayan Hoffman, Screenshot.