To end HIV, TB and malaria as public health threats and address emerging dangers to global health security, we need to reach the most vulnerable people with prevention and treatment services, wherever they are. That means directing a sharper focus on challenging operating environments (COEs) – countries or regions that experience infectious disease outbreaks, natural disasters, armed conflicts or civil unrest, weak governance, climate change-related crises and/or mass displacement. Despite hosting less than 14% of the world’s population, COEs account for approximately one-third of the global disease burden for HIV, TB and malaria.
The upheavals that afflict COEs destroy or severely stretch fragile health systems, causing considerable disruption to health services. In such environments, infectious diseases are likely to spread fast. Logistics and supply chains break down, leading to interruption in the supply of health products. Prevention measures fail. Diseases go untreated or treatment is interrupted, leading to more severe illnesses or death and the development of drug-resistant infections. Hard-won gains against HIV, TB and malaria are lost. In the worst cases, health systems collapse.
In conflict and following natural disasters, infectious diseases, lack of treatment and food insecurity can sometimes kill more people than from the violence or crisis itself.1 As security declines, traditionally vulnerable people are even more at risk, particularly adolescent girls and young women, children, the elderly, and key populations such as gay men and other men who have sex with men, sex workers, people who use drugs, transgender people and people in prisons. Attacks on gender equality and violations of human rights increase, including summary executions, torture, rape, war crimes, ethnic cleansing, people trafficking, destruction of civilian infrastructure, looting of food, medicines and other necessities, fraud and corruption, and many forms of discrimination. Huge numbers of people flee or are forcibly displaced, which leads to the additional vulnerability of becoming a refugee or an internally displaced person (IDP). These forms of abuse and persecution, as well as being harms in their own right, have a damaging effect on the health of the population and health systems, and accelerate the appearance and spread of infectious diseases.
Our response
The Global Fund prioritizes health needs in COEs to increase coverage of HIV, TB and malaria prevention and treatment services, reach key and vulnerable populations and save lives. COEs, because of their complex needs and the obstacles they present, account for approximately 30% of the Global Fund allocation. We have disbursed US$15 billion in COEs since 2002.
Our COE Policy, created in 2016, aims to adapt the Global Fund’s approach to COE countries. Through innovation, increased flexibility and partnership, the Global Fund seeks to accelerate the response to HIV, TB and malaria in COEs, while building resilience through stronger community and health systems and by addressing gender-related and human rights barriers to services. Even in crisis, we must leave no one behind.
By working with partners who have expertise and comparative advantage in emergencies, we can provide a speedier response in humanitarian settings, while at the same time strengthening in-country governance and service delivery and improving technical assistance. The Policy recognizes the need to adapt approaches to each context, while maintaining responsible fiduciary oversight of funds and with the goal of enhancing the timeliness of our investments, reducing administrative burden for partners, and facilitating more effective service delivery to populations in need. This new approach places the Global Fund at the intersection of development and humanitarian work.
Every year, the Global Fund updates a list of COEs based on the External Risk Index (ERI), which can be added to during the year. The current list of COE countries eligible for the 2020-2022 allocation include Afghanistan, Burkina Faso, Burundi, Central African Republic, Chad, Democratic Republic of the Congo, Eritrea, Guinea, Guinea-Bissau,
Haiti, Iraq, Democratic People’s Republic of Korea, Lebanon, Liberia, Mali, Myanmar, Nicaragua, Niger, Nigeria,
Pakistan, Palestine, Sierra Leone, Somalia, South Sudan, Sudan, Syria, Ukraine, Venezuela and Yemen.
Source: The Global Fund