26 May 2023
The Challenging Operating Environment (COE) policy aims to systematize the Global Fund’s approach in countries or regions characterized by weak governance, poor access to health services, and/or otherwise impacted by manmade or natural crises. COE portfolios often face heightened programmatic and implementation challenges; the policy provides opportunities for countries or regions to benefit from innovative approaches and operational policy flexibilities. It also helps countries or regions to get the best out of partnerships. The COE classification is one mechanism that the Global Fund can use to provide a differentiated approach to countries based on their unique circumstances, thus increasing the impact of Global Fund investments.
The Office of the Inspector General (OIG) selected Burkina Faso to observe the operationalization of the COE policy and its efficacy. The Global Fund started investing in Burkina Faso in 2003; despite facing recent years of security, humanitarian, social and pandemic-related challenges, the country has made significant progress in the fight against HIV, tuberculosis (TB) and malaria. Between 2015 and 2021, there was a 51% reduction in HIV prevalence and a 55% reduction in AIDS mortality. During the same period, TB incidence declined by 13% and TB mortality by 29%. Whilst malaria remains a significant burden for Burkina Faso, with malaria incidence increasing by 27% during this period, the malaria mortality rate has dropped by over 40% since 2013; these gains remain stable. This progress has been facilitated in Burkina Faso by the Global Fund grants and in-country partners, actively responding to the unique and evolving country context and applying a number of adaptations to implementation of Global Fund grants as part of the ongoing portfolio management, most notably over the course of 2020-2023.
As the OIG report notes, the Secretariat did not classify Burkina Faso as a COE country until March 2022, given that prior to that time the high-security risk areas were significantly isolated to specific areas of the country. Following the January 2022 military coup, armed violence increased, targeting security forces and civilians throughout the country and health facilities in 9 out of the 13 health regions. As a consequence, the Global Fund determined that this rapidly deteriorating security situation warranted Burkina Faso to be designated as a COE. It is important to note that the invocation of COE status for a country is not an automatic process. The Secretariat is committed to ensuring that COE categorization be a highly consultative process, with expertise engaged from across the Secretariat to assess the risk and programmatic benefits that invoking COE status could provide. Similarly, decisions to apply operational policy flexibilities are driven by identified challenges and assessed on a case-by-case basis for COE portfolios. Those decisions are also driven by important considerations and risk trade-off decisions, which must be made to ensure that we are delivering the right solutions for a country, based on its unique context. This is the case for Burkina Faso, as for all countries classified as COEs.
Since 2022, the political and security situation in Burkina Faso has continued to deteriorate. Burkina Faso is now rated as the second country most impacted by terrorism globally, and the most affected in Africa. The Global Fund Secretariat continues to provide Burkina Faso with the necessary technical assistance and important adaptations and flexibilities. In parallel to the COE classification, we provided technical assistance to Burkina Faso to develop an Integrated Contingency Plan (ICP) funded by the Global Fund and the World Health Organization, which consolidates a comprehensive emergency response proposition into one functional plan to help implementing partners address difficult country contexts through innovative approaches. The ICP is fully endorsed by the Burkinabe government, and it is being implemented in the Sahel region with World Bank funding. It is also currently under negotiations for the Centre Nord region, an opportunity that has been made possible due to Global Fund reinvestment. In addition, Burkina Faso now benefits from critical flexibilities to support a differentiated approach and adaptations to the implementation of activities. This includes adapting supervision in hard-to-reach and conflict-affected areas by leveraging virtual tools and platforms, differentiated assurance approach in areas that have high-security risk parts, identifying alternative transporters and routes to ensure that health products reach health facilities in impacted regions, and a differentiated approach for delivering mass distribution long-lasting insecticidal net (LLIN) campaigns in hard-to-reach areas.
The OIG audit identified that the existing operational policy and procedures that facilitate the implementation of the COE Policy be reviewed and updated in order to be more effective and more accurately reflect how the Global Fund operationalizes the policy. The Global Fund Secretariat began this review in May 2022, with the objective of ensuring that the operational policy provide greater clarity on the criteria and process applied to categorize a country or region as a COE, the roles and responsibilities of the Secretariat and country stakeholders in this process, and COE policy implementation, including flexibilities that are available to countries or regions classified as COE. To reaffirm this commitment, the Secretariat and OIG are aligned on an agreed management action that formalizes the work the Secretariat is already undertaking. In addition, the Secretariat is conducting workshops for in-country partners and implementers to further explain the COE policy, identifying challenges, and exploring additional opportunities for differentiated approaches.
We thank the OIG for this audit report. The work of the OIG complements our active grant management and the risk oversight and controls put in place by the Secretariat and upholds our proactive approach of full transparency in the performance of the operational policies and procedures that support grant implementation. The Global Fund remains committed to meeting the unique needs of our partner countries that experience significant challenges. We want to ensure that our response is agile and innovative, and that implementers and country stakeholders receive the necessary support to adapt Global Fund grants to better address evolving needs and increase the impact of Global Fund investments to accelerate progress toward ending AIDS, TB and malaria as public health threats.