The Global Fund in China: success beyond the numbers

In June, 2014, the Global Fund to Fight AIDS, Tuberculosis, and Malaria completed its support for operations in China.¹ The 10-year partnership between China and the Fund measurably improved China's management of the three diseases, but it also created benefits that extend far beyond the metrics usually used to assess public health programmes. These benefits include deeper engagement with civil society organisations, stronger public health systems, and the implementation of innovative approaches for disease management. As China celebrates these achievements, it must also devise a roadmap for continuing its record of success, now that the Fund has left.

China's relationship with the Global Fund began shortly before the 2003 severe acute respiratory syndrome epidemic, an event that proved the importance of containing public health threats that could undermine the country's economic growth. Successful pilot programmes have shown the effectiveness of various interventions against tuberculosis, malaria, and HIV/AIDS, and demonstrated the potential for scaling up those programmes in a way that would create a greater impression. In fact, it was the very potential large-scale interventions and strategic public health programming that made China and the Fund such natural partners. The results have been impressive.

Access to quality diagnosis and treatment of multidrug-resistant tuberculosis (MDR-TB) expanded from just two pilot projects in 2006 in two provinces to 92 sites in 30 provinces in 2013. China has also expanded access to innovative rapid diagnosis for MDR-TB in more than 900 counties across the country. And, by the end of June, 2014, more than 9000 patients had started treatment for MDR-TB (unpublished data).

Extraordinary progress was made towards the elimination of malaria. In 2002, the objective was to control malaria's spread; by 2020, the goal will be to eliminate local transmission of the disease entirely.² Between 2002 and 2012, the number of Chinese provinces reporting domestic cases of malaria has plummeted from 24 to five, and the number of reported malaria cases decreased from 100 106 cases and 48 deaths in 2005 to 4498 cases and 33 deaths in 2011.³

Finally, China's rate of HIV infection has been stabilised at 0·06%; between 2005 and 2012, the number of patients receiving antiretroviral therapy increased from 19 282 in 2005 to 176 655. HIV prevention outreach services achieved 81% coverage in commercial sex workers and 77% in men who have sex with men (MSM) by 2011. Harm reduction interventions in people who inject drugs have brought about substantial reductions in HIV incidence (from 0·54% to 0·31%) and prevalence (from 9·3% to 6·4%) over 2009–11 (unpublished).

Important though they are, numbers alone do not tell the whole story. Engagement with the Global Fund has changed China's fundamental approach to these three diseases, resulting in many gains that are hard to quantify but nevertheless invaluable. The first is a change in mindset. The way China's leaders think about development has progressed, making the public health system more transparent, open, and accountable. This quantum advance in governance derived partly from procedural and reporting requirements that came with China's alliance to the Global Fund. The Chinese Government cofinanced the Global Fund programme, a move that transformed China from an aid recipient into a full and active partner. Such a collaborative arrangement meant that all costs and other procedural details were clearly and publicly allocated, and that all programmes were audited, infusing the system with international standards of transparency.

Another benefit has been the development of a more coherent public health strategy. The Global Fund seeks to back programmes that show a unified strategy, rather than a series of individual projects. After several years of collaboration with the Fund, China became one of the first countries to seek support for a national strategy aimed at controlling HIV/AIDS, tuberculosis, and malaria. The result has been a greater integration and, ultimately, a more strategic and coherent programme of interventions.

The China and the Global Fund partnership also used a health system approach by assisting local manufacturers through the WHO prequalification process to provide quality-assured tuberculosis, HIV, and malaria drugs. Collaboration also supported State Food and Drug Administration (now China Food and Drug Administration) alignment with Good Manufacturing Practices, Pharmacopeia, and laboratory testing international standards.

Partnership with the Global Fund also introduced a dose of pluralism into China's management of the three diseases. In accordance with the Fund's procedures, China established a Country Coordinating Mechanism, a platform for coordinating several stakeholder inputs and mobilising support. When deciding whether to back a particular public health effort, the Fund looks for evidence of involvement by civil society, usually manifested by the presence of non-governmental organisations (NGOs).

The Country Coordinating Mechanism requirements spell out criteria for stakeholder involvement that includes a balance in the representation of the different stakeholder groups, and a transparent process of selection. On the basis of these criteria, UNAIDS and WHO, in close collaboration with the chair and secretariat of the Country Coordinating Mechanism, supported the NGO constituency to develop bylaws and rules of order, following Robert's Rules of Order,⁴ and to undertake a nationwide transparent election to establish which groups would represent the sector. Such a democratic process had previously not been applied to determine stakeholder engagement and might serve as a model beyond the Global Fund governance structure in China.

Now that its partnership with the Fund has ended, China is in a strong position to move into the next phase of managing the three diseases. Despite the great strides made in controlling tuberculosis, China still counts 1 million new cases a year, including roughly 54 000 cases of MDR-TB.⁵ As with any public health disease, access to diagnosis and treatment should be free of charge to patients. Currently, MDR-TB treatment costs about 50 000 RMB (about US$8025) per year. Unless the government covers the cost, while making a simultaneous commitment to improving treatment quality, China might undergo a major public health crisis that could set back its developmental progress by 20 years or more.

Malaria is in the elimination phase, and its reach is much more restricted than that of tuberculosis. But malaria travels across borders, so China must collaborate with its neighbours. This collaboration will require decisive action in managing critical issues related to the cross-border spread of artemisinin-resistant malaria, and to the mobile population of migrants who become infected in Cambodia or Laos and then enter China.⁶ Although daunting, as with other public health concerns, these challenges present China with an opportunity to take a more active role in public health at a regional and global level.⁷

China has decided to take over the Global Fund's financial commitments on HIV/AIDS. The task now is to establish further collaboration between grassroots organisations and the Chinese Government. Hard-to-reach populations are most effectively targeted through community programmes, since many such populations, such as intravenous drug users, MSM, and commercial sex workers will not go to regular hospitals. Now that China has committed to funding continued treatment of HIV/AIDS, it must make a parallel commitment to supporting at-risk groups and the civil society organisations that represent them. Although outreach to at-risk populations is a challenge everywhere in the world, China's public health system in particular must make a special effort to connect with these groups.8, 9, 10

Each of the three diseases presents its own unique challenges: HIV/AIDS, with its need to manage social and other intimate behaviours; malaria, now in the elimination phase but still casting its shadow across China's borders; and tuberculosis, imposing an unacceptably heavy disease burden on the country. With the Global Fund gone, China must integrate the management of these three diseases into its broader programme of health reform. Key indicators or measures of progress will include better governance, more transparency, and greater accountability. It is up to China's leaders to pick up where the Global Fund left off, supporting these efforts financially and with an ongoing commitment to good governance.