Timor-Leste lacked infrastructure and human resources when it applied for its first Global Fund grant; the country had just secured its independence in May 2002. Despite all the constraints and limitations present, Timor-Leste managed to successfully implement the three-year Global Fund malaria programme grant.
Globally, it is acknowledged that the Global Fund has improved the coverage and quality of services for HIV/AIDS, TB and malaria control
. In Timor-Leste, there was a positive impact on malaria morbidity reduction although this was only around 10 % at the end of the implementation period, below the overall goal of a 30 % reduction. By the following year, however, further reductions were noted. However, it needs to be emphasized that the morbidity reduction was not solely due to the supports of the Global Fund and other development partners, government contributions in terms of supporting the provision of infrastructure and human resources in the wider health sector also contributed to this outcome.
This reduction in morbidity is less than seen in other countries such as Rwanda (61 %) and Ethiopia (75 %) through rapid scale-up of ITN and ACT coverage
[21–23]. In Laos, there was a reduction of 12.3 % of confirmed malaria cases from 2005 to 2009
The imbalance of resource allocation towards ITN distribution and behavioural communication change, and the underfunding for diagnosis, treatment and vector control interventions, and the political instability in 2006, are likely to have contributed to the Global Fund not achieving its objectives. A study conducted earlier to assess the impact of political instability on malaria control suggested that the instability in 2006 contributed to the increase of malaria rates in 2007
A robust health system is generally seen as a pre-requisite for the success of implementing donor support programmes
. In Timor-Leste, the Global Fund grant made a significant contribution to capacity building and to the broader health system, which in the long-run is likely to further facilitate reduction of morbidity and mortality due to malaria, and most likely to other diseases. The utilization of mosquito nets, including ITNs, appeared to have increased by a little more than 10 % (approximately 41 % in 2001 to 52 % in 2007 for the general population, and for children under age of five, the increase was from 52 % in 2011 to 63 % in 2007)
. However, this study also noted a few sporadic misuses of ITNs for other purposes (see Figure
2). The misuses of ITNs have been reported by another study
. Therefore, continuous efforts need to be made to maintain these gains, as suggested by one informant, “continue to keep us warm with information” and beyond that translating this knowledge into practice. The government, implementing partners, and the community should work hard to convince people not to misuse ITNs for purposes other than to protect them from mosquito bites thus protecting them from mosquito-borne diseases including malaria.
Based on the MoH annual reports, the health education programme reached 93,444 people (around 10 % of the country’s population) at that time
[13–15]. This was made possible by a notable contribution from SRs of the NGO sector. An earlier study documented that about 90 % of the sampled population knew about malaria terminology but there were also misconceptions about malaria causation and transmission
. This study found an improved community understanding of malaria and also documented that communities knew about the malaria programmes being implemented in their villages.
The implementation of the Global Fund funded programme also created partnership with the non-government sector as the implementing partners for the MoH in fighting HIV/AIDS, TB and malaria at country level. This study also revealed that funding from the Global Fund was an additional resource as demonstrated by the commitment of other donors, particularly the European Commission (through Care International) and USAID (through TAIS), who also funded malaria interventions. Therefore the reduction of malaria morbidity, strengthened malaria programme and general health systems should be seen as a result of combined efforts from the Global Fund funded programmes for malaria, contributions from government and donors outside the Global Fund.
The lack of capacity within the Global Fund structures at national level reflected the lack of available expertise within the country and delays in seeking external technical assistance, even though, the Global Fund guidelines permitted the PR to seek technical assistance (TA) to support proposal development and grant implementation
. This was a key contributor to both the malaria and TB grants in Timor-Leste being put under the Global Fund’s EARS List. This highlights the importance of basic management and system capacity to ensure effective implementation
. To a certain extent, other donor agencies (for example, the World Bank, AusAID and USAID) from countries which had contributed funding to the Global Fund centrally in Geneva (not necessarily at country level), could have offered assistance to support the implementation of the Global Fund grant. The grant could have achieved more if supported with adequate human resources, infrastructure, and general support. Poor coordination among participants involved in the implementation, lack of capacity in project management, and weak monitoring and evaluation contributed to low absorptive capacity and slow progress in grant implementation in Timor-Leste. Poor coordination, weak monitoring and evaluation were major hurdles not only for implementation of this grant, but also in the implementation of a new Malaria Treatment Protocol applied in 2008
. Absorptive capacity had been a major concern raised by donors during the discussions of the Global Fund establishment
. For example, Zambia also experienced poor coordination and insufficient monitoring and evaluation affecting its Global Fund grant implementation
The key tenet of the Global Fund is that of “performance-based funding” and is seen as key for achieving measurable results. However, at the same time, many countries including Timor-Leste, have found the system burdensome, rigid, and fixed exclusively on the measurement of process indicators and short-term outputs rather than on key longer-term outcomes, results and capacity building. The quote “We should not be the slave of the process with no result” carries important messages for improvement. The programme should strive to achieve its defined objectives and goals with the processes in place supporting the achievement of such longer-term impact.
Strengths and limitations
The strength of this study is that it documented the results of the Global Fund support programme on Malaria Control in Timor-Leste and its wider impact on the morbidity reduction as well as on health system strengthening. It captured perspectives of actors involved in the grant implementation and views of the beneficiaries and communities on the benefits of the programme. It also revealed factors that impeded the implementation of this grant.
The use of morbidity data reported to the Ministry of Health demonstrated the impact of the Global Fund intervention particularly towards morbidity reduction, to some extent. Many studies have highlighted the importance and validity of routinely collected statistical data on morbidity and mortality
[31–34]. However, there are limitations inherent to the use of routinely collected data as it may not fully reflect the actual incidence of malaria, it may result in either overestimate and underestimate the burden of disease burden itself. The use of clinically diagnosis approach in detecting malaria cases prior to the introduction of rapid diagnostic test in 2008 may over-diagnose malaria cases and thus affect the estimate of incidence rates. This can be considered as a potential limitation for this study. Therefore, it is important to exercise caution when interpreting routinely morbidity collected data.