Clinton Foundation

By Jeremy Shoham, ENN

After he left the White House, President Bill Clinton wanted the Clinton Foundation to focus on areas where he could make the most difference as a private citizen. President Clinton visited a number of national leaders from the developing world to ascertain views on priority areas for intervention that the Foundation might support. A prevailing view was that poverty alleviation strategies would be less effective for many countries without simultaneously addressing the supply and roll out of anti-retroviral (ARV) drugs for the treatment of HIV/AIDS. The Clinton Foundation therefore initially focused on strengthening the market for ARVs through working in parallel with both drug manufacturers and national treatment programmes. The Foundation's recent involvement in the procurement of Ready to Use Therapeutic Foods (RUTF) has since raised its profile with agencies working in the nutrition sector. The ENN therefore invited the Clinton Foundation to be the subject of this issue's agency profile slot.

Phone interviews were conducted with Rebecca Egan - clinical programme manager for the 'Nutrition Access Team' and Seema Arora - the market development manager for the team. Rebecca has spent a year and a half working with the Clinton Foundation's country teams on CMAM (community management of acute malnutrition) roll out, providing technical assistance and liaising closely with partners. Seema initially started work with the Foundation in the Drug Access Team but has been working on the Nutrition Access Team for approximately one year, focused on the supply-side. There are two other team members - Erika Wagner, the director based in London and Sam Mayer, a senior analyst based in New York. In addition, there are a number of Clinton Foundation staff working in the nutrition sector in countries where the Foundation is active. For example, there is a group dedicated to nutrition and CMAM implementation in Malawi.

OTP centre located in a rural region several hours outside Addis Ababa, Ethiopia, supported by the Clinton Foundation.

Although the Clinton Foundation initially began work in the HIV/AIDS sector, the Foundation swiftly grew to include other global initiatives in areas like climate change, as well as more domestic focused work in small business development, problems of poor nutrition and childhood obesity, and sustainable growth initiatives based domestically and abroad. The objective of the Clinton Foundation HIV/AIDS Initiative (CHAI) is to increase access for HIV/AIDS care and treatment in the developing world through lowering prices for drugs, diagnostics and other commodities. When CHAI began in 2003, the ARV market was fragmented and suppliers were unable to take advantage of economies of scale and therefore, unable to lower the price of drugs. To address this, CHAI has worked to increase coordination between the demand and supply sides of the AIDS treatment market in order to catalyze significant price reductions for ARVs.

Because ARV access for children has historically lagged far behind that of adults, CHAI began to focus on paediatric HIV treatment with the launch of its Paediatric Initiative in 2005. This was effectively the entry point for CHAI's work in nutrition, as the relationship between HIV and severe acute malnutrition (SAM) is so pronounced in many developing countries. The Foundation quickly came to realise that there are many strong linkages between SAM and HIV, and that in addressing SAM the quality of care for HIV treatment could be significantly improved. CHAI was subsequently chosen by UNITAID (a donor organisation supported by many national governments and seated within the World Health Organisation (WHO)) to be an implementing partner for a large scale donation of paediatric commodities. At CHAI's request, RUTF was included in this donation with 25 countries eligible to receive it. Since the inception of the UNITAID programme, CHAI has become the third largest purchaser of RUTF globally (behind UNICEF and Medecins sans Frontieres).

CHAI has established memoranda of understanding (MOUs) with a number of governments to provide RUTF. Programme implementation support is offered via national governments in select countries where local partners are strong. CHAI-procured RUTF is used to treat SAM-affected children whether HIV positive or not. In countries where CHAI is offering programmatic support in addition to the donation of the product, this can include assistance with development of treatment protocols, offering forecasting and supply chain management support, supporting trainings and seconding staff, or clinical mentors for paediatric and CMAM facilities.

The significant growth seen in the past year in RUTF production capacity has reduced the supply-side bottlenecks associated with the scale up of CMAM programmes. In CHAI's experience, the stumbling block is now on the programmatic side, with a lack of capacity to implement CMAM. CHAI has been working closely with UNICEF and governments to identify implementing partners for CMAM and has been strongly advocating to get more funding for CMAM implementation and roll out.

Another focus of CHAI's work in RUTF has been in looking at whether price reductions for RUTF are possible. CHAI has conducted significant analyses of supplier cost structures to determine if there are areas where costs can be cut. These analyses have revealed that in general, RUTF suppliers are operating with slim margins and there is minimal potential for price reduction if the RUTF formulation remains unchanged. To address this, CHAI is working to generate funds for research into alternative formulations involving industry partners. Other supply side initiatives are centred on addressing concerns of new regional and local suppliers. CHAI have worked to form a consortium for purchasing milk powder, thereby cutting out intermediaries and extra costs, and has also mapped out solutions to other commonly faced barriers to market entry. CHAI is optimistic that as new products and new suppliers enter the market, prices will come down to a level that governments can eventually afford so that programmes become domestically sustainable.

CHAI have endeavoured to strengthen government capacity to actually implement CMAM although with a growing evidence base of success in some countries, the political buy in is likely to increase demand and create sustainable resources and capacity for implementation. CHAI believe that decentralisation of CMAM to community level may be more challenging at this stage, but that with greater funding for HIV programming and home based care programmes, there is the potential for CMAM to piggy-back onto these existing programmes. This is already occurring in countries like Cameroon and Nigeria. Greater integration with Integrated Management of Childhood Illness (IMCI) will also help with decentralisation.

The Clinton Foundation obtains funds from a number of foundations, private donors, and governments. President Clinton is still very involved in fund-raising and is an excellent spokesperson for the Foundation. As UNITAD funding for RUTF winds down over the coming years, CHAI has been working with agencies like PEPFAR, the Global Fund and others to ensure a smooth transition of CHAI RUTF procurements beyond the UNITAID programme. The Global Fund has begun to consider RUTF procurement in their grants, so funding for the commodity could become secure in the short-term. The Foundation is very aware of issues around RUTF supply sustainability and transition funding. For example, in Malawi where government is significantly decentralised and CMAM is being rolled out nationally, an agreement has been reached for each district to provide a certain percentage of resources for RUTF procurement. This percentage should increase each year by that percentage annually until most, if not all costs, are ultimately paid for by the districts.

Both Seema and Rebecca see CHAI as unique in that it works on both the demand and supply sides of commodity marketplaces. Although CHAI began its work in RUTF as a procurement body with little intention of being 'hands-on', it has had to roll up its sleeves and get involved in overseeing programme implementation in certain countries. This has necessitated forging strong relationships with government and often providing consultants and specialists seconded to government. CHAI has also supported government proposal writing to the Global Fund so that some programmes are now successfully funded.

When asked about major gaps and challenges in the nutrition sector from a Clinton Foundation perspective, Seema and Rebecca cited a number of areas. The lack of comprehensive care for SAM children leading to fractured programme implementation is a big worry. This is caused by lack of funding for key implementation components, with the problem most pronounced in development rather than emergency settings. They also expressed concern about high default rates in outpatient therapeutic programme and supplementary feeding centre facilities, especially in urban areas, as well as weak monitoring and evaluation of these phenomena. In connection with this they wondered about the appropriateness of SPHERE standards in some contexts and whether there may be a need to re-think these.

The Clinton Foundation has now grown into a global non-governmental organisation with 1,100 staff and volunteers in more than 40 countries. Its rapid expansion and diverse funding sources suggests that the Foundation will continue to grow in scope and engagement. It will be fascinating to see how the Foundation chooses to engage with the humanitarian community, as well as how big a player it becomes.