FRUSTRATIONS WITH FIDELIS: PROMISING IDEA, PROBLEMATIC APPROACH

Despite increased funding over the last decade, global tuberculosis (TB) control efforts have fallen short of their intended case detection targets.1 The FIDELIS initiative2 could help to close the gap by funding locally developed, innovative solutions that go beyond the current paradigm of passive case finding.3 Unfortunately, although FIDELIS’s overall objective is worthy, the approach is inadequate. First, it is not clear how much room for local, “innovative” proposals actually exists in the FIDELIS framework. Though the initiative purports to engage in-country contractors, its Web-based call for applications and its minimum proposal request of US$150000 exclude grassroots groups with low Internet access and limited capacity to manage large funds. Thus, FIDELIS is most accessible to organizations with significant capacity (i.e., those with affiliates in developed countries), whose proposals may be influenced by outside notions of “innovation” that are not locally relevant. Second, proposals are evaluated by experts within the existing TB control structure (Stop TB Partnership, National Tuberculosis programs, etc.), whose involvement in existing standardized strategies may limit their endorsement of new approaches. A shift toward innovative, context-specific strategies is key to improved TB control,4,5 but the FIDELIS framework is not conducive to realizing this goal. Third, the 2 key principles of FIDELIS’s proposal evaluation process contradict each other. To “focus on people with limited access to health services,”2 it may be necessary to violate the stringent cost-per-treatment-success target of US$80. Isolated populations are often underserved precisely because of the higher fixed costs inherent in reaching them (i.e., greater transportation expenditures). By imposing a cost-per-cure ceiling, FIDELIS favors urban and periurban locales. Focusing primarily on cost-effectiveness can be shortsighted and will ultimately hinder progress toward global TB control.6 Finally, the proposed funding cycle is problematic. The quick disbursement of funds and short project cycle may seem desirable in principle, but the 1-year funding cycle leaves little time to build project capacity before activities are expected to begin. Projects delayed by long waits for government approval could receive negative evaluations. The 8- to 10-month delay between the funding cycle’s end and the availability of TB treatment outcomes2 may leave projects in limbo. Increasing the contract length to 2 years, even without increased funding, might be beneficial for all parties. FIDELIS is a promising concept, but one that requires an improved approach to achieve the desired results.

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