Bangladesh’s “ambitious, but realistic” TB funding request to the Global Fund receives positive reviews

12. NEWS
6 Nov 2017
The two grants will expand case finding interventions, upgrade diagnostics and scale-up a public-private mix approach to TB

The TB funding request submitted by the Bangladesh CCM received positive reviews from the Technical Review Panel (TRP) and the Grant Approvals Committee (GAC). The two grants emanating from the request were approved by the Board on 17 October. A total of $110.9 million was approved, reflecting the total TB allocation for Bangladesh of $97.9 million and an additional $13.0 million in catalytic matching funds. The two grants will have implementation periods beginning 1 January 2018 and ending 31 December 2020.

The matching funds were for TB case detection and diagnosis ($12.0 million) and support for the National TB Control Program to strengthen its routine reporting systems ($1.0 million), an RSSH intervention.

The funding request, which named two principal recipients (PRs) – BRAC, and  the Ministry of Finance (for the National TB Control Program) – was submitted in Window 1 (20 March 2017) as a “full review” type application. The TRP completed its initial review on 25 April, at which point grant-making negotiations commenced between the PRs and the Global Fund country team. The information in this article is primarily from the Grant Review and Recommendation Form for this funding request.

Strengths

In its overall assessment of the funding request, the TRP considered it to be “technically sound and strategically focused,” because it proposed several evidence-based interventions for key populations, an accelerated introduction of better TB diagnostic tools and medicines, and the leveraging of a public-private mix of TB care delivery. That the request also details government plans to expand its co-financing contribution was also important to the TRP.

“The request is ambitious but realistic, taking calculated risks to try to achieve greater impact,” the TRP said. It noted that one of the PRs, the National TB Control Program, has very high treatment success rates. The other PR, BRAC, an NGO headquartered in Dhaka, was described as having “good coverage and enormous reach at the community level.”

Other strong-points of the request included the application of lessons learned from the current grant period; the adoption of GeneXpert machines for improving diagnostics and case finding; and the commitment of the government to take on the costs of personnel salaries and procurement of all first-line TB drugs.

Concerns

The top concern for the TRP was what it termed was a “too-slow” roll out of short-course multidrug-resistant TB (MDR-TB) treatment. The funding request called for the regimen to be scaled up to the whole country by 2020, in accordance with the national TB strategic plan.  The TRP indicated that it would like to see the regimen applied sooner because, it said, “Adopting the short regimen fully should allow the system to treat more patients.” During grant-making, the National TB Control Program appears to have agreed with the TRP; it committed to rolling out the short-course treatment to eligible patients “before 2018.”

While the TRP applauded the piloting and scale-up of public-private mix (PPM) models described in the request, it raised a concern about the National TB Control Program’s ability to monitor the quality of TB diagnosis and treatment in the private sector. The PPM models represent an effort to leverage private health care delivery systems for TB diagnosis and care, which have traditionally been the sole province of public health systems. Expanding these into private care, where many people in Bangladesh and other countries receive other care, has been shown to improve rates of case finding and lead to better outcomes for TB patients. 

The TRP concern here specifically regards the quality-control of TB services in the private sector. The funding request did not provide assurances concerning how this would be addressed, or describe a plan for documenting and disseminating lessons learned. The TRP and the GAC considered that this issue was only partially addressed during grant-making. Apparently, an agreement was reached for quality indicators to be measured throughout grant implementation. Additionally, the Global Fund country team plans to conduct an independent evaluation of the PPM models so as to ensure lessons learned are documented and disseminated.

Another major concern raised by TRP concerned services for key populations. The funding request proposed case finding interventions targeting migrant, floating and slum populations; people living with and at risk for HIV infection; malnourished people; and children in urban settings. Although it proposed these interventions, the request also noted that high-level political support would be a necessary pre-condition for implementation and for achieving impact in these communities, and that this support would be difficult to obtain. The TRP echoed these concerns and questioned whether the targets were appropriate given the anticipated political challenges. However, by the end of grant-making, this issue seems to have been resolved. Bangladesh cited the high-profile participation of its Prime Minister, Sheikh Hasina, in the Global Fund Replenishment Conference in 2016 as evidence of strong political commitment for TB programs.

Prioritized above-allocation request

The funding request contained a $47.9 million prioritized above-allocation request (PAAR) in addition to the within-allocation request. The TRP generally agreed with the prioritization of interventions between the within-allocation request and the PAAR. However, the TRP considered that two proposed PAAR interventions, totaling $1.7 million, did not constitute “quality demand.” The larger of the two, at $1.3 million, was for program management staff salaries. The TRP saw the salaries as not being tied to any specific interventions.

The remaining $46.2 million of the PAAR was considered quality demand. After deducting the $13.0 million awarded for matching funds (because there was overlap between the PAAR interventions and the initiatives proposed for the matching funds), $33.3 million was added to Unfunded Quality Demand Register. By far the largest initiative in the PAAR involved further expanding case finding efforts. Another PAAR initiative was for the support of community-level provision of care for MDR-TB cases.

Sustainability

Bangladesh, with its growing economy, has recently transitioned from low-income to lower-middle-income status, according to the World Bank’s classification system. Nevertheless, the nation still relies heavily on donor support for its health systems, and as such is not in a position to be transitioning out of Global Fund eligibility anytime soon. Still, important advances have been made in recent years in terms of domestic financing of health systems.

Domestic expenditures on health have risen, and are expected to continue to increase significantly over the 2018-2020 implementation period of the grants. The Government of Bangladesh’s commitment to finance procurement of all first-line TB drugs, mentioned above, represents a major step towards sustainability of the TB response. According to the review and recommendation form, with the government contribution, about 93% of the funding needed for drug-susceptible TB treatment is met.

Domestic co-financing commitments for the 2018-2020 period are 78% higher than for the current period, furthering the trend toward sustainability and satisfying the Global Fund’s co-financing requirements. Of the $240.1 million estimated need for TB control in Bangladesh, about $191 million is accounted for between domestic and donor commitments, leaving a gap of 20% between needed and available resources, down from 40% in the prior period. See the table for more details on the TB funding landscape in Bangladesh.

Table: Overview of funding landscape ($ million)

Component: Tuberculosis
Estimated funding need for program 240.1

As % of
funding need

Change vs. previous period
Total domestic resources 56.9 24% Increase from 13%
Total external resources (non-GF) 24.0 10% Decrease from 11%
Total Global Fund resources 110.9 46% Increase from 36%
Total resources available 191.9 80% Increase from 60%
Unmet need gap 48.2 20% Decrease from 40%
 

Of the 110.9 million approved for the two grants, $74.9 million was earmarked for BRAC, and $36.0 million for the National TB Control Program. The Global Fund Secretariat says that it usually takes about two months to go from Board approval to first disbursement. It is possible, therefore, that the two grants will be signed by mid-December and will begin implementation on schedule in January 2018.


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