Disease-Specific Observations from the TRP’s Review of TFM Proposals
In the report to the Board on Transitional Funding Mechanism (TFM) proposals, the Technical Review Panel (TRP) made observations specific to each of the disease components. This article provides a summary of these observations. (In a separate article, we describe the lessons learned identified by the TRP with respect to all proposals.)
MARPs. The TRP expressed concern that activities for most-at-risk populations (MARPs) were reduced in scale or were missing in TFM proposals. The TRP said that there were serious reductions in the number of community-based organisations working in this area. Further, the TRP noted that there were reductions in MARPs-related targets; and that where there were targets, they were often absent from performance frameworks or poorly covered in the frameworks. In some cases, the TRP said, activities mentioned in the proposal were not included in the budget even though they were listed as priorities in the proposal.
According to the TRP, proposals that included activities designed to sustain treatment services rarely mentioned issues of access by MARPs to treatment, counseling and testing services – despite the fact that these populations are often over-represented among the people needing treatment. In addition, the TRP said, overall the proposals demonstrated a lack of knowledge among applicants regarding most-at-risk populations.
Prevention. The TRP expressed concern that, for the most part, applicants did not provide details of prevention activities in proposals. The TRP said this was particularly noticeable for activities relating to MARPs. The TRP said that in order to assess proposals, it needs detailed descriptions, which include what is being done, how is it being done, who is doing it, what access they have to the targeted populations, where is it being done, what barriers are faced, how those barriers are being addressed, and what has been achieved.
Indicators. The TRP said that the prevention indicators currently being used do not reflect actual grant performance. The TRP recommended that prevention indicators for coverage, effectiveness and impact be included in proposals.
Other observations. The TRP observed that there was a stronger emphasis on treatment activities compared to prevention activities; that half of the 26 HIV proposals included prevention of mother-to-child (PMTCT) activities; and that few TB-HIV activities were included in the TFM proposals.
The TRP said that TB proposals were generally well focused on essential services, but that there were some weaknesses.
DOTS. The TRP said that it is very concerned that poor service delivery is effectively breeding multi-drug resistant tuberculosis (MDR-TB) in various countries. Improving the quality of programming was not prioritised in proposals, even in countries where case notification and treatment success rates remain alarmingly low or in some instances are in decline. The TRP noted that applicants tended to favor the inclusion of MDR-TB activities at the expense of core DOTS interventions
MDR-TB. The TRP noted the rapid expansion of programmatic management of drug-resistant tuberculosis, without giving adequate attention to quality assurance; and, in some instances, despite poor treatment outcomes.
New diagnostic technologies. The TRP said that it remains concerned about the absence of clear diagnostic algorithms that incorporate the use of new diagnostic technologies for tuberculosis. (The TRP has raised this issue before.) The TRP said that it was also concerned about the over-use of expensive tests – for example, the use of drug sensitivity testing of all new smear-positive cases in low-MDR contexts. Further, the TRP further noted that proposals contained limited external quality assurance and proficiency testing.
Proof of effectiveness. The TRP said that some interventions were included in proposals without adequate evidence that they work. It cited two examples: (1) providing food support as an incentive of adherence to TB treatment; and (2) use of advocacy, communication and social mobilisation activities.
Other observations. The TRP noted that while some proposals addressed the problem of drug stock-outs, generally the proposals failed to include activities to strengthen related systems to ensure the effective procurement and delivery of the drugs. The TRP also observed that there were limited activities to promote treatment adherence and case detection among hard-to-reach populations.
Long-lasting insecticide-treated bed nets (LLINs). The TRP said that although the TFM demand for bed net replacement represented 72% of the total funds requested for malaria, the amount of money requested was still very modest compared to the global need.
The TRP also noted that there is a need for more contemporary evidence on the lifespan of bed nets in various contexts. The TRP recommended that an index of the effective lifespan for LLINs be developed that combines both the physical durability of the bed net and the persistence of the insecticide. The TRP also recommended that countries be given assistance to conduct research on the lifespan of LLINs in different contexts.
Mapping. The TRP said that because many countries are making rapid progress in malaria control, which is resulting in changes in the epidemiology of the disease, there is a need for malaria risk mapping and information on country disease trends to be updated frequently, and interventions tailored appropriately.
Drug quality. The TRP noted that applicants need to focus more attention on routine measurement of the quality of antimalarial drugs given the threat posed by sub-standard medication.
The report of the Secretariat and the TRP on the TFM proposals is available on the Global Fund website at www.theglobalfund.org/en/trp/reports.