Editor’s Note: Guinea-Bissau was one of seven applicants for which the Global Fund recently approved renewal funding. Articles on each of the other six renewals are available on GFO Live. Go to www.aidspan.org/page/gfo-live or follow the links for each article in the “Available on GFO Live” section of this newsletter, immediately below this article.
Despite a sub-par performance in Phase 1 of a Round 9 TB grant to Guinea-Bissau, the Global Fund Board has approved funding for Phase 2 in the amount of $6.0 million, but with certain conditions attached. One of the conditions is that there be a change of principal recipient (PR). The PR in Phase 1 was the Ministry of Health (MOH).
In approving the funding, the Board was acting on recommendations from the Grant Approvals Committee (GAC).
Guinea-Bissau has the population of 1.5 million, with high TB prevalence and incidence rates. Since 1990, the TB prevalence rate has remained steady. The incidence rate, however, has been steadily increasing. The GAC said that the treatment success rate for smear-positive TB patients, at 73%, is low; and that the treatment success rate for other patients, at about 55%, is very low. The case detection rate for all forms of TB, estimated at 56%, has been steadily declining since it reached a high of 71% in 2006. In the opinion of the GAC, this indicates a decline in programmatic performance.
The financial absorption rate during Phase 1 was only 25%, due to the non-payment of performance-based incentives and severe delays encountered by the MOH in undertaking infrastructure renovations and procurement.
The GAC said that its review of Phase 1 revealed a number of programmatic challenges. The implementation of basic directly observed therapy, short course (DOTS) was weak, with low case detection and high default rates. There was no strategy or guidelines for TB/HIV co-infection activities despite a high co-infection rate. The design of the community component was weak. Stock-outs occurred and some drugs passed their expiry date while still in storage.
The GAC said that financial irregularities were uncovered in 2011, and that the 2012 coup d’état compounded an already fragile situation. As a consequence, then Global Fund General Manager Gabriel Jaramillo evoked the Additional Safeguard Policy in August 2012 and a fiscal agent was put in place.
The GAC said that despite the difficulties encountered in Phase 1, the Global Fund must continue to be a major source of funding for the TB programme in Phase 2. The focus in Phase 2 will be on strengthening basic DOTS, responding adequately to TB/HIV co-infection and other challenges, improving health care systems, and strengthening the community component of the programme.
The GAC said that antiretroviral therapy access for co-infected patients needs to improve in Phase 2. Guinea-Bissau hopes that by the end of Phase 2, the treatment success rate will increase to 85% from 73% currently, the number of MDR-TB patients treated annually will reach 20, and HIV testing will be provided to all TB patients.
The GAC said that in the original proposal approved by the Global Fund, a significant amount of money was identified to implement PAL (Practical Approach to Lung Health). However, the TB technical partners on the GAC pointed out that PAL was designed for middle-income countries. They said that investments in PAL would not achieve significant impact on the TB epidemic in Guinea-Bissau. (Technical partners are non-voting members of the GAC.)
The GAC said that savings arising from efficiencies and the elimination of activities with low returns, including PAL, should be used to fund TB/HIV collaborative activities and much needed technical assistance.
The GAC said, and the Board agreed, that a change in PR was required because of the many management issues encountered in Phase 1. The CCM has nominated UNDP to be the new PR. The Global Fund is also requiring that a programme review be conducted as soon as possible, followed by further revision or validation of the most recent draft national strategic plan (2013–2015).
Information for this article was taken from Board Decision B28-EDP-19 and from B28-ER-15, the Report of Secretariat Funding Recommendations and Decisions for April 2013. These documents are not available on the Global Fund website.