Global Fund expresses concern over Benin’s plan to shift funds away from HIV and malaria towards an RSSH funding request

9. NEWS
23 Oct 2017
Secretariat decides to leave program split decision open until the RSSH proposal is received
Size of salary incentives linked to grant performance ratings

When it reviewed the funding requests from Benin, the Grant Approvals Committee (GAC) and the Technical Review Panel (TRP) expressed serious concerns about what they perceived as gaps in Benin’s HIV and malaria programs – which, they said, were partly due to the decision of the country coordinating mechanism (CCM) to shift some of its allocation towards an RSSH funding request.

The original allocation for Benin was as follows:

HIV – € 26,699,475
TB – € 7,396,130
Malaria – € 32,925,878

Total – € 67,021,483

Benin proposed a revised program split in which it reduced the HIV portion by almost € 3.0 million, the TB portion by about €1.0 million, and the malaria portion by almost € 6.0 million in order to generate a budget of approximately €10.0 million for an RSSH component. The GAC and the TRP recommended that no final decision be made concerning the program split until the RRSH funding request is reviewed ­– in order to ensure that Benin has the flexibility to shift money back to its HIV and malaria components to address the gaps.

Benin was also awarded matching funds, as follows:

HIV: Key population impact – € 1,514,870
HIV: Human rights–related barriers to health services – € 1,336,650
RSSH: Integrated service delivery and health workforce – € 2,138,640

Total – € 4,990,160

This article provides a summary of the comments of the GAC and the TRP on the HIV and malaria funding requests from Benin.

Benin’s HIV funding request (€ 23,705,512) was entirely within its allocation. Benin later submitted a prioritized above-allocation request (PAAR) which will be presented to the TRP before the end of 2017, along with Benin’s request for matching funds which was also submitted recently. Benin is expected to submit its RSSH funding request in January 2018. (The World Bank and the World Health Organization are providing support for drafting the proposal and the Global Fund’s country team will travel to Benin in early December.)

One of the gaps in the HIV program identified by the GAC was treatment and follow-up for about 5,000 patients. The GAC said that the program described in the funding request would result in a quasi-stagnation of the antiretroviral treatment (ART) cohort whereas Benin has the capacity to increase the ART cohort by 5,000 additional patients on ART per year. The CCM said that it would address this gap in its above-allocation request. 

The GAC also identified gaps in addressing human rights–related barriers to services, and in prevention and support services for key populations. The GAC noted, however, that some of these gaps would likely be addressed in Benin’s matching funds request. 

Benin’s malaria funding request (€ 26,976,038) was also entirely within its allocation. The GAC said that a significant risk became apparent during grant-making, when a funding shortfall in the amount of € 4 million was identified to cover the costs of two million long-lasting insecticide-treated bed nets (LLINs) for a mass distribution campaign in 2020. Benin said it would include a request to fund the LLINs in an upcoming PAAR. Despite becoming aware of this critical gap, the GAC noted, the CCM chose not to revise its proposed program split.

The GAC encouraged Benin to look critically at its RSSH application to ensure continued treatment availability for all patients on ARVs and continued effectiveness of the malaria program; and to ensure that Global Fund money goes to the most critical interventions expected to achieve the most impact. The GAC said that Benin’s RSSH request would have to demonstrate that it represented value for money and that it was clearly linked to disease outcomes. Should the TRP decide to recommend only a portion of the RSSH request for approval, or if efficiencies are identified during grant-making, the GAC said, Benin should be given the opportunity to invest funds from its RSSH allocation to address critical gaps in the HIV and malaria programs.

Once the final grant for a given component has been approved by the Board, any increase in the upper ceiling amount for that component would require Board approval. Hence, the determination to keep the decision on the final program split open until the RSSH funding request is reviewed.

The size of the TB funding request was € 6,286,711. The TB request, as well as the HIV and malaria requests, were all of the program continuation type. The RSSH request will require a full review. The GAC expressed concern that the delayed submission of the RSSH request may lead it to being out of sync with the other components. In addition, the TRP said it was concerned that current RSSH activities may run out of funding before the end of 2017.

Review of the HIV funding request

The TRP said that the program continuation request demonstrated the continuing relevance of the strategic objectives and key interventions of the HIV program in Benin – with thus far good program results achieved, a high absorption rate, and good indicator progress.

The HIV funding request nominated two principal recipients (PRs): Programme de Lutte Contre le Sida (formerly PNLS) and Plan International Benin. These are the same PRs that are currently implementing Benin’s HIV grants.

The TRP noted that three issues were still outstanding from the review of Benin’s 2014-2016 HIV concept note:

  • a transgender people survey is being carried out, the results of which need to translate into appropriate interventions in the new grant; 
  • the PR is drafting a gender-based violence strategy that needs to inform interventions in the new grant; and 
  • the proposed pilot for condom provision and needle exchange for prisoners has not yet started. 
 

The first two issues were addressed during grant-making. The third issue has been deemed not feasible. The CCM explained that prison authorities have reported cases of homicide and suicide using condoms and needles. The CCM said that advocacy efforts undertaken during grant implementation have so far failed.

Review of the malaria request

The TRP said that it considers Benin’s malaria funding request to be strategically focused and technically sound, and aligned with both the National Health Plan and global normative guidance.

The TRP noted that the proposed program includes specific interventions for the following vulnerable populations: (a) populations living far from health centers (100% coverage of villages); (b) poor or deprived populations in contexts where socio-cultural barriers continue to impede early use of malaria prevention and treatment services; and (c) persons deprived of liberty. The main initiatives planned for this last population are training and supervision for prison care staff, provision of treatment and prevention protocols, and consultation with ministries involved with security to improve the availability of services. 

Domestic financing

In the allocation letter it sent to Benin, the Global Fund said that the minimum investment Benin is required to make in 2018-2020 to access the full co-financing incentive is € 6,702,148 for all three diseases combined. The government has committed to invest about € 3.5 million more than that, as shown in the table. 

Table: Co-financing investment by Government of Benin (€)

Component
2015-2017
actual
2018-2010 commitment
Increase
HIV
11,036,235
13,054,723
+ 2,018,488
TB
3,614,853
5,911,004
+ 2,296,151
Malaria
12,925,256
18,899,648
+ 5,974,392
Total
27,576,344
37,865,375
+ 10,289,031
 

The GAC noted that the government’s contribution for HIV health products is increasing from 30% (for 2015-2017) to 40% (for 2018-2020). The GAC said that there is a risk of the increased investment from government not materializing because the government failed to meet the 30% commitment for 2014-2017, resulting in stock-outs of cotrimoxazole, opportunistic infections drugs and viral load tests. The GAC noted that despite failing to meet this specific commitment, the government has met the requirements for co-financing for previous allocation period as a whole. 

To address the risk of the government’s 40% commitment not materializing, the Secretariat has inserted a condition in the grant confirmation form that the CCM will work with the country team to monitor the materialization of the government’s contribution. 

The GAC said that the government is making specific efforts to increase its contribution to funding for malaria control in Benin. For example, the government is: 

  • purchasing 500,000 LLINs to contribute to the LLIN campaign;
  • implementing the policy of free malaria treatment for pregnant women and children under five years of age; and
  • strengthening health systems through the development of qualified staff, construction and equipment of health care infrastructure, and procurement of drugs and health care consumables and other products. 
 

Currently, the government is only covering a small proportion of Benin’s total health expenditures (2.3% in 2014). However, the GAC noted, the health budget has been gradually increasing. It rose 16% from €106.0 million in 2016 to € 123.0 million in 2017. The projections for 2018 and 2019 are € 128.0 million and € 155.0 million, respectively. 

According to the GAC, during a National Dialogue on Domestic Financing held in February 2017, the government committed to aim toward contributing 15% of the national budget to the health sector – this is the target set by member states of the African Union in the Abuja Declaration of 2001 – and to increase its contribution for the three diseases. For the 2017-2019 period, the government is committing to spend € 41.9 million for all three disease components, which is € 17.0 million more than for the previous period. The CCM indicated that a significant proportion of the additional funding would be allocated to HIV.

As part of the health sector reform underway in Benin, the government is developing a universal health care (UHC) model. However, the GAC noted, this initiative will take time to be fully realized.

Performance-based funding

The current performance-based funding (PBF) scheme is being evaluated by the government. This could lead to revisions to the scheme or even to scrapping the scheme entirely, the GAC said. The latter would negatively impact the motivation of staff in health care facilities as they currently receive performance bonuses under this scheme. The GAC said that the Secretariat will be actively involved in decisions on the future of the PBF and UHC schemes with the goal of ensuring that the health sector will be adequately financed and that quality health service delivery will be maintained. 

Salary incentives

The GAC noted that the performance-based incentives that Benin plans to pay to staff of the government PRs are in line with the Global Fund’s budgeting guidelines. Incentive payments will be made to 27 of the 55 staff of the Programme de Lutte Contre le Sida (at a cost of € 74,733 over three years), and to 40 of the 82 staff of the National Malaria Control Program (at a cost of € 137,081 over three years). These key staff were selected based on the criteria that their efforts can be linked to the performance targets expected to be achieved with Global Fund financing. This incentive will be paid at 20% of the base salary if grant performance is rated A1, and 15% if grant performance is rated A2.

Some of the information for this article was taken from Board Document GF-B37-ER04, Report of the Secretariat’s Grant Approvals Committee, a copy of which was obtained by Aidspan. This document is not available on the Global Fund website.

See also separate articles in this issue on the approval of grants emanating from the funding requests for Zimbabwe TB/HIV, and Malawi TB/HIV. In addition, see separate article in this issue providing an overview of the 46 grants approved for funding.


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