There were huge obstacles confronting Democratic Republic of Congo as it navigated the new requirements of the Global Fund's new funding model (NFM): a lack of credible, national-level data; logistical hurdles to reach key populations in a nationwide consultation around a country with just 2,250 km of paved roads; and a leadership vacuum and entrenched disorganization. Add to this the lack of clarity in both Geneva and Kinshasa in the first stages of the NFM -- as DRC was an early applicant -- and it spelled almost certain defeat for the country's prospects of touching its desperately needed allocation.
A first concept note, delivered in January by a fractious, untrained and leery country coordination mechanism, was rejected two months later as having poorly articulated its priorities. Its implementation roadmap was 'imprecise' and failed to deliver even the promise of high-impact interventions.
"We should have provided harmonized data [for TB and HIV]; what we did was provide multiple sources [of conflicting data]," acknowledged Sylvain Yuma, who shepherded the first note towards submission. "Nor did we really address the problem of co-infection of HIV and TB, whereas we have a really high rate here of co-morbidity."
So back to the drawing board they went, this time charged with the task of developing a joint note due to that high co-morbidity, as recommended by the Technical Review Panel. Seizing on the lessons learned from the first failed attempt, and bolstered by considerable external support from technical partners, a second submission was made in August. This time, success; the TRP endorsed the proposal and recommended to the Grants Approval Committee that DRC proceed to the next phase. By the end of November, DRC was among the countries approved to go through to the negotiations phase of the NFM, for a grant worth nearly $230 million, including some $14.5 million in incentive funding for TB and HIV activities. Once this is approved by the Board, funds should be disbursed from mid-2015.
Steep learning curve for the NFM
The Secretariat of the Global Fund considers that this investment of time and effort will only benefit DRC, and address some of the particular difficulties it had in integrating into the new way of working under the NFM. One early problem related to confusion among principal recipients about how much they should contribute to the development of the concept note. Some considered that it would be a conflict of interest to be both involved in the design of the HIV/TB note and then be a designated recipient of funding for the proposed activities. As a consequence, their absence from the discussions meant that the first submission lacked nuance and clarity around objectives and budgeting.
"Principal recipients could have brought more expertise to the budget discussions because they have the experience there," said Patrick Kanku, in charge of the HIV program for the rural health program Sanru, a state-operated structure. Sanru is likely to be chosen among principal recipients for HIV under the new grant.
In response, many PRs insisted that while they were not 100% engaged in the concept note development, they were at least there in the design stage.
"Seeing that the development of the concept note lacked technical and organizational leadership, some of the technical partners raised the alarm; so it was France Expertise Internationale that asked me to step in," explained Eric-Marie Dupuy, an independent consultant who was part of the concept note steering committee. "For example there were discussions that went on forever about whether a community-based PR could be included -- ultimately the CCM said yes."
Another challenge: the lack of experience in collaboration between government and civil society. Marie Nyombo Zaina, coordinator of the national network of NGOs addressing gender issues, and a member of the steering committee for both concept notes criticized what she saw was a lack of consideration of the particular needs of the fledgling Congolese civil society.
"As representatives of civil society, we found it difficult to be considered equal contributors to discussions that involved experts from various government ministries. For example, doctors from the national programs didn't see the importance of including a psycho-social component -- and a rights-based approach -- to treatment," she said. "They were reluctant to let us have a taste of the cake that they were used to eating alone. But with the NFM, they gradually realized that we all had to go in the same direction, towards reform."
The second time around, in developing the joint concept note, things were easier, said Joseph Bulakali, the secretary general of the CCM. "There were misunderstandings the first time that were resolved by the second effort. Technical assistance the first time was already a done deal, with the technical partners -- UNAIDS, WHO, Pepfar, USAID, UNICEF -- making the choices," he explained. "For the second concept note, we were able to have more open discussions about who should be providing that assistance. And crucially, we had a roadmap that we were able to follow almost to the letter."
A joint note, approved with some recommendations
While the joint concept note was approved, there was still room for recommendation. The TRP said that the CCM had failed to elaborate how it was going to implement the new WHO guidelines for who is eligible for ARVs. The TRP also urged that DRC develop more programming to target patients with TB who are also HIV-positive, as well as HIV-positive pregnant women. The number of condoms and packages of lubricant for men who have sex with men and sex workers was judged insufficient, and HIV prevention activities for miners, truck drivers and security personnel needed more clarity and nuance.