NFM Update: TRP flags shortcomings as concept notes keep rolling in
The Technical Review Panel (TRP) has highlighted some of the most common gaps and shortcomings of the concept notes submitted since the full adoption of the new funding model (NFM), even as modifications to expedite the review process for straightforward proposals are instituted.
In the monthly progress update about the NFM to the Board, the Secretariat emphasized that concept notes were being submitted roughly in line with a schedule developed prior to the roll-out of the NFM. Twenty-three concept notes were submitted to the TRP for review in July. By mid-September it is anticipated that another 33 concept notes will begin the screening process, bringing the total of NFM applications to 66 thus far, excluding early applicants, for a grant portfolio worth as much as $6.02 billion.
These figures are slightly behind predictions made prior to the NFM roll-out that 72 concept notes would be in-hand by 15 August, but it is expected that the cumulative number of concept notes to be submitted during the allocation period 2014-2017 will reach 280 -- slightly more than half of which (146) should be with the TRP before the end of 2014.
Thus far, the majority of the concept notes submitted have been to secure resources for malaria programming. It is anticipated that the number of concept notes for TB and HIV -- as well as joint TB/HIV proposals -- will increase in the next submission windows.
An expedited review by the Grant Approvals Committee of concept notes that are not eligible for incentive funding has been instituted by the Secretariat, in what appears to be an effort to bring as many technical resources as possible to those concept notes requiring more attention.
The 41 countries in Band 4 -- a portfolio worth a total of $1.1 billion -- are not eligible for incentive funding.
Although a disease split was included in the allocation amount that was communicated in March to each eligible country, countries were allowed, subject to approval, to modify that split. To date, the Secretariat has agreed the split for 40 countries, excluding those eligible for funding for only one disease component.
In a bulletin of lessons learned that was also shared with the Board, the TRP noted a number of gaps and shortcomings in the concept notes received, some of which have required a refocusing of attention by country coordinating mechanisms (CCMs) and a resubmission.
The TRP reminded CCMs of the technical assistance available from both the Fund itself as well as technical partners in order to address these shortcomings and emphasized the need for all concept notes to be based on sound, data-driven evidence collected at national and sub-national levels.
Among the thematic areas of concern flagged by the TRP were:
A thorough analysis of epidemiological data, backed by clear explanations of how proposed interventions will target and reach key populations, has been lacking in some proposals. More care must be taken to ensure that rights and gender issues are not only identified, but that programming to address them is strong.
A number of concept notes reviewed thus far failed to include a broad range of interventions to address gender, gender-based violence and the rights of women and girls. Nor was there enough demonstrated support for the needs of young people (especially adolescent girls), who are at extremely high risk in generalized HIV epidemic settings. Budget considerations must also be made for human rights and key population activities.
The TRP recognized that some countries lack the resources and capacity to ensure program sustainability beyond the life of Global Fund grants. However, this lack of resources should not prevent countries from showing how they intend to ensure that these programs continue, particularly with respect to the need to integrate disease programs and health system strengthening into delivery of primary health services through the national health system. This lesson emphasizes the move away from vertical programming towards more cost-effective integrated programming that is central to the NFM's health policy objectives.
Although 40 countries have had their program split approved, the TRP noted "a general lack of engagement of experts on health systems strengthening" and the apparent exclusion of some stakeholder groups from "thoughtful and robust country dialogue around program split and prioritization of interventions".
Applicants thus far have struggled to present a clear and prioritized concept note that explicitly explains strategic choices made in the allocation of limited resources to high-impact, cost-effective activities. The TRP noted: "Concept notes that fail to reflect evidence-based prioritization based on geographic and population data and lessons learned from past implementations will be asked by the TRP to undergo iteration before moving to grant-making".
Implementation of new WHO guidelines on ART
The TRP expressed concerns that some HIV concept notes have failed to "holistically consider (sic) the country’s readiness to move to a CD4 threshold of 500, nor did they appear to acknowledge the aspects of the [WHO guidelines] that allow for prioritization of people with CD4 less than 350 and for discordant couples and key populations".
Also of concern is countries' ability to find the appropriate balance between prevention and treatment, with many countries seemingly targeting the lion's share of their funding allocation to treatment, specifically the purchase of anti-retroviral therapies.
"Without appropriate prevention efforts, ART will ultimately prove unaffordable and, therefore, unsustainable," the TRP brief said. "If a major portion of the resources requested is going to ART scale-up, the concept note should make clear how essential prevention services are to be sustained through other national or donor resources as ART is scaled up."