Zimbabwe’s TB/HIV funding request to the Global Fund: “Not much room to manoeuver”
As GFO reported a few weeks ago, Zimbabwe submitted a TB/HIV funding request for $629 million in Window 1 of the current funding cycle. The $629 million request consisted of $432 million that was within Zimbabwe’s allocation, and $197 million for a prioritized above-allocation request (PAAR).
In this article, we examine two challenges that arose during the development of the funding request: (1) the applicant did not have much room to maneuver with respect to the program interventions it could include in the request; and (2) a group of donors criticized the process and the outcome.
Challenge: Too little room to manoeuver
As we explained in our earlier article, despite the size of the funding request, there was little money available for programmatic activities. About 70% of Zimbabwe’s allocation had to be dedicated to the procurement of essential medicines and health products, and a further 20% had to go towards retaining critical human resources for health and program management.
Despite this limitation, the Zimbabwe CCM managed to include in the funding request cross-cutting activities to strengthen resilient and sustainable systems for health as well as a clear emphasis on key and vulnerable populations. The problem was that the CCM was not able to devote as much money to these interventions as it would have liked.
In an effort to “make everyone happy,” the CCM tried to come up with a funding request that was “balanced” between prevention and health systems strengthening, on the one hand, and treatment on the other. But the amounts budgeted in an initial draft of the funding request for prevention and health systems strengthening had to be scaled back when a team from the Global Fund Secretariat pointed out that the proposal would create a treatment gap – a gap that reached 100% in Year 3. The team said that not only would this not be acceptable to the TRP, but it would of course also not be in the best interests of the country.
So the proposal had to be re-shuffled to ensure there was no treatment gap. Hard choices had to be made. The RSSH interventions were reduced by about 50%, from representing 16% of the total budget to representing 8%.
The CCM opted to prioritize HIV prevention for adolescent girls and young women, sex workers and men who have sex with men by including interventions targeting these groups in the within-allocation portion of the final proposal. HIV prevention for the general population, prisoners, transgender people and people with disabilities was moved to the PAAR portion of the proposal. No activities were removed completely during the reshuffle.
Another reason for putting HIV prevention for the general population in the PAAR portion was that PEPFAR invests large sums in condoms as well as voluntary medical male circumcision. In other words, the gaps for these interventions were not all that large, compared to the gaps for the key populations that were prioritized.
Challenge: Group of donors criticize the process and the outcome
In a letter sent to the Chairperson of the CCM, a group of European Union (EU) and Swiss donors expressed concern about the “unsatisfactory process leading up to the finalization of the funding request.” The letter, dated 30 March 2017, also raised concerns about the outcome.
The letter was signed by representatives of the embassies of France, Ireland and Sweden; by representatives of bilateral development agencies in Switzerland and the U.K.; and by the Ambassador and Head of the EU delegation in Zimbabwe. Technical representatives of all six countries either sit on the Zimbabwe CCM or at least regularly attend meetings of the CCM.
The donors sent copies of their letter to Mark Edington, Head of the Global Fund’s Grant Management Division, and Dumitru Laticevschi, the fund portfolio manager for Zimbabwe.
In the letter, the donors said that the original funding request was developed through a detailed and comprehensive process which involved specialists from a range of fields and organizations, as well as representatives from civil society and beneficiary groups.
“This process was consultative, collaborative and country-led,” the letter stated. “However, these efforts were undermined by a last-minute intervention by a team from Global Fund headquarters that visited Zimbabwe towards the very end of the drafting process. On the basis of information shared at their exit meeting, the proposal-writing team made significant changes to the budget allocations resulting in a greatly increased focus on treatment at the expense of health systems strengthening, preventative programmes and work with key at risk population groups.”
The donors said that the final proposal differed significantly from earlier drafts and was submitted to the Global Fund “despite not being subject to the proper scrutiny or formal approval through the CCM or the Oversight Committee.”
“The significance of the change is considerable,” the donors said. “Within the overall picture of an increasingly fragile economy in Zimbabwe, the health sector is itself faced with funding challenges that threaten the integrity of the health system at a time when it is still recovering from the economic shocks and collapse of the last decade. There is real concern that without proper investment, there is a real risk of further rapid decline, which would adversely affect all health outcomes, including targets around the treatment and care of patients with HIV.”
On 19 April, the Chairperson and Vice-Chairperson of the CCM responded. The CCM leadership took issue with some of the statements in the donors’ letter. The CCM is of the opinion that the process for developing the fund request was “very satisfactory, transparent, consultative and very inclusive” they said. “The reprioritization was done on very practical and ethical grounds to at least continue availing uninterrupted treatment to those already on treatment and the CCM is in agreement with the writing team on this.”
The CCM leadership said that all of the priorities approved by the CCM are in the funding request. “However, due to the size of resource envelope available to us, some of the activities on RSSH and prevention were put in the PAAR and this was endorsed procedurally,” they said.
The Global Fund’s guidance was very consistent, the CCM leadership said. “In their exit interview with the Chairperson they indicated that they had discussed the issue of the ARV gap with the partners on 14 March 2017.… It would be rather unfair therefore to say that the country team undermined our process, and we feel that they, in fact, enriched it. This was a CCM-led process and the CCM takes full responsibility for the decisions taken.”
“Your letter came as a surprise to us as we would have expected your technical representatives … to bring up the issues as we developed and concluded our application as per CCM procedures and practice,” the CCM leadership said.
The CCM leadership added that the letter from the donors – which, they said, was widely circulated, including to the Technical Review Panel – “despite the good intentions the letter might have had, puts our funding request at risk and in a way undermines the very reputation of the Zimbabwe CCM.”
The CCM leaders also copied Mr Edington and Mr Laticevschi on their response.