In June 2016, the Global Fund Board approved $179 million in funding for 13 grants emanating from concept notes submitted by nine countries. Of the $179 million, $80 million represented new money; the balance was existing funding that had been approved prior to the new funding model but was nevertheless included in the NFM allocations to countries. The Board was acting on recommendations from the Grant Approvals Committee and the Technical Review Panel.

No interventions were added to the registry of unfunded quality demand. See the table for details.

Table: Funding for country grants approved by the Global Fund, June 2016 ($ million)

¹ The new funding for Lesotho (TB/HIV) includes $3.1 million in incentive funding. ² The new funding for Madagascar (HIV) includes $5.5 million in incentive funding.

The largest awards went to Lesotho ($64.5 million for two TB/HIV grants), and Nepal ($44.4 million for three grants, one for each disease).

In addition, funding in the amount of $3.4 million was awarded to a regional grant in Central America.

The following is a summary of the GAC’s comments on some of the grants awarded funding. (See separate article in this issue on the funding award to Nepal.)

Afghanistan (HIV)

The goal of the Afghanistan program is to maintain HIV prevalence below 5% among populations at highest risk. The main driver of the epidemic in Afghanistan is injecting drug use. The principal recipient is the UNDP. The program’s targets include the following:

• increase safe injection practices at last injection among people who inject drugs from 78% in 2012 to 95% in 2017;
• increase the coverage of comprehensive harm reduction packages for people who inject drugs from 22% percent in 2015 to 40% percent in 2017 in 10 target provinces;
• increase the coverage of prevention services among people in prisons from 8% in 2015 to 52% in 2017 in 10 target provinces; and
• increase coverage of TB screening for people living with HIV from 19% percent in 2015 to 90% in 2017.

Afghanistan is categorized as a challenging operating environment due to the political instability, civil unrest, and armed conflicts. Specific risks and mitigation measures related to the implementation of this grant include the following:

• Poor data quality and insufficient monitoring and evaluation systems.

   The grant includes workplan tracking measures in the performance framework as well as risk management actions in the grant agreement. Geographic mapping and a description of implementation arrangements for existing and proposed interventions will provide better clarity on addressing key programmatic gaps and will help to avoid duplication with other funding sources.

• Inadequate quality of certain health services.

   Coordination with partners will be increased to ensure that voluntary testing and counseling is integrated into the basic package of health services. Technical assistance will be made available for the national programs to set up policies and processes ensuring greater access to overdose prevention services.

• Human rights issues and limited access to health services for key populations.

   Funds are earmarked for geographical expansion and scale-up in coverage of existing interventions for people who inject drugs. This includes outreach to women who inject drugs, prisoners, and men with high-risk behavior. TA will be provided to address the specific needs of women who inject drugs, and to address issues of violence and sexual exploitation of minors.

The grant has budgeted $28,000 for performance incentive payments for provincial communicable disease control coordinators in five new provinces which currently do not have coordinators. The payments are for the work that these coordinators will undertake for the Global Fund grant that is additional to their regular duties. This is considered a more cost-effective alternative to hiring staff dedicated to The Global Fund. The GAC said that if this model proves efficient, the Ministry of Public Health will absorb these additional costs.

Afghanistan was granted an exceptional waiver to the counterpart financing and willingness-to-pay requirements for the current implementation period due to the absence of national disease accounts and in light of the exceptional economic and political crisis. Afghanistan is in the process of developing national health accounts under its HSS grant.

Lesotho (TB/HIV)

In 2013, Lesotho was ranked as the country with the second highest HIV prevalence among people aged 15-49, at 22%. That same year, TB incidence in Lesotho was estimated to be the second highest in the world. The goal of the TB/HIV program is to reduce by 2018 (compared to 2012) new HIV infections by 50%, HIV-related mortality by 50%, and mother-to-child transmission of HIV to below 2% percent; and to reduce TB prevalence and mortality rates by 25% and 50% percent respectively.

Funding was awarded to two grants, for which the PRs are the Ministry of Finance and the Pact Institute. Despite past investments, there hasn’t been much impact on the HIV and TB incidence rates. To address this, the grants include the following measures:

• high-level advocacy to promote institutionalize collaboration between entities and synergies between partners;
• a commitment to increase absorptive capacity from 70% to 95% under the Ministry of Finance, and from 45% to 67% percent under the Pact Institute;
• the development and roll-out of a decentralized, defined accountability framework, with ongoing mentoring, as well as tailored risk management and oversight by the Secretariat;
• the reinstatement of the national AIDS council;
• enhancing active case finding and treatment retention; and
• increased attention to cross-cutting interventions for community strengthening, and resilient and sustainable systems for health.

The GAC commended the collaboration of the two disease programs. It recommended that interventions focused on adolescent girls and young women be considered a priority area given that the country has now set specific gender-disaggregated targets. The GAC recommended that savings found during grant implementation should be invested in such interventions. According to the GAC, the Secretariat is planning a regional-level examination on how to improve the quality of interventions for adolescent girls and young women to build on lessons learned by other countries with high HIV burdens in this population.

Although Lesotho continues to be heavily dependent on external financing, the government continues to make progress in increasing its contributions, which exceed the willingness-to-pay requirement. During this implementation period, domestic financing will cover all first-line TB treatment, and will pay for a greater share (i.e. 70%) of the costs of antiretroviral procurement. The GAC said that the government is pursuing other initiatives designed to improve long-term sustainability. These include (a) development of a national health financing strategy, with support from Irish Aid, to outline mechanisms to mobilize additional financial resources for the health sector; and (b) efforts to leverage private sector resources for health from mining and services industries.

Madagascar (HIV)

Madagascar has a relatively low prevalence rate among the general population (0.3%) but higher rates among key populations. The HIV program’s targets include the following:

• reduce the proportion of men who have sex with men living with HIV from 14.8% in 2014 to less than 10% in 2017;
• reduce the proportion of sex workers with HIV from 1.3% in 2012 to less than 0.3% in 2017; and
• reduce the proportion of people who inject drugs living with HIV from 7.1% in 2012 to less than 5% in 2017.

There are two PRs: Population Services International and the Secrétariat Exécutif du Comité National de Lutte Contre le VIH/Sida. Global Fund grants to Madagascar face a number of operational issues and risk. They include poor coordination between PRs; weak management of sub-recipients; weak national monitoring and evaluation systems; limited financial capacity; and weak procurement and supply chain management systems.

To address these risks, the following mitigating actions have been included in the grants:

• the Secretariat, working with the various entities involved, will ensure that program data is regularly reviewed and that the quantification assumptions are revised to keep track of changes in patient enrolments;
• the PR will be required to share the stock status reports for all commodities before orders are confirmed;
• TA will be provided to build the capacity of both the PR and the national program in the areas of quantification, and procurement and supply chain management;
• specific TA for HIV monitoring and evaluation is planned to support the national program to review and strengthen the data collection and reporting system for HIV, to ensure that the country can monitor service delivery along the prevention and care continuum, and track progress towards achieving the UNAIDS 90-90-90 goals; and
• about 10% of The Global Fund allocation for this period will be invested in health system strengthening activities to increase the capacity and functioning of the overall health system, and specifically in procurement and supply chain management and monitoring and evaluation systems.

Malaysia (HIV)

The HIV epidemic in Malaysia is largely concentrated among key populations: people who inject drugs, men who have sex with men, transgender people, and female sex workers.

The goal of the Global Fund-supported program, implemented by the Malaysian AIDS Council, is to strengthen quality of HIV prevention and care services to key populations by using a case management approach which has been successfully piloted with MSM in Malaysia. The program plans to scale-up this approach among MSM, and to extend it to people who inject drugs and sex workers.

Some of the elements of this approach are as follows:

• finding and encouraging MSM, sex workers, people who inject drugs – and their sexual partners – to test and, if appropriate, enroll in treatment;
• supporting adherence and retention to antiretroviral therapy and to methadone maintenance therapy among people who inject drugs;
• establishing linkages and relationship building between NGOs, government and private health services to coordinate efforts to reach, test, and assist enrollment in and adherence to treatment for key populations; and
• enhancing social protection and reduction of stigma and discrimination towards key population through engagement with law enforcement, health service providers, relevant public officials, and civil social stakeholders.

The Government of Malaysia funds well over 90% of the costs of the HIV program. The Ministry of Health has committed to continue to fund the procurement and supply of condoms, needles, syringes, and safe injection kits until the end of 2018.

Pakistan (HSS)

According to the GAC, the health system in Pakistan faces a number of challenges, most of which stem from the fact that the HIV, TB, and malaria programs have been implemented separately using a “vertical” approach. The major challenges are related to a lack of or low capacity of institutionalized oversight bodies; high overhead costs and duplications in areas that could be more efficient; and reporting and information systems that are not sufficient for logistics management or epidemiological reporting.

The grant focuses primarily on optimizing storage and distribution through the construction of a prefabricated warehouse (62% of the request) and an integrated health management information system (13% of the request).

The health system of Pakistan was fully devolved to the provinces with the abolishment of the central Ministry of Health in 2011. To address institutional fragmentation, a new ministry was created at the federal level, known as the Ministry of National Health Services, Regulation and Coordination, under whose jurisdiction the three national disease programs fall. The proposed PR, the Health Planning System Strengthening and Information Analysis Unit, comes under the ministry and is new to The Global Fund. Its capacity is being built with the help of the national TB program, which will oversee the implementation of the grant until December 2016.

Uzbekistan (HIV)

According to the GAC, the Uzbekistan HIV program initially submitted a reprogramming request to the TRP in Window 2 in July 2014, and the TRP recommended that it be re-submitted due to the lack of sufficient data on the epidemiological situation, the activities being proposed, and how the activities would be carried out. The Uzbekistan country coordinating mechanism requested and was granted a one-year costed extension until the end of 2015 in order to provide essential services during the transition to the allocation-based funding model. During this period, the Secretariat provided assistance to build the capacity of the proposed PR, improve data for key populations, and address risks related to procurement and supply chain management.

In addition, UNAIDS provided TA to the CCM and the PR, the Republican AIDS Centre, to help them address the TRP comments and develop a well-focused concept note. The revised concept note was submitted in Window 8 in November 2015 and was considered by the TRP to be strategically focused and technically sound.

The objectives of the HIV program are as follows:

• to deliver evidence-based, integrated and regionally prioritized HIV prevention and treatment services to key populations groups at risk of HIV and living with HIV;
• to support the development of a national health infrastructure that can provide a sustained, relevant and optimal HIV response; and
• to strengthen community systems and support civil society to ensure an HIV response that is based on needs, driven by human rights and public health, and is sustainable – and has a particular focus on key populations.

The Republican AIDS Center is taking over from the UNDP as PR. The GAC said that it expects that the new PR will continue to engage civil society sub-recipients, which have demonstrated experience and existing capacity to effectively delivering prevention services to the key populations.

Regional grant

Known as the REDCA+ grant, the program is implemented by the Secretaria de Integracion Social Centro Americana. It seeks to strengthen the capacity of people living with HIV in the Central American region through a community approach. Funding goals include developing a socio-demographic profile of people living with HIV in the region to inform the design of intervention strategies, and empowering people living with HIV to actively participate in their health care and in the defense of their human rights. The program covers the following countries: Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, and Panama.

The grant was awarded $3.4 million, of which $3.2 million was new funding.

The HIV epidemic in Central America is largely concentrated among MSM, with a prevalence rate varying from 7.5% to 17.1%. Legal barriers to accessing HIV care and prevention, particularly for key populations, have been identified in all seven countries. The barriers are related to the lack of a protective legal framework and to the inadequate implementation of existing policies and laws. The specific objectives of the program are as follows:

• to strengthen the technical and legal capacities of people living with HIV and their organizations to participate in the promotion and defense of the human rights of people living with HIV through oversight, social auditing, and political advocacy at the regional and sub-regional level;
• to promote improvements to legal frameworks, public policies and their implementation to reduce violations of the human rights of people living with HIV; and
• to strengthen the REDCA+ sub-regional system.

Information for this article comes from the June 2016 report of the Secretariat’s Grant Approvals Committee to the Board (GF-B35-ER03). This document is not available on the Fund’s website.