On 28 August 2017 (Window 3), Swaziland submitted a TB/HIV funding request to the Global Fund. The total request was for $93.8 million. When broken down, $47.2 million of this amount was within the country’s allocation, $1.5 million was a matching funds request for catalytic funding to prevent HIV among adolescent girls and young women (AGYW), and $45.1 million was a prioritized above allocation request (PAAR). “Swaziland is grateful to the Global Fund for this significant investment in our next implementation phase, October 2018 – September 2021,” said Dr Simon Zwane, Permanent Secretary to the Ministry of Health and Chair of Swaziland’s country coordinating mechanism (CCM). “I have no doubt that the funding will help us achieve our vision of an AIDS-free Swaziland by 2022,” he said. Swaziland has the world’s highest adult HIV prevalence, at 27.3% in 2016. The country has set the ambitious target of ending AIDS by the year 2022 – eight years earlier than the global target. The funding request is tailored to material change, which is intended to be less comprehensive than full review applications. According to the funding request instructions, tailored review applicants should identify material changes that might have occurred in the country, leading to the need to revise and/or re-prioritize certain program areas funded by the Global Fund. In its funding request, Swaziland identifies six “triggers” for material change and proposes a “strategic modification” for each trigger (see table). No changes are proposed to the implementation arrangements. Swaziland wishes to retain the National Emergency Response Council on HIV and AIDS as the government principal recipient (PR) and the Coordinating Assembly of Non-Governmental Organizations as the civil society PR.
Elaborating on the triggers for material change and strategic modifications shown in the table above, the sections below provide more information on the reasons for the changes and how the funding request is tailored as a result.
Strategic modification #1: Innovation for “last mile” impact
New data from the second Swaziland HIV Incidence Measurement Survey (July 2017) reveals remarkable progress. Since the first survey in 2011, new infections fell by nearly half, and viral load suppression among people living with HIV more than doubled (see GFO article). Similarly, new (unpublished) 2016 TB data from the World Health Organization indicate that Swaziland continues to close the gap in missing TB cases. In 2016, just 16% of TB cases went undetected, compared to 56% in 2013. These changes in the country’s epidemiological context (the first trigger for material change) mean that it will get harder to reach those not yet tested for HIV, or screened for TB, and to put them on treatment. Many of these unreached people may be hidden or criminalized populations, or those that face extra barriers to accessing services. To reach these populations, Swaziland proposes several innovative activities for “last mile” impact. With its Global Fund investment, the country will roll out HIV self-testing among HIV and TB key populations, including sex workers, men who have sex with men, people who inject drugs, factory workers, and TB contacts, among others. For TB screening, a cadre of active case finders working in the community will be guided by the use of geographic information system (GIS) mappings of high risk groups, including mine workers and ex-mine workers (see figure).
Strategic modification #2: 

Exploit new policy opportunities for increased impact
Swaziland’s funding request proposes modifying the current Global Fund program in light of several important new policies and strategies. In October 2016, the country launched test-and-start, offering immediate antiretroviral therapy (ART) to all people living with HIV. From April 2017, the country moved to routine viral load testing, providing at least one test per year to all people living with HIV. There is also a new (draft) defined core package for HIV prevention, tailored by age, sex and population. As of June 2016, community ART has been national policy, enabling people living with HIV to travel to facilities less frequently to collect medication. In January 2017, the country launched new guidelines for the management of drug-resistant TB (DR-TB), including the new short-course treatment regimen and the use of new TB drugs. The funding request harnesses opportunities within all these new policies (and several others). In support of the new test-and start policy, the government of Swaziland has committed to procuring all first-line antiretroviral drugs (ARVs) for the country, meaning that the Global Fund grant will be modified to procure only second- and third-line ARVs. In addition, more than 10% of the within allocation budget goes towards ensuring viral load testing scale-up, aiming for routine offering among all people living with HIV. The newly defined core packages for HIV prevention are used as the basis for all services to be delivered to AGYW, men who have sex with men, and sex workers. Investment in nutrition and transport support for DR-TB patients will nearly double compared to the current grant, scaling up in line with the new guidelines.
Strategic modification #3: 

Enhance integration for greater impact against the diseases
The funding request points out that there are significant missed opportunities because not all health facilities offer integrated HIV, TB and reproductive health services. Swaziland has a 70% TB/HIV co-infection rate, yet only 118 out of 170 ART sites also offer TB treatment. In addition, while 41.1% of pregnant women are living with HIV, there are 13 antenatal care sites which do not offer ART. To improve integrated service delivery, the funding request prioritizes rolling out the country’s new essential healthcare package, training community health workers, and introducing integrated management of childhood illnesses. The training of community health workers is to ensure that integrated service delivery can happen at the community level, as more facilities transition to offer a full package of services. In the PAAR, funding is requested for necessary refurbishments so that more facilities can become accredited TB basic management units.
Strategic modification #4: 

Take a more location- and population-specific prevention approach
The focus on HIV prevention is significantly enhanced in this request, accounting for more than a fifth (21.1%) of the total budget. This is more than seven times greater than what was in the country’s last application, which, at just 3%, was one of the smallest HIV prevention requests of any African country (see GFO article). The vast majority of this prevention funding is focused on AGYW. Young women age 20-24 have the highest rates of new infections in Swaziland. The funding requested for young women is highly targeted, mostly focused on just 13 high-density, low-income areas with high rates of teenage pregnancy. The proposed program includes community health fairs, provision of sanitary pads and educational subsidies to keep girls in school; and peer-clubs for out of school girls. The matching funds application requests money for the piloting of a voucher system to link girls to pre-paid health services at their preferred outlets. Also included in this strategic modification are peer outreach initiatives for newly prioritized key populations. In addition, the funding request allocates money for people who use drugs – a first for Swaziland’s Global Fund program.
Strategic modification #5: 

Implement a phased transition of MSF TB programs
MSF is a major funding partner for Swaziland’s TB response, contributing over $4 million a year – about a third of the country’s total TB budget. The organization has made an executive decision to hand over and close all MSF-supported activities by 1 July 2018. The funding request proposes that some of the money from the Global Fund should be used to enable a responsibly managed transition, ensuring that there are no major program disruptions or reversed impact against the disease. In a letter from MSF that was submitted as an attachment to the funding request, the organization states that “to facilitate a smooth transition of MSF activities to the Ministry of Health, the National Tuberculosis Control Programme and partners, a stepwise approach is used.” While the staged handover has already begun (as of April this year), the funding request proposes that the country’s next Global Fund TB grant be structured in support of this transition. It includes Year 1 investments in certain diagnostic and laboratory equipment and Years 1 and 2 investments in human resources. By Year 3 of the grant, the government will take over the areas which MSF was previously funding.
Strategic modification #6: 

Harness technical, allocative and implementation efficiencies
The last strategic modification – to harness efficiencies – is driven by a significant reduction in Swaziland’s Global Fund allocation. It has been reduced from $80.4 million in the 2014-2016 funding cycle to $51.3 million in the 2017-2019 funding cycle. On a per year basis, assuming that the 2014-2016 allocation exceptionally covered a period of four years, the 2017-2019 allocation represented a reduction of $3 million each year. Regardless of its size, any reduction has implications for a program looking to scale-up its high-impact activities – as Swaziland is. To try and “do more with less”, the funding request proposes aligning the Global Fund program to the country’s investment case. The investment case suggests that strategic investment in the short term can lead to cost savings later on. In fact, investing in the high-impact investment case interventions has the potential (a) to bring down the cost per HIV infection averted from $1,135 in 2014 to $250 by 2030; and (b) generate a 70% financial savings for the TB program. In addition, the work being done by the Ministry of Health in partnership with Oxford Policy Management on the potential for implementing universal health coverage shows that if Swaziland continues on its current efficiency improvement trend, but with greater focus, this would generate more than $48 million a year in savings. The funding request aims to harness these efficiency opportunities.
Domestic financing and sustainability
As noted in Strategic Modification #2 above, the government of Swaziland is dedicated to financing all first line ARVs for the next three years to cover the country’s full need. This is a landmark commitment, submitted in writing from the Ministry of Finance as an attachment to the funding request. Altogether, government spending will make up just less than half of total HIV and TB resources in the country over the coming years. However, Swaziland still anticipates that the need will outpace available resources, estimating a $25 million gap in the HIV response and a $10 million gap in the TB response by the year 2020. The funding request states that identifying efficiencies in spending – Strategic Modification #6 – is the country’s best option for closing this gap.
Funding request development process
“The process to develop this funding request was one of the most consultative we have ever embarked on,” said Vulindlela Msibi, the Executive Secretary for Swaziland’s CCM. Msibi told Aidspan that the country held dedicated sessions with HIV and TB key populations, including sex workers, men who have sex with men, people living with HIV, ex-mineworkers, people who use drugs, TB survivors, ex-prisoners, among others. “The tremendous support from Government and our partners enabled the CCM Funding Request Development Team to conduct extensive consultations with all relevant stakeholders, including adolescent girls and young women,” said Msibi. “We even held several focus groups down at community level.” “The writing team was not only professional in its approach, but also dedicated and committed to ensuring that the inputs into the draft extended well beyond consultation fora,” said Zwanini Shabalala, the chair of the writing team. “Along with receiving – and systematically responding to – over thirty sets of comments, the writing team also traveled to Uganda in July for an in-depth technical peer review process.” Swaziland received feedback from Angola and Pakistan at the peer review. The Technical Review Panel (TRP) is expected to meet from 29 September – 6 October 2017 to review funding requests submitted in Window 3. The TRP’s response to Swaziland’s funding request is anticipated in mid-October.
Gemma Oberth was the lead consultant for Swaziland’s TB/HIV funding request. Her work on the funding request was in her capacity as an independent consultant.