Mainland Tanzania submitted a funding request for its HIV and TB components that resulted in the Global Fund Board approving three grants, including a TB/HIV grant to a civil society principal recipient (PR) –– AMREF Health Africa. The Ministry of Finance and Planning (MOFP) was awarded an HIV grant and a TB grant. Tanzania is one of the countries in sub-Saharan Africa most heavily impacted by HIV and TB. The HIV prevalence among adults aged 15–49 was estimated at 5.3% in 2012, which nevertheless represents a steady decline from 7% in 2003. HIV prevalence is highest among key populations. These include men who have sex with men (MSM), people who inject drugs (PWID), and sex workers, whose rates are estimated at 25%, 36% and 26%, respectively. Data suggests that HIV infection rates begin to rise much earlier in girls than boys, creating a need to provide age-tailored prevention services to adolescent girls. Significant strides have been made to address vertical transmission of HIV with near universal antiretroviral therapy (ART) coverage of HIV-infected pregnant women. Tanzania ranks 6th globally in terms of its TB and TB/HIV burdens. The prevalence of TB is estimated by the World Health Organization (WHO) to be 528 per 100,000, with treatment coverage of only 37%, making it particularly critical for the National TB Program to identify and treat the missing TB cases. Tanzania’s allocation for 2017–2019 was $579.6 million. The indicative breakdown of the allocation was as follows: HIV –– $408.5 million TB –– $25.8 million Malaria –– $145.3 million
Total –– $579.6 million
After Tanzania moved $43.5 million from HIV to malaria to cover resilient and sustainable systems for health (RSSH) activities, and made additional minor adjustments, the final approved program split was as follows: HIV –– $364.3 million TB –– $26.5 million Malaria –– $188.8 million
Total –– $579.6 million
Tanzania’s country coordinating mechanism (CCM) submitted a TB/HIV funding request in the amount of $390.9 million. The CCM also submitted a matching funds request for $14.0 million. The amounts of the approved grants are shown in Table 1.
Table 1: Approved TB and HIV grants to Tanzania

Component	Name	PR	Amount ($ million)
TB	TZA-T-MOFP	MOFP	30.5 m
HIV	TZA-H-MOFP	MOFP	349.4 m
TB/HIV	TZA-C-AMREF	Amref Health Africa	25.0 m
Total			404.9 m

The total of $404.9 million includes the $14.0 million in matching funds ($6.0 million for finding missing TB cases and $8.0 million for initiatives targeting adolescent girls and young women). Tanzania also submitted a prioritized above allocation request (PAAR) of $38.4 million, of which the Technical Review Panel (TRP) deemed $37.9 million to be quality demand. During grant-making, budget efficiencies of $955,942 were identified. The funds were reinvested in the grant to expand TB case finding community interventions beyond eight regions. In the end, interventions worth $37.3 million were added to the Unfunded Quality Demand (UQD) Register. (Separately, the Board awarded $145.3 million to Tanzania for a malaria grant. Tanzania had also submitted a request for RSSH activities, in the amount of $43.5 million, to be included in its malaria grant. The RSSH request is still under iteration [according to grant documents].)
Notable strengths
The TRP considered the TB/HIV funding request to be technically sound and strategically focused. In its review, it said that the applicant provided a strong epidemiological and situational analysis and used that data to design interventions addressing the needs of key populations. The TRP said that the funding request was aligned with existing national strategic plans for HIV and TB, as well as the national roadmap on reproductive, maternal, newborn, child and adolescent health. The TRP also noted that the funding request prioritized TB and HIV interventions in high-prevalence regions and high-prevalence “pockets” in low-prevalence regions. In addition, the TRP observed that the funding request built on lessons learned from Global Fund programs and in-country best practices from other donors such as PEPFAR. The TRP said that the funding request outlined examples of effective interventions for early and complete TB case finding, such as working with accredited drug dispensing outlets; developing a specimen transport system; and strengthening TB case finding at the health facility level through quality improvement. The request also highlighted the contribution of the private sector in TB case detection, the TRP said. The TRP made the following additional observations:

• The funding request included a module designed to reduce legal barriers to service access.
• A gender-based violence (GBV) intervention within prevention programs for the general population was well-described. GBV-related services were incorporated in multiple modules.
• The funding request identified vulnerable groups for TB, including HIV-positive adults and children, mining communities, elderly persons, prisoners, people with diabetes, PWID, health workers and people living in urban slums.

Weaknesses, gaps and action steps
The TRP identified eight issues pertaining to the funding request. The issues were discussed by the Secretariat and the CCM during grant-making. Seven issues were cleared and one was partially addressed. Below we briefly summarize the issues that were fully addressed, and we indicate what the outcomes were.
ISSUE: Lack of a diagnostic algorithm to support progress towards universal drug susceptibility testing (DST).
Tanzania plans to expand access to GeneXpert machines while at the same time expanding smear microscopy services. It was not clear, therefore, what the overall TB laboratory diagnostic expansion strategy was. Nor did Tanzania clearly explain the calculations used in the TB diagnostic algorithm, or how coverage and progress towards universal DST will evolve during the implementation of the grant. DST is key to identifying whether a patient has drug-resistant TB.
Outcome
: The CCM clarified the diagnostic algorithm and provided a GeneXpert roll-out plan as well as a quality improvement toolkit for case detection.
ISSUE: Unrealistic timeline to expand coverage of external quality assessment (EQA) of laboratories for sputum smear microscopy.
The request stated that all TB laboratories providing sputum smear microscopy services will have been included in the national EQA system by the end of 2017. The EQA assessments can reveal common issues with supply chain management, skilled personnel, logistical support and quality standards. At the time the funding request was prepared, only 40% of laboratories were included in the EQA system and, of these, less than half demonstrated adequate performance in the last round of proficiency testing. It is unclear how the planned rapid EQA coverage to reach 100% of laboratories providing smear microscopy services will be achieved in the limited period covered by this grant.
Outcome:
The timelines for the expansion of EQA were revised to make them more realistic. The country team will continue to follow-up the on the milestones in the action plan.
ISSUE: Insufficient budgeting of the key interventions for finding missing TB cases.
Many key interventions for finding missing TB cases –– such as private provider engagement, community engagement and activities to enhance case finding among children –– were not included in the within-allocation request, but instead formed part of the PAAR.
Outcome
: Key interventions for missing cases –– some of them taken from the PAAR –– were added to the within-allocation request. To make this work, $3.3 million was reallocated from the proposed HIV budget to the TB program.
ISSUE: No plan to improve treatment retention.
The funding request acknowledged that low retention of people living with HIV on treatment has been a problem. However, the funding request did not sufficiently explain how retention will be improved, especially in light of the planned rapid expansion of ART.
Outcome:
The CCM proposed steps to retain patients on treatment. The country team will monitor this during the implementation period. As well, the PR will be asked to re-submit the interventions with defined timelines, responsibilities and participants.
ISSUE: Lack of information on current HIV and TB interventions in prisons.
Although the funding request included some activities for TB prevention and care in prisons, the details were not clear. Nor was the scope of the proposed interventions. Further, the request did not provide data on infection rates, ART coverage or the availability of prevention services for this population. Finally, if the key prevention interventions recommended by the WHO for prisoners are not yet available –– namely condoms, needle and syringe programs and opioid substitution therapy (OST) –– Tanzania should outline plans for introducing these interventions.
Outcome:
Tanzania described the plans and the partners that will ensure data is collected on HIV and TB in prisons; and funding for these activities appears to be available. A plan and resources exist to guarantee HIV care coverage in prison settings, including linkage to care on exit and TB prevention interventions and treatment coverage.
ISSUE: Lack of clear plan and budget for OST scale-up.
Tanzania was asked to explain the feasibility of the plan to scale up coverage of OST from the current level of 20% to 80% by 2020. It is not clear what activities Tanzania will implement to achieve scale-up, or where the funding will come from.
Outcome:
A methadone scale-up plan and budget were developed. Scale-up of methadone assisted treatment (MAT) will start in three regions supported by government funding.
ISSUE: Need to strengthen basic health and community system structures to support ambitious scale-up.
Tanzania was asked to explain how it intends to overcome substantial performance gaps in community- and facility-based service delivery to ensure that the Global Fund’s investment in commodities and equipment translates into health outcomes for both HIV and TB patients.
Outcome:
During grant making, the country team’s dialogue with government and partners ensured the inclusion of activities to institutionalize capacity building at health facilities and in communities. Budgets for trainings, support supervisions and mentoring at regional, district and facility levels have been developed; innovative strategies have been adopted to address the issue of health worker shortages; and a mix of interventions have been proposed for implementation at the community level.
Other considerations
The Grants Approval Committee (GAC) expressed support for the guidelines for key and vulnerable populations which were approved in 2017. In addition, the GAC said, there is a need for the Secretariat and partners to continue to work with in-country stakeholders to ensure effective programming and access to services for all vulnerable populations. During grant-making, it was agreed that the issues concerning programming for key populations will require continuous monitoring. Delivery of key populations services is in the HIV/TB grant to be implemented by Amref Health Africa. The GAC noted the proposed rapid ART scale-up and outlined the implications for the broader health system, particularly concerning the capacity to identify, enroll and retain patients on treatment. The GAC highlighted the need for the Secretariat and partners to support Tanzania to carefully plan for the system to absorb the increased number of patients and provide quality services through a successful roll-out of the country’s differentiated delivery model. The country team will continue to monitor this process.
The funding landscape, co-financing and sustainability
Table 2 provides an overview of the country’s funding landscape for HIV and TB for the 2018–2020 period.
Table 2: Overview of Tanzania’s funding landscape in 2018–2020 ($ million)

Component: HIV
Estimated funding need for program:	1,881.5 m	As % of funding need	Change vs. previous period
Total domestic resources	173 m	9%	Increase
Total external resources (non-GF)	1,121.2 m	60%	Increase
Total Global Fund resources	367.6 m	20%	Increase
Total resources available	1,661.9 m	88%	Increase
Unmet need gap	219.6 m	12%	Decrease

Component: TB
Estimated funding need for program:	1,881.5 m	As % of funding need	Change vs. previous period
Total domestic resources	34.9 m	18%	Increase
Total external resources (non-GF)	44.2 m	23%	Increase
Total Global Fund resources	23.2 m	12%	Increase
Total resources available	102.3 m	53%	Increase
Unmet need gap	90.1 m	47%	Increase

The TRP determined that Tanzania made sufficient co-financing commitments for the allocation period, as per the requirements of the Sustainability, Transition and Co-Financing (STC) policy. To access the full co-financing component for 2017–2019, the government is expected to invest an additional $29.3 million in 2018–2020 for HIV and TB over and above the what it spent in 2015–2017. Tanzania exceeded this requirement by $8.8 million. The government said that its investment would support activities in the following areas:

• For HIV: Program management, voluntary medical male circumcision, prevention of vertical transmission of HIV, blood safety and prevention activities.
• For TB: MDR-TB drugs (modest share), TB/HIV–related activities and TB care and prevention activities.

In addition, the government is in the process of approving a national health financing strategy (HFS) which has as its main objective the achievement of universal health coverage through increased mobilization of domestic financial resources. The HFS envisages a National Health Insurance Scheme, which would provide a standard minimum benefit package as a legal entitlement to all citizens, financed by mandatory contributions and government subsidies for the poor and the vulnerable.