ANOTHER 18 GRANTS OKAYED FOR FUNDING
David GarmaiseArticle Type:
Article Number: 3
$364 million approved for 12 countries
ABSTRACT In July 2016, the Global Fund approved $364 million in funding for 18 country grants, of which $152 million represented new money. Haiti and Madagascar received the largest awards.
In July 2016, the Global Fund Board approved $364 million in funding for 18 grants emanating from concept notes submitted by 12 countries. Of the $364 million, $152 million represented new money; the balance was existing funding that had been approved prior to the new funding model (NFM) but was nevertheless included in the NFM allocations to countries. The Board was acting on recommendations from the Grant Approvals Committee (GAC) and the Technical Review Panel (TRP).
The funding awards included $18 million in incentive funding. As well interventions totaling $63.3 million were added to the registry of unfunded quality demand. See the table for details.
The Board added $1.2 million to the program budget for a previously approved HIV grant to Iran. The money comes from uncommitted funds from a Round 8 grant.
The Board also approved additional funding of $388 million for six shortened and early applicant grants. GFO plans to provide further details on these awards in a future issue.
Table: Funding for country grants approved by the Global Fund, June 2016 ($ million)
|Angola (TB/HIV)||AGO-H-UNDP||UNDP||1.3 m||28.7 m1||30.0 m6|
|Angola (malaria)||AGO-M-MOH||Ministry of Health||12.5 m||18.1 m||30.6 m|
|AGO-M-WVI||World Vision International||0.0 m||8.2 m||8.2 m|
|C.A.R. (malaria)||CAF-M-IFRC||IFRC||8.2 m||11.7 m2||19.9 m|
|Haiti (HSS)||HTI-C-PSI||Population Services International||61.1 m||4.1 m3||65.2 m|
|Honduras (HIV)||HND-H-CHF||Cooperative Housing Foundation||2.2 m||13.0 m||15.2 m|
|Kosovo (HIV)||KOS-711-G04-H||Community Development Fund||0.2 m||1.5 m||1.7 m|
|Liberia (malaria)||LBR-M-MOH||Ministry of Health||21.9 m||5.7 m4||27.6 m7|
|LBR-M-PII||Plan International Inc.||3.1 m||9.0 m4||12.1 m7|
|Madagascar (malaria)||MDG-M-PSI||Population Services International||39.7 m||1.0 m||40.7 m|
|MDG-M-MOH||Ministry of Health||18.9 m||0.0 m||18.9 m|
|Mauritania (TB)||MRT-T-SENLS||SENLS||0.0 m||4.8 m||4.8 m|
|Mauritania (HIV)||MRT-H-SENLS||SENLS||1.6 m||7.6 m||9.2 m|
|Mauritania (malaria)||MRT-M-SENLS||SENLS||0.0 m||15.6 m||15.6 m|
|Namibia (TB)||NMB-T-MOHSS||Min. of Health and Soc. Services||15.3 m||0.0 m||15.3 m|
|Peru (HIV)||PER-H-PATH||Path||5.9 m||6.6 m||12.5 m8|
|SLE-Z-MOHS||Min. of Health and Sanitation||14.7 m||16.0 m5||30.7 m9|
|SLE-M-CRSSL||Catholic Relief Services||5.3 m||0.0 m||5.3 m9|
|TOTALS||211.9 m||151.6 m||363.5 m|
The awards to the Central African Republic and Kosovo were in euros, which we have converted to US dollars at a rate of 1.10303.
1 The new funding for Angola (TB/HIV) includes $3.9 million in incentive funding.
2 The new funding for Central African Republic (malaria) includes $2.3 million in incentive funding.
3 The new funding for Haiti (malaria) includes $1.9 million in incentive funding.
4 The new funding for Liberia (malaria) includes $7.3 million in incentive funding.
5 The new funding for Sierra Leone (malaria) includes $2.8 million in incentive funding.
6 An additional $39.5 million was added to the unfunded quality demand (UQD) register.
7 An additional $3.0 million was added to the UQD register.
8 An additional $410,000 was added to the UQD register.
9 An additional $2.4 million was added to the UQD register.
The largest award went to Haiti ($65.2 million for an HSS grant), and Madagascar ($59.6 million for two malaria grants).
The following is a summary of the GAC’s comments on some of the grants awarded funding.
As a country with a high rate of TB/HIV co-infection, Haiti submitted a joint TB/HIV concept note. The HIV component was reviewed and approved first to align with the national planning cycle. Then the TB component was reviewed and approved, and the funding for both HIV and TB was consolidated under one grant, HTI-C-PSI. Funding for the HSS component will be added to the same grant.
According to the GAC, the health system in Haiti faces substantial challenges, including a shortage of health workers, decaying infrastructure, and risk of natural disasters. The HSS component is designed to support the implementation of the disease-specific Global Fund–supported programs. It will invest in health information systems, monitoring and evaluation, health and community workforces, and a results-based financing program for health facilities. A total of 415 community health workers will be recruited and trained.
The Global Fund believes that managing the three disease components and HSS under a single principal recipient (PR) will enhance synergies between the programs and make it easier to overcome the difficulties of working in a challenging operating environment.
Malaria is a major public health issue in Madagascar; 88% of the population live in high transmission areas. In 2014, in public health facilities, malaria was the fifth biggest cause of death for all age groups and the eighth biggest for children under the age of five. However, data from health care facilities show that the malaria morbidity rate for all age groups fell from 18.8% in 2003 to 5.5% in 2014. The goal of the Madagascar malaria program is to reduce malaria-related deaths to zero, and to reduce the test positivity rate to less than 5% percent in all districts by the end of 2017.
Funding was awarded to two grants, for which the PRs are the Ministry of Health and Population Services International. Among other things, the grants plan to reduce the malaria test positivity rate from 49.6% in 2015 to less than 10% in 2018; and to increase the number of long-lasting insecticide-treated nets (LLINs) distributed through social marketing from 122,756 in 2015 to 225,000 in 2018, and to targeted risk groups from 118,926 in 2015 to 723,418 in 2018.
The GAC said that for the new grants, the number of staff receiving performance incentives will be drastically reduced from rounds-based grants and will use up less than 0.03% of the total malaria grant budget.
To address issues that have been identified with respect to the capacity of the PRs as well as procurement and supply chain management, the following actions will be taken:
- technical assistance will be obtained;
- a fiscal agent will be hired;
- to improve reporting, new accounting software will be installed, existing software will be updated, and PR accounting specialists will be trained;
- a technical support unit will be established within the MOH to undertake program management, monitoring and evaluation, and procurement and supply chain management; and
- to avoid over- and under-stocking, the PR will submit stock status reports to the Secretariat for all commodities before new orders are confirmed.
The grant for which funding has been approved has an end date of 30 June 2018. The GAC pointed out that a mechanism will have to be found to allow Madagascar to access new funds prior to this date in order to place orders for long-lasting insecticide-treated nets (LLINs) for a mass campaign planned for the end of 2018. The GAC suggested this order be placed before the end of 2017 to ensure timely arrival of the nets. The Secretariat told the GAC that such a mechanism will be in place because it will also be needed for other countries. A spokesperson for the Secretariat explained to GFO that “mechanism” in this context means finding a way to advance money to countries from their expected 2017-2019 allocations. A Board decision may be required to allow this to happen.
Angola (TB/HIV, HSS, and malaria)
According to the GAC, the TRP initially reviewed the Angola TB/HIV and malaria concept notes in June 2015 and recommended further iteration, noting that the significant health system barriers that affect quality of services across the country were not addressed in the applications. In November 2015, the revised TB/HIV and malaria concept notes were resubmitted together with a cross-cutting health systems strengthening (HSS) concept note.
The TRP and the GAC recommended an incentive funding award of $3.9 million for the TB/HIV program but made it conditional on the Government of Angola matching the amount with domestic funding in its 2017 health budget.
During the grant-making process, the GAC said, Angola contended with a number of challenges, notably a significant increase in malaria transmission, an outbreak of yellow fever, and a leadership change at the Ministry of Health (which included a reshuffle of senior management staff). According to the GAC, to address these developments, and some long-standing challenges with respect to grant implementation – such as treatment disruptions, stockouts, poor data quality, and the failure of the government to live up to its commitments – Angola and the Secretariat have agreed to adopt innovative implementation arrangements. They include a pilot project approach which focuses investments and service delivery on geographical areas with highest transmission rates (hotspots) and highest potential for scale-up.
The goal of the Global Fund-supported malaria program in Angola is to reduce morbidity and mortality of malaria by 60% between 2014 and 2020.
The malaria grant to be implemented by World Vision includes a “community workforce module” that was included in the HSS concept note. The GAC said that young women and girls are considered a priority by Angola; and that the Secretariat is working on strengthening community-level systems through health workers in order to provide test and treat services.
Central African Republic (malaria)
The goal of the malaria program is to reduce malaria-related morbidity and mortality in the general population by 50% between 2010 and 2017. The PR for the malaria grant is the International Federation of Red Cross and Red Crescent Societies.
The GAC said that the fragile political context and conflict in Central African Republic has resulted in operational challenges and has posed barriers to measuring expected impact and outcomes of the proposed programming, such as limitations in terms of the reporting, the completeness, the quality and the timeliness of data, as well as the analysis and use of the data. Therefore, the Secretariat was unable to provide baselines and targets for the program at the time that this funding was recommended for approval. However, a malaria indicator survey planned for 2016 is expected to provide the necessary information to establish a sound epidemiologic basis for the program. In addition, the grant is funding five positions in the PR’s monitoring and evaluation unit to improve data collection and management.
The malaria program has faced challenges in stock management. To address these challenges, the Secretariat and the PR have agreed to establish a nine-month buffer stock of malaria health products.
The Central African Republic was placed under the Additional Safeguard Policy in 2014. According to the GAC, security has steadily improved since the last outbreak of violence in September and October 2015, but the situation remains uncertain and some grant activities have been delayed as a result.
Honduras has an HIV prevalence rate of 0.4% among the general population. The epidemic is primarily concentrated among men who have sex with men (MSM), transgender females, female sex workers and the Garifuna indigenous population. The goals of the Global Fund-supported Honduras HIV program, to be implemented by the Cooperative Housing Foundation, are to:
- reduce the number of new cases of HIV infection by at least 50%;
- reduce the rate of mother-to-child HIV transmission to 0.3 cases or fewer in every 1,000 live births; and
- reduce TB co-infection among persons diagnosed with HIV by at least 10%.
None of the goals or planned achievements mentioned in the GAC report related to the key affected populations mentioned above.
The Kosovo HIV program initially submitted a concept note to the TRP in Window 5 in March 2015, which the TRP recommended for further iteration. Considering that the Kosovo HIV program had previously been extended twice for the total duration of 24 months to allow for the development of the funding request, less than 40% percent of Kosovo’s allocation remained available for the revised concept note. In light of the above, the GAC said, Kosovo was allowed to undergo a simplified application process through an extension, under two conditions: (1) the applicant address the issues raised by the TRP or provide plans outlining how outstanding issues would be addressed during implementation; and (2) a full request be submitted to the TRP for review during the 2017-2019 allocation period.
While only 100 cases of HIV infection have been officially registered in Kosovo, a country of 1.8 million, the country is regarded as vulnerable to HIV epidemic due to its high rates of poverty and unemployment; increasing drug use and high-risk sexual behavior, particularly among young Kosovars and other vulnerable groups; high mobility of Kosovars to and from Europe and Balkan countries that have higher prevalence rates of HIV; and the presence of large international community, the majority of whom are unaccompanied workers.
The goal of the Kosovo HIV program, to be implemented by the PR, the Community Development Fund, is to maintain the low prevalence of HIV and improve the quality of life of people living with HIV in Kosovo by:
- ensuring equitable access to high quality prevention, treatment, care, and support with a focus on key populations;
- strengthening the health and community systems that enable needs-based, sustainable and integrated interventions for key populations most affected by the HIV epidemic; and
- creating a supportive environment for a sustainable response to HIV in Kosovo.
Performance-based incentives in the grant are provided for four positions, which are to be used to put in place a system of HIV case management. According to the GAC, the incentives will be phased out following the extension and the associated duties will be integrated into the terms of reference of the relevant individuals.
The Liberia malaria program, through the CCM, was allowed to submit a simplified funding requests in March 2016 based on the Investment Plan for Building a Resilient Health System in Liberia 2015-2021, which was written in response to the Ebola virus disease outbreak of 2014-2015. Funding was awarded for two grants, for which the PRs are the MOH and Plan International.
The GAC said that poor early recognition of suspected cases of Ebola because of inadequate infection prevention and control standards led to a disproportionate infection rate among health care workers. Ebola had a devastating impact on the already fragile health system and severely affected the Global Fund-supported programs. Health service provision declined significantly because of facility closures; the refusal of health workers to provide routine health services in the absence of protective equipment; and fear in the community to attend health services. Communities turned to private, traditional, and informal health providers, with the number of outpatient visits in the public sector dropping by 61%. Women and children were most affected: Antenatal care provision declined by 43%, and institutional deliveries by 38%. A significant decline in immunization coverage was also reported.
Reporting through routine channels such as logistics or health management information systems was also severely disrupted. By the time Liberia was first declared Ebola-free in May 2015, it was estimated only 30% of facilities were functioning adequately. By March 2016, the ministry succeeded in re-opening all of the health facilities closed during the Ebola outbreak. The outbreak had a profound impact on the malaria disease program, with malaria testing, community-level activities and planned scale-up all suspended throughout the outbreak.
In the post-Ebola context, 3% of the approved funding will go to support malaria positions directly working for the malaria program and the supply chain management unit at the MOH. Under the rounds-based grants, the Global Fund and Liberia had been working towards a gradual transition of Global Fund-supported salary incentive payments to the government payroll. Obviously, the Ebola outbreak has negatively impacted this work. Nevertheless, the MOH grant includes a condition that the PR submit an updated budget to the Global Fund with respect to the transition of salary and incentive to the government payroll by no later than 31 July 2016, reflecting a transition in two tranches by the end of 2017.
In addition, to mitigate risks related to procurement and supply chain management, further actions will be put in place to strengthen the recording and storage system at the central medical store; and consideration will be given to expanding the fiscal agent team in-country.
Mauritania (HIV, malaria, and TB)
The goal of the HIV program is to reduce new infections by 70% by 2018 and to ensure that at least 80% of adults living with HIV and 50% of children living with HIV receive ARV therapy. The malaria program aims to reduce confirmed malaria cases per 1,000 population from 46 in 2013 to less than three in 2018. The objectives of the TB program include testing at least 90% of notified TB cases for HIV, and ensuring a treatment success rate of 80% of TB/HIV co-infected patients by 2018; and successfully treating at 85% of new confirmed TB cases by 2018.
The CCM nominated the Secrétariat Exécutif National de la Lutte contre le Sida as PR for all three grants. The PR is currently undergoing a restructuring. With the support of the French 5% Initiative, three international staff will support the restructured PR to efficiently manage the grants, including the selection of civil society sub-recipients. The Secretariat is currently recruiting a fiduciary agent to provide financial oversight as well as capacity building for the PR.
In 2013, HIV prevalence rate among adults in Peru was estimated to be 0.3%. The epidemic is concentrated in key and vulnerable populations, mainly MSM and transgender women in urban areas. The goal of the Global Fund–supported program, implemented by Pathfinder International, is to contribute to the reduction of new HIV cases in the most affected populations in Peru by bridging the gaps in HIV screening, prevention, and care. Expected outcomes of the planned programming include increasing condom use among MSM and transgender sex workers from 50% in 2011 to 70% in 2017; and increasing the rate of people living with HIV on treatment 12 months after initiation of ART from 31% in 2013 to 80% in 2019.
Sierra Leone is another country hit hard by the Ebola outbreak. According to the GAC, the Sierra Leone malaria program submitted its funding request through a simplified approach in order to link with the post-Ebola health sector recovery plan, which was developed in consultation with a full range of stakeholders and reflects extensive country dialogue.
Poor early recognition of suspected Ebola cases and inadequate infection prevention and control standards led to 296 infections and 221 deaths among health care workers, including 11 specialized physicians. The Ebola outbreak had a direct impact on the malaria program. Gains made in malaria control regressed with halting of confirmatory testing of suspected malaria cases, as well as limited continuity and scale-up of malaria key control activities as the country prioritized the response to the Ebola epidemic. The number of antenatal care visits declined by 27% and the number of LLINs distributed in antenatal care clinics declined by 63%. However, to try to address malaria in the context of Ebola, mass drug administration with antimalarials was conducted in highly endemic Ebola areas to attempt to reduce febrile cases presenting to Ebola treatment units and provide short-term protection for malaria.
Information for this article comes from the July 2016 report of the Secretariat’s Grant Approvals Committee to the Board (GF-B35-ER07). This document is not available on the Fund’s website.