The third batch of funding approvals by the Board (see GFO article) included two TB/HIV grants from Zambia. In this article, we report on the comments from the Technical Review Panel (TRP) and the Grant Approvals Committee (GAC) on the funding requests from which these grants emanated.
Zambia’s national adult HIV prevalence is estimated to be 11.3%, with 14.5% HIV prevalence among women compared to 8.6% among men. The HIV prevalence for young people aged 20–24 is more than four times higher among women (8.6%) compared to men (2.1%). According to the funding request, this is attributed to gender inequality and gender-based violence, which is a critical structural driver of HIV among women in Zambia. The World Health Organization (WHO) reports that Zambia is among the top 30 TB and TB/HIV high-burden countries in the world. The national TB incidence in 2015 was 391 per 100,000 people, which is 40% less than what it was a decade ago. In 2015, the WHO estimated incident TB cases to be 63,000, but Zambia only notified about 36,000 new and relapse TB cases, which means that almost 40% of TB cases were undetected.
The TRP said that the funding request was strategically focused, aligned to the National HIV and AIDS Strategic Framework 2017–2021 (NASF) and informed by local evidence. The GAC noted that this funding request will enable Zambia to:
- further optimize its HIV and TB budgets so that funds can be allocated to technically sound interventions that have the most impact;
- reduce gender- and age-related disparities and close the gaps in service delivery for key populations; and
- create flexible and adaptable patient-centered systems for health that enable a sustainable HIV and TB response.
The total value of the grants approved for Zambia was $194.0 million. The program will be implemented by two principal recipients (PRs): The Ministry of Health (MOH) and the Churches Health Association of Zambia (CHAZ).
Zambia submitted a Prioritized Above Allocation Request (PAAR) of $112.4 million, of which $102.6 million was deemed “quality demand.” The efficiencies made during grant making produced $11.2 million in savings, of which $2.7 million was ploughed back into the grants to cover variances in the costs of some budget items that were revealed during grant-making; and $8.4 million was used to cover the costs of some of the PAAR interventions. In the end, initiatives valued at $94.2 million were added to the Unfunded Quality Demand (UQD) Register.
Strengths of the funding request
The TRP commended Zambia for its use of data to inform the prioritization of geographical areas for HIV and TB programming. The GAC applauded the efforts of the country coordinating mechanism (CCM) to ensure alignment of Global Fund investments with the NASF. In addition, the TRP said, the funding request included ambitious targets for TB diagnosis and treatment, which Zambia aims to achieve by increasing access to rapid molecular diagnostic tests.
Regarding the resilient and sustainable systems for health (RSSH) portion of the funding request, the TRP said that the procurement and supply chain management (PSM) challenges were well described and that investments for two new distribution hubs and the planned recruitment of a procurement coordinator are well aligned to Zambia’s Health Sector Supply Chain Strategy and Implementation Plan 2015–2017.
Issues and concerns
The following issues were raised by the TRP; some were addressed during grant making while others will be addressed during grant implementation.
HIV testing. Increasing access to HIV testing is a key strategic priority for the country, given that 32% of people living with HIV (PLHIV) do not know their status. The funding request proposed a door-to-door provider-initiated HIV testing program that focusses on couples. The TRP said that door-to-door testing of couples might not be as scalable or as effective in reaching key populations as HIV self-testing. Zambia has had recent self-testing pilots. Preliminary results show that self-testing is seen as being more convenient and discreet. The TRP recommended that the country incorporates HIV self-testing into its HIV testing program. During grant making, the principal recipients (PRs) expanded the HIV testing program to include activities to increase the uptake of HIV self-testing, particularly in high incidence areas. During grant implementation, the Secretariat will work with the Ministry of Health and key partners to monitor implementation of these activities.
Interventions for key populations. The funding request lacked clear descriptions of the interventions that will target the following key populations: men who have sex with men (MSM), female sex workers (FSW), transgenders and people who inject drugs (PWID). Interventions included in the funding request included information, education and communications (IEC) materials comprising 90% of the budget for key populations. The TRP requested that the applicant broaden the package of interventions that will be offered to key and vulnerable populations beyond IEC materials. Further, the TRP requested a plan, including budgets, for introducing targeted prevention services for MSM, FSW, transgenders and PWID. The TRP was satisfied with the plan submitted by the applicant during grant-making, which consisted of a multi-pronged demand creation approach to reach key populations with services. These include HIV testing services; prevention services; linkage to and retention in care; and monitoring, data collection, reporting and self-coordination. Zambia undertook to prepare, during the first nine months of grant implementation a detailed plan and budget for targeted prevention services for these key populations. It was noted that the definition of key populations in the NASF has been broadened to include MSM and transgenders, a development which strengthens the policy and enabling environment for program implementation for key populations in Zambia.
Sustainability of new healthcare workers costs. Training, commodities and salary costs for new nurses, community health assistants (CHAs), adherence support workers and community health workers have been included in the funding request and will be covered by the new grant, but the TRP raised some concerns about the sustainability of these costs beyond the period of the grant. During grant-making, it was revealed that the new National Health Strategic Framework includes a commitment from government to sustain the resources through a planned staged transition of donor-supported staff to government payroll. The GAC said that it is confident in this commitment based on Zambia’s track record of absorbing onto the government’s payroll health workers from previously funded programs by the (U.S.) Centers for Disease Control, the Swedish International Development Agency and the (U.K.) Department for International Development.
Prison interventions. There wasn’t enough information in the funding request on the interventions that will target prisoners, especially since prisoners have been identified as a key population. During grant-making, the PRs provided a description of the planned HIV and TB interventions in prisons. In addition, the PRs indicated that condoms are already freely available in prisons and that HIV-positive prisoners are transferred to an ART clinic near their new home upon their release. During grant implementation, the Secretariat will monitor activities to ensure that the condoms provided to prisoners are in line with guidelines from the UNDP, United Nations Office on Drugs and Crime, and the WHO.
Gender-based violence interventions. Gender based violence (GBV) is highly prevalent in Zambia and has been identified by the CCM as a critical structural driver of the HIV epidemic among women, particularly young women. However, a clear description of the interventions addressing GBV was not provided in the funding request. During grant making, the PRs described these interventions and provided details of other interventions in the funding request that relate to GBV.
The GAC applauded Zambia’s $7.0 million matching funds request, which proposed investments in three strategic priority areas: keeping girls in school, recruiting and training additional human resources for health; and integrated HIV/TB/cervical cancer services.
The TRP considered the matching funds request for interventions targeting AGYW as high impact. They will keep an additional 3,000 AGYW in school through direct school fee payments as well as provide social cash transfers in high-burden districts. The TRP noted that social cash transfers have a catalytic effect on investments for AGYW in several ways:
- they enable AGYW to access school-based social and behavior change programming as well as comprehensive sexuality education;
- they promote the use of adolescent centered health services and condom distribution; and
- they enable AGYW to learn and apply condom negotiation skills.
The matching funds for RSSH include the training and deployment of 500 CHAs per year to enhance community-level demand creation in the areas of ART delivery, adherence support, condom distribution and voluntary male medical circumcision. In addition, 600 rural front-line professional nurses will be recruited. The TRP said that “the scale of this catalytic effect is impressive” because the CHAs will provide access to preventative and curative services to nearly 5.3 million rural residents by 2018, which will leave professional nurses free to provide more advanced health services for complicated and severe referral cases.
Integrating HIV/TB/cervical cancer services are expected to reduce cervical cancer–related mortality among women living with HIV. In its funding request, the applicant highlighted that Zambia has the second-highest incidence rate of invasive cervical cancer in the world. Zambian women living with HIV have a five-fold risk of developing cervical cancer compared to other women.
To meet its co-financing requirements for 2018–2020 (the implementation period for the Zambia grants), the Government needs to invest $39.5 million more than the $245.0 million it committed in 2015–2017. The government said it will invest $307.0 million in its three disease programs in 2018–2020, so that is in excess of the amount required. The table below provides a breakdown of the commitment.
Table: Co-financing commitments for 2018-2020
|Program||Description||Value ($ million)|
|HIV||Covering ARVs and treatment-related costs||179.0 m|
|TB||Provision of anti-TB medicines and repayment of a World Bank loan of $45 million during 2017-2021||28.0 m|
|Malaria||Procurement of insecticides and covering operation expenses related to the malaria program||100.0 m|
Given the challenging economic climate Zambia has been facing since 2015, initiatives to increase domestic funding for HIV and TB programs have not been prioritized. Although the Government of Zambia has continued to increase domestic spending on health, this is less visible because the Zambian Kwacha has depreciated by 42% against the U.S. dollar. The three major initiatives to improve sustainability of HIV and TB programming in Zambia are as follows:
- the National Health Strategy 2017-2021 with a focus on primary healthcare and eliminating malaria, which has been formally adopted;
- the development of a Health Financing Strategy which includes national social health insurance and innovative financing mechanisms and care models; and
- a Social Health Insurance scheme as part of the “national social protection bill” which is expected to be tabled in Parliament to introduce a levy of 5% payroll taxes to both formal and informal sector employees in order to make rapid progress towards universal health coverage.