On 22 March 2019, the Global Fund Board approved funding for two country grants and supplementary funding for a third –– for a total value of $11.0 million. Interventions worth $4.1 million were added to the Unfunded Quality Demand (UQD) Register. Domestic commitments for the programs included in the approved country grants amounted to $28.5 million. (See Table 1 for details.)
Table 1: Country grants approved from the 2017–2019 allocations –– 18th batch (amounts in $US)
|Amount approved 1||UQD||Domestic commitment 2|
|Armenia 4||TB/HIV||ARM-C-MOH||Ministry of Health||3,138,925||61,187||19,320,177|
- Amounts shown are upper ceilings.
- The domestic commitments shown are for the disease programs and exclude RSSH.
- MSPAS = Ministry of Health and Social Assistance
- Armenia TB/HIV is also included in Table 3 (funding for UQD interventions).
- As a non-CCM applicant, Egypt is exempt from co-financing requirements
The Board was acting on the recommendations of the Technical Review Panel (TRP) and the Grant Approvals Committee (GAC). This was the 18th batch of approvals from the 2017–2019 allocations.
The Board also approved funding for a multi-country grant worth $3.6 million. Interventions from this funding request valued at $460,000 were added to the UQD Register. (See Table 2.)
|Applicant||Grant name||Principal recipient||Amount approved||UQD|
|Multicountry Caribbean MCC||QRB-C-OECS||OECS 1||3,550,000||460,000|
- OECS = Organization of Eastern Caribbean States (regional coordinating mechanism)
In addition, interventions from the UQD Register valued at $30.2 million were approved for five grants (see Table 3). The funds for these awards come from a portfolio optimization exercise that was carried out in 2018 for the 2017–2019 allocation cycle.
|Amount approved 1||Domestic commitment 2|
|Armenia||TB/HIV||ARM-C-MOH||Ministry of Health||300,000||7,923,240|
|Malawi||TB/HIV||MWI-C-MOH||Ministry of Health||5,000,000||369,669,494|
|Niger 1||Malaria||NER-M-CRS||Catholic Relief Services||13,392,807||68,887,214|
|Togo 1||Q2waqq||TGO-M-PMT||PMT 2||1,513,088||35,748,826|
- For grants denominated in euros, an exchange rate of 1 euro = 1.132 dollars was used.
- PBSP = Philippine Business for Social Progress | PMT = Primature de la République Togolaise
In its report to the Board, the GAC provided comments on two of the three country grants; and on the interventions funded from the UQD Register. In the balance of this article, we provide a summary of the GAC comments.
Egypt received an allocation for the 2014–2016 funding cycle, but no grants were awarded. What happened was that in 2015, the Office of the Inspector General (OIG) conducted an investigation and published a report identifying misuse of funds and ineligible expenses. (The report is available here; a GFO article on the investigation from October 2015 is available here.) At the time, Egypt had submitted a funding request for TB/HIV. The TRP recommended that the request proceed to grant-making and it identified some risk-mitigation measures to address concerns about financial management.
However, the Fund could not reach an agreement with the principal recipient (PR), which was the government, concerning the proposed risk-mitigation measures. As a result, grant-making was terminated. Instead, the existing TB and HIV grants were extended to enable essential interventions (including the purchase of antiretrovirals [ARVs] and MDR-TB medicines) to continue. A spokesperson for the Secretariat, Lindsay Smith, told the GFO that the extensions were financed with savings from previous rounds-based grants. In addition, from 2018 on, the Government of Egypt has been financing ARV purchases.
As Egypt does not have a country coordinating mechanism (CCM), a TB/HIV funding request for 2017–2019 was submitted by the U.N. Resident Coordinator on behalf of the U.N. The United Nations Development Program was proposed as the PR.
The HIV epidemic in Egypt has grown but remains mostly concentrated in key populations. According to the GAC, the most recent data, from the 2010 Integrated Biological and Behavioral Surveillance Survey, shows an overall prevalence of 0.5% among street boys and girls, 6.1% among men who have sex with men, 7.2% among people who inject drugs and 2.9% among female sex workers.
The grant aims to achieve the UNAIDS 90-90-90 targets through the following strategies: increasing key populations’ access to HIV services; improving the quality of HIV testing and treatment; reducing stigma; and developing the institutional capacity of the National AIDS program.
TB incidence and mortality in Egypt has been declining. However, multidrug resistance is a concern –– estimated at 14% for new patients and 30% for retreatment patients. The grant aims to reduce the incidence and prevalence of TB and MDR-TB through strategies that include expansion of molecular testing; introduction of the shorter treatment regimen for MDR-TB; and case detection and notification of TB among priority groups.
The GAC acknowledged concerns raised by the TRP about the limited potential for impact for both the TB and HIV programs, given the relatively small investment compared to the needs of key populations. However, the GAC said that the grant will have a catalytic impact by, among other things, enabling greater collaboration with partners in-country and facilitating data collection to better inform programming in future.
In March 2018, Armenia submitted separate TB and HIV funding requests. The TB component was subsequently approved for funding. The HIV component was sent back for iteration; was resubmitted in September 2018; and has now been approved. All activities will be implemented as a single TB/HIV grant.
Armenia was awarded $3.1 million for its TB/HIV grant; and a further $0.3 million from portfolio optimization (see next section).
Armenia has a low prevalence of HIV. The prevalence is higher in key populations (e.g. 2.0% among people who inject drugs and 2.7% among men who have sex with men) than in the general population (0.2%).
The grant’s strategies include targeted prevention interventions among key populations; scaling-up antiretroviral treatment; and strengthening the enabling environment for the HIV program.
Armenia’s domestic funding commitments exceed the Global Fund’s co-financing requirements. The government has made specific commitments related to a progressive transition from Global Fund support to domestic financing. The grant confirmation document will include a requirement that the Ministry of Health (MOH) use domestic funding to co-finance civil society organizations to deliver HIV prevention services among key populations no later than 31 March 2020.
(Smith explained that as of 1 April 2019, grant funds for prevention services for these populations will be channeled through a social contracting mechanism established in the MOH. The NGO contracting documents are being adapted “to improve the transparency, organization and equity of the process,” Smith said. The 31 March 2020 date is the expected deadline for signing the contracts with the NGOs.)
As Armenia is an upper-middle-income country with less than a high disease burden, its TB and HIV components will not be eligible for regular funding in 2020–2022, but they will still be eligible to receive transition funding.
The GAC said that Armenia is in the process of finalizing reforms related to TB care. A program to improve adherence to treatment for drug-sensitive TB patients is planned. So is the introduction of an additional intervention: performance-based bonus payments for out-patient TB and primary health care medical service providers.
The GAC said that because of several developments in the political scene in Armenia –– including changes in government several times during 2016–2018; the revolution in April–May 2018; and multiple priorities of the newly elected government –– a few planned actions, including the TB services optimization reform, have been delayed.
(According to Wikipedia, the revolution involved a series of anti-government protests staged by various political and civil groups led by a member of parliament.)
Smith explained that Armenia has achieved substantial progress in the reform of the TB program governance structure, including the shift from inpatient to ambulatory care. These efforts have led to a reduction in TB beds from 428 in 2013 to 308 in mid-2017. The total number of patient bed days declined from 84,480 in 2013 to 55,015 in 2016. However, Smith said, the implementation of the reforms is not yet complete.
To finish the reform of TB services and the revision of the financing mechanisms, the MOH and the National Tuberculosis Program (NTP), with the support of the World Health Organization (WHO), developed a concept note on optimal model of TB care in Armenia, which they plan to implement in 2019. The Global Fund’s country team is very involved in the process.
Awards from portfolio optimization
Armenia TB-HIV. In Armenia, social support for both drug-sensitive and drug-resistant TB (DR-TB) patients has been provided under Global Fund-supported programs since 2011. Because Armenia’s allocation for TB was reduced in 2017–2019 compared to 2014–2016, the country had to prioritize social support for DR-TB patients over social support for drug-sensitive TB patients. The $0.3 million from portfolio optimization will enable Armenia to provide more social support for drug-sensitive TB patients.
Malawi TB/HIV. The $5.0 million from portfolio optimization will help Malawi meet its 90-90-90 targets. Of that amount, $3.0 million will be invested in self-testing interventions and $2.0 million will support voluntary medical male circumcision (VMMC). The VMMC program will receive an additional $3.0 million from in-country optimization. In all, 50,000 circumcisions are expected to be performed in 2019.
Niger malaria. The $13.4 million from portfolio optimization will allow Niger to expand a planned long-lasting insecticidal net campaign to cover all 29 high-burden districts. In all, more than 6.8 million people will be covered by the expansion.
Philippines TB. With the $10.0 million award, the Philippines becomes the first country to use funds from portfolio optimization to cover transition to the new MDR-TB regimens recommended by the WHO in August 2018. The additional investment will support initiating the new long oral treatment regimen in 42% of patients, a modified shorter regimen in 45% of patients; and enrolling the remaining 13% in an operational research protocol.
Togo malaria. The $1.5 million from portfolio optimization will support the second phase of a project to improve the quality of integrated TB, HIV and malaria care in antenatal and postnatal services. It will also complement Togo’s efforts towards reaching universal health coverage.
The Board approved 3-month extensions for a TB grant and an HIV grant in Chad; and 6-month extensions for three grants in Mauritania, one for each disease. In all cases, the purpose of the extensions was to prevent program disruption while funding requests from the 2017–2019 allocations are in grant-making.
Smith told the GFO that the extensions are funded from the 2017–2019 allocations. The amount used for the extension will be deducted from the allocation amounts available for the coming grants; and the grant implementation periods will be shortened accordingly.
Most of the information for this article was taken from Board Document GF/B40/ER07 (“Electronic Report to the Board: Report of the Secretariat’s Grant Approvals Committee”), undated. This document is not available on the Global Fund website.