As mentioned elsewhere in this issue, the Board has approved 18-month costed extensions for two HIV and two TB grants to Nigeria. The Board decision was based on recommendations from the Grant Approvals Committee (GAC) contained in a report on the fourth batch of grants for 2017–2019 that was approved by the Board on 13 December 2017 (see separate article).
Nigeria had submitted a TB/HIV funding request in May 2017, but the request was returned for iteration. According to the country team for Nigeria, the decision to ask for the funding request to be revised was driven partially by questions that the GAC and the Technical Review Panel (TRP) had about the current state of the HIV epidemic in Nigeria, but more fundamentally by the perceived need for the Nigeria country coordinating mechanism (CCM) to come up with a “compelling” funding request, using existing program and other data and a “robust, inclusive dialogue.” The purpose of the 18-month extensions for existing HIV and TB, the country team said, is to ensure that there is no major disruption to funding and to program activities during the time it will take for a new funding request to be reviewed and considered for grant-making.
When we reported in August 2017 on the decision to send the TB/HIV back for iteration, Nigeria was expected to submit a revised request in the first window in 2018 (on 7 February). It is obvious now, however, that the request will not be submitted until later in 2018. When the Secretariat requested the extensions for the current grants, it said that plans for the submission of a revised TB/HIV funding request — one that included health systems strengthening activities –– are currently being discussed by the CCM and partners at both global and country levels; and that these discussions would determine when during the extension period an updated funding request can realistically be submitted for review by the TRP.
The GAC reported that there is “widespread frustration” within the Secretariat and among partners about the slow progress towards impact of Nigeria’s TB program. The GAC underscored what it called a “universal call” for a strategic shift in TB programming to inform the upcoming funding request which, it said, should also be based on the annual TB program review planned for February 2018. The GAC reported that the Secretariat will explore the opportunity of separate submissions for the TB and HIV funding requests, in close collaboration with the applicant and partners, in case the timing is not optimally aligned between diseases.
See the table for details on the four grants and the amounts of the extensions.
Table: Nigeria grant extensions ($ million)
|Comp.||Grant name||Principal recipient||Extension budget||Additional funding||Lapsing funds|
|HIV||NGA-H-FHI360||Family Health International
|88.5 m||88.5 m||NIL|
|HIV||NGA-H-NACA||National Agency for the Control of AIDS (NACA)||29.6 m||29.6 m||NIL|
|TB||NGA-T-ARFH||Assoc. for Reproductive and Family Health (ARFH)||20.9 m||NIL||20.9 m|
|TB||NGA-T-IHVN||Institute of Human Virology Nigeria
|28.0 m||8.0 m||20.0 m|
|Totals||167.0 m||126.1 m||40.9 m|
The full amount of the extension budgets will be taken from the 2017–2019 allocations. This is in accordance with the terms of the Comprehensive Funding Policy, which states that money cannot be carried over from one allocation period to the next. The amounts shown in the table as additional funding represent the total extension budget minus the funds forecasted to remain in the current grants as of 31 December 2017. The last column shows the funds forecasted to remain in the current grants; these funds will be returned to the general pool.
When Nigeria was informed of its allocation for 2017–2019, the indicative amounts for HIV and TB were $239.8 million and $107.5 million, respectively. The program split was subsequently altered, but not significantly. We don’t have all of the numbers for the latest program split (the Global Fund does not make these numbers public) but we understand that the split has not yet been finalized.
Preparations for the grant extension requests were almost as intense as the process that is followed when funding requests are drafted. The CCM, the principal recipients (PRs), technical partners –– including the World Health Organization (WHO) and UNAIDS –– the country teams in the Secretariat, and U.S. government agencies for TB and HIV all had substantial involvement. Disease technical advisors in the Secretariat provided support. Civil society and key populations were engaged both through the CCM and in the negotiations for the key population grant (see below).
The current grants were all scheduled to end on 31 December 2017.
The amount required for the extension of the HIV grants represents 41.9% of the 2017–2019 allocation for the component. During the extensions, the principal recipients (PRs) will continue focusing on antiretroviral treatment (ART) scale-up and prevention, and care and treatment services for key populations, including prevention of mother-to-child transmission (PMTCT).
There will be some adjustments. The extension period may include a phased approach to differentiated care. And the general population prevention approach will be scaled back in favor of a more targeted key populations approach. In addition, some of the targets have been adjusted in recognition of the fact that there was often a gap between the ambitious targets set during the 2014–2016 funding cycle and the results achieved.
The implementation arrangements for the HIV grants will remain largely the same, with one notable exception: The PR that is currently implementing community-based activities related to HIV testing, ARFH, in the TB grant NGA-T-ARFH, will continue providing these activities in the extension period but it will do so as a sub-recipient (SR) for an HIV grant, NGA-H-FHI360.
In its report to the Board, the GAC referred to challenges regarding data quality and it noted that an upcoming national HIV prevalence survey is expected to address general population prevalence issues. The study protocol has been submitted for review to the Institutional Review Board, and data collection is expected to end in December 2018 with the final report expected by mid-2019. The GAC said that program data is available to support resubmission of the funding request should data from the survey not be available in time. In that eventuality, the expectation is that there would be some reprogramming once the survey data becomes available.
Recommendations to extend two additional HIV grants – NGA-H-SFH, covering key populations; and NGA-H-LSMOH, covering Lagos State – were expected to be presented to the Board in December 2017. The country team said that the key populations grant was not ready to be included with the extensions request due to revisions to the implementation arrangements proposed by the PR, the Society for Family Health (SFH), but not yet agreed between the country team and SFH. The PR proposed expanding the number of SRs to include “KP-led and KP-friendly” community-based organizations.
The amount required for the extensions of the TB grants represents 50.6% of the 2017–2019 allocation for the component. To maximize the impact of investments during the extension period, the grants will focus on five states with high yield (out of the 20 states currently supported by the program) and pursue the expansion of DOTS (directly observed treatment, short-course) to an additional 2,236 public health facilities.
Current TB case notification rates have been flat. According to the request for extensions, it was agreed to set a target that is higher than the one presented in the original funding request, but lower than the highly ambitious targets from the 2014–2016 funding cycle.
With respect to drug-resistant TB (DR-TB), during the extension period the TB program will aim for 8,733 DR-TB cases to be notified nationally, of which 2,500 will be treated through funding from Global Fund and the remainder covered by other partners (including the Government of Nigeria and USAID). However, the Secretariat noted, funding for DR-TB from these partners has not been confirmed.
For both the TB and HIV programs, the health product buffer levels were adjusted downwards due to funding limitations. The Secretariat said that it will be important to initiate the procurement process for the period July 2019 to December 2020 well before June 2019, to mitigate against potential treatment disruptions occurring immediately after the extension period.
Nigeria still owes $3.6 million in recoveries; the amount was due to be repaid by 31 December 2017. The GAC said that if the balance was not fully refunded, suspension of disbursements to NACA will be “reinstated.” In the section of its report on the Nigeria malaria grants, the GAC made a similar statement concerning disbursements for the grant to the National Malaria Elimination Program (NMEP).
Key risk matrix
In its request for extensions, the Secretariat noted that the Nigeria portfolio has a comprehensive key risk matrix (KRM) reviewed and approved on an annual basis by the Operational Risk Committee of the Global Fund Secretariat (most recently in June 2017), and monitored on a regular basis by the country team. The request included a table highlighting the risk areas and the mitigating actions that have been taken.
The Secretariat said that an additional programmatic risk was identified during the negotiations for the extension period. There is a major risk of lack of treatment for potential multiple-drug-resistant TB (MDR-TB) cases if national targets are reached. Funding available through the TB grant to IHVN is for treating up to 2,500 MDR-TB patients during the extension period, out of the national target of 8,733. Funding is not available from other sources to treat MDR-TB patients, the Secretariat said. So, if the program is able to find more MDR-TB patients than the 2,500 planned, these patients might not be treated. (In 2016, 1,686 MDR-TB patients were notified of whom only 1,251 were enrolled to treatment.) The Secretariat said that this is potentially a critical risk for the Global Fund because Nigeria has a material share of the worldwide disease burden for MDR-TB.
The request for extensions noted two factors outside the control of the Global Fund and its PRs that could impact the TB/HIV programs. Presidential elections are scheduled for February 2019, but informal campaigning and political positioning has already begun. President Buhari is not seeking reelection. The campaign cycle, the election itself, and the transition between administrations could affect the grants.
The second factor is continued conflict in the Northeast of the country which, by its very nature, is unpredictable.
See GFO article elsewhere in this issue on the approval of two malaria grants to Nigeria.
Some of the information for this article was taken from GF/B38/ER03 (Electronic Report to the Board: Report of the Secretariat’s Grant Approvals Committee) and other documents related to the approval of Nigeria’s request for HIV and TB grant extensions. These documents are not available on the Global Fund’s website.