The Grant Approvals Committee says that there is a risk that the Democratic Republic of Congo (DRC) will not able to meet its 2017-2019 co-financing requirements. The GAC made this statement in a report to the Board in which it recommended a number of grants for approval (see separate article in this issue), including a TB/HIV grant, an HIV grant, a TB grant and three malaria grants to the DRC.
In order to fully access the co-financing component of the DRC’s 2017-2019 allocation, the government needs to invest $39.5 million more than the amount it spent for the previous allocation cycle. However, the government has not yet formalized its commitments for the 2017-2019 allocation period. Given the DRC’s economic constraints, the GAC stated, there is a risk of non-compliance with the co-financing commitments. There will be a requirement in the grant agreement that the DRC provide a formal commitment regarding the co-financing investment. In addition, the Secretariat will attempt to mitigate the risk of non-compliance by increasing its monitoring of progress towards meeting the commitment.
TB and HIV grants
The principal recipient (PR) for the joint TB/HIV grant will be the Catholic Organization for Relief and Development Aid (CORDAID). The Ministry of Health will manage the separate TB and HIV grants. These are the same PRs that currently manage the DRC’s TB and HIV grants.
The TB/HIV, TB and HIV grants will focus on 14 provinces identified as high priority and will use a differentiated approach for care and treatment – including implementation of a “one-stop shop,” intensification of community activities, gradual HIV testing for all TB patients, and the deployment of GeneXpert machines. Key strategies include outreach for key populations to provide a minimum package of screening and treatment services as well as close monitoring where necessary and referral to a nearby treatment site; gradually extending HIV testing of TB patients to additional TB health zones; and improving the TB/HIV results through the implementation of the one-stop shop model.
The DRC is eligible for matching funds for programs to find missing TB cases ($10 million); for programs to remove human rights–related barriers to health services ($3 million); and for data systems, data generation and data use ($10 million). It appears that the matching funds requests were submitted after the TB/HIV and malaria funding requests, given that the matching funds requests were still in grant-making at the time of the GAC meeting that resulted in the TB/HIV and malaria funding requests being recommended for approval to the Board.
The GAC noted that some challenges remain with respect to TB missing case detection and notification, and it expressed concern that these challenges might stall the achievement of the ambitious program targets. Secretariat staff pointed out that enhanced strategies for finding missing TB cases – including increasing laboratory capacity and supporting civil society – are part of the matching funds application. The matching funds detailed budget and work plan are being finalized, staff said, and will be submitted to the Board for approval and incorporated into the grants during implementation.
Partner organizations at the GAC meeting expressed concern about the lack of access to HIV testing for TB patients in some regions, and encouraged the Secretariat to work with partners and other stakeholders to reverse this trend. The GAC said that considering the financial constraints, there will be only a gradual undertaking of HIV testing of TB patients in hard-to-reach areas in collaboration with the government.
The PRs for the malaria grants are the Ministry of Health (MOH), Population Services International (PSI), and Soins de Santé Primaires en Milieu Rural (SANRU). These three PRs are managing the DRC’s current malaria grants.
The GAC said the DRC has made significant programmatic progress, including achieving universal LLIN (long-lasting insecticidal net) coverage during the 2014-2016 allocation period. The new grant will build on the results achieved by focusing on high-impact interventions such as: (a) prevention through the mass distribution of LLINs, maintaining a rolling three-year distribution cycle complemented with routine distribution; (b) ensuring availability of malaria commodities at all health structures, and further scaling up diagnosis and treatment at the community level; and (c) reinforcing surveillance through further investment in health information and infectious disease surveillance systems.
The GAC expressed concern about a gap of funding for 20.9 million LLINs for a 2020 mass campaign in eight provinces. It said that the gap may threaten coverage achieved in the 2014-2016 allocation period. The GAC encouraged partners to work with the Government of the DRC to mobilize additional investments to close the funding gap. A provision in the grant agreement allows for the reprogramming of funds towards additional distribution costs, should LLIN funding become available from other sources.
The SANRU malaria budget includes $10 million to support a performance-based funding (PBF) program. The current grant ending 31 December 2017 supports an investment in a joint PBF project with the World Bank which is aimed at improving utilization and quality of maternal, newborn and child health (MNCH) services delivery and governance – as well as strengthening health administration directorates and health policy capacities. The $10 million may be used for a possible launch of the PBF program in the province of Kongo Central, to be co-financed with domestic funds or by renewing the current partnership with the World Bank. An assessment of the World Bank PBF project is planned in the first quarter of 2018.
Additional funding of the PBF program by the Global Fund, in partnership with the World Bank, is subject to approval by the Board – or, alternatively, putting in place implementation arrangements which provide the Office of the Inspector General (OIG) with the access and audit rights necessary to fulfil its mandate. This was a sticking point when in May 2017 the Board authorized the Secretariat to enter into an Administration Agreement with the World Bank regarding the PBF program. The agreement was required to allow the Fund to make a $10.5 million investment to co-finance PBF payments. In (reluctantly) authorizing the Secretariat to sign the agreement, the Board was essentially accepting that the OIG would not have right of access to the project’s books, records, personnel or sites. (See GFO article.)