Sixteen Eastern European and Central Asian countries (EECA) will submit a total of 27 concept notes to the Global Fund under the new funding model, to access their share of the $659 million allocated to the region. For some of these countries, this is likely to be their last allocation of Fund grants as they transition out of eligibility towards state-funded programs for the fight against HIV and TB.
Additionally, the EECA Network of People Living with HIV (ECUO) and PAS Moldova were two of 16 organizations invited to submit a regional proposal, currently under review by the Technical Review Panel.
Each of the countries -- Albania, Armenia, Azerbaijan, Belarus, Bulgaria, Georgia, Kazakhstan, Kosovo, Kyrgyzstan, Moldova, Romania, Russia, Tajikistan, Turkmenistan, Ukraine, Uzbekistan -- is in a different stage of the NFM process.
Moldova, Romania and Ukraine have begun implementing programs with initial disbursements. Kazakhstan is also preparing to move forward. Other countries are putting the finishing touches on concept notes intending to be submitted during Window 6, in April. Armenia and Azerbaijan have already submitted TB concepts in August 2014 and January 2015 respectively, and will both submit HIV concept notes by 20 April. Uzbekistan will submit a full malaria concept note and a second iteration of its HIV proposal, while Albania is preparing its joint TB/HIV note.
No matter where they are in the process, however, there are a number of emerging trends and similarities in the respective national experiences, both in relation to the NFM itself and to the priorities being set for use of Global Fund resources to support the national disease response.
Most representatives from civil society and in country coordinating mechanisms (CCM) told Aidspan that developing concept notes under the NFM was a smoother, more inclusive process than the grant-writing that took place under the rounds-based approach. By linking concept notes to costed national strategic plans, stakeholders were reassured that the priorities being identified at the national level were going to be supported both domestically and with external investment. This was particularly important in terms of activities specifically targeting key affected populations, which have traditionally not benefitted from much domestic financial support.
Also happening in EECA countries is the replacement of international organizations with ministries of health as principal recipients managing the grant funds. This is being presented as a cost-containment measure and a driver of increased country ownership but also has political implications as it could narrow the space, going forward, for civil society to maintain its vocal, decision-making seats at the table.
Below is a country-by-country look at where EECA is in the NFM process. This is not an exhaustive survey, and will be updated as events warrant.
Armenia submitted its TB concept note under Window 3 and is slated to begin implementation of the $9.4 million grant on 1 July. PR for the grant is the Ministry of Health.
The CCM intends to submit its HIV concept note in Window 6, by 20 April. Currently, country dialogue and concept note development are occurring in parallel, with identified priorities to increase coverage with HIV testing and anti-retroviral treatment, including activities targeting seasonal migrants, who have a high HIV prevalence. Interventions including opioid substitution therapy will transition to full state responsibility by 2017, as well universal ARV coverage for children and 100% coverage of PMTCT.
Azerbaijan submitted its concept note for TB in Window 5, and is awaiting approval from the TRP to access the $11 million it was allocated under the NFM. Azerbaijan has costed its two-year national strategic plan at around $64 million, and Global Fund investments should be used to purchase commodities and support an adherence incentive program.
Delays in validation of the NSP for HIV have forced the delay of Azerbaijan's concept note until Window 6. The Global Fund's resource envelope of $9 million will be managed by the Health Ministry's Project Implementation Unit. Azerbaijan is somewhat of a pioneer in the region, with government fully funding OST and, from 2015, fully funding ARV treatment.
Belarus intends to submit both its HIV and TB concept notes in Window 6, awaiting the results of a comprehensive, nationwide epidemiological survey. Priorites already identified for the nearly $12 million Belarus is allocated for TB include treatment of MDR/XDR TB and the purchase of new GeneXpert machines. Improved diagnostics, monitoring and evaluation, and better management of co-infection with HIV are also envisioned. The Global Fund contribution to the national TB response represents about 5% of the national cost of the TB program.
In developing its concept note for HIV, Belarus' team of stakeholders confronted a perennial problem in the country related to the state law preventing NGOs from receiving funds from state institutions. This means that while Belarus is covering 75% of ARV treatment, it is not paying for any of the prevention activities carried out by a network of local and regional NGOs. Some of the funding, then, is likely to be used to help NGOs improve their fundraising abilities in order to prepare for the country's looming transition away from Global Fund eligibility. Belarus has also thrown open a tender for PRs, with an eye towards replacing UNDP. Results were expected in April.
An HIV grant is ending in December 2015 after a one year extension. Bulgaria is still working to find domestic resources to replace Fund investments in HIV. A TB grant is currently in negotiation, with an anticipated start date of 1 October 2015
Georgia should submit its HIV concept note on schedule, in Window 6, and its TB note in Window 7. The development of both concept notes is running in parallel with the government's finalization of its NSPs. Discussions in country dialogue have identified possible priority interventions as services for key populations in the HIV concept note and an emphasis on MDR/XDR-TB treatment and strengthening of the community-based case management system.
Kazakhstan was an early applicant to the NFM, but persistent challenges with financial mismanagement have resulted in a massive reform of its Global Fund-related systems and procedures that have contributed to some delays.
Kyrgyzstan was encouraged to revise a proposal submitted in June 2014 for support to HIV activities in order to include TB interventions as well. The revised concept note for a $20 million, two-year program will now take a holistic approach to co-infection, particularly among key populations. Roughly 80% of the allocated funds will be spent on treatment, presenting what civil society stakeholders fear is a missed opportunity to strengthen the health system and invest in community system strengthening as well. Kyrgyzstan is also transitioning away from international NGOs as PR, opting to replace UNDP and Project Hope with the Ministry of Health.
As one of the first applicants to complete the NFM process, Moldova has been implementing activities outlined in its HIV concept note since January 2015, through a pair of PRs: the non-governmental Center for Health Policy and Studies (PAS Center) and a public institution, PCIMU. Moldova's concept note was enhanced by a series of epidemiological and behavioral studies conducted in anticipation of the NFM; the result is an integrated approach that includes prevention and treatment, community- and systems-based work and an advocacy component to help overcome legal barriers to access. Implementation of Moldova's TB grant should begin on 1 July.
Romania is awaiting the anticipated 1 May start of its two-year, $8-million TB grant which is expected to fill the remaining gaps in the national TB program and establish coordination mechanisms to work more closely with the national HIV program. There will also be some coordination, including distribution of information materials and testing, to mitigate hepatitis co-infection. Romania's CCM has also undergone considerable reform, including the overhaul of its structure, updates to its regulations and a clarification of its conflict of interest policy.
Russia is the only country in the Global Fund system submitting a concept note under the NGO rule. Instead of a CCM it now has a coordination committee, which has guided both the country dialogue and concept development process. Since February 2015, the committee has a secretariat and an operating budget. The HIV concept note is emphasizing a series of community-strengthening activities and innovations, focused exclusively on support for key populations. Part of the allocation will go to community-level HIV and STI testing and there is a whole slate of activities responding to sex workers, men who have sex with men and drug users that emphasizes health and human rights. The concept note has been extensively and repeatedly reviewed by the TRP. The grant's anticipated start date is 1 July.
Concept notes for both HIV and TB were submitted in Window 5. During an extensive country dialogue hailed by civil society as inclusive and transparent, proposed activities emphasized human rights including support for the removal of legal barriers to access to services and the development of monitoring tools to help with reporting of HIV-related rights violations. Scale-up of ARV coverage is another identified priority through country dialogue, alongside improved diagnostics. A new coalition of TB activists was also established, including 32 organizations and representatives from the disease-affected community and their families.
A grant agreement for Ukraine was signed in February 2015, allowing the country to access $134 million allocated for HIV activities. The new program running through 2017 will aim to integrate the HIV response into the public health system, against a backdrop of continuing political and security turmoil. Key populations being targeted with specific activities in patient-oriented prevention, treatment, care and support include PWID, sex workers, men who have sex with men and prisoners.
Uzbekistan submitted a TB concept note on 30 January emphasizing universal access to TB diagnosis and treatment in areas including: treatment of multi-drug and extensively drug-resistant TB; TB care and prevention; and TB/HIV co-infection management. Another iteration of the HIV concept note first submitted in June 2014 is underway in order to respond to TRP comments requesting a more complete picture of the epidemiological situation, to specifically include improved data on key populations. The CCM will also have to revise the note to incorporate some work to support the introduction of OST, responding in particular to the needs of HIV-positive PWID already taking ARVs or on TB treatment. A malaria concept note is also expected on 20 April.