A number of strategic high-impact activities were not implemented during Phase 1 of a Round 8 TB grant in the Republic of Congo, and a significant portion of the budget was not spent, according to the Global Fund’s Grant Renewals Panel. Nevertheless, the Global Fund Board has approved new funding of $234,687 for Phase 2 of the grant. The overall Phase 2 budget recommended by the panel was approximately $2 million. The reason why the Board only approved a small amount of new funding is that some or all of the unspent funds from Phase 1 will be used for Phase 2.
The principal recipient (PR) for this grant is the Ministry of Health and Population. In approving Phase 2 funding, the Board was acting on a recommendation from the Grant Renewals Panel.
The panel said that TB remains a public health concern in the Republic of Congo. Although rates have decreased slightly since 2005, TB incidence, prevalence and mortality were all considerably higher in 2011 than they were in 1990. The panel said that the Republic of Congo is unlikely to reach the Millennium Development Goal for TB (which is that by 2015 the growth in the incidence of TB cases will have been halted and the incidence numbers will have started to decline).
In 2011, the panel said, the TB programme reported 11,142 TB cases (case detection rate: 68%). The panel said that the treatment success rate for smear-positive TB cases in the 2010 cohort, at 77%, was low – and that the success rate for retreatment cases, at 57%, was very low. In addition, in 2010, about 18% of the registered TB cases were not evaluated for treatment outcomes. Multiple-drug-resistant TB (MDR-TB) patients are estimated to represent 3.1% and 10% of all new TB cases and retreatment cases, respectively.
Among the high-impact activities that were not implemented during Phase 1, the panel said, were community TB care, TB detection amongst high-risk groups (including prisoners), and an MDR-TB programme. In addition, the panel said, many interventions that were implemented demonstrated limited progress. The performance of the grant during Phase 1 was rated B2 (“inadequate, but potential demonstrated”); the expenditure rate, at just 29%, was very low. According to the Global Fund website, the budget for Phase 1 was $2.5 million.
Despite data that shows that TB/HIV co-infection is a significant problem in the Republic of Congo (31% of TB patients are co-infected), most of the TB/HIV collaborative activities planned for Phase 1 were not implemented, the panel said. Only 20% of TB patients were tested for HIV, whereas the current international standard requires that all TB patients be tested.
According to the panel, the Republic of Congo does not have an effective MDR-TB programme. There is no drug susceptibility testing laboratory and, in Phase 1, none of the TB patients received drug sensitivity testing or second-line treatment.
The Grant Renewals Panel expressed concern about the low case detection rate and highlighted the need for strengthening the community-based DOTS (directly observed therapy, short course) approach. Concern was also raised over the lack of collaboration between the TB programme and prison authorities regarding the implementation of TB activities in prisons.
Despite the fact that there was limited progress in target achievement in Phase 1, the implementation strategy proposed by the CCM in its request for continued funding was largely unchanged. As a result, the panel said, the Secretariat proposed a number of amendments. These were designed to ensure that the activities reflected better value for money; took into account key issues identified by technical partners regarding the implementation of DOTS; and addressed programmatic gaps and risks linked to the procurement of pharmaceutical and health products.
In the first year of Phase 2, sufficient pharmaceutical and health products will be purchased to provide one year of stock plus a six months buffer. For the balance of Phase 2, the panel said, government resources will be used to cover procurement and distribution costs.
In Phase 2, funds will be increased for MDR-TB treatment; however, the additional money is conditional upon the submission of a detailed work plan and budget.
The National TB Control Strategic Plan for 2013–2018 has not yet been developed. Consequently, the Global Fund Board said that disbursements for the second and third years of Phase 2 are conditional upon the development of a sound national strategic plan and the submission of a revised budget and performance framework for the grant.
The Grant Renewals Panel said that the Global Fund needs to continue efforts to engage national stakeholders and partners to build political leverage in the Republic of Congo and to improve cooperation with the government.
Information for this article was taken from Board Decision B28-EDP-17 and from B28-ER-13, the Report of Secretariat Funding Recommendations for March 2013. These documents are not available on the Global Fund website. The Secretariat recently gave notice of its intent to issue No-Go recommendations for two malaria grants in the Republic of Congo; see GFO article.