On 13 May 2019, the Global Fund Board approved, by electronic vote, funding for five country grants having a total value of $25.2 million. Domestic commitments for the programs included in the approved country grants amounted to $937.9 million. The five country grants were for four countries: Gabon, Georgia, Peru and Serbia. The largest award ($9.3 million) was for a Georgia HIV grant. (See Table 1 for details.)
The Board also approved two multi-country grants worth $9.0 million (Table 2).
In addition, interventions from the Unfunded Quality Demand (UQD) Register valued at $58.4 million were approved for 18 grants (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. The largest award ($13.2 million) was for a Burkina Faso malaria grant.
The Board was acting on the recommendations of the Technical Review Panel (TRP) and the Grant Approvals Committee (GAC). This was the 20th batch of approvals from the 2017-2019 allocations.
Table 1: Country grants approved from the 2017-2019 allocations –– 20th batch ($)
|Amount approved 1||UQD||Domestic commitment 2|
|Gabon 4||TB||GAB-T-CERMEL||CERMEL 3||1,190,025||755,228||4,506,322|
|Serbia 4||HIV||SRB-H-MOH||Ministry of Health||1,230,483||288,962||80,305,249|
- Amounts shown are upper ceilings.
- The domestic commitments shown are for the disease programs and exclude RSSH.
- CERMEL = Centre de Recherches Médicales de Lambaréné | NCDC = National Centre for Disease Control and Public Health | SES = Socios en Salud Succursal Peru
- For grants denominated in euros, an exchange rate of 1.1203 to the dollar was used.
- The end date for all grants in this table except Gabon TB is 30 June 2022. The end date for Gabon TB is 31 December 2021.
|Applicant||Grant name||Principal recipient||Amount approved 1||UQD|
|MC Africa ECSA-HC||QPA-T-ECSA||ECSA 1||4,500,000||1,319,599|
|MC LAC PIH||QRA-T-PIH||Partners in Health||4,500,000||0|
Note: (1) ECSA = East, Central and Southern Africa Health Community
|Applicant||Comp.||Grant name||Principal recipient||Amount approved ($)||Revised
|Benin 1||HIV||BEN-H-PSLS||PSLS 2||1,397,619||26,417,794|
|Burkina Faso 1||Malaria||BFA-M-PADS||PADS 2||13,218,225||108,046,364|
|Malaria||COD-M-MOH||Ministry of Health||525,201||84,020,305|
|Haiti||TB/HIV||HTI-C-PSI||Pop. Services Intl.||900,000||87,262,929|
|Mali 1||Malaria||MLI-M-PSI||Pop. Services Intl.||9,488,322||61,968,890|
|Montenegro 1||HIV||MNE-H-MOH||Ministry of Health||201,570||825,485|
|PAK-T-TIH||The Indus Hospital||1,180,438||41,180,438|
|Sierra Leone||HIV||SLE-H-NAS||Nat. AIDS Secretariat||700,000||32,499,803|
|Ukraine||TB/HIV||UKR-C-AUA||Alliance for Public Health||1,600,000||46,722,811|
- For grants denominated in euros, an exchange rate to the dollar of 1.242 was used.
- RSPCMT = Republican Scientific and Practical Center for Medical Technologies, Informatization, Administration and Management of Health | PSLS = Programme Santé de Lutte Contre le Sida | PADS = Programme d’Appui au Développement Sanitaire | SPCNLS = Secrétariat Permanent du Conseil National de Luttle Contre le Sida et les IST | CORDAID = Stichting Cordaid | MoFPED = Ministry of Finance, Planning and Economic Development
In its report to the Board, the GAC provided comments on two of the country grants; on both multi-country grants; and on all of the interventions funded from the UQD Register. In the balance of this article, we provide a summary of the GAC comments.
Gabon has the highest TB burden in Central Africa. The main driver of Gabon’s TB epidemic is TB/HIV co-infection.
The fight against TB in Gabon is led by the National Tuberculosis Control Program (NTP) with funding from the government, particularly for the procurement of first-line TB drugs, as well as contributions from research centers –– namely the PR, the Centre de Recherches Médicales de Lambaréné, and the Centre International de Recherches Médicales de Franceville –– to strengthen program capacity in relation to diagnosis and treatment. “However,” the GAC said, “the capacity in program management and coordination remains suboptimal, centers for TB diagnosis and treatment to cover the population in need are limited, and stockouts of first-line drugs have been recurrent in previous years.”
The goal of the NTP is to contribute to reducing TB mortality from 98 per 100,000 population in 2017 to 74 per 100,000 in 2021. The strategies to achieve this goal include the following:
- Improve TB notification;
- Increase the treatment success rate for new cases of confirmed pulmonary TB;
- Provide counselling and HIV testing to at least 83% of TB patients, and provide antiretrovirals and cotrimoxazole to at least 74% of co-infected TB-HIV patients;
- Test at least 234 MDR-TB cases over three years and treat 100% of confirmed cases; and
- Strengthen the management and coordination of human resources of the NTP and at all levels of the health pyramid, including the capacity to ensure high-quality monitoring and evaluation.
The main concern raised by the GAC has to do with whether Gabon will meet its co-financing commitments. Gabon’s commitment for the 2017-2019 allocation period more than meets the country’s co-financing requirement. However, the GAC noted, Gabon failed to invest in line with its co-financing commitments for 2014-2016. For that period, Gabon had promised that 95% of the co-financing spending would be for the procurement of first-line TB drugs and commodities. But, in reality, only 30% of the funds were spent on first-line TB drugs, while the other 70% was invested in recurrent costs –– i.e. salaries and maintenance.
For the 2017-2019 allocation period, Gabon aims to use the co-financing funds to procure 100% of the first-line TB treatment drugs needed. Citing the potential risks of the commitments not being realized, the GAC noted that the Global Fund Secretariat will closely monitor the materialization of the commitments through bi-annual reviews and an analysis of the lists of TB health procurements. In addition, the Secretariat said that it will continue to work with partners to persuade the government to increase the budget for health.
Serbia is an upper-middle-income country which became re-eligible for Global Fund support for HIV in the 2017-2019 allocation period due to increased prevalence among men who have sex with men. UNAIDS data for 2017 for this population shows a prevalence of 8.3%.
Serbia’s previous rounds-based HIV grants ended in 2014. According to the GAC, HIV diagnostic and treatment services, including voluntary counselling and testing (VCT) and opioid substitution therapy (OST), were transitioned to government funding. The GAC said that the government program was successful in continuing to scale up coverage with antiretroviral therapy (ART) and OST. However, financing for preventive services and care and support services for key populations was limited, resulting in significantly reduced service delivery across the country during 2015-2017.
“Whereas historically, civil society organizations (CSOs) had played an important role in forming and developing a national response to the HIV epidemic,” the GAC said, “the concurrent dissolution of both the National AIDS Council and the country coordinating mechanism (CCM) in 2014 and the expiry of the National HIV/AIDS Strategy” created a situation where there was limited dialogue among HIV stakeholders.
As a result, the GAC stated, the new grant will focus on investments in key populations –– specifically by providing prevention, care and support services; and providing finances through Serbia’s social contracting mechanism for engaging NGOs.
The GAC said that the grant aims to scale-up HIV testing services and preventive programs for key populations, including men who have sex with men, sex workers and people who inject drugs, while facilitating access to care and support services for people living with HIV and strengthening treatment literacy.
Most of the funds will be spent on two regions –– Belgrade and Vojvodina –– because that is where key populations and HIV transmission are concentrated.
The GAC noted that Serbia has:
- Re-established a National AIDS Commission, which, acting as the CCM, will provide oversight of the grant;
- Integrated into the Ministry of Health’s budget specific lines for key populations services with an annual commitment of €180,000 by 2021;
- Developed a National AIDS Strategy 2018-2025, in which civil service organizations are recognized as strategic and implementation partners; and
- Developed procedures for social contracting.
The GAC said that although Serbia has no plans to complete a transition readiness assessment at this time, the grant itself has been designed to address the main transition and sustainability challenges.
The GAC said that each year Serbia will issue a joint Global Fund and government call for proposals; select recipients through a national evaluation committee; and manage the funds under the national HIV program, “without creating any parallel systems or procedures for programmatic or financial reporting to the Global Fund.”
The GAC stated that government and grant funds will be jointly programmed using an aligned average unit cost per client reached for each key population. “This approach will, amongst other things, allow the country to better link resources to targets,” the GAC said, “and transform the mindset of in-country stakeholders from a grant-based support perspective to the procurement of health services delivered by NGOs.”
Multi-country Africa TB: East, Central and Southern Africa Health Community (ECSA-HC)
This grant builds on a 2014-2016 grant to the same PR involving strengthening the quality and diagnostic capacity of national reference laboratories (NRLs) to support other TB laboratories. The grant covers 21 countries –– Angola, Botswana, Burundi, Eritrea, Eswatini, Ethiopia, Kenya, Lesotho, Liberia, Malawi, Mauritius, Mozambique, Namibia, Rwanda, Seychelles, Somalia, South Sudan, Tanzania, Uganda, Zambia and Zimbabwe.
The grant’s objectives are to:
- Strengthen the inter-state regional network of NRLs;
- Improve laboratory service provision for quality assurance, and phenotypic first- and second-line drug susceptibility testing (DST);
- Enhance the impact of the World Health Organization’s recommended diagnostics; and
- Consolidate the capacity of NRLs to undertake disease monitoring surveys such as drug resistance surveillance, TB prevalence and other operational research.
The GAC said that the grant has the potential to contribute significantly to the global effort to find and treat missing TB cases and to achieve the goals of the WHO End TB Strategy and associated targets of a 90% reduction in TB deaths, and an 80% reduction in the TB incidence rate, by 2030 compared to 2015.
The GAC said that it shares the concerns raised by the Technical Review Panel (TRP) regarding the sustainability of programs beyond the Global Fund grants. It noted the challenges of ensuring that high-quality TB diagnosis and robust laboratory networks across the region will be maintained should the Global Fund withdraw its support at the end of the 2017-2019 allocation period. The GAC acknowledged that ownership of programs and the engagement with supranational reference laboratories in the region are critical to promoting sustainability.
Multi-country Latin America and Caribbean TB: Partners in Health
This grant aims to strengthen the capacity of TB civil society organizations (CSOs) and to promote the inclusion of civil society in national TB programs (NTPs). The grant covers eight countries: Bolivia, Colombia, Dominican Republic, El Salvador, Guatemala, Haiti, Mexico and Peru.
The GAC said that the PR, Partners in Health, and the TB Coalition of the Americas will work with civil society, CCMs, relevant ministries, NTPs and the Parliamentary Front of TB in each country to achieve the following objectives:
- Disseminate the ENGAGE TB approach and integrate community activities regarding the fight against TB into the work of CSOs;
- Establish eight national social observatories of TB (SOTB) to monitor the response against TB, engage in advocacy, and support the mobilization of resources (including financial resources for civil society activities); and to develop the capacities of civil society to more effectively participate in the prevention, diagnosis and treatment of TB;
- Strengthen the TB Coalition of the Americas as a strategic regional organization for (a) monitoring and control of regional commitments; (b) promoting the effective exchange of experiences between communities in different countries; and (c) assessing the regional response against TB “with a focus on human rights”; and
- Strengthen systems of accompaniment and community monitoring for effective referral and counter-referral processes for migrants affected by TB.
(Counter-referral is when the receiving facility refers a patient back to the initiating facility.)
The GAC said that the creation and consolidation of SOTBs will enhance sustainability because the grant will give SOTBs visibility among national and regional stakeholders and will support their operational activities. The grant will ensure that the SOTBs work with governments and civil society to secure budget lines in national budgets to enable governments to progressively assume responsibility for funding these programs.
The GAC noted that the work plan tracking measures will further contribute to sustainability of the SOTBs by (a) monitoring implementation and development of SOTB activities, including advocacy plans to address stigma, gender and human rights issues; and (b) including an assessment of local CSOs that can become home to the SOTBs which, in turn, will entail considerable savings and will help to empower the hosts.
ADDITIONAL FUNDING FOR UQD INTERVENTIONS
Benin HIV. The extra resources will fund 5,118 additional patients on ART, bringing ART coverage to 70% by the end of 2020 (from an estimated 63% at December 2018).
Belarus TB/HIV. The added funds will allow Belarus to implement the new MDR-TB regimen for 700 patients whose treatment is covered by the government and for 548 patients supported by the Global Fund.
Burkina Faso malaria. The added investment will cover seasonal malaria chemoprevention in 40 districts.
Burkina Faso HIV. The extra funds will help to increase retention in treatment and care of mothers and their babies; and will contribute to the elimination of mother-to-child transmission of HIV.
Chad malaria. Currently, distribution of long-lasting insecticide-treated bed nets (LLINs) funded by Global Fund and government resources reaches only 44% of populations at risk in eight regions. The additional investment will support distribution of the nets in five additional regions, thus enabling Chad to reach 73% coverage nationally in 2020.
DRC TB/HIV. The additional investment will support the scale-up of HIV treatment: 29,773 patients will be treated, of whom 1,516 are children.
DRC malaria. The additional funding will allow DRC to implement in two provinces a community-based surveillance model that has already been piloted.
Cuba HIV. The extra funding will allow Cuba to increase the proportion of people living with HIV who have low viral-load suppression from 43% to 76%. This investment is designed to support Cuba’s transition away from Global Fund support.
Haiti TB/HIV. For HIV, the additional resources will support activities to increase the proportion of people living with HIV who have achieved viral load suppression. For TB, the extra funding will support increased case detection.
Mali malaria. Current resources cover an LLIN distribution campaign in two regions. The added funding will allow Mali to extend the campaign to a third region.
Montenegro HIV. With the extra funding, Montenegro will be able to implement integrated bio-behavioral surveys and population size estimates for key populations.
Paraguay TB. The added funding will enable Paraguay to enhance active case-finding activities in hard-to-reach areas.
Pakistan TB. The extra resources will support the national program to engage with additional general practitioners (2,500), NGOs (210), private hospitals (50) and parastatal hospitals (50); and will help to ensure that diagnosis and treatment of TB patients by private practitioners is in line with national TB guidelines.
PNG TB/HIV. The extra investment will support additional staff in four districts and clinics; enable training, mentoring and support supervision of community health workers; and increase ART retention from 55% to 75-80%.
Sierra Leone HIV. The goal of the extra funding is to increase treatment coverage from 44% to 56% by 2020.
Ukraine TB/HIV. The added investment will enable 1,132 patients in non-government-controlled areas to transition to the new MDR-TB regimen.
Uganda TB. The additional resources will enable Uganda to transition additional patients to the new MDR-TB regimen.
Most of the information for this article was taken from Board Document GF/B40/ER12 (“Electronic Report to the Board: Report of the Secretariat’s Grant Approvals Committee”), undated. This document is not available on the Global Fund website.