There is little information in the TB/HIV funding request submitted by the Kyrgyzstan country coordinating mechanism (CCM) on the program that the applicant proposes to implement. And there is almost no information on how Kyrgyzstan plans to cope with an allocation that is significantly lower than what it received for 2014-2016.
The CCM submitted a program continuation request for TB/HIV on 20 March 2017 (Window 1). The request was for $23,470,014 ($11,266,362 to HIV and $12,203,653 for TB). This matches the allocation that Kyrgyzstan received for 2017-2019. The split between HIV and TB matches the indicative split provided by the Global Fund. The CCM is proposing that the new grant run from 1 January 2018 to 31 December 2020 and that the current principal recipient, UNDP, be retained.
The Technical Review Panel (TRP) has reviewed the funding request and has recommended that it proceed to grant-making. Aidspan understands that the Secretariat would like to see grant-making completed by 1 September 2017.
Kyrgyzstan TB/HIV was one of 93 funding requests submitted in Window 1, 78 of which used a program continuation approach. There is a separate template for these requests. By definition, the program continuation approach should be used only when there is no “significant change” being proposed compared to the existing grant. (The Fund also uses the term “material change” to mean the same thing.) Changes and additions to the program are permitted as long as they are not significant. Aidspan understands that a full proposal and budget will be prepared only after the request advances to grant-making.
The funding request states that the new grant will have “essentially” the same goals and strategic objectives as the current grant. It also says that the new grant will have similar program interventions.
For HIV, the priority areas for both the current grant and the new grant are (a) prevention programs for people who inject drugs, sex workers, men who have sex with men, and prisoners; (b) treatment, care and support; and (c) “creating an enabling environment and program sustainability.” Aidspan believes that this last priority area is meant to include transition planning and promoting an enabling environment for the transition. The priorities of the TB program are diagnosis and treatment of drug-resistant TB, and development of TB community care services.
Proposed changes to the program
The funding request does contain some information about the proposed program and the implementation modalities.
The new grant will follow the latest guidelines from the World Health Organization (WHO) which call for antiretroviral treatment (ART) to be initiated immediately upon diagnosis. The current grant uses the old guidelines (i.e. initiating ART when viral load falls below 500). The funding request does not provide an estimate of how many additional patients will be treated under the new guidelines. Nor does the request explain how the grant will manage to treat an increased number of people with ART given the significant decrease in Kyrgyzstan’s allocation.
The funding request states that specific activities will be implemented in an effort to remove legal barriers to human rights-oriented services implemented by NGOs, but the activities are not identified. (The request states the CCM will be applying for $1 million in matching funds that the Global Fund has earmarked for Kyrgyzstan for programs to remove human rights–related barriers to health services.)
The changes to the TB program reflect the focus of the national strategic plan on shifting from hospital to ambulatory care services. The new program will implement the updated national drug-resistant TB guidelines, which include the provision of new TB drugs and shortened treatments regimens. Diagnostics will also follow the updated algorithms.
The funding request acknowledges that there are some challenges related to the integration of TB and HIV services, as both programs are still managed vertically. The request states that the current grant made some progress in integrating these services; and that these efforts will continue in the new grant. In particular, the diagnosis of TB among HIV patients will be improved, as will the quality of TB treatment for people living with HIV. Finally, the new grant will more thoroughly measure TB success rates among HIV patients.
In the new grant, both disease components will pay more attention to the strengthening of the health information systems, particularly to segregated data collection (gender, age, etc.). The funding request did not provide details.
The funding request provides some information about elements of transition preparedness, such as reform of the CCM and capacity strengthening of the Ministry of Health (MOH). The request states that the current grant has made some progress in developing social contracting mechanisms and that this process will be continued in the new grant. (“Social contracting” refers to setting up mechanisms in government departments to contract civil society organizations [CSOs] to provide services.)
“We expect the government to approve legislation by the end of this year and to begin designing the social contracting mechanisms so that they can be tested in 2019, when the government assumes responsibility for funding prevention services,” Aibar Sultangaziev told Aidspan. Sultangaziev is the Director of the Partnership Network (also known as the Harm Reduction Association Network), and one of the CSO representatives on the technical working group that wrote the funding request.
The funding request states that by the end of the new grant, the MOH will have sufficient capacity to assume the responsibilities of principal recipient, including contracting CSOs to provide services to key populations, and purchasing health products and other supplies. More detailed information is contained in Kyrgyzstan’s transition plan, a copy of which was attached to the funding request.
The funding request states that the coverage and targets of the current programs will be amended and recalculated during the grant-making process.
The allocation that Kyrgyzstan received for 2017-2019 was significantly reduced from the allocation it received for 2014-2016. According to the funding request, on a per year basis the 2017-2019 allocation for TB and HIV combined is about 20% lower than the 2014-2016 allocation. (Editor’s note: Aidspan calculates that the per year reduction is actually about 28%, not 20%. Either way, it is significant.)
Even if the strategic directions in the new grant remain essentially unchanged and the interventions are not modified significantly, it is obvious that a reduction in the order of 20-28% in the budget for the two programs combined means that the activities and expenditures cannot remain completely unchanged and, therefore, that the new grant cannot literally be seen as a continuation of the activities of the current grant.
“Even in continuation format, some changes in the design will be unavoidable,” Sultangaziev explained. “Because the program budget is reduced, it will not be possible to meet the same objectives with less money. So, some activities will be cut and those that remain will have to become more efficient. We are planning to provide more details in the full proposal.”
It should be noted that there is a question on the program continuation template asking if there has been a significant reduction in the allocation. Where there has been a significant reduction, the applicant is asked to provide an explanation on how the scope of the program will be maintained or increased and what the alternative sources of funding are to maintain or increase the current level of coverage. When it responded to this question, the Kyrgyzstan CCM provided very little information.
With the exception of this one question, the program continuation template does not specifically ask the applicant to describe the program that is being proposed or to describe any changes or additions to the programs covered by the current grant. The template is short and relatively simple. It contains only six sections, asking the applicant to (1) update the epidemiological context; (2) describe the revisions to national policies and strategies; (3) explain how the current program continues to be relevant and on track to achieve results and impact; (4) demonstrate how the current program aligns with the Strategic Objectives 2 and 3 of the Global Fund Strategy 2017-2022 (i.e. regarding resilient and sustainable systems for health [RSSH], and human rights and gender equality, respectively); (5) describe the effectiveness of the current implementation approaches; and (6) discuss sustainability, transition and co-financing.
The section on sustainability, transition and co-financing (Section 6) contains the question about a reduction in the allocation. The only other question in this section concerns whether there are any changes in domestic or international financing. The applicant is not specifically asked to describe plans for sustainability or transition.
In its recent comments on the Window 1 applications, the TRP recommended that in future program continuation funding requests not be used by applicants whose allocation was significantly reduced. In these situations, the TRP said, the tailored-to-material-change applications should be used instead (see GFO article).
Viorel Soltan, who is a WHO consultant and who was the leader of the team that developed Kyrgyzstan’s funding request, said that he wonders why a TRP review was required for the program continuation proposals. “In my opinion, the TRP was placed in a situation, where basically all they had to was to confirm the continuation,” he said. “Otherwise, there was no way to complete the grant-making process in a timely fashion and ensure no disruption in the provision of services.”
Editor’s note: Although the program continuation funding request does not specifically solicit information on the contents of the proposed program, applicants could still provide such information if they chose to. We reviewed a program continuation funding request from Zanzibar for an article we published in GFO 310 on 27 April 2017. That request contained considerable information about what Zanzibar was proposing be included in the new grant. We have not reviewed a sufficient number of program continuation funding requests to discern if there are any patterns. The Secretariat does not make the funding requests public until much later in the process, so we have to ask individual CCMs if they will release a copy to us. Not all CCMs are prepared to do so.
The process of developing the funding request
The process of developing the funding request was facilitated by the CCM secretariat. It created a working group which consisted of eight technical experts, four for each component (TB and HIV). Each person was assigned an area of responsibility. This technical working group was headed by a representative of the World Health Organization. Two people represented CSOs and communities, one for HIV and one for TB.
The representatives were selected by participants in the country dialogue group. This is a virtual, online group which was established at the beginning of the 2014-2016 funding cycle. There are about 100 people in the group, including both individuals and representatives of CSOs and community groups. The country dialogue group functions via an email listserv. It has its own facilitator, who is a volunteer chosen from among the members of the group. The CSO representatives in the country dialogue group were responsible for organizing two-way communications – i.e. providing feedback to their constituents and reflecting the views of these constituents back to the country dialogue group.
In addition to selecting the members of the technical working group, the country dialogue group discussed what the priorities of the funding request should be. Although the communication was predominantly virtual, the CSOs also organized an in-person workshop, where participants met with the technical working group to exchange ideas.
Feedback on the funding request
Aidspan interviewed several CSO representatives to find out what they thought of the funding request itself and the process of developing the request.
There was a general consensus that the format of the funding request template was clear and easy to follow. But several people pointed out that the simplicity of the format might create tensions down the road because the template does not ask for information about the budget and does not require detailed information on the proposed program. Therefore, the simplicity of the program continuation format is seen as both a strength and a weakness for Kyrgyzstan: It has simplified the application, but this just postpones the main challenge, which involves coping with a significantly reduced budget and making hard decisions about which interventions will be curtailed or entirely eliminated.
For this reason, many of the people we talked to said that it is too early to evaluate the funding request properly. Sultangaziev stated, “We still have to work on the content-related details later, in the full proposal. At least we will be able to “borrow” from the contents of Kyrgyzstan’s transition plan which is more detailed than the funding request.”
Opinions varied when it came to the process of engaging communities in the development of the program continuation funding request. Some respondents said that the consultations could have been more productive. Daniyar Orsekov, Executive Director of the LGBTI community-based organisation, Kyrgyz Indigo, explained that “the process of consultations with communities was transparent, much more transparent and improved than few years ago. If we compare the process with the past, it was better; if we compare to how it should be done ideally, it was below average.”
“The limited time [between December 2016 and March 2017] for organizing the consultations with CSOs and KAPs [key affected populations] has definitely decreased the quality of the discussion,” said Sergei Bassenov, Executive Director of the Harm Reduction Network in Kyrgyzstan. “It was fortunate that some key populations insisted on having an in-person workshop, which turned out to be very effective.”
The feedback Aidspan received from people who were involved in the development of the funding request suggests that the consultation process was not ideal. Some people mentioned that country dialogue members were not always prompt when responding to requests and comments, and were not always willing to provide comments or share feedback. Others were skeptical about the need to comment because they felt that the consultations were a formality and that the main decisions had already been made.
However, Evgeniya Kalinichenko – who is Executive Director of the Country Network of People Living with HIV; a representative of the PLWH community on the CCM; and deputy chair of CCM – said that the consultations were inclusive and transparent. “All voices were heard and taken into consideration,” she said, “Most CSOs agree with the priorities outlined by the continuation proposal, but we have serious concerns about the reduction of the allocation and the ability of the government to bridge the gap.”
All stakeholders understand that the reductions in the budget for the new grant might be quite painful for some CSOs serving as sub-sub-recipients. They may find it difficult to find alternative sources of funding to allow their organizations to survive.