New implementation arrangements have been put in place for the TB programs funded through Nigeria’s new TB and TB/HIV grants.
Under the new arrangements, the National Tuberculosis and Leprosy Control Program (NTBLCP) in the federal Ministry of Health (MOH) will manage TB activities in public health facilities and communities as principal recipient (PR); and another PR, the Institute of Human Virology Nigeria (IHVN) –– selected through an open competitive process –– will manage implementation of the private sector component.
According to information on the Global Fund website, the PRs for the current TB grants are the Association for Reproductive and Family Health (ARFH), and IHVN. The current IHVN grant is not focused on the private sector. The NTBLCP, which is part of the federal MOH, is a sub-recipient under the ARFH grant.
To avoid service interruptions, the transition to the new implementation arrangements will take place over the first six months of 2019 and will be closely monitored. A number of mitigation measures have been instituted to ensure a smooth transition.
When Nigeria originally submitted a joint TB/HIV funding request in June 2017, the TRP recommended an iteration. An 18-month extension for the current TB and HIV grants, from 1 January 2018 to 30 June 2019, was granted to allow services to continue while Nigeria worked on revising its request.
Following discussions in-country, Nigeria decided to restructure its funding request. The country submitted a separate TB/RSSH request in June 2018, and a separate HIV request in September 2018.
On 21 December 2018, as part of the 15th batch of funding approvals –– see our coverage in GFO 348 –– the Board approved two TB grants and one TB/HIV grant for Nigeria (see table) from the country’s TB/RSSH request. The Board was acting on the recommendations of the Grant Approvals Committee (GAC) and the Technical Review Panel (TRP). A stand-alone RSSH grant is scheduled to be submitted for Board approval in early 2019. An HIV grant, emanating from Nigeria’s HIV funding request, is also scheduled to be submitted to the Board in early 2019.
Table: Nigeria’s approved TB and TB/HIV grants from its 2017–2019 allocation
|Component||Name||PR||Program budget ($)|
|TB/HIV||NGA-C-LSMOH||Lagos State Ministry of Health||5,089,851|
|TB||NGA-T-IHVN||Institute of Human Virology Nigeria||29,703,883|
|TB||NGA-T-NTBLCP||National TB and Leprosy Control Program||36,422,481|
The grants will focus on the following priority areas:
- Expansion of TB services from 8,653 public health centers (PHCs) in 2018 to 14,670 PHCs by 2020 (an increase in coverage from 35% to 60%);
- A more aggressive focus on TB case detection, to include screening and diagnosis with GeneXpert machines; use of chest X-rays; and the introduction of mobile digital X-ray vans in Lagos;
- Intensified TB case finding among key populations;
- Increasing the proportion of TB services provided by the private sector from 2.5% in 2017 to 51.0% by 2020; and
- Maintaining treatment success rates, which are currently very strong, while TB case finding is intensified and while responsibility and accountability for TB services shifts from NGOs to the public sector.
Under one of the current grants, the NTBLCP, as sub-recipient, provided its staff with salary incentives. This practice will continue under the new grant that the NTBLCP will be managing. The grant provides for performance-based incentives to be paid to civil servant staff who are not part of the Program Management Unit (PMU) and who receive significantly lower remuneration than the staff of the PMU because they are paid at civil service rates. Performance–based incentives will also be provided to two staff at each tertiary-level facility (i.e. where comprehensive primary health care services are provided), tied to achievement against targets for TB case detection.
(The fund portfolio manager for Nigeria, Ibrahim Faria, told Aidspan that in public health centers at the village level, community health workers will be mobilized, and they will offer an integrated package of services that includes referrals, treatment follow-up and increasing awareness.)
The GAC stated that salary incentives and other short-term investments in human resources for health (HRH) should only be implemented if it can be shown that they are required to mitigate an imminent risk of service delivery disruptions. They should not crowd out more comprehensive RSSH investments, the GAC said. The Secretariat said that it agreed with this approach but added that salary incentives are crucial to the success of the Nigeria TB program and are in line with the Global Fund’s current budgeting guidelines.
The GAC said that IHVN’s tenure as PR for one of the TB grants was contingent on Nigeria repaying an outstanding recovery amount of $63,850 by 31 December 2018. (Aidspan has learned that the outstanding recoveries were paid on time.)
Lagos State grant
The new TB/HIV grant will be managed by the Lagos State Ministry of Health (LS-MOH). The GAC recommended an integrated grant for Lagos State. The plan is to add RSSH and HIV components to the Lagos State grant in the coming months, providing funding for these components is approved by the Board. Currently, the grant being managed by LS-MOH includes only an HIV component.
As part of its grant, LS-MOH will pilot a mobile screening initiative with three vans to be procured jointly by LS-MOH and the Global Fund. If the approach is successful, the GAC said, it will be considered for wider implementation.
Global Fund financing is contingent upon LS-MOH procuring one mobile van (using funds from its co-financing commitment) before the end of the first quarter of 2019. “Non-compliance will result in grant funds being reprogrammed,” the GAC stated.
Nigeria was awarded $14.0 million in matching funds for the “finding TB missing cases” priority area. In the opinion of the TRP, Nigeria’s initial request for the matching funds did not sufficiently explain how the proposed interventions would contribute to the goal of finding missing cases. The issue was addressed during grant-making and a revised plan was submitted which contained enough details to satisfy the TRP.
The GAC noted that Nigeria failed to meet the increase in allocation condition, one of four conditions for accessing matching funds. This condition requires that the country invest more for the given priority area in programs funded by the 2017–2019 allocation compared to programs funded by the 2014–2016 allocation. However, in light of the expected catalytic impact of the matching funds, the GAC decided to waive this condition.
According to the GAC, domestic financing in Nigeria remains a critical issue requiring continued attention.
The GAC said that the majority of the willingness-to-pay requirements from the 2014–2016 allocation period were expected to be met by substantive commitments by the Government of Nigeria to a recent project on integrated testing and treatment. However, the GAC said, budget execution reports are not readily available at the federal or state levels, so tracking expenditures is challenging. In the end, the government and the CCM were unable to provide satisfactory evidence that the willingness-to-pay commitments were met. As a result, in December 2017, the Global Fund reduced Nigeria’s 2014–2016 allocation by $170.61 million, an amount that is greater than the entire allocation of most countries.
Regarding the co-financing requirements for 2017–2019, the GAC said that the government was expected to commit to investing the required amount. However, the GAC noted that given the fiscal and economic situation in the country, fulfilment of that commitment faces “significant constraints and challenges.” As a result, the GAC said, the Secretariat proposed that certain conditions be included in the grant agreements that would enable the Global Fund to closely monitor attainment of the commitments. The Secretariat was also seeking a revised commitment letter from the federal government and a commitment letter from the State of Lagos.
Most of the information for this article was taken from Board Document GF-B40-ER2 (“Electronic Report to the Board: Report of the Secretariat’s Grant Approvals Committee”), undated. This document is not available on the Global Fund website.