6 Jan 2014
GAC calls for more flexibility in managing grants in fragile states

The Global Fund Board has approved a $32.6 million grant to respond to the continued challenges posed by multi-drug resistant TB in Somalia, acknowledging the security and corruption concerns that make health service delivery in the country extraordinarily difficult.

The focus of Phase 2 of the grant SOM-T-WV will be on expanding coverage for case detection and DOTS. Critical for Somalia, Phase 2 will also include the roll-out of treatment for multi-drug-resistant TB (MDR-TB), as well as for increasing laboratory capacity, and strengthening health systems and monitoring and evaluation skills. World Vision will continue to serve as principal recipient.

TB incidence in Somalia is 286/100,000 and prevalence is 581/100,000. The mortality rate from TB excluding HIV/TB coinfection has been assessed at 64/100,000, although data collection has been challenging due to the chronic conflict that has prevailed in Somalia for more than two decades. The estimated prevalence of MDR-TB is 5.2% among new cases and 40.7% among retreatment cases.

Barriers to access to services are disparate among different population groups due to socio-economic status, cultural practices and traditional gender norms, which means that women and girls and internally displaced populations -- about one in 10 people in Somalia -- as well as people living with HIV, adolescents and children, and people living in rural or geographically isolated settings, find it most challenging to access treatment and support.

As expected in a country with a crumbling infrastructure that remains hostile to most outside interventions, the TB laboratory network is inadequate, with a lab-to-population ratio of 6.5 per million (compared to the World Health Organization recommended minimum of 10 per million). Only 44% of TB patients are being tested for HIV, and only 27% of those found to be HIV-positive are on antiretroviral therapy.

Because of problems with data quality, the GAC said that it is difficult to ascertain whether any progress has been made in terms of diminishing the impact of TB. The Somalia national TB programme is entirely dependent on the Global Fund; the request for Phase 2 funding represents 89% of the financing needs for the next implementation period. There are no domestic resources available and no material contributions from other sources.

In Phase 1 the grant achieved a B1 performance rating. The TB case detection rate was only 41% but, according to one cohort study, the treatment success rate was 86%. The GAC said that the high success rate may be attributable to the wide network of treatment supporters and “guarantors” who ensure treatment adherence at community level.

The GAC also said that data generated about the treatment of MDR-TB “raises questions about the quality of the treatment programme which need to be further investigated". The GAC said that in March 2013, the grant was materially reprogrammed to add MDR-TB treatment and that this was operationalized in September. To date, 47 patients have been enrolled.

Due to the instability in the country, there is limited, if any, verification that the services are reaching intended beneficiaries. The Global Fund, like most international actors in Somalia, has had to rely on its technical partners to provide assurances.

Numerous risks associated with the implementation of this grant have been identified, including poor human resource capacity, a weak infrastructure in Somalia, fragmented health services, lack of a harmonized remuneration system, inadequate pharmaceutical and health product management, no drug susceptibility testing, and the unsustainability of the programme. The GAC said that risk mitigation measures were put in place in Phase 1 and will be further enhanced during Phase 2, including a million-dollar investment in alternative power sources for stabilising electricity required for running highly technical equipment in laboratories and for ensuring that the cold chain is maintained in pharmacies and storage warehouses.

The challenges confronted in Somalia illustrate the need for more flexibility and more use of adaptive solutions for Global Fund grant management in fragile states, the GAC noted.

Information for this article was taken from Board Decision GF-B30-EDP3 and from GF-B30-ER2, the Report of Secretariat Funding Recommendations. These documents are not available on the Global Fund website.

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