The Global Fund has approved $4.2 million in incremental funding for Phase 2 of a TB grant to Yemen despite concerns about performance in Phase 1 and serious risks associated with programme implementation.
Yemen's estimated TB prevalence is 70 per 100,000 population, incidence is 49 per 100,000 and mortality is 5.6 per 100,000. Prevalence of multi-drug resistant TB (MDR-TB) is estimated at 1.7% among new cases and 15% among previously treated cases. The treatment success rate is estimated at almost 90%.
Each of the country's 333 districits has a TB coordinators, who also coordinates with village health care workers on referral, treatment supervision, defaulter tracing and health education projects. Prevailing insecurity and instability in Yemen has damaged or delayed elements of the network, but the programme has, for the most part been maintained. Challenges that remain include inadequate coverage for TB/HIV co-infection cases (at only 6%), and low antiretroviral coverage for co-infected patients (at less than 50%).
Priorities under Phase 2 respond to concerns that key populations were not adequately targeted in Phase 1, and include the following interventions: (a) improving TB case finding through national TB programme (NTP) providers and non-NTP providers; (b) improving programme management of drug-resistant TB by strengthening laboratory capacity, training, the provision of second-line drugs and patient support; (c) initiatives to address TB among refugees, internally displaced persons, prisoners, women and contacts of TB cases (including children); and (d) strengthening implementation of TB/HIV collaborative activities.
Phase 2 will also invest in additional GeneXpert machines to improve diagnostic capacity and in technical assistance to address identified weaknesses.
The review of the request for continued funding downscaled costs by $1.3 million for training and meetings to align with Global Fund policies on human resource support.
Deficiencies from Phase 1 represent significant risks that will need remedy in Phase 2, the Secretariat's country team found. The Grants Approval Committee identified these as: (a) inadequate financial management and weak controls on grant funds; (b) inadequate human resource capacity; (c) poor storage conditions at the central warehouse; (d) a non-functional logistics management system; and (e) poor quantification of health products.
Limited ability to travel in Yemen has curtailed access to TB facilities, mitigating risk management efforts including onsite data verification. The grant received a rating of B2, reflecting both programmatic performance and a failure by management to address and manage risks identified in Phase 1.
The GAC recommended that the Phase 2 proposal be reviewed by the Secretariat’s Operational Risk Committee before grant signing to provide assurance that adequate investments and robust risk mitigation measures required to safeguard Global Fund investments are in place and are balanced with the need for the Global Fund to achieve its mission. GFO understands that the committee has conducted the review and concluded that risk mitigation measures were appropriate.
Gender inequities that are entrenched in Yemeni society must be addressed in Phase 2 programming, the GAC recommended, by strengthening the engagement of women and women’s groups in decision-making to improve uptake of TB services by women and children.
Also of concern to the GAC is the low absorption of funds in Phase 1 (at only 30%). Programme performance must improve in Phase 2 to prevent a further downward spiral of the programmatic response and escalation of prevalence due to the large numbers of economic migrants being forcibly returned from Saudi Arabia. Estimates from the International Organization for Migration suggest some 200,000 Yemeni nationals have been deported since June 2013.
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.