TB funding requests did not convey a sense of boldness, innovation or ambition in the setting of targets or in the design of interventions, to quickly “move the needle.” This was one of many technical lessons learned identified by the Technical Review Panel (TRP) in a debriefing document which describes the outcomes of its review of funding requests from Window 1 of the current funding cycle.
Aidspan obtained a copy of the debriefing document from the Secretariat. The TRP is planning to produce a report for public release but not until after it has also reviewed the requests from Window 2, for which the deadline for applications is 23 May 2017.
This is the second of three articles Aidspan has prepared based on the TRP debriefing document. In this article, we report on the technical lessons learned for malaria, TB and HIV.
[In the first article, also in this issue, we provide information on (a) the outcomes of the TRP’s review (including requests for matching funds); and on (b) the general lessons learned from the review. And in a third article, also in this issue, we report on the lessons learned in two priority areas: resilient and sustainable systems for health (RSSH), and gender and human rights.]
Please note: (1) The TRP debriefing document was in the form of a slide deck, which means there were lots of bullet points and very few complete sentences. In this summary, we have done our best to correctly interpret the meaning of the TRP’s findings and recommendations. (2) For space reasons, we have had to be selective in terms of which findings and recommendations we include in this article.
Findings: Few countries identified cross-border issues as a critical bottleneck to malaria elimination. Funding requests provided only limited information on how to address service provision among different key populations in border areas. The TRP said that there is no “one size fits all” approach for dealing with cross-border issues, and that each country needs to develop an appropriate response based on its context.
Recommendations: Applicants should engage in strategic partnerships to address cross-border issues. | The Secretariat and partners should (a) support countries and (b) identify opportunities in regional projects to address malaria in border areas.
Data use for decision-making
Findings: Few applicants used empirical data to justify how they prioritized proposed interventions.
Recommendations: Applicants should increase in-country collaboration in order to analyze and use the latest empirical data not only to prioritize interventions but also to continuously update sub-national epidemiological profiles, and to identify the most affected key populations.
Role of private sector in service provision
Findings: Although many countries identified the delivery of malaria case management through the private sector as an important goal, the funding requests contained no specific strategies or financial resources to make this happen.
Recommendations: Applicants should ensure that strategies and financial resources to increase the contribution of the private sector are included in their base allocation requests. Applicants should engage the private sector in the fight against the use of monotherapies and counterfeit drugs. | Partners should support countries to identify the best approaches to address the role of the private sector.
Services provision and linkages with RMNCAH activities
Findings: While funding requests generally identified the key populations that needed to be reached with services, they were far less likely to describe how to provide services to these groups. | Linkages between malaria programs and RMNCAH services are weak (RMNCAH = reproductive, maternal, newborn, child and adolescent health). The TRP described this as a missed opportunity.
Recommendations: Applicants should utilize opportunities for leveraging with RMNCAH services. | Partners should provide technical assistance on integrating RMNCAH into disease programs, and integrating gender into human resources for health and RSSH initiatives.
Findings: Many countries are including quality assurance of commodities in their funding requests, but without providing specific strategies or a rationale.
Recommendations: The Secretariat should provide countries with clear guidance on how to ensure quality assurance of commodities.
Diagnostics: GeneXpert machines and digital radiography
Findings: While every country is scaling up the use of GeneXpert machines, there is considerable room for improvement in how the machines are used. Current machines are under-utilized, and the funding requests do not describe where and how countries will use new machines. | Funding requests often lack descriptions of clinical and diagnostic capacity, including diagnostic algorithms. Meeting the diagnostic needs of hard-to-reach populations, such as nomads, has been challenging. | The funding requests contained little information on how countries will operationalize the use of digital x-rays. | Specimen transport systems need to be improved.
Recommendations: Applicants should develop diagnostic capacity plans with clear indications of the number of GeneXpert machines, and should link the plans to outcomes. Applicants should adapt existing clinical management algorithms to incorporate new diagnostic tests; and should include activities related to developing clinical management capacity in future applications. With respect to specimen transport, applicants should consider linking with other programs that already have transport systems in place, such as other health programs or initiatives in the private sector. | Partners should work with countries to better define the needs related to the use of GeneXpert machines.
MDR-TB program expansion
Findings: Countries are moving too slowly on MDR-TB diagnosis: For the most part, case finding targets are not being achieved. | Most countries are moving to a shortened regimen for treating MDR-TB, but they are moving at different speeds due to capacity issues related to SLD–DST (second-line drugs – drug susceptibility testing).
Recommendations: Applicants should accelerate detection of MDR-TB cases and ensure all diagnosed patients are treated as soon as possible. Applicants should prioritize the use of short-course regimens as capacity for SLD–DST is built. (This will lead to treatment optimization and better patient outcomes, the TRP said). | Partners should provide support to countries to build capacity to enable rapid implementation of short-course regimens.
Findings: TB prevalence surveys confirm that there is a large proportion of missing TB cases in many settings. Funding requests mention interventions to find these cases, but lack sufficient detail – such as geographic location of the missing cases, specific interventions to diagnose them, and especially, how active TB case finding will be intensified. | Funding requests did not convey a sense of boldness, innovation or ambition in the setting of targets or in the design of interventions, to quickly “move the needle.” | Key populations are described “lightly.” The TRP warned that countries are not going to close the gap without a more detailed understanding of how to reach key populations.
Recommendations: Applicants should learn from TB REACH projects. Applicants should strengthen role of communities and information technology for case finding, retention in care, and contact management. Applicants should research and re-apply strategies that worked for finding missing cases. | Partners should support countries to better understand country survey and epi data, identify vulnerable populations and design enhanced and sustainable interventions to find “missed” cases.
Human rights and gender
Findings: Generally speaking, human rights and gender are not well addressed in TB funding requests. Issues such miners’ right to free diagnosis and treatment, and access to care by migrants, were missing from the requests.
Recommendations: Applicants should consider human rights and gender in programming prioritization decisions. | The World Health Organization should revise its reporting tool to include age- and gender-disaggregated outcomes.
Findings: Countries with large burdens of TB and HIV are making tremendous progress in bi-directional testing and antiretroviral coverage. However, implementation of TB/HIV collaborative activities remains weak in low burden countries.
Recommendations: Applicants should continue to promote TB-HIV collaborative activities, and should offer one-stop shopping.
Findings: There is a lack of innovation: Many applicants did not propose any novel prevention activities despite changes in context, but relied instead on “tried and true” methods. Few applicants recognized the need for differentiated approaches for prevention within groups. | There is a lack of use of data, both epidemiological and qualitative, for targeting prevention programs. This includes both key and general populations. For example, disaggregation by gender, age and key populations was not used for prioritization. | There is limited data on the cascade in the funding requests, starting from prevention – i.e. how prevention outreach helps with finding undiagnosed cases for testing. | While more funding requests sought to implement PreP, several requests lacked an understanding of the normative guidance and how it applied to their countries’ epidemic and context. | Some programs are again allocating funding for condom programming – which the TRP viewed as a positive development – but this is not happening at the levels needed. There should be less focus on social marketing, more on free condom distribution.
Recommendations: Applicants should find ways to better use epidemiologic and program data, and to tailor guidance recommendations to local situations. Applicants should develop innovative strategies to reach different segments of the population, considering age, risk, use of new social networking technologies and products, and changes in local country situations. | Partners should provide support to countries in using available disaggregated data and qualitative research to inform the choice of strategic priorities and to address bottlenecks in linking prevention to the treatment cascade. Partners should provide better support for differentiated approaches for prevention.
Findings: There is greater prioritization of key populations in all applications, compared to the previous funding cycle. All countries are working to identify these populations, estimate their size and address their needs. | The TRP noted what it called an “increasingly restrictive environment” for key populations: Legal, political, cultural barriers in accessing key populations with evidence-based interventions were becoming more severe in many countries, putting programs at risk. | Interventions to address bottlenecks are still more of the same – i.e. trainings to decrease stigma. | Generally speaking, there was a lack of national ownership and political commitment for funding, contracting and managing CSO-led key population programs.
Recommendations: Applicants should provide increased domestic contribution and commitments for key population programming. | Partners should provide more support to countries with restrictive environments for key populations.
The first 90 – HIV testing and linkage to care and treatment
Findings: Differentiated testing strategies are needed for better HIV case finding. This concept has been increasingly used in funding request narratives, but without implementation details. Countries presented low-yield results; they need more emphasis on higher risk targeting and case finding. | Insufficient attention is paid in the funding requests to test quality and lab and supply chain issues. This is identified as a key bottleneck in many funding requests, but initiatives to address the bottlenecks were lacking in both narratives and budgets. | Early infant diagnosis still lags behind; the TRP noted alarmingly low rates in West Africa. | Finally, the links between testing and treatment received insufficient focus in the funding requests.
Recommendations: Applicants should develop innovative strategies to reach hard-to-reach populations (e.g. community-based testing, self-testing) and to reach segments with low coverage (e.g. infants, men). Applicants should use data to develop the appropriate case finding strategies. | Partners should support implementation of test and start and other policies that improve case finding and linkage. Partners should support countries in adopting a feasible phased approach in the 90-90-90 context that would maintain both the gains of prevention programs and manage the risks, while maintaining the ambition to reach the goals.
The second 90 – antiretroviral treatment
Findings: Differentiated service delivery models are increasingly reflected in the funding requests, which the TRP considers a positive trend. | In the program continuation requests, it was difficult to discern the degree of program scale-up. | Access to affordable and quality drugs is a major challenge, especially in upper-middle-income countries with 80-90% domestic coverage of HIV programs. Some countries face barriers in access to international markets and procurement mechanisms. | Pediatric treatment coverage remains low in some regions, particularly in West Africa.
Recommendations: Applicants should provide clear data on treatment scale-up plans, including for children. | Partners should support applicants to maintain scale-up to reach 90. Partners should provide technical support to government-led ARV procurement.
The third 90 – treatment retention and viral load suppression
Findings: There are insufficient data on 12-month retention; the quality of the third 90 and cohort monitoring varies across continents. | Adherence and resistance monitoring is low: Few funding requests discussed adherence to drugs, and interventions to address low adherence rates. | Differentiated care models: countries have not picked that up yet. | Viral load availability remains low in several countries; yet existing viral load platforms and GeneXpert machines are underutilized.
Recommendations: Applicants should include in their funding requests support for data systems for cohort monitoring; and should address PSM and sample transport. | Partners should help applicants to undertake strategic planning of laboratory investments. Partners should provide support to countries in improving systems for cohort monitoring and antiretroviral treatment outcome analysis.
The TRP’s debriefing document on Window 1 funding requests is on file with the author. The TRP is scheduled to review Window 2 funding requests from 19-28 June 2017.