In their recommendation to the Board on Zimbabwe’s TB/HIV funding request, the Technical Review Panel (TRP) and the Grants Approvals Committee (GAC) commented favorably on Zimbabwe’s inclusion of interventions to address barriers related to human rights and gender, and its focus on key populations for HIV, TB and STI care and treatment. The TRP stated that the request was technically sound and strategically focused, and that the activities were clearly aligned to the epidemiological profile of Zimbabwe and the country’s national strategic plans.
Aidspan has previously reported on the contents of Zimbabwe’s TB/HIV funding request. About 70% of the request was dedicated to the procurement of essential medicines and health products, and 20% towards retaining critical human resources for health and program management.
The Board approved a total of $450.2 million for two grants, including $17.9 million in matching funds. The Ministry of Health and Childcare (MOHCC) and the United Nations Development Program (UNDP) are the two principal recipients (PRs). These are the same PRs managing Zimbabwe’s current HIV and TB grants.
The funding request included a prioritized above-allocation request (PAAR) of $197.0 million, of which $179.5 million was deemed by the TRP and the GAC to be “quality demand” and was added to the Unfunded Quality Demand (UQD) Register.
In its comments on the funding request, the TRP noted that it included innovative care delivery models (i.e. the expansion of community health service delivery). It also said that the request included a clear presentation of the gaps in human resources, and in particular, those relevant to TB and HIV.
Issues and recommendations
Several issues were identified during the TRP/GAC review process – most notably: poor quality of HIV care; unclear condom distribution strategies; and lack of a systematic process to identify key and vulnerable populations. These issues were addressed during grant-making, as follows:
- the MOHCC plans to scale up and strengthen health system and patient-related interventions by, among other things, enhancing health care workers’ capacity in the areas of adherence, counselling skills, defaulter tracing, etc.;
- a comprehensive Condom Operational Plan (2017-2020) was developed to lay out a clear strategy for efficient and targeted condom distribution; and
- the country has mapped hotspots for key populations in the Zimbabwe National HIV and AIDS Strategic Plan and has defined a comprehensive package of services for key and vulnerable populations, which include PrEP, access to treatment, and care and legal services.
Among outstanding issues that still need to be addressed after grant-making is one that concerns human resource retention. Zimbabwe has developed a new human resources retention scheme and Health Financing Policy. When it reviewed the funding request, the TRP recommended that the applicant justify its current salary and per diem policy and provide a mid-term and longer-term sustainability plan. A consultation involving the MOHCC and key stakeholders to shape the strategic direction of human resources retention interventions was planned for September 2017. The GAC said that output from the consultation will shape the strategic direction of the human resource retention interventions under the 2018-2020 implementation period.
UQD, efficiencies and matching funds
The $179.5 million from the PAAR request that will be added to the UQD Register consists of 59 different initiatives. Most notably, there is a $67.0 million initiative for monitoring the viral load of HIV-positive persons. Other interventions rated “high priority” include prevention programs for adolescents and youth addressing gender-based violence, and a program providing male circumcision.
During grant-making, savings due to budget adjustments amounted to $23.6 million. These efficiencies have been poured back into the grants.
The $17.8 million in matching funds that was approved will fund 17 different initiatives including, for example, behavior change programs for adolescents and youth; community mobilization; behavioral interventions for sex workers and men who have sex with men; and activities aimed at keeping girls in school.
Co-financing requirement may not be met
Although the country complied with the co-financing requirement of the previous allocation period, the GAC said that there is a major risk that Zimbabwe will not be able to meet its $36.2 million co-financing requirement for this allocation period.
Zimbabwe is a heavily aid-dependent country with a vulnerable economic and political environment, highly susceptible to internal and external shocks, the GAC said. The financing of health, it said, is heavily dependent on external aid, and household and private spending, with government accounting for only about 21%.
Zimbabwe’s AIDS levy, a 3% individual and corporate income tax to fund AIDS programs, contributes about $30-$35 million annually towards HIV programs. A newly introduced Health Fund levy of 5% of every dollar spent on airtime and mobile data, is specifically intended to fund procurement of equipment and drugs for public hospitals and clinics. This levy may help Zimbabwe make good on its co-financing requirement. The GAC requested that Zimbabwe submit an estimation by January 2018 of what its Health Fund levy income will be for 2018-2020, and that Zimbabwe then report annually on the utilization of the proceeds.
The proposed grant start date is 1 January 2018, and the end date is 31 December 2020.
See also separate articles in this issue on the approval of grants emanating from the funding requests for Malawi TB/HIV, and Benin TB/HIV and malaria. In addition, see separate article in this issue providing an overview of the 46 grants approved for funding.