Global Fund uses innovative approach for iteration of funding requests from Nigeria

Author:

David Garmaise

Article Type:

Article Number: 1

Revised requests offer significantly improved value for money, says the GAC

ABSTRACT The Grant Approvals Committee has welcomed what it called an “alternative and constructive iterative modality” for funding requests from Nigeria. The modality was recommended by the Technical Review Panel. In April, acting on recommendations from the TRP and GAC, the Global Fund Board approved four new grants to Nigeria and additional funding for a fifth grant.

When Nigeria submitted a joint TB/HIV funding request in 2017, the Technical Review Panel (TRP) recommended an iteration, which resulted in an 18-month extension of the grants. Subsequently, Nigeria submitted a TB/RSSH funding request, which proceeded to grant-making, and a separate HIV request. When the TRP reviewed the HIV request, there was a risk that it would require another iteration. However, in an effort to avoid any interruptions in service delivery, the TRP recommended an alternative iterative modality: the applicant could proceed to grant-making on the condition that the TRP would review the outcomes of grant-making.

In a report to the Board, the Grant Approvals Committee (GAC) welcomed what it called “this alternative and constructive iterative modality.”

The GAC stated that the revised funding requests submitted by Nigeria offered significantly improved value for money compared to the previous submission, made possible by significantly reduced program management costs, changes in implementation arrangements, and additional support for states to begin planning to take over the national treatment program.

Four grants for Nigeria were among the 11 new country grants approved for funding by the Global Fund Board on 19 April 2019 (see GFO article elsewhere in this issue [link]). The grant names and the respective principal recipients (PRs) are as follows:

NGA-H-NACA          National Agency for the Control of AIDS
NGA-H-SFHNG         Society for Family Health Nigeria
NGA-H-FHI360         Family Health International
NGA-S-MSH              Management Sciences for Health

The first three grants were for HIV; the fourth was for RSSH.

A fifth grant, NGA-C-LSMOH, for which the PR is the Lagos State Ministry of Health, had been approved earlier but received some additional funding. That grant covers TB, HIV and RSSH.

This article provides a summary of the comments made on the Nigerian grants by the GAC.

HIV component

The GAC said that although Nigeria has made progress in responding to the HIV epidemic, new infections have only declined by 5% between 2010 and 2017. “Without accelerating the response …  the country cannot achieve the 90-90-90 targets set by UNAIDS,” the GAC stated.

The goal of the HIV grants, the GAC said, is to contribute to epidemic control and reduce HIV/AIDS morbidity and mortality as well new HIV infections by 2021. See the table at the end of this article for a list of the strategic priorities for achieving this goal.

RSSH component

The RSSH grant will focus on strengthening national structures and systems –– with activities cascaded down to the state level –– with the goal being to strengthen health management information systems; laboratory systems; procurement and supply management; and public financial management.

Co-financing

The GAC said that the majority of the willingness-to-pay (WTP) requirements of the 2014–2016 allocation period were expected to be met by substantive commitments for malaria through the Integrated Testing Treatment and Larviciding project. However, budget execution reports are not readily available at the federal and state levels, so tracking expenditures is challenging. The government and the CCM were unable to provide satisfactory evidence that the WTP commitments were met. As a result, the 2014–2016 allocation was reduced accordingly in December 2017 (see GFO article).

For the HIV component, to access the co-financing incentive, the government needs to invest a minimum of $35.7 million in 2018–2020, over and above its spending in 2015–2017. According to the GAC, a commitment to invest an additional $37.0 million has been made by the Federal Ministry of Finance (FMF). This would be sufficient to meet the co-financing requirement. The Global Fund Secretariat will work with the FMF and the Ministry of Health to obtain bi-annual reporting for health budgeting and expenditure as well as annual health accounts reports as mitigation measures to monitor co-financing commitments.

Similar commitments have been made for the TB and RSSH components.

To further mitigate co-financing risks, the GAC stated, the Global Fund will support the annual production of national health accounts (NHAs) and state health accounts. Specifically, the RSSH grant included support for the  2017 NHA quality assurance validation; implementation of 2018 and 2019 NHA data collection activities; and  the production of state health accounts reports in four states.

New survey

In 2018, the Government of Nigeria conducted a National HIV/AIDS Impact and Indicator Survey (NAIIS), designed to provide critical, revised data on HIV prevalence, incidence and other HIV-related health indices. The results of this survey have now been published.

The survey found that national HIV prevalence among adults aged 15–49 is 1.4% (half the 2.8% figure previously used). The survey findings influenced the strategies for the approved HIV grants as they emerged from grant-making.

Based on the new data, the government is revising the National HIV/AIDS Strategic Framework. The GAC said that it welcomed this marked political leadership which, it said, “has enabled an environment that is conducive to addressing the programmatic performance and implementation challenges, and which is likely to result in greater impact.”

The GAC noted that although HIV prevalence is lower than previously reported, programmatic gaps –– particularly, treatment coverage gaps –– remain.

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Table: Strategic priorities for Nigeria’s new HIV grants

PR	Strategies
FHI 360	Provision of quality HIV testing services Prevention of mother-to-child transmission (PMTCT), including early infant diagnosis (EID) and related services Treatment, care and support for the general population Comprehensive prevention programs for key populations Prevention and treatment of TB/HIV co-infections Community system strengthening through the Association for Reproductive and Family Health and the networks of persons living with HIV/AIDS EID service uptake.
NACA	Strengthening routine reporting and capacity for data analysis Strengthening data quality, program reviews and evaluation, surveys, surveillance and operations research Strengthening financial management and oversight Mobilizing domestic resources from both private and public sources Strengthening the evidence base for improved targeting of key populations Promoting and strengthening platforms for integrated service delivery Strengthening the overall coordination and oversight of the HIV response Strengthening institutional systems
SFH	Implementing a comprehensive community-based HIV service package Strengthening community and institutional systems Creating an enabling and legal environment for key population programming
LSMOH (HIV comp.)	Strategic HIV testing services PMTCT Early Infant Diagnosis Differentiated care model for antiretroviral therapy and monitoring Prophylaxis and treatment of opportunistic infections TB/HIV collaborative activities Sexual and reproductive health and HIV integrated services Strategic information, program monitoring and data use Social mobilization, building community linkages, collaboration and coordination Institutional capacity building, planning and leadership development in the community sector

Most of the information for this article was taken from Board Document GF/B40/ER09 (“Electronic Report to the Board: Report of the Secretariat’s Grant Approvals Committee”), undated. This document is not available on the Global Fund website.

Further reading:

• New implementation arrangements for the Global Fund’s TB grants to Nigeria, GFO, 28 January 2019
• Global Fund chops $170.6 million from Nigeria’s 2014–2016 allocation, GFO, 21 March 2018
• Extensions to the Global Fund’s existing HIV and TB grants to Nigeria will be funded from the 2017–2019 allocations, GFO, 9 January 2018