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GFO Issue 314



Gemma Oberth

Article Type:

Article Number: 3

Two new civil society PRs will support the implementation of a significantly scaled-up key populations program

ABSTRACT On 23 May 2017, Mozambique submitted a full review TB/HIV funding request for $513.1 million. The country is one of the Global Fund’s largest investment portfolios, with the fourth largest disease allocation and the third largest catalytic funding opportunity. The funding request proposes a significantly scaled-up key populations program, to be implemented by two new civil society principal recipients.

On 23 May 2017, Mozambique submitted a full review TB/HIV funding request for $513.1 million. Of this amount, $335.0 million constituted a within allocation request, $160.0 million was a prioritized above-allocation request (PAAR) and $18.1 million was a matching funds request.

Mozambique’s total allocation for the three diseases ($502.9 million) makes it the Global Fund’s fourth largest investment portfolio (behind Nigeria, Tanzania and the Democratic Republic of Congo). Mozambique will receive 4.9% of the Global Fund’s country-level funding over the 2017-2019 funding cycle.

In addition to having one of the largest country allocations, Mozambique is also eligible for the third largest amount of matching funds (after Kenya and Indonesia). An amount of $19.7 million was made available to the country on top of its allocation, for human rights-related barriers ($4.7 million), adolescent girls and young women ($6.0 million), finding missing TB cases ($6.0 million) and data systems, data generation, data use ($3.0 million).

The significant levels of Global Fund investment in Mozambique are a result of high disease burden and low ability to pay (see GFO story on the 2017-2019 allocation methodology). According to global estimates, Mozambique has an adult (ages 15-49) HIV prevalence of 10.5% and a TB incidence of 551/100,000 population, placing the country among the top 10 in the world for both indicators (see the table).

Table: Top 10 Countries for HIV Prevalence and TB Incidence, 2015

Top 10 countries for HIV
Top 10 countries for TB
Swaziland (28.8%) South Africa (834/100,000)
Lesotho (22.7%) Lesotho (788/100,000)
Botswana (22.2%) Swaziland (565/100,000)
South Africa (19.2%) North Korea (561/100,000)
Zimbabwe (14.7%) Mozambique (551/100,000)
Namibia (13.3%) Kiribati (551/100,000)
Zambia (12.9%) Timor-Leste (498/100,000)
Mozambique (10.5%) Namibia (489/100,000)
Malawi (9.1%) Gabon (465/100,000
Uganda (7.1%) Papua New Guinea (432/100,000)
Sources: UNAIDS and WHO


Mozambique is heavily dependent on external funding partners to finance its response to the two diseases. One study (published in The Lancet) estimates that by 2018, Mozambique will be able to cover about 5% of its total HIV program needs with domestic resources – up from a baseline of 2% in 2013.

The bulk of Mozambique’s funding request ($201.4 million or 61%) is dedicated to HIV treatment, care and support. A further $92.9 million was requested for antiretroviral medicines (ARVs) in the PAAR. Aidspan has previously reported that all HIV treatment in Mozambique is funded by external donors, with approximately 48% coming from the Global Fund and the remaining 52% from the U.S. Government (see GFO article).

The country also requested a substantial amount – $18.3 million – for the prevention of mother-to-child transmission (PMTCT). By comparison, neighbouring Zambia requested $3.4 million for PMTCT and Zimbabwe just $1.8 million in their recent funding requests (see GFO articles here and here). Mozambique’s funding request notes that vertical transmission is a major avenue for new HIV infections in the country, accounting for over 13% of all new infections in 2016. Transmission to newborns currently stands at 11.1% in Mozambique, which is far higher than in Zambia (5.8%) and Zimbabwe (5.2%).

As noted, Mozambique’s funding request is highly commoditized. Despite these constraints on the allocation, the country requested $11.5 million for comprehensive HIV prevention programs for key populations, including activities for men who have sex with men (MSM), sex workers, people who inject drugs (PWID) and prisoners. The funding request is very explicit about its targets and remaining gaps for key populations, which not many countries are able to do in the absence of reliable size estimates. The proposed investment aims to reach and provide services to 20,000 MSM, 75,301 sex workers, 3,833 PWID and 2,249 prisoners, achieving coverage of 37%, 63%, 91% and 98%, respectively.

The proposed investment in key populations is significantly higher than what was in Mozambique’s last funding request. For the 2014-2016 funding cycle, the country requested $0.8 million for MSM and $2.8 million for sex workers. No funding was requested specifically for PWID or prisoners. In order to deliver such a scaled-up key populations program, Mozambique’s funding request specifies changes to the implementation arrangements, adding two new civil society principal recipients (PRs): Centro de Colaboração em Saúde (CCS) and Associação dos Empresários Contra SIDA, TB e Malária (ECOSIDA). The funding request states that these new PRs are experienced in working with key and vulnerable populations, especially where coverage of services has been low. Mozambique will now have four PRs, with CSS and ECOSIDA joining the Ministry of Health and the existing civil society PR, Fundação para o Desenvolvimento da Comunidade (FDC).

The funding request notes that activities for TB key populations (such as prisoners, miners and health care workers) are largely covered by other funding sources. For instance, Mozambique’s Ministry of Health is supporting the expansion of TB and HIV screening from the current 19 prisons to cover all 84 prisons, using mobile vans with digital chest x-ray and on-site GeneXpert Omni testing. The World Bank is funding a TB and HIV package of interventions among miners and their communities in Gaza and Maputo provinces, from 2016 to 2021. Systematic TB and HIV screening of health care workers (including non-governmental ones) as well as training on infection control principles is supported, in large part, by Jhpiego and the World Bank.

Among the TB case detection strategies for the general population, Mozambique’s funding request proposes scale-up of the “FAST” strategy (Find cases Actively, Separate safely, and Treat effectively). The country requests funding to train 1,650 additional “cough officers” who will be placed in 550 selected health facilities. The current cough officers, along with lay health workers and community level activists, currently contribute roughly 5% of cases detected and notified at facility level. With the added investment, the country expects this to increase to 15%.

Bolstering the proposed investments in HIV and TB, Mozambique requested $39.1 million for resilient and sustainable systems for health (RSSH). This is greater than what was dedicated to RSSH in the 2014-2016 allocation period, which was $30.8 million according to the country’s allocation letter.

The largest portion ($8.7 million) of the funding requested for RSSH is dedicated to strengthening procurement and supply chain management systems (PSM). The requested funding will go towards rehabilitating and expanding regional medicine storage facilities in Beira and Nampula to serve the North and Central regions of Mozambique, while also refurbishing and equipping eight provincial-level storage facilities that are currently in critical condition. The country also proposes outsourcing drug transportation to decentralized levels in order to ensure more timely availability of essential medicines at health facilities.

The high levels of proposed investment in PSM are warranted by significant challenges with drug stock levels in Mozambique. A November 2015 report from Médecins Sans Frontières (MSF) indicates that although stable HIV patients are supposed to receive three-month ART refills, national supply insecurity in Mozambique often prohibits this. Indeed, MSF found that 41% of facilities they monitored reported at least one stock-out of ARVs in the first half of 2015.

The Technical Review Panel (TRP) is expected to meet from 19-28 June 2017 to review funding requests submitted in the May 2017 window. The TRP’s response to Mozambique’s funding request is anticipated in early July.

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