Strong role for private sector in Global Fund’s TB grants to India
Keith MieniesArticle Type:
Article Number: 4
India has ambitious goal to end TB by 2025
ABSTRACT India, the second most populated country in the world, and soon to become the largest, contributes 27% of the world’s TB burden. It plans to end TB by 2025. This article summarizes the comments from the Technical Review Panel and the Grants Approvals Committee on India’s TB funding request. In January, the Board approved four TB grants and one TB/HIV grant to India.
Among the grants approved by the Board recently were four TB grants and one TB/HIV grant to India. In this article, we report on the comments from the Technical Review Panel (TRP) and the Grants Approvals Committee (GAC) on the funding request from which these grants emanated.
See separate article in this issue on the approval of India’s HIV grants. In addition, we plan to publish in the near future an article on the sustainability of India’s Global Fund grant portfolio.
The TRP commended India for its strategically focused and technically sound funding request. It said that the request addressed the priority areas identified in India’s National Strategic Plan (NSP) for TB, which was developed through a consultative in-country process and includes the ambitious goal to end TB in India by 2025.
India is the second most populated country in the world with a population of 1.32 billion. It is projected to be the world’s most populous country by 2022. TB remains a major public health issue in India, with an estimated 2.8 million new TB cases and 130,000 new multi-drug resistant TB (MDR-TB) and MDR/RR-TB cases in 2015. MDR/RR-TB includes patients with MDR-TB as well as patients who have TB resistant to rifampicin. The estimated mortality in 2016 due to TB in India was 423,000. India contributes 27% of the world’s TB burden.
India’s TB funding request contained a strong focus on interventions that promote meaningful engagement and collaboration with the private sector, the TRP said. The interventions included TB diagnosis; case notification and treatment; scaling up laboratory services; improving active case finding among key affected populations; and expanding MDR-TB management and treatment outcomes. According to the funding request, the private sector for TB is “massive, heterogeneous and growing,” and accounts for roughly 80% of the first contact between patients and healthcare providers. It is estimated that more than half of the TB cases are diagnosed and treated in the private sector in India.
The Board approved $283.8 million for India’s TB and TB/HIV grants (see Table 1 for details).
Table 1: Approved TB and TB/HIV grants to India ($US million)
|Comp.||Grant name||Principal recipient||Total program budget|
|TB||IND-T-CTD||Central TB Division, Ministry of Health||201.3 m|
|TB||IND-T-IUATLD||International Union Against TB and Lung Disease||15.5 m|
|TB||IND-T-CHRI||Centre for Health Research and Innovation||15.6 m|
|TB||IND-T-FIND||Foundation for Innovative New Diagnostics India||33.1 m|
|TB/HIV||IND-T-WJCF||William J. Clinton Foundation||18.2 m|
All five grants proposed a start date of 1 January 2018 and an end date of 31 March 2020. Adding an “extra” three months to the grants (39 vs. 36 months) will allow India to align its grant implementation periods to the country’s fiscal cycle.
India submitted a prioritized above allocation request (PAAR) of $180.5 million, all of which was deemed to be quality demand by the TRP, including a $40.0 million loan buy-down to the World Bank (more on this below). During grant-making, the GAC found efficiencies worth $42.4 million, which were invested in two PAAR interventions. In the end, interventions valued at $141.5 million were added to the Unfunded Quality Demand (UQD) Register.
Strengths of the funding request
The TRP said that India’s funding request addressed some of the challenges experienced during the previous Global Fund TB and TB/HIV grants to India, such as inadequate oversight of principal recipients (PRs) and sub-recipients, a lack of streamlined financial reporting, and weaknesses of supply chain management.
The TRP praised India for its cognizance of the different levels of vulnerability within TB-affected populations, which the TRP said is reflected in the program design and prioritization of interventions, including active case finding activities to reach these populations.
Finally, the TRP commended India for its increase in domestic resources for TB-related activities and its ability to describe how these domestic resources will complement the activities in the proposed 2018–2020 implementation period of the grants.
Issues and concerns
The TRP raised several issues when it reviewed India’s TB funding request. Some were addressed during grant making, while others will be taken up during grant implementation. Some of these issues are described below.
Human rights and gender barriers. In its funding request, the country coordinating mechanism (CCM) highlighted that gender, social and cultural barriers hinder access to services by TB patients. However, the TRP said, the request did not include interventions to address these barriers. The CCM responded that the government has developed a Patient Charter that outlines the rights and responsibilities of people with TB. The Charter is a tool to empower TB patients and their families to make the relationship with health care providers mutually beneficial, the CCM said. In addition, special sensitization sessions will be conducted to brief patients about their rights. To address social and cultural barriers to accessing TB services, the CCM said, the program plans to conduct active case finding in high-risk and vulnerable populations, which include migrants, slum dwellers and tribal populations.
Sustainability of technical assistance and use of consultants. A concern raised by the TRP was that the funding request did not include a plan to integrate into the work of the national program the technical assistance which India has been receiving through a network of technical assistance consultants funded by the Global Fund. The assistance received to date includes planning, monitoring and implementation management. The GAC said that funding from external donors to cover the costs of these consultants is not sustainable and recommended that these costs be covered fully by the government by the end of this grant period. The CCM agreed to gradually reduce the number of technical consultants over the next three years.
Program management costs. The TRP considered the staff costs under the program management module to be very high, which, it noted, has implications regarding long-term sustainability. The TRP recommended that the CCM and the Global Fund Secretariat carefully review grant management costs for each PR to avoid duplication and disproportionate amounts. The grant documents don’t say precisely how this issue was resolved, except that the GAC expressed satisfaction with the detailed budget reviews and said that the program management costs are now optimized.
Patient support to improve TB outcomes. The TRP noted that initiatives relating to support for MDR-TB patients were mainly included in the PAAR. It said that results from a few pilot projects in India provided enough evidence to demonstrate the effectiveness of patient support in ensuring treatment adherence. The TRP recommended that this intervention be moved from the PAAR to the within-allocation budget. Changes made to the within-allocation budget during grant-making as a result of efficiencies and other decisions resulted in 40% of the costs of the patient support initiatives being covered. Additional funding could come from savings realized during grant-making.
Loan buy-down to the World Bank
As mentioned above, the PAAR included a request for $40.0 million to be provided as a buy-down for a large World Bank loan as part of a blended finance project (see GFO article for a description of blended finance). The plan is to use the loan financing to cover funding gaps for priority activities related to the missing one million TB cases; patient support incentives; and diagnostics and treatment for drug-resistant TB (DR-TB) cases. The CCM believes this investment will yield a 60% reduction in the annual number of missing TB cases by the end of 2020, and at least a 60% improvement in treatment outcomes among DR-TB patients. The TRP considered this request to be quality demand because it leverages substantial financial resources for TB programming in India. Following discussions with the Global Fund’s Audit and Finance Committee, the GAC agreed to register the loan buy-down as a high-priority need on the UQD Register.
In order for India to meet its co-financing requirements for its TB grant for the 2018–2020 implementation period, the government needs to invest $55.9 million more than the $149.0 million it committed in 2015–2017. The government said it will invest $740.0 million in the Revised National Tuberculosis Control Program. See Table 2 for a list of the program areas covered by this investment.
Table 2: Breakdown of the Government of India’s investment
in TB control ($ million)
|TB drugs||310.0 m|
|Human resources||146.0 m|
|Patient support||44.0 m|
|Pooled Procurement Mechanism (PPM)||31.0 m|
|Supervision and monitoring||36.0 m|
|Program management||17.0 m|