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GFO Issue 393



Arlette Campbell White

Article Type:

Article Number: 4

Sub-nationally-focused interventions pave the way for a more comprehensive response to the three diseases and health system improvement

ABSTRACT An innovative one-off approach for Angola’s very specific situation is the first of its kind for the Global Fund. The Global Fund obtained guidance from the Technical Review Panel before the development of the funding request, based on an allocation for activities for four pre-selected provinces, chosen according to the burden of disease, partner funding landscape and implementation feasibility. This highly customized approach has enabled more targeted dialogue and prioritization at the provincial level and resulted in a funding request for the three diseases and health systems strengthening that responds to the real situation and needs of the priority provinces.

The Global Fund investments in Angola have not had the desired impact on trends for the three diseases over the past ten years. As a result, Angola’s latest funding request for 2021-2024 presented an original approach that is far from ‘business as usual’. Angola’s grant application has replaced diffused limited impact interventions at the national level with a focus on high impact activities at the sub-national level. The country will achieve this by delivering a comprehensive package of services for HIV, tuberculosis (TB) and malaria, and corresponding interventions for resilient and sustainable systems for health (RSSH) in two priority provinces. Based on the mid-term results, a further two provinces may be supported under Prioritized Above Allocation Request (PAAR).

The Global Fund’s Technical Review Panel (TRP) has recently approved this funding request in February 2021, paving the way for grant-making by April 2021 and the start of implementation by 1 July 2021.

Global Fund investments in Angola

Angola has received more than $300 million from the Global Fund since 2004. The country currently has five grants totalling $56 million between 2018 and 2021, being implemented by three Principal Recipients (PRs): the Ministry of Health (MOH), the United Nations Development Programme (UNDP) and World Vision International.

Table 1: Angola’s Grants for the Current 2018-2021 Implementation Period


Grant number Principal Recipient Grant component Grant period Signed amount (US$)
AGO-H-UNDP UNDP HIV July 2018 to June 2020 11,291,777
AGO-M-MOH Ministry of Health Malaria July 2018 to June 2020 6,227,996
AGO-M-WVI World Vision International Malaria July 2018 to June 2021 10,885,834
AGO-T-MOH Ministry of Health TB Jan 2019 to June 2020 5,153,554
AGO-Z-UNDP UNDP Multi-component July 2020 to June 2021 22,577,090
                                          Total: 56,136,251

Source: Global Fund’s Data explorer


A radical solution to ensure maximum impact from Global Fund and country investments in Angola

Global Fund assessments of its grants to Angola have found that impact trends in the three diseases appeared off-track. The incidence and mortality rates of HIV, TB, and malaria have increased in the last decade. For instance, new HIV infections rose by 8% between 2010 and 2018, while AIDS-related deaths have increased by 40% in the same period.

The routine audit of the Office of the Inspector General (OIG) in 2019 highlighted significant challenges in the grants and criticized the country for failing to implement suggestions made under an earlier OIG report. The Global Fund acknowledged the need for a fundamental change of its operational model and that this would be an opportune time for an essential redesign regarding what it would finance, where and how, during the 2021-2024 allocation period. The Global Fund Angola Country Team Fund Portfolio Manager (FPM), Joshua Galjour, told the GFO that “We want to be able to show the results that we know can be possible in Angola through sustained and targeted funding for the three diseases in the priority high-burden provinces”.

The Global Fund identified several issues in the Angola grants, highlighted their negative impact on the national response and proposed innovative solutions, summarized in Table 2 below.

Table 2. A New Approach for Angola: Global Fund Suggestions for Addressing the Problems


Observation Effect Solution
Program design is not appropriate for the Angolan context, being ‘overstretched’ or spread too thin
  • Lack of catalytic nature of investments
  • ‘Tries to do everything’ ― the Global Fund allocation was $58 million yet there were high operating costs, vast geographical distances and a high burden of disease
  • New business model for Angola: Better focused and prioritized Global Fund investments
  • prioritized sub-national approach in four prioritized and targeted provinces (according to burden of disease, partner funding landscape and implementation feasibility) with a complete package of health products for the three diseases and a subnational approach at provincial level for services for the three diseases and RSSH (e.g., community-based delivery)
Funding requests of suboptimal quality, submitted late in the funding cycle
  • Less time to implement grants
  • Lower absorption rates
  • Chronically late submissions in the funding cycle
  • Streamline the model:
  • Agree on high-impact interventions early on
  • Provide hand-holding approach through funding request development
Implementation arrangements are overly complex  Enormous workload for the national coordinating mechanism (Mecanismo de Coordenação Nacional or MCN), PRs, Country Team, Local Fund Agent and Fiduciary Agent
  • Reduce the number of grants to one grant/one PR
  • Consider the capacity of the PR
Failure to meet co-financing agreements Recurrent stock-out of TB and malaria drugs in the past two years
  • Mobilize civil society organizations (CSOs) to advocate to government to honor co-financing commitments:
  • Put in place a co-financing committee at the level of the MCN
  • Target high-burden provinces
  • High-level mission and messages to the government with key partners to raise concerns about government commitment and domestic funding for health

Source: Based on Global Fund Country Team presentation, Angola Funding Request Working Group, 8 September 2020


The new grant and the Technical Review Panel response

The TRP approved the funding request for an allocation of $82,600,349, representing an increase of 56% from the current grants, in addition to $6,210,035 approved through the Global Fund’s COVID-19 Response Mechanism (C19RM). It praised the funding request for being technically sound and strategically focused, building on lessons learned in previous funding cycles and proposing an innovative approach to improving outcomes through intensive sub-national interventions that can subsequently be scaled up. The TRP also noted that the submission of a single funding request that includes the three diseases and RSSH has allowed the design of real integration of the disease programs and that this will deliver efficiencies and other improvements.

In this new sub-national approach, Angola will provide comprehensive services for the three diseases and health systems in two provinces, Benguela and Cuanza Sul, for the three years of grant implementation. The country would then potentially receive funding for the PAAR through portfolio optimization to cover two additional provinces, Bié and Cuando Cubango.

These four provinces have 26% of the HIV cases, 24% of the TB burden and 42% of under-five malaria cases. HIV prevalence ranges from 1.4% to 6.8%; the TB notification rate varies from 73 to 452 per 100,000 population and malaria prevalence ranges from 10% to 38%. The provinces are extremely underserved but represent about 7.7 million inhabitants, a large subset of the country‘s population.

The country has also reduced the number of PRs to one, UNDP, who will work with five Sub-recipients including the MOH, the provincial governments and CSOs. The choice of UNDP as the PR, selected by the Secretariat in consultation with the MCN, was a direct result of the Global Fund placing Angola under the Additional Safeguards Policy in January 2020, following the poor OIG report. Other reasons given by the Global Fund included: the limited impact of Global Fund grants due to lack of government interest, commitment and ownership; a history of failing to meet specific commodity commitments; the inadequate management capacity of the Global Fund Project Management Unit in the MOH as PR; pending recoveries and lack of commitment to reimburse; insufficient MCN oversight and capacity; and significant data quality issues that hamper program monitoring.

Early engagement with the Technical Review Panel has been critical to the funding application’s success

A key factor that provided the framework for the new approach was the decision of the Global Fund Secretariat to request the TRP to review and provide guidance on a very detailed package of potential activities in selected provinces prior to developing the funding request. This TRP Early Engagement is rare for the Global Fund and the request for TRP review of a highly detailed allocation letter is to date a one-off way of working. Galjour remarked on the uniqueness of the approach: “I admit that engaging twice with the TRP is not part of our normal business process, but in the exceptional case of Angola, the Country Team thought it made a lot of sense, since it was critical to ensure alignment across the entire Global Fund partnership – Board, Secretariat, OIG and TRP.”

The allocation letter provided full details of what the Global Fund would cover at the sub-national level and by Global Fund standards was rather prescriptive; but Angola had ample opportunity to discuss and agree on the proposed interventions. The allocation letter also laid out the Global Fund’s expectations that the government would continue investing in human resources, the operating costs of health facilities and stipends for community health workers.

The development of the funding request also renewed and strengthened the engagement of the MCN with the Global Fund that will facilitate the roll-out of the new programs, and ensure better implementation and closer monitoring. Galjour noted “Since our meeting with the Angolan Head of State last year, we have been able to engage much more directly and in a hands-on way with the Angolan authorities at all levels. Mutual trust and collaboration are the values that are underpinning the new approach and dialogue with the Angolan national authorities.  For example, since last year’s OIG audit results, we have seen notable progress from the Ministry of Health and Ministry of Finance in putting in place a basic system for regularly reporting co-financing commitments to the Global Fund. This is a good foundation that we want to build upon in 2021.”

“The TRP approval is a great moment for the Global Fund-Angola partnership.

This approval reflects the commitment made by the Angola funding request team (MCN, Global Fund Country Team, programs, PRs and consultants) to achieve the best results to ensure the proposal is financed. The $82,600,349 will help to reduce the morbidity and mortality of thousands of people and will influence the country’s achievement of other positive metrics reflected in the allocation letter.

The fact that we worked on a new methodology, the sub-national approach, and obtained TRP approval for the first submission, gave us an unique experience, adding value and capacity building.

Our wish is to finalize all grant-making steps and start the implementation phase as planned, and see the smiles of all the beneficiaries of this new grant.”

Doctora Ana Ruth Luis, MCN Interim President

The pre-selection of four potential provinces for funding enabled the MCN to play a much more effective role in the national dialogue.

Members of the proposal development team, MCN civil society representatives and the United Nations Joint Programme on HIV/AIDS (UNAIDS) Country Director managed to travel to three of the four proposed regions to hold discussions with a wide range of stakeholders. These visits took place at a time when the country was in lockdown due to the COVID-19 pandemic and there were no internal flights, necessitating a very long road trip by car. Dr Michel Kouakou, UNAIDS Country Director, praised the new approach to developing the Funding Request, noting that the early identification of priority provinces meant that there could be much more in-depth and meaningful consultations with the key actors in each target region.

Support to the country’s decentralization process

As the allocation letter states, the new provincial-level focus is in line with Angola’s Constitution which structures its public administration on what it calls ‘the basis of the principles of administrative simplification, bringing services closer to local people and administrative devolution and decentralization’. The Global Fund recognized the need for more active involvement of provincial governments in the design and effective implementation of its grants, hence the new approach.

Leveraging private sector partnerships has also had a positive impact for the Global Fund

Last year, the Global Fund and Chevron Corporation celebrated a 12-year partnership that has served as an example of the private sector’s contribution to the fight against infectious diseases and to building resilient health systems. Chevron, a Global Fund partner since January 2008, has supported Global Fund programs against HIV, TB and malaria for a total investment of $60 million in Angola, Indonesia, Nigeria, the Philippines, South Africa, Thailand and Vietnam.

Since May 2020, Dr Ana Ruth Luis, the Regional Public Health and Special Projects Manager for Chevron in Angola, has served as interim President of Angola’s MCN during this critical time for the country.

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