Philippines’ HIV funding request to the Global Fund contains a good mix of prevention and treatment: TRP

14. NEWS
7 Nov 2017
However, the country’s matching funds request was sent back for iteration

The Philippines’ HIV funding request was strategically focused with appropriately targeted investments towards HIV prevention programs for key populations, and access to testing and treatment services. This was the conclusion of the Technical Review Panel (TRP) and the Grant Approvals Committee (GAC) when they reviewed the request. However, the TRP and the GAC were not as impressed with the Philippines’ request for $1 million in matching funds; it was sent back for iteration.

The Board approved $8.4 million for the grant emanating from the funding request. The Philippines country coordinating mechanism (CCM) also submitted a prioritized above allocation request (PAAR) of $4.2 million, of which $2.7 million was deemed by the TRP to constitute “quality demand.” Interventions totaling about $1 million were added to the Unfunded Quality Demand (UQD) Register. The principal recipient (PR) for the grant is Save the Children.

Strengths

According to the TRP, the funding request is based on a comprehensive situational analysis and demonstrates a clear understanding of the epidemiological patterns of HIV among key populations in the Philippines. The TRP said that the request was developed with extensive engagement of key populations.

The TRP said that the funding request builds on the lessons learned from current program implementation and that the proposed program takes these lessons into account. It said that the request “provides a strategic framework comprising Reach-Screen-Test-Enroll-Adhere to ART (RSTEA) interventions based on lessons learned from the previous Global Fund grants, acknowledges the limitations of the current prevention approach… [and] proposes … a shift in the testing strategy to more community-based approaches and rapid methods and plans to engage community health outreach workers.”

The TRP said that in recognition of the critical importance of addressing human rights-related barriers to accessing HIV and TB services, the funding request will implement a three-prong gender-sensitive approach, which includes: (a) high level advocacy for policy reform; (b) rights-based, age- and HIV-sensitive program delivery capacity building; and (c) the expansion of legal frameworks.

Concerns and issues

In its review and recommendation form, the TRP described several concerns it had with the funding request. We describe three of the concerns here:

The TRP said that given the current legal impediments and barriers for key populations, particularly persons who inject drugs (PWID), to access services, the targets of reaching 90% with prevention services and 95% being tested and put on treatment seem rather ambitious. Furthermore, it said, these targets can be attained only if a significant portion of the PAAR is funded. The TRP said that the applicant should set ambitious but realistic targets, and should adjust the targets to reflect funding available in the within-allocation portion of the request. This issue was to be addressed during grant-making. The review and recommendation form does not indicate whether it was addressed or what the outcome was.

The TRP pointed out that the funding request refers to a comprehensive program to improve the national procurement and supply chain management (PSCM) system, which is to be funded under the Philippines’ TB funding request. However, the TRP said, the TB proposal does not have any details of the proposed PSCM system. Further, the HIV proposal lacks a detailed description how condoms and other HIV-related medical supplies are to be made available to the target populations. The TRP requested that the CCM develop a comprehensive package of activities with a complementary budget to improve the national PSCM system, and that the package address the availability of the required health products and other (medical) supplies for the three disease programs. This was another issue that was to be addressed during grant-making. Again, the review form does not provide information on the outcome.

While the funding request identified the “leakage” in the treatment cascade and provided a general approach to identify and help key populations navigate the continuum of care with assistance from the care agents, the TRP observed, “it provides insufficient detail about the strategies needed to maintain new people living with HIV on treatment and achieve viral suppression.” In addition, the request did not explain how the financial barriers related to treatment enrolment and treatment monitoring will be addressed, the TRP said. Finally, it said, the funding request did not include any information regarding TB associated to HIV and regarding the integration of TB prevention and treatment with HIV service delivery. The TRP requested that the CCM develop a roadmap to ensure that the efforts of the Global Fund investments, primarily oriented to prevent and link key populations to services, actually lead to treatment enrolment and retention, and improved virologic outcomes. In addition, the TRP requested that the applicant include in the roadmap information and relevant activities regarding the integration of TB prevention and treatment with HIV service delivery. This issue is to be addressed during grant implementation.

Cost savings and matching funds

A total of $1.7 million in budget efficiencies were found during grant-making. The full amount was reinvested in the grant to fund activities related to (a) reducing human rights–related barriers to HIV services; (b) prevention for PWID; (c) access to care, treatment and support; (d) HIV testing services; and (e) prevention among young key populations, MSM and transgender persons. In fact, these reinvestments are projected to result in a major increase annually in program reach of 7,059 men who have sex with men (MSM), 2,391 transgender people and 794 young persons.

The TRP said that it did not approve the matching funds request of $1.0 million because the costs were predominantly related to human resources and capacity building and, therefore, did not meet the conditions for these matching fund, which were that requests must directly fund interventions to remove human rights–related barriers to HIV and TB services. A revised matching funds request is expected to be submitted in the first quarter of 2018.

The $2.7 million of the PAAR which was deemed quality demand was reduced by $1.7 million because of the efficiencies which were reinvested in the grant. Initiatives totaling $1.0 million were added to the UQD Register. The initiatives consist of behavioral interventions to address stigma and discrimination and violence against MSM; condoms and lubricant programming; and HIV testing services to reach 20,654 MSM and 8,900 transgender persons – as well as activities to improve mapping of key population venues that the TRP said will “generate strategic information that is needed for program planning and implementation.”

Sustainability

Domestic budget allocations for HIV have increased from $9.6 million in 2015 to $46.0 million in 2017. In the Philippines, co-financing commitments (direct government contributions to the HIV program) represent an additional $188.3 million for the period 2018-2020, which is a 257% increase compared to the previous phase (see table). 

Table: Additional domestic investments in the HIV program ($ million)
Source of funding 2015-2017 2018-2020 Additional resources % increase
Budget 46.2 m 173.6 m 127.4 m 276%
NHIP* 27.2 m 88.1 m 60.9 m 224%
Total 73.4 m 261.7 m 188.3 m 257%

* National social health insurance program

 

In support of the goals of the Health Care Financing Strategy 2010-2020 (HCFS), the government enacted the Sin Tax Reform Act in 2013 which raised taxes on cigarettes and alcohol. The government anticipates additional revenues of $6.0 billion in the first five years of the new taxes. This has already resulted in significant increases to national health budgets – specifically, a 383% increase in direct budget allocations to the HIV program, a 39% increase for malaria control and a 29% increase for the TB program between 2013 and 2017.

The grant start date is 1 January 2018, and the end date is 31 December 2020. 


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