Political instability, decreasing resources and a resurgent malaria epidemic: A challenging environment for Global Fund grants in Burundi

1. NEWS
6 Feb 2018
Malaria incidence doubled between 2014 and 2016

A combination of recent political instability and continuing economic challenges have created a complex environment for programming in Burundi. It is one of the five poorest countries in the world and is heavily dependent on external aid to finance its health sector. An attempted coup in May 2015 caused a political crisis. The suspension of aid by major donors that followed the crisis resulted in an 87% decline in external resources, which, in turn, led to 54% decrease in the 2016 health budget. Fortunately, Burundi’s 2017 health budget envisions the restoration of donor support to a significant extent.

According to the Secretariat, limited fiscal space for domestic spending, high dependence on volatile donor financing, weaknesses in public finance management, inefficiencies in health spending, sub-optimal social health protection, lack of adequate infrastructure and human resources to meet urgent community health needs –– all of these factors constitute major constraints for the long-term sustainability of Global Fund–supported programs.

The Global Fund is operating in this challenging operating environment under the Additional Safeguard Policy (ASP). On 13 December, the Global Fund Board approved a malaria grant ($36.7 million) and a TB/HIV grant ($35.6 million) to Burundi. In this article, we report on the comments of the Technical Review Panel (TRP) and the Grant Approvals Committee (GAC) on the funding requests submitted by the Burundi country coordinating mechanism (CCM). We focus primarily on the malaria request.

MALARIA

The funding request proposed a program that included a mass long-lasting insecticidal net (LLIN) campaign in 2019; case management activities; integrated community case management (iCCM); the continued scale-up of intermittent preventive treatment during pregnancy; and the use of artesunate injectable to treat severe malaria.

Since November 2015, Burundi has suffered a malaria epidemic, with a doubling of the number of cases. The goal of the Burundi National Strategic Plan (NSP) 2013–2017 is to reduce malaria-related morbidity and mortality by 75%. The TRP said that the national program anticipated a 75% reduction in incidence from 2014 to 2017, but instead incidence doubled between 2014 and 2016. “Burundi must now must focus on reversing the increasing trend,” the TRP said.

When it reviewed Burundi’s request, the TRP said that the country was not on track to achieve the intended results and impact of its current grant. “There is a need for increased urgency and scale-up of interventions in the face of the current epidemic emergency. The program has not been acting with sufficient speed, partly due to complex political and financial issues and [a] delay in grant signing,” the TRP said.

The TRP observed that the last mass distribution of LLINs was in 2014. The funding request states that LLINs are being distributed every three years to vulnerable populations, including educational institutions, police and military camps, and refugee and internally displaced people (IDP) camps, the TRP noted. However, it said, due to a lack of information, it is unclear whether this is actually occurring. The TRP also observed that the funding request did not say anything about routine distribution of LLINs between mass distribution campaigns.

Nevertheless, the TRP said that the funding request was well-developed and was responsive to previous TRP inputs. “Burundi’s malaria strategy is appropriate but given the political unrest and current worsening of malaria epidemiology, the interventions need to be applied with increased speed and urgency.”

Strengths of the funding request

The TRP said that funding request was technically sound and strategically focused because it is based on the NSP. It said that the proposed interventions were “relevant and appropriate in the current situation.”

The TRP noted that an analysis of the barriers to access services for key affected populations has been conducted, resulting in the development of specific program approaches and their partial implementation. Given the context of current political unrest, there will need to be to continued efforts made to reach these populations, the TRP said.

Issues and concerns

The TRP raised three principle concerns:

  • the slow speed of scale-up activities;
  • insufficient attention being paid to vulnerable populations; and
  • a lack of understanding of the causes of the upsurge in the epidemic.
 

We examine each issue in turn.

Scale-up

The TRP said that the malaria program has been slow to implement previously funded interventions, despite steadily rising malaria incidence, a trend which, the TRP said, was apparent in 2014.

“There needs to be a more urgent, persistent and creative approach to roll out and scale up the funded activities,” the TRP said. “Treatment availability at all health facilities and enhanced distribution of preventive interventions are critical.” The TRP also said that rapid expansion of indoor residual spraying (IRS) and accelerated distribution channels for LLIN routine distribution should be implemented.

The TRP requested that, towards the end of the first year of grant implementation, the CCM conduct a mid-term program review in order to assess whether the epidemic was brought under control, and to plan for mitigation of similar situations in the future.

Outcome: During grant-making, the country team undertook to follow up with the National Malaria Program on the response plan to ensure that activities are implemented effectively and in a timely manner. According to grant documents, the country team is closely tracking activities and working with partners and the government to address bottlenecks limiting timely implementation –– and to track commodities to ensure that there are no stock outs.

Vulnerable populations

The TRP noted that the political unrest is resulting in a high number of refugees, internally displaced persons, and mobile and migrant populations, as well as defined worksite populations. However, it said, it is unclear from the funding request whether their needs are being met.

The TRP recommended that innovative approaches and strategies be devised to reach these populations, including mobile clinics and routine LLIN distribution strategies. The TRP recommended that technical partners engage with neighboring countries, especially Rwanda and Tanzania, which are adjacent to highest incidence districts, to discuss the current malaria situation in Burundi, since these countries are similarly affected by the current epidemiology prevailing in the region. The TRP also recommended that the Secretariat ensure that a contingency plan is in place to protect vulnerable populations should the planned epidemic response be delayed.

Outcome: The grant documents state that this issue was cleared during grant-making, but they don’t say how.

Causes of the upsurge in the epidemic

The TRP said that the factors that have led to the increase in malaria cases are unknown but could include insufficient application of prevention and control strategies; insecticide resistance; lack of access to treatment; ineffective treatment; vulnerability due to food insecurity; population movements; and environmental and climate considerations. The TRP said that the causes of the epidemic need to be investigated but added that this process should not delay a speedy response to the epidemic.

The TRP recommended that the CCM apply for a prioritized above-allocation request (PAAR) at the earliest opportunity (see below). It said that PAAR funds could be used for an enhanced and intensified epidemic response, and that some of the funds could be allocated for a post-epidemic situational analysis. The TRP recommended that a rigorous assessment be conducted during grant-making to understand the determinants of the epidemic.

Outcome: This issue was discussed at length during grant-making. The discussions concluded that the exact causes of the upsurge in malaria cases in Burundi are multiple and not all determined. With support from the World Health Organization (WHO), the potential contributing factors were identified. They included a lack of prevention measures (non-availability and low use of LLINs in households), and environmental factors, such as the extension of rice fields and climate change. A therapeutic efficacy study that started in September 2017 will provide additional information. In addition, a post-epidemic situational analysis will be conducted in 2018 with support from the WHO, which will collect additional data on the causes of the epidemic, evaluate the level of implementation of the response plan and make appropriate recommendations.

PAAR

The CCM has applied for a PAAR. The request included: (a) conducting IRS in priority districts; (b) using LLINs to fill gaps before the 2019 mass campaign; (c) strengthening the surveillance system through the establishment of a geographic information system coupled with the weekly monitoring of malaria cases; and (d) strengthening data analysis for rapid decision-making to respond to emergencies and to understand the causes underlying the unusual resurgence of malaria cases.

Other issues

The GAC also noted the potential gap for the LLINs to reach national coverage (approximately 466,000 nets out of 7.0 million, which represents 7% of the total mass campaign needs), as well as the 182,000 nets needed for special groups (e.g. boarding schools, hospitals, prisons). The Secretariat said that this gap in LLINs, which amounts to approximately $1.5 million, will be closely monitored and that efficiencies identified during grant implementation will be reinvested to cover the gaps.

The GAC highlighted the need for IRS in 11 eligible districts, including the four districts covered by Global Fund under the previous implementation period. The GAC said that it was concerned about potential gaps in funding for IRS from 2018 on, and it underlined the critical contribution that IRS can make towards bringing malaria below the epidemic threshold.

Co-financing

The government has provided a commitment of $16.8 million, enough to meet the co-financing requirements. However, the GAC noted, the economic, fiscal and political situations pose significant risks for the realization of the commitment.

IMPLEMENTATION ARRANGEMENTS

In its report, the GAC says that it endorses the change in implementation arrangements from using national principal recipients (PRs) to using the UNDP, “given major governance challenges in the past.” UNDP will manage both the TB/HIV and malaria grants. The proposal to change PRs appears to have come from the Secretariat rather than the CCM. Aidspan understands that the decision caused some distress among stakeholders in Burundi.

The GAC also said that the portfolio will be streamlined from five grants down to two, with the national programs acting as sub-recipients, while also providing effective mechanisms for civil society organizations to implement activities going forward.

Additionally, the new implementation structure will enable significant reductions in salary top-ups –– by 90% for the malaria program and 85% for TB/HIV program.

TB/HIV

The GAC noted the critical partnership support and collaboration with multilateral and bilateral partners and civil society in-country. The GAC further noted the need for continued engagement and technical assistance during grant implementation, notably in four key areas:

  • development of a national laboratory strategy, including for the implementation of viral load scale-up;
  • improved access to, and coverage of, virologic testing among infants born to HIV-positive mothers;
  • ensuring the quality of interventions for key populations, including linkages of prevention activities with HIV testing and treatment services; and
  • a comprehensive supply chain management plan for the country, including warehousing and distribution until the last mile.
 

Noting severe fiscal constraints, the GAC expressed concerns regarding the risk of antiretroviral (ARV) shortages, should the country shift to test-and-treat in all provinces and if government contributions for funding ARVs do not materialize. Implementation of test-and-treat in all provinces may potentially result in a funding gap for ARVs of approximatively $3.0 million. The GAC said that the HIV cohort audit, the results of which are expected by the end of 2017, will ascertain the number of people on ARVs and enable a more accurate determination of funding gaps.

The GAC said that the Secretariat and partners are engaging in strategic discussions with the government on concrete actions and steps to secure the government’s contribution to the procurement of ARVs from 2018 onwards. Additionally, the GAC noted that the CCM is planning to submit a PAAR outlining the ARV needs for inclusion of new patients, which could be funded should additional resources become available.

RSSH

The TRP noted “with appreciation” that investments in resilient sustainable systems for health (RSSH) are embedded in the three disease components, in a synergic and coherent manner.

The strategy includes investments in the following areas:

  • expansion of primary care services with community health workers and a referral system;
  • implementation of a defined minimum package of activities for health centers; and
  • roll out of district health information software from districts and hospitals to the community level.
 

The CCM allocated 10% of the overall budget to RSSH activities.

 
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