In a Window 1 application to the Global Fund, Zanzibar grapples with limited data and tensions affecting key populations

3. ANALYSIS
27 Apr 2017
Lessons from Zanzibar may help countries applying in subsequent windows

On 20 March 2017, Zanzibar submitted a TB/HIV program continuation request for $6.4 million. Of this amount, just over $0.5 million was a prioritized above allocation request (PAAR), details of which will be presented only during the grant-making stage. The Ministry of Health is the sole principal recipient.   

While Zanzibar maintains a political union with Tanzania, it is considered a semi-autonomous territory. For Global Fund investments, Zanzibar has its own allocation and a country coordinating mechanism that operates completely separately from the one on the mainland.

Zanzibar’s funding request prioritized several strategic improvements to the current program, including index testing for HIV key populations (where health workers visit the households of existing HIV-positive clients to target and test other household members); and greater involvement of TB community-based organizations to do active detection and referral of cases. 

However, several challenges were experienced during the funding request development process. With a new funding cycle, and several changes to the funding model, this is bound to happen. Since Zanzibar is among the countries submitting funding requests in the first wave of the 2017-2019 cycle, it’s experience may be a useful one for other countries to learn from. This article presents three challenges which the country experienced: (1) planning in the absence of new data, (2) fostering dialogue despite limited space for programmatic adjustments, and (3) prioritizing key populations amid tensions regarding service provision for these groups. 

Challenge #1 – No new data

The funding request states that since the last Global Fund application, no new epidemiological studies have been conducted to inform a change in Zanzibar’s HIV and TB programs. Though the request states that program performance and epidemiological models indicate stabilization of HIV and TB trends, the absence of recent data poses a challenge for the country’s response.

Zanzibar’s last two funding requests to the Global Fund rely on epidemiological data from two surveys conducted as far back as 2011-2012. At that time, HIV prevalence was found to be 1% in the general population, 11.3% among people who inject drugs, 19.3% among sex workers and 2.6% among men who have sex with men (MSM).

Several years after these surveys, VOA news reported that researchers and community health organizations in a number of sub-Saharan Africa countries have begun to document an increase in HIV prevalence among drug users. According to Rick Lines, head of Harm Reduction International, there are “new and emerging patterns of injecting drug use” in such places as Tanzania, Zanzibar, Uganda, Senegal and Kenya.

“There’s also a critical gap in terms of gender-sensitive data,” says Faye Richardson, a Zanzibar-based consultant who has been providing support to key populations and civil society during the process. “The data we have is not age- and sex-disaggregated, so you don’t know how people are being affected by the diseases or which interventions to focus on,” says Richardson. 

In the absence of new survey data, Zanzibar’s funding request elevates the importance of program data and epidemiological modelling to inform decisions. This is a useful lesson learned for other countries that may be facing similar challenges with evidence and data.

Challenge #2 – Limited space for programmatic changes

Under the Global Fund’s new differentiated application process, Zanzibar was invited to submit a program continuation request. Program continuation dramatically simplifies the funding request process, requiring a brief self-assessment in order to continue the current program without any material changes.

The opening paragraph of the funding request states that in the absence of new data, “no programmatic adjustments are required at goal, strategic objective or programmatic intervention level.”

“The process was much easier compared to the previous funding cycle” says Benedicta Maganga, Coordinator of the Zanzibar Global Fund Country Coordinating Mechanism (ZGFCCM). “Roll Back Malaria came in December 2016 to do an orientation around changes to the funding model, and the Global Fund country team visited in February 2017 to provide helpful inputs and clarifications,” she said. Maganga said this support made the entire process much smoother than in the past.

The program continuation request template – which is not available on the Global Fund’s website – is a short one requiring a 2800-word response. The applicant is asked to outline any epidemiological or policy updates; and explain how the current program aligns with the Global Fund’s new Strategy for 2017-2022, and how sustainability, transition and co-financing aspects will be taken into account.

While a program continuation request is beneficial in that it can save time and resources, it also has the potential to limit space for meaningful interrogation of strategies and approaches. Zanzibar’s stakeholder priorities report presents several issues that civil society, key populations and other stakeholders would like to see changed or improved. The report was produced during country dialogue meetings, supported by ICASO and EANNASO, and was attached to Zanzibar’s application as an annex.

For example, the priorities report states that “data shows almost 60% of [the] 7,229 people with HIV in Zanzibar are female between 15-24 years, yet little else is known about them. Most interventions (prevention and care) are targeting small groups with high prevalence (sex workers, drug users or MSM) or the general public. Specific interventions for these young women need to be a priority.” Though the funding request states that there will be adjustment of some activities to make them friendlier to youth, the nature of a program continuation request means that material changes to more significantly prioritize adolescent girls and young women may not be possible.

That said, the funding request states that “as part of the assessment for program continuation, we understand that opportunities for programmatic adjustments should be identified for reprogramming as appropriate, and that reprogramming of grants can take place at any time throughout the grant cycle to ensure that the program is on track to deliver results and achieve highest impact.” For this reason, while there may have been limited space for strategic changes to the program during the funding request development stage, opportunities for stakeholders to push for changes or new approaches may be created later on.

“We ensured that critical wording on stakeholder priorities was included in the proposal so it has to be addressed during the grant-making stage,” says Richardson. As a result, Richardson emphasized, there needs to be ongoing key population involvement and input throughout the funding model to continue advocating for their priorities – not only during the development of funding request.

Thus, for other countries submitting program continuation requests, there is an important lesson from Zanzibar’s application, and that is that opportunities for influencing programmatic adjustments may arise at a later stage. This underscores the importance of an ongoing country dialogue and continued meaningful engagement.

Challenge #3 – Tensions around key populations

In March 2017, Aidspan reported that several Global Fund-supported programs had been suspended in Tanzania amid tensions around service provision for the lesbian, gay, bisexual and transgender (LGBT) community (see GFO story). This has had ramifications for other key populations, too, with sex workers and drug users also suffering a recent surge in human rights abuses and noticeably fewer health services available.
 
According to stakeholders in Zanzibar, the crackdown on key populations is not isolated to Tanzania’s mainland. “It’s affecting the whole community,” said a young gay-identifying man from Zanzibar, who wished to remain anonymous. “Now, people are afraid to go for services.” This young man told Aidspan that there are no measures to help this situation in the Global Fund application. “Removing barriers to access needed to be in there,” he said. “Legal support is needed.”
 
When asked if key populations groups were consulted as part of country dialogue, the young man confirmed that there was indeed an open and inclusive process for the funding request development. However, the voices of key populations are sometimes muted. “You can say these things and raise issues, but because of the cultural and religious situation, you are not always heard,” he said.  
 
Further, the young man emphasized that the availability of lubricants is a particularly acute issue for his community in Zanzibar, as it is in the mainland. In Tanzania, the government has banned the distribution of lubricants as part of the country’s Global Fund program, claiming it promotes homosexuality.
 
A ripple effect from Tanzania’s embargo on Global Fund-procured lubricants is being felt in neighbouring countries. In a recent article published in Uganda’s Daily Monitor, stakeholders reacted to finding out that Global Fund money is being used to procure lubricants there too. “We have never approved any such lubricants or any such commodities to be brought into this country,” Sarah Achieng Opendi is quoted as saying. Opendi is the State Minister of Health for General Duties in the Ugandan cabinet. “Homosexuality remains an illegally [sic] activity, according to our laws and, therefore, as Ministry of Health, we cannot be seen doing the opposite…. The Global Fund money is supposed to help in the fight against malaria and other diseases not buying lubricants for homosexuals.”
 

The experience of tensions affecting key populations in Zanzibar, Tanzania and Uganda highlight the importance of including activities under the removing legal barriers module in funding requests. As a lesson for other countries facing similar challenges, including funding under this module may help ensure that key populations are able to access essential health commodities procured with Global Fund resources.  


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