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Issue 253: 27 October 2014

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CONTENTS OF THIS ISSUE:

1. NEWS: Abolish incentive funding, TRP says

The Technical Review Panel says that incentive funding is not meeting its goals and is creating additional burdens for applicants under the new funding model. The panel recommends that the money be reallocated to countries where the most lives will be saved. In addition, the TRP calls for the allocation methodology to be revised for the next allocation period.

2. NEWS: Nigeria malaria grant recipients to reimburse $350,000 in irregular spends after OIG investigation

Two principal recipients of Global Fund malaria grants in Nigeria were implicated in fraud  and will repay a total over more than $350,000, according to a new report by the Office of the Inspector General. Tighter financial controls will, going forward, be imposed in Nigeria to guard against future irregularities.

3. NEWS: OIG audit in Guinea-Bissau questions whether PBF is possible where performance data are not reliable

“The expectations for reporting, management and oversight placed on fragile states by the Global Fund have not been realistic,” the Office of the Inspector General said following an audit in Guinea-Bissau. Meanwhile, OIG investigations in Mali and Ghana revealed that some grant funds were misused.

4. NEWS: Morocco's open campaign against a secret epidemic starts with diagnosis

In Morocco, a country of more than 30 million people, government and civil society are working together to find more than 20,000 people who are thought to be HIV+ but do not know their status. Reaching them, then treating them, is the key to preventing the spread of the disease into the general population.

5. NEWS: EECA civil society joining forces to call for domestic spend on harm reduction

NGOs and community groups working on harm reduction and the HIV response in Eastern Europe and Central Asia are consolidating their services to maximize foreign investment and present a unified front in the call for domestic financing.

ARTICLES:

1. NEWS: Abolish incentive funding, TRP says

David Garmaise 24 October 2014

Panel also calls for the allocation methodology to be revised

The incentive funding stream should be eliminated and the money reallocated to countries that need it the most to save lives. This was a central recommendation of the Technical Review Panel Report on Windows 1 and 2 of the new funding model. The first two windows were in May and June of 2014.

The TRP said that incentive funding was not achieving its intended outcome – to stimulate ambitious and innovative approaches in concept notes – and was instead creating additional burdens for applicants.

The TRP said that in an attempt to secure additional funding, many applicants placed essential core services in the above-allocation portion of their request instead of in the base funding portion where they belonged.

According to the TRP, the current allocation methodology is flawed and should be revised for the next allocation period. The current methodology awards disproportionate amounts of funding to countries that will have a relatively low impact on reducing mortality, the TRP said.

The TRP recommended that in their concept notes, applicants indicate clearly the priority of the interventions in both the base funding request and the above-allocation request, and that applicants present a strong evidence-based rationale for their prioritization. The TRP said that while some improvement in this area was noted from Windows 1 to 2, it remains an issue.

TRP reviewers said that the overall quality of three-quarters of the concept notes in Windows 1 and 2 was “good” or “very good.” To achieve even better quality, the TRP said, applicants would benefit from more guidance and assistance.

“Perhaps of most concern,” the TRP said, “was the number of poor quality concept notes coming from countries that have, apparently, relatively weak systems and capacity. It is imperative that appropriate technical assistance be prioritized for [these] countries.”

Use of data

The TRP said that some countries are not using many sources of information, provided to or known by the TRP, to inform their choices of target populations and their decisions concerning which areas of the country to prioritize. The TRP said that countries should consider investing in a central data hub, which gathers multiple sources of epidemiological, behavioral and programmatic information in one location, regardless of funder or implementer.

The TRP said that countries should also seriously consider investing Global Fund resources in building sustainable national analytic capacity to use the large amount of data collected to guide future program decisions, rather than relying too heavily on external consultants.

The TRP recommended that partners and the Secretariat provide more support to countries to enable them to strengthen their data systems.

The TRP also recommended that countries ensure that implementers regularly track the outcomes of interventions in the field through routine program management data collection. The data should be used to make mid-course adjustments to programs, the TRP said. In addition, the data should be referenced in future concept notes to demonstrate the strategic value and potential impact of the support requested.

The TRP said that it understands that a shorter implementation period may be appropriate for some grants, but that the concept notes in question should explain where funding will come from to cover the period to December 2017. The TRP said that it may request another iteration of a concept note if it has “unanswered concerns that a shorter time frame puts the continuity of programs at risk in the event that the necessary funding does not materialize or falls short.”

In a separate report on Windows 1 and 2, issued by the Secretariat, it was revealed that in its concept note Thailand included plans to transition away from Global Fund support. The TRP applauded the decision and said that more applicants should move in this direction.

NFM progress report

Meanwhile, in its October NFM progress report, the Secretariat said that is has lowered its forecast of disbursements for 2014 from $3.9 billion to $3.1 billion. In 2013, $3.9 billion was disbursed. One of the reasons for the lower forecast, the Secretariat said, is that many countries are deciding to take more time to develop their concept notes.

However, the Secretariat still anticipates that about 40% of the expected 280 concept notes for 2014-2017 will be reviewed by the TRP in 2014. This amounts to 111 notes with a value of $8.5 billion. Thirty-three notes were reviewed in the first two windows combined, and an additional 39 notes were reviewed in Window 3 in August. For Window 4 in October, 46 notes are currently being screened.

The progress report also provided updates on two special initiatives: the technical partnership agreements with the WHO and UNAIDS; and technical support for community, rights and gender.

[This article was first posted on GFO Live on 24 October 2014.]

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2. NEWS: Nigeria malaria grant recipients to reimburse $350,000 in irregular spends after OIG investigation

Tunde Akpeji 14 October 2014

Two principal recipients of malaria grants in Nigeria have been implicated in fraud and financial irregularities, following an investigation by the Office of the Inspector General (OIG), and have committed to returning some $350,000 to the Fund.

Multiple irregularities were uncovered in a 2010 audit of Nigerian principal and sub-recipients of Global Fund malaria grants; this investigation, the results of which were published in early october, was a follow-up to that audit to delve more deeply into the financial mismanagement. The investigation was one of the legacy cases opened prior to 2012 and is part of the backlog the OIG aims to clear prior to the anticipated January 2015 departure of Martin O'Malley, the current inspector general.

The Society For Family Health (SFH) and the National Malaria Control Program (NMCP) were found to have committed violations in four key areas, according to the audit.

SFH was implicated in a self-procurement scheme that accrued a profit of more than $300,000 after it marked up a shipment of long-lasting insecticide-treated nets (LLIN). Those funds have since been refunded to the Global Fund.

Self-procurement is a fairly standard practice; it entails charging against a Global Fund grant the price of an asset that was already purchased and held as inventory. Where SFH erred, however, was in raising the price by some $0.71 per LLIN, rather than charging the Fund at the original purchase price for the more than 426,000 nets in the inventory.

To improve transparency going forward, the local fund agent will be expected to certify that any products that were self-procured were purchased and charged at the same price. Additionally, future purchases of LLINs in Nigeria will be done through the Fund's own pooled procurement mechanism, in an effort to reduce any risk of additional charges or costs.

Enrollment in the pooled procurement mechanism has become standard procedure for most countries that have been found to have procurement irregularities through OIG or other investigations.

The NMCP, meanwhile, submitted claims for a number of fictitious airline tickets and was found to have improperly procured six vehicles and information technology equipment. Those funds, amounting to roughly $50,000, are to be reimbursed shortly, according to the OIG.

NMCP employees will now be required to submit boarding passes along with expense claims in order to be reimbursed for flights.

Nigeria is one of the largest recipients of Global Fund support under the new funding model (NFM).  In March 2014, the country was allocated some $499.5 million for malaria activities, for the period 2014-2017.

[This article was first posted on GFO Live on 14 October 2014.]

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3. NEWS: OIG audit in Guinea-Bissau questions whether PBF is possible where performance data are not reliable

David Garmaise 14 October 2014

Investigations in Mali and Ghana uncover some misuse of grant funds

The Office of the Inspector General (OIG) says that its recent audit of grants to Guinea-Bissau raises questions about the suitability of performance-based funding in countries where performance data are not reliable.

“The expectations for reporting, management and oversight placed on fragile states by the Global Fund have not been realistic,” the OIG said.

To mitigate this, the Secretariat has committed to reviewing how its performance-based approach can be tailored in countries with significant data quality challenges.

The report on the audit in Guinea-Bissau was published on 3 October. Around the same time, the OIG released reports on investigations in Mali and Ghana. In both investigations, the OIG identified expenditures that were not compliant with the grant agreements. All three reports are available here.

In Guinea-Bissau, the OIG audited an HIV grant managed by the National Secretariat to Fight AIDS (SNLS), and a TB grant and a malaria grant, both managed by the United Nations Development Program (UNDP). The review covered the period from 1 January 2013 to mid-2014.

Guinea-Bissau is the first country in the OIG’s 2014 work plan to be audited using a new and tailored approach to examine the controls in place to safeguard future investments.

The audit found that financial controls were generally effective, but that there were problems not only with the reliability of performance data, but also with supply management and programmatic performance. There was no testing of the quality of Global Fund-financed products after they arrive in country, and stock management and storage conditions at health facilities were inadequate.

With respect to programmatic performance, the OIG singled out poor infrastructure, limited supervision and a lack of qualified staff at health centers.

Guinea-Bissau, one of the world’s poorest countries, is a difficult environment in which to implement grants. For this reason, and because the country experienced a coup d’état in 2012, grant activities have been scaled back to provide only priority services.

The OIG said that from the time of the coup d’état to the installation of a new government following elections in July 2014, almost no international aid entered the country. The Global Fund was the only donor contributing to the health sector during this period.

In the past two years, the Secretariat has implemented a number of actions to better manage the grants, including allocating a dedicated fund portfolio manager (FPM), reducing the level of disbursements, implementing a zero cash policy, changing the PRs for the TB and malaria grants (to UNDP), and implementing pooled procurement. A zero cash policy means that the PR will make direct payments to vendors instead of transferring the funds to sub-recipients (SRs). The Secretariat also re-tendered the local fund agent (LFA) contract as a result of a number of performance issues.

Mali investigation

In its investigation into a Round 4 HIV grant to Mali, the OIG found numerous irregularities in procurement transactions involving expenditures of $2.2 million which the OIG said were not in compliance with the grant agreement.

The $45 million grant was active between 2005 and 2010. The principal recipient (PR) was the Haut Conseil National de Lutte contre le Sida (HCNLS). The grant focused on prevention and care.

The investigation found irregularities in 357 separate transactions by the PR, its SRs and sub-SRs; and that there was collusion between implementers and vendors in the preparation of quotations.

Since 2011, HCNLS has no longer served as a PR, but it is currently an SR for some grants.

In June 2011, the OIG had identified serious fraudulent practices in two malaria and two TB grants managed by the Ministry of Health. There have also been problems with other HIV grants to Mali. (See GFO articles here, here and here.)

The OIG said that it had to curtail its investigation because of security issues that arose in 2012 as a result of tensions between the OIG and government officials. Subsequent political unrest  halted the OIG investigation completely. As a result, plans to review activities under two other HIV grants and a malaria grant were dropped.

In 2010, in response to the OIG’s preliminary findings, the Secretariat undertook a series of “corrective and preventive” actions that affected all grants to Mali. The actions included reducing grant activities to essential services, replacing some of the PRs, and instituting a zero cash policy for SR expenditures. As a result of this latest investigation, the Secretariat will implement additional actions, including appointing a fiscal agent to review PR and SR transactions.

It will be up to the Secretariat’s Recoveries Committee to decide how much of the $2.2 million in non-compliant activities should be recovered. The earlier investigation into TB and malaria grants identified $5.2 million in misused funds. In a statement accompanying the release of the latest OIG report, the Secretariat said that $300,000 of the $5.2 million has been recovered and that the Fund is “securing a signed protocol agreement for the repayment of the remaining US$4.9 million with a schedule for repayment".

The Secretariat said that the Mali portfolio now operates under a set of risk mitigation measures that are among the most stringent in the Global Fund.

Ghana investigation

In its investigation of Global Fund grants to Ghana, the OIG found that between 2005 and 2011, the Ghana Health Service (GHS) spent $8.2 million on the construction of six buildings without approval from the Global Fund. The GHS was the implementing arm of the Ministry of Health (MOH) and PR for several HIV, TB and malaria grants.

The construction included the rebuilding of a residential bungalow owned by the MOH and used by the program manager of the National AIDS Control Program, at a cost of $159,000.

The investigation also found bidding irregularities in tenders managed by the GHS.

The investigation was spurred by an audit of grants to Ghana in 2009-2010 that identified $9.8 million in non-compliant expenditures, most of which was for construction contracts.

The OIG said that there were efforts to hide the true nature of the construction expenditures. Neither the GHS nor the LFA mentioned the existence or extent of the construction projects in progress reports submitted to the Secretariat. In other documents, the GHS identified the projects as either “refurbishment,” “redecoration” or “remodeling.”

The OIG found that the full $8.2 million spent on construction was not in compliance with the relevant grant agreements, was unapproved and unbudgeted, and was expended through non-competitive procurement. However, the investigators concluded that $6.7 million of the expenditures were related to the programs being funded by the grants and that the buildings  involved were important components of the health system. The OIG did not recommend that the Global Fund recover these expenditures.

However, the OIG said, the other $1.5 million, which included the construction of  the bungalow, could not be justified. The Secretariat has agreed to seek the recovery of this amount from the MOH.

The OIG noted that since 2011, the Secretariat has implemented several actions to address the problems identified by the investigation. These actions included providing more guidance for the LFA; assigning a dedicated FPM to the Ghana grants; improving record keeping; and providing clearer guidance on budgeting and financial reporting. 

The OIG observed that “the nature of renovation and construction work is inherently risky,” and that “the architecture of funding from the Global Fund and the associated oversight are not well suited to these types of activities.” The OIG concluded that renovation projects require additional scrutiny and safeguards. 

Read this article in French. Lire l'article en français.

[This article was first posted on GFO Live on 14 October 2014.]

To comment on this article, click here.

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4. NEWS: Morocco's open campaign against a secret epidemic starts with diagnosis

Robert Bourgoing 27 October 2014

Finding the estimated 20,000 people who are unknowing carriers of HIV is the key to containing the epidemic

Objectively, Morocco's HIV indicators paint a relatively reassuring picture of a country only grazed lightly by an epidemic that has had ruinous consequences elsewhere in Africa.

Dr Abdelaziz Oussadan

Prevalence rates have never risen above 0.2% and, for the most part, only a small sub-section of the population is really at risk of infection: members of those globally identified vulnerable groups, including sex workers, men who have sex with men and people who inject drugs.

But delve a little deeper and the picture is not as rosy -- because among those vulnerable groups, there is serious danger in the unknown. Three in four of Morocco's most at-risk do not know their status, according to Dr Abdelaziz Ouassadan, coordinator of the diagnostics department at the Association for the Fight Against AIDS (ALCS). And while Morocco's human rights record is improving, stigma and discrimination continue -- so finding them is like searching for a needle in a haystack.

"It's really challenging, in the context of a 0.1% prevalence rate, to find 30,000 people," he told Aidspan during a recent visit. "Think about just how many tests you would have to do to find 100% of the infections."

Since 1992, ALCS has been responsible for most of the diagnostic testing in Morocco. But of course it cannot be responsible for testing all 30 million people in Morocco alone and, despite all of the awareness campaigns of the last decade, many of which received Global Fund support, voluntary testing remains rare. A goal of reaching 80% of both men who have sex with men and sex workers seems far off.

Rather than abandoning the effort, however, the Moroccan government is putting more resources into achieving the diagnostic goals. A 'know your status' campaign is at the heart of the national strategic plan (NSP) for 2012-2016, and includes an arsenal of activities, education and community mobilization led by grassroots organizations that know their clientele: the clandestine and vulnerable key populations. Taking diagnostics out of the hands of medical professionals and putting them into the hands of community health workers is another innovative component of a program currently in development.

Overcoming fear and ignorance

Educatrice Paire de l'ASCS

Since 2013, ALCS has joined other sub-recipients of Global Fund support such as OPALS and the Southern Association Against AIDS in pivoting towards working exclusively on the issues affecting key populations. In Morocco's large cities and priority regions, teams of educators work directly in the communities of vulnerable populations, developing trust and affinity as they encourage people to get tested.

In Agadir, it is teams of women who are sent by ASCS into the red light zones where sex workers ply their trade. Equally, ALCS is doing its part to reach the truck drivers who form the largest part of the sex trade client base and those who are most likely to pass infections into the general population. 
Work in this population has shown some modest result, said Dr Fatima Zahara, who heads the truck driver outreach program. The number of sex workers visited on average by a truck driver has declined from nine to six since 2007, and higher condom usage has been recorded. Truck drivers are also more inclined to get tested than they were before, she said, and they are taking fewer risks.

Routiers à Agadir

"I got tested, like almost half of the others in the [Association of Truck Drivers] because ALCS encouraged us to and brought the mobile clinic to make it easier," said Taoufik Choukri as he relaxed next to his rig at a truck stop in Petromin, Agadir's industrial zone.

NGOs have had to be more innovative in their efforts to reach the Moroccan gay community, which remains in the shadows for fear of stigma and persecution.

"There are a lot of people we have not been able to reach, who use chat sites," said Abdoullah Tif, who manages the web presence for ALCS. It was at Tif's initiative, therefore, that ALCS has created a profile on PlanetRomeo, the most popular site for gay men in Morocco. "If you're gay and can read and write, you're on PlanetRomeo," Tif said. ALCS now has an profile it uses to reach out to the more than 13,000 Moroccan users, to chat anonymously and share health information on topics such as HIV education, invitations for people to come to the ALCS office, and subtle encouragement for people to get tested and know their status.

Taoufik ChoukriBut for all the innovations and efforts to overcome HIV-related stigma, it remains a complicated proposition to reach the people most vulnerable to infection, said Mouna Balil, who runs ALCS programs in Marrakesh, the country's third-largest city.

"We've had a tough time finding doctors. Some of them have said very clearly that they will help us carry out diagnostic testing -- but not with men who have sex with men," she said. So how to bridge the gap between a medical community that is still stigmatizing homosexuality and a gay community staying firmly underground poses a critical challenge.

For ALCS, it means removing doctors from the equation. A new program about to get under way will provide training to community volunteers in diagnostics and counseling, so that people can work directly with their peers. 

Abdoullah TifThe volunteers use a simple finger-prick test, deriving immediate results from a single drop of blood.

"In light of the need, the Health Ministry has approved the program," said Younes Yatine, who leads the prevention campaigns for ALCS within the gay community. "Now it's up to us to find the right volunteers, to provide the right kind of training, and to have the right start to the campaign."

These community-led diagnostic programs should only be one among a number of different activities, cautioned Boutaina El Omari, who is the Global Fund focal point for the Ministry of Health "It's not the one and only solution," she said. "Studies have clearly shown that even with the tremendous effort being made by the NGOs, they will never reach everyone."

Mouna Balil et Younes Yatine

So for now the ministry will continue with other strategies that have worked in the past: annual diagnostic campaigns that target the entire population with ads on social media, television and radio. While expensive, this campaign has seen the number of HIV tests administered skyrocket, from 70,000 to more than 500,000 per year. And while just 300 new infections were identified in 2011, another 1,100 people were diagnosed in 2012, and 1,200 in 2013. These campaigns have also helped bring down the numbers of people who are unaware of their HIV status, from 80 to 75%.

"We've been an interesting case study for the World Health Organization," said El Omari. "They have hypothesized that where there is a low infection rate, generalized campaigns don't work; we are evidence to the contrary."

 

Read this article in French. Lire l'article en français.

[This article was first posted on GFO Live on 27 October 2014.]

To comment on this article, click here.

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5. NEWS: EECA civil society joining forces to call for domestic spend on harm reduction

Tinatin Zardiashvili 27 October 2014

Groups are consolidating their resources to maximize impact as clock winds down on Global Fund support

Civil society groups across Eastern Europe and Central Asia are consolidating resources and presenting a unified front to national governments to call for a greater domestic investment in harm reduction as part of the HIV response.

As the resources available from the Global Fund for regional programs are limited due to the implementation of the new funding model (NFM), there is a very real risk to the sustainability of existing harm reduction activities across the region -- most of which were in large part supported by Global Fund grants.

At a series of regional events hosted by the European Harm Reduction Network (EHRN) in Georgia and Latvia, civil society stakeholders were exhorted to plan strategically and develop an evidence base for the value of harm reduction programming in order to advocate with national governments.

Advocacy by communities in favor of policy change is the only way harm reduction will make it on to the agenda, and into the budget, of regional governments, said Anna Dovbakh, deputy director of technical support and information for EHRN -- itself a recipient of a Global Fund regional grant. In response to declining support from the Fund, the network itself is transitioning away from direct service provision into a more strategic role, helping at the country-level to develop advocacy and policy campaigns to promote harm reduction as a pillar of the public health response to HIV.

Stakeholders from countries participating in the EHRN meetings were encouraged to share best practices and demonstrate how the case can be made for governments to support harm reduction, which has been politically sensitive due to the nature of responding to the needs of people who inject drugs. But because this vulnerable population is the driver of the majority of HIV infections in the region, doing nothing poses an even greater health risk, noted Dovbakh.

Much of the discussion was conducted within the context of the three-year regional initiative underwritten by the Global Fund called Harm Reduction Works: Fund It!

Launched in May 2014 in Belarus, Georgia, Kazakhstan, Moldova, Tajikistan and Ukraine, the program seeks to mobilize community support as a political tool to encourage legislative and budgetary support for harm reduction.

An assessment tool for community-level stakeholders to measure program quality and accessibility was presented at the Georgia meeting, to allow individual countries to prioritize the right kinds of activities and interventions based on the needs of their populations. Developing this evidence base will go a long way towards building an investment case for harm reduction, according to EHRN.

There are some good examples of state-supported harm reduction in the region; Ukraine, for example, is seen as a regional leader in integrating opioid substitution therapies, needle exchange and methadone programs into its national response to HIV. Other best practices were shared during a session co-sponsored by the International Alliance - Ukraine that included representatives from Armenia, Azerbaijan and Russia.

Although the majority of Global Fund-eligible countries in EECA saw their envelopes diminish in the March 2014 announcement of country allocations under the NFM, the region remains eligible for regional programmatic support. EHRN together with the East Europe and Central Asia Union of People Living With HIV (ECUO) were invited to submit a proposal for a 7 million-dollar project to strengthen the advocacy potential of communities to ensure the sustainability of harm reduction and HIV programming.

Regional dialogue has begun and a three-day workshop took place October 19-21 to begin to develop the concept note, due in January 2015. Lively discussions about what areas to emphasize, how to achieve maximum efficiency and how to ensure collaboration and coordination ensued, according to Gennady Roshchupkin, a participant and the co-founder of the Eurasian Coalition on Male Health.

"We met against the backdrop of a bleak picture due to a funding crisis, but gradually realized that there are opportunities available -- we just have to move quickly," he told Aidspan. "Some of our priorities are bringing drug prices down, changing the policy environment and implementing the [new WHO recommendations on ARV use]. In order to accomplish this, we have to work hard on coming up with a cooperative strategy [involving all of the participating countries]. So that is where our emphasis needs to be, now."

[This article was first posted on GFO Live on 27 October 2014.]

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